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IICSA Independent Inquiry into Child Sexual Abuse

Children in the care of the Nottinghamshire Councils Investigation Report

E.4: Policy and practice developments in Nottinghamshire

10. The Councils’ understanding of and approach to harmful sexual behaviour mirrors, to a large extent, the national picture. In 1990, the County was aware that a significant number of children known to be exhibiting harmful sexual behaviour were in its children’s homes.[1]

1970s and 1980s

11. The County’s first Policy, Procedure and Practice Guide for Community Homes in April 1978 included guidance on responding to children in care suspected of involvement in unlawful sexual intercourse.[2] Rod Jones, Senior Professional Officer (Child Care), clarified the guidance later that year:

“Clearly where this is experimental horseplay (for want of better words) there is no question of the Police needing to be involved … Where a child has been the subject of U.S.I. or serious homosexual or other activity and the staff have good reason to believe that an offence has been committed – then the policy is that the Area Director should consider informing the Police immediately. As I understand it, the policy also states that only the Divisional Director has the power to agree to withhold information from the Police.”[3]


Healthy Inappropriate Problematic Abusive Violent

Children display developmentally expected sexual behaviour that is consensual and appropriate to the specific care context in which it is displayed

One or several children have displayed instances of inappropriate sexual behaviour

Children repeatedly display concerning sexual behaviour in the care setting

Children have been sexually victimised in the care setting including the use of coercion or force

Children are exposed to physically violent, highly intrusive sexual behaviours, which may at times appear sadistic in nature

Carers effectively put in place boundaries in the care setting to model and encourage appropriate sexual behaviours

Individual carers effectively address inappropriate sexual behaviours displayed by children and their responses are known by other children in the care setting

Children and/or carers perceive that attempts to challenge such behaviours are ineffective

Carers and/or other professionals fail to identify or challenge the sexual behaviours or attitudes that put children at risk of harm

External scrutiny is avoided and policies or procedures are lacking or not followed

Carers take an active and consistent approach to being guardians and feel equipped and empowered to support and protect children in the care context

Some structural elements in the care environment may allow inappropriate sexual behaviours to go undetected

Weak structural features that enable problematic sexual behaviour have been identified but remain unaddressed

Policies and procedures that govern the care context insufficiently guide the response required to address the issues

Structures and systems in the care setting actively support abuse and violence

Strong environmental structures, including clear roles and responsibilities, support healthy interpersonal relationships

Some inappropriate sexual behaviours may become normalised amongst peers

Children and staff demonstrate a level of normalisation about the sexual behaviours displayed

Carers have limited understanding of the frequency of the behaviours or the associated risks

Carers normalise violent sexual behaviour being displayed or blame those being harmed for what has happened

Children feel sexually safe in the care setting and they enjoy being there

Staff group responses may be inconsistent in promoting safe and pro‑social sexual behaviours

Children identify the context as one in which problematic sexual behaviours occur and/or they feel safe

Professionals and others outside the care environment actively encourage or normalise abusive sexual behaviour that has been displayed

Children and non‑abusive carers are intimidated, silenced and feel unable to speak out about the abusive culture or seek help externally about their experiences

      Children expect sexually abusive behaviour as routine in the care setting  

Derived from the work of Firmin and Hackett, 2018

A context continuum model of care settings and harmful sexual behaviour

12. Following an internal inquiry into an allegation of harmful sexual behaviour at Amberdale Secure Unit in 1988 (discussed further below), a multi‑agency Adolescent Sex Offenders Group was created and met from October 1989 “to develop services designed to address the risks presented by male adolescent sex offenders”.[4] 

1990s and 2000s

13. Between March and September 1990, the Adolescent Sex Offenders Group undertook a range of work regarding harmful sexual behaviour and made a number of findings:

13.1. An increasingly high level of reporting of sexual offences carried out by adolescents,[5] as shown for example by a snapshot[6] of 380 children resident in children’s homes in Nottinghamshire on one particular day in June 1990. This found:

  •  32 children (8 percent) had been sexually abused by other residents (of those 26 had also been sexually abused before entering care and six were sexually abused for the first time by other residents);
  •  out of 79 children (21 percent) who had been sexually abused before entering care, 16 had gone on to sexually abuse other residents; 
  •  23 children (6 percent) had been placed in care having already committed sexual offences; and
  •  15 children (4 percent) committed a first sexual offence whilst in care.

David White, the County’s then Director of Social Services, was “astounded to find the number who had been subjected to abuse … However we’re probably not untypical of Departments generally.[7]

13.2. A “lack of departmental and multi-professional guidelines and resources” which meant that “what happens in each case is a matter of chance”.[8]

The group proposed setting up a new unit to work with adolescent sex offenders and sought the implementation of guidelines for staff,[9] and joint police and children’s social care investigations in response to allegations of harmful sexual behaviour.[10] Although the placement of abused children alongside children exhibiting harmful sexual behaviour was common practice across England and Wales in the 1990s,[11] the group recommended in 1990 that “adolescent sex offenders should no longer be housed with other children without very careful consideration of the risks”. It also provided a definition of “sexual abuse by juveniles” and identified an “urgent” need to develop treatment services for young offenders.[12]

14. The 1991 Area Child Protection Committee (ACPC) procedures in Nottinghamshire appear to have drawn on the group’s work (as well as on the national Working Together guidance in 1991, which referred for the first time to harmful sexual behaviour[13]). The procedures included guidance on ‘Abuse between children and young people’. Those exhibiting harmful sexual behaviour were to be seen as children who may have been abused, and placement decisions had to take into account the risks they posed to other children. Joint investigation procedures were to apply to allegations of harmful sexual behaviour in children’s homes.[14]

15. A “landmark” National Children’s Home report about harmful sexual behaviour in England, Wales and Scotland, published in 1992, considered for the first time on a wide scale the issue of children and young people who sexually abuse other children.[15] It noted “an absence of policy, practice or ethical guidance to assist practitioners” with young people demonstrating harmful sexual behaviour, and that much sexually abusive behaviour went unreported or unrecognised, or was simply not formally dealt with by the criminal justice system. A model was proposed to establish the range of sexual behaviours which a child could demonstrate.[16]

16. The 1991 ACPC procedures highlighted the need to consider risks around placement because of concern about harmful sexual behaviour between children in residential care.[17] Despite this, in 1992, a County working party report entitled ‘As if they were our own’: Raising the Quality of Residential Child Care in Nottinghamshire concluded that a failure to monitor admissions into residential care had led to:

“young people who have been sexually abused being placed at risk by being accommodated with young people who have committed sexually abusive acts”.[18]

It found that 80 percent of sexual abuse within community homes was committed by young male residents against young female residents.[19]

17. The report noted that the work of the Adolescent Sex Offenders Group in monitoring those exhibiting harmful sexual behaviour and providing them with treatment had “helped to project Nottinghamshire as a lead Authority in recognising and responding” to their needs.[20] The working party recommended an additional “systematic and informed service” for adolescent sex offenders, but funds were withdrawn three weeks before the service was due to start.[21] This was despite the report’s warning that:

“In the absence of such a service the problem continues to increase with real cost to the young people, both offenders and victims, and the possibility of the County Council being held liable for claims of compensation becomes more concerning.”[22]

18. By this point, two years on from the 1990 survey,[23]As if they were our own’ included some statistics on the 285 children in residential care:

  • 90 children (32 percent) had been sexually abused before coming into care;
  • 11 children (4 percent) had been placed in care as having been abused and were subsequently abused by other residents whilst in care; and 
  • five children (2 percent) had been sexually abused for the first time by other residents whilst in care.[24]

19. In 1997, an ACPC project on ‘Children who sexually abuse other children’ reviewed 57 alleged incidents of harmful sexual behaviour in the County over a six‑month period, four of which involved children in residential care.[25] Responses to harmful sexual behaviour remained inconsistent.[26] Although most cases had been referred for investigation, in some child protection procedures had not been followed. It proposed “further briefing or training”.[27] In a March 1997 progress report to the ACPC, the Project Manager drew attention to the fact that “the scale of the problem” of harmful sexual behaviour was “bigger than initially thought”, and that there was “no consistent approach for dealing with these children”. She proposed setting up a panel with the aim of diverting children away from the criminal justice system.[28] By 1998, “both the City and the County each had established their own respective panels” (subsequently known as assessment and early intervention panels),[29] to which the majority of cases were referred, usually by the police or children’s social care.[30] 

20. The County’s Child Protection Practice Guidance was also updated in 1997, in relation to responses and support to both victims of and children exhibiting harmful sexual behaviour. It also included guidelines on what was ‘normal’ sexual experimentation and what was abusive.[31] However, this does not appear to have been accompanied by training for residential care staff or foster carers.[32]

21. National interagency procedures and a practice framework for assessing children and young people with harmful sexual behaviour (Assessment Intervention and Moving On (AIM)) were introduced in 2000.[33] The framework became best practice and was in use by the Councils by the mid‑2000s.[34]

 22. By 2005, the County was carrying out risk assessments of children exhibiting harmful sexual behaviour,[35] which were provided to the foster or residential home where the child was being placed.[36] The County’s process changed in 2006,[37] from local individual assessment and early intervention panels to a strategy meeting approach with multi‑agency planning and assessment. The assessment evaluated the level of risk posed by children exhibiting harmful sexual behaviour to other children in the same household or establishment including younger or more vulnerable children.[38]

23. Over the next few years, the City funded a part‑time post in relation to harmful sexual behaviour[39] and sought to intervene early to prevent future incidents.[40] In practice, a large number of children arrested for sexual offences in the City were still not being referred to the assessment and early intervention panel. There was substantial delay in referring cases and, where cases were referred, the panel often had little or no information about the victim or the impact of abuse.[41] The panel could only recommend, rather than direct, that children’s social care take decisions, including the placement of children exhibiting harmful sexual behaviour.[42] Although police attendance was “a useful and effective process ensuring best outcomes for victims and alleged young perpetrators”,[43] it was infrequent.[44] 

24. Since 2007, the Councils’ safeguarding boards have produced cross‑authority guidance on ‘Children who display sexually harmful behaviour’.[45]

Recent developments and present day 

National developments

25. In 2013, a Criminal Justice Joint Inspection[46] identified concerns about the effectiveness of multi‑agency working with children and young people who had committed sexual offences. It found little evidence of oversight, gaps between policy, procedures and practice, and no evidence that implementation of procedures had been monitored or reviewed.[47]

26. Professor Hackett referred to 2014 research which suggested that victims of sexual abuse and children exhibiting harmful sexual behaviour were still being placed together, even though placement providers had become more aware of the need to “look very carefully” at risks presented by young people when making placement decisions.[48]

27. In 2015, following unsuccessful attempts to formulate a national strategy, the National Society for the Prevention of Cruelty to Children (NSPCC) developed, in conjunction with some local authorities,[49] an Operational Framework[50] for harmful sexual behaviour to help local authorities structure their interagency response to the issue.[51] Professor Hackett considered this a “really important step forward”, giving local agencies the ability to audit their harmful sexual behaviour practice against the Framework and promote standard practice in assessment, in the availability of intervention services and in training.[52] 

28. Guidance and advice on harmful sexual behaviour have been published in recent years by the National Institute for Health and Care Excellence[53] and by the Department for Education,[54] and awareness and procedures have improved. However, “there is still no national strategy” or model for local authorities to use in addressing harmful sexual behaviour.[55] In Professor Hackett’s view, there is a need for an “overarching strategy that actually brings together some of these principles in an overarching national framework”.[56]

The County

29. Chris Few, chair of the County’s Local Safeguarding Children Board,[57] recognised that the County’s approach to harmful sexual behaviour, as at October 2018, was not as he would wish.[58] Nevertheless, in recent years, the County has taken steps to audit its practice, quality assure its work and develop multi‑agency responses to harmful sexual behaviour cases. The 2016 audit (using the NSPCC framework) found that residential staff and foster carers were trained and able to support children exhibiting harmful sexual behaviour, but that the County had no overall picture of the scale of harmful sexual behaviour or the efficacy of its response. Recommendations included setting up an annual data return on children who sexually harm, a multi‑agency audit on harmful sexual behaviour practice and the introduction of the Brook Sexual Harm Traffic Light Tool.[59] The Traffic Light Tool is a step‑by‑step guide to assist professionals in understanding whether behaviour is abusive, problematic or appropriate, and to inform the appropriate interventions.[60]

30. A multi‑agency audit in May 2018 examined 10 cases of harmful sexual behaviour in the County, two of which involved children in residential care. This found delays in identifying and responding to harmful sexual behaviour, inconsistent advice given to children and their carers, an over‑dependence on police decision‑making, and a lack of understanding of the purpose and use of the AIM assessment. Recommendations included aligning practice across agencies, reworking local guidance and developing a model to quality‑assure cases involving harmful sexual behaviour.[61] Chris Few assured us that the County’s Harmful Sexual Behaviour Panel[62] was working on the audit’s recommendations and the issues it had raised.[63] At the time of our hearings, an action plan was still being implemented to respond to the 2016 and 2018 audit recommendations. While a number of actions had been completed (including the introduction of the Brook Sexual Harm Traffic Light Tool), annual data on children who had been sexually harmed had yet to be collated and the development of new procedures and protocols was still ongoing.[64] The County held training in 2019 on harmful sexual behaviour for all practitioners working directly with children and young people and the training team were “overwhelmed with interest”.[65]

31. As of October 2018, the County notifies incidents of harmful sexual behaviour to the Service Director[66] and the Lead Member for Children’s Services,[67] as well as Ofsted, local safeguarding partners and the national Child Safeguarding Practice Review Panel.[68] However, on some occasions in the past the notification process was not followed.[69]

The City

32. As at October 2018, the City’s Assessment and Early Intervention Panel – renamed the Assessment of Sexual Harm Arrangements (ASHA) panel in 20141014 – met monthly.1015 Its remit, since 2017, has broadened to include those whose behaviour suggested they might sexually harm other children as well as those who had done so.[70] Although Clive Chambers (the City’s Head of Service for Children in Care) told us that the City’s approach mirrors the NSPCC’s framework,[71] we have not seen evidence to support this or of steps taken to understand the extent of harmful sexual behaviour exhibited by or carried out against children in the care of the City or to audit their practice.[72] 

33. The City’s Lead Member for Children’s Services until May 2019, Councillor David Mellen, thought that it was less likely he would be informed of a case of harmful sexual behaviour, in contrast to other sexual abuse,[73] and he had no sense of the scale of harmful sexual behaviour in the City.[74]


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