Serious Case Review into Child Sexual Exploitation in Oxfordshire: from the experiences of Children A, B, C, D, E, and F Approved by the OSCB February 26th 2015 Update14.3.15 Independent Reviewer: Alan Bedford MA (Social Work), Dip.Crim FOREWORD i. What happened to the child victims of the sexual exploitation in Oxfordshire was indescribably awful, and a number of perpetrators are serving long periods of imprisonment following the investigation known as ‘Operation Bullfinch’. The child victims and their families feel very let down. Their accounts of how they perceived professional work are disturbing and chastening. There is clearly a demand to find out how such extensive abuse could have continued for so long before it was properly identified, and why there was not speedier action. There was a strong public reaction last year and this year to two Rotherham inquiries (which were not Serious Case Reviews) and to similar concerns reported elsewhere, and there have been calls in such cases for individuals to be held to account. ii. The Serious Case Review (SCR) has seen no evidence of wilful professional neglect or misconduct by organisations, but there was at times a worrying lack of curiosity and follow through, and much work should have been considerably different and better. There is little evidence that the local understanding of child sexual exploitation (CSE), or how to tackle it once identified, was significantly different from many parts of the country. iii. On the surface, many of the illustrations described in the report can seem like professional ineptitude, unconcern, or inaction. They become more understandable when put in the context of the knowledge and processes at the time, practical difficulties around evidence, and a professional mind-set which could not grasp that the victims’ ability to say ‘no’ had been totally eroded. However, understanding it does not make what happened right. The analysis of ‘why’, on the surface, there was inexplicable behaviour by organisations is to explain, not excuse. It is in understanding the context in which professional work took place, and what impacted on the thought processes and actions of staff, that there can be learning for individuals and organisations. This is the prime purpose of an SCR. The answers to ‘why’ cannot be reduced to a few simple sound bites, as there are many complex interlocking issues, which are described in detail in the Review. iv. The County Council and Police have apologised for not preventing or stopping the exploitation, (and some agency and multidisciplinary arrangements should indeed have been better). The Chief Constable apologised that it took so long to bring the offenders to justice, and said she was “sorry that we did not identify the systematic nature of the abuse sooner, and that we were too reliant on victims supporting criminal proceedings”. The Chief Executive for the County Council said that, “we would like to publically apologise for not stopping this abuse sooner and to reassure everybody listening that we have learnt a huge number of lessons in terms of how to tackle this type of abuse and that we are now taking decisive action to stop it happening in Oxfordshire”. The attitude seen by the Review is not one of denying the scale of abuse or the errors, but an acceptance of what was missed and a determination to ensure things are better. v. This SCR is not an ‘inquiry’, but does identify where there is evidence that things were not good enough. The fact that scores of professionals from numerous disciplines, and tens of organisations or departments, took a long time to recognise CSE, used language that appeared at least in part to blame victims and see them as adults, and had a view that little could be done in the face of ‘no cooperation’ demonstrates that the failures were common to organisational systems. There have been similar cases to those in Oxfordshire, most notably in Rochdale, Derby, Bristol and Rotherham. The same patterns of abuse are seen, the same views of victims and parents, and similar long lead-ins before effective intervention. For all this everywhere to be the result of inept, uncaring and weak staff, and leaders who need to go, seems highly improbable. The overall failings were those of a lack of knowledge and understanding around a concept (of CSE) that few understood and where few knew how it could be tackled, but also of organisational weaknesses which prevented the true picture from being seen. It is important this is recognised so organisations can, and can continue to, get it right on CSE, and can respond better when the next new challenge occurs. vi. There were many errors. Some organisations and some staff should have acted with more sensitivity, rigour, imagination or indeed common sense. Some processes and procedures should have been implemented much better, and the collective agency work around safeguarding before 2011 should have been much stronger. Over a number of years there were many signs of CSE of the type revealed in the Bullfinch trial, and whilst they were not recognised as ‘CSE’, the extreme nature of those signs required concerns to be escalated to top managers, but this did not happen. Even if what had been happening were unconnected individual cases, the effectiveness of professional work was not good enough. The abuse, as a result, continued for longer than could have been the case. vii. The issue in Oxfordshire was not very top management and governing bodies knowing about CSE and not acting, but that they didn’t know there were cases being dealt with that were showing indications of CSE, even if not defined or recognised as such. viii. While much should have been better, professionals working with the families concerned, over many years, worked relentlessly (if not always very effectively) to fulfil their professional duties to the victims and their families. Ultimately, it was the efforts of staff on the ground, and their observations and persistence, which was the main driver in the eventual identification of CSE. ix. Five of the seven convicted perpetrators were of Pakistani heritage. No evidence has been seen of any agency not acting when they should have done because of racial sensitivities. The victims were all white British girls. x. The vast majority of the information for this SCR has come from the agencies’ own internal reviews, so the accounts of any deficits in performance have come from the agencies themselves voluntarily, and reflect a laudable willingness to be open about the past. They were equally forthcoming when the author made additional inquiries. The learning in Oxfordshire has already been significant, with much good practice now in place, and a professional mind-set now attuned to CSE, with children seen as children, however they behave. There is a growing arsenal of tools to identify, prevent, disrupt and prosecute CSE. Operation Bullfinch and subsequent prosecutions have shown concerted and rigorous action. xi. This Review focuses on what can be concluded and learned for the system overall and about the period leading up to Operation Bullfinch, and includes an overview of progress since. In an associated document, ‘CSE in Oxfordshire: agency responses since 2011’ the detailed learning identified by each agency is set out, together with key actions taken and points of contact for further learning. Alan Bedford, Independent Reviewer February 2015 Para Page Foreword 1 SUMMARY AND INTRODUCTION 1 1.1 Summary of findings 1 1.11 The need for a Serious Case Review 2 1.13 Terms of reference 3 1.18 Independent Reviewer 3 1.19 Review process 4 1.23 Anonymity 5 1.26 Report structure 6 1.28 Definition of CSE 6 1.29 Terminology around ethnicity 7 2 BACKGROUND 8 3 THE EXPERIENCE OF VICTIMS AND THEIR FAMILIES 11 3.1 Introduction 11 3.8 Vulnerability 12 3.9 Experiences after grooming 12 3.10 The victims’ experience of professionals 13 3.12 The parents’ experience 15 4 IMPROVEMENTS IN OXFORDSHIRE 19 4.5 OSCB overview 19 4.6 Leadership commitment 20 4.15 Countywide service improvement 22 4.20 Investigation, disruption, prosecution 24 4.25 Community relations 24 4.26 Involved agency progress 25 4.34 The views of girls currently at risk 30 4.38 Moving on – an apology 31 5 WHY THE DELAYED INDENTIFICATION AND ACTION ON CSE? 32 5.1 Introduction 32 5.4 Why the delays? 32 5.6 Knowledge 32 5.13 Language 34 5.19 Consent and age 35 5.26 The nature of the families 37 5.38 Levels of cooperation 39 5.46 Crime/No crime and evidence 40 5.60 Lack of curiosity and rigour 44 5.68 Disruption 46 5.72 Escalation 47 5.85 ‘Nothing can be done’ 50 5.88 Missing persons management 51 5.103 Pressures in Children’s Social Care 54 5.111 Supervision 57 5.112 Working with the parents 57 5.114 ‘Professionalism’ 58 5.115 Looked After Children processes 58 5.128 Assessments 61 5.130 Use of Child Protection procedures 62 5.135 Minutes and meetings 63 5.136 Donnington Doorstep 63 5.139 School-related issues 64 5.144 Drug and alcohol issues 65 5.146 Summary of health issues 65 5.149 Taxis 66 5.150 The whole multi-agency team 66 5.151 Ethnicity 67 5.154 Summary 67 6 WHAT MIGHT HAVE BEEN KNOWN ABOUT CSE? 68 6.1 Introduction 68 6.2 Guidance 68 7 ORGANISATIONAL AND LEADERSHIP AWARENESS 74 7.1 Introduction 74 7.2 Priorities 74 7.5 Oxfordshire’s journey 75 7.6 The Oxfordshire Safeguarding Children Board (OSCB) 75 7.25 The growing awareness in Oxfordshire 79 7.66 Top of the office knowledge 89 7.71 Operation Bullfinch 90 7.73 Comment 90 8 APPRAISAL AND LEARNING 92 8.1 Introduction 92 8.3 Learning points 92 8.4 Were