Independent review publishes findings of death of Sunderland teenagers

An independent report commissioned to look at the common themes and maximise learning from serious case reviews into the deaths of two Sunderland teenagers in 2013 publishes its findings today.

Dr Mark Peel and Dr Trish Shorrock were commissioned by Sunderland Safeguarding Children Board to look at the issues emerging from a number of serious case reviews, covering a period from 2013 to 2015 when services were under particular strain.

Their resulting report calls for a review of services for vulnerable adolescents to protect other youngsters.

Despite these criticisms however, it concludes that the serious case reviews reflect the underlying issues prevalent at the time, namely:

• A safeguarding workforce under considerable pressure both in terms of time and resource, with insufficient leadership direction and support

• resulting in issues around consistency and the opportunity for human error.

• A safeguarding partnership operating at a basic and pragmatic level only, and working in parallel rather than in an integrated cohesive manner.

Responding to today's report, Jane Held, Independent Chair of Sunderland Safeguarding Children Board, said:

"The deaths of both these girls were tragic and distressing. They had a devastating impact on everyone who knew them.

“It is a great sadness for all involved, especially for their families and those providing care to the girls that despite very intensive levels of professional care and intervention, their deaths were not prevented. We want to apologise strongly and unreservedly to everyone for letting them down and failing to protect them.

"We owe it to the girls to learn from what happened in their lives to help improve services to other young people in similar circumstances and try to prevent similar tragedies from happening in the future.

"While there is no evidence to suggest that the deaths were in any way linked there were certain similarities between them which is why we decided to publish the serious case reviews together alongside the independent report we commissioned to identify the key themes."

The report highlights a number of key themes across both serious case reviews:

• Communication within and between agencies

• Issues regarding assessments and assessing risk

• Management and supervision issues

• Records, chronologies and procedures

• Awareness of child sexual exploitation (CSE)

• The importance of the internet and social media

Commenting on the findings, Ms Held said:

"The report and both serious case reviews identified many of the issues and concerns we had already identified and begun to address.

"The executive summaries make it clear that no one agency is culpable for the girls' deaths. They also show there were many dedicated individual professionals working hard to protect and support the girls and minimise the risks they were exposed to.

"Nevertheless we completely accept that the agencies involved in the girls' care acting as their corporate parents did not do enough to support them which is something I deeply regret.

"We wholly accept the findings of the report which identifies important themes relating to child sexual exploitation, the internet and use of social media, working with risk taking behaviours, intervening early in a child's life when problems first arise, and the impact of domestic violence on children's mental health. The quality of assessment and care planning and the absence of strong advocates for the girls were also key issues.

"We know multi-agency services to support vulnerable families, safeguard their children and promote their welfare were not operating well during at this time (2011- 2013). The findings of the reviews and the independent report mirror those of last summer's Ofsted's inspection which found safeguarding services across the board in Sunderland to be inadequate.

"A huge amount of work has been done since then to improve safeguarding across the partnership. This has resulted in a steady improvement over the last year. Plans are progressing to ensure that all the agencies involved provide the services that children, young people and their families need to live safe, happy and healthy lives.

"Extensive work was carried out immediately following the girls’ deaths, during and in response to the reviews themselves and significant progress has been made. This included reviewing the case of every adolescent identified as being at risk of self harm or suicide and providing additional training for those working with young people where there's a risk of self harm or suicide.

"There has also been major investment in and changes to Looked After Children Services and evidence of significant improvement as well as significant investment in the NHS and partners in setting up a specialist multi-agency CSE service (Sanctuary South).

"This improvement has been recognised by Ofsted who noted that significant progress has been made since the July 2015 inspection when they paid their first monitoring visit to Sunderland Children's Services last month to review care leavers services.

"We have strengthened how we work with and support children and young people who are missing and/or at risk of CSE and trafficking, and other forms of risk taking behaviour.

"And we are looking at how we can work with parents, carers, schools and professionals to raise awareness of e-safety and of where people can go for help if they have suicidal thoughts or are self-harming."

Actions taken to address the issues raised in the report include:

• A thorough review of arrangements around CSE and Missing and Trafficked Children

• The appointment of a CSE Strategy Co-ordinator

• A joint missing children protocol with Northumbria Police for children placed outside their local authority area who go missing

• Work in schools and with foster carers to raise awareness of exploitative relationships

• Commissioning a voluntary organisation to complete thorough return home interviews for every young person who goes missing

• Specialist training for social workers around CSE

• Working with the taxi trade, private hire, social landlords, pub watch schemes, bar staff and door supervisors, off licences, takeaways, guest houses and hotels to raise awareness of CSE

The serious case reviews on Young Person I and Young Person K is published on the Sunderland Safeguarding Children Board website here:

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