1. CHSCB Torbay Serious Case Review
Brian Boxall
In-Trac Training & Consultancy
Associate

2. INTRODUCTION Case Overview Prevention and early intervention
Disclosure
Children in Care
Offenders
Lessons

3. Serious Case Review C26 Review Period March 2006 –Feb 2011
Op Mansfield Commenced November 2010
Proactive Feb 2011
Two males convicted/cautioned

4. Headlines
'Girls' education and life prospects damaged permanently' by sex predator (This is Devon)
How deprivation led to sexual exploitation in Torbay (The Guardian)
Torbay child sexual exploitation investigated (BBC)
Up to 50 children may be victims of internet sex ring in seaside area Torbay (Daily Mirror)

5. Operation Mansfield
All were resident in Torbay at the time of the offences
Two young people were the responsibility of Devon County Council and were both looked after
Four were children in need
Seven were not known to Children’s Services
Two were young adults (18-24 years)
Two were adults (25+)

6. Victims Reviewed
Two girls were looked after children. They knew each other for a period of three weeks in 2007 when they were in the same foster placement in Torbay.
One girl was involved with the male in 2007, but did not have links with the other girls.
Two of the girls were friends and became involved from 2009 onwards with a number of males, again these girls were not known to the other girls.

7. Lack of awareness by Professionals
Inhibitors
Lack of awareness by Professionals

8. Adolescent Behavior
There was information about the men involved with these three girls which should have been an additional indicator that the girls were likely to come to serious harm in their company therefore it should not have been accepted that their behaviour was that of normal teenagers. (Social Care IMR)
an acceptance that pregnancy and other risk taking behaviour such as substances including alcohol and nicotine was normal and that the vulnerability of the young people especially those who were Looked After was not given sufficient focus and taken full account of.
(PCT IMR)

9. Blaming Young Person
Whilst in some cases the behaviour was accepted as being a feature of adolescence, in others judgemental language was used to describe the young person. The behaviour and its consequences was perceived to be their life choice and they were therefore to blame for the situations they found themselves in. (Overview)
Commonly, the language used (both verbally and in writing) to describe the girls and their behaviours gave the responsibility for what happened to them firmly to the girls themselves – throughout the records and during the interviews there was little sense of the girls as victims, and little sense of the possibility of men grooming the girls. The girls were seen as ‘putting themselves at risk’, ‘using risky behaviour’, and ‘absconding’. What would now be seen as a potential indicator of abuse or subsequent distress was described as ‘bizarre behaviour’. (Social Care)

10. Local Environment
There was a level of acceptance and a sense of inevitability shown by the practitioners interviewed that young people living in these areas of deprivation are at risk of negative outcomes including substance use, mental health problems, poor academic achievement and teenage pregnancy. This level of acceptance can lead practitioners to be less challenging of risk taking behaviour, and a degree of professional inertia and a form of cultural relativity emerges which results in thresholds for safeguarding/child protection interventions being higher than in other areas. (PCT )
Outcome
Vulnerability may be increased due to the social context within which young people live.

11. Intervention Requirement
The focus was too often on stopping the behaviour. For example, the response to sexual activity and drug use led to sexual health and drugs advice being offered by services such as the Children’s Society, but the reasons why the young people were taking drugs or becoming sexually active at very young ages were not explored or addressed. The fact that the young women were being controlled by others and sexually exploited was not, therefore, considered. (overview)
Requirement
Right help at early stage
Assistance to families facing difficulties

12. Prevention & Early Intervention
Vulnerable 
High Risk
Sexual Exploited

13. Discuss
When should the professionals consider the sexual activity of girls/boys as a possible risk?
At what point may this risk be identified?
Is there an age issue?

14. Sexual Activity
“Although the age of consent remains at 16, the law is not intended to prosecute mutually agreed teenage sexual activity between two young people of a similar age, unless it involves abuse or exploitation.
Young people, including those under 13, will continue to have the right to confidential advice on contraception, condoms, pregnancy and abortion.”
Working within the Sexual Offences Act 2003 (HMSO 2004)

15. Sexual Activity
London Child Protection Procedures 2010 Sexual activity with a child under 16 is also an offence. Where it is consensual it may be less serious than if the child were under 13, but may nevertheless have serious consequences for the child’s welfare. In every case of sexual activity involving a child aged 13 to 15, professionals should consider, with their agency’s nominated safeguarding children adviser, whether they should initiate a discussion with other agencies about the risk of harm to the child and whether a referral should be made to LA children’s social care. Professionals should base this judgement on an assessment using the considerations in sections and below.

16. Sexual Activity
In order to determine whether a relationship presents a risk of harm to a child, the following indicators should be considered:
Whether the child is competent to understand, and consent to, the sexual activity they are involved in (children under 13 are not legally capable of consenting to sexual activity);
What the child/ren in the relationship’s living circumstances are, whether they are attending school, whether they or their siblings are receiving services from LA children’s social care or another social care agency etc;
The nature of the relationship between those involved, particularly if there are age or power imbalances;
Whether overt aggression, coercion or bribery was or is involved, including misuse of alcohol or other substances as a disinhibitor;

17. Sexual Activity
Whether the child’s own behaviour (e.g. through misuse of alcohol or other substances) places them in a position where they are unable to make an informed choice about the activity;
Any attempts to secure secrecy by the sexual partner beyond what would be considered usual in a teenage relationship;
Whether methods used to secure a child’s compliance, trust and / or secrecy by the sexual partner are consistent with grooming for sexual exploitation. Grooming is likely to involve efforts by a sexual predator (usually older than the child) to befriend a child by indulging or coercing them with gifts / treats (i.e. money or drugs), developing a trusting relationship with the child’s family, developing a relationship with the child through the internet etc in order to abuse the child;

18. Sexual Activity
Whether the sexual partner is known by one of the agencies as having, or previously having had, other concerning relationships with children (which presupposes that checks will be made with the police);
Whether the child denies, minimises or accepts the concerns held by professionals.

19. Fraser Guidelines
The guidelines state that contraceptive advice or treatment can be provided to a child under 16 without parental consent or knowledge provided that the health-care professional is satisfied:
1. That the girl will understand the advice
2. That they cannot persuade her to inform her parents or allow him to inform the parents that she is seeking contraceptive advice
3. That she is likely to begin or to continue having sexual intercourse with or without contraceptive treatment
4. That unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer
5. That her best interests require him to give her contraceptive advice, treatment, or both without parental consent
(Cornock, Marc (2007). ‘Fraser guidelines or Gillick competence?’ Journal of Children’s and Young People’s Nursing, 1(3), p )

20. Gillick Competence
Gillick competence, on the other hand, refers to the fact that some children under the age of 16 are able to give consent. The key to whether the child can give consent is their emotional and intellectual maturity and their ability to understand the proposed treatment. Those children who are deemed by the health-care professional to be Gillick competent are the ones who can provide consent for the proposed treatment …
It should be noted that the first point in the Fraser guidelines, that of understanding, may refer to the process of determining Gillick competence and it can then be seen that the two terms are not interchangeable. Rather, as shown above, they are two different concepts: Fraser guidelines referring to specific guidance that must be followed by the health-care professional to provide specific treatment to a child, and Gillick competence referring to the ability of the child to give consent.
(Cornock, Marc (2007). ‘Fraser guidelines or Gillick competence?’ Journal of Children’s and Young People’s Nursing, 1(3), p )

21. Challenges when providing sexual health advice
Sexual Activities
Challenges when providing sexual health advice
Practitioners in the Sexual Health Service in particular expressed the challenge they face in maintaining a balance between gathering full and accurate information from the young people without alienating them such that they and their peers become reluctant to use the service, which in turn would put them at risk of sexual infections and unwanted pregnancies. (Health Care IMR)
There are indications that within this local context, sexual activity at young age was the perceived to be normal and the acceptance of risky behaviour by adolescents was high. The focus inadvertently became the requirement to reduce teenage pregnancies rather than the protection of the young person. (Overview)

22. Relationships
All of subjects of this serious case review disclosed to their carers, police or other agency staff that they had been in, or were currently in relationships. Different professionals were in receipt of this information but in most cases no positive action was taken.
Similarly there is no evidence that workers were aware that any abuse was taking place as the girls were returning home of their own accord and were seeing themselves in boyfriend / girlfriend relationships (and therefore not being abused). It appears that the practitioners involved also considered these relationships as consensual, despite some significant age gaps (e.g. with x, aged 25 years). (Social Care IMR)

23. Relationships
While initially posing as ‘boyfriends’, perpetrators may target and approach victims in known areas where young people congregate; such as bus stations, car parks, shopping centres, fast food outlets and taxi ranks, etc. Using flattery, gifts and other forms of coercion, potential victims are treated as ‘grown up’, while the perception of a friendship is instilled. Often a sexual relationship will develop. This will be paralleled by a process of manipulation through, for example, coercion into drug use, enticement to go missing from home for short periods, and subsequent encouragement of family estrangement.
(Cavener (2010) Sexual Exploitation: ‘Internal Trafficking of Children and Young People at risk in the North East and Cumbria1. Final Report to the Northern Rock Foundation: Compiled by John Cavener on Behalf of Barnardo’s SECOS)

24. Response to Disclosure
One of the girls, aged thirteen, made a number of disclosures They included:
Admissions that she was taking cocaine.
Had a large alcohol consumption
Had a boyfriend who had been violence towards her and that he was scary.
She was having sex for drugs
Still referred to her abuser as her boyfriend.
She would not support a prosecution

25. Response to Disclosure
A significant number of the victims would not provide the support required, probably due to a number of factors:
They did not believe they had been sexually abused (the ‘boyfriend’ perception)
They were frightened of the abusers and the repercussions
They did not believe agencies could keep them safe
They did not want to go through the court process and the pressure they might come under as witnesses

26. Response to Disclosure
Agencies response to disclosures must not be totally reliant on the co-operation of the victim and or parents or carers. There was a requirement to make the girls feel safe; they needed to be removed from the situation that they faced. They needed to be dealt with by someone they trusted.
(Rochdale Borough Safeguarding Children Board. /Child Sexual Exploitation Themed Review/ Final September 2012)

27. The Need to do Something

28. Children in Care Assessment of the young Person
The lack of re-assessment of the girls’ needs and the reduced working relationship identified in the quote above appears in this case to have resulted in those responsible for providing care having insufficient background information about the girls. It is evidenced within the individual management reviews, for example, that neither the foster carer nor the school in the Torbay area had any real understanding about the background of the girls, and that this proved problematic when responding to their behaviour. (overview)
Assessment of the Placement
Recommendation 2: Before placing a child in another local authority, the home local authority should, in collaboration with the receiving local authority, make an assessment of the geographical area to determine whether or not it is safe for the child based on what is known about the risks facing the child.
(June 2012) The APPG for Runaway and Missing Children and Adults and the APPG for Looked After Children and Care Leavers REPORT FROM THE JOINT ENQUIRY INTO CHILDREN WHO GO MISSING FROM CARE.

29. Children In Care
Effective joint working between Children’s Social Care and the Health LAC nurses in order to ensure that when the young person changes placement the nurse links in with the local services such as the GP school etc. to confirm that they are aware of the looked after child and their needs. (Overview) There is a need for awareness and continuity, and the Looked After Nurse system has an important part to play.

30. Offenders Had difficult upbringing Similar problems to victims
Fine line between victim and offender

31. Drugs and Sexual Exploitation
Strong links between drugs and sexual exploitation
Drugs used to
Attract
Incapacitate

32. Challenge Lack of challenge by professionals.
Assumptions were made about what other agencies were doing.
Concerns not escalated.

33. Lessons Learnt
Professionals from all agencies need to be made fully aware of sexual exploitation, including how to identify signs of vulnerability.
All professionals should have access to a supervisory relationship within which they can reflect on the biases, values and assumptions that may be influencing their assessments and decisions.
There is a need to identify whether Fraser Guidelines are being implemented correctly along with the Gillick competences.
There is a need to consider the review of the National guidelines in light of the growing knowledge about sexual exploitation.
To review local guidelines in the light of growing knowledge about sexual exploitation

34. Lessons Learnt cont..
There is a need to undertake full assessments of the geographic location and an update assessment of the young person when considering placement changes.
Agencies supervising young people within the criminal justice system need to work with assessment frameworks which enable them to assess fully the potential vulnerability of the individual as well as well as their risk of re offending.
Disclosures of sexual exploitation/abuse must be dealt with as a serious crime in line with procedures. The victim must be fully supported in order to reduce their future exposure to risk.