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IICSA published its final Report in October 2022. This website was last updated in January 2023.

IICSA Independent Inquiry into Child Sexual Abuse

Child sexual exploitation by organised networks investigation report


K.3: External inspections in the case study areas

8. There is a clear focus on child sexual exploitation in HMICFRS national child protection inspections. Reports are explicit about the numbers of child sexual exploitation and missing children cases that inspectors review in each area and provide details of how many cases were found to be good, requiring improvement or inadequate. A summary of the main findings in respect of the cases reviewed is also provided. The evidence base for findings on child sexual exploitation and missing children is therefore transparent. The Inquiry focussed on the most recent HMICFRS reports for the case study areas.[1]

9. Unlike HMICFRS, Ofsted does not report the number of child sexual exploitation or missing children cases it reviews. Its records, some of which are in paper notebooks, are not stored in a way that enables it to routinely provide this for its inspections of local authority children’s services (ILACS).[2] Recent Ofsted reports from the case study areas refer only in broad terms to child exploitation and lack sufficient focus on the issue.[3]

10. Findings and recommendations from external inspectorates can act as a catalyst for improvement, provided their input is accurate and evidence-based. However, to do so, the published reports must be sufficiently detailed. Positive inspection reports which do not contain a detailed evidence base hinder the ability of third parties to interrogate and compare their findings with those of other reports. There is a risk that, if the detail underpinning these reports cannot be adequately understood, they can give rise to false reassurance and lead to complacency.

11. One example of this can be found in Ofsted’s inspection of Durham County Council’s children’s social care in September 2019. Inspectors reviewed 18 child sexual exploitation cases plus the case of one missing child where there was a specific mention of sexual exploitation.[4] The inspection rated the experiences and progress of children who need help and protection as requiring improvement. Areas for improvement included management oversight, the timeliness of assessments, the quality of children’s plans and the response to children with disabilities. However, the report made a positive comment about the response to missing and exploited children, without indicating how the wider identified weaknesses impacted on them:

The strength of the local authority’s and partners’ response to missing children and children at risk of exploitation is helping to reduce risks, disrupt the activity of perpetrators and protect children. Children who go missing from home or care are routinely offered return home interviews. Information is well shared and well used. Actual and potential risks are carefully considered, regularly reviewed and closely monitored.[5]

The evidence for this finding was not set out in the report nor was any detail provided about the quality of child sexual exploitation cases reviewed during the inspection.

12. A March 2020 HMICFRS inspection featured criticism of Durham Constabulary’s response to missing children, which was described as “inconsistent and inappropriate for some children”. HMICFRS recommended that the Constabulary “immediately improves practice in cases of children who go missing from home”.[6] Of nine cases involving missing and absent children which were reviewed, one was considered ‘good’, two as ‘requires improvement’ and six as ‘inadequate’. HMICFRS identified limited activity to locate children overnight, children’s cases wrongly assessed as ‘low’ or ‘no apparent’ risk, failure to refer cases to children’s social care, lost opportunities to understand why children went missing and failures to transfer cases onto a computer system.[7] The lack of detail provided in Ofsted’s assessment of the Council and its partners’ performance in respect of missing children makes it difficult to understand the interaction between this and the apparently poor performance of the police as observed by HMICFRS.

13. A further example can be found in the October 2019 review by Ofsted of 10 cases of child sexual exploitation in St Helens plus two other cases where sexual exploitation was specifically mentioned.[8] This concluded that children’s social care in St Helens was “inadequate” overall (and had declined in quality since 2014).[9] The inspection found failings in areas such as the quality of assessments and plans, management oversight and support for children and families on the edge of care. It determined that the “progress of children who need help and protection” required improvement.[10] However, in relation to child exploitation specifically, Ofsted found that:

Children at risk of exploitation are recognised and responded to effectively. Multi-agency child exploitation (MACE) meetings are held to facilitate multi-agency consideration of risk, and plans are put in place to protect children.”[11]

14. Without more detail, it is difficult for the reader to understand the interaction between this more positive finding and the wider failings in the quality of assessments. There is a risk that this can hinder learning and improvement and give rise to complacency.

15. In some cases, the findings of external inspections appear to be at odds with the experiences of children. For example, although the Ofsted inspection of Warwickshire children’s social care in July 2017 identified shortcomings in some areas, such as too many placement changes and inadequate access to Child and Adolescent Mental Health Services (both of which were issues in CS-A1’s case), it found that risk assessments were “detailed and thorough” and that children in care who went missing were “consistently well addressed”.[12] This was not the case for CS-A1.[13]

16. The extent to which criticism by external agencies has driven improvement in the case study areas is mixed.

17. Durham Constabulary’s action plan for responding to the March 2020 HMICFRS report included the introduction of a Children and Family Practice Scrutiny Panel to review police interactions with children on a monthly basis.[14] A deep dive audit carried out in May 2020 reviewed cases across the themes identified by HMICFRS, finding that positive progress had been made but that there were still areas for improvement in relation to the management of missing children investigations.[15]

18. Mr Jim Leivers (Interim Director of Children’s Services at St Helens Council) explained that Ofsted’s 2019 inspection was “a real wake up call for the authority”.[16] In August 2020, an Ofsted monitoring visit recorded that St Helens has continued to invest substantial funds in children’s services – an increase of up to 30 percent – and that changes within the service were starting to improve responses for children and families. This has included increased capacity across children’s services and an increase in quality assurance through audit. Ofsted cited areas which required improvement across different aspects of the service but noted that there had been a concerted effort to act upon and improve the service children receive.[17] The Department for Education conducted a progress review in July 2020 and came to similar conclusions.[18] However, in January 2020, St Helens’ own internal audit found that more than four out of every five referrals were either inadequate or required improvement.[19] Mr Leivers accepted that this was “not a good picture”.[20] It is unacceptable that only 16 percent of referrals reviewed were considered to be good. Risks to children will be missed because of this. St Helens has accepted that there was evidence in the past of poor risk assessments but said that “isolated poor decisions” did not demonstrate generally poor practice and the assessment of child sexual exploitation risks to children was not a particular failing of St Helens even when its children’s social care department was of a much lower standard.[21]

19. In the London Borough of Tower Hamlets inspections, Ofsted inspectors reviewed 28 child sexual exploitation cases, plus two criminal exploitation cases where sexual exploitation was specifically mentioned.[22] The Ofsted 2017 inspection found serious weaknesses in child sexual exploitation and rated children’s social care overall inadequate.[23] A further inspection was carried out in 2019, which rated children’s social care as ‘good’. The inspection found that:

Highly vulnerable children at risk of exploitation, including those missing from home, school or care, receive effective, bespoke services, delivered sensitively by skilled and committed staff. Strong partnerships serve to protect these children from harm. This is a significant improvement since the inspection in 2017, when too many exploited children were left unprotected.”[24]

20. In 2016, HMICFRS inspected child protection in the Metropolitan Police Service, including in Tower Hamlets. Significant failures were found in areas such as the police failing to request strategy meetings when children were at risk and not recognising the links between children going missing and their vulnerability to sexual exploitation. In fact, 36 of the 38 missing cases inspected were found to be inadequate or requiring improvement.[25]

21. The most recent HMICFRS post-inspection review of the Metropolitan Police Service area in 2019 found that there had been structural change and improvements in the approach to child protection. An internal dedicated inspection team was established after the earlier inspection and was found to be a strength. However, the management of online child sexual exploitation remained a major concern as was the investigation of offences of indecent images of children, which showed little sign of improvement since 2016. Children were still being recorded as absent with no apparent risk when they went missing, despite there being identified risk factors.[26]

22. HMICFRS inspected the approach of Merseyside Police (which covers the St Helens area) to child protection in 2018, with a revisit in 2019. Of the child sexual exploitation cases reviewed, six were good, eight required improvement and five were inadequate. Investigations were being conducted promptly but there was insufficient recording of strategy discussions and their outcomes and of the views of the children.[27]


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