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Serious Case Review (SCR) analysis 2020 for the education sector: Adolescents

Wellbeing in adolescence is influenced by early childhood and can in turn influence adult health and behaviour. There are many sources of risk and harm for adolescents and understanding the nature of this requires professionals to understand the child’s family, social and community networks.

In the SCRs analysed here, 44 per cent involved risk-taking or violent behaviour and child sexual exploitation (CSE) as the cause of serious harm. Both exploitation and social media use have, in this review, arisen as significant emerging risks and pathways to harm.

Going missing

Professionals face many challenges when working with adolescents who go missing. Some adolescents repeatedly go missing and some refuse checks on their wellbeing when found. However, they go missing for a reason and it should be seen as a signal that all is not well.

Children who go missing regularly are an increased risk of harm, particularly of being exploited by others.

There is statutory guidance in place to safeguard children missing from home or care, and for when they go missing from school.

Case example: Assessment of underlying issues

Reece was a 16-year-old White British boy who died by suicide whilst looked after in a children’s home. He was part of a very large sibling group. His parents received disability-related benefits and the family lived in poverty. He experienced abuse and neglect throughout his childhood and witnessed domestic abuse and alcohol misuse. He became looked after by the local authority at the age of 10 years and was initially in a long-term foster care placement for seven years. During that time, he attended school regularly and achieved well, participating in many school activities. His parents regularly missed contact meetings and eventually stopped any contact with Reece for some years but he continued to have regular contact with his maternal grandmother.

He moved to a children’s home after an escalation in going-missing episodes, substance misuse, self-harm and excessive consumption of high-energy drinks. Reece had multiple presentations to A&E with serious self-harm. He sometimes shared images of the harm on social media. He attempted suicide several times and disclosed to practitioners his feelings of rejection, being unwanted and unloved. He went missing from foster care, school and the children’s home where he was placed during the latter part of his life. During ‘missing’ episodes, he had increased substance misuse and self-harming behaviour.

When found by police they appeared to complete interviews with Reece (when he was willing) in line with local procedures at the time. They diligently completed vulnerable child forms requesting urgent assessments and review of plans but there was little discussion between other agencies and the police. After every missing episode, he returned to the same environment. Reports collated when he self-harmed or went missing focused on his immediate circumstances and feelings rather than underlying issues.

It is up to professionals working with children and young people to be professionally curious about the underlying factors prompting episodes of going missing and seek opportunities to assess this – school staff are particularly well placed to do this given the existing relationships established.

Upon being found, a ‘prevention interview’ should be conducted by the police to check that they are safe and well.

In addition, the local authority has a statutory obligation to provide an independent ‘return-home interview’ within 72 hours of their return.

Prevention and return-home interviews should focus on the child’s voice and explore underlying risks and concerns. However, children do not always engage with these interviews and they are not always conducted effectively as a ‘reachable moment’ in taking meaningful protective action.

Focus on: Children missing education

Statutory guidance exists to make clear the expectations and responsibilities of parents, schools and the local authority to manage those who may go missing from education. However, in some cases analysed, a child going missing from education was not treated in the same light as a child missing from home would be. There was a subsequent failure to be professionally curious and take protective actions.

One child went missing from education when just 10 years old. She was seen walking to school but did not arrive. The school reported the episode to the police and she was found. It was known that she had a much older ‘boyfriend’, an adult male, but despite her young age, a decision was made to take minimal action and log the incident for information only:

This event was perceived as an isolated incident and primary education indicated this was an initial event, having previously had no problems with her. There is no multi-agency evidence to suggest that any further risk assessment or interventions were considered at the time, in line with either safeguarding or missing children guidance. Whilst she was seen by the police officer there is no evidence she received a formal safe-and-well check on recovery. Current guidance is not clear whether this would be offered when children go missing from education, as happens when they go missing from home or care, which could be an inconsistency in practice.


In the cases reviewed in this analysis, it was evident that exploitation can occur in a range of circumstances, including when a child is missing from home, care or education. Harm can be complex and cumulative in these cases and it is important for education professionals to understand the nature of exploitation and recognise the importance of early intervention and assessment.

Child criminal exploitation

Adolescents vulnerable to exploitation may have had early experiences such as abuse and neglect, witnessing domestic abuse, parental mental health issues, parental substance abuse and parental separation or loss.

Case learning tells us that professionals often see adolescents as being to blame for exploitation as a result of their risky behaviours.

A combination of a lack of confidence in support services, a will to be more independent and experience of abuse in the home can push an adolescent to seek a sense of belonging outside the home, thus exposing them to potential exploitation and gang activity.

Criminal exploitation in the four SCR cases reviewed, revealed a close link to education and school factors such as having special educational needs, multiple fixed-term exclusions, managed moves, permanent exclusion, attendance at a Pupil Referral Unit and a poor attendance record.

In efforts to avoid criminalising of young people, schools in these cases may try to manage concerns in-house. However, this means that other agencies are not aware of concerns and leads to fractured perspectives.

Child sexual exploitation (CSE)

CSE continued to be a notable theme in this analysis, present in nine per cent of the SCRs reviewed.

Even in the context of much guidance and national attention to the issue, professionals remain slow to recognise vulnerabilities to CSE and respond to the risk appropriately.

This risk of failure to recognise risk is even greater when the child is male, with reviewers reflecting that were male children female, professionals would have taken disruptive and protective action more urgently.

This may be compounded by males finding disclosure more difficult and professionals should consider how they create opportunities and reassurance for disclosure.

Non-statutory agencies with established relationships or experience in working with those at risk of exploitation may be better placed to provide support to vulnerable adolescents, and this may include schools.

Case example: Good practice by schools

Often school staff identified and referred adolescents to children’s social care and worked closely with other agencies. In one example of supporting a male who had been sexually exploited, a school was cited for its good practice:

‘School was ‘a beacon of good practice’ – worked closely with parents and pupils, put in place practical measures and ensured other agencies were kept informed.’

In a further example of good practice, staff at one primary school were particularly proactive in collecting Child S from home when she was not brought to school and her secondary school provided new shoes and a uniform. However, it was not possible for the secondary school to provide the same intensity of support as that experienced at primary school. Nonetheless, the secondary school actively sought to develop a positive relationship with Child S and contacted other agencies to express their concern for her welfare.

Harmful sexual behaviour (HSB)

Seven SCRs were analysed in the review in which the adolescent displayed HSB, reflecting the impact of their own trauma.

Learning from cases of harmful sexual behaviour tells us that a child’s experience of maltreatment is often present in the history and experience of those who display HSB, and professionals should not assume that it is always a result of their own sexual abuse.

Case example: Good practice by schools

A 17-year-old boy who originated from the Caribbean, died from stab wounds. He was brought up in a family where the father had been in prison for drug offences and later deported. His mother had fled her home country due to violence. She had also experienced domestic abuse in her relationship. She had overstayed her visitor’s visa and had no recourse to public funds until a year prior to the fatal stabbing of her son. The family lived in poverty and poor housing, which exacerbated Carlton’s chronic health condition and affected his social and emotional development. They were eventually offered new accommodation funded by the No Recourse to Public Funds (NRPF) team.

The boy had low-level special educational needs and saw the school counsellor as he felt depressed. His behaviour at school deteriorated. At age 15, he sexually assaulted a young girl with a group of peers but the case did not proceed to prosecution, as that would ‘have a disproportionate adverse impact on his future prospects’. A year later he was involved in another rape of a young girl. It took a year before the case was put to the Crown Prosecution Service. This time a decision was made to proceed and he was awaiting trial at the time of his death. He did not receive a specialist service for children who display harmful sexual behaviour as the cost was deemed prohibitive by the NRPF team.

He worried about his safety in the community and felt threatened by local gangs. He was the victim of a mugging and a stabbing prior to the fatal stabbing. He believed he was being watched at college by a gang member and was given a personal alarm by the police. There was confusion as to which council Carlton resided in and therefore he was without agency monitoring and support during the last few months of his life.

A history of limited contact with, or involvement of the father, was present in almost 60 per cent of the cases reviewed. Poor parenting or ambivalence of caregivers was noted as a feature in other cases.

Criminalisation of adolescents displaying HSB may not be appropriate or effective in preventing further such behaviour. Educative and therapeutic work with children involved is needed to ensure an understanding of its harmful effects.

Long delays in the criminal justice system create uncertainty about the seriousness of an incident and are not helpful for young people.

Professionals should consider contextual safeguarding and the aspects of a child’s life that may pose a risk, being prepared to intervene to protect them beyond their home or school life.

Focus on: Children missing education

It is recognised that sharing images can increase the risk of exploitation and other harm, but the seriousness of these risks was not always recognised by professionals.

In one example, a school’s safeguarding lead contacted the key social worker advising that inappropriate videos had been seen on a boy’s mobile phone. The safeguarding lead was advised to bring the phone to the next CIN meeting and to hand it to the police. Feedback from the practitioners was that this related to the boy having taken inappropriate pictures of a girl on her mobile phone in the family home. After the phone had been seized the images were viewed by the police. The risk assessment outcome at the time was that this had been an isolated incident which did not warrant further action. It was understood that the boy had been coerced into taking the pictures by a third person on the phone and the incident was not perceived to pose an ongoing risk.

Whilst it is important to minimise criminalisation of young people, coercion by a third party is a criminal offence and statutory agencies should have considered addressing the offender and treating this as a safeguarding incident.

Social media and technology harm

Adolescents are increasingly using social media to communicate, explore friendships and find information.

This can have a powerful effect, especially in the absence of educative work to counter harmful messages that they experience.

Adolescents are more likely to use social media to find a sense of identity and belonging where they feel disconnected from friends and family, potentially exposing themselves to harm, exploitation and grooming from those they come into contact with.

Use of social media can, conversely, increase feelings of loneliness especially when experiencing online bullying.

Monitoring internet and social media use is often not practical, given the potential for multiple device and account access, so cannot in itself be a practicable protective measure.

Where risk is understood by professionals, it is difficult to know how to address concerns other than recording them – leading to a lack of learning interventions with young people, or professional curiosity as to any underlying factors.

Key learning for education

  • Going missing is a powerful signal that all is not well in a child’s life, and should prompt professional curiosity to explore underlying concerns and risks.
  • For children missing from education, guidance must be followed as detailed in Keeping children safe in education (DfE, 2019).
  • Adolescents who are victims of exploitation are vulnerable and have often experienced other forms of abuse or neglect in their lives.
  • Working to support these adolescents requires trust and established relationships to be effective and accepted. Schools remain well placed to build and nurture these relationships.
  • No agency can address CSE in isolation; agencies must work together where there are concerns about an adolescent – a will to prevent criminalisation should not hamper information sharing to prevent ‘fractured perspectives’.
  • Learning interventions are crucial for those engaging in harmful sexual behaviour; reliance on the criminal justice system to provide this is not adequate.
  • Being a victim and a perpetrator can be closely related and both require support and safeguarding.
  • Professionals must be aware of the link between sexting and exploitation, considering the potential for bullying and blackmail.
  • Social media may provide a sense of belonging and identity, but can conversely widen the feeling of isolation and loneliness experienced.
  • Young carers can experience loneliness and isolation to a greater extent than other groups; efforts must be made to establish whether children are young carers and support put in place for them.
  • The use of social media by adolescents can be complex and difficult to supervise and manage; education is key to help individuals understand the risks.

Questions for education settings to consider

  • Are your policies and procedures on responding to children missing education understood and enacted?
  • For children who are reported missing, how confident are you that your current processes encourage an exploration of wider risk factors and issues? Is this process supported by statutory agencies?
  • What training have staff in education settings received in the different forms of exploitation, and how to identify them?
  • Are staff sufficiently aware of and alert to the difficulties that boys may have in disclosing CSE?
  • In responding to challenging or disruptive behaviour, do you routinely engage the support of specialist staff (e.g. special education needs coordinator educational psychology, virtual school for looked-after-children)?
  • Is your safeguarding training sufficiently localised to consider the relevant contextual factors that the children you work with may experience?
  • How effective is your current provision of education to children on e-safety, social media and grooming?
  • Could parents be usefully educated on online safety and, if so, how might this most effectively be achieved?
  • Do you have processes for identifying young carers and assessing their support needs?