Embedded Files
The following case studies are anonymised national cases.
Stacey
Stacey is a White British girl aged 15. She lived with her mother and stepfather who was a known and convicted sex offender. The stepfather was involved with the family for 10 years and sexually assaulted Stacey on two occasions. She had poor school attendance from the age of 5 years (at times as low as 50%), unspecified behaviour issues and experienced bullying at school and in the community. The GP saw Stacey for a number of minor illnesses and her school mistakenly believed that her poor attendance was because of various illnesses. There was no school/doctor liaison.
The mother suffered from a chronic but manageable illness, which she exaggerated, and Stacey worried about her dying. Both the mother and maternal grandmother had experienced sexual abuse.
Children’s social care were involved with the family for eight years during which time they drew up four written agreements:
1. After stepfather indecently assaulted a child related to Stacey, the mother had to promise she would not allow unsupervised contact between Stacey and her stepfather (they all lived in the same home).
2. Mother physically assaulted Stacey and she had to promise not to use physical punishment.
3. Stacey had an unexplained bruised eye and a third agreement specified similar actions to the ones above.
4. The fourth written agreement was drafted without regard to the knowledge that all previous agreements had been breached. Stacey was assumed to be safe staying with her maternal grandmother who undertook not to allow stepfather contact with Stacey.
Life for Stacey continued to be the same despite written agreements and agencies being aware that agreements were not adhered to. CSC closed her case, preventing effective monitoring of agreements whereas the intended consequence of non-compliance with the agreements was that an initial child protection conference would be convened.
Other agencies were reassured by a written agreement and saw it as evidence of parental commitment to keep the child safe. The mother and stepfather later said that they did not understand the agreements as they were not explained in terms they could understand.
Key learning points:
Written agreements need to be explained clearly to parents/carers and non-compliance must be acted upon and challenged by other agencies if necessary;
The repeat use of written agreements and case closure can serve to wrongly reassure other agencies that the risk to a child is low;
Practitioners cannot assume that a mother or grandmother will have an understanding of sexual abuse and the ability to protect her child because of their own experiences of sexual abuse;
When there is a focus on parental illness and other difficulties, the voice and lived experience of the child can easily be overlooked.
Rose and Saffron
Rose and Saffron’s family have had a long history of Children’s Social Care involvement due to concerns about neglect. It involved long periods of the children being subject to a CPP and stepping down to Child in Need (CIN) plans, and then closure.
Concerns began to re-emerge shortly after the closure of the CIN plans and a second period of child protection planning followed. Legal proceedings commenced and following a multi-agency decision that the Child Protection Plan (CPP) did not achieve the changes that were required to safeguard the health and development of Rose and Saffron.
After the children were removed into care, they began to talk about being sexually abused in their previous home life.
The girls were aged between three to nine years at the time the child sexual abuse was first reported.
The children’s individual statutory care reviews initially focused on their care needs rather than giving attention to the disclosures. Professionals first decided that it would not be in the children’s best interest to be medically examined as it would be unlikely to produce credible forensic evidence or would not be seen as needed. Examinations eventually took place more than two years after the children made the allegations.
A complex and lengthy investigation followed due to protracted disclosures by the children, delays in the ability to interview the mother due to health issues, and delays in disclosure of material to the criminal investigation.
There were limitations to therapeutic work that could be started in case the children were required to give evidence in criminal proceedings, and the need for therapy to adhere to Crown Prosecution Service Guidance.
The children were also aware that their mother and her partner were subjects of protracted criminal law proceedings and this had an adverse effect on the children’s emotional wellbeing.
The children’s mother and her male partner were subsequently convicted of multiple offences of sexual abuse relating to both children. There was no evidence that the mother was manipulated or targeted by the perpetrator although it was recognised that she was a woman with significant vulnerabilities.
Child L (2024)
Disclosure of sexual abuse of a 13-year-old girl in 2022 by a known sexual offender. At the time of the incident, Child L was subject to an interim supervision order and a child protection plan and had previously made three allegations of rape and sexual assault outside of the home.
Learning themes include:
appreciating the child's lived experience and the cumulative impact of adversity, harm, and trauma;
listening to children and young people who make disclosures of abuse with intent to take action;
ensuring systems and practice are domestic abuse aware and trauma-informed; recognising the safety that school can provide for children experiencing intra and extra-familial harm;
increased awareness of the signs of child sexual exploitation and processes to access specialist guidance and support; and
developing a whole family response to support understanding of risk where there are complex adult issues.
Recommendations to the partnership include:
consider how it can strengthen practitioner skills that enable the child’s voice and experiences to be listened to and responded to verbally or non-verbally, including child observations and understanding of behaviours that may reflect harm and distress;
work undertaken with regard to the role of education in providing a key protective factor should include learning about the importance of relational practice, trusted adults, and advocacy;
clear leadership and challenge should be provided about victim-blaming language; and
seek assurance that when services are commissioned/decommissioned, a relational approach is taken with regard to children and families to be mindful of the importance of continuity of relationships from the child’s perspective.
Jez (2024)
Death of a 17-year-old boy in December 2022 from a drug overdose. Jez was autistic and known to services due to experiences of domestic abuse, mental health issues, substance misuse and self-harm. There were allegations against Jez’s stepfather of domestic abuse and sexual abuse.
Learning includes:
response to concerns about child sexual abuse and the impact a lack of a robust response can have on children’s lives;
support for children and families when they experience domestic abuse;
responding to allegations of physical abuse;
support to mothers with care and support needs; and
professional response to deteriorating mental health, self-harm, and substance misuse in the context of a trauma informed approach.
Recommendations to the partnership include:
set up a task and finish group to improve the multi-agency response to child sexual abuse;
consider how to strengthen practitioner skills that enable the child’s voice and experiences to be listened to whether there is a verbal or non-verbal disclosure;
ensure that all partner agencies have awareness of self-harm NICE guidance and the key principles of safety planning, managing risk and suicide prevention;
and implement a domestic abuse-informed response within child safeguarding responses.
Case A (2024)
Conviction of an adult male in 2023 for over 30 sexual offences involving both children and adults. He had previously been found guilty of possessing indecent images of children and given a suspended sentence.
Learning includes:
the sufficiency of the arrangements in place to risk assess and manage Mr A as a 'registered sex offender';
effectiveness of multi-agency practice at the point it was established that Mr A had children;
the sufficiency of the arrangements in place to engage relevant agencies and share information about known child sex offenders; and
the extent that practitioners across all agencies understand the potential risks posed by viewers of child sex abuse material.
Recommendations include:
in all cases where known child sex offenders are having contact with children, the Metropolitan Police service (MPS) should ensure that referrals are always made to children's social care. Both the MPS and the safeguarding children partnership should review their guidance on the risk management of known offenders and as required, strengthen the clarity on triggering a Section 47 enquiry when known child sex offenders are believed to be in contact with children;
the MPS should consider the sufficiency of its arrangements covering the disclosure of an offender's details to third parties; the child safeguarding practice review panel should look at the potential for the secure and routine information sharing of Level 1 MAPPA offenders with other key agencies, particularly GPs;
and the partnership should commission context specific training on child sex offenders and include this as part of its annual programme open to all practitioners.
Child Bk (2024)
Disclosure of sexual abuse from an 11-year-old girl in January 2023. The perpetrator had been investigated for downloading and distributing child sexual abuse (CSA) images in 2019 and was later found to have been sexually abusing Child Bk over a period of 12 months.
Learning themes include:
the multi-agency response to adults who view CSA images; the identification of CSA; and
responding to concerns from members of the public.
Recommendations include:
explore barriers to professionals applying the correct thresholds to risk and subsequent convening of strategy meetings;
review the need to create a separate pathway for children that live with those who have viewed CSA images;
ensure that the police are informed immediately of any suspicion that indecent images of children are being viewed and any connected child(ren) are being protected;
develop guidance for multi-safeguarding agency responsibilities regarding bail conditions including police communication and what action is required from all agencies;
develop a workstream to consider issues around the identification of CSA;
complete work around the issue of the sharing of single assessment outcomes with partners who have a continued role with the child and make expectations explicit in procedures;
review the current practice of relying on a mother/family member to supervise children’s contact with adults who pose a risk, and develop guidance and an approach to safety planning;
develop a risk assessment process to consider the risks adults pose to children of sexual abuse; and
where concerns are raised by the public it is essential they are not considered malicious but explored thoroughly.
John (2023)
Examines the involvement of agencies and services with a young adult. There were concerns around John exhibiting harmful sexual behaviours, which reached a criminal threshold.
Learning includes:
early identification, plus early and targeted intervention are important in helping children through childhood, transition positively into adolescence and onto adulthood;
assessment of risk and safety planning, in cases of potential harmful sexual behaviours (HSB), needs to be viewed as a multi-agency activity but with a clear lead role coordinating the combined efforts of all professionals involved;
supporting young people that have experienced adversity in their lives, and who go on to follow negative pathways through adolescence, is achievable by developing meaningful and trusting professional relationships.
Recommendations include:
information sharing guidance for practitioners providing services to children, young people, parents and carers should be reviewed by explicitly naming all the signatories of the guidance so that it carries greater authority and weight, it should also be strengthened with practice examples to aid professional understanding about when information can legitimately be shared;
online procedures should be reviewed and, where necessary, strengthened to reflect practice relating to HSB and specifically the practice challenges for professionals when responding to those children & young people who are victims of abuse but also pose a risk to others; use of professional challenge and escalation guidance should be further promoted to all professionals; and oversee the implementation of the action plan arising from the NSPCC audit, and should work together to identify, and where possible remove, any barriers to implementation.
Alex (2023)
Intrafamilial child sexual abuse of a 12-year-old girl by her father which had started when she was around 6 years old. The father is a registered sex offender and had served a custodial sentence having admitted sexually abusing a 14-year-old girl.
Learning includes:
the need for detailed knowledge and robust information sharing in respect of any historic concerns and potential on-going risks when a known sexual offender is living with, or having contact with, children;
the need for all professionals to understand the complexity of working with families where there is a risk of sexual abuse;
the importance of schools in providing a safe space for children to be supported; and
the need for professionals working with children and families to have adequate and appropriate knowledge about perpetrators of intrafamilial sexual abuse.
Recommendations include:
that the partnership asks partner agencies to ensure there is a focus for the whole system on the development of staff to enable them to work with children where sexual abuse in the family environment is an issue;
that the partnership informs the relevant partner agencies of the expectation that they robustly consider their response when concerns are shared by a person who is not a professional; and
that the partnership seeks assurance about the mechanisms in place across the relevant partner agencies that ensure that decision making considers previous assessments and the family history that is available in their own agency and in other agencies.
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