ISLE OF WIGHT SAFEGUARDING CHILDREN

BOARD

SERIOUS CASE REVIEW RELATING TO THE

Q FAMILY

Approved by the IOWSCB on 8 July 2014

Published March 2015

Independent Reviewer:

Alan Bedford

CONTENTS
Section
1
1.1
1.4
1.6
1.12
1.13
1.14
1.15
1.19

Page
3

INTRODUCTION
Background to the Review
Terms of Reference
Review Process
Independent Reviewer
Anonymity
Agencies Participating
Report Structure
Acronyms used

4
5

HISTORY and IMPACT ON CHILDREN and

PROFESSIONALS

INTRODUCTION TO FINDINGS

10

4
4.1
4.4
4.63

ILLUSTRATED APPRAISAL OF PRACTICE

Introduction
Actions and Appraisal
Summary

11

5
5.1
5.3
5.17
5.28
5.36
5.37
5.46
5.51
5.66
5.81

LEARNING AND WHY

Introduction
The Influence of the Father
Managing Different Views on Risk
Single Issue Thinking
A&E Attendances
Management of Allegations
ADHD
Meetings
Overarching Themes
Views of the Family

27

6
6.1
6.2

CONCLUSION
Introduction
Could one or more of the children have been protected
earlier?
What would need to happen to protect more quickly children
in the future in a similar position?

48

RECOMMENDATIONS

50

WHAT IS BETTER NOW? - UPDATES FROM AGENCIES

52

App 1
App 2

Collated learning points from Section 5 Learning and Why

Police Review June 2014. Conclusion and Recommendations

61
64

6.5

25

30
32
34
36
37
41
45

49

1. INTRODUCTION
1.1 Background to the Review: In October 2013 the new Chair of the Isle of Wight
Local Safeguarding Children Board (LSCB) concluded that the circumstances of
the case concerned met the statutory requirements for a Serious Case Review
(SCR) as set out in statutory guidance Working Together to Safeguard Children
(DfE March 2013). These are that there should be an SCR for every case where
abuse or neglect is known or suspected and either a child dies or a child is
seriously harmed and there are concerns about how organisations or
professionals worked together to safeguard the child. The SCR was accepted by
the LSCB on July 15th 2014. Publication was delayed to avoid compromising
further Police inquiries.
1.2 The Q case had originally been referred to the LSCB for consideration of an SCR
in 2009 but it was thought the criteria were not met, and was referred back to the
Council for a review. It was referred again in March 2013 but was not considered
by the SCR Working Group until June 2013. The new LSCB chair made the SCR
decision on taking up post, on the grounds that abuse or neglect were suspected,
a child has been seriously harmed, and there were concerns about how agencies
and professionals had worked together with the family.
1.3 The statutory guidance says that when compiling and preparing to publish reports
(an LSCB should) consider carefully how best to manage the impact of publication
on children, family members and others affected by the case. In this case there
are a number of children involved, who have experienced much unhappiness and
abuse over many years. The Chair of the LSCB has concluded that it is possible
to publish a SCR without the children being identified and further harm being
caused to them. However, this requires that only a certain level of detail can be
given and some identifying facts might be left out or changed. This report, whilst
giving a full appraisal of agency performance, therefore reduces detail that could
lead to anonymity being breached.
1.4 Terms of Reference: The 2013 guidance no longer provides core terms of
reference for SCRs, but says that final SCR reports should provide a sound
analysis of what happened in the case and why, and what needs to happen in
order to reduce the risk of recurrence.
1.5

This SCR will :

Appraise the quality of work in this case
Establish what lessons can be learned about the quality and effectiveness of
agency and multiagency working
Identify the key themes that characterised work with this family
Make proposals for improvement where any shortfalls are identified
3

 Involve front line staff and family members in the Review

There is a key underlying question:
Could one of more of the children have been protected earlier? If so, why, and
what would enable this to happen with future children in a similar position?
1.6 Review Process: The Review used the flexibilities contained in the guidance to
follow a methodology that fitted local needs. It was decided, as the case was so
large, and covered nearly two decades, that it would be an unnecessary use of
agency resources to study the whole case in detail as in the traditional model of
SCRs. For example, full chronologies would be vast, as would full analysis of all
agency actions.
1.7 To think through a way forward, a scoping day was held, chaired by the
independent reviewer, with around 30 involved staff (the staff group) who had
available brief agency reports and some chronologies commissioned either for the
SCR Working Group when making its recommendation to hold an SCR, or for the
scoping day itself. The Chair of the LSCBs SCR Working Group was in
attendance.
1.8 The conclusion of the scoping day was to focus on themes of how the family
impacted on professional staff (and what could be done better with similar families
in future) and on some key turning points in the case, rather than the whole case
history. The independent reviewer would work with agency staff and documents
to elaborate on these areas of focus. It was also agreed that the staff group would
be reconvened to consider the draft findings and to contribute to the learning and
how things could be done better. This meeting was held and the staff contributed
further analysis and thoughts about recommendations. A participative approach
like this was thought to enhance learning and buy in, and also for staff who found
the case so hard to play an active part in shaping the Reviews conclusions.
Around 40 staff took part in one or both of the staff group meetings.
1.9 To support the process there was a Reference Group of senior staff from involved
agencies which the reviewer could use as a sounding board, and if necessary to
facilitate any stumbling blocks in the process. The Boards SCR Working Group
quality assured the final draft before presentation to the Board.
1.10 The independent reviewer met all the children who were a focus of the Review,
and their views are reflected in this report. The father and mother were seen
separately, and their views are also in the report.
1.11 At the end of the process the reviewer was provided with an internal Police
management review of the Police response to allegations of abuse to the children

in the Q family. The findings from this have been incorporated into the SCR. It is
referred to as the Police Review below.
1.12 Independent Reviewer: Alan Bedford was asked by the LSCB to undertake this
Review. He has a background in child protection social work with the NSPCC,
where he was also national training manager. Following this he spent 18 years in
the NHS, the majority of the time as a CEO in Trusts and Health Authorities. He
now works independently as Alan Bedford Consulting on a range of issues from
infection control, to emergency health care, to safeguarding. From 2009-11 he
was Director of Safeguarding Improvement for NHS London, leading a London
wide peer review programme, and from 2009-13 was chair of the Brighton and
Hove Safeguarding Children Board. He has conducted many SCRs, is accredited
as a SCIE Systems Reviewer, and has completed the 2010 and 2013 national
training for SCR authors.
1.13 Anonymity: As described in 1.3 the LSCB believes it is important to preserve the
identity of the children. This Review will not therefore describe the family in detail.
Some facts may be altered a little to enhance anonymity. This is also necessary to
comply with the legal requirement not to publish the identity of victims of sexual
offences.
1.14 Agencies Participating: All involved agencies participated in the Review. These
included:
Isle of Wight Council:
Childrens Social Care
Youth Offending Team
Education/schools
Legal
Hampshire and Isle of Wight Police
Isle of Wight NHS Trust
Child and Adolescent Mental Health Services
Hospital services
Midwifery
Health Visiting
Isle of Wight NHS Clinical Commissioning Group
General Practice
Two surgeries
Hampshire Probation Trust
Portsmouth and Isle of Wight area
5

1.15 Report Structure: This report describes the history in Section 2, not in detail so
anonymity is preserved, but by describing the sort of family this was and the
impact it had on professional staff. Section 3 introduces the Findings, which
begin in Section 4 by an illustrated appraisal of practice.
1.16 There is a Learning and Why Section 5 which identifies the key themes of
professional practice and why those patterns of work occurred. It is in
understanding why that needed improvements can be identified. The Conclusion
in Section 6 summarises the learning, and answers the key question about
whether protection could have been quicker.
1.17 There are recommendations in Section 7 for the LSCB to consider. They are
addressed to the Board rather than each agency separately, given the Boards
collective responsibility for assuring the quality of child protection systems.
1.18 This report does not set out to describe and analyse each agencys contribution in detail.
This is to adhere to the planned intention to focus on what is most important in the story,
and for priority learning.

1.19 The following acronyms are used in this report:

A&E
ADHD
CAMHS
CCG
CPS
CSC
D
H
LSCB
R
SCIE
SCR
X
Y

Accident and Emergency

Attention Deficit Hyperactivity Disorder
Child and Adolescent Mental Health Service
NHS Clinical Commissioning Group
Crown Prosecution Service
Isle of Wight Council Childrens Social Care
A CAMHS worker
One of the children
Local Safeguarding Children Board
One of the children
Social Care Institute for Excellence
Serious Case Review
A non-family member now deceased
A non-parent adult family member

2 HISTORY and IMPACT ON CHILDREN AND PROFESSIONALS

2.1 This section describes what characterised the case, what professionals and the
children were faced with over the years, and the impact this had on them.
2.2 The family, which had several children, was characterised by continuous problems
which involved professional agencies, over the life time of those children. The
parental relationship was subject to numerous domestic disputes which included
violence, and many Police interventions. The disputes continued even after the
parents had split up and had new partners, and the atmosphere of conflict and
physicality was such that some of the children themselves became violent
between themselves, and with others outside and inside the family. The father
also had convictions for violence (often alcohol related, but not against his
children), and there was concern about over chastisement within the family.
2.3 There were concerns about the quality of parenting when children were young,
frequent A&E attendance including injuries when young, and concerns about their
failure to thrive. There were also practical issues such as housing where agency
help was sought.
2.4 The childrens behaviour was the subject of much medical/therapeutic endeavour
with diagnoses of specific behaviour disorders, although the cause was, in the
main, likely to be mainly the upbringing and modelling they received at home. At
least two of the children had youth offending problems, involving violence.
2.5 After the parental split there was much to-ing and fro-ing of children between
parents (with the children alternating which side they took), with little consistency
of care. There were child protection concerns about children in their parents new
families which are not the subject of this Review.
2.6 Over many years there were allegations that one or more or the children were at
the very least subject to a highly sexualised environment, or sexually abused or at
risk of such abuse, either through parentally uncontrolled access to a high risk
individual, or by a family member. Such suggestions of sexual abuse were
investigated on a number occasions over a decade by the Police and/or Childrens
Social Care (CSC) but with no further action conclusions, for reasons that will be
explored in Findings below. There was eventually a conviction in relation to a
number of offences against a child subject of this review, but the fact that most of
the allegations looked into led to no further action, created a sense in some
professionals that little could be achieved.
2.7 For two brief periods some or all of the children were placed on the Child
Protection Register, but most names were removed within months. The off-on
nature of the concerns was a characteristic of this case, especially for CSC, which
opened and closed the case of one or more children, or parental support, or took
7

referrals without further action, on numerous occasions. Reasons for the cyclical
nature of the case are explored in Findings below.
2.8 There were also tensions between agencies with, typically, health and education
staff having higher levels of concern about the childrens safety than CSC.
2.9 Over a period of nearly two decades, professionals have found dealing with the
family hard, mainly because of the volatile, aggressive and manipulative nature of
the father, and because of the turbulent relationship between the adults. Children
have taken sides, and then changed their minds, and allegations received about
their well-being were often unclear as the allegations appeared to be part of the
adult battles to prove each other the problem. One child told the Review that
evidence was withdrawn because of fear of retribution at home.
2.10 Staff have told the Review how daunting it has been to work with the family.
Paternal complaints about staff have led to several staff being changed, which had
another undermining effect on their confidence in working with this challenging
family. Staff have felt a degree of fear in face of such challenging and aggressive
responses. A Police officer noted that he felt (the fathers) volatility and anger
were such that I felt in real danger, as did my colleagues. Some social work staff
have described being harassed in a way that has been most uncomfortable for
them, and indeed quite unacceptable.
2.11 The author was struck by the strength of feeling in a number of staff created by
this case (and how it was managed) even many years after their last involvement.
A health worker could describe vividly how bad she felt knocking on the family
door over 15 years ago. In other workers, emotions still ran high sometimes many
years after last contact with the family. These feelings were of sadness about the
extreme plight of the children, and also frustration that little was done to intervene
for so long.
2.12 The children were of course the prime victims of the family dynamics and lifestyle.
They have witnessed domestic violence, and have often had to switch allegiance
from one parent to another. It is not possible to give their overall perception as
they vary in their public acceptance that anything untoward has happened to
them. But from a combination of official records, relative comments and
discussions the children had with the Review, there is little doubt that they
experienced a chaotic upbringing where heavy handedness and sorting problems
through violence was seen to be the norm. As they grew older, two of the children
had serious behaviour issues leading to considerable involvement with the justice
system for violence.
2.13 There was (at the very least) an over-sexualised environment around the home
quite inappropriate to their ages, and there was insufficient protection from known
risks inside and outside the family.
8

2.14 The children were at one time on the child protection register for emotional abuse.
They were the subject of, or the initiator of, numerous allegations of physical
and/or sexual abuse for over a decade, and in only one incidence was an
allegation proven, and that after the children had become Looked After. This
meant that at least for one, probably two, of the children there was a long term
sense of not being listened to or believed and their vulnerability to abuse not
stopped. At one point, the school said it was hearing almost daily accounts from
one or more children that suggested abuse.
2.15 It is also likely that one or more children were unable to adhere to original
allegations when formally investigated for fear of further abuse if they stuck to the
allegation.

3. Introduction to FINDINGS
3.1 Section 4 summarises the findings of the Review in an appraisal of how well
agencies worked separately and together over the period. This is not easy to do
as the case goes back over many years when organisations, procedures,
understanding, and expertise were different or developing. It could be wrong to
judge agency activity of, say, a dozen years ago by todays standards. On the
other hand, it does help to identify what needs to be in place now. The closer any
activity described is to now, the more one would expect it to approach good
current practice.
3.2 The appraisal is followed in Section 5 which looks at Learning and Why. This
elaborates more on the appraisal themes and identifies the lessons to be learned
for future action. (The Conclusion is in Section 6, Recommendations in Section 7
and an update from agencies on current progress in Section 8).
3.3 The LSCB believes it is not in the interests of any of the children involved for them
to be identified by this report, and where any child is a victim of sexual offences, it
would be illegal to do so. This means that at times there may be a lack of
specificity in this report, and that general conclusions are described.
3.4 The account and comment below does not intend to tell the full story but key
events.
3.5 It is for the LSCB to form a view on how widespread is any issue identified in the
Review. The Review identifies what can be learned from this case, and it is where
the Findings reflect patterns that are wider than this case that action should focus.

10

4. ILLUSTRATED APPRAISAL OF PRACTICE

4.1 Introduction: This section illustrates an appraisal of agency action over the
course of this case, and indicates whether children could have been protected
earlier. It needs to be born in mind that the events in this case covered a period of
nearly two decades, and it is not necessarily appropriate to judge practice some
time ago by todays standards or knowledge. The reasons why something was,
say, not good enough, are explored in Learning and Why from page 27.
4.2 This section does describe some detail in order to demonstrate the volume of
concern over many years, as the learning comes from considering the
accumulation of knowledge about the family against actions taken. The detail
given is still only a part of what could have been described. There is a deliberate
lack of clarity about family composition to avoid identification of the children and
other children in the wider family.
4.3 This section says what happened and comments on the quality of work. The
following section looks at why agencies and professionals acted as they did.
4.4 Actions and Appraisal: Across 2013, each of the children subject to this SCR
was made subject to a full care order, and are deemed as Looked After Children
by the Council. This process marked a firm, thorough approach leading to child
protective action. There were good multiagency child protection case conferences
through this process. There were comprehensive core assessments on each child
which marshalled together the events and risks over nearly two decades, and
accurately highlighted the current risks to the children. Appropriate legal steps
were taken by the Council to initiate care proceedings. The Police, after an
internal audit, had identified an insufficiently robust decision making about sexual
offences involving a child, and subsequently did charge someone who was later
convicted.
4.5 It might be argued that the court could have ordered the removal of some of the
children from their home earlier in the year than did happen, but the end result of
them all being protected allowed the children at least a chance of experiencing life
in a more stable environment. The key question is whether this could and should
have happened earlier and, if so, why it did not?
4.6 One or more of the children experienced: frequent attendances at A&E when
young, failure to thrive in early years, parental rows and violence (including
coincidental injury to a baby), violence between siblings and between siblings and
parents, violence to and from peers, over chastisement, physical abuse, sexual
abuse, severe behaviour problems (in some cases leading to Police intervention)
with associated heavy medication, exposure by their parents to adults
known/feared to be a risk to children and against whom most serious allegations
were made, ongoing parental disputes about their custody often played out in
11

private court hearings, and problems with education as a result of the chaos and
poor parenting. A Police chronology for 2009-13 alone had 94 entries relating to
the family, indicating the degree to which one or other member of the family,
separately or jointly, came to their attention. Could the helping agencies have
done better?
4.7 In the half a dozen years after the first child was born, the professional
involvement was about ongoing domestic disputes and violence (often involving
alcohol), consequential risk to the children, failure to gain weight, and numerous
A&E attendances, maternal mental health, paternal violence, and a number of
anonymous or neighbour referrals concerned about the children. The father, for
example, received a caution after the mothers arm was broken in a domestic
incident, and by 2003 had also been convicted for several offences of violence
and threatening behaviour. There is no evidence that in those earlier years,
despite the level of violence, and insecurity for the children, that a child protection
conference was any more than threatened.
4.8 Police and CSC were involved, but no record has been seen of multiagency
meetings to review the overall position. These should have happened. A pattern
began of making decisions on the evidence for criminal action, and if that was
deemed lacking, no other action was taken such as multiagency consideration of
registration, or an holistic assessment of what was going on in the family. This
also applied to CSC.
4.9 In mid-2002 there was a professionals meeting (a private meeting of involved
staff) concerned about frequent A&E attendances by the children, and by the
father who would be aggressive with hospital staff. (The father had also attended
A&E twenty times in a six year period, during which several children were born,
including for self-harm and post-fight injuries). Such a meeting was good practice,
and drew together known information, but did not involve the Police so missed
their (considerable) background knowledge. It recommended a core assessment
by CSC but it seems that was not done. A strategy meeting/child protection case
conference would have been a more proportionate action given the accumulated
concern. In the autumn of 2002, a hospital paediatrician, whilst continuing to draw
attention to more A&E attendances, implied that the explanations were consistent
with the injuries, which would have lowered concern. He also asked for a CSC
core assessment so must still have had concerns. Some of the parental
explanations of injury might have warranted more scepticism, especially given the
frequency of attendance.
4.10 A child protection case conference was eventually held in 2005, but the prior three
years had been very fraught. In early 2003, there were disclosures by two of the
children about inappropriate sexual behaviour by X (not a family member). At the
very least it was clear that the parents had not kept them from X despite being
made aware of the risks. Police and CSC related well in attempting to assess the
12

risks, but despite the family history and the potential severity of the allegations
there was no child protection case conference. With the children changing their
stories, and no corroborating evidence, again no action was taken. In the autumn
of 2003 CSC passed on information they had received about X to the Police, but
again joint work led to no action.
4.11 Fathers assurance that he would keep his children away from X was accepted
despite the fathers own erratic, aggressive and challenging presentation. This
confidence in the father was rather optimistic, and at a number of later points
when it was clear one or more children were being allowed contact with X, there
was no change of plan.
4.12 Even if the allegations about X were not true, the childrens graphic accounts
would suggest a sexualisation (at 5 and under) that would suggest something
rather worrying. CSC closed the case mid-year, and another pattern in this case
was of frequent closures once any sort of calm emerged, rather than assessing
the long term needs of the children.
4.13 By 2004/5 the attention was moving to behaviour problems of two of the children,
and child mental health services (CAMHS) and paediatrics were involved, but
parental cooperation was poor. Child behaviour then became associated with
inappropriate parental (mainly paternal) attempts to control. One such led to a
referral to Police, but judged not worthy of further action, and CSC kept the case
closed. By February 2005, CSC told CAMHS that family non-cooperation had led
to the case being closed as no present role. In the same month, the father sought
help from CSC with one child said to be running amok, but the next day the case
is recorded as closed. A few days later father says they will cooperate and the
case is opened again.
4.14 Two months later, there is a referral about over chastisement, and on a home visit
the social worker hears a childs suggestion that the father is using a belt on
another child, but also of sexualised games with one child implicating another
relative. Police and CSC looked at the chastisement together. The 2014 Police
Review concluded that the school/s should have been involved in strategy
discussions to help inform and plan the investigation. Two children were
interviewed in the presence of their grandparents, which was unlikely to lead to
any critical evidence about family members. The comment in the Police
chronology says This was not the original plan and was clearly recognised as not
ideal by the officer. The father was interviewed under caution, but the childrens
evidence was inconsistent and no further action was taken. Again, the
accumulated concern merited a full multiagency case conference to assess the
overall risks. In the early autumn, Police attended another domestic violence
incident, and found the home to be disgusting. Initial assessments of the children
did not lead to any new action. A month later there was an anonymous allegation
that the parents were abusing a child who had lower body bruises. A joint Police
13

/CSC interview led to disclosures by several children and the fathers arrest. The
Police Review concluded the arrest was good practice to ensure the children could
be interview without the suspects influence. As was often the case, the childrens
story changed and a pogo stick was blamed. A decision was taken to take no
further action on the basis of insufficient evidence.
4.15 However, it was good practice to hold the case conference at the end of 2005, and
both parents, both paternal grandparents and a family solicitor attended. This
scale of family attendance is exceptional and would have increased the difficulty of
professionals sharing all they knew, and the minutes show how much the social
worker was criticised by the family. The minutes do show a thorough sharing of
background, ranging from the fathers convictions for violence to various abuse
allegations, to the risks from X. All the children discussed were put on the child
protection register for the likelihood of emotional harm.
4.16 The conference conclusion was about a vigorous support package for the family,
and this was reported to be working well at the follow up two months later in 2006,
but registration was continued. (There was no Police attendance or report at this
conference). The next review was in mid- 2006, by which time the parents had
split, with the father, now with a new partner, retaining most of the children. The
conference (from which Police apologised) heard about the father allowing at least
one child (described here as H), access to X, despite commitments to the
contrary, and that X might be grooming children and parents. The children were
said still to be witnessing domestic violence, and that there was considerable
instability and a violent atmosphere. The Police had submitted a report on prior
convictions for the conference, but the details are not recorded in the minutes.
4.17 This conference, whilst clearly conscientious, and working well to try and plan for
the needs of each child, recommended an anger management course for the
father (presumably because he had not adhered to the same plan at the previous
conference six months earlier). Why it was believed he would comply this time
was not stated, a further illustration of undue optimism. Within a month of the
conference CSC referred to the Police, concerned about risks to the children from
domestic violence including threats of potentially life threatening arson. It was
agreed that the risks would be looked at by CSC alone as each particular incident
had been investigated by the Police, and also covered in private law family court
proceedings about the residence of the children. The following month CSC again
approached the Police when the mother alleged the father was allowing the
children access to X. It was agreed that only CSC would inquire into this as there
were no specific allegations of criminal offences. The Police Review, seeing that
information at the time included suggestions of X going into the childrens
bedrooms, concluded that the decision was not appropriate, and that this should
have led to Police inquiries, which that Review added would be done now under
current guidance in similar circumstances.

14

4.18 Optimism was shown again at a review conference in the autumn, where the
children were removed from the Child Protection Register as there was said to be
good parental progress, despite there still being concern about the children having
access to X, with the mothers written comments to this effect being shown to the
Conference. Indeed a Paediatrician wrote to CSC after the Conference and
described the minutes as optimistic. The pattern of health staff taking a more
concerned view of the childrens well-being at home became common in this case.
There was no mention in the minutes of a Police investigation into threats of
extreme violence from father to mother since the previous conference.
4.19 Within a few months, in early 2007, there was a joint Police/CSC look at an
allegation that the father (or his new partner) had assaulted one of the children,
but it could not be substantiated. A further three months on there was an
allegation that the same child had been unlawfully held by X and forced to make a
tape implicating several family members as having had sex with H. A month later
another child alleged an assault by X. A Police investigation led to no
corroboration as the childs evidence was inconsistent. Whether the tape or
allegations were true or forced, this was more evidence that the parents were
unable to keep children safe from either X or inside the family, yet there was no
multiagency meeting or child protection conference to consider the overall wellbeing and future of the children. This should have happened, as inability to
prosecute does not stop child protection through other means. The Police Review
again concluded that it would have helped if the school/s had been involved at the
strategy discussion stage. It also concluded that Xs premises should have been
searched. The SCR author concludes it was unwise to use the fathers parents to
accompany the child to the Police interview suite (though not in the interview)
given the taped allegation was against their son.
4.20 At the end of 2007 there was another allegation of paternal over chastisement of a
child. An investigation by CSC only was agreed. The Police Review says it should
have been joint with the Police given previous referrals of over chastisement, and
now it would be joint.
4.21 2008 brought further investigations that the father had hurt a child, but no further
action could be taken for lack of evidence. The Police Review says that while one
child was appropriately medically examined, it was a superficial investigation and
that two children should have had ABE interviews. There were more disputes
between the now estranged parents, and allegations and counter allegations
between them. A combination of the childrens known behaviour problems, the
long history of disputes, and inconsistent stories, meant that there was always
something to complicate any assessment.
4.22 In 2008-9 there was a pattern whereby professionals outside CSC were
consistently seeking greater CSC involvement, with the response being usually, in
general terms, that there was a limited or no role for social work. This led to
15

considerable tension between agencies which is analysed in Learning and Why

in section 5. In early 2008, a head teacher wrote to the Director of Social Services
and others on behalf of a professionals meeting which included teachers, social
worker, and a paediatrician, referring to almost daily reports about from a child
about incidents which suggest abuse. She referred to the longstanding nature of
the case, and high concern that the children were not registered and CSC was not
visiting regularly. The letter suggested that CSC were reluctant to get more
involved in case the father disengaged more. It ended and still the children remain
without support. CSC said there was no programme of visits as the case was
closed 7 months previously, pointed out that CSC had not been getting referrals
from the school, and that there were other organisations providing support. There
was no offer to explore the concerns, which seems inappropriate given by then a
12 year history of worrying events in the family, some quite recently,.
4.23 Through 2008 and into 2009 there continued to be allegations of possible physical
harm from the father, but also concerns about violence between the children. In
the autumn of 2008 a paediatrician, following another professionals meeting,
wrote to CSC asking for a case conference because of the escalating violent
behaviour of one of the children. It suggested removing the child from home for
stabilisation and to wean the child off extensive medication for ADHD. No
multiagency meeting was held in response to this accumulated concern. Generally
any agency should be able to ask CSC to convene such a meeting.
4.24 In early 2009, there were continued concerns by other agencies, and a
CAMHS/Sure Start worker (D) wrote on behalf of her and the paediatrician to CSC
seeking respite for child known here as H who was said to be the victim of
violence at the mothers home from a child relative and violence between child
relatives. The CSC replied to worker, and said that their view was that short
removals were not helpful and that working to improve the parenting was the right
course. As it was stated in the reply the case was currently closed, this was not
based on any current assessment, and participation in a new assessment was
rejected. Again, given the accumulated concern, some sort of new assessment or
multiagency assessment was warranted. The same CAMHS/Sure Start worker
wrote again concerned that the mother and partner were not cooperating, not
engaged with therapy, and so were being re-referred to CSC as she had had to
close the case due to that failure to engage. A case conference was requested.
The Early Years Team were also told the same day by D that the children were
deemed to be at risk of serious harm. There was no strategy discussion/case
conference.
4.25 Two months later, in response to a long email referral from D, concerned about
violence between children at home, and parental non-cooperation, CSC
suggested a common assessment framework (CAF) could be undertaken in order
to highlight any additional support needs of a child, about which there were

16

particular concerns. This might have been a reasonable suggestion had there not
been so many longstanding concerns.
4.26 On the same day that CSC received a referral from a neighbour about the care of
the children living with the father, D made a several page written referral. Ds
concerns included hearing disclosure from H about sexual abuse which the child
said had been reported to school, Police and CSC some years ago, but which D
had not heard mentioned before and needed to know if it had been actioned. D
requested an urgent assessment as the child was receiving inadequate emotional
support and was distressed by the disclosures. None of the advice D received
from CSC, when this had first been phoned in, involved any action by CSC.
4.27 The disclosure about sex with X, which H said was known by the father, was
reported to CSC in detail in the letter. The disclosure also referred to violence from
the father. D declined CSC advice to report the disclosure to the parents as she
felt this would put the child at risk. The letter was widely copied. A senior CSC
manager agreed to a meeting between D and a Team Manager. That meeting
took place and the following day there was a multiagency professionals meeting
called by the designated nurse for safeguarding. CSC, education, community
health and CAMHS were represented. All the children in this Review were
discussed plus others from their parents new relationships. The minutes said that
all the professionals expressed frustration at the lack of progress and intervention
available to reduce the negative circumstances on the children both physically,
emotionally and educationally. The meeting concluded that CSC should do initial
assessments and if these were not done, the health professionals would consider
calling a child protection case conference themselves. A senior education
representative at that meeting recalls being shocked that the social worker present
said, as the meeting commenced, that what those present said would be listened
to but it would not make any difference to the CSC position of not being involved.
4.28 A written response to that meeting 6 weeks later from a CSC social worker who
had done the initial assessment said that I do not share the view that H is at risk
of serious harm, and that statements made at the professionals meeting about
neglect, weight loss, poor presentation, and self-harm proved difficult to unravel,
put in context and still more evidence. However, it went on to say that clearly one
child had experienced sexual abuse in the past. If it was that clear one wonders
why protective action was not taken. The letter commented on another child in this
review and another child not the focus of this Review. The conclusion was that no
role could be identified for targeted CSC intervention and urged other agencies to
share concerns with the parents and/or CSC as they arise. This may well have
been the judgement of the social worker concerned, but a response from
someone more senior was warranted given the weight of concern expressed by so
many professionals. In the same month as the reply, and the next, there were
several disputes, some violent, between adults or children and adults in both the
homes of the separated parents, and Police were involved.
17

4.29 In the autumn of 2009 a professionals meeting of a wide range of NHS staff and
education (with apologies from CSC) met to discuss H following that childs
admission to a paediatric bed for observation around behaviour. Despite very
significant behaviour problems at home, none were seen on the ward. A
psychiatrist concluded that the behaviour issues related to environmental issues. It
was noted that, a few days before, H had disclosed sexual abuse which had been
reported to CSC. It was agreed agencies would make referrals to CSC about their
ongoing concerns.
4.30 That disclosure by H was of very serious sexual offence by an adult relative (not
the father) referred to here as Y. There was a thorough investigation by Police
which the Police Review described as very good example of good process. This
included the arrest of Y, but insufficient and inconsistent evidence prevented
prosecution. Again there was no multiagency child protection meeting to discuss
the safety and well-being of H which must have been in question simply in making
such allegations. Again, it seems that proving a crime became the yardstick for
child focussed protective considerations. Prosecution is only one means of
protection.
4.31 The following month children in the care of father were made subject to Police
Protection when the father was very drunk in charge of the children. He was later
convicted of assaulting Police in this incident, receiving a sentence that included
supervision by Probation. The home was said by Police to be a total mess and
filthy. The next month, December, a health visitor shared with CSC her difficulties
visiting the mother and partner (where H was then living) as she had been rejected
by them. She said she would keep trying. In January 2010 the case was closed to
the CSC Family Support and Intervention team. The reason is not clear.
4.32 In March 2010 there was, at last, a child protection case conference, the first since
2006. It was on H, and a sibling and step sibling also living with the mother. The
parents and three family solicitors attended - a degree of legal presence which
was probably without precedent. Isle of Wight Council legal services were not
invited to attend this Conference despite the large legal presence. From this
conference onwards Police attendance was regular. It was called due to an injury
to a step sibling eventually judged to have an innocent cause. There were also
concerns about Hs relationship with the mothers partner, and Hs emotional wellbeing in that household. There was no discussion about the children still cared for
by the father. All the children with mother were made subject to a Child Protection
Plan. It was good practice that H was able to give signed advance views to the
conference.
4.33 There was no invitation to Probation, even though they had called CSC twice to
obtain information to help prepare a pre-sentence report on the father who was
shortly due in court for assaulting Police when they attended the home of a
children related concern. Indeed this serious incident was not referred to in the
18

minutes at all. It might have been because the conferences, and the next two,
were on children in the care of mother, but such were the complexities of the
relationships that any risk related to the father should have been detailed.
4.34 In May 2010 the CPS decided they could take no further action with Y about Hs
allegations of sexual abuse.
4.35 The March 2010 case conference was reconvened in June as the mother and
partner had complained about the first one. It was appropriately arranged that the
father and mothers partner were not present for discussions of the other. It
referred to various private law court orders on which child lived with whom, as in
parallel with any professional concerns there were many private law hearings
initiated by parents to resolve disputes over residence and access. It
acknowledged that H had alleged sexual abuse by two perpetrators. H had
chosen to live with mother despite there being a residence order to be with the
father. H was still in treatment with CAMHS. All bar H were removed from Child
Protection Plans, with H to get social work support, and a re-referral to CAMHS. At
the conference the father said there were three sexual abusers of H not two, and
is recorded as having named the third. The Plan said H should have no contact
with Y until there had been a risk assessment by CSC.
4.36 At the June conference, the Probation Officer gave apologies, but submitted a
brief report. The fact that this answered none known to the proforma question
about any child related issues, and none known to the question about risk of
serious harm e.g. domestic violence, sexual abuse etc suggests limited contact
between CSC and Probation and their mutual client.
4.37 Shortly after the conference the father told the school that a child (described here
as R) had genital bruising from a fight with a boy, but shortly after had said that it
was caused by a bike. Apparently R had spent the weekend before with Y. There
is no record of a CSC or Police investigation despite the differing stories, or a
medical examination, despite Y having been recently arrested (later convicted) for
an offence (not with relatives) which might be deemed relevant. Differing stories is
a well-known indicator of possible abuse (See the CPS guidance described on
p35 below).
4.38 H was seen at school by a new social worker, and confirmed the allegation of a
very serious sexual offence by Y. H was on new medication for ADHD, and agreed
a referral to CAMHS to help deal with the aftermath of abuse. In the same month
the mother alleged a very serious historical offence by father, but Police could not
pursue as she did not follow up her complaint.
4.39 In September 2010 there was a further case conference on H, to consider if H still
needed to be on a Child Protection Plan. Hs bedroom at the mothers house was
said to be without door, equipment or furnishings. CAMHS had still not decided
how to respond to the referral. The conference decided to remove H from a Child
19

Protection Plan and move H to a lesser Children in Need (CIN) plan. It was
recorded that if H had access to Y then CSC should be informed immediately so
H can be protected. There was input from Probation who were supervising father.
Again, the earliest opportunity is taken to lessen the degree of oversight, which
was an example of agencies not taking a longer term perspective - which would
have indicated that nothing stays better for long with this family.
4.40 The CIN plan was reviewed the following month with no new major concerns but
on-going work on health, behaviour, education, safe sex advice. In December a
psychiatrist convened a professionals meeting, so they would all work together
closely around H. (No Police or Probation were ever invited to professionals
meetings). Also in December, Police were informed of father being heavy handed
in public with a child. CCTV was examined, but no one spoken to, or the child
identified, and no further action was taken. The Police Review described the
investigation as not being of an acceptable standard. In the same month Police
were called to a violent dispute between H and a peer. A further CIN review in
January 2011 focussed on Hs behaviour.
4.41 In February 2011, Police were called to the mothers home as H wanted to give
further information about the rape by X, that H had alleged in 2008. Police
records say CSC thought it unnecessary for the Police to do anything and CSC
would look at it alone. (X was by then deceased). The Police Review says that the
Police should still have obtained a full account in case others still alive were
involved. This event does not appear in the CSC chronology provided to the SCR.
Through the first half of 2011 concern was mainly around Hs behaviour but also
Hs allegation of violence against the mothers partner (where the Police judged
his constraint to be justified) and his counter allegation that H was harassing him.
H decided to move back to the father (fed up apparently from aggression from
other children at the mothers) and, appropriately, a risk assessment was done by
CSC of this. The father agreed not to allow H access to the alleged abuser Y. The
conclusion of the assessment was that concerns about the father were not
current. The fathers assurances about Y were accepted (even though his similar
assurances about X were not kept in the past).
4.42 In June, the mother spoke to CSC about her fears about her child R spending time
with relative Y, who by this time had been convicted of a non-family related but
relevant offence, and been the subject of serious allegations by H. She said R was
visiting Y alone. The father regarded the concern as harassment from his ex-wife.
The mother asked to speak to a manager as it was a child protection issue. The
next month the mother called again concerned R was spending most of the time
with Y despite his recent conviction. The mother was told that a previous social
worker had not been concerned about the contact with Y, so nothing would be
done now, and it was also Rs choice. When spoken to, R was angry with mothers
intervention.

20

4.43 Not long after this, father was arrested after his ex-wifes partner alleged he had
assaulted H, but the lack of visible injuries contributed to the Police decision to
take no further action. The day before H had reported a sibling to the Police for an
assault, and due to the siblings age the matter was left to CSC. H had disclosed
several incidents of the father being violent to her.
4.44 CSC did a core assessment on H in August 2011. There was no reference in it,
despite its main function being to look at how or whether H should stay with father,
to relative Y. A conference only a few months earlier had seen father restricting
Hs access to Y as very important. There was no mention of fathers convictions
for violence.
4.45 A Section 7 report was prepared the following month to advise the court during
private law proceedings (in this case the parents battles over the children). This
was a very good report, being quite clear about all the children suffering from
parental dysfunction. It refers to Hs disclosures, and says Hs behaviour
difficulties are not unexpected given it is likely H has experienced all levels of
abuse: sexual, physical, emotional and neglect. There was, however, no
reference to fathers convictions for violence, nor any contribution from Probation
who were supervising the father.
4.46 Given this clarity in the Section 7 report, it is surprising that by that point it was still
deemed acceptable for H to be with either parent. It is remarkable that the next
month CSC closed the case. With the court determining who lived with whom,
CSC records said There is no requirement for Childrens Service in this
process, and as there are no ongoing concerns of a child protection nature, case
to close.
4.47 H was by this time back with mother although father wanted to see H and there
were the usual disputes. H was also in regular trouble for violence, and had two
offences dealt with by the Youth Justice Team (YOT). The Police were involved in
a drunken brawl between father and partners ex-husband (no action taken).
Father was planning to sleep (in mid-winter) in the car with the children. The
children were taken to be cared for by Y, an interesting decision given the
allegations against Y. When CSC inquired, they found that child R was actually
residing with Y. After an Initial Assessment (which concluded erroneously that
alcohol had not been an issue historically) the CSC group manager decided that
the case should be closed again. The potential implications of Y and children
seem un-noticed, despite previous concerns. The fact that the notes say that if
there was repetition that child protection procedures should be initiated only
emphasises the strangeness of the decision to completely close the case. There is
though concern about mother and an impending new baby, but notes say she was
giving no cooperation.
4.48 The first few months of 2012 were characterised by disputes over where H would
reside, and H was back with father. In May, H was given a referral order following
21

an assault. YOT made contact with CSC mid-year, but were asked to consider
doing a CAF. A few days later Police contacted CSC concerned H was frequenting
a house where cannabis was used. CSC phoned the father - whose response was
mainly about not wanting H to see the mother. Police were also involved in relation
to R and a relationship with an adult.
4.49 In July 2012, R reported to Police an assault by Y. The Police investigation
decided that Y had acted reasonably in trying to restrain R. CSC was told but
there was no further action. In August 2012 CSC received a referral from worker
D, now with YOT, saying that H was living with Y despite Hs allegation of a very
serious sexual offence against Y, and asking for a CSC investigation into Hs
circumstances.
4.50 A few days later a child (not covered by this SCR) alleged that one of the Q family
children had been sexually abused in his and others presence by Y. The
allegation was also Y encouraging sexual acts between children/young people,
and engaging in sexual acts. Police told father that neither R nor H should go to
Ys house. After investigation, there was no Police action and indeed no question
put to the Crown Prosecution about the wisdom of prosecution as the Police
thought there was insufficient evidence to do so. Given the severity of the story,
even if later denied, this was not appropriate and indeed the later Police audit
ruled that the investigation was substandard, and re-instituted action. It is
unacceptable that despite all the previous history and concerns about child
protection there was no multiagency conference to think through what was
happening in the family given these allegations. The recent Police Review says
that during the first week what was absent was a coherent strategy between
Police and CSC which could have led to more joint inquiries into the various
allegations which included sexual abuse within the family. That Review also
thought Y should have been arrested rather than invited to be questioned
voluntarily.
4.51 The absence of any protective action was highlighted by a September agency
referral saying that the alleged victim in the August events described above had
stayed at Ys house. The CSC chronology says the child was strongly advised not
to stay with Y. There is no record of any action to keep the child safe, bearing in
mind earlier recorded concern about such contact by Q family children. At the end
of September 2012 Police become aware from the child that the child was still
staying over with Y. CSC were also aware of this from the child directly. CSC
decided to do an initial assessment. That this was not done until 12 days after the
YOT referral shows the priority given to assessing the risk to the child from Y
who was on bail for an alleged serious assault against the child. The initial
assessment showed no disclosures of concern.
4.52 Towards the end of October, R reported to Police wanting to stay with mother, with
R saying there had been sexually assaults by Y for over a year, and as recently as
22

the day before. Y was arrested. No forensic examination was deemed necessary
(clothes had gone in the wash), nor was there a medical examination but the
Police Review says it was offered and turned down. Police found Rs evidence
unclear and imprecise and R, they said, lacked credibility, so no further action was
taken and the case not referred to the CPS for a decision. The SCR has seen
what R actually said happened and it was quite specific, and also said to be a
daily occurrence at one time. There was to be a CSC Section 47 inquiry, but it is
likely that this did not happen as a temporary senior manager later could find no
record of it and instituted discussions and conferences which led to protective
action in 2013. Whatever the doubt about the evidential quality, what R described
indicated at the very least a most dysfunctional and over sexualised family and it
should have led to a strategy meeting and case conference - especially as
allegations against Y continued. Also, it was evidence that the father was not
keeping his children away from Y which had been a long standing requirement
(although not actioned when the requirement went unheeded).
4.53 The following month, the mothers partner reported that R was being bribed by Y
to drop allegations. Police spoke to R, and looked at bank accounts, and ruled the
suggestion unfounded. In December 2012, R told a therapeutic worker of a
sexual assault by Y, that there was an attack by father with a fork, and could not
understand why the Police did nothing. (That specific incident is not in Police
files).
4.54 Generally, the concerns about the behaviour of two of the children have not been
built into the above account which has focussed on child protection issues. In
summary, both children had been treated for ADHD, often with significant
quantities of medication. Both were involved in violence with each other, with
peers, sometimes with their father and were under the supervision of the youth
justice system. By the end of 2012 one had had a final warning, then a 6 month
referral order for assaults. The other had also had a Police reprimand, and a final
warning after both property and violent offences
4.55 2013 was the year during which the children were finally protected. The Section
47 that should have occurred the previous October commenced around the
childrens access to Y. A strategy meeting was held in mid-January, and according
to Police notes there was no apparent risk of serious harm requiring emergency
protection powers but there was discussion about how to prevent the father
allowing contact with Y. The day after the meeting a PC and social worker spoke
to the children at school and no confirmation of risk from Y was received so the
matter was left with CSC. The Police Review concluded that the matter was too
serious for only a PC to attend the strategy meeting given several recent sexual
abuse allegations. Eight days before the meeting R had told social workers about
sexual assaults by Y, and also relayed an incident about a sibling and Y that at
least hinted of inappropriate sexual activity.

23

4.56 Core assessments on the children in the review were commenced in the first week
of February 2013 and concluded in mid-March. In Hs, it refers to the high level of
possibility that H had suffered sexual abuse from Y not prevented by the parents,
and that H reported being sexually and physically assaulted by a number of family
members throughout childhood. It also referred to the suggestions of abuse from
X. It says that without change H would be at risk of a wide range of harm. The
assessments testify to the failure of the parents to provide any boundaries. Rs
assessment says the father will not protect R from relative Y. Whilst these reports
do describe the fathers behaviour they do not specifically mention his violent
convictions. A child protection case conference was recommended for H and
siblings. The assessments were very clear about the overall risks to the children.
This was good, and for a change was not based on whether any one allegation
was proven or not.
4.57 In the period leading up to the Case Conference held towards the end of March
2013, the childrens behaviour continued to create challenges and the family
disputes continued. In early February, the child involved in the events of August
2012 which led to Ys arrest confirmed being involved to the police.
4.58 Also, H told Police about being subject to a very serious sexual offence by Y
regularly through childhood. The Police chronology said that Hs disclosure did not
add to the case, no further action was taken against Y, and he was not
interviewed about the rape allegations. There were also allegations that two
children including R had been assaulted by father but an injury was found to have
been accidentally caused at school and no further action taken. There were further
altercations between R and father, ending with R being charged with assault.
There was another assault by R against a peer. There were also altercations
involving H.
4.59 The decision by the Police to take no further action was subject to a review by
Police internal audit and found inappropriate and there were concerns about the
standard of the investigation. The matter was looked at again by a Detective
Inspector, and as a result papers were forwarded to the CPS who subsequently
authorised the charging of Y (who was later convicted). The Police should be
praised for having internal audit processes which identified the need for CPS
involvement. In the view of this SCR, children who make repeated allegations of
the most serious nature should not be denied justice because in the past they
gave inconsistent evidence leading to no further action then. They should have
every opportunity to improve their evidence rather than just concluding that the
matter was dealt with before. (The Police decision is analysed in section 5). The
2014 Police Review quite rightly says that the Police will be making sure that
evidence is not overlooked now just because there have been earlier no further
action decisions. The Police have assured the SCR that if a victim denied an
allegation took place and at that point a decision was made that there was
insufficient evidence to charge, but later made a "statement" (or ABE interview)
24

that the events did take place (and particularly if it was explained why it had been
said otherwise in the past e.g. coercion), this would amount to additional evidence
and the no further action decision would be re-visited. This seems to provide a
good safeguard for victims who may not be able to give consistent evidence at the
time when still under the influence of perpetrators, but who later when freer feel
that they can.
4.60 At the case conference, H said the father had taken money in return for X having
sex with H. There was a good analysis of the risks, although whilst there were
references to numerous allegations, the minutes made no reference to the fathers
convictions for violence. All the children were made subject to a Child Protection
Plan for all four categories of abuse, with a conclusion that they all needed
placement away from home, with interim care orders to be applied for in the next
few days. The LSCB was to be asked if it should conduct a review of the case.
This meeting marked a turning point in the case as it was the first time there had
been a fully agreed conclusion that whatever the rights and wrongs of specific
allegations, the children would continue to be significantly harmed and needed
protection.
4.61 The council had already decided to issue care proceedings in relation to R, and
seek accommodation for H. The court (at a private law hearing), learning of these
intentions, ordered that any contact with Y prior to a Police decision about
charging Y should be supervised by the father. This seems to be a most
remarkable decision, given the fathers proven inability to protect the children from
Y and the allegations H and R had made against Y. When the interim care order
applications were made, the childrens guardian ad litem did not support the
council and the judge denied the application, presumably accepting the fathers
commitments.
4.62 The positive planning in the case conference, in the opinion of this Review, could
have happened months if not years before as the evidence of the childrens
overall well-being was not significantly different than at many times in the past. R
was placed shortly after the conference, as was H. The court initially refused for
other children to be moved to foster care.
4.63 Progress was looked at in a review case conference in June 2013. The father is
not prepared to stop Y having access to the children but he had agreed not to let
them stay overnight. It is not clear how this breach of the courts requirement that
he keep children from Y was dealt with.
4.64 After a review of decision making by the Police, Y was charged and eventually
convicted of a number of offences against one of the children.
4.65 Summary: Explanations will be looked at in Section 5 below. However this
Review concludes that protective action should and could have been taken earlier.
No abuse had been proven when the decision was taken in 2013 to seek care
25

proceedings on the children, so the absence of proof in the past is not sufficient
reason for not seeking protection before. The pattern that seems to have been
repeated over many years was that the inability to prove a criminal case led to
scrutiny of the family quickly reducing or stopping, rather than rigorous
multiagency assessment of the long term needs of the children. There were a
number of occasions when the inability to establish abuse should not have led to a
step back, but rather to an in depth study of what even the existence of such
extreme and at times sexual allegations meant about the family and the childrens
well-being. There were long periods without multiagency meetings to share
concerns and form such a conclusion.
4.66 There was insufficient focus on the overall life experiences of the children, but
rather a pattern of attempting to solve presenting issues sequentially. Not until
very late in the case were the issues around the childrens behaviour, violence to
and by the children, sexual abuse of children, parental dysfunction and noncooperation, and frequent un-proven allegations of abuse, put together into a
coherent picture about the physical and emotional safety of the children.
4.67 There were times when other agencies had major concerns but CSC decided
there was no role, despite considerable knowledge over many years of the chaos
and violence in the home/s and the impact of this on the childrens emotional
health and behaviour, which for two of them involved many offences.
4.68 At the time of the disagreements between CSC and other agencies about council
intervention there was no effective, senior enough escalation process to ensure
such disagreements were resolved at a high level. The Review has been advised
that such arrangements are now in place.
4.69 The Police were unable to obtain sufficient evidence (for charging) on any
allegations of sexual abuse against the children in this case until those that led to
Ys conviction, and even that was after initially deciding not to consult the CPS. It
is possible that that conviction might make it more likely that at least some of the
childrens earlier allegations were true, which raises questions about the style and
thoroughness of previous investigations.
4.70 The council should be praised for its work in 2013 to remedy the previous weak
assessments, and to initiate care proceedings on the children. The decision by a
court to leave some of the children at home for many months after proceedings
were started, and even require the father to be the protecting force for them
against relative Y, does not seem to have been in the interests of the children.
However, the Council legal department advised the Review this was in
accordance with current case law.

26

5. LEARNING AND WHY

5.1 Introduction: This section looks at what can be learned from this case and where
agency action could have been better, and why this was the case. It is important
to put what happened in a systemic context rather than looking at individual
action. The approach is to look at themes rather than an agency by agency
analysis, and to show the complex processes that impacted on decision making.
5.2 It was also decided in conjunction with the staff involved in the case and the LSCB
that given the enormous scale of the case that it would be better to focus on key
themes or turning points in the case than attempt to describe or analyse it all.
There will be a degree of repetition as some factors impacted in many different
ways
5.3 The Influence of the Father: (Although focussing on the father, the principles of
the learning points in here would apply to more than the father). The author has
found this to be the single most pervasive factor in this case. Many staff have
described how the aggressive and manipulative environment he created made
them most uncomfortable, and sometimes created real fear. The mother and a
child made similar comments. Para 2.10 described a Police officers sense of real
danger from him. CAMHS describe how the mother and partner were so angry
and abusive when a medical assessment determined a child did not need
powerful medication for behaviour issues that it was judged not safe for them to be
seen at the CAMHS office. A sense of impending violence can be a very
paralysing factor for staff. Although only actually violent to Police, staff have
described what can only be described as harassment and intimidation even whilst
this Review was underway. The father had a number of convictions for violence,
often when in drink, and on one occasion had been cautioned after his wifes arm
was fractured. The Police were called to numerous incidents of domestic violence
and family disputes. He had frequent A&E attendances for fight related injuries
and self-harm.
5.4 He had a legalistic and complaining approach, so that for example case
conferences were appealed on more than one occasion. Lawyers were brought to
conferences. A number staff had to be reallocated away from the case after his
complaints, and the expectation that they might be next undermined the
confidence of other staff. Also, the fact that no allegations against the father in
relation to the case were ever proven (other than an assault on Police) built a
sense of untouchability that also undermined confidence.
5.5 At case conferences, he would take advantage of the proper involvement of
parents in such deliberations to hector staff and even tell children present what
they should say. It is likely that many of the times where allegations against him
and others were unproven that he instructed, through fear, the children to say
what he wanted them to say.
27

5.6 Scrutinising the minutes of key meetings (where that father was usually present
and at times with legal back up) it is a hard to see a very focussed analysis of his
role. At many meetings there seems to be no reference to his convictions, little
reference to his serial non-compliance with previous conference requirements (or
even signed agreements), but more attempts to keep going as if something would
change. (This is analysed further in overarching themes below). What is also
interesting is that where there are assessments that read damningly of his (or
parental) capacity the decisions do not seem to reflect the power of those
statements. (From 2013 this changed- see 4.54).
5.7 Over the years, there was hardly any evidence of him cooperating with
professionals, and no evidence of him taking active steps to protect his children
against those he knew to be a risk. When, for example, he did not keep children
away from X or Y there were never any consequences from the authorities. The
situation was complicated by a veneer of respectability that he and Y had which
seemed to provide a protective wall around him.
5.8 More than just non-cooperation, other than for very short periods there was little
sign of the childrens lives ever improving, or at least two of them being kept safe,
yet he managed to persuade courts that he could be a protective factor for them.
This was despite evidence over the years of him openly defending abusers, or at
the least refusing to acknowledge potential risk.
5.9 Why did this situation carry on for so long? There are many answers to this some which will be seen under other headings in this section - but at its simplest,
aggressive men who are manipulative, argumentative, serial complainers etc do
have the capacity to undermine professional assessment, decision making and
action. In many walks of life, similar men get away with things that seem in
hindsight inexplicable. One senior social worker speaking to the Review said, He
creates a lot of self-doubt, so staff feel they are incompetent. A very experienced
social worker who was involved in removing the children from home said, It was
the most frightening removal I have ever done.
5.10 There is reluctance in professionals, who rely on a relationship with family
members and cooperation from parents in the interests of children, to be too
authoritative and controlling in case it damages that relationship. And when
firmness is tried, it is countered by a barrage of complaints, legal defences and
implied threats which deflects the attempt. This can only be countered by the
highest quality supervision and support of staff so that their fears and concerns
are understood and addressed, by high quality appraisals of parental functioning,
and decision making meetings where the presence of the parent does not diminish
the depth of analysis as seems to have been the case here.
5.11 There was also an issue with the continuity of knowledge, as the case was open
and closed many times, as workers were changed, and in long periods (such as
28

before December 2005 , 2007-9, and 2011-12) there were no meetings of the
status of multiagency case conferences. The Review has seen how such meetings
and others might not mention the fathers violent records, or to past sexual abuse
allegations, and when the staff group met to discuss the case for this Review there
were some who were surprised at what they did not know. CSC did keep a
running chronology throughout most of this case but one wonders how often it was
scrutinised as its growing story is one of great concern.
5.12 One child, the victim in many of the allegations of abuse, described being unable
to stick to evidence on those allegations about several alleged abusers for fear of
the fathers wrath. The fear created prevented evidence which might have led to
the protection of children and so the non-protection continued. (The fathers view
is that the allegations by the children were false and made at the instigation of
their mother in order to get at him).
5.13 Many SCRs have written about fathers who are under the radar, insufficiently seen
or understood, and whose risks are never grasped. This case is different in that he
was very upfront, known well, very involved (if not co-operative) and there was
more than enough knowledge, if pooled, to know he was unreliable, violent, unprotective of his children, and so on. The likely reason for him being able to retain
control of his children (or at least those residing with him, but often the others) was
a combination of
i. his manipulation and grip over the children resulting in inadequate evidence
on allegations;
ii. his ability to undermine the confidence of staff; his forceful presence at key
conferences preventing more realistic assessments, and where assessments
were more accurate, a sense that nothing much could be done;
iii. the lack of any high level stepping back and looking at the case coolly and
dispassionately over history, and instead dealing only with the current
challenge;
iv. the absence through most of the case of any in depth analysis of his capacity
as a parent and the risks he posed.
It should be pointed out that the fathers overriding sense was that his frustration
was created by social work staff not listening to his point of view, and not taking
seriously enough his concerns, for example about one childs serious behaviour
problems, or the difficulty he says the mothers emotional well-being created for
him.
5.14 Given the fear and anxiety he created it is surprising that that there is no record of
any meeting where a corporate plan could have been created to manage
relationships with him. This might have benefitted both staff and children, and
created a structure for him. One social worker told the Review that around 2006
the father used to phone many times a day and this was unmanageable, and the

29

father was set a limit of one call a day which was largely heeded. This was good
practice to provide some boundary to contact.
5.15 This section has focussed on the father. There were other adults in the wider case
who also created difficulties for staff, if not of this magnitude. This is not described
here for two reasons. Firstly, to make the scope of this review manageable it
focusses on the core family. Secondly, to describe more than the core family
increases the likelihood of identifying children.
5.16 The summary learning points are:
Fathers with such personalities as this one, can have a debilitating impact on
case management
Staff must feel free to share their feelings about working with such families
and expect support
Those providing management and supervision, especially in CSC which runs
the multiagency meeting, must be aware of the potential of aggressive fathers
to undermine confidence and objective decision making
Those providing supervision and quality control of cases must check to see
that assessments and decisions fit the evidence accumulated over the years
Agencies should have formal processes for agreeing how aggressive parents
are managed to ensure the safety of their staff
Review meetings/conferences should always be reminded of historical risk
factors, and not assume those present will all be aware of them
5.17 Managing Different Views on Risk: In the Illustrated Appraisal of Practice
above, a key period in this case was described whereby CSC and other agencies
took different stances about the need for council action or intervention. Education
staff who saw children daily and health staff who were addressing the childrens
emotional well-being and behaviour communicated formally in writing on a number
of occasions in 2008-9 seeking CSC involvement and sometimes child protection
case conferences. Their concerns, from the evidence seen by this review,
seemed well founded given what they saw of and heard from the children, the
serious behaviour problems, the parental discord and lack of cooperation, violence
between children and daily disclosures of abuse. One letter on behalf of medical
nursing and mental health staff referred to the children being at risk of significant
harm, and, at times, are experiencing significant harm. Another letter described H
repeating the allegations of being sold for sex by the father, and having to have
penetrative sex with X. A number of the letters were copied up to Director of Social
Services level.
5.18 The responses from CSC took the stance, in general, that there was no role for
CSC, no specific allegations had been made other than those that had been
investigated, why not do a CAF, and ignoring request for case conferences. The
fact that where there had been investigations, no further action could be taken,
would have raised the sense that nothing could be done.
30

5.19 The impact of this on the referring staff was significant. One head teacher told the
review that at the time they had a sense of being completely let down as a
schoolno one wanted to pick up the case...a real sense of issues not being
taken seriously. The head teacher also added that at the time (2008) this was a
general issue with other heads beginning to feel there was no point in referring to
CSC. Another senior teacher recalls feeling blocked.
5.20 This Review concludes that there was indeed little that could be done to improve
the lives of the children in their then home environment, but the response to this
should have been for CSC to hold the ring while there was the best possible
assessment of what would need to be done to protect the children and not
standing back. The childrens overall welfare was a different issue than whether
specific allegations were found to be true.
5.21 Such tensions about the thresholds in CSC for taking on work are not uncommon,
and need to have a clear escalation process in place to resolve disputes. The
Review has been told that such a process is now in place but then it was not. Staff
interviewed have acknowledged that there were limits to how hard or high they
pushed up the line, and indeed a number conveyed a sense that they didnt know
what to do or who to speak to. Given that the strength of those concerns 5-6 years
ago was still felt in 2014, it is interesting that neither the NHS Trust executive
director for safeguarding (then a statutorily required position) nor the CEO was
brought in to raise matters with counterparts in the Council.
5.22 It was not just that the case might not meet the threshold. One school recalled that
when the school tried to refer Rs serious behaviour problems to the CSC early
intervention team, the response was that R was beyond their help, yet nothing
else was offered.
5.23 Why were there these problems with CSC? It would appear from discussions with
a CSC manager at that time, that it was likely CSC saw the referrals as vague,
looking at issues explored before, and where little practical could be done. The
Review was also told that at the time of this dispute specific allegations would
always be looked at, but there were high vacancy rates and due to the frenetic
nature of the work, there was a clear difficulty in being able to stand back and
reflect the service responded reactively when having to balance competing
priorities ... although not an excuse it was the reality of working in that pressured
environment.
5.24 Ofsted reported in early 2013 on the adequacy of council safeguarding services at
in inspection in 2012 and found them inadequate. This report referred to a 2010
LSCB finding that in most child protection cases, assessments of risk were weak
and child protection plans were poor or incomplete. The inspection found that no
significant progress has been made in those areas. For example it concluded that
in 2012 the effectiveness of help and protection provided to children, young
31

people and their families is inadequate. Despite a clearly outlined thresholds

document, the initial response to referrals is variable, lacks consistency of decision
making and fails to correctly identify risk. As a consequence not all children are
being correctly identified as at potential risk of harm, they are not always being
protected and in too many cases their needs are not being responded to in an
effective and purposeful way.
5.25 At a previous inspection, in 2010, Ofsted concluded that risk and protective factors
were not always clearly identified. Some assessments contained insufficient
information to make effective decisions or plans. For example, some assessments
were closed prematurely leading to further contacts being made soon after case
closure. It added that the frequency and quality of recording of supervision were
inconsistent, supervision was not providing appropriate challenge to the quality of
casework and the professional development of some staff. Decision-making and
effective planning was not sufficiently well evidenced in case records. A social
worker who managed the case for a time said that the degree of risk could be lost
as new staff taking over a case would not have sufficient time to study past
records very thoroughly, and that time for cool dispassionate review of progress
and risk was hard to come by.
5.26 It is likely then that weaknesses seen in the year or two before the 2010
inspection, and later, reflected a department that needed considerable
improvement. These issues have been widely publicised and are being addressed
through special measures and the oversight of Hampshire County Council, and
need not be repeated in this report. However the learning points remain to check
against current performance.
5.27 The summary learning points are :
The need to ensure that robust escalation processes are in place, and
understood and used by staff when there are concerns between agencies
about the quality of responses
Requests from staff in other agencies for child protection case conferences
should normally be accepted
Even if there appears to be a good reason not to accept a particular referral,
CSC should regard repeated referrals/conference requests from multiagency
sources as needing further understanding, especially when there are clearly
stated concerns about child safety
Investigations that do not prove offences do not necessarily in themselves
prove that children are safe, or that their development is not being harmed
5.28 Single Issue Thinking: This was identified at the staff group meeting as a theme
that beset this case, and has been mentioned above already. The pattern seen is
that with a family that is constantly throwing up challenges, the specific challenge
is addressed rather than what that challenge means for the children in the longer
term. Before the parents split, there were numerous Police attendances for
32

domestic violence. Each was assessed and dealt with in its own right, and mostly
referred on appropriately to CSC. But if the incident was resolved (calmed
down/no offence proved etc) then the basic question of ongoing child physical and
emotional safety was rarely addressed. The mother described this stop start
approach very clearly to the Review. The same applied to extreme behaviour by
the children, so the issue was whether the behaviour had been addressed
(doctors/medication/containment etc), rather than why are these children behaving
so badly and can the parents affect the change needed? Later their offences
focussed things more on them than their family.
5.29 When the health staff were involved to address psychological/behavioural issues,
that was seem as the solution, with no role for CSC, despite only CSC having
legal authority. When health staff challenged this there were barriers created by
the quality of CSC organisation, as described in 5.25 onwards.
5.30 This pattern was also seen over many years in relation to allegations of neglect,
physical abuse and sexual abuse. As has been illustrated above, allegations were
normally explored but never proven until Ys conviction (for reasons explored
below). It was not until 2013 that there was any appreciation through formal
multiagency process, as in the fourth bullet of 5.27 above, that being unable to
prove something beyond reasonable doubt does not mean there is nothing of
concern, nor that the children have been other than deeply affected. Any
retrospective look at the history screams this out, although it was clearly not
obvious to everyone at the time.
5.31 The fact that the case (in reality several cases due to the parents split and
reconstituted families) was closed so many times, despite very serious events
sometimes adjacent to these decisions, illustrates the lack of long term focus. The
closures were by CSC which did not see a role, and by health agencies due lack
of family cooperation.
5.32 Why did this happen? There seem to have been a multitude of reasons,
interacting on each other. As the father challenged every allegation so vigorously
and with such impact, it is likely there was a degree of relief when investigators
could move on. There was also a view, amongst some, that the allegations
reflected disputes between adults who used allegation and counter allegation to
prove their supremacy in any argument, rather than them being true. The no
further action conclusions to Police or CSC investigations also provided a reason
(justified or not) to cease involvement when priorities had to be made by CSC.
5.33 Staff also identified that as the case was so difficult, there might be a sense of
relief and lets move on when a particular referral event was found not to be
proven as that was one more challenge out of the way. They also identified the
lack of opportunities to stop the clock and review the whole case and what it
meant for the children, given pressure of work.
33

5.34 The pattern of taking a short term issue focussed approach, rather than the bigger
picture, is further evidence of the weaknesses in supervision and lack of
opportunity for deep reflection described above.
5.35 The summary learning points are :
The need for a long term perspective when so many short term problems are
posed by a family
The need to regard chronic issues as important as the single dramatic event
The need for time to reflect on the meaning of events (even if disproven) on
childrens physical and emotional well-being
The need for robust supervision to identify, and to support/challenge, staff who
do not look at the bigger picture
5.36 A&E Attendances: There were high levels of attendance when the children were
young many years ago. There might have more suspicion about some injuries,
but it is only with hindsight of later events that some look particularly worrying and
it would have been hard at the time to prove this. The SCR is satisfied that there
are good processes in place now for spotting frequent attenders and child
attendances that need wider professional involvement. Indeed much of this was in
place many years ago. At the time good processes led to a multiagency meeting
to discuss the situation which was concerned about parental health and capacity,
child development and neglect (seeing some of the accidents as preventable).
However there is no evidence of the recommended core assessment and there
was no further multiagency meeting for three and a half years despite many
corroborating concerns.
5.37 Management of Allegations: Other than the conviction of Y, no allegation of
abuse about any of the children subject to this Review has been substantiated
over a period of at least a decade and a half. This is whether it was related to over
chastisement, neglect, assault, being forcibly held, or sexual abuse, whether
against family members or non-family members and whether investigated by CSC
or Police or both. If suggestions of domestic violence, referrals from concerned
neighbours, disclosures by the children (including those repeated when earlier
investigations had led to no action) and allegations from one parent are
considered then there at least 35 occurrences which did not lead to any formal
action. Several of these were very serious allegations of sexual assault. Some of
the overall number may have been false, some would have had little evidence,
and some might have been vexatious suggestions. However, even the allegations
that led to Ys conviction were initially not even referred for a CPS view by the
Police, and it was only a (good practice) internal audit of a random number of
Police investigations into offences against children and young people that led to
the conclusion that the investigation could have been better, and that the decision
should be reconsidered. The scale to which family, children and public concerns

34

were found unsubstantiated requires this Review to see if there are lessons to be
learned.
5.38 Why did this happen? Investigating possible offences was never easy. The
evidence was often contradictory, or not repeated in formal settings. It is very
likely that the children were under great pressure within the family to withdraw or
change disclosures, or to side with whichever parent held most sway at the time.
This is a very well-known possibility in familial abuse, and it is the opinion of this
Review that insufficient thought was given by agencies to this, especially that it
was quite clear that the father was a manipulative, frightening, violent man. To
balance this, the 2013 CPS guidance1 on disclosure and evidence was not in force
in the period under review. This guidance makes it clear that such contradictory
evidence may well be a sign that supports the likelihood of sexual abuse having
occurred, and does not rule out taking such cases to court so that the court can if
it wishes decide between versions of a changed story. It is likely that had this
guidance been in place before 2013 then the childrens difficulty in giving
consistent evidence would not have been such a barrier to action.
5.39 The 2014 Police Review also described changes in the law in 2004 about when
reasonable punishment can be used as a defence by parents, and how in this
case there seemed to be some uncertainty about how to assess cases alleging
excessive parental force. That Review recommends that the Hampshire
Constabulary issue additional guidance to investigating officers regarding the
investigation of parents using excessive force to punish children.
5.40 The childrens behaviour issues and communication limitations also made it hard
for their evidence to be seen as convincing, but this could have argued for them
being interviewed in even more specialist ways rather than their accounts put to
one side. The scale of allegations and some of their extreme nature in terms of
sexual assault, would strengthen this need for the very highest level of skill being
applied to discussions with them. Achieving Best Evidence (ABE) interviews were
used in some inquiries and some allegations could be seen to have been
thorough. One investigation was described by the Police Review as being best
practice but there were instances of children being interviewed at home, or in the
presence of the father or other involved relative, when making initial inquiries
about the need for more in depth work. There were also instances where children
made a repeat allegation, and because the initial allegation had been discounted
the Police left it to CSC alone to talk the child concerned as it was an old
allegation. Whilst it may have indeed have been old, there is no sign in the files
that CSC or the Police were considering the possibility that the repeat allegation
may have been because the child was indeed a victim and was desperate for
justice to be done. The risk these children took in repeating allegations about

Guidelines of Prosecuting Cases of Child Sexual Abuse. CPS 2013

35

adults they lived with or saw regularly was high, and would not have been made
lightly.
5.41 The Police Review also pointed out that on several occasions the agencies
consulted in strategy discussions/meetings were too narrow which led to
information that might have helped investigations be better was not heard.
5.42 The decision not to initially refer the allegations (which were eventually subject to
a conviction) to the CPS, was changed after an internal Police review, but the
senior officer who made the non-referral decision did so because, he said, in his
experience the level of evidence was similar to that which he felt would have been
turned down in the past. The Police review also concluded that the decision not to
refer reflected their perception of what the CPS might be seeking. At the time the
CPS did not have the chance to consider the evidence so one cannot conclude
what the outcome would have been.
5.43 Until considering submissions for this Review recently, the Police had no plans to
revisit the most serious previously unsubstantiated allegations by the children
against Y following Ys conviction, but there are now plans to explore this. The
Review strongly supports this, so that at the least the childrens voice can be
heard, even if formal action is deemed still not possible.
5.44 The 2014 Police Review has looked at detail at most of the child abuse related
investigations (not domestic violence, or other crimes) and has given a frank
appraisal of the process of work with the Q family. Its appraisal of investigations is
reflected in the previous paragraphs. It is not clear from the Police Review why
there were problems with the quality of work with this case. The Internal audit
which identified the inadequate decision making about the investigation of Y did
not, according to the Police, identify similar issue in the other cases reviewed.
The Police Review conclusion and recommendations are in Appendix 2.
5.45 The summary learning points are:
The need to be very aware of the possibility of intimidation of children by
relatives when disclosures are made
The need to tailor investigations to any likelihood of relatives attempts to
intimidate children
The need to use the new CPS guidance to test in court evidence that might
have some vulnerability
The need to strongly consider the meaning of repeated disclosures by children,
even if a prior investigation had found those disclosures unsubstantiated
The value of internal case audit in establishing the quality of work assessing
abuse inquiries
The need to be clear about the current laws on excessive force/reasonable
punishment
36

5.46 ADHD: Two of the children were diagnosed with, and treated for, ADHD (attention
deficit hyperactivity disorder). Prescriptions for medication came from hospital
paediatrics who worked with CAMHS. The parents, according to a psychiatrist,
were pushing so much for medication, and were very threatening and
aggressive when denied it. This came after an admission to a paediatric ward
where a child was not seen to demonstrate any of the behaviours seen while living
at home. A paediatrician also spoke about the tension felt between the pressure
from parents for more medication and concern that too much was being
prescribed.
5.47 During this period there were tensions between clinicians about the best way to
treat ADHD, and the balance between environmental and genetic causes. An
audit showed that children were being given antipsychotic drugs (which have
strong side effects) at a very high level comparatively, and for a while joint clinics
between CAMHS and paediatrics were paused over this. Relationships between
CAMHS and paediatrics are now stabilised, with new dedicated medical
leadership on ADHD, and antipsychotics are only given with joint agreement.
There is also a 2013 Shared Care Agreement between general practice and
paediatrics on the use of medication with for children with ADHD.
5.48 This Review is not the place to discuss in detail the differing views around the
nature and meaning of ADHD or the debate about its treatment. It is hard to say
whether the varying views between clinicians about ADHD treatment had an
impact on the children concerned, and whether the medication regimes were
helpful or not. What is relevant is that going forward there needs to be a shared
understanding between agencies about appropriate care pathways, and especially
the balance between medical treatment through medication, or through therapy,
and work more focussed on the family/social environment. In 2008-9 when there
was tension between other agencies and CSC described in 5.17 onwards above,
it was seen that CSC did not see a role on the family/social environment side, and
saw the health input as the answer. It has been put to the SCR that CSC could
now have more understanding of environmental factors and their role in behaviour
disorder, rather than seeing the solution as mainly a medical one. However, there
is still an NHS view that CSC does not yet appreciate how significant their role
needs to be in the tripartite work across health, education and social work.
5.49 It does have to be pointed out that the parents were not cooperative with health or
CSC. For example a 2009 paediatric note said that neither parent would
undertake Managing Challenging Behaviour or Parenting Support programmes.
Interestingly the mother told the Review that what was needed was programmes
like those, so it is possible that the objection was just the fathers.

37

5.50 The two children, speaking with the Review, were generally positive about
CAMHS and also felt they could not do without the medication prescribed by
paediatrics.
5.51 Meetings: The Review has not researched each meeting in detail, but some
themes emerge which the LSCB and agencies can check against current practice,
to see if the themes could repeat now. The LSCBs website says much of the
guidance around case management is under review so it may be timely to
consider comments from this review.
5.52 Calling a Child Protection Conference: There are two issues: not calling one when
it would have been a good thing to do, and not convening one when agencies
strongly request one. This SCR has already described how there were no such
conferences such as before December 2005, and from 2007-9, and 2011-12. In
each of those periods there were events which seem to be of considerable
concern. On a number of occasions, there were investigations into quite awful
allegations/disclosures which led to no further action, and it is the authors view
that these events (especially when taken together with a relentless history of
problems for the children) still indicated something seriously wrong. It is a strong
theme of this report that not being able to meet the threshold for prosecution does
not negate the need for strong review of family functioning in a child protection
context. This comment does not mean that there is a prejudgement that abuse
has happened whatever the conclusion of an inquiry, but that the meaning of
events for children should have been much more strongly considered. The author
can see nothing in the procedures which says a conference cannot be called in
such circumstances. The result in this case was often long periods with no formal
and widely attended multiagency meetings.
5.53 The other issue was about not calling one when other agencies ask for one. The
Isle of Wight procedures (shared with three other LSCBs) give, in the authors
opinion, too much authority to CSC. The current procedures, based on the 2010
national guidance, do say that CSC should strongly consider any request from
other agencies. And if differences remain it should be resolves between the
respective agencies LSCB representatives. The Review has not heard of any
such use of such a process and the LSCB must make it clear this arrangement
can be used. Additionally, the author suggests that if still no agreement the LSCB
independent chair should decide.
5.54 One implication of the lack of meetings for long periods is that, according to a
senior NHS child protection adviser, NHS staff might not know about referrals to
CSC that were open and closed quickly, so were unable to contribute any
background information.
5.55 Strategy Meetings: 5.46-48 above discusses child protection conferences, but
procedurally these should follow a strategy meeting or discussion between key
38

agencies where the need for and nature of any prompt action or assessment is
determined. The Review saw hardly any reference to strategy discussions in the
files, so in most cases it is likely that where this Review has said there should
have been a multiagency conference there was no strategy meeting either. This
means that on those occasions there was no formal process with other agencies
to mull over the best way forward. This could mean that, for example, when CSC
turned down an education/health request for a conference, there might be other
referrals coming into CSC around the same time of which the education/health
referrals were unaware.
5.56 The Police Review of June 2014 says that it highlighted the importance of strategy
discussions and meetings in planning joint investigations, and identified the
importance of inviting agencies in addition to Police and CSC if they are likely to
be involved in the investigations, especially referring to schools. The Police
Reviews recommendations are in Appendix 2.
5.57 Parental Attendance: Whilst it was good practice to ensure parental invites to
conferences, there is little evidence that the discretion to exclude relatives, notably
the father, was used. There was an exception in 2006 when both parents were
asked to leave due interruptions and disputes which were not helpful to the
conference. Given how staff have described his oppressive stance, how he would
tell children what to say in meetings, and that he was subject to a number of
allegations, it would have been better if there had at least been some time at
conferences when agencies could pool their views as frankly as they wished. The
procedures say that exclusion should be rare, but this may have been one of
those cases where the degree to which staff felt daunted should have led to some
discretion being used. Even in conferences where the minutes seem to describe a
very open discussion, parental presence might have impacted on what meaning
staff were prepared to put on that information. It may well be, with conferences
being appealed, parents inviting solicitors, and the fathers persistent complaining
that there was some reluctance to stimulate more of this by persuading him that
his absence might be in the childrens interests. Decisions here are difficult
judgement calls, and staff should be encouraged to make it clear to conference
chairs when they think it would be in the childs interests to have at least some
time alone with other professionals. The Review saw some good illustrations of
gathering childrens and parental views before conferences.
5.58 Professionals Meetings. In 2002, and 2008-9 there were several professionals
meetings. These do not seem to be part of formal procedures and consisted of
multiagency staff (never Police) who met to discuss the case. It seems likely from
interviews with staff that they were convened as a way of achieving two things:
being able to have a frank discussion without family members, and to gather
information which could be used to press CSC into action. The notes sometimes
indicate that the social worker present shared the view of other professionals

39

there, but a different stance would be taken by say a CSC team leader on hearing
the recommendation of the meeting (usually to say no).
5.59 The Review has two comments, accepting that getting together with colleagues to
discuss a case is a good thing. Firstly, if such meetings are being called to get
round another process which is deemed not to be working, it would be better to
escalate the issue so that the process is put right. Secondly, if professionals do
meet and with their combined skills and expertise come up with clear
recommendations, then those receiving those recommendations should start with
an assumption of their validity. In this case had the views of those meetings in
2008-9 been more heeded it is possible that the process leading to the childrens
protection would have started earlier.
5.60 Consistency of Information: It is hard to track through conference minutes what,
for example, was or was not known about the father as only rarely is his history of
convicted violence recorded. This may have been either because of the heavy
parental involvement, or might have been an assumption that everyone knew
because of some prior reference. At the staff group it was clear there was a range
of knowledge about risk factors, and some were surprised when the history was
clarified. Some were also not clear about the background of sexual abuse
disclosures. It is important, with allocated staff changing, new services becoming
involved, and with some only seeing minutes, that care is taken to ensure the
multiagency team know what they need to know.
5.61 GP attendance: The Review has seen notes of nine child protection conferences
between 2005 and 2013. At none was there a GP present or any record of a
report from the GP. Indeed in the three 2013 conferences there is no minuted
indication of any GP being invited. The Review met with the two main GP
practices and they had a good record of relevant parental health, and of the
childrens treatment for ADHD, so could have contributed even if in writing. It
would appear that conference decisions were made without GP input which
should have been actively sought if not forthcoming. GP records did show that
minutes were received and read.
5.62 Why were the multiagency processes not used more? There was a circular
process by which CSC, in not believing that allegations were proven, or that there
was an ongoing role for them to fulfil, also determined that such multiagency
meetings were not needed (not always but for substantial periods). In not getting
together, opportunities to pool everyones views were lost, and nothing changed.
5.63 Secondly, the procedures are rather event based, and emergency based, and are
not so clear to staff when the need is to have a very serious discussion about
overall progress and child well-being when there might not be a specific allegation
to investigate. In this case the need was to have a very well attended
comprehensive discussion about whether (should specific allegations be proven or
40

not) the overall progress and well-being of the children was such as to justify them
remaining at home. During the Staff Group discussions there was no shared view
of how that need fitted the formal procedures. This is not to say that the formal
procedures do not allow for such discussion.
5.64 The national guidance at least as far back as 2006 says that A strategy
discussion may take place following a referral, or at any other time, so is not tied
to specific events or allegations. The guidance also encourages a broad
attendance (CSC, Police, health and other bodies such as the referring agency).
It is important that there is a shared understanding that strategy meetings can be
used to discuss professional concerns about chronic situations, and without a
specific trigger event.
5.65 The Summary Learning Points are:
Strategy meetings can be used for concerns about chronic situations, where
multiagency pooling of information and views would allow a step back and review.
Strategy discussions/meetings may need to involve more than just CSC and
Police, and should involve health and any other agency to be involved in the
investigations
When professionals set out an argued case for a child protection conference it
should be only in exceptional circumstances that CSC do not convene one. (If
there are disputes about interpretation of thresholds the escalation process should
be used).
The LSCB needs to be sure staff understand that disputes about calling a
conference can be escalated to LSCB level
The discretion to exclude parent/s from part of a conference needs to be exercised
when there is a history of staff feeling intimidated, and there is any chance that
parental behaviour would inhibit discussion in a childs interests, or impact on
decision making
Staff need to make their views about this very clear to the conference chair
Where two parents in dispute attend conference the possibility that one might feel
unable to contribute for fear of the other should be considered.
Conferences need to be aware of the risks from assuming those present or
receiving minutes know prior risk factors
5.66 Overarching Themes: Through the case run, to one degree or another, three
dynamics which the LSCB and its member agencies must continually guard
against. They are not new issues to SCRs, but no apology is made for writing
about them again as they are so powerful. Without the best training, supervision
and management they continue to impact on child protection work because they
are common human tendencies.

41

A rule of optimism. (Described in Brandon et al2, as a common and previously

identified theme in their biennial review of learning from SCRs).
Failure to revise judgements. (Fish, Munro and Bairstow3, say that One of the
most common, problematic tendencies in human cognition is our failure to
review judgements and plans once we have formed a view on what is going
on, we often fail to notice or to dismiss evidence that challenges that picture).
Lack of challenge of parents and fellow professionals (Brandon et al4, describe
numerous lessons from lack of challenge and critical thinking in SCRs).

5.67 The rule of optimism is where professionals wrongly assume positive outcomes for
children. It rationalises evidence that contradicts progress so even where the
facts show that risk is on-going or increasing, professionals tell themselves that
the opposite is true. It is more likely to exist when staff feel under pressure, or
when staff find it hard to face up to potentially life changing decisions. It is fair to
say that not all agencies were optimistic and in 4.17 onwards this report describes
those difference of views. However, there were many signs of undue optimism,
especially in CSC. As far as this Review can see, the father never stuck to
commitments, even signed ones, about receiving help or about protecting children
from high risk adults. These included not going on domestic violence or alcohol
related training, keeping children away from X, then Y, or cooperating with
CAMHS. Even a court asked the father to protect his children from Y, with little
evidence of prior cooperation.
5.68 The current national guidance, Working Together 2013, puts it well. A desire to
think best of adults and to hope they can overcome their difficulties should not
trump the need to rescue children from chaotic, neglectful and abusive homes.
5.69 Related to this is a feature that E. Munro5 describes as, The single most
pervasive bias in human reasoning is that people like to hold on to their beliefs.
This leads to a failure to revise judgements whatever the evidence. There was in
this case, for a long time, a failure to revise judgments. Again, this was primarily
in CSC as health and education repeatedly drew attention to their view that
enough is enough, and recommended more vigorous intervention.
5.70 Whilst CSC might have been the most strongly optimistic, other agencies were
involved in decisions to remove children from Child Protection Plans after only ten
2

New learning from serious case reviews: a two year report for 2009-2011
Brandon, H. et al. Department for Education, 2012

Fish, S., Munro, E. and Bairstow, S. (2008) Learning together to safeguard

children: developing a multi-agency systems approach for case reviews,
London: Social Care Institute for Excellence.

op.cit

Munro, E. (2008) Improving reasoning in supervision, Social work now, 40

(August), 6.

42

months in October 2006, and in September 2010 removing H from such a plan
after only six months. In the period prior to the first removal there were continued
concerns about Y and his grooming, parental separation, a very serious threat
from father to his estranged wife, knowledge of fathers convictions (as far as I can
see for the first time at conferences), and father resisting requirements to keep H
from X which was reported at the de-registration conference.
5.71 In the period between registration and deregistration in 2010, there were a number
of events which hardly suggested any long term change. Y was arrested for a nonfamily relevant offence, H repeated allegations of sexual assault by Y, R had
abdominal bruising after a weekend with Y, and the mother alleged an historical
very serious offence against her by the father. There were also two anonymous
referrals to the Police about shouting in fathers household which led to no further
action. Whilst only Ys arrest (eventually) led to a conviction, the concerns do not
seem to suggest life for children being that different.
5.72 A feature of these dynamics is a lack of challenge both professional to parent
and professional to professional. A dictionary definition of challenge includes
summons to engage in a contest and demand an explanation. Often it can be
the fear of coming over as engaging in a contest that stops professionals
demanding explanations. This can apply to work with families (such as not
challenging parents too much in case it lessens their motivation or impacts on
relationships with staff). Also, it can be hard for workers to challenge parents
when certain of their answers might lead to life changing decisions about the
family such as the removal of a child, and the consequential pain for parents.
5.73 In this case, there was, as with optimism, not a uniform pattern but a number of
examples of where challenge could have been greater. There is little sign that the
parents were seriously challenged about failure to follow formal agreements, and
there is little evidence that there was ever any consequence to father not only not
protecting his children from X and Y, but openly arguing against the need to do so.
On the contrary, the moment anything looked a little better, the pressure was
reduced for example by removing the children from Child Protection Plans, or by
repeatedly closing the CSC case.
5.74 One version of this was brought to the attention of the Review by the staff group.
This was in relation to the children moving or being moved between
parents/relatives and how certain moves were deemed to be beneficial. Whereas
in the view of those staff, the children might be safer with one than another, but in
neither place actually safe.
5.75 In terms of interagency challenge, there was challenge, especially in 2008-9 from
health and education, but even that was at a relatively junior level, and the Review
has seen no evidence that more senior staff copied in became involved. It is
unlikely that there were robust processes of (positively) challenging supervision in
CSC or it would be difficult to believe that the case could have drifted for so long.
43

(There was some positive internal challenge when a temporary social work
manager found no record of a Section 47 being undertaken, and instituted a range
of processes in 2013 which led to the protective action despite, says that
manager, some discouragement from doing so).
5.76 Why do these overarching themes happen? A preliminary answer is that this is
simply what happens in child protection work. There is always a tendency or wish
to be optimistic about making things better, to work in partnership with parents,
and produce change, and to see maintaining the family as the first objective. This
has been seen, in many SCRs, around a sense of sympathy for parents, giving
them every chance, or a last chance and so on, and this had led to errors due to
insufficient child focus as evidence of continuing or increasing risk is overlooked,
as views become unchanging, and over optimistic, and challenge is held back.
However, in this case it does not seem to emanate from sympathy, more from
everything seeming to be so difficult, or even threatening. The pattern of parental
complaints, aggression, manipulation, and the high resistance of both real help
and any suggestion of poor parenting, created a sense that getting anywhere with
this family was so hard, that proving anything was so hard, and that no one told
the same story twice. This seems to have led to either keeping on trying in old
ineffective ways, or giving up and closing the case, or not accepting referrals. One
can see from the files that CSC did not accept there was a serious problem, and
held a picture of risk to the children which (looked at over time) was extremely
worrying.
5.77 The area of challenge is one where there needs to be a culture of supporting it (in
the sense of seeking explanations), where a challenging culture is seen as a good
thing, and modelled by supervisory and management staff. In other words
supervisors need to show good constructive challenge of staff who can then be
more comfortable in challenging parents or each other. A Safeguarding Board
needs to be challenging of its members who in turn can respond well to it, and so
model the benefits of challenge.
5.78 In small communities, where people may know each other better than larger
areas, there can be a culture of expecting the best of local people, and it is
sometimes hard to believe that awful things can happen. This can lead to there
being an insufficiently sceptical or querying mind-set, that may in turn lead to less
pursuit of suspicions and less challenge when something untoward is quickly ruled
out. In considering the findings of this Review the LSCB and member agencies
should consider whether there is a culture which encourages professional
challenge, or whether this requires more work.
5.79 The tendencies described above need management. David Jones, the vice chair
of the English Association of Independent LSCB Chairs said6 If you need to help
6

Professional Social Work (Nov 2013)

44

people as a social worker you have to be optimistic, but you also have to be
realistic, which means you have to hold the possibility that people are playing
games with you, or there is deception going on. Holding that together is really
quite complicated which is why it is essential to have supervision. The key thing is
having someone outside the situation who can talk it through and take another
perspective. The principle of having someone to talk to applies to other
professions whether supervision is part of their arrangements or not, and the
LSCB should ask its members to ensure that there are good arrangements for all
staff to have the opportunity to discuss cases like this, and their feelings about
them, with someone more distant from the direct management of the case.

5.80 The summary learning points are:

The need for all agencies to expect there to be a tendency towards optimism,
fixed views, and insufficient challenge in child protection cases and...
to ensure that there are sufficiently robust processes of supervision and case
review in place
The need to recognise that not only getting too close to parents can create such
unchanging views, but also where parents can paralyse staff thinking by
aggressive, confrontational and manipulative behaviour
The need for challenge to be accepted part of professional and agency culture,
and modelled by senior staff
The need for a sceptical and challenging mind-set, especially around any
suggestion of children being at risk.
5.81 Views of the Family: The Reviewer met each of the children subject to the SCR,
and the parents. Seeking a view about how the children could have been
protected earlier, and how agencies might have helped more, was difficult as
some children did not seem to share the view of the court that any protection was
necessary. They did have some issues about the looked after process which were
fed back to CSC. Comments from children are given here without comment from
the Review. The father was also seen, and as he thought the childrens
allegations, even those proven in court, were falsely made by children at the
instigation of their mother (his former wife) it was again difficult to discuss with him
whether protection could have been earlier. His views are also given without
comment from the Review. The mother was also seen, and had a different
perspective which is reflected below.
5.82 Two children separately gave views about what might help children in interviews
about allegations about abuse. They (and both are now young people) said that
there should be toys and drawing materials to help the child or young person be
more relaxed. One said there should be an opportunity to talk about what I want
to talk about, in other words not just answering questions. The same child said
that Police should not take pupils out of class to discuss such distressing issues,
45

because going back into class afterwards, with fellow pupils knowing where they
had been, was awful.
5.83 A child did say that many untoward things had happened, and described how
upsetting it was that whilst teachers and CAMHS worker D (who was highly
praised by the child) believed what they heard, Police and social workers did not.
The child did acknowledge that inconsistent evidence was given due to fear of
adult relatives, and feeling unsafe if allegations were maintained. There was also
a description of how it felt to witness domestic violence - I was always in the
middle - and how the mother would stick up for the father even after making
allegations against him, making it hard for the Police to act.
5.84 The same child, in discussing how protection could have happened earlier, said
that childrens services did not investigate allegations thoroughly enough and
shied away from confronting the father. The childs advice for childrens services
was to make them investigate more thoroughly try harder and not believe
parents so much. Another child said that childrens services should return calls
quicker and listen before coming to conclusions.
5.85 When asked how professionals might handle someone with an approach like the
fathers, another child said that such a person should be approached gently,
dont push him to the limit, but also added that staff should be firmer.
5.86 The fathers take on the same issue was that his frustration was caused by staff,
social workers in particular, because they dont listen and that they were like
robots as if pre-programmed. Also because he felt he was trying very hard to
care for children, some of whom were at some point diagnosed as having ADHD,
and the difficulty they created was not taken seriously enough. In other words, he
was blamed when in fact he needed more help. He also thought any allegation
against him or Y made by children or other parties were at the instigation of their
mother as part of her disputes with him, so he felt accusations were unfair.
5.87 He also felt let down by services in relation to abuser X. He said he was referred
to live in the property rented out by X by a council funded agency, but then found
the council criticising him for having children near a man of apparently known risk.
He also said that he had verbal and written permission from CSC to leave H alone
for short periods while he struggled to deliver a number of children to different
schools, and it was on one of those occasions that H became the victim of Xs
behaviour.
5.88 In discussing how services did help, or might have helped her and the family
during the period when there was domestic violence, the mother usually felt
unable to challenge her husbands own conclusion on what help she or the family
needed. She said he kept her quiet as she would be victimised for having her
own view. The mother could not recall any advice given about how to keep
46

safe/get help when there was domestic violence. She also felt unable to give her
views in child protection conferences (other than in advance to the chair) due to
the fathers forceful views and she didnt want him flying off the handle across the
room.
5.89 She thought health visitors did not take a feeding problem seriously enough with
one child and that no one took that childs behaviour problems seriously enough
for some time.
5.90 On the ADHD the mother felt that medication levels were too high, and that there
should have been more help for the parents in teaching them how to manage
ADHD rather than just looking at a medication solution.
5.91 She said that she passed on to the social workers that children were afraid of their
father, but the response was always that nothing could be done without a specific
event. The mother said that she did her best to protect children from X, and after
the parents split made sure social workers were aware of risks from X and then Y.
With Y, the mother thought the Police had done all they could, but thought CSC
should have been much more active in checking whether one or more children
were staying with Y despite major concerns being investigated. She thought that
there should have been more checks to be sure the children were not left
unsupervised, and that they should have been seen more often.
5.92 The interview with mother was after this SCR had been nearly finished, and she
made a comment that echoed what the Review, unknown to her, had already
concluded. She said Social Services should be there (i.e. attached to the family)
constantly, not in and out, in and out. Whilst she thought their investigations into
allegations were quite thorough she did not agree with them withdrawing support
on so many occasions. She said if there is a problem they would come, and
when the presenting problem was sorted or an allegation unproven their stance
would be everything is ok, were off.
5.93 The differing perspectives given in interviews with family members, illustrate the
difficulty staff would have had in reaching clear conclusions over the facts of
alleged abuse.

47

6. CONCLUSION
6.1 Introduction: This section looks at the answer to the key question in this Review:
Could one of more of the children have been protected earlier? If so, why, and
what would enable this to happen with future children in a similar position? The
specific recommendations which are in addition to the learning points in 5 are in
the next section.
6.2 Could one or more of the children have been protected earlier? The Review
concludes that the answer to this is yes. Regardless of the difficulties in proving
specific allegations, there were many indications of serious dysfunction within the
family. The fact that young children even had the language to make certain of the
allegations, the frequency with which there were serious concerns, the behaviour
of the children, the non-cooperation of parents, the failure by parents to protect
children from abusers, the lack of change, and the chaotic, sexualised, violent
nature of life for the children, all warranted intervention at an earlier stage. In the
absence of action through the criminal courts, earlier use of care proceedings
should have happened.
6.3 Why did this not happen? Section 5 analysed this in detail. In summary, the
reasons, at the time, included the following:

The intimidation perceived by staff from the father to some extent paralysed
objective analysis, and limited challenge by agencies
There was insufficient assessment of parenting skills, and a varying
understanding across agencies of risk factors
Insufficient weight was given to the lack of parental change and cooperation,
and the fathers inability or unwillingness to protect the children
Too much focus was given to the presenting problem of the day, rather than
assessing the long term well-being of the children
On a number of occasions when serious allegations were unsubstantiated for
court purposes, there should nevertheless have been multiagency discussions
to considered the implications for children
Too many of the investigations were single agency, and CSC took an
approach where if there was insufficient evidence for a conviction they also did
not intervene
This led to CSC frequently closing the case, when the overall evidence was of
an unchanging or worsening situation where the children were at risk
emotionally and/or physically and/or sexually
More consideration could have been given to why, after investigations had
found insufficient evidence, children repeated allegations of abuse by
relatives, especially given the risk to the children in doing so
Escalation arrangements to resolve disputes between agencies were not then
sufficiently well-defined or used

48

The degree to which there was undue optimism in CSC, regardless of the
evidence, suggests supervision and case review processes were not
sufficiently robust
There was not a shared understanding between clinicians, and between
clinicians and CSC, on the importance of social/environmental factors in
extreme behaviour disorder

6.4 This list explains why opportunities were missed but these are not the root cause,
which lies in the system within which the staff worked and the degree to which that
provided sufficient preparation, support, supervision, and management of staff
working with the most challenging of families, and had sufficiently robust
interagency working. Improvement lies in making sure the system within staff work
operates effectively.
6.5

What would need to happen to protect more quickly children in the future in
a similar position? The Staff Group wanted it to be clarified in this SCR that any
change would not just benefit children referred in the future, but current families
with chronic, not improving, situations where there is a similar need to take a long
term and less event based perspective. Generally the answer lies in training,
supervision and management being robust enough to ensure that good practice is
followed and that the specific issues highlighted by this Review have been or are
being addressed.

6.6 To address a similar situation, the approach would need to be less event-based
and more focussed on the long term well-being of children. It would require the
meaning for children of repeated no further action referrals to be considered. It
would need a level of resilience nurtured in staff which would be able to deal with
the pressures from an aggressive parent/s, and a degree of challenge that would
be appropriate to a long term non-improving situation. It would need supervision
and management processes that are able to identify where there is undue
optimism, and where assessments remain similar despite changing
circumstances. It would need strong interagency relations where professional
views are respected and heeded, and a good process for resolving disputes. It
would also need clear processes for multiagency discussion of the overall
progress of families and childcare that does not necessarily need to be linked with
a specific referral.
6.7 This Review is not saying that the position described in 6.5 is not in place, as the
Review has not being auditing current practice. There have been a number of
improvements since this case, and each involved agency has provided the SCR
with a note on progress to date, which can be seen in Section 8. The
recommendations that follow are not, as traditionally done, a list of specific actions
for each agency, but a menu of what needs to be in place for the LSCB and its
member agencies to consider, and then provide assurance of progress.

49

RECOMMENDATIONS

7.1 Introduction: The recommendations are set out for the LSCB, which with its
member agencies will decide the priority for each and develop an implementation
plan or a process for assurance of compliance, as necessary. In the main the
recommendations apply to all agencies to one degree or another. The
recommendations are based on what was found in this case, but will have a more
general application, which is the intention of Serious Case Reviews.
7.2 Whilst 7.3 lists the formal recommendations, Section 5 above also contains
around 30 learning points from the Review which can also be seen in Appendix 1.
7.3 Recommendations from the SCR for the Local Safeguarding Children Board
(LSCB)7
The LSCB should require member agencies to ensure there is the necessary and
appropriate training, guidance, supervision and support so that the following will
happen, which will be subject to ongoing assurance processes. There should be
no automatic assumption that the list below is not now in place, but that the LSCB
and agencies should be sure that it is, or take appropriate steps to ensure it is.
That in complex long term cases there is time to step back and reflect, away
from the heat of current crises
That the impact of aggressive parents is understood, and staff are supported
with this so that they become resilient in face of the pressures
That the value of history is high, that records are easily accessible, and that
assessments always take the full history into account
That optimism in the face of changing evidence will sometimes happen and
needs to be addressed through good supervision and case review
That challenge is valued, and modelled by supervisors and managers by both
giving and receiving challenge well
That escalation procedures to resolve inter-professional and inter-agency
disputes are understood and used
That the resolution of a current problem, does not prevent the consideration of
the long term well-being of the children
That there are clear processes in place for multiagency discussion of chronic
cases without necessarily a single trigger event

The LSCBs response to these recommendations, and action plan, will be published alongside this SCR

50

 That, whilst valuing the contribution of parents to conferences, there are clear
processes in place to ensure staff can have some time to discuss their views
without the parents being present
That CSC would, other than in the most exceptional circumstances, convene
multiagency meetings to discuss major concerns by other agencies, and that
the procedural requirement for the LSCB to rule on any dispute is understood
That contradictory evidence from children about an allegation or disclosure
does not lead to a failure to consider what is happening overall in the childrens
lives
That contradictory evidence is considered as a possible indicator of abuse
rather than something that disproves it

51

8. WHAT IS BETTER NOW? - AGENCY UPDATES

8.1 This section sets out, from each agency involved and the LSCB, a self-report on
what has already been put in hand as a result of their learning from this Review, or
has improved since the events described. Quality assuring these contributions
was outside the terms of reference of the SCR, and the LSCB will need to be
assured that progress described is ongoing. The updates were written as at July
2014.
8.2 Isle of Wight Local Safeguarding Children Board This update is set in the
context of Ofsted finding the effectiveness of arrangements to protect children to
be inadequate in January 2013 and declaring the LSCB to be under developed in
terms of its role and impact. The inspectors identified specific statutory failures in
relation to the LSCBs role and functions and an absence of effective oversight of
child protection services.
Since that time the Board has undergone a transformation in terms of its strategic
leadership and accountability. A new independent chair was appointed in October
2013 and its governance arrangements reviewed so that senior managers from all
agencies lead on key areas of business, as set out in its refocused strategic plan.
There are new governance arrangements with the Health and Wellbeing Board
and the Childrens Trust.
The Board re-introduced multiagency training on the Island in January 2014. This
is having a positive impact on frontline practice across all agencies, as evidenced
by the attendance of over 350 staff at serious case review learning lessons events
delivered from January 2014 to May 2014. 120 staff attended a conference on
Neglect in June 2014 picking up the local theme highlighted in recent case
reviews.
Sandstories events (cited by Ofsted in their neglect report In the childs time:
professional responses to Neglect, March 2014) were delivered on the Island in
June and July 2014. The one day workshops will support staff to work more
effectively with hostile and uncooperative parents in the context of neglect.
The escalation policy has been recirculated to all staff across the Island and
reinforced through all of the events held since January 2014. The LSCB
reviewed, in partnership with Hampshire, the multiagency thresholds document
which sets out the eligibility criteria for referral of child protection and child in need
cases, and this was launched in April 2014.
Safeguarding procedures have been updated to reflect Working Together 2013
and an event took place in July 2014 to make staff aware of updates to a range of
4LSCB policies and protocols. The redesigned LSCB website www.iowscb.org.uk

52

has made up to date information on events, policies and procedures more readily
and easily accessible to frontline practitioners.
The LSCB now has in place a multiagency audit plan overseen by its Performance
and Quality Assurance Subgroup. The effectiveness of supervision and
management oversight is looked at in all types of audits. A look back over the
year will take place at its annual conference on 9 September 20148 which is
focusing on adolescents at risk. The event is aimed at engaging 200 frontline
practitioners with LSCB members along with input from a range of young people.
The LSCB is committed to learning lessons swiftly from cases that go wrong and
commissioning Serious Case Reviews where children die or suffer significant
harm. The findings of all SCRs are published and placed on the LSCB website.
8.3 Isle of Wight Council
Childrens Social Care: The report of the Ofsted inspection of local authority
arrangements for the protection of children on the Isle of Wight was published in
January 2013 and found the local authority inadequate in its ability to protect
children. A Childrens Improvement Board was established, chaired by Professor
Ray Jones, and the improvement plan developed. In June 2013, the Isle of Wight
Councils education department was also inspected by Ofsted. Ofsted judged that
the local authority was not providing the level of support and challenge to schools
that was required to promote high standards and fair access to educational
opportunity for all their children.
In response to these inspections, the Isle of Wight Council entered into a legal
partnering arrangement with Hampshire County Council in July 2013 over a three
to five year period. This arrangement has since provided in situ senior managers
for education and childrens social care since October 2013. The Director and
Assistant Director of Childrens Services for Hampshire County Council are also
the Director and Assistant Director of Childrens Services for the Isle of Wight. The
senior managers from Hampshire County Council joined the Childrens
Improvement Board and have since integrated the improvement plan with the
service plan and through into the team plans.
The impact, effectiveness and influence of this partnering arrangement with
Hampshire County Council is evident and is clearly responsible for the rapid
improvements achieved in the last six months9. The Isle of Wight childrens social
care front door, through Hampshires Multi-Agency Safeguarding Hub and
Childrens Reception Team is now safe. Leadership and management, custom
8
9

This event did take place

This is ongoing, as evidenced by Ofsted inspection published November 2014. The five-year strategic
partnership between the Isle of Wight Council and Hampshire County Council is providing essential
stability and is driving demonstrable improvements across childrens services on the island.

53

and practice, and systems and processes in childrens social care on the Isle of
Wight are now very different and much improved since the last Ofsted inspection.
In addition all Policies and Procedures for the Isle of Wight have been updated,
are available to all staff and briefings/workshops set up to support staff with their
application. The partnership has also led to the electronic social care system for
the Isle of Wight Childrens Services being updated to the most recent version
assisting in recording compliance and expectations. In addition, there is a revised,
shared and embedded threshold document which there is evidence is being
applied within Childrens Services.
The partnering arrangement has stabilised childrens social care through the
reorganisation of services in line with Hampshire County Council. This was to
deliver the identified priorities within the improvement plan. The reorganisation
was completed swiftly and with minimal disruption to children, families and staff.
The partnering arrangement has stabilised the workforce for staff and families.
Agency staff numbers have fallen dramatically as successful recruitment drives
have appointed permanent staff. Partnership working has enabled good practice,
knowledge and experience to be shared rapidly. There are numerous formal and
informal opportunities for peer mentoring, buddying and coaching between the Isle
of Wight and Hampshire County Council staff.
The partnering arrangement has provided the Isle of Wight with the updated ICS
system it needed through accessing Hampshires ICS system. Again, this
implementation was completed swiftly and with minimal disruption to children,
families and staff. The changeover has provided an increased intelligent use and
sharing of data to provide management oversight and to improve performance.
The partnering arrangement is inculcating a culture of performance, continuous
improvement and learning within the organisation. This is evidenced through
improving social work practice, safeguarding and outcomes for children on the Isle
of Wight.
Education: Key areas of learning for educational institutions and services relate to
the knowledge and ability to challenge partner agencies and ensuring staff had
opportunities to stand back and reflect on the history and decision making in very
complex cases and to be challenged about their decisions in such cases.
Guidance and training that has been given to school and education staff and
changes to supervision processes of the Education Welfare Service staff have
enabled these key points to be addressed and practice strengthened.
The LSCB escalation policy has been disseminated to schools and education
agencies and this has enabled staff to feel confident that it is their professional
responsibility to escalate concerns to senior staff in Childrens Social Care should
they feel the action that has been proposed by Childrens Social Care or another
agency does not address concerns they have raised. This is routinely and
regularly restated within all safeguarding training and Learning Lessons events. All
educational institutions have staff who are trained in safeguarding including a
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Child Protection Liaison Officer with level 3 safeguarding training. This training has
also enabled educational institutions to have a greater understanding of their right
to request a child protection conference if they have sufficient concern that a child
might require protection. There is a greater awareness amongst staff now that
disputes regarding conferences can be escalated through Childrens Social Care
and to the LSCB. Child Protection Liaison Officers meet regularly with senior
managers from Childrens Social Care and this provides another opportunity for
this message to be reinforced and for education staff to share concerns.
The Hants Direct line and Multi-Agency Safeguarding Hub enables information to
be collated and for historical information to be reviewed and taken into account
more readily and this has led to better recording in schools which has given
greater confidence to staff to share their information and knowledge from the
chronologies their files provide. This has been noted in the multiagency audits that
have taken place.
Change in systems and more open and challenging leadership within Childrens
Social Care has also modelled to educational institutions the open, supportive and
challenging working that Childrens Social Care expect within their staff and with
partner agencies and this is enabling greater inter-agency challenge. Challenge is
seen less as a contest but more professional support. Childrens Social Care staff
now model the benefits of challenge which is supporting improvement in
relationships between agencies and greater trust that information will be shared,
taken seriously and acted upon appropriately/consistently.
There are robust processes of supervision within the Education Welfare Team,
providing officers with monthly supervision that enables them to be supported with
cases and for challenge to explain their decision making.
8.4

Youth Offending Team:

In November 2012, IOW Childrens Services had been inspected by Ofsted. As a
result, (and in conjunction with other education Ofsted inspection results on the
island) the IOW Council entered into a partnership arrangement, following a DfE
direction, with Hampshire County Council which commenced on 1st July 2013.
One of the tasks for Hampshire was to reconstitute a Childrens Services
Department, several parts of which, including the YOT, had been placed in other
directorates. With regards to the Isle of Wight Youth Offending Team (IOW YOT),
partnership arrangements commenced formally on 1st October 2013 with the
Head of Service for Hampshire YOT assuming line management responsibilities
for the IOW YOT Operational Team Manager and strategic oversight of the work
of the team. This resulted in more specialist resource being made available to
support and manage the work of IOW YOT, and a greater alignment with wider
childrens services as well as Childrens Social Care.

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Additionally, in line with feedback received via Peer Review undertaken in

September 2013, the role and membership of the IOW YOT Management Board
has been strengthened, with the Deputy Director for Childrens Services and the
Area Director for the Isle of Wight both joining the management board and
additional resource allocated to the YOT by the management board in terms of
frontline staff. Both have had the result of strengthening the way in which IOW
YOT delivers its functions, how these are supported or monitored and also
integrated with others.
Indeed, the IOW YOT is now better positioned to work with partners to identify
areas of strength and stretch as well as to resolve any difficulties or concerns
which arise. Importantly, IOW YOT is now specifically represented at a variety of
forums, including LSCB and Childrens Trust, which provide greater opportunity for
partnership working and identification/addressing of concerns as well as areas of
good practice. This ties in well with the circulation of escalation policies by
Childrens Social Care and LSCB which can be followed when necessary, and
now means that there is a clear, written process for addressing any concerns
arising in relation to a particular child and/or their family, as well as mechanisms
for notifying them to the appropriate Senior Manager or local forum if not resolved
in this way. Operationally, whilst IOW YOT staff have always been able to raise
concerns for addressing with IOW Management at any time, there is now a
specific escalation agenda item on regular IOW YOT Practice and Team
Meetings to ensure these can be considered across the Team (where appropriate)
to identify trends, blocks or positive outcomes for wider team learning. All of these
factors have been key in ensuring a more integrated approach is taken by IOW
YOT in relation to safeguarding, but also that there are clear mechanisms in place
to challenge processes or decision making in relation to specific referrals (if that is
required).
Furthermore, an increased and more broadly varied range of training is available
locally to IOW YOT staff and managers via Childrens Social Care and LSCB to
equip them in dealing with difficult issues and support them in ensuring that
safeguarding duties are fully met. Whilst this is a relatively recent development,
IOW YOT staff have been able, and will continue, to access training across a
broad range of subjects including lessons learnt, working together in child
protection, and working with disguised compliance and/or disengagement
(including application of the reviewed Threshold document). IOW YOT also has
identified its own training resources to support broader work in this area (e.g.
assessment of vulnerability), which will be rolled out across the coming year.
Therefore, there seems to be now a greater opportunity for workforce
development and increased worker confidence to tackle difficult issues which was
not consistently available in the past.
Overall, these developments provide an increasingly robust approach to
safeguarding and child protection work and form part of a wider process of
56

improvement both within the IOW YOT and local childrens services which not only
recognised the need for change, but ensured that it is implemented within wellestablished improvement plans.

8.5

Hampshire Probation Trust

The following summarises improvements made in child safeguarding practice
within Hampshire Probation Trust. From the June 6 2014 Hampshire Probation
Trust has been replaced by two new organisations. The National Probation
Service (NPS), which manages offenders subject to Multi Agency Public
Protection Arrangements (MAPPA) and those offenders assessed as likely to
cause high risk of harm and Hampshire, and IOW Community Rehabilitation
Company (HIoWCRC), which manages those offenders assessed as presenting
with lower risks. Both organisations are however working to the following set of
arrangements:The Revised Hampshire Probation Trust Safeguarding Children Policy and
Practice Guidelines were published in October 2012 and now adopted by the NPS
and HIoWCRC. This policy provides for the requirements on probation staff where
there are child safeguarding concerns, either at pre- sentence stage; during the
management of a Community Order or pre and post release from a period in
custody. It strengthens arrangements in respect of notification of concerns;
information sharing; attendance at child safeguarding meetings; management
oversight of cases where there are child safeguarding concerns; home vesting
and recording in all cases with child safeguarding issues. All staff have been
briefed on this policy and practice guidelines and this is now fully operational.
All staff in the NPS and HIoWCRC with direct access to children or their
information are required to undertake mandatory Safeguarding Children training
as part of their induction. This training must be refreshed every 3 years. Both
organisations are keeping detail records of staff training and requiring team
managers to ensure their staff access refresher other training as appropriate.
Senior Probation Officers as team managers undertake supervision with Offender
Managers on a monthly basis. It is a requirement that cases involving
safeguarding children issues are discussed in monthly supervision and staff are
able to escalate concerns to their line manager as and when required.
The NPS and HIoWCRC are now actively involved in LSCB multi-agency case
audits. Both organisations also undertake an annual audit of a sample of cases
where child safeguarding issues are present to inform development of policy and
practice.

8.6 Hampshire Constabulary

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Larger, dedicated child abuse investigation teams now investigate all categories of
child abuse - they previously dealt with only the most serious and complex. This is
leading to improved consistency and professionalisation of the constabulary's child
abuse response and ensures that accredited and well trained staff deal with child
abuse cases.
A Central Referral Unit has been established which is the single gateway and
assessment centre for all vulnerability reports including those relating to child
abuse, adult abuse, domestic abuse and hate crime. This enables central
oversight of all force public protection matters and enables the easy identification
of repeat cases, linked incidents etc as well as acting as a Single Point Of Contact
for all local authorities' social care teams. The Central Referral Unit recently
became co-located with Hampshire Childrens Services Department, Adult
Services Department and Solent Health to create a Hants and Isle Of Wight Multi
Agency Safeguarding Hub (MASH). The Multi Agency Safeguarding Hub presents
opportunities for more efficient, timely and informed assessment, through
information sharing, strategy discussions etc leading to evidenced-based decisionmaking, and ultimately better outcomes for children.
We have established a dedicated Serious Case Review team which is responsible
for managing the Police contribution to, and actions/recommendations arising
from, all child and adult Serious Case Reviews and partnership reviews, as well as
Multi Agency Public Protection Arrangements and Domestic Homicide Reviews.
This team is part of a wider review and force organisational learning team, focused
on raising standards of policing across the board and embedding good practice.
The 4 LSCB policies and procedures, including those on escalation, have been
reinforced with the specialist child abuse investigation and safeguarding teams
across the force. There is a clear expectation on supervisors to challenge issues
of concern until an appropriate resolution has been identified.
8.7 Isle of Wight NHS Trust
There is a good and efficient system of Emergency Department (ED)
safeguarding liaison in place, now supported by the Named Nurses for
Safeguarding Children.
All children admissions to ED (also known as A&E) are screened daily on
weekdays. There are good processes in place for spotting frequent attenders and
child attendances that need wider professional involvement. There is a safety net
mechanism and chronology of attendances is being done. Safeguarding staff
escalate if needed and provide feedback to A&E staff.
There is a clear, written escalation policy, supported by senior managers which
can be implemented in the case of professional disagreement. The escalation
policy was introduced, advertised among staff both in hospital (via intranet) and
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community (health visitors, school nurses) and included in team briefing and staff
training. There is much better awareness of how to escalate if a professional is not
satisfied with the safeguarding decisions. There is evidence of this policy being
applied and escalation happening. Regular meetings between Social Services,
Police and Health were introduced over the last year and provide an additional
forum for an escalation.
The provision of care for children with behavioural and mental health issues is
much better now. At the period of time described in the Serious Case Review
(SCR) the Child and Adolescent Mental Health Service (CAMHS) was staffed by a
single, locum child psychiatrist. Now there are two substantive consultants in child
psychiatry employed by IoW CAMHS supported by a team of psychologists and
therapeutic workers.
In September 2013 a new consultant paediatrician with expertise in mental health
was employed. She is a new lead consultant for Attention deficit hyperactivity
disorder (ADHD), Autism spectrum disorder (ASD) and paediatric mental health
problems in paediatrics. An audit of antipsychotic treatment in paediatric patients
was done in 2012 and presented to the Clinical Directors Forum (Medical Director,
Clinical Directors and Associate Directors). Now the joint clinics of paediatrician
and psychiatrist are taking place and antipsychotic treatment is prescribed only
with a joint agreement between psychiatrist and paediatrician.
Since 2013 regular bi-monthly meetings of CAMHS and paediatric team have
been taking place addressing both governance and clinical issues. There is also
better access for counselling and family therapy. Since summer 2013 families of
children with ADHD take part in New Forest Parenting Program provided by the
Barnardo's charity.

8.8 Isle of Wight Clinical Commissioning Group

The improvements in provision of Attention Deficit Hyperactivity Disorder (ADHD)
service, Children and Adolescent Mental Health Service (CAMHS) and counselling
services described in 8.7 were actively facilitated by commissioners from CCG
working closely with clinicians from the NHS Trust.
GP non-attendance at safeguarding conferences is being addressed. There was
concern that attendance at safeguarding meetings is not given a high enough
priority, which is exacerbated by the current pressures and vacancies in primary
care. The importance of submitting a written report, particularly if they are unable
to attend, is raised at all safeguarding training events.
The main topic of the GP practice closure afternoon in March 2014 was
safeguarding which was attended by the majority of GPs and representatives of all
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practices. A variety of safeguarding professionals presented the current issues

and responsibilities for primary care, including the issue of information sharing in
safeguarding, underlining the rules of information sharing by GP and their duties in
this area. This remains a priority area for improvement and is being closely
monitored.

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Appendix 1: Collated learning points from Section 5 Learning and Why

The Influence of fathers

Fathers with such personalities as this one, can have a debilitating impact on
case management
Staff must feel free to share their feelings about working with such families
and expect support
Those providing management and supervision, especially in CSC which runs
the multiagency meeting, must be aware of the potential of aggressive fathers
to undermine confidence and objective decision making
Those providing supervision and quality control of cases must check to see
that assessments and decisions fit the evidence accumulated over the years
Agencies should have formal processes for agreeing how aggressive parents
are managed to ensure the safety of their staff
Review meetings/conferences should always be reminded of historical risk
factors, and not assume those present will all be aware of them

Managing differing views on risk

The need to ensure that robust escalation processes are in place, and
understood and used by staff when there are concerns between agencies
about the quality of responses
Requests from staff in other agencies for child protection case conferences
should normally be accepted
Even if there appears to be a good reason not to accept a particular referral,
CSC should regard repeated referrals/conference requests from multiagency
sources as needing further understanding, especially when there are clearly
stated concerns about child safety
Investigations that do not prove offences do not necessarily in themselves
prove that children are safe, or that their development is not being harmed

Single Issue Thinking

The need for a long term perspective when so many short term problems are
posed by a family
The need to regard chronic issues as important as the single dramatic event
The need for time to reflect on the meaning of events (even if disproven) on
childrens physical and emotional well-being
The need for robust supervision to identify, and to support/challenge staff who
do not look at the bigger picture

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Management of Allegations
The need to be very aware of the possibility of intimidation of children by
relatives when disclosures are made
The need to tailor investigations to any likelihood of relatives attempts to
intimidate children
The need to use the new CPS guidance to test in court evidence that might
have some vulnerability
The need to strongly consider the meaning of repeated disclosures by children,
even if a prior investigation had found those disclosures unsubstantiated
The value of internal case audit in establishing the quality of work assessing
abuse inquiries
The need to be clear about the current laws on excessive force/reasonable
punishment

Meetings
Strategy meetings can be used for concerns about chronic situations, where
multiagency pooling of information and views would allow a step back and
review
Strategy discussions/meetings may need to involve more than just CSC and
Police, and should involve health and any other agency to be involved in the
investigations
When professionals set out an argued case for a child protection conference it
should be only in exceptional circumstances that CSC do not convene one. (If
there are disputes about interpretation of thresholds the escalation process
should be used)
The LSCB needs to be sure staff understand that disputes about calling a
conference can be escalated to LSCB level
The discretion to exclude parent/s from part of a conference needs to be
exercised when there is a history of staff feeling intimidated, and there is any
chance that parental behaviour would inhibit discussion in a childs interests, or
impact on decision making
Staff need to make their views about this very clear to the conference chair.
Where two parents in dispute attend conference the possibility that one might
feel unable to contribute for fear of the other should be considered
Conferences need to be aware of the risks from assuming those present or
receiving minutes know prior risk factors

Overarching themes (optimism, not revising judgements, lack of challenge)

The need for all agencies to expect there to be a tendency towards optimism,
fixed views, and insufficient challenge in child protection cases and...

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 to ensure that there are sufficiently robust processes of supervision and case
review in place
The need to recognise that not only getting too close to parents can create such
unchanging views, but also where parents can paralyse staff thinking by
aggressive, confrontational and manipulative behaviour
The need for challenge to be accepted part of professional and agency culture,
and modelled by senior staff
The need for a sceptical and challenging mind-set, especially around any
suggestion of children being at risk

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Appendix 2 Police Review - June 2014 Conclusion and Recommendations

Note: Due to issues arising from this case, and after the conviction of Y, the Police
commissioned an internal detailed review of previous Police investigations of
abuse in the Q family. The following extract was that Reviews conclusion and
recommendations.
Conclusions and Recommendations
This review has highlighted the importance of strategy discussions and strategy
meetings in the effective planning of joint investigations. It has identified the
importance of inviting agencies in addition to police and childrens social care to
these meetings if they are to be involved in the investigation. Working Together
(2013) states strategy discussions and meetings should involve at least police,
social care and health but this review has also identified the importance of also
inviting schools to attend when appropriate.
This review has identified the importance of police managers being involved in
strategy discussions and meetings to plan joint investigations rather than
constables undertaking this role. Recommendation 93 in the Climbi Inquiry
Report (2003) is explicit about the involvement of managers in setting strategy
both at the initial referral stage and thereafter.
The lack of strategy meetings and discussions in joint investigations plus
involvement of police managers have both been identified in other recent serious
case reviews including one on the IOW and Child K and Family A in Southampton.
Recommendation 1
Hampshire Constabulary should give clear instructions to those officers
supervising joint investigations into allegations of child abuse that having
multiagency strategy discussions and/or meetings is a compulsory element
of the investigative process and it is their responsibility as a supervisor to
represent the police in these discussions or meetings.
Recommendation 2
Police supervisors involved in strategy discussions and meetings to plan
joint investigations should actively encourage attendance of all agencies
involved in the investigation.
This review has highlighted the need for allegations of parents using excessive
force to punish their children to be investigated more thoroughly and decisions
made regarding reasonable punishment to be in line with Section 58 of the
Children Act 2004. The victim has to be seen as part of the investigation to
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determine what injuries, if any, s/he has and the suspect spoken to establish if
s/he can rely on this defence.
This issue has also recently been identified in a case review on the IOW and Child
K in Southampton.
Recommendation 3
Hampshire Constabulary should issue additional guidance to frontline
officers regarding the expectations regarding investigating allegations of
parents using excessive force to punish their children and this guidance
needs to include an explanation of Section 58 of the Children Act 2004.
This review has identified the difficulties encountered by frontline uniform officers
in undertaking joint child abuse investigations with childrens social care. This is in
respect of their skills and experience (including conducting ABE interviews of child
victims/witnesses) but also their availability in working with other agencies taking
into account their 24 hour duty patterns and their response role.
This issue has also been identified in the Child K serious case review in
Southampton but since then the Child Referral Unit (CRU) grading and allocation
policy has been amended in January 2014. The amendments will mean if applied
strictly that joint investigations or investigations regarding intra familial child abuse
will be allocated to Child Abuse Investigation Team (CAIT) investigators. This is
likely to have resource implications for CAITs and it would be helpful for
Hampshire Constabulary to know whether this policy is working in practice or
whether resourcing is impacting on its application in all of these cases.

Recommendation 4 ( updated August 2014)

In light of recent changes to both the CRU grading process and the increase
in resources within CAITs, Hampshire Constabulary should conduct a review
and evaluation of how grade B referrals are being allocated to ensure
specialist CAIT resources are now being routinely deployed for joint
investigations and investigations into intra familial child abuse
H made several allegations of serious child sexual abuse against a suspect that
had since died. These were not investigated by police and were passed to
childrens social care to offer support to the victim.
High profile national investigations have identified the importance of obtaining an
account from the victim in these cases to be clear what it is they are alleging and
about whom. Only then can a decision be made as to whether any action should

65

be taken to prevent offences, safeguard children or instigate any investigations

into other suspects who are still alive.
Recommendation 5
The CRU grading and allocation policy should be amended to include what
investigative action Hampshire Constabulary expects, and from which
teams, when allegations of historic child sexual abuse are made against
suspects who are deceased.
The introduction of the 2013 CPS Guidance on Prosecuting Cases of Child Sexual
Abuse may result in some cases that would have previously not resulted in
charges being authorised now been assessed as meeting the evidential threshold
for charging. Police supervisors would benefit from having some guidance on
what their threshold should be in child sexual abuse cases for submitting cases for
CPS advice.
Recommendation 6
Hampshire Constabulary should provide guidance to police supervisors as
to the threshold for submitting child sexual abuse case files to CPS for CPS
to make charging decisions.
In a number of investigations into serious indictable offences (including serious
child sexual abuse offences) the suspects were not arrested but invited to their
local police station for a voluntary interview. This had implications regarding the
standard of the investigations (e.g. houses were not searched as Section 18
PACE powers were not able to be utilised) and the ability to protect vulnerable
victims (e.g. by applying conditional pre-charge bail).
Officers seem to have difficulty in applying the necessity test to justify arrests in
these cases.
Recommendation 7 ( updated August 2014)
Hampshire Constabulary is currently conducting a review of recent changes
to legislation and police practice in relation to the requirement for officers to
consider the 'necessity' to arrest individuals suspected of an offence. The
content of this review should be considered in that ongoing piece of work.

SCR Ends

66