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Response from Sunderland Safeguarding Children Board
The Thematic Review of the Serious Case Reviews on Young Person(s) K and I
Introduction
This report presents the overall response of Sunderland Safeguarding Children Board (SSCB) to the
publication of a thematic overview report on two Serious Case Reviews (SCRs) which was published
today, 13 September 2016. The Executive Summaries of the two SCRs were also published today.
The two SCRs were undertaken during 2014 and 2015 and were completed in late 2015. The
thematic overview report was commissioned in spring 2016 and has recently been completed. The
delays have been very hard for the families involved and we regret that sincerely but were
determined to ensure we were thorough and robust in and got the maximum possible amount of
learning from the reviews.
Summary
As the Interim Independent Chair of Sunderland Safeguarding Children Board I am clear that the
deaths of both these young women were tragic and distressing. Both girls had had troubled and
disrupted lives, and many emotional problems and both were looked after 1 by the Local Authority
at the time of their deaths. Both girls died in late 2013. The coroner gave a verdict of suicide in
relation to K. In relation to Teenager I, there was an open verdict in that the Coroner found that
there was no indication that she intended to kill herself.
It is a great sadness for all involved, especially for their families and those providing care to the
girls, that despite very intensive levels of professional care and intervention from a range of
agencies their deaths were not prevented. We owe it to the two girls to take all the learning from
what happened in their lives in order to help improve services to other young people in similar
circumstances and try to prevent similar tragedies in the future.
The executive summaries of the two SCRs both make it clear that no one is individually culpable for
the deaths of the girls. Indeed in each case the SCRs show that there were many hard working and
dedicated individual professionals working hard to protect and support the girls and minimise the
risks they were exposed to. Both had been moved some distance from Sunderland in order to
better safeguard them and to move them away from the exploitation and victimisation they were
experiencing locally. A wide range of services were involved and invested in trying to help both
young women protect themselves and improve their life.
The SSCB took the decision to undertake each SCR using the Significant Incident Learning Process
(SILP) methodology. Comprehensive SCRs have been completed in line with statutory requirements
but in order to protect the privacy of the families involved the SSCB has published short executive
summaries of the full reports. These summaries deal with all the issues identified as being of
concern.
Because of the similarities between the two SCR’s, the timescale involved, and the common
learning themes that have emerged, the Board also decided to commission a thematic overview of
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Looked after – A child is 'looked after' if they are in the care of the local authority for more than 24 hours.
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both SCRs, from a highly respected academic. The SSCB agreed to publish that thematic overview
(as attached) in order to ensure we as a Board, the frontline staff in all our partner agencies and the
public understand, and can maximise the learning and identify the key things we need to focus on.
The Board had at the same time also commissioned a second thematic overview report from the
same academic in relation to four SCRs relating to vulnerable babies. That full thematic overview
report was published on 6 September 2016. Unsurprisingly much of the content of this thematic
overview report is the same as that for the vulnerable babies.
During the period these reviews cover (2011-2013) we know that multi-agency services to support
vulnerable families, safeguard their children and promote their welfare were not operating well.
There are a significant number of important common themes in terms of what has been learnt from
what happened which we must act on. There are also some important themes in relation to these
two young people in respect of child sexual exploitation as well as the use of social media. We
wholly accept the overview report’s findings.
We know that:
• Services were extensively involved with these young women and were working hard to
address their behaviour
• The risks the girls were taking were significant
• Their lives were far from good, and they were constantly struggling with very difficult
circumstances, that many adults struggle to cope with
• Staff were unable to reach the girls emotionally and make relationships with them, so had
less impact on their behaviour than was ideal
• The amount of time the girls spent missing from care, and the implications of was not fully
understood and return interviews did not take place, so the girls did not have an
opportunity to disclose what was happening to them
• Staff recognised many risks but underestimated the depth and enduring nature of the girls’
distress or that the girls were victims of serious exploitation
• The degree of professional anxiety about the risk-taking behaviour obscured the need for
action to disrupt the perpetrators of risk
• Staff were reactive rather than proactive in managing what was going on for the girls, care
plans were not always well made and at time inconsistent, and the care provided not always
the right form of care
• Good leadership, management support and advice and guidance was not available to help
staff do a difficult job well
• The services, tools, and specialist advice, support and input was not available in a timely way
Regrettably the themes identified by the two thematic overviews are ones already well known from
other parts of the country when things are not done well. Sunderland was clearly not, at this time,
applying or using the learning from elsewhere. This is a matter of extreme seriousness and indicates
that the Board was not at the time doing the job it is established to do.
We know from the thematic review that in these two cases the key overarching issues were:
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Values and principles There was no clarity in relation to what the Board and the wider
safeguarding partnership aspired to with respect to children and young people in need and
no clear multi-agency statements of values and principles in relation to how best to work
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with those children and young people. Nor was there a common understanding of how best
to work with young people who are challenging and determined to follow a particular
course of action. This is particularly important when working with very vulnerable young
people with very complex needs who are involved in risk taking behaviours. Without
common purpose there is the opportunity for inconsistency, and outcomes for vulnerable
children and young people can as a consequence fall far short of what good parents would
reasonably agree is “good enough”
The Safeguarding Board was not addressing this absence of clarity or working to challenge
agencies and improve their practice in order to improve children’s lives. Working together
well requires consistent clear leadership, and is the foundation of good safeguarding
practice. The values and aspirations of not just the Council but also the other partner
agencies need to be clear and known to everyone from the bottom to top of each
organisation, in order to build confidence and inform and guide practice, as well as hold
everyone to account
Services to vulnerable adolescents Working with vulnerable adolescents is a particularly
complex task which requires very skilful and insightful professionals who understand the
cumulative impact of need, loss, and adverse family experiences and disadvantages on the
normal challenges of adolescent development and behaviour. In addition, they need to be
able to make, build and strengthen trusting relationships with young people despite the
challenges to doing so. Young people who are looked after are often the most
disadvantaged and the most challenging, and frequently become looked after in order to
mitigate the impact of their earlier lives on their behaviour and keep them safe. However
the damage caused by those early experiences to their emotional wellbeing and mental
health is often deep rooted and very tough to address. The SCRs indicate that services to
adolescents and in particular looked after adolescents in Sunderland need to be fully
reviewed and significantly improved which has now taken place, as part of the Ofsted
Improvement Programme.
The degree to which parents and the wider family are partners in the care of vulnerable
young people The SCRs indicate that involving the families of these young people was not
consistently done as part of a whole system response. Parent’s views, knowledge and input
is crucial when working with young people, despite any shortfalls in their own ability to
manage and parent their children. Professionals did not consistently engage with the young
people’s families in seeking to manage and improve what was happening and to involve
them positively in finding ways to support their daughters.
The recognition, awareness of and response to child sexual exploitation (CSE) At the time of
these SCRs awareness of and understanding about how best to respond to children and
young people known to be at risk of going missing, being sexually exploited or trafficked was
limited in Sunderland. There were insufficient tools, systems and process to ensure the risk
was identified, staff knew what to do and ensure the needs of the girls were effectively
addressed and that measures to safeguard them were adequate. We now that it can take
many months of patient work to reach the point where victims of CSE and exploitation are
able to accept help, and they need consistent trusted adults in their lives during that period
to help them reach that point. Sadly the consistency of safe care needed was not always
provided, and the focus was on managing their behaviour not on understanding the causes
of it better. At times the young women did feel cared for and safe but not consistently.
A flawed approach to assessment and intervention and the use of strategy meetings and
other multi-agency meetings Associated with the lack of recognition of CSE, in addition,
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there were issues in terms of the way multi-agency professionals identified each young
person’s needs overall, the assessment of that need, and in particular the tools and
processes used to identify and respond to their risk taking behaviours and the extent to
which any assessments led to interventions designed to improve their lives and better
safeguard them. Linked to this was the absence of robust early help and assertive protective
interventions when these young people were children living in difficult challenging family
circumstances. If services had supported them better when they were younger they may not
have had such difficulties in adolescence.
The importance of the internet and social media in young people’s lives There was a very
limited understanding amongst the families and professionals involved with these young
people of the importance in their lives of the internet and the use of social media. Not only
was the internet providing opportunities to target, groom and exploit the young people,
provide access to friends living elsewhere, draw them back home etc, it was used to
victimise and bully them and to control their behaviours as part of exploitative behaviour.
Professionals were not equipped with the awareness and knowledge they needed
The Board must and will maximise the learning from these SCRs and overview report, and act
assertively, decisively and robustly in response to those themes in order to minimise the chance of
similar practice continuing. Much has already happened to improve things (as set out below). The
SSCB and all the agencies that make up the Board are strongly committed to focussing on and
making the changes planned to address the themes in this review with a new structure, new plan,
and a new approach to its responsibilities. This will complement to the radical changes already
taking place in Children’s Services
Context
Each SCR was completed in its own right, and each SCR resulted in a series of learning points,
recommended actions and action plans for each agency and collectively. The SCRs were
undertaken by the same independent lead and second reviewer, supported by a case specific
review panel and each one has been debated and signed off by the SSCB Full Board. A detailed
action tracker of all the actions resulting from the SCR’s is reviewed and updated monthly by the
Board’s Learning and Improvement in Practice Sub-Committee.
The overview report was commissioned in order to examine what the overall themes were in terms
of not just what had happened, but why and in addition to establish what responsibility the SSCB
itself had in terms of how well the system did or did not work. It is important to recognise that the
analysis applies to reviews of the period between 2011 and late 2013 and the themes are
congruent with the findings of the Ofsted Inspection in relation to SSCB and to the SSCB’s own selfassessment and diagnostic which was undertaken prior to the Ofsted Inspection. A second selfassessment and diagnosis indicates that overall progress has been made in terms of the key issues
but that the themes remain relevant and require focussed, well led, and driven attention to
increase the speed of change.
Whilst both girls sadly died in the same month, and both were affected by similar difficulties in their
lives the two were not directly linked. However both girls:
• Had complex and difficult family lives
• Experienced, as children, domestic violence, family breakdown and family disruption
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Had been made subject to child protection plans then taken into care in response to their
risk taking behaviours
Were unable to make and sustain good relationships or develop strong attachments
Were self-harming, going missing, struggling to stay in education, and using substances, in
particular what were called “legal highs2”
Were emotionally vulnerable, distressed and depressed and in need of specialist mental
health interventions
Were bullied at school and through social media
Were associating with older young men, sexually active from a young age and at a high risk
of exploitation
It is clear that the degree to which they were at risk of CSE was missed and that professionals
worked hard to respond primarily to the girls’ behaviours. There was also a very significant amount
of professional input and some intensive and skilled professional engagement with both girls.
What has changed as a result of the SCR’s so far?
Both executive summaries set out in full the extensive work done during immediately after the
death of both girls, and during and in response to the reviews themselves. Significant progress has
been made. There has been major investment in and changes to Looked After Children Services and
evidence of significant improvement. There has also been significant investment in the NHS and by
partners in setting up a specialist multi-agency CSE service (Team Sanctuary South).
A significant amount has changed since these tragic events. We are publishing at the same time as
this thematic overview report and the two Executive Summaries of the two SCR’s the consolidated
impact statements setting out the response each organisation involved has made to the key
recommendations relevant to them and the difference this has made. In addition the Sunderland
Safeguarding Children Board has fully reviewed our arrangements around CSE, Missing and
Trafficked (MSET) children and made progress as follows:
• We now have a well-established CSE strategic sub group, (the MSET Sub Committee of the
Board)
• Children’s Services have appointed a temporary CSE Strategic Coordinator based within the
Council but working for the partnership
• We have reviewed and updated the SSCB CSE procedures
• We have implemented a joint missing children protocol with Northumbria Police and are part
of North East cross-boundary arrangements for young people in care placed outside of their
own local authority who go missing
• We have strengthened the MSET Operational Group (previously known as the SEAM
Intelligence Group) by linking in with the Licensing Section who can provide intelligence and
undertake disruption activity linked to licensed activities such as fast food premises, taxi
drivers, hotels and clubs and bars
• The MSET Operational Group provides a monthly update to the MSET Sub Committee
including attendance of multi-agency professionals to measure and ensure agency
engagement. This is closely scrutinised to ensure appropriate agency engagement and that
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New psychoactive substances – often incorrectly called legal highs – contain one or more chemical substances which
produce similar effects to illegal drugs
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young people’s needs regarding MSET risks are being robustly addressed by each partner
agency
Challenges resulting in improvements have included changing a looked after child’s care plan
to better safeguard them
We have facilitated the delivery of a theatre production into schools across Sunderland
named ‘Chelsea’s choice’ aimed at raising young people’s awareness of exploitative
relationships. This has been well received by all schools reaching 100% of schools. This has
also been provided for foster carers
We have raised awareness of the MSET agenda with the Local Multi Agency Problem Solving
Group (LMAPS) in order to increase vigilance. Links between the Community Safety
Partnership, MSET intelligence group and LMAPS is established through the Lead Policy
Officer in the Safer Sunderland Partnership
We have commissioned a voluntary organisation to complete return to home interviews in a
timely and thorough way
We have commissioned a mapping exercise to understand what the local resources are and
where the gaps are in service and are committed to finding the best way to close those gaps
We have developed a list of resources for staff to use where appropriate
We are establishing a comprehensive training package with different levels to meet the
differing needs of staff across the partnership
Children’s Services have commissioned and delivered specialist social work training around
CSE
We have reviewed the current risk assessment tool and guidance and developed a more
robust tool based on national best practice
An analysis of the use of that tool has strengthened the SSCB CSE action plan
We are working with partners and neighbouring LSCB’s to develop a robust Problem Profile
We have developed and implemented awareness raising programmes with the Taxi Trade,
Private Hire, Social Landlords, Pub watch schemes, Bar Staff and Door Supervisors, Off
Licence/ Takeaways and Guest Houses and Hotels
We have delivered a high profile sub-regional CSE Conference in partnership with
neighbouring LSCBs and Northumbria Police with national speakers to extend knowledge and
improve practitioner skills
In particular as well as always putting children at the heart of what we do, and taking action on
those themes identified in both thematic reviews we are prioritising and focussing on:
• Prioritising the work we do to address the needs of children and young people who are
missing and/or at risk of CSE and trafficking, as well as exposed to other forms of risk taking
behaviour.
• We are regularly reviewing our development of practice improvements with staff in how to
support missing and sexually exploited children at the Board for compliance and
effectiveness in order to ensure that all children and young people currently known to be at
risk of missing, sexually exploited, trafficked are having their needs effectively addressed
and that measures to safeguard them are adequate. This includes regular and independent
sample auditing, quality assurance and performance management through the MSET sub
committee
• Developing tools and evidence based models of intervention to support young people
involved in risk taking behaviours, reduce the risks they are taking and best manage their
behaviours
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Considering, as part of the CAMHS Transformation Fund, the effectiveness of rapid access
for priority groups (especially young people who are looked after, self-harming, and at risk
of exploitation)
• Looking at how we can work with parents, carers, schools and professionals to raise
awareness of e-safety and of where people can go for help and guidance if they are suicidal
or self-harm
• The Board taking steps to ensure that all professionals are afforded the opportunity to
acquaint themselves with awareness of the use of the internet and of all forms of social
media.
• Evaluating the quality of services to young people, and looking at how best to improve staff
knowledge and skill in working with adolescents who indulge in challenging or risk taking
behaviours
Common themes in both reviews:
In addition there were themes common to both thematic overview reports (the four babies and the
two teenagers):
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Working Together and poor communication At that time we had a safeguarding partnership
operating at a basic and pragmatic level, and frequently working in parallel rather than in an
integrated, cohesive manner. Agencies were not working as well together as they could and
professional behaviours and relationships were often not as good or child focussed as they
should have been between different organisations and agencies. Robust, mutually
respectful and professional challenge was not as good as it should be in these two cases but
there was a lot of mutual concern and co-operation. Despite this the communication
between agencies was not always as good as it could have been
Workforce pressure and poor leadership Overall we had a safeguarding workforce (in
several agencies) under considerable pressure both in terms of time and resource, with
insufficient leadership direction and support, with consequent and predictable issues
around consistency and opportunity for human error. In particular access to specialist
interventions in relation to emotional health, well being and mental health was complex and
not as rapid as it should have been
Management and supervision Management and supervision of front line staff was not as
good as it should have been in order to support reflective practice, or for support
considering how best to manage risk taking behaviour. Front line staff doing complex
difficult work were working in an overstretched system which placed less emphasis than it
should on informing, equipping and supporting staff to undertake high quality professional
practice. Assertive escalation of concerns when professionals did not agree about what
action to take did not take place and managers did not help staff negotiate a shared
understanding of both the risks the girls were taking and the best way to respond
Action being taken to address the common themes:
We are taking strategic action to address the common themes in both reviews as follows:
• Becoming a much stronger Board which provides high support and high challenge across the
system, with clearer functions, a new structure, and newly developed and robust
approaches to performance management, quality assurance, practice development, and the
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application of learning from research, evidence and review, as well as evaluating compliance
with required standards of practice
Supporting (and challenging) the improvement programme for Children’s Services and
continually evaluating the improvements taking place, the investments being made and the
differences these are making to children, young people and vulnerable families as well as
supporting and challenging each partner agency’s own improvement and development
plans
Working with the Children’s Strategic Partnership, as well as the Improvement Board to
develop a more coherent approach to the identification, response to, and provision of
support or early help with children and families, including neglectful parenting and risk
taking behaviours
Working with the Children’s Strategic Partnership on the development of shared
behaviours, values, and relationships, as well as shared tools, techniques, frameworks and
protocols
Working to improve practice through a strong multi-agency SSCB led workforce
development, learning and improvement strategy and programme, to build confident,
competent, well supervised, well managed front line professionals
Reviewing and refreshing our Threshold framework, and multi-agency tools in relation to
identification of need, assessments, referrals and interventions, developing new risk
management tools and approaches and reviewing the compliance through extensive audit
and quality assurance activity
We are also:
• Supporting partners to ensure they are supporting frontline staff with the knowledge, skills
and ability to always understand and respond to the lives of young people and to maintain a
focus on what they are telling us through their conversations or behaviour
• Supporting partners to ensure they are developing and building the skills of frontline
managers to ensure they can supervise and manage their staff against reflective supervision
and good practice standards, and are comfortable with inter-professional escalation and
dispute resolution
• Supporting partners to ensure they are supporting their staff to develop the skills to work
more assertively with and to build relationships with vulnerable families, and to be able to
demonstrate respectful uncertainty and professional curiosity
Conclusion:
The death of these two young ladies is deeply upsetting for everyone, not least their families. The
reviews into why the services they received were not always as good as they could have been show
that there are common reasons why this happened. Those reasons are not excuses but are
important to understand if we are to learn from what happened and improve how well we support
other vulnerable children and young people. The publication of these reports shows how seriously
we are taking the learning and what we are doing about it.
The learning from these SCRs is being disseminated in a learning bulletin to every frontline member
of staff in every agency working with children in Sunderland, and we expect every team in every
setting to review their practice against the learning, identify what they themselves need to do, and
engage actively in transforming practice.
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We will report to the Board regularly on progress in implementing the new strategic plan and
business plans which incorporate all the actions set out in this and the previous report and will in
particular report on how well our improvement working is making a difference to other vulnerable
young people. We will also report in our annual report publically on the progress made. Most
importantly we will significantly increase our engagement and interaction with vulnerable young
people to assess whether they feel they are getting the right help at the right time from the right
people.
Jane Held
Interim Independent Chair
Sunderland Safeguarding Children Board
13th September 2016
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