Vulnerable teenage girl became pregnant while in care
A report's raised concerns about safeguarding in placements in Gloucestershire
A Gloucestershire child with complex behavioural needs was groomed and sexually abused by her carer and became pregnant while in care.
A safeguarding review into Child X, who was 15 at the time and cannot be named for legal reasons, has raised alarm over the lack of supervision, safety, and quality of care.
The review found that the basics of safety and containment were not achieved, she was sexually abused, had access to cannabis and tobacco and absconded at times
Child X experienced a traumatic childhood and has complex behavioural and emotional needs which can mean she poses a risk of serious harm to herself and sometimes to other people who are caring for her.
She first entered care when she was nine years old and has lived in dozens of different placements including foster homes, secure unit, and residential care. In October 2021, Child X was subject to a secure order.
The aim of this secure accommodation for Child X was to provide intensive support and safe boundaries to help to manage her behaviours and enable her to move safely to a placement in the community.
However, the secure unit struggled to care for Child X safely and needed Gloucestershire to commission additional external agency care staff for support.
There was a staff to patient ratio of five to one in the secure unit and agency mental health nursing care staff working with her.
The unit gave notice on the placement but there were no alternative secure or suitable regulated community placements available for Child X.
Things came to a head when the secure unit gave 48 hours’ notice to move Child X citing the need for a local child to occupy Child X’s place in the unit, the report said.
Despite making representations to the local council responsible for the secure unit and to the High Court, Gloucestershire County Council says it had no choice but to move Child X, according to the report.
With no other secure or regulated placements available, they put together an emergency bespoke care package for her at Placement One and as an alternative to the secure order a Deprivation of Liberty order (DoL) was granted by the High Court.
The placement identified for Child X was an empty assessment unit which is part of but separate from a semi-independence care provision.
The care staff from the two nursing recruitment agencies that had been working with Child X at the secure unit were commissioned to continue working with her on a staffing level of five to one.
Although this setting was not deemed appropriate, it was clinical, sparse, with no kitchen, and it was unregistered, part of the rationale was that the building was designed to limit possibilities for self-harm which was a risk for Child X.
However, the review heard that despite the imperative for Gloucestershire to secure Ofsted registration as soon as they could there was no possibility of this because of the unsuitability of the accommodation.
The nursing recruitment agencies understood they were supplying temporary care staff who would be under the ‘supervision, direction and control’ of Gloucestershire County Council.
The staff who moved with Child X had been trained and supervised by managers at the secure unit.
In the first 24 to 48 hours, the placement structures and management systems were not established. This was an emergency with the focus on ensuring as stress free as possible a move for Child X.
However, this situation continued for the next nine months.
Records of the commissioning process for the care staff are poor and staff and managers in the agencies and in the commissioning team have now left their organisations, so some key managers were not available to contribute to the review.
There is no record that Gloucestershire undertook their own due diligence checks on the agency care staff, presumably relying on the secure unit to have done these previously.
The children in care nurse was concerned that the placement could not meet Child X’s health needs and they struggled to obtain information to formulate assessments and plans for her.
At one time Gloucestershire had developed an Intensive Recovery Intervention Service (IRIS) for children in care with complex needs but this service no longer exists.
Even the basics of safety and containment were not achieved, she had access to cannabis and tobacco, she absconded at times, according to the review.
She was groomed and sexually abused resulting in pregnancy. In the absence of clear boundaries, it appears that Child X took control of the unit, the report says.
She would choose which staff she would ‘allow’ on shift and make others stay outside in their cars for their entire shift.
This need to take control is often a response to a lack of stability or feeling contained, according to the review.
Child X’s mother highlighted the irony of Placement One being selected as a building that could minimise self-harm but in fact Child X was abused by the staff who were meant to be caring for her.
The review found there was a closed culture at Placement One and such poor culture can lead to harm, which can include human rights breaches such as abuse. There was weak leadership, poor quality of care, poor support and poorly trained staff and a lack of external oversight.
Poor communication hindered the progress of education assessments and plans. The simple matter of obtaining social worker consent for an educational psychologist assessment was delayed for weeks.
Special Educational Needs and Disabilities team was not invited to multi-disciplinary meetings initially so were kept out of the loop and there were significant delays to the review of Child X’s Education, Health and Care plan.
There was a lack of emphasis on the importance of education for Child X. The virtual school was not kept fully informed or included in care planning.
Child X was moved to Placement Two In January 2022 after the commissioning team found a local provider.
That placement was willing to care for Child X but it took several months to find a suitable building for her and then for the provider to be registered with Ofsted with Child X finally moving in June 2022.
Child X refused to move unless her care staff team moved with her and it was agreed that these staff would initially go with her but gradually be replaced by the provider’s own staff.
Placement Two undertook due diligence checks on all the care staff and provided training on a trauma informed approach.
They employed a behaviour support specialist and therapist to work directly with Child X and to support the care staff.
Placement Two effectively took back control from Child X. Commissioning advised them that Child X refused for a manager to be on site, but Placement Two found this untenable and insisted on putting very clear boundaries in place including a manager.
They also did not tolerate Child X dictating which staff were ‘allowed’ to come into the house.
In July 2022, Child X disclosed she was at least three months pregnant.
Further information and disclosures raised concerns that a member of the care staff had abused Child X resulting in the pregnancy.
Agency Two withdrew all their staff and Agency One was not able to provide any more staff willing to work with Child X.
Placement Two found it untenable having staff on shift who were not trained and were not known to Child X and concerned about the viability of their Ofsted registration, they gave notice on the placement.
Placement Two, the new placement (Placement Three) and the midwifery service worked sensitively with Child X and her mother during the transition between placements to support her through the pregnancy and subsequent decision making.
In September 2022, Child X moved to a third placement out of county.
This was registered by the Care Quality Commission as a supported living placement for young people 16 years and over.
A house was identified, and a staff team recruited for Child X and she has remained there since the move.
The report says this placement has seen some positive progress for Child X, the DoL Order has been removed and the staffing ratio reduced slightly.
As this was not a crisis emergency move there was the opportunity to carefully plan it.
Child X told the reviewer that when she was at Placement One the staff did not keep her safe, in fact there were no boundaries in place.
She was sexually abused by staff. She felt she was given anything she asked for, trips out often far afield, expensive meals out, takeaways three times a day and even cannabis.
There was no one that Child X felt she could talk to, the care staff were always there.
In fact, getting all the material things that she asked for while on a DoL order felt OK in her situation.
She asked the reviewer, “if so many professionals were worried about me being at Placement One why did no one take me out of there?”
Child X did not recall any professionals doing unannounced visits as a way of checking the placement.
During the year under review, Child X had two temporary agency social workers and for a very short time a newly qualified social worker was allocated as additional support.
The social workers at that time complied with statutory visiting frequency of 6 weekly visits but she refused to see them if they went unannounced.
Given the high risk and vulnerability of this placement there should have been more frequent social work visits and oversight, the review says.
The review found that there were no professionals involved with Child X during this period with whom she could have had a trusting relationship or who knew her and her story well.
Child X’s mother tried to voice her concerns about Placement One and challenged her access to cannabis but in fact she felt blamed and suspected of providing the drugs herself.
She recognises the challenges in caring for Child X and is concerned that by missing out on education Child X has not been able to develop basic academic skills or normal peer relationships and has many challenges ahead of her in adulthood.
Child X’s mother felt she was not listened to or involved and is not entirely sure about how much of a role she can play in her child’s life in care.
The review found that lines of accountability and responsibility for planning and decision making was unclear which resulted in confusion and lack of action with staff being unclear about their roles and responsibilities.
Ultimately this led to a fragmented approach to Child X’s care where she took control of her immediate environment and decision making herself.
The report also said that while this case is extreme and highly complex it is not unique.
It reflects the national problem of a growing gap between the complex needs of children in crisis and the range and availability of services to meet their needs including secure accommodation and children’s mental health services, the report concludes.
Ann James, executive director of Children’s Services at Gloucestershire County Council, said they accept the reviews’ findings and are implementing changes to ensure children are safeguarded in future.
“It is appalling that this young person suffered abuse by someone in a position of trust, and we welcome the custodial sentence imposed by the courts,” she said.
“We know that more could and should have been done to ensure their safety and have taken action to improve commissioning arrangements for children in similar situations.
“We accept the findings of this review in full, and we are implementing the recommendations to ensure children and young people are safeguarded in future.”