Agencies “informed by traditional ways of working” were unable to safeguard a looked-after teenager whose initial vulnerability progressed to gang involvement and high-risk behaviours before he was killed following a moped crash.
A serious case review for Croydon Safeguarding Children Board found professionals lacked the tools to change the life of Child Q, who died in July 2017 after being fatally injured in a crash between a moped and a police car. He experienced permanent school exclusion, a lack of mental health treatment, multiple missing episodes and significant placement instability but developed a “deep-rooted attachment” to his peers and the identity his gang membership afforded him.
The SCR found that child protection approaches were not effective, in isolation, in dealing with the “complexity, risk and vulnerability of a child with behaviours like Child Q”. It said the “blurred line between vulnerability and risk, in the home or in the community or both”, created uncertainty for professionals over how to respond.
‘Traditional ways of working’
The review said that, although risks were identified early around the teenager, they went unaddressed and were not appropriately prioritised until Child Q started offending. It added that “traditional ways of working” did not make an impact.
“There were many multi-agency meetings where multi-agency plans were developed, but these did not adequately keep Child Q safe or create the stability needed for the necessary treatment to take place,” report authors concluded.
He was reported missing 28 times but these were handled separately to his gang membership – an example of how issues to do with the exploitation and vulnerability of young people were handled independently of those to do with offending, despite the high degree of overlap between the young people concerned.
In the light of this, it said Croydon’s children’s services had recognised the need to join up multi-agency risk and safety forums, including those covering missing, all forms of exploitation, including county lines, gang membership and youth violence, and said agencies should review operational arrangements to support this approach.
More on county lines and criminal exploitation
The review complemented the findings of a thematic review into the experiences of 60 children in Croydon, which was published in February following the death of three teenagers in 2017 and highlighted the need for “universally accessible” early help services to engage children from a young age.
All three teenagers were well known by the council, but were failed by agencies, who implemented short-term, narrow interventions, according to the thematic review, which also said children’s lives had been blighted by social worker turnover and over-complicated multi-agency arrangements.
Victim and perpetrator
At the time of Child Q’s death, he was a looked-after child with Croydon children’s services and was living in the Midlands with members of his extended family.
An assessment of available intelligence from police, youth offending services and the gangs’ team indicated Child Q was a gang member though this was rejected by his mother.
The review found he had formed a “deep-rooted attachment” to his peers. An assessment by a social worker shortly before his death found his “anti-social identity… was intrinsic to his sense of self” and that by that point for him to change would require him to “totally reconstruct who he was happy to be”.
Throughout his life, Child Q lived with various family members and foster carers. Each of his placements broke down, with children’s services at one point searching 160 different providers a without success.
Child Q would often go missing, was involved in high-risk behaviour and was both a victim and perpetrator of offences.
He was able to “position himself in service gaps, and to navigate the systems in such a way that enabled him to do as he chose, challenging agencies to keep up with him”, the review said.
At one stage “incidents were being noted almost on a weekly basis that resulted in agencies responding to the presenting issue and not being able to address one incident, before another was highlighted”, it added.
Information sharing delays
The serious case review criticised information-sharing between agencies involved in providing care to Child Q.
Due to the numerous changes to Child Q’s living arrangements, several local authorities were charged with looking after his care. But delays in information transfer led to agencies playing ‘catch up’, poor continuity of service and interventions happening too slowly, the review said.
Agencies’ inability to provide Child Q with access to “much-needed” mental health treatment, at a time when it could have made a difference, was also flagged by report authors.
Child and adolescent mental health services (CAMHS) “stuck rigidly to a model of behaviour that did not engage [his] family” and insisted on Child Q reaching an “unattainable” level of stability before they would start treatment, the review said.
“Had Child Q been engaged at aged nine, when he was first referred to CAMHS, the deterioration of his emotional well-being and mental health may have been prevented,” it added.
The review said CAMHS needed to review existing service models in order to provide treatment to children who exhibited high-risk behaviours and had limited stability in their lives.
Lack of secure accommodation
Instead, having moved between numerous placements, Child Q was eventually made subject to a secure accommodation order after he committed a serious offence.
However, the national shortage of secure accommodation, which many judges have called attention to, meant it took 18 months before a suitable bed could be found.
Judges’ concerns over secure care gap
The review concluded that the delay in decision making and the lack of available placements to meet Child Q’s needs “compromised decision making by agencies and ultimately compromised Child Q’s safety”.
“If a secure placement had been available, it may have been possible for Child Q to receive the treatment he needed which could have had a significant impact on the behaviour he displayed thereafter,” concluded the report.
The review said Croydon children’s services should available data to identify challenges in identifying suitable placements for young people exhibiting high-risk behaviour and make national representation on this issue.
Father’s criminal influence
The review also found agencies had “no specific plan” to protect Child Q from the impact of his father’s criminality.
Mr S, as the review referred to him, had been in and out of jail throughout the boy’s life, and while he tried to get his son to change his lifestlye, Child Q witnessed some of the behaviours his father was asking him to refrain from.
The report found professionals shared concerns about Mr S, and the criminal activity Child Q would be exposed to, but failed to act.
It added that joint work between probation officers, members of the youth offending service and social workers could have made a significant difference to Child Q, but this was not routine or expected practice.
“If agencies are to effectively prevent and tackle gangs, crime and the associated lifestyle, agencies should consider how they can effectively work with parents of children like Child Q to have a more positive constructive influence over their child’s behaviour, health and wellbeing,” the review said.
‘Not equipped with necessary tools’
Di Smith, the independent chair of Croydon Safeguarding Children Board, said that despite professionals having a wealth of experience, skills, knowledge and expertise, “they were frequently not equipped with the tools they needed to keep [Child Q] safe, at the time they needed them”.
She noted the difficulties sourcing appropriate secure accommodation had posed a particular problem, but acknowledged that there were times when professionals had failed to meet his needs.
“It is not possible for us to say what difference this would have made to Child Q,” Smith said. “However, both the case of the Child Q and the vulnerable adolescents review clearly highlight the importance of strengthening families, building their resilience at an early stage – and the pivotal importance of education in children’s lives.”