The school of a teenager who was sectioned in 2015 too readily accepted a social worker’s decision not to intervene following a referral it made two years earlier, a serious case review (SCR) has found.
The review was one of three published by Sunderland Safeguarding Children’s Board (SSCB) last week. It found that as early as 2013, when the boy – ‘Mark’ – was 12, school staff were concerned about his persistent drug use and deteriorating health and appearance.
A referral to children’s services was subsequently made, but a duty social worker apparently felt reassured that Mark and his family were involved with drug services, without checking whether they were engaging.
They were not – but no further action was taken at the time, nor were follow-up referrals made.
‘Rachel’: secure accommodation
The second of Sunderland’s SCRs concerned ‘Rachel’, another teenager, who was in 2015 accommodated by the local authority and made subject to a secure accommodation order following concerns about her vulnerability, safety and wellbeing.
By 2015 Rachel was “associating with known sex offenders, misusing substances and openly talking about risky sexual behaviours”, the SCR found, adding that there was “no clear rationale” for not intervening sooner.
The SCR also flagged the national shortage of suitable secure placements for young people with complex needs, which a number of court cases have drawn attention to recently.
“This readiness of referring agencies to accept the decisions of social workers without being offered a clear rationale for their decision-making has emerged in other SCRs, both in Sunderland and elsewhere,” the review found. “If CSC [children’s social services] are noted ‘not to be concerned’, referring agencies can sometimes be reassured that ‘things can’t be that bad’.”
The review’s publication follows government statistics published at the start of November revealing that the proportion of initial social work assessments that do not lead to further action is at its highest for six years.
The figures also showed that schools put forward the second highest number of referrals, after the police, in the year to 31 March 2017.
The review period of Mark’s case coincided with Sunderland children’s services being taken into special measures, following a 2015 ‘inadequate’ Ofsted inspection. Children’s services have since been transferred to an arms-length community interest company, Together for Children. This week, a report into an Ofsted monitoring visit to Together for Children found it was “making sustained progress in improving services for its children and young people”.
The serious case review noted that no “significant contravention” by any professional could be identified in the lead-up to Mark’s sectioning. “There was evidence that many professionals with whom Mark came into contact were concerned about his welfare and safety and sought to engage him or seek access to other services.”
But the SCR highlighted systemic local failings found by other reviews, and by Ofsted, around multi-agency working, professional curiosity, the use of chronologies and a perception of harmful adolescent behaviour as ‘just what teenagers do’.
From 2013, Mark’s use of drugs, including cannabis and MCAT (mephedrone), escalated, with even some of his peers who used substances with him reporting their fears for his welfare to professionals. Concerns were also raised about his vulnerability to sexual exploitation – an area of safeguarding identified as a weakness in Ofsted’s 2015 report. Between May 2013 and January 2015, agencies had “at least” 14 contacts with children’s services relating to Mark, the review found.
“What is clear is that referrals and concerns, when they were raised with CSC, were viewed as individual episodes rather than emerging and escalating patterns of risk,” it said. “Consequently opportunities to view what was happening to Mark from a wider perspective were lost.”
Discussions with practitioners and managers revealed that “for some professionals the interplay between adolescent choice and risk was not well understood nor carefully explored”, the review added. “According to various agency records, Mark’s behaviours seem to have been seen as ‘freely chosen, informed, and adult-equivalent’.”
As well as tying in with the findings of previously published local SCRs, the review of Mark’s case noted several ‘new learning’ points of wider relevance for Sunderland.
One of these was around professionals’ apparent lack of knowledge around the impact of different substances, which has been exacerbated by the recent proliferation of so-called legal highs, also known as new psychoactive substances (NPS). Prior to the advent of synthetic cannabis, or ‘spice’, mephedrone was perhaps the most notorious of these.
“Mark’s continued use/progression from cannabis to the use of MCAT and other drugs did not appear to generate any additional concerns,” the review said. “Given the diversity of drug and alcohol use in young people, practitioners told the review team it is not always easy to decide what constitutes problematic use.”
‘Family X’: “dissensus” around neglect
The final serious case review concerned a family, ‘Family X’, known to multi-agency safeguarding services for more than 20 years.
“In late 2014 a large sibling group…were removed from their parental care because of a range of concerns for their welfare which indicated they had been exposed to, and were suffering from, chronic neglect.”
The case, the SCR found, was illustrative of the “dissensus” around what constitutes neglect. “For Family X, the classification of neglect was generalised, and the records did not show how that neglect was manifested or experienced by the individual children,” it said.
Similarly to another recent SCR, regarding two brothers who were killed in Syria after being radicalised, the review also noted that the child protection system itself is not always a good fit for adolescent risk. “The review team could find no evidence of any shared values and principles to govern specific work with adolescents,” it said.
“Practitioners were very vocal in expressing their views that a different way of working with troubled adolescents was urgently required,” the review added. “They expressed the view that senior managers in all agencies needed to address this despite the challenges of shifting resources from already stretched services.”
‘Major piece of work’
Paul Ennals, SSCB’s independent chair, said that among other activities the board was now “leading a major piece of work to develop a framework to support practitioners working with highly vulnerable adolescents, especially where drug use is involved”.
“All the agencies in Sunderland involved with the three cases have reviewed their own practice and are acting on lessons learnt. Sunderland Safeguarding Children Board will monitor the delivery of those actions.”
Ennals said the publication of the three reviews meant Sunderland was “nearing the end” of a series of cases reviewing practice up to and including 2015, the year of the council’s Ofsted report.