Naivety among social workers about how sex offenders operate and a reliance on written agreements led to a failure to prevent a known paedophile abusing his stepdaughter, a serious case review has found.
The finding comes in the serious case review examining the case of Child P, a Norfolk girl whose mother dated a man previously convicted of indecently assaulting his 14-year-old sister.
Despite knowing the man posed a threat to children, services in Norfolk missed multiple opportunities to protect Child P over a 10-year period that ended in late 2014 when Child P disclosed two incidents where the stepfather sexually assaulted her.
After these disclosures Child P was taken into care and the stepfather convicted of sexual abuse. Child P’s mother, who knew that her partner posed a risk to her daughter, was imprisoned for cruelty.
During the 10 years between the first signs that something was amiss and Child P entering foster care, children’s social care made four written agreements with the mother. All four agreements required the mother not to allow the stepfather to be left alone with Child P or live at the same address.
The first agreement, made in 2006, followed the stepfather being accused of indecently assaulting the mother’s 14-year-old half-sister. No further steps to protect Child P were considered because children’s social care accepted the mother’s claim that the stepfather lived at a different address.
“Though reportedly ‘custom and practice’ at the time, the use of even the first written agreement in 2006 was questionable, assuming as it did, mother’s ability and willingness to detect and report her partner’s grooming or explicitly sexual abusive behaviours,” said the review.
In November 2007 it emerged that the stepfather was living with the family in breach of the agreement but the initial child protection conference that was promised should the agreement be broken did not happen.
A second agreement in early 2010 followed accusations about the mother hitting Child P. Again social workers accepted the mother’s claim that the stepfather did not live with them.
A few days after making the agreement, children’s social care closed the case. “It is not obvious how this agreement was to be monitored because a decision was made within days to close the case,” noted the review.
After a probation officer reported that the stepfather intended to move back in with the family, an initial assessment was made. The social worker accepted the mother’s assurances that she did not allow the stepfather to be alone with Child P and a third written agreement was made. The next day the case was closed again.
“The aims of this latest written agreement were unrealistic and incapable of being monitored after case closure,” said the review.
Later Family Focus, a service providing early help to troubled families, contacted children’s social care with concerns about the unsupervised contact the stepfather had with Child P.
After a duty team manager said Family Focus should remind the mother of the third written agreement despite it clearly being social care’s responsibility to do so, the early help service referred the case to the multi-agency safeguarding hub (MASH).
The MASH referral led to an assessment by a social worker but once more the mother’s assurances were accepted and the case closed, on the basis that since the mother had been a victim of child sex abuse too she would be more likely to spot and act to prevent abuse of her daughter.
The review said this belief was “questionable”. “It was more likely that mother’s experiences rendered her less able, confident or even motivated to act to prevent her daughter’s abuse; this episode was a further significant missed opportunity,” the review said.
In October 2014, Child P made her first disclosure of a sexual assault by the stepfather, who was subsequently arrested. In response a fourth written agreement requiring Child P not to have contact with the stepfather and to live with her maternal grandmother was drawn up.
Children’s social care did not inform the police that all the previous agreements had been breached and it later emerged that the stepfather continued to stay overnight with the family. The mother and grandmother also tried to get the criminal enquiries against the stepfather dropped.
While it was intended that the written agreement would quickly be superseded by an initial child protection conference, the allocated social worker went on sick leave and the need to call the meeting was lost in the handover.
In November 2014 Child P made a second disclosure of a sexual assault by the stepfather that lasted an hour and a half.
This revelation led to a strategy meeting between the police and social care at which social workers proposed a fifth written agreement that, the review says, was “commendably challenged” by the police. Subsequently, the police exercised their powers of protection and Child P was placed with foster carers.
The review concluded that social workers in Norfolk had poor awareness of how sex offenders operate due to insufficient training. They were naive in their acceptance of the mother’s assurances that the stepfather would not have time alone with Child P and belief that it was possible for him to live there and not have unsupervised access to the girl.
This failures in the case were further compounded by “a near total failure” of the children in need team to maintain records about the case while it was allocated to them, a failure to involve Child P’s birth father and inadequate arrangements for covering absences in the social care team.
The review said the lack of record keeping was an “extremely serious organisational failing and a breach of professional standards”. “Representatives of the agency have acknowledged that this was not unusual at the time and have attributed the failings to weakness within and discontinuity of management,” it added.
Poor information sharing across services was also cited as a key factor in the lack of action in the case. The GP practice was not aware of the stepfather’s sexual offending and the scale of Child P’s non-attendance at school. The school, meanwhile, did not know that Child P’s absences were not medically justified as claimed by the mother.
The review also said the school was ineffectual in its management of Child P’s years of poor attendance.
The review said that information sharing in Norfolk has improved and social care now have a clear policy on the use of written agreements. However it said there still needs to be mandatory training for operational social workers and managers on working with adults known to pose a risk to children.
The review also recommended evaluations of the extent of compliance of the new written agreements policy and systems to ensure decisions to initiate child protection conferences cannot get lost due to staff absence.