The following conclusions are presented in response to the specific terms of reference agreed for this review and based on the information provided above. It is acknowledged that in a number of agencies there have been significant changes in practice and policy since the time covered by this review and that a number of the issues raised may not reflect current practice and procedure.
Overarching Aim
• How effective were multi agency safeguarding and risk management arrangements upon the identification of the nature and subsequent management of REYNOLDS’ risk and offending, covering the time period from 1st January 2008 until 31st May 2013
Multi-agency safeguarding and risk management arrangements were not effective following the January 2008 offence. Three multi-agency safeguarding meetings took place but these were narrow in focus and failed to ensure that the protective measures identified were followed through. Not all relevant individuals were considered within the process and relevant agencies were excluded.
One multi-agency Professionals meeting took place where the need for multi-agency working and risk management was acknowledged but not followed through. Lead responsibility was never clearly defined and acted upon by any one agency although in my view, at various times Police, Children’s Services and YOS might have been
expected to fulfil this role.
In the absence of a clearly co-ordinated approach the work undertaken in respect of REYNOLDS following the offence in 2008 was disjointed, lacked focus, did not include a clear multi-agency risk management plan and was restricted to single agency, short term perspectives. Some risk management measures were identified and put in place but it seems that these were never monitored or reviewed for their effectiveness. At no time did all relevant agencies meet together. Some independent information exchange also occurred between agencies but this was inconsistent and led to some discrepancies in the understanding of and access to relevant information between agencies.
In the absence of clear communication between agencies there was an over reliance upon REYNOLDS’ own reported account of issues relevant to risk and safeguarding despite awareness that his accounts could be unreliable and he was manipulative and selective in the information which he shared.
My own sense is that there was some ambiguity within agencies between
acknowledgement of the risk which REYNOLDS posed and the need to consider the potentially negative impact upon him as a young, first offender, of responding fully to that
risk.
In the absence of statutory supervision of REYNOLDS some key agencies lacked authority in dealing with him and despite ongoing concerns at the termination of their contact with him, closed the case without responding to those concerns.
When REYNOLDS once more came to the attention of the Police links were not made with the 2008 offence so that an opportunity to identify and respond to an emerging pattern of behaviour was missed.
To be achieved by reviewing the following:
• The investigation into the offence reported in 2008 focusing in particular upon the basis of the decision making and the management of risk
In my view there are serious concerns about the quality of the investigation into the 2008 offence by REYNOLDS and subsequent enquiries relating to the assault upon
REYNOLDS and the incident at the service station by REYNOLDS in 2011. These are largely internal police issues but they had an impact upon subsequent multi-agency working.
It is my view that there was a sufficient level of concern and information available about REYNOLDS’ behaviour to have prompted a more thorough investigation of the 2008 offence. This should have been considered in the context of both better understanding of the nature of the offence and the motivation for it as well as the impact of any outcome upon opportunities for future risk management.
Within the 2008 offence procedures were followed in terms of liaison with YOS following the decision to consider a final warning. The Police had a presence at the professionals and safeguarding meetings where some concerns were expressed about the decision to issue a final warning.
In the absence of clear multi-agency working consideration was not given by the
appropriate agencies to the possibility of influencing the outcome of the 2008 offence, in order to facilitate work and a greater degree of influence and control over REYNOLDS.
• Were the views and concerns of REYNOLDS’ parents considered in any assessment of his risk?
JLS and CAMHS did have contact with REYNOLDS’ parents and were aware of their concerns when undertaking assessments. CAMHS maintained contact, especially with REYNOLDS’ , throughout the period of their involvement with REYNOLDS and seemed to depend upon her for information about the actions and decisions of other agencies.
Children’s Services did not undertake any assessment of REYNOLDS although it would have been appropriate for them to do so and they had no contact with his parents other than one meeting with the to discuss .
YOS appear to have had some limited contact with REYNOLDS’ parents. In addition, having concluded at the end of the final warning period that REYNOLDS represented a high risk of harm, this information appears not to have been shared with either
REYNOLDS or his parents.
Although it would have been usual practice to involve them in assessment and review, the NSPCC did not record having contact with REYNOLDS’ parents and he refused to
allow them to see the final report written by the NSPCC worker. I understand there was a ‘views of the parents’ form completed by the but this does not appear to have been used during the course of contact with REYNOLDS. There is no explanation given but it may be that HC4 felt she had to respect REYNOLDS’ wishes as he was now eighteen years old and that as a voluntary client, she did not wish to alienate him when he clearly did not want his parents involved. Had contact been made HC4 may have had a clearer picture of REYNOLDS’ capacity for invention and of creating ‘victim’ situations for himself.
REYNOLDS’ parents were given a number of responsibilities in managing this case but it seems they received little support or ‘follow-up’ other than by contact with CAMHS. I am not aware that the protective measures which they were asked to put in place were ever reviewed or monitored with them.
During the course of his contact with CAMHS and the NSPCC, based on his own reports, REYNOLDS’ parents were identified as negatively impacting upon REYNOLDS’ well being but I have no information to indicate if there was any evidence to support this viewpoint.
At the point where contact with CAMHS ended REYNOLDS’ parents had no reason to believe there were any ongoing concerns or outstanding risks in relation to REYNOLDS and they were being encouraged to show more trust in REYNOLDS and to respond to him more appropriately in terms of his age and maturity.
• Were the views of the victim of the 2008 offence considered in relation to any assessment of his risk
The victim was not contacted by any agency to seek her views with regard to any assessment of risk.
Following the provision of her statement to the police, they notified her by phone of the issuing of the final warning. It is unclear if the Police sought to obtain her consent to YOS contacting her during the course of the final warning process but it is clear that she was not contacted by YOS at any time as part of either the assessment process for the final warning or the programme of delivery, although this would have been appropriate in terms of the relevant guidance. I understand that at this point in time contact with a victim would not have been viewed as usual practise within the area.
Alison was also contacted following an assault on REYNOLDS to which it is believed she was a witness but she refused to give a statement.
In the absence of any significant contact with Alison I do not believe her views were known to anyone or the impact of the offence upon her recognised. When Alison complained about REYNOLDS’ comments and behaviour towards her there is no evidence that any action was taken.
Alison was not considered in the context of safeguarding procedures although it is clear that she should have been.
• What was the process of escalation within each of the agencies at the relevant time and was this process used effectively in relation to the particular issues raised between agencies?
involved appear to have felt that there were unresolved issues or concerns either during the course of their involvement in the case or at the point of closure. As a result the process of escalation was not tested.
It is concerning that differences in viewpoint regarding the outcome for the 2008 offence were not fully acknowledged or explored and it seems the individuals concerned did not seek to escalate the matters within their own agencies.
In addition, despite on going concerns regarding risk at the point of closure of the case within YOS and the NSPCC these were not responded to and there is no indication that the staff involved or their supervisors took any steps address these concerns and to identify any steps which could be taken.
It is acknowledged that for both agencies opportunities were limited due to a lack of any statutory involvement with REYNOLDS but both gave consideration to and then failed to follow through, the idea of consultation with the MAPPA co-ordinator through whom opportunities to respond to their concerns could at least have been explored.
• What was the process around consideration of a referral into MAPPA for each agency involved?
Referral to or consultation with MAPPA was considered at various stages by the Police, Justice Liaison Service, YOS and the NSPCC.
It is unclear why Police and JLS did not proceed with a referral. Within both agencies it seems that this decision was based on the views of individuals and not as part of any specific policy or procedure.
YOS concluded that the case did not qualify for referral and although the basis of this was understood, it is not clear who made this decision, although the matter was appropriately discussed between the social worker and their supervisor, during supervision. Further consideration was given to consultation with the MAPPA co- ordinator at the closure of the case but this was not followed through.
The NSPCC were notified by YOS that the case was not eligible for referral and accepted this although the social worker and their manager did conclude that consultation with MAPPA would be appropriate towards the point of closure. This was never followed through.
• What was the intended purpose of the Professionals meeting, was its purpose met, what mechanism was identified for disclosure to victims and families and how effective was the disclosure process to those that may have been at risk of harm as identified within the professionals meeting? The Professionals meeting was called appropriately and did represent the first attempt to draw together relevant agencies and to consider risk and future assessment. In my view it was incomplete in terms of membership and the failure to consider all relevant issues. In addition there was no follow up to the meeting so that in effect it took place in isolation and agreed action was not followed through.
The meeting appears to have recognised the need for multi-agency risk management but concluded without having ensured this was in place with no lead agency or mechanisms for continued multi-agency risk management being identified.
The Children’s Services Strategy meetings which followed were not linked to the
two potential victims identified from the photographs was for the social worker (rather than the police) to meet with them but she was to be intentionally limited in terms of the information conveyed, to the extent that in my view it did not provide any protective element. In regard to the second of these two victims despite it being agreed contact would be made, this was never followed through.
Additionally, whilst there was some consideration of potential risk to REYNOLDS’ r and some steps taken to assess this, it was never followed through and the final
assessment of risk was based solely on the parents view.
Wider risks and potential victims beyond these three females were never considered, although it would have been appropriate to do so.
• How effective was the agency management of transition from young person to adult in terms of risk management?
The only agency which had contact with REYNOLDS leading up to and following his eighteenth birthday was the NSPCC although in reality all relevant contact took place after his eighteenth birthday in November 2008. As a result it was accepted that
REYNOLDS should be treated as an adult and his wish that information about him should only be shared on a limited basis was respected.
The consequence of this was that a number of issues raised by REYNOLDS which I consider may have been relevant to an overview of risk, where not tested and
REYNOLDS’ sometimes unreliable account of his situation was accepted without question.
In addition, it meant that at the point where the assessment by HC4 of the NSPCC was completed, indicating the need for significant further work with him, REYNOLDS no
longer fell within the remit of either YOS or CAMHS who had been the two other agencies working with him directly and the NSPCC were operating in isolation.
• Test out current pre-court decision making processes for their effectiveness. This area of work has not been fully considered in the context of the work undertaken to date, which has largely focused on events in 2008 to 2010. The SMB need to give
consideration as to whether they still wish this work to proceed and if so, by what means. • Test out current LSCB procedures for their effectiveness in respect of the
issues raised in this case. As above
• The process to be completed by the end of February 2014, with individual agency reports completed by the 15th November, 2013