Social worker changes undermined engagement with children later convicted of violent crimes – review

Inquiry into cases of seven young people charged in relation with deaths of three others finds six had history of involvement with social care marked by significant practitioner turnover

The message 'lessons learned' pinned to a corkboard
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High levels of social worker turnover undermined engagement with six young people with histories of social care involvement who were later convicted of violent offences, a review has found.

The inquiry into seven children and young people charged in relation to the deaths of three others in 2021 concluded that “consistent and trustworthy relationships” with practitioners were critical to preventing needs escalating.

However, the six who had a history of involvement with children’s social care experienced “significant flux” in their allocated social worker, which meant that “new relationships had to be formed with the child and the family; and trust re-established”, said the review report.

Understanding how to prevent serious violence

Croydon Safeguarding Children Partnership (CSCP) commissioned the thematic child safeguarding practice review (CSPR) into safeguarding children from serious youth violence in response to the unrelated deaths of the three children in 2021 and previous reviews into the lives of victims.

Based on these and feedback from family members of victims, it concluded that examining services’ involvement with those found responsible for serious violence would improve understanding of what could be done to prevent it.

The review, led by safeguarding consultant Bridget Griffin, was based on conversations with one of the seven young people and three of their families and the involvement of over 100 practitioners, through a survey, workshops, case discussions and a webinar.

The seven young people were aged 15-20 at the time of the 2021 deaths. Three (Ade, Gabe and Flynn) were convicted of murder, two (Blake and Cole) of manslaughter and the others (Ethan and Dane) of robbery.

All are black British and male and had lived in areas of very high deprivation within Croydon.

History of involvement with children’s social care

Six (all excluding Ethan) had a history of involvement with children’s social care and other services in Croydon that started before they were aged nine, for reasons including domestic abuse and parental mental illness. There were also early concerns about the mental ill-health of some of the children.

By aged 10-12, three were already misusing substances and, by 13-14, extra-familial harm, including missing episodes, county lines and gang membership had become a significant issue, manifesting in both offending behaviour and being the victims of violence.

At 15-16, the young people were given custodial or community sentences in relation to offences, but four were also referred to the national referral mechanism for being potential victims of modern slavery. All six of those involved with children’s services were either excluded from school or the subject of a managed move from one school to another.

The review found that, with the benefit of hindsight, there had been “missed opportunities to make a difference to these children earlier in their lives”, despite them receiving wide-ranging services designed to prevent serious harm to themselves or others.

‘Revolving door’ of service provision

A key issue identified by services was a “revolving door” of provision, which started and stopped based on the young person giving and withdrawing consent or engaging and disengaging.

A key finding from the review was the importance of practitioners building trusted relationships with young people and their families to promote engagement, which echoes a 2020 report on protecting children from exploitation by the Child Safeguarding Practice Review Panel.

It found evidence that many of the practitioners working with the children, including allocated social workers, had achieved this, through “exemplary” commitment, with many examples of staff “going above and beyond what [was] required of them in their respective roles”, and some successful interventions.

The review particularly highlighted the work of the Croydon adolescent team, a dedicated social work resource for young people at risk of serious violence.

‘Loss of experienced practitioners’

However, the team was reduced from 15 to five social workers in 2020 as a result of Croydon council having to issue a section 114 notice declaring that it was unable to balance its budget.

Staff told the review panel that this represented “a loss of very experienced contextual safeguarding practitioners who were passionate about working with children at risk of serious youth violence/extra-familial harm and the continuity of relationships with children was lost”.

What is contextual safeguarding?

Contextual safeguarding, a term coined in 2015 by social work academic Carlene Firmin, is an approach to protecting children from extra-familial harm that addresses the contexts in which those harms occur, such as neighbourhoods, schools, peer relationships and online spaces.

Find out more from the contextual safeguarding team based at Durham University, headed by Firmin.

More broadly, the review found that there was “a significant flux in the social workers allocated to the children”, which meant new practitioners had to forge relationships with the child and family and re-establish trust.

“This undoubtedly impacted on the continuity of the relationship, on the direct work that was completed, and on the engagement of children and families.

Importance of trusted relationships

“Social workers and managers are clear that trusted relationships are at the very heart of achieving good outcomes for children.”

The review found that Croydon’s children’s social care service was currently using a contextual safeguarding approach aimed at strengthening the emotional wellbeing of children at risk of serious violence.

While practitioners more experienced in contextual safeguarding were better able to form relationships with these children, frequent changes of social worker remained the biggest barrier to engagement.

“The retention of social workers was felt to be critical in building trusted relationships and thereby promoting positive engagement,” said the review report.

Practitioners told the review panel that a recent restructure had resulted in practitioners receiving more management support within Croydon children’s services, which they hoped would improve recruitment and retention.

Concerns over adultification

The review also stressed the importance of practitioners understanding and respectfully exploring children and families’ cultural origins, faith and experiences of intergenerational poverty, discrimination and state intervention in order to build trust.

Practitioners who contributed to the review highlighted in particular the importance of understanding black families’ experiences with mental health services and the police, including through the use of stop and search.

Case records also identified instances of ‘adultification’, when certain children – often those who are black – are seen as having more agency and less vulnerability than others. For example, Dane, Fynn, Cole and Gabe were variably described as ‘aggressive’, ‘manipulative’ and ‘angry’.

“Systems and professionals must be vigilant to the risks of adultification and question whether an unconscious bias may be influencing the way services respond to children by regarding, and treating, children as adults.”

Principles for reducing risk of violence

The report set out 10 principles for reducing the risk of serious youth violence, which it urged agencies in Croydon to adopt. These include:

  • Identifying children who require early help and providing timely support particularly in relation to emotional wellbeing, speech and language therapy and learning.
  • Applying tenacity when working with children, young people and families and asking why if people do not engage.
  • Identifying and eliminating unnecessary overlaps and duplication in services for children and families.
  • Responding to the feedback of families and practitioners on what is needed to reduce levels of serious youth violence.
  • Drawing on local and national good practice, for example, in relation to adultification.
  • Finding creative ways to work with communities and families in equal partnership.

The report also called on the Croydon Safeguarding Children Partnership (CSCP) to highlight the national issues raised in the review, including with the Child Safeguarding Practice Review Panel.

Response from Croydon partnership

In response to the report, the chair of the CSCP executive, Debbie Jones, said: “On behalf of the Croydon Safeguarding Children Partnership, my condolences to the families of the three young people who lost their lives, and all those who were impacted by these tragic events.

“Most of the children in this review were provided with extensive support from a young age, delivered over many years by a wide range of professionals. The review highlights many examples of caring, compassionate support from committed individuals. Yet the help that was provided did not alter their outcomes.

“Much has changed since these children first came to the notice of statutory services 10 years ago – but there is still a lot we can learn from these tragedies, not only in Croydon but across the country. We are sharing this review and its 10 key principles for reducing violence nationally. In Croydon, we will be working with the community to put in place an action plan and take this important learning forward.”

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