A schoolboy sectioned after years of drugs misuse, a sexually abused, self-harming teenage girl described as "stroppy" and a large group of youngsters removed from their parents for "chronic neglect"
These shocking stories involving Sunderland children who were failed by the system can be revealed today.
The findings of serious case reviews into three separate matters can be published today, as Children's Services bosses and key organisations look to improve how they deal with issues facing youngsters.
The stories include:
:: 'Mark' - who first started taking drugs aged 11 and who ended up being sectioned under the Mental Health Act because authorities failed to intervene properly at an early age and offer him the right help.
:: Rachel - who wasn't taken into local authority care until the age of 15 despite long-term fears she was being sexually exploited.
:: 'Family X' - who were known to the authorities for 20 years and where a large group od siblings were taken into care in 2014 but whose background should have created a "greater alert" for professionals.
The reviews make various recommendations for all agencies involved with the youngsters - including social workers, police, GPs, health and youth workers.
All of the cases refer to circumstances leading up to the 2015 Ofsted report that branded children's services in Sunderland as "inadequate".
Sir Paul Ennals, independent chair of the Sunderland Safeguarding Children Board - the partnership of various agencies in Sunderland working to keep youngsters safe - said all those organisations involved would be "acting on lessons learnt."
He said: "In the case of Family X, the review group considered the learning from practice over a twenty year period leading up to the removal of a group of siblings from the family home in 2014 as a consequence of neglect.
"Previous case reviews have led to the creation of a major programme of change and improvement in children’s services, so this review audited a number of other cases involved with neglect, to consider how far services are improving.
"The broad conclusion was that whilst there has been much progress, there is further to go before the partnership can feel fully confident that practice in response to neglect is consistently effective. The board has agreed a further programme of work, to develop new tools and processes, and to share these across the partnership.
"The cases of Young Person Rachel and Young Person Mark focus on two highly vulnerable young people whose needs were so severe that they needed to be placed in secure placements in late 2015.
"Rachel was removed from her family through a Secure Accommodation Order at the age of 15, and Mark was sectioned under the Mental Health Act.
"The reviews find much to commend in the care and engagement of the staff who tried hard to meet Rachel’s and Mark’s needs in the lead up to their placements.
"They also recommend some important areas for learning, in the interface between adolescent choice and risk, especially in relation to sexual behaviour and exploitation.
"The Board has agreed to strengthen the skills and knowledge base of staff across the partnership in recognising and responding to sexual abuse within a family where this occurs, and reconsider the services available to support young children who are displaying inappropriate sexual behaviour. The Board is also leading a major piece of work to develop a framework to support practitioners who are working with highly vulnerable adolescents, especially where drug use is involved.
"All the agencies in Sunderland involved with the three cases have reviewed their own practice and are acting on lessons learnt. Sunderland Safeguarding Children Board will monitor the delivery of those actions."
Following the 2015 Ofsted report, a new organisation - Together for Children - was set up to deliver services in Sunderland and recent Ofsted monitoring visits have reported progress being made.
MARK - "NO SERIOUS QUESTIONS WERE ASKED"
The serious case review into 'Mark' revealed that he first came to the attention of agencies as a 12-year-old back in 2013 when his school reported concerns about his misuse of drugs.
Over the next three years, professionals from different services were involved with 'Mark' and his mother due to his "continued and escalating drug use, his offending behaviours and frequest periods of going missing".
But it was not until early 2015 that he was made the subject of a Child Protection Plan and when his mental health began to deteriorate that September he was sectioned under the Mental Health Act and put in a secure setting.
The situation concerning 'Mark' was referred to Sunderland Safeguarding Children Board by the Youth Offending Service as "they were of the view that Mark had suffered significant harm because agencies did not act early enough to safeguard his safety and wellbeing".
A decision by the SSCB that October to carry out a Serious Case Review was challenged by Children's Social Care and so the review did not immediately begin. In May 2016, the incoming interim chair of SSCB said the circumstances met a citeria for a SCR.
The first recorded concerns about Mark's substance mnisuse came shortly after he began secondary school at around the age of 11. Records suggest he had four moves between schools between age of 11 and 13 in connection with his drug use
In May 2013, Mark's school referred his case to Childrens Social Care (CSC) over his persistent use of cannabis and deterioartion in his health and presentatioon. However, it took no further action as a social worker noted Mark and family were working with Youth Drug and Alcohol Project (YDAP).
However, the review said that had CSC had they carried out an Initial Assesement it would have highlighted the difficulty YDAP had in engaging with Mark and mother and father, who did not live with family and worked abroad regularly.
The report said: "There was an acknowledgement that some professionals supported by their agencies can too easily view substance misuse as 'something that young people do these days' and therefore may unwittingly minimise the dangers and risks involved. These early days were an opportunity to better understand what was happening to Mark and to try and identify the reason for his substance misuse so the right services were offered and taken up by the family. This did not happen and Marks vulnerabilities went unrecognised and remained for for almost two years."
Mark's offending and use of alcohol and substances escalated in 2013 and became daily occurrences. He was frequently reported to be using legal highs, including MCAT. Friends said he was too often "out of it" and would take anything to "get high" but the report said little evidence of those concern being responded to which "raises questions about how well young people are listened to."
The review also said that concerns began emerging around this time that Mark was being sexually exploited. "However, as late as 2014 professionals in Sunderland were slow to respond to Mark’s vulnerabilities and the risk of sexual exploitation."
In February 2015 a meeting was told of police reports about the number of times he had gone missing. According to CSC records, there were at least 14 contacts or referrals to children’s services between May 2013 and January 2015 including child concern notifications from the police.
Mark was referred to Intensive Community Treatment Service - a children and young people's service to children and young people who present with mental health difficulties - in September 2015 . The referral was made by YDAP due to concerns that Mark was withdrawn and writing suicide notes. The referral was deemed a priority and attempts were made to see Mark that day. He was eventually seen in late summer 2015 and workers indicated that Mark’s mental health problems were due to his substance misuse and no intervention had been offered other than YDAP.
The review found that, until 2015, there had been little evidence of various agencies working together in Mark's case. It also noted that between March 2013 and Sepotember 2015, he had contact with four separate social workers, some of whom only had "essentially short term" contact with him.
The report said: "At twelve years old and certainly until he was 15, Mark was showing clear signs of being a troubled young person, yet it appears that no serious questions (a seeming lack of professional curiosity) were asked by professionals as to why he misused alcohol and substances, what the underlying reasons might be for such behaviour and what the impact of long term drug misuse could be on his mental and emotional health.
"What emerged from discussions within the Review Team and with practitioners and managers was evidence that for some professionals the interplay between adolescent choice and risk as not well understood nor carefully explored.
"According to various agency records, Mark’s behaviours seem to have been seen as ‘freely chosen, informed, and adult-equivalent’. In one agency report there is reference to Mark making a ‘lifestyle choice’ in terms of his continued substance and alcohol misuse."
The report added: "There was a lack of professional curiosity about Mark’s background, what had happened, and what was happening in Mark’s life, which meant that his behaviour and substance misuse were regarded as ‘the problem’, rather than being symptomatic of other stresses in his life."
It continued: "Some agencies clearly considered risks to Mark in the context of his repeat offending and failure to reach educational targets, but there was no evidence of any shared assessment between agencies about the risks to which Mark was exposed and which were impacting his well-being or future safety and welfare. There is little to evidence however that Mark was assessed during 2013/2014 in terms of his psychological vulnerabilities which, had they been recognised, may have indicated he was at significant risk of mental health problems known to be associated with cannabis and MCAT and other legal highs."
RACHEL- "AT BEST UNRECOGNISED AT WORST DISREGARDED"
Rachel and her family had been known to agencies since she was a very young child.
But as she grew older, concerns about her safety continues amid fears she was being sexually exploited.
However the review team said the impact of such abuse "appears to have gone unrecognised and at worst was disregarded."
However, it wasn't until the summer of 2015, when Rachel was 15, that she was made subject to a Secure Accommodation Order by the local authority, even though she was associating with known sex offenders and involved in substance misuse and self-harm. The review team said they could find no "clear rationale" as to why that didn't happen earlier.
The review also highlighted the problems faced in trying to find Rachel secure accommodation in 2015, with only one offer made despite 170 providers being contacted nationwide.
The report said: "Concerns about parental neglect in the family are first recorded when Rachel was a very young child.
"As Rachel grew older, concerns about the physical and emotional care within the family continued and there were frequent reports about her parent’s lifestyle and that children in the family were often left in the care of a slightly older family member.
"As a result of a concern about Rachel’s sexualised behaviour when at primary school, a social worker undertook an initial assessment, but following discussions with family members no further action was taken. However, concerns about the behaviour of the children in the family continued to emerge."
It continued: "Rachel’s worrying behaviour at such a young age should have alerted professionals to the need for further more detailed assessments, if not under child protection procedures then certainly under child in need arrangements.
"Rachel was diagnosed with ADHD when she was young and the naming of her ‘condition’ seems to have distracted professional’s attention from thinking more deeply about what may have been happening in her life. The Review Team found that the frequent references in agency records to Rachel’s ADHD in relation to her risk-taking and self-harming behaviours indicated that professionals accepted ADHD as a purely objective medical diagnosis.
"There is little evidence to suggest consideration of how the ADHD diagnosis came about and whether the experience and impact of adverse childhood experiences could have better explained Rachel’s behaviours. These issues should have been explored in far greater detail then and in the many assessments to which Rachel was later subjected.
"Upon reading and listening to details of Rachel’s background, it appears highly likely that Rachel was subject at an early age to some form of sexual activity/abuse and yet this and its impact on Rachel as a young child, and as she became an adolescent, appears at best to have gone unrecognised and at worst was disregarded.
"Rachel’s behaviour from such a young age and the nature of that behaviour towards other children was a very clear indicator that she had been subjected to or had witnessed some form of sexual activity and was acting out this behaviour with other children at school."
It went on: "The Review Team could find no clear rationale as to why protective action was not taken earlier for Rachel, i.e. before 2015; she was associating with known sex offenders, misusing substances and openly talking about risky sexual behaviours.
"Practitioners suggested that at the time sexual exploitation of children was not well understood locally or nationally despite statutory guidance being in place since 2009.
"They added that volume of work, poor leadership and a lack of joined up working by agencies meant that work with Rachel just ‘kept on going’, and without any good assessments or effective multi-agency planning, work was not as effective as it might have been. In times of competing priorities it is often work with adolescents that is deprioritised, especially if there is an organisational or sometimes a professional mindset which holds the view that because of their age, adolescents are more ‘resilient’ and can ‘walk away’ from harm, unlike a young child.
"Underpinning this view is an assumption that some of the risks encountered by adolescents are a result of choices that are ‘freely made, informed and adult-equivalent’. The Review Team was interested to note evidence of this assumption implicit even in agency records where Rachel’s behaviours were described as: ‘placing herself at risk’, ‘associating with known sex offenders’, ‘acting impulsively’, and ‘choosing to self-harm’."
It continued: "The view that Rachel was ‘placing herself at risk’ should have been challenged in supervision and professionals supported to be more curious about the reasons why Rachel was behaving in this way.
"A challenge for professionals however was in determining which of the above factors better explained Rachel’s self-harming behaviours. There is evidence that views of professionals were influenced initially by a perception that this was ‘stroppy teenager wanting attention’. Police records clearly indicate this view.
"The Review Team concluded that it was this perception, without analytical assessments, multi-agency collaboration, and challenge and quality supervision, which prevented earlier intervention."
The report also noted: "As late as 2014 professionals in Sunderland were slow to respond to the vulnerabilities of Rachel as a child whose behaviours indicated she was not just at risk of CSE, she was actually being significantly harmed through sexually exploitation.
"Rachel was clearly not just at risk of significant harm, the harm was evident. Agency records highlight that whilst some risks to Rachel were well understood, they were not well managed.
"Rachel was subject to numerous assessments during 2013 and 2015 but the Review Team could find no evidence of any quality risk assessments which sought to identify her needs or which captured views and information from Rachel herself or from other agencies or education. It is these assessments which are so essential to the development of carefully designed and purposefully maintained child in need, child protection plans and safety plans. Although the focus of risk for Rachel centred on sexual exploitation, she was also at risk as a result of her childhood experiences, her disengagement with education and the fact she was misusing substances and alcohol."
The review said that "Rachel was clearly not just at risk of significant harm, the harm was evident." But it added: "Agency records highlight that whilst some risks to Rachel were well understood, they were not well managed."
The review said: "It is clear that until decisions were taken in September 2015 to seek a Secure Accommodation Order, professionals were of the view that risks to Rachel could be managed and the harm to her minimised, but without a robust multi-agency safety or child protection plan, Rachel remained at significant risk and highly vulnerable.
"There is little to evidence that assessments took into account parenting lifestyle, and the family dynamics do not appear to have heightened concerns or led to any assessment process."
FAMILY X - "SHOULD HAVE CREATED GREATER ALERT FOR PROFESSIONALS"
A large sibling group - referred to as Family X - were removed from their parents in late 2014 over "chronic neglect" concerns.
But the family had been known to agencies and safeguarding services for over 20 years.The children had been made subject to Child Protection Plans on two occasions for a total of five years.
The father of the older children in the family had been jailed or domestic violence.
The eldest children were placed on a Child Protection Register more than 20 years ago for a period of over three years, in which time a new male partner moved into the family home.
However, repeated concerns were identified including criminality, drug dealing, non-school attendance, high levelk of accidents suggesting low-level supervision and sexualised behaviour by one or more children.
However, despite being under child protection, the review said "the children remained at ongoing risk from the living conditions and chaotic parenting, all of which had a significant impact in their life chances.
The report said: "For Family X there were many indicators of sexualised behaviours and allegations of sexual abuse that should have created greater alert for professionals."
The case of Family X became the subject of a wider Serious Case Review to examine the wider effectiveness of safeguarding systems for children in Sunderland.