Child Safeguarding Practice Review – Devon & Lancashire – A child-centred review of learning, barriers and challenges following a review of the significant harm suffered by Child Sydney (full report)

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1. Introduction

1.1 Working Together 2023 explains that “sometimes a child suffers a serious injury or death as a result of abuse or neglect. Understanding not only what happened but also the why it happened can help improve our response in the future”.

1.2 Where a Local Authority in England knows or suspects that a child has been abused or neglected, the Local Authority must notify the Child Safeguarding Practice Review Panel if:

The child dies or is seriously harmed in the Local Authority’s area.
While normally resident in the Local Authority’s area the child dies or is seriously harmed outside England.

1.3 The details of the serious incident that is the focus of this review are as follows:

1.4 In April 2023, Sydney went missing from her placement in Lancashire. She went missing from a trip to a local bowling alley with their friend who was also a resident at the same Residential Children’s Home that Sydney had been residing at since January 2023.

1.5 Sydney and her friend were reported as high-risk missing people. They were located by police 5 days later and disclosed that they had been sexually assaulted by a number of older males. They also disclosed that they had been drinking alcohol and taking drugs whilst they had been missing for five days. They also hadn’t been eating and were being held against their will. Police arrested one male and continued an investigation into the offence of Rape.

1.6 Whilst the serious incident occurred before the publication of Working Together 2023 in April 2023, given this Child Practice Safeguarding Review is being undertaken following its publication, Working Together 2023 is being used as the reference document and requires safeguarding partnerships to conduct a Child Safeguarding Practice Review in certain, defined circumstances.

1.7 The Child Safeguarding Practice Review Panel Guidance states that “Where a case involves services delivered across more than one safeguarding partnership, the safeguarding partners should liaise and agree which partnership will take the lead in conducting the rapid review. Normally this would be the safeguarding partnership in the area where the child is usually resident. Consideration should be given to how any other safeguarding partners might be included in the decision making, including whether a joint Local Child Safeguarding Practice Review might be required”.

1.8 CAFCASS contacted the Devon Safeguarding Children’s Partnership to alert them to the fact that a Serious Incident Notification and Rapid Review had not been undertaken to consider the serious harm that Sydney experienced in April 2023.

1.9 Through liaison with Lancashire colleagues, it was identified that there had not been a Serious Incident Notification made to the National Panel in April 2023 and it was agreed that this would be completed by Devon Children’s Services. The notification was made in July 2023. The Devon Safeguarding Children’s Partnership, in discussion with Lancashire colleagues agreed jointly to undertake a Rapid Review initially in respect of the serious harm that Child Sydney had experienced.

1.10 The Rapid Review took place in August 2023 and the report was submitted to the National Panel. The report did not recommend a Child Safeguarding Practice Review was undertaken citing “The panel assessed that the case meets the criteria for LCSPR; however, clear, identified learning has been gained from the Rapid Review and the panel agreed that an LSCPR will not add any additional learning of significance”.

1.11 Upon reviewing the report from the Rapid Review, the National Panel requested a CSPR be initiated in relation to the serious harm Sydney suffered. This request was made in September 2023. The National Panel requested that significant events in the chronology of this case were explored further in terms of how Sydney was supported as well as exploring the assessments and related decisions that were made in response.

1.12 The name Sydney is a pseudonym, and the child will be referred to as Sydney throughout the remainder of this report to protect their anonymity. The name was selected randomly with the family not expressing any views about the choice of pseudonym.

2. Key lines of enquiry and methodology

2.1 The author of this report is the Head of Service for Quality, Practice, Reviewing and Safeguarding Services for Devon County Council. Her role sits within the Children’s Health and Wellbeing Directorate and not within the Children’s Services Directorate. Her role is independent of operational colleagues and activities. The author has been a qualified social worker for 18 years, with considerable experience in auditing, quality assurance and practice development as well as experience of managing and leading operational children’s services in Multi-agency Safeguarding Hubs, Assessment and Intervention Services and long-term Child in Need and Child Protection Services. The author also has several years’ experience of working for the Ministry of Justice and with children and families subject to both Private and Public Law Proceedings. The author is also the co-chair of the Devon Safeguarding Partnership’s Quality Assurance and Workforce Delivery Group and as such she is experienced in reviewing safeguarding practice both for Devon Children’s Services and across the wider multi-agency partnership. The author has not previously been involved with Sydney’s care arrangement, nor has she provided any decision making linked to Sydney’s care planning.

2.2 The author of this report wanted to ensure that this Child Safeguarding Practice Review took a child-centered approach. Being child-centered is crucial to understanding the child’s holistic needs and development and in safeguarding and promoting the welfare of every child. Being child-centered ensures that the interests, wellbeing and views of children are elevated and inform our practice. As such, it was crucial to the author to meet with Sydney as part of her enquiries for this review. The author is incredibly grateful to Sydney for meeting with her and sharing her views and wishes. Sydney showed exceptional insight into her experiences and shared powerful messages for professionals who seek to protect and care for children and young people.

2.3 In addition to meeting with Sydney it was also essential that her mother’s views were gained and informed this review. The experiences of Sydney from her family’s perspective allow for the situation to be viewed through an alternative lens to that held by professionals. The author is grateful to Sydney’s mother for meeting with her and talking through the circumstances for Sydney and for providing context to her journey from birth through to the serious incident that caused harm to her child. The contributions from Sydney’s mother were invaluable in helping the author to understand Sydney’s experiences and those of her family, as well as contributing to the overall learning resulting from this review.

2.4 Sydney’s father was not spoken with as part of this Child Safeguarding Practice Review. Sydney has not had any direct contact with her father since 2017 and no contact at all since 2019. In 2021 during Private Law proceedings, the court made a s91(14) order preventing Sydney’s father making another application to spend time with Sydney and her sister for three years. This expired on 09/06/2024.

2.5 The scope of the Rapid Review and therefore this Child Safeguarding Practice Review was for 2 years prior to the significant incident occurring. Where Sydney and her mother offered information relating to events that occurred prior to this timescale, this has been included by the author where it was deemed relevant to the context of the serious incident in April 2023 and where it was appropriate to include in line with the National Panel’s request for the Child Safeguarding Practice Review to ensure “significant events in the chronology of this case were explored further in terms of how Sydney was supported as well as exploring the assessments and related decisions that were made in response”.

2.6 Information from professional agencies who knew Sydney was gathered, in detail, for the Rapid Review that was undertaken prior to this Child Safeguarding Practice Review. It has not been necessary to repeat the information sharing process, however the chronologies of involvement from Compass School and Compass Children’s Home (both based in Lancashire) were received after the Rapid Review and the information they have provided has been considered within this report.

2.7 As the agency who raised concerns that a Serious Incident Notification was required and supported the subsequent Rapid Review process, the author has also met with a senior regional leader from CAFCASS (Child and Family Court Advisory and Support Service). The author is appreciative of their time and in their sharing of ideas and ways to address the learning evidenced within this Child Safeguarding Practice Review.

2.8 For all other enquiries made for this Child Safeguarding Practice Review, an Appreciative Inquiry (AI) approach was adopted. It is a strengths-based and systemic approach that seeks to understand the wider context in which professionals’ practice.

2.9 This Child Safeguarding Practice Review aims to address the following Key Lines of Enquiry:

a) Was there further support and/or assessment that should have been offered/undertaken that could have prevented Sydney from suffering serious harm? Focusing on the whole partnership not just individual agencies.
b) Do all partners have robust processes/systems in place to ensure that the experience of children who are looked after by the Local Authority are understood and collectively responded to?
c) Do all partners understand how to respond to contextual safeguarding risks and concerns for children who are at risk of Criminal and Sexual Exploitation?
d) What can be done differently in the future to make positive, permanent changes? How can we minimise barriers for our workforce / frontline professionals? Develop SMART recommendations for improvement through local implementation.

3. Background

3.1 Sydney is now 14 years old and is a young person in the care of Devon Local Authority. She has a history of trauma, mental health difficulties and repeated episodes of going missing, with identified contextual risk factors. Sydney was 13 at the time of the serious incident.

3.2 Sydney first became known to Devon Children’s Services in 2010, with concerns being raised by her mother in 2016 regarding struggling to manage her behaviour. There was minimal involvement from Children’s Services until 2021 when the first Single Assessment is recorded on Sydney’s electronic record. The reasons for this assessment were due to Sydney’s mother requesting support because she was struggling to set boundaries for Sydney and keep her safe. Sydney’s mother was asking for and open to, support for both her and Sydney as well as Sydney’s sibling who lived at home with them both.

3.3 By June 2022, Sydney was living with an extended family member who too reported difficulties in keeping Sydney safe. Sydney had moved between extended family members for the last month. In the same month there were concerns raised about Sydney’s emotional wellbeing and Sydney made a report about the family member which included her being exposed to sexually inappropriate behaviours. In June 2022, after an incident where Sydney was admitted to hospital following making threats to kill herself, powers of Police Protection were exercised. It was not possible for Sydney to return to the care of her mother or extended family members and her mother agreed for the Local Authority to look after Sydney and signed Section 20 paperwork.

3.4 Following being placed with a Local Authority Foster Carer, Sydney’s behaviour became more concerning, with further attempts and threats to self-harm, increasing missing episodes and violence towards others. Devon Children’s Services took the decision to issue Care Proceedings for Sydney and Sydney subsequently moved from a foster care environment to several unregistered arrangements with support in place from independent care agencies.

3.5 Sydney’s Initial Child in Care Review in July 2022 records her as being “at significant risk of child sexual exploitation” as identified within her social worker’s assessment presented to the Child in Care Review. In September 2022 the first Risk Assessment was completed by Children’s Services which also identifies that Sydney was at high risk of harm through exploitation.

3.6 In February 2023 an Interim Care Order was granted in respect of Sydney.

3.7 Between June 2022 and January 2023, Sydney experienced several placement moves, and stayed in numerous unregistered arrangements with independent support staff commissioned to care for her. During this time concerns continued to be raised regarding violence towards others, increasing missing episodes, being raped by a number of older males and online sexual exploitation. During this time Children’s Services continued to pursue an assessment for Autistic Spectrum Conditions and support from CAMHS for Sydney.

3.8 In January 2023, when Sydney was 13 years old, she was placed at Isadora House, a Residential Children’s Home in Lancashire. Having spoken to Sydney, she understood this to be a Children’s Home designed to specifically work with children and young people to address behavioural and emotional needs caused through sexual harm and trauma. Having reviewed the Compass Children’s Home webpage, they say the following about Isadora House “Working as a residential therapeutic community, IH offers high quality care and substitute parenting for up to eight girls aged between 10 and 17, who have experienced childhood trauma”. It is also clear that appropriate support was implemented for Sydney to address the risk of exploitation that had been identified through the “Safety Programme” that Sydney participated in with the home’s in-house therapist which was combined with careful monitoring and use of her mobile phone.

3.9 Sydney received an Autistic Spectrum Diagnosis in January 2024 and within this report it was highlighted that Sydney presents with “features of Pathological Demand Avoidance”.

4. Context

4.1 On the 15 of April 2023, Sydney went missing from her placement in Lancashire. She went missing from a trip to a local bowling alley with her friend who was also a resident at the same Residential Children’s Home.

4.2 Sydney and her friend were reported as high-risk missing people. They were located by police five days later and disclosed that they had been sexually assaulted by a number of older males. They also disclosed that they had been drinking alcohol and taking drugs whilst they had been missing for five days. They also hadn’t been eating and were being held against their will. Lancashire Police arrested one male and continued an investigation into the offence of Rape.

4.3 The Rapid Review undertaken in relation to these circumstances for Sydney found that she had made a call to Lancashire Police during the five days that she was missing. Sydney did not have a mobile phone provided by her placement but had approached a member of the public to ask for help to call 111. Sydney had identified herself to the call handler, but the response that she received led to Sydney disengaging and therefore increasing her exposure to risk, as she returned to the men that had held her against her will.

4.4 Devon Children’s Services held strategy discussions during the time that Sydney and her friend were missing in April 2023 (the last strategy meeting being held following information that the girls had been located). These included local representatives as well as representatives from Cumberland and Carlisle Children’s Services (responsible for Sydney’s friend with whom she had been missing) and also the Lancashire Police who were trying to find Sydney. A S47 Child Protection Investigation was not initiated by Devon Children’s Services. Lancashire Children’s Services were not invited to these Strategy Discussions.

4.5 The Strategy Discussion minutes record that the current care plan was to continue and a single agency investigation to continue. The Strategy Discussion identified the following actions to be completed:

Complete a Safer Me Assessment for Sydney
Let Sydney’s mother know that she has been located.
Consider a Risk Assessment for Sydney
Review planning and support after Return Home Interview

4.6 A briefing was produced for Senior Leaders about Sydney’s circumstances and recent concerning events which was shared with Ofsted, because at the same time, Ofsted were completing a Monitoring Visit of Devon Children’s Services. Consideration was not given to a ‘Need to Know’ form being completed. The ‘Need to Know’ process would have triggered a review by the Head of Service for Quality Assurance, Practice, Reviewing and Safeguarding Services who is responsible for making Serious Incident Notifications to the National Panel which could have led to a discussion about the need to make a Serious Incident Notification.

5. Sydney's views

5.1 When the author met with Sydney, she was accompanied by her previous Social Worker from Devon Children’s Services, with whom she has a very positive relationship. This Social Worker became involved with Sydney following her time in Lancashire and after the significant event occurred. A letter was written to Sydney introducing the author and explaining the purpose of the visit.

5.2 It was explained to Sydney that she did not need to recall detail about the events that happened in Lancashire because at no point did the author wish to cause Sydney any distress by recounting specific detail about the significant incident. It was explained to Sydney that it would be really helpful if she could talk about her views and what advice she would give professionals, more generally, to keep her safe in the future and to help other young people who are cared for by the Local Authority (Sydney talked about her experience of being in the care of Devon Local Authority).

5.3 Sydney was extremely insightful and provided the following comments:

“The home I was in was about reducing sexual harm/trauma. I had locks on the doors and no phone, and their job was to keep me safe. They put me in danger and didn’t bother looking for me, they just called the police. I felt like they didn’t care in general. But I had a really good relationship with one staff member”.
“They could have been nicer. We felt so trapped. Every single kid is a bad influence in the house on each other. Matching is bad”.
“I kept running, but the running didn’t keep me safe”.

5.4 Sydney also expressed that she didn’t feel her Social Worker at the time, from Devon Children’s Services, cared about her saying “I used to cry every time I saw him because he didn’t say anything nice to me”.

5.5 Sydney talked about the Social Worker who accompanied her during the author’s conversation with her. Sydney said “She gets me. People who work in care aren’t real to kids. They act different to what they normally are and pretend they haven’t done things when they were younger. [Social Worker] will
tell me straight and doesn’t sugar coat things. Feel like [Social Worker] hears what I have to say. You should match Social Workers to kids”. Sydney also explained “I used to force myself to get arrested to get out of the homes I used to be in. Since being here haven’t felt like I’ve needed to get arrested. I like this home. I haven’t been arrested for a long time now”.

5.6 When Sydney was asked about what professionals could do better, Sydney said “CAMHS took since year 5 in primary school to assess me. I’ve always felt different and knew there was something wrong with me, it’s better to get everything done whilst you’re young because then you get the help early”.

5.7 Sydney explained that professionals should also consider the following when working with young people who are cared for by the Local Authority:

Social Workers should be matched carefully with the children they are to work with.
Children and young people should be put in the right environment/home for them and matched with other young people in the placement properly.
“If you really don’t want kids to go missing you have to try hard to build a relationship and care about them. If you have a relationship, then it shows you care”.
“You have to expect every kid that comes into care to go missing”.
Children coming into care should understand what is going on.
“These emergency placements when you come into care are “not on”. You’ve got to be in a good place when you come into care otherwise it will end badly. Unregulated placements should not be a thing”.

6. Sydney's mother's views

6.1 Sydney’s mother spoke about Sydney with emotional warmth, pride and love describing Sydney as “always being ahead of the game”. “A bundle of joy…so fun!” “Sydney is amazing but has struggled so much”.

6.2 Sydney’s mother recalled she had spent “years” trying to get support for herself and Sydney prior to making the difficult decision that she could no longer care for Sydney or keep Sydney safe. She recalled as far back as Sydney being in nursery school and explaining that professionals at the nursery were struggling to manage Sydney’s behaviours.

6.3 Sydney’s mother talked about her own experiences of working with professional agencies. She felt “there is something wrong in the system. When someone is begging for help, you should listen. At times I felt I couldn’t do it anymore and as a result have suffered from severe anxiety and depression”. Sydney’s mother felt that “a lot of the decisions that were made for Sydney were not the right ones…I kept saying [Sydney] needs somewhere more secure and an assessment to really understand [Sydney]. I felt like I wasn’t being listened to. Sydney was viewed as silly and naughty when actually, Sydney has really complex needs”.

6.4 When talking about the significant incident that caused Sydney harm, Sydney’s mother stated “[Sydney] is known to do things that put [Sydney] at risk. Why on earth were staffing ratios not higher? That could have 100% been avoided”. Sydney’s mother is concerned that it took so long to go public with a missing person alert.

6.5 Sydney’s mother described the following ways in which things could have been done differently, or better, for Sydney:

Rather than placing a child in the first place that becomes available for them, think carefully and check it’s the right place to meet their needs. Decision making needs to be thorough.
Should consideration have been given to Sydney being placed in a more secure provision?
Moving a child with additional needs a long way from home and their familiar surroundings became a barrier to Sydney communicating effectively and not understanding how to interact. Sydney was at greater risk when missing.
Moving a young person frequently leads to assessments being cancelled and responsibility shifting to other agencies in other areas and CAMHS assessments can’t be undertaken as the young person is not deemed to be “stable”.

6.6 When discussing Sydney’s current placement, her mother explained that this placement is “homely” and is responsive to her and to Sydney. She receives weekly updates and felt that Sydney feels at home there.

7. Reflections on practice relating to Child Sydney considering interviews with Sydney and their mother and the multi-agency chronologies provided

7.1 From the point that Sydney came into care under Section 20 in June 2022, she displayed extremely dysregulated behaviours indicating she was not feeling safe. It could be argued that the lack of stability and consistent unregulated accommodation for Sydney was emotionally harmful, thus we saw Sydney react in ways that posed a risk to herself and to others which appear to have escalated each time Sydney moved placements.

7.2 From reviewing the multi-agency chronology, it can be seen that a repeating pattern emerges which indicates Sydney may have potentially been protesting to or disrupting her circumstances. This is supported by Sydney’s own narrative when she explains “I used to force myself to get arrested to get out of the homes I used to be in”. Transitions to care arrangements led to dysregulation and distress, repeated allegations against carers, absconding and repeat return to family members.

7.3 During these cycles where Sydney was living unhappily in care arrangements that were unable to meet her needs – risk escalated and Sydney was reacting emotionally and physically, for example in an aggressive manner, climbing onto roofs, jumping out of windows, throwing water onto electrics, attempting to exit moving vehicles. This literal “fight or flight” acute stress response led to Sydney being physically restrained on many occasions and contained in police custody.

7.4 In the unstable periods when trying to appropriately accommodate Sydney, both the understanding and ability to meet Sydney’s needs and keep her safe appears to have decreased. With services that were fundamental to supporting professionals to really understand Sydney and her needs falling away or ceasing with each placement move. I have seen no evidence that concerns for services withdrawing their support was escalated through any channels to try to keep them in place for her.

7.5 For Sydney, her mother states that she first raised concerns about Sydney’s ability to interact with others, be socially aware and regulate her emotions and responses when Sydney was in nursery school. It took a further 10 years for an Autistic Spectrum Condition Assessment to be undertaken which resulted in an Autism diagnosis and acknowledgement that Sydney also displayed traits of Pathological Demand Avoidance (PDA). Understanding Sydney’s specific needs has not been achieved until recently and had professionals understood these needs earlier, it may have been possible to tailor support to meet Sydney’s unique needs and approach Sydney’s care arrangements differently. Requests for assessment were made for Sydney but frequent moves in and out of the county and the instability that these moves caused meant that the services that were there to undertake these assessments either could not or would not.

7.6 Whilst Sydney’s view is that CAMHS failed to complete her Autistic Spectrum Condition Assessment for 5 years, it should be noted that Assessments for a diagnosis of an Autistic Spectrum Condition are facilitated by Children and Family Health Devon and not specifically CAMHS. Assessments can be accessed through the Neurodiversity Pathway overseen by Children and Family Health Devon.

7.7 For Sydney, there was local GP registration and the universal records had been transferred to school nursing in Lancashire. Sydney was known to local health services but as key information relating to Sydney’s vulnerability and exploitation risk hadn’t been shared, the local health offer was universal.

7.8 In February 2023 Lancashire HCRG Care Group received information that Sydney was residing in Lancashire but there was no reference to her being a child in care. 2 weeks later in February, the Duty Children in Care Nurse (Lancashire HCRG) contacted Isadora House where it is reported that Sydney was settling in well and there were no health issues reported. The following day the Lancashire HCRG Care Group Administrator added a notification to their system, received from Devon Children and Family Health Children in Care Team, advising that Sydney is a child in care and moved to Lancashire at the end of January 2023. On the same day the Duty Children in Care Nurse contacted Isadora House again to ascertain which school Sydney was attending and ensuring that she was registered with a GP, Dentist and Optician. It is not documented that a verbal or written handover was received or requested from the previous health services responsible for Sydney as would be expected practice.

7.9 There is also no reference to a referral being made to any Lancashire Children’s Health Services requesting an assessment of Sydney to understand if she had an Autistic Spectrum Condition and no evidence of a referral being made to CAMHS for any additional emotional/mental health support for her. It is accepted however that Sydney was receiving therapeutic input through the in-house Therapist at Isadora House.

7.10 Sadly, it is not just Sydney who has experienced significant delays in assessments for additional needs or for emotional/therapeutic support and many of our children and young people who are cared for by Local Authorities across the country also experience frequent placement moves and as a result find themselves in the same cycle of referrals ending or not being possible, and information about them not always being transferred between services in a timely way, resulting in them having unmet needs and the professionals around them lacking an understanding of their specific and unique needs. This is acknowledged in the Department of Education’s ‘Stable Homes, Built on Love: Implementation Strategy and Consultation Children’s Social Care Reform 2023, February 2023’.

7.11 In hindsight, the author wonders whether given that we now know that Sydney has an autism diagnosis and traits of Pathological Demand Avoidance it is not surprising that frequent changes in carers, care arrangements, locations and changes to routine and structure caused Sydney significant dysregulation and distress. However, for any child or young person who has suffered significant trauma, placed far away from home and who has experienced several placement moves in quick succession, it would also be accepted that they may display behaviours that are dysregulated and demonstrate distress. The Autistic Spectrum Condition diagnosis may not have significantly impacted on Sydney’s reactions to her situations but may have supported professionals to have a better understanding of how to meet her needs.

7.12 It is important to note here, that whilst there was no diagnosis in place for Sydney at the time at which she was placed at Isadora House or prior to the significant incident occurring in April 2023, there was a clear chronology evidencing her behaviours that could have heightened her risk of being sexually exploited and patterns of behaviours, that if fully understood and recognised, could have informed professional approaches and responses to Sydney. Care Planning should have considered how to best meet the needs of Sydney’s presentation that gave cause to believe she may have been autistic, or certainly behaviours that were closely linked to autistic presentations.

7.13 It is unclear if conversations took place with Sydney that were informed by professional opinions that she may have traits associated with an Autistic Spectrum Condition or how these professional opinions were utilised when considering placement moves, placement locations, placement matching and placement suitability. The absence of a confirmed diagnosis should not have prevented careful and considered planning about how to meet Sydney’s needs and what placement would be best placed to do so. It should be noted however, that the full Statement of Purpose from Isadora House is clear that they are equipped to work with children and young people with additional needs, such as Autistic Spectrum Conditions. Even though experienced in this field, the support and care provided to any child placed in care needs to be clearly outlined in their Care and Placement Plans.

7.14 It is not clear whether consideration was given by Devon Children’s Services to commissioning a paid Autistic Spectrum Condition Assessment either by Children’s Services or by the Integrated Care Board if her needs could not be assessed within a timely way, to have obtained a diagnosis earlier for Sydney.

7.15 As already highlighted, Sydney experienced numerous placement moves yet also has a family who love her and, significantly, a mother who has voiced consistently that she wants the best for Sydney and for Sydney to have the right support. There was significant support offered to the family and to Sydney from Devon Local Authority’s Bridges Service¹ to try to keep Sydney within the family unit and prevent Sydney from being received into care. Professionals should carefully reflect on whether this support could have been bolstered further, if only in the interim, to keep Sydney safe whilst a suitable and stable placement option was found for her as an alternative to several unregistered arrangements and frequent placement moves.

7.16 An Interim Care Order was not in place until February 2023, with a Care Order being granted in June 2023, a year following Sydney being received into the care of Devon Local Authority. Whilst consideration was given earlier in Sydney’s timeline, to placing an application before the court, the focus for Sydney became upon her stability and her placement. However, on reflection Devon Children’s Services could have utilised the jurisdiction of the court to support them in accessing the right assessments to help identify the right placement to meet Sydney’s needs.

7.17 As Sydney has voiced, all professionals should be anticipating that children in care may go missing and the court appointed Guardian’s oversight of her care planning may have been more robust had they pushed for clearer risk assessments and safety planning to reduce the risk of missing episodes.

7.18 The role of the court appointed Guardian is to scrutinise the assessments undertaken by the local authority and the care plan they propose for the child and then, based on their scrutiny and analysis, to carry out their own independent enquiries with any such persons as they consider appropriate, or the court directs.

7.19 Alongside the Guardian, Sydney also had an Independent Reviewing Officer whose role it is to “ensure effective independent oversight of the child’s case and ensure that the child’s interests are protected throughout the care planning process” (Independent Reviewing Officer Handbook, 2010). The Children’s Services chronology shows several interventions and actions suggested by the Independent Reviewing Officer recorded on Sydney’s electronic record, yet often these were not actioned or followed up. There is evidence of escalation of actions/interventions for Sydney from the Independent Reviewing and Safeguarding Service, however these were not always timely and/or responded to. Records show that Supervision between the Team Manager and Sydney’s Social Worker (in Devon) were taking place in line with organisational expectations, on a monthly basis, but there is no evidence that escalations by the Independent Reviewing Officer were reviewed or discussed in these supervision sessions. There is also no Management Oversight recorded reviewing the concerns raised by Sydney’s Independent Reviewing Officer.

7.20 Records show that Sydney was assessed by her Social Workers in Devon as being at high risk of sexual exploitation in both June 2022 and August 2022. However, concerns regarding continued inappropriate use of social media, apps and location sharing placed Sydney at risk of sexual harm.

7.21 A Safer Me Assessment² was not completed on Sydney’s electronic record until February 2024 resulting in the understanding and coordination of support for Sydney being significantly delayed. It is not clear if, as corporate parents for Sydney, Children’s Social Care considered basic measures such as a non-smart (not internet accessible) phone for her, or identification of an adult with shared phone control such as Google Family Link. This would be a tool used by birth parents and as corporate parents we have the same responsibility to the children within our care to keep them safe.

7.22 It is also not clear that appropriate assessments of risk and associated Safety Plans were put in place prior to, or promptly after, Sydney’s move to Isadora House. Given that no Safer Me Assessment had been completed at this time, it is unlikely that any information provided to those caring for Sydney were equipped in understanding fully the high risk of exploitation that it was assessed that Sydney was at. Certainly, it was not clear to Isadora House, ways in which to carefully manage these risks to keep Sydney safe from harm.

7.23 Children’s Services notes are clear that upon being placed at Isadora House, Sydney was to complete their “Safe Programme” with their in-house Therapist which focussed on online safety. There were restrictions in place regarding Sydney’s use of her mobile phone as a result and phone use was offered as a reward and full access to her phone would not be accomplished until Sydney had successfully completed the programme. This indicates that some relevant information regarding the risk of exploitation of Sydney was shared with Isadora House, however records are unclear as to how much information was shared.

7.24 It is clear from the multi-agency chronology completed for the Rapid Review that there was a “successful pre-assessment” prior to Sydney moving into Isadora House in January 2023, again suggesting that relevant information about Sydney and her care needs were discussed. Following Sydney’s first missing episode from Isadora House in March 2023 there is a clear record of “risk assessments updated” and regular notes of risk assessments being updated following incidents with Sydney during her stay at Isadora House.

7.25 At the time of the significant incident in April 2023, 3 strategy meetings were held which included representatives from Cumberland and Carlisle Children’s Services as the responsible local authority for the young person who had gone missing with Sydney. Lancashire Children’s Services (where Sydney’s placement was based) were not invited to the Strategy Meetings however they were notified when Sydney went missing via ‘Missing from Home’ alerts and their MASH team have records of liaison with Sydney’s allocated Social Worker about undertaking the Return Home Interview. However, Lancashire Children’s Services were not included in strategy discussions and coordination of responses within the multi-agency network around Sydney.

7.26 Lancashire Children’s Services did not know that Sydney was a child looked after until March 2023 (Sydney had been residing in Lancashire since 30th January 2023) when Sydney came to the attention of Lancashire Police and MASH following a missing from home episode. This means that for approximately 2 months, Sydney was living in Lancashire without the knowledge of the Local Authority’s Children’s Services. There is no record of Devon Children’s Services notifying Lancashire Children’s Services that Sydney had been placed in their area as a child in care.

7.27 Between the beginning of March 2023 and the date of the significant incident in April 2023, Lancashire Children’s Services received 3 missing notifications. They were made aware that Sydney was residing in a Residential Children’s Home within these contacts.

7.28 On 17th April 2023 Lancashire Children’s Services received a request for information from Devon Children’s Services. The request was for police information for a Strategy Discussion being convened by Devon Children’s Services. This contact was closed down as “information sharing” by Lancashire Children’s Services. However, the information was also considered at a briefing between the Contextual Safeguarding Team and the Police Exploitation Team on 17th April 2023 and noted to be a “high risk missing episode”. Unfortunately, no actions were recorded from the Contextual Safeguarding Team/Engage briefing and there is no record of information being shared with the allocated Social Worker in Devon.

7.29 Since April 2023 and until Sydney moved to another accommodation provider in June 2023, there was evidence of Lancashire Children’s Services sharing information with Devon Children’s Services about further missing episodes for Sydney.

7.30 It has been clearly evidenced that Sydney experienced and was at risk of experiencing significant harm during her time living in Lancashire. Such risks required the need for coordinated information sharing between the police, as lead agency for criminal and missing person responses, Lancashire Children’s Services, as the lead for responding to significant harm for a child living in their area, and Devon Children’s Services, as the authority holding care planning responsibility for Sydney. Lancashire Children’s Services did not trigger or undertake a strategy meeting discussion or S47 Enquiry on the basis that Devon Children’s Services were aware of the missing episodes and would trigger such action and seek input from Lancashire Children’s Services. Whilst there was some email-based sharing of information between Devon and Lancashire, what is not evidenced is any proactive and direct telephone discussions, in either direction, between Devon and Lancashire to review the emerging concerns linked to missing episodes and agree tasks and responsibilities for the safeguarding responses to these.

7.31 The Northwest Association of Directors of Children’s Services (NADCS) has produced regional guidance that builds on the regulatory requirements in respect of children placed out of area. This requires that children who are known to be vulnerable to missing episodes or exploitation concerns are flagged at the point of notification, so they are known to local police and exploitation services. This then triggers additional information sharing such as Missing from Home Plans being in place and shared to local agencies. This procedure also requires the placing Local Authority to undertake pre-placement due diligence with the host Local Authority so that local risks and services can be understood, alongside Director approval for any child placed beyond the placing Local Authority or its immediate neighbours.

7.32 As a result of Sydney’s experiences, arrangements in the MASH for Lancashire Children’s Services have now been strengthened so that a manager has oversight of any missing episode that reflects safeguarding concerns and there is a direct conversation between the MASH in Lancashire and the placing Local Authority to agree responsibility and contributions within any strategy meeting or S47 Enquiry. In addition, arrangements have also been strengthened so that when a looked after child comes to the attention of MASH via a missing episode but is not recorded in Lancashire as being a young person looked after by another Local Authority, the Child Looked After Event status will be added, and an alert sent to the Child Looked After Support Team that manages out of county notifications. They will then contact the placing Local Authority to seek a full notification. The pan-Lancashire Children’s Safeguarding Assurances Partnership has already identified the need to strengthen the arrangements and awareness of out of area notifications. An updated procedure has been developed with briefing sessions held with providers across the region. The notification form and procedure for all out of county placements has been updated so that specific information is sought in respect of risk factors linked to missing children or exploitation. Where this is indicated, the notification

7.33 It is also important to highlight that there were some strengths in practice noted in relation to Child Sydney:

Following Sydney being reported missing in April 2023 there were multi-agency strategy meetings held regularly and clear lines of communication between Sydney’s home, Lancashire Police and Devon Children’s Services resulting in a national missing alert being issued which essentially resulted in Sydney being identified and located by a member of the public.
Strategy meetings included representatives from the Local Authority responsible for the other young person who went missing with Sydney.
Sydney has spoken honestly about the relationship that they had with the Devon Social Worker to whom Sydney was allocated following the missing episode in Lancashire and about the positive relationship they have and the trust that has been built. Sydney’s interactions as observed by the author with the Social Worker show mutual respect and honesty and are supporting Sydney to feel safe and cared for.
Whilst significantly delayed, an Autistic Spectrum Condition Assessment has now been undertaken for Sydney and has allowed professionals to understand better ways in which to communicate with and care for Sydney.
Every decision that was made for Sydney was made with a view to reducing risk of harm and keeping Sydney safe.
CAFCASS appropriately brought Sydney’s situation to the attention of the Devon Safeguarding Children Partnership who recognised the significant harm that Sydney had suffered and initiated a Serious Incident Notification and Rapid Review.

¹ Bridges is an innovative and collaborative service that aims to safely prevent and reduce the number of children and young people entering care in Devon.

²The Safer Me Assessment is a multi-disciplinary assessment that identifies and analyses the risk of exploitation, extra-familial and contextual harm to a young person. The harm is considered and assessed within a variety of different contexts to include individual, peer, school and neighbourhood.

8. Responses to the key lines of enquiry

8.1 The following Key Lines of Enquiry were outlined at the outset of this report. Each will be answered below with the answers to line of enquiry d) forming the recommendations from this review.

a) Was there further support and/or assessments that should have been offered/undertaken that could have prevented Sydney from suffering serious harm?

8.2 Sydney has now been assessed as having Autism and traits of Pathological Demand Avoidance. Requests for assessments of Sydney’s functioning and development had been requested since Sydney was in nursery school. Drift and delays in these assessments being undertaken, compounded by Local Authority service boundaries, as well as significant periods of instability experienced by Sydney, meant that it took almost 10 years for these relevant and important assessments to be completed.

8.3 Professionals are now equipped with an understanding of how best to communicate with and relate to Sydney. However, this comes too late in Sydney’s journey and had this assessment been completed at an earlier juncture a tailored approach to Sydney’s care may have reduced the risk of Sydney experiencing significant harm.

8.4 The most recent risk assessment completed for Sydney by Devon Children’s Services was in September 2022, prior to her stay in Lancashire. This identified that Sydney was at risk of Sexual Exploitation. The assessment explains that Sydney had access to Snapchat, Instagram, Facebook and TikTok. Snapchat allows for the sharing of location. It is not clear if this risk assessment was shared with Sydney’s accommodation provider in Lancashire, however it is clear that Sydney was provided with the “Safety Programme” from Isadora House’s in-house therapist which suggests that relevant information relating to the risk of exploitation was shared with Isadora House, albeit there is no clear record of this taking place.

8.5 The multi-agency chronology shows that a Risk Assessment for Sydney was completed by Isadora House in March 2023 following Sydney’s first reported missing episode. It is not clear if there was a risk assessment in place when Sydney moved to that placement and this appears to have been completed in isolation without input from other professionals, such as her Social Worker from Devon. The multi-agency chronology shows that this risk assessment was regularly updated following each missing episode; however, the author questions the efficacy of the risk assessment given it did not reduce the frequency or severity of Sydney’s missing episodes. At no point does it appear that updates to the risk assessment were made in conjunction with the professional network around Sydney.

8.6 CAFCASS were aware that Sydney was deemed to be at risk of Sexual Exploitation when they first reviewed the court application made for Sydney in February 2023. It does not appear that the Guardian ensured that there were risks assessments in place within the home where Sydney resided or that Devon Local Authority had ensured that these had been completed, or that they were sufficiently robust to protect Sydney.

8.7 The multi-agency chronology highlights that there is a service in Lancashire that specialises in working with children and young people at risk of exploitation. However, whilst internal enquiries within Lancashire were undertaken with this team, the support and local knowledge that they could offer was not shared with Devon Children’s Services and could have informed planning and risk assessments for Sydney following notifications from March 2023 that Sydney was going missing, during the extended missing episode and significant incident in April 2023, or following this time until Sydney left Isadora House in June 2023. Communication between Devon Children’s Services and Lancashire Children’s Services was not effective in keeping Sydney safe or providing a coordinated response to increasing risks. Devon Children’s Services did not invite Lancashire to participate in the Strategy Discussions that did take place in respect of Sydney both during and following the serious incident and this was a missed opportunity for Lancashire to be invited to share information about these specialist services.

8.8 Devon Children’s Services have a policy in place that prior to moving to a new area, health services should be made aware of children in care moving to their area, or in cases of emergencies, within 5 working days. Feedback from Devon Integrated Care Board and Child and Family Health Devon obtained during this Child Safeguarding Practice Review, indicate that timescales are not consistently adhered to and joint system working continues to be hindered by notifications not being received in a timely way.

8.9 A Safer Me Assessment was not completed on Sydney’s electronic record until February 2024 by her Social Worker in Devon, resulting in a lack of understanding and a coordination of support for Sydney being significantly delayed. The lack of a Safer Me Assessment suggests that the process is not well embedded in social work practice in Devon. Whilst there has been progress made in the coordination and completion of Complex Strategy Meetings and clear guidance published as part of the Adolescent Safety Framework³, it does not appear that at all times this has been followed rigorously.

8.10 The author is reassured that there is a current review of the Adolescent Safety Framework underway in Devon and a revised version of the Safer Me Assessment template, that is more intuitive and easier to complete, has already been developed and is awaiting a launch onto the electronic recording system. The author’s view is that it is not just the Assessment form itself that, when reviewed, will increase timely completion of Safer Me Assessments, but also that awareness needs to be raised across practitioners in Devon about the purpose of Safer Me Assessments and the Adolescent Safeguarding Framework for it to effectively be embedded in practice.

8.11 As stated earlier in this report, an Interim Care Order was not in place until February 2023, with a Care Order being granted in June 2023, a year following Sydney being received into the care of Devon Local Authority. Whilst consideration was given earlier in Sydney’s timeline, to placing an application before the court, the focus for Sydney became upon her stability and her placement. On reflection Devon Children’s Services could have utilised the jurisdiction of the court to support them in accessing the right assessments to help identify the right placement to meet Sydney’s needs.

b) Do all partners have robust processes/systems in place to ensure that the experience of children who are looked after by the Local Authority are understood and collectively responded to?

8.12 Devon Children’s Services have a clear policy for children and young people who are cared for by the Local Authority and placed in accommodation that is outside of the Local Authority boundaries. This policy explicitly states:

8.13 “Written notification must be given to the area authority of the arrangements for the placement before the placement is made or, if the placement is made in an emergency, within five working days of the start of the placement unless it is not reasonably practicable to do so.

8.14 The notification must include:

Details of the assessment of the child’s needs and the reasons why the placement is the most suitable for responding to these; and
A copy of the child’s care plan (unless already provided in the event of a Placement at a Distance)”
8.15 Whilst there is a clear policy in place regarding the actions that are required in Sydney’s circumstances, this was not followed and thus Lancashire Children’s Services did not know that Sydney was resident in their area and who the placing Local Authority was until several weeks following their placement there. They were also unaware of the high risk of exploitation and harm present for Sydney and her significant vulnerability to further harm.

8.16 There are robust processes now in place in Lancashire with arrangements in the MASH for Lancashire Children’s Services having now been strengthened so that a manager has oversight of any missing episode that reflects safeguarding concerns and there is a direct conversation between the MASH in Lancashire and the placing Local Authority to agree responsibility and contributions within any strategy meeting or S47 Enquiry. In addition, arrangements have also been strengthened so that when a looked after child comes to the attention of MASH via a missing episode but is not recorded in Lancashire as being a young person looked after by another Local Authority, the Child Looked After Event status will be added, and an alert sent to the Child Looked After Support Team that manages out of county notifications. They will then contact the placing Local Authority to seek a full notification. The pan-Lancashire Children’s Safeguarding Assurances Partnership has already identified the need to strengthen the arrangements and awareness of out of area notifications. An updated procedure has been developed with briefing sessions held with providers across the region. The notification form and procedure for all out of county placements has been updated so that specific information is sought in respect of risk factors linked to missing or exploitation. Where this is indicated, the notification is shared with Lancashire Police and with the area-based Exploitation Team.

8.17 The multi-agency chronology for Sydney begins in May 2022, approximately a year prior to the significant incident. In June 2022 Children Family Health Devon offered an appointment to Sydney to begin the process of an assessment for Autistic Spectrum Conditions. Sydney expressed not being keen to engage and had experienced another change of living arrangements resulting Sydney being less settled. It was agreed that due to the uncertainty in Sydney’s life the assessment would be delayed. By the end of June 2022, Children Family Health Devon record a request from Sydney’s allocated Social Worker for an ADHD assessment to be completed. Sydney remained awaiting CAMHS partnership work. In August 2022 Sydney had moved out of the Devon area and notes record that a smooth transfer of information took place to the new area’s ‘Child in Care’ Nursing Team.

8.18 In September 2022 Speech and Language Therapy colleagues advise that the Autistic Spectrum Condition Assessment for Sydney closed due to Sydney living in another area. Devon Autism Assessment Team states responsibility for this is with the new Local Authority where Sydney is residing. In October 2022 CAMHS record that Sydney had been on their waiting list but as Sydney had moved out of Devon their involvement was discontinued and a re-referral would need to be made if Sydney returned to Devon in the future. There is no evidence of the request for support for Sydney from CAMHS or from the Devon Autism Assessment Team being sent onwards to the new Local Authority in which she was residing. Certainly, the Lancashire & South Cumbria NHS Foundation Trust have no record of Sydney on their systems. Of note, Sydney did have an Initial Health Assessment completed in October 2022 (at the same time at which it appears there were active referrals for an Autistic Spectrum Condition Assessment for her) which detailed concerns about Sydney potentially having an Autistic Spectrum Condition, however she did not present with behaviours suggestive of any autistic traits whilst being seen at the clinic and thus the health report did not make any recommendations regarding further assessment of such conditions. The Health Assessment did make a recommendation that Sydney should see a “LAC Psychologist” but provided no additional detail about why or what the aim/purpose of the intervention should be. The lack of a Review Health Assessment for Sydney may have meant that vital information about her emotional wellbeing and her behaviour may have contributed to further delay in appropriate service and support being sought for her.

8.19 Following an escalation by Sydney’s Independent Reviewing Officer in August 2023 (following the significant incident earlier that year) to CAMHS it was advised that CAMHS understood Sydney’s difficulties to be an expression of psychological distress in the context of childhood trauma, communicated through behaviour, rather than a diagnosable mental health condition.

8.20 There is clear evidence within the review of the circumstances both prior to and since the significant incident of Local Authority boundaries acting as a barrier to the progression of assessments and support for Sydney creating delay in vital assessments being completed. In addition, it does not appear that any agency working with Sydney was proactive in identifying alternative specialist support for Sydney in the absence of CAMHS or Autism Assessment support being available.

c) Do all partners understand how to respond to contextual safeguarding risks and concerns for children who are at risk of Criminal and Sexual Exploitation?

8.21 Throughout Sydney’s history concerns were raised about Sydney’s online activity. Numerous “apps” were identified that Sydney was using and Sydney’s vulnerability to sexual exploitation increased due to her online activity. Whilst this was a factor that was known by Sydney’s professional network, there has been a lack of evidence suggesting that protective action was taken to reduce the risks posed by Sydney’s online presence, until she arrived at Isadora House where phone use was monitored and subject to her engagement with the “Safety Programme,” which included education around online risks.

8.22 This review has highlighted that there is potentially a gap in professional knowledge across the Devon multi-agency partnership of the risks present to our vulnerable children and young people online, but additionally, a lack of understanding of how to combat and reduce such risks when they are identified. The author is aware that there are educational sessions provided directly to young people via Personal Social Health and Economic lessons as part of the curriculum and this supports young people’s understanding of such issues and risks, however this relies on their attendance at school and engagement in lessons which we know was not something that Sydney was able to do.

8.23 In both Lancashire and in Devon Children’s Services there are specialist teams in place who can provide advice and support regarding sexual exploitation, however, referrals and contact to these teams are dependent upon those professionals in roles with children and young people outside of this specialism having the necessary skills and knowledge to identify that specialist support and advice needs to be sought.

8.24 In Lancashire there is a well-established Child Sexual Exploitation offer across the multi-agency partnership. The EmPower Contextual Safeguarding Model⁴ was launched in March 2024 bringing together the Exploitation Team, the Extra Familial Harm Team and the Missing from Home Team working with multi-agency partners to provide a coordinated and effective response to contextual safeguarding concerns known as the Power2 Service. In addition, in Lancashire the multi-agency exploitation teams can be contacted on Operation Awaken (North), Operation Engage (East) and Operation Deter (central) if Social Workers are worried about a young person who may be at risk of Sexual Exploitation.

8.25 Within Devon there is Technology Assisted Harmful Sexual Behaviour AIM3 Training that is being rolled out later in 2024 via the Early Help and Partnerships Service, however, this training will look at supporting and assessing those presenting with harmful behaviours, not those who may become victims of such behaviour. It is the view of the author that training and development opportunities in this area of practice within Devon are essential if children and young people such as Sydney are to be protected from online risks and exploitation.

8.26 Within Devon there is a new service in development called “Links” which combines practitioners who specialise in responding to missing episodes, contextual safeguarding and youth justice to provide a holistic response to young people at risk of exploitation. This service will be launched in the Autumn of 2024 and is a welcome development in the support services available to young people such as Sydney.

8.27 As mentioned previously, in Devon, the review of the Adolescent Safety Framework is ongoing, however in addition to this a review of the Missing and Child Exploitation (MACE) group and its functions is also taking place.

8.28 The Philomena Protocol went live across Devon and Torbay on 1st April 2024. The protocol sets out clear expectations and responsibilities for Children’s Homes and Foster Carers to follow, in respect of reporting a child who is missing from care.

8.29 The Philomena Protocol is a national scheme which is used by the majority of Police Constabularies across the country. The Philomena Protocol is a scheme that asks carers to identify children and young people who are at risk of going missing, and to record vital information about them that can be used to help find them quickly and safely. The adoption of the protocol will not change the process for reporting children missing but will complement existing processes and is intended to support and speed-up the locating of missing children. A three-month review is due to commence in Devon in July 2024 which will examine data and impact since its introduction. For Lancashire, the Police Constabulary have already commissioned a formal review, including consultation with partners to consider force compliance with and the benefits of the Philomena Protocol. The Lancashire Missing from Home Protocol was re-written by the Lancashire Safeguarding Partners in 2022/23 and is currently being reviewed and will take into consideration the findings of the Lancashire Police Corporate Review⁵.

8.30 Regarding the actions of the call handler during the time Sydney was missing from her placement and experienced significant harm, Lancashire Police assured the Rapid Review panel that the call handler has received appropriate feedback and training. Their investigation found no evidence suggesting this was a widespread issue within the force. Police call handlers receive vulnerability training and specific training in relation to managing reports of missing people, which includes voice of the child. Their core function is to use the THRIVE model (Threat Harm Risk Intelligence Vulnerability Engagement) to assess risk and vulnerability.

8.31 Sydney has clearly expressed that professionals should expect all children in care to go missing. This poses the question about what can sometimes be seen as “reactive” practice, responding to events after they have occurred, and asks whether professionals in Devon should more consistently be considering such events before they have happened? Whilst not wishing to pre-empt missing episodes, should professionals be doing more to ensure children and young people are equipped with safety planning in the event of a missing episode with clear instructions for them and for their carers about what to do in the event that this occurs? Ensuring contact details are in mobile phones and the introduction of open conversations about keeping safe in the community and online at the earliest point for our children and young people may reduce missing episodes, but most importantly, provide support, reassurance, advice and a feeling of care and consideration from the multi-agency network around them in the event that they are missing from home.

³The Adolescent Safety Framework (ASF) is a pioneering approach to managing contextual risk which will support children, young people, families and professionals from across the partnerships. These risks are often found outside of the family environment and place young people at risk or compromise their safety. This includes risks caused by peer groups, exploitation, locations and persons of concern outside the family. The model is bespoke to Devon and has been adapted and is flexible to meet the needs of the organisation and locality. It is based on the national Safer Me model, the work of Hackney Children’s Services and research from the Contextual Safeguarding Network, but the Framework remains unique to the county.

⁴The model has been developed to strengthen multi-agency and multi-disciplinary working and plans with some of our most vulnerable children who are at risk of exploitation, extra familial harm and/or who are at risk of experiencing breakdowns in their family relationships and to reduce the number of children who become looked after as a result.

⁵ The Lancashire Children’s Safeguarding Assurance Partnership Missing from Home Protocol & Trigger plan can be found here: 7MB_MFH_Protocol_2023-1.docx

9. Recommendations

d) What can be done differently in the future to make positive, permanent changes? How can we minimise barriers for our workforce / frontline professionals? Develop SMART recommendations for improvement through local implementation.

Devon Children’s Services to raise awareness of the Out of Area Placements Policy to ensure that for all children placed outside of Devon, the host Local Authority is aware that they are there. In addition, to ensure the sharing of information, Risk Assessments, Statutory Health Assessments and Care Plans for those children at the earliest opportunity so that the professional network around children and young people who are in the care of the Local Authority are aware of plans, contingency plans and risks. It is recommended that there is Quality Assurance work undertaken within Devon Children’s Services in the form of a Thematic Audit 6 months after the completion of this action to provide assurance that this is taking place.
Devon Children’s Services to ensure that the Devon Child in Care Nursing service are made aware prior to children in care being placed in another Local Authority area, of the planned move so that health records and notifications can be shared with the receiving Integrated Care Board (or within 5 days if placed in an emergency). This should be emphasized as part of the Rapid Improvement Plan for Children in Care across Devon and requires a commitment to be made to supporting this process from all appropriate partners. Multi-agency auditing activity is recommended to ensure that this is embedded in practice (facilitated by the Devon Safeguarding Children’s Partnership) to provide assurance that this is taking place.
Devon Children’s Services to ensure that Risk Assessments are regularly reviewed and updated and shared with the professional network around children who are in care. It is recommended that there is Quality Assurance work undertaken within Devon Children’s Services (linked to the Quality Assurance Work outlined in Recommendation 1) in the form of a Thematic Audit 6 months after the completion of this action to provide assurance that this is taking place.
Devon Children’s Services to implement a process whereby all children and young people who are received into care are equipped with a safety plan in the event of a missing episode. This should have been implemented within 3 months of this report being finalised.
Devon Children’s Services to ensure that the new version of the Safer Me Assessment is embedded within the electronic recording system as a matter of priority. This is awaiting sign off in terms of priority with the Devon Eclipse (the record management system used by Devon Children’s Social Care) Team and action needs to be taken by Senior Leaders to ensure that this “goes live” within 3 months of this report being finalised.
Devon Children’s Services to provide further guidance to practitioners regarding timely applications to court to protect our vulnerable children, irrespective of instability in their care arrangements. The Principal Social Worker for Devon Children’s Services to create a briefing for all practitioners within 3 months of this report being finalised.
Devon Children’s Services and representatives from the Integrated Care Board are actively working to seek to improve timeliness and completion of both Initial Health Assessments and Review Health Assessments for children in the care of the Local Authority. It is imperative that this continues to be a key focus of the Health Me Sub-group of the Devon Corporate Parenting Board.
Devon Children’s Services Leadership Team to develop practice guidance in relation to the matching of children within placements and the matching of children to their allocated Social Worker. CAMHS/Health Services should be included in discussions when there are challenging health or additional needs identified for children. The Principal Social Worker for Devon Children’s Services to create a briefing for all practitioners within 3 months of this report being finalised.
Devon Children’s Services Leadership Team to consider replicating the robust processes now in place in Lancashire with arrangements in ensuring that within the MASH, a manager has oversight of any missing episode that reflects safeguarding concerns and there is a direct conversation between the MASH in Devon and the placing Local Authority to agree responsibility and contributions within any strategy meeting or S47 Enquiry. In addition, that when a looked after child comes to the attention of Devon MASH via a missing episode but is not recorded in Devon as being a young person looked after by another Local Authority, the Child Looked After Event status will be added, and contact made with the placing Local Authority to seek a full notification.
Lancashire Children’s Safeguarding Assurance Partnership to seek assurance on the processes that have been implemented for Children in Care who are Missing from Home and to ensure that these are up to date and the findings from this Child Safeguarding Practice Review are considered in any review of process/procedure.
The Early Help and Partnerships Service within Devon to ensure that when the new “Links” Service is launched, that statutory partners are made aware of the support and expertise available within this service and are equipped with the knowledge of how to contact the service and the role which the service can play in supporting children and young people.
The Early Help and Partnership Service within Devon to raise awareness of the Philomena Protocol with statutory partners.
The Devon Safeguarding Children Partnership to ensure that the revised Adolescent Safety Framework and Multi Agency Child Exploitation group overseen by the Exploitation Operational Task and Finish Group which sits under the Strategic Sub-Group of the Partnership, is in place by the Autumn of 2024 and that communications and any relevant training is rolled out across the partnership once the revisions have been implemented.
The Devon Safeguarding Children Partnership to explore commissioning options for training to all partners with both statutory and non-statutory responsibilities for children and young people regarding online safety, risks and exploitation.
The Devon Safeguarding Children Partnership to work with Children Family Health Devon (CFHD), Integrated Care Board Commissioners and Integrated Care Board Designated Children in Care Nurse colleagues to resolve drift and delay caused to children and young people in care in having ASD or ADHD assessments completed when they move in and out of the county and to raise awareness across the partnership of the Neurodiversity Pathway.
CAFCASS to consider implementing a mandatory task for all Guardians to ensure that for children and young people subject to Care Proceedings, they have had sight of any Risk Assessments that have been undertaken and that they request Risk Assessments are completed for young people where contextual safeguarding concerns have been identified if these have not already been completed.
The National Safeguarding Panel to consider strengthening existing guidance regarding the use of unregistered placements for Children in Care to build on local policies and the North West ADCS guidance.
The findings and recommendations from this review to be disseminated to all partners via the Devon Safeguarding Children Partnership.