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Serious Case Review finds opportunities missed to manage risk young adult posed

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Friday 17 February 2023

A Serious Care Review has found that opportunities were missed to provide support and protection for a young person from birth to adulthood, but also effectively manage the risk he posed others.

The Islands Safeguarding Children Partnership has published a summary document outlining the key findings from the Serious Case Review (SCR), which was instigated to examine if there was any learning for relevant services who had encountered and worked with 'John' prior to him committing serious sexual offences. The young adult has been anonymised due to their age when engaging with services and to encourage their full cooperation with the review.

The learning summary can be read at 

John had contact with some agencies while he was young due to his challenging behaviour at home and at school and the harmful pathway he was on caused John to be at risk himself but also pose risks to others. 

A multi-agency record of interactions with John indicates multiple times when he came to the notice of agencies due to welfare-related issues or potentially harmful sexualised behaviour. These included Children & Family Community Services, Police and the Children's Convenor. 

Sarah Elliott, Pan Island Independent Chair Safeguarding Partnership Boards, said:

'We publish the findings of Serious Case Reviews to demonstrate how the ISCP meets its statutory responsibilities for reviewing serious safeguarding incidents but also to raise awareness of the learnings identified. Managing the impact of children and young people exhibiting harmful sexual behaviour is an incredibly challenging area of work for agencies across Health and Care, Justice, the Police and Education. It is important that they are not immediately criminalised prior to their behaviour escalating, yet agencies must consistently - and rightly - focus on the impact of such behaviour on potential victims. As the learning has emerged from this case, the Safeguarding Partnership has led work on the development of a Harmful Sexual Behaviour to ensure all frontline staff are trained and equipped to identify and manage these behaviours at the earliest stage possible.'


The Review concluded with four recommendations for the Partnership to strengthen and improve working arrangements to safeguard and promote the welfare of children.

  1. The Partnership's 2019 Information Sharing Guidance for practitioners providing services to children, young people, parents and carers should be reviewed and strengthened. Once revised, it should be disseminated to all relevant agencies and briefing sessions provided to front-line practitioners and managers.
  2. The Partnership's online procedures should be reviewed and, where necessary, strengthened to reflect practice relating to harmful sexual behaviours and specifically the practice challenges for professionals when responding to those children and young people who are victims of abuse but also pose a risk to others.
  3. The use of professional challenge and escalation guidance should be further promoted to all professionals.
  4. The Partnership should continue to oversee the implementation of the action plan arising from the NSPCC audit on harmful sexual behaviours, and should work together to identify, and where possible remove, any barriers to implementation.

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