Serious Case Review Overview Report for Publication Child STRICTLY CONFIDENTIAL Date: 14"" October 2012 Safeguarding Children ammo 4.6 Once Child E's keyworker at the residential unit was dismissed a pahern 0f Child going missing commenced. This continued when Child moved in KRU1 Despite information being available to agencies lo indicate that Child was being sexually explailed. including divulged by Child himself, the protective response was inadequate. The reason for this appeared to be a view that there would need id be evidence, in the way of a disdosure by E, in arder to take action. The evidence available to agencies would have been clearer and easier to analyse had it been collated in a multi agency chmnulogy. and this would have supported agencies to act without a disclosure. The SCR panel concluded there was sufficient evidence to act despite the lack cl disclosure. Agencies involved had a duty to safeguard Child whether or not Child had the capacity to recognise his own need to be safeguarded. Child E's self-harming behaviour escalated during l'llS time at KRU1 and KRU2. The risk assessments that were undertaken by agencies did not always take into account Child E's history, possibly due to him being accompanied to appointments by carers who did not have this knowledge. The levels of supervision within KRU1 and KRUZ fell below the high levels uf supervision that were expected Within the commissioning arrangements, in order to safeguard Child and meet his complex needs. 4.7 5.15 Lack quhallengev There were om'asions wh agencies requesting a service or rfiponse did not challenge decision making or lack of action. for example, before Child was accommodated. School 1, the Community Faediatn'cian and the Educational made representah'nns to Social Care about their concerns relating to possible emotional abusev Huwever, the lack 0! effective intervention by Social Care was not challenged or escalated higher, anther to managers within Social Care or via the management structures within their own agency. 5 30 Corporate Any child looked afler by the Local Authority should receive the standard of rare that would be reasonable to expect from a parent. However there were occasions when action was not taken that would have been reasanable to expect a parent to take, Child regularly went missing from residential units with little attempt to stop him or find out where he went. He was in regular contact with his former keyworker by mobile phone but, with apparently only one exception, no steps were made to confiscate the phone or check his calls. Despite the risk of self--harm and suicide, routine inspections of Child E's room and possessions to remove anything that he could use to harm himself were not undertaken, Concerns over regulations relating to legal restraints may have inhibited residential staff from taking action that would be expected of a parent. This is dealt with in more detail in the section entitled 'missing from home and care' 6 56 From a very early age Child was demonstrating self-harming and suicidal behaviour, He had a history of climbing onto roofs. The first recorded incident of Child self-harming and attempting suicide was on 5mJune 2005. Throughout the scoping period, there are at least 24 recorded occasions when Child displayed selHlanning or suicidal behaviour. From the age of 11 there were 7 serious incidents of attempted suicide including threatening to jump from the root of School 1; attempted hanging. putting a plastic bag over his head, two occasions of taking paracetamol overdoses, and an incident at NRU where he had attempted suicide by cutting himself and then having to be talked down' trim the roof by emergency sen/Ices After his death at KRU2, evidence was found that he had already made an attempt to hang himself in his room. residential units. There were escalating Cuncems that his periods of being missing from [he resideniiai unlis were due (0 Child E's Continuing to have caniam will! his former keyworker, In lhe three years lhat he lived at ECRU, he was recorded by Leicesiershire Police as having absconded 46 times. Records provided by BCRU indicate that Child absconded an 52 occasions during his placement Nut all of these incidenis were classed as 'missing episodes' however as they were alien of a very short duration, someiimes a matter of minutes. 6,85 Whilst there was a growing pattern of information indicating Child E's vulnerability to sexual abuse, Ihe key agencies responsible for intervention were overly dependent on the need for 'evidence' of abuse or a criminal act rather than taking proactive action to investigate concerns on the grounds of reasonable suspicion. The Leicestershire Police IMR acknowledges that there was also an almost total reliance on the premise that without some form of disclosure of a crimlnal offence there was no role for the CAIU. The key agencies appeared to adopt the view of Lerceslershire Police in that they needed 'evidenoe'. possibly in the form of a disclosure from Child in order to act to protect him Child himself would appear to have been giving indications of continued Contact even though he denied any sexual contact but these were not responded to appropriately. There was a lack at confidence within key agencies about how to respond to this uncertainty and how to engage with Child on this issue. There is no sense at any professional talking to Child frankly about their belief that he was being abused and their acknowledgment of Child not feeling able to disclose while providing mm with an assurance that protective action was going to be taken in any event. To remove the responsibility away from Child might have enabled him to develop trust in professionals that were concerned for his welfare and might have led him to disclose earlier. There was a real sense of the professional network believing that Child was being abused but feeling powerless to do anything Given the amount or agency involvement with Child E. this is not an acceptable situallon 8.7 In Conclusion the SCR process has enabled the systemallc collection of about lhe risks of continuing harm to Child E, lhe predictability of a poor oulcnme him. and the clear potenfial for suicide. The process has lhe mulli agency analysis of these risks via the SCR Panel For the future' the task of Ihe LSCB must be lo ensure that robust processes exist loi mum agency analysis of risk during a child's life, mlher man follnwing a death. Had all the inlormation been collared' understood and analysed efleclively during Child E's llfe and high level of vulnerability identified, men miligallng actions particularly in lhe final law days prior to his death, could have led la a different'oulcome.