Commissioned by the Strategic Management Board of West Mercia MAPPA

Transcription

1 West Mercia Multi-Agency Public Protection Arrangements Discretionary Serious Case Review Jamie Reynolds Commissioned by the Strategic Management Board of West Mercia MAPPA October 2015

2 "We appreciate West Mercia Police initiating this report having recognised that the 2008 investigation was inadequate to say the least. "However, considering that Multi Agency resolutions are considered a way of achieving best results this report shows how this approach can be disastrous. "Having lost Georgia to pure evil we cried when we read this report and the failings of all agencies involved because it was so obvious that Reynolds was, if not one already, a murderer in the making. "Georgia's death could have been prevented - LEARN if nothing else." Steve and Lynnette Williams

3 WEST MERCIA MAPPA DISCRETIONARY SERIOUS CASE REVIEW Not for publication or wider circulation without the prior approval of the MAPPA Strategic Management Board PLEASE NOTE: REPORTING RESTRICTIONS EXIST IN RESPECT OF; Alison, Jennifer and Lucy. Name of offender... Jamie REYNOLDS Offence Murder 1. Why a MAPPA Discretionary Serious Case Review? This is a discretionary serious case review which has been undertaken on behalf of the Multi-Agency Public Protection Arrangements; Strategic Management Board (MAPPA SMB). A number of agencies were involved in working with REYNOLDS following an offence which occurred in It is felt that some links may exist between the two offences and that a review of the 2008 case might indicate areas for review and improvement in practice for the future management of such cases. The case does not formally come within any of the usual statutory review provisions and was never referred to MAPPA but as the key concerns are about the identification and management of risk, the SMB felt it appropriate to undertake a discretionary review. N.B. During the period when these events took place the report author was, for part of that time, the Probation representative on the MAPPA SMB and also Chair of the SMB. In view of the fact that no referral was ever made to MAPPA, it is not considered that this link impacts on the independence of the report author. 2. Case Background In 2008 REYNOLDS was issued with a final warning by police, following what was processed as a section 47 assault in January of that year, on a sixteen year old girl who he knew through college. He created a ruse to entice her to his home and then attempted to strangle her. She struggled and was able to escape. It emerged from information provided by his and, that for the previous two years REYNOLDS had been accessing pornography on the internet that involved images of women being hanged and that he had also altered school photographs of RESTRICTED 1

4 some girls that he knew to include makeup and nooses around their necks. As a result of this offence REYNOLDS was put in contact with local mental health services Children and Adolescent Mental Health Service (CAMHS) and the Justice Liaison Service (JLS), the Youth Offending Service (YOS) and a special project, which closed in 2011, for adolescent sexual offenders run by the National Society for the Prevention of Cruelty to Children (NSPCC). The scheme will be referred to throughout this report collectively as the NSPCC. Children s Services were involved in respect of concerns over possible victims and the offender, all of whom were under eighteen years of age. Contact with REYNOLDS via one agency or another continued until January In August 2011 REYNOLDS came to the attention of the police after he drove into a colleague s parked vehicle at their work premises, after she had complained to her manager about REYNOLDS behaviour and made clear she had no interest in his advances towards her. This was dealt with by way of a non-reportable road traffic offence with no further police action required. On the 26 th May 2013, Georgia went to REYNOLDS address, believing it was to take part in a photo-shoot. Her body was discovered five days later on the 31 st May in North Wales, it later emerged that she had been hanged. Prior to the murder, it is now known that there was an additional, unreported incident in 2013, when REYNOLDS locked a young woman, who had visited him, into his home and then when she wanted to leave, claimed he could not find the key. She became angry and distressed and eventually he told her where to find the key and she left. 3. The Review Process In order to complete this review I have received Individual Management Reviews (IMRs) from involved agencies: 1. West Mercia Police. 2. Children s Services. 3. NSPCC 4. Children and Adolescent Mental Health Services (CAMHS) Community Health National Health Service (NHS) Trust 5. West Mercia Youth Offending Service (YOS) 6. West Mercia Probation Trust. 7. A brief chronology, copy of meeting notes and assessment of REYNOLDS were received from Adult Mental Health Services of the Community Health NHS Trust, who are responsible for the mental health Justice Liaison Service. Following receipt of the reports, additional written questions were asked of (and responses received from) all agencies. In addition, I have spoken directly to all report writers other than adult mental health services. In respect of Children s Services, and YOS, some key individuals involved in the case at the time are no longer in post and could not be interviewed for the purposes of the IMRs. I understand that the NSPCC worker is also no longer employed by them but did have some informal discussion about the case with the report author. In completing RESTRICTED 2

5 their review the police have not interviewed the individuals specifically involved in the case in In respect of YOS, records are restricted to contact entries in the electronic case record system. They inform me that files are destroyed when the offender is twenty-two years of age. As a result it is not possible to be confident that we are aware of the full extent of their engagement with REYNOLDS. Police records also contain some gaps in information. The NSPCC electronic case notes were largely completed retrospectively by the staff member working with REYNOLDS and the information has been migrated onto a new data base which may have resulted in the loss of some data. Children s Services electronic records are incomplete. There is no hard paper copy for records from 2007 onwards as service user records went electronic at that point and the single contact made in 2006 was not migrated across as it would have been destroyed in line with the destruction policy at that time. As a result of the gaps in information from each agency, the sequence of events and information about actions taken which are included in this report, are not always based specifically on the IMR of the agency concerned. Since 2008 there has been a complete re-organisation and re-structure at New College and they advised me they were unable to locate any staff involved at the time or any records relating to REYNOLDS. As a result they were not asked to undertake an IMR but I did meet with a representative of the college to discuss the case. I understand that the College were able to produce a file in respect of REYNOLDS which they have provided to the police to support their investigation into the murder of Georgia. I have received a copy of the notes of the professionals meeting held on the 5 th February I have also received copies of the notes of the Safeguarding Strategy meetings held on 8 th February 2008 and 22 nd February As part of their involvement in the case, CAMHS referred to the Early Intervention in Psychosis team, (EIP) following a referral via the Justice Liaison Service and they also contacted the CAMHS forensic service for advice. These agencies contributed to the overall management of REYNOLDS mental health, which was led by CAMHS. Their involvement is documented within the CAMHS record. I have attempted to contact the professionals involved (Dr A, Dr B and HC1) direct but have been unable to locate them. I have spoken to HC2, health records manager, who confirmed the date of the closure of the case by EIP. CAMHS have provided me with a copy of an independent review into their management of the case, which they commissioned direct. I have read the Final Warning 2002; Guidance for the Police and Youth Offending Teams published by the Home Office and Asset Risk of Serious Harm Guidance, published by the Youth Justice Board (not dated). I have seen the 2004 National Standards for Youth Justice relating to final warnings. I have also received from West Mercia Police a summary of the case against REYNOLDS, relating to the offence against Georgia, which triggered the need for this review and which also refers to the assault in 2008 and the subsequent involvement of various agencies. I have met with Alison and the parents of Georgia in order to discuss the role and purpose of the review and to hear their views. Finally, I have met and spoken by phone with J1, MAPPA co-ordinator, about referral RESTRICTED 3

6 procedures in The following report is based on information which has been gathered from the sources above and strives to provide a whole picture view of how agencies responded, both individually and collectively, between January 2008 and May 2013, in relation to their involvement with REYNOLDS and the victims of his offending in The focus is largely upon the issues of inter-agency working and risk assessment which are viewed as the key areas of concern in this case. There is some reference to key procedures and standards where appropriate but in the absence of a number of detailed records, it has not been possible to give detailed consideration to agency compliance within operational standards. 4. List and role of the relevant agencies in the context of the review West Mercia Police West Mercia Young Offender Service (In the period covered by this review YOS in West Mercia was made up of two separate organisations; with the YOS being the one relevant to this review. In January 2012 a merger created the West Mercia YOS, which has undertaken the internal management review) NHS Trust- Children and Adolescent Mental Health Services (CAMHS) Responsible for the arrest and investigation in Responsible for the decision to make REYNOLDS subject to a final warning following the 2008 offence. (With YOS) Responsible for responding to reported incident by youths at REYNOLDS home, in Responsible for the investigation following the assault on REYNOLDS in 2008 Responsible for responding to the incident with a motor vehicle in Responsible for detection, arrest and investigation following offence in Lead criminal justice agency working directly with REYNOLDS. Undertook Asset Assessment to inform police as to whether REYNOLDS was suitable for a programme of voluntary contact as part of the Final Warning, following the 2008 offence. Following final warning had statutory responsibility for three months voluntary contact with REYNOLDS and implementation of the agreed work plan. Referred REYNOLDS to the NSPCC for completion of the work plan, focused on offending. Provided mental health assessment and ongoing treatment of REYNOLDS following RESTRICTED 4

7 2008 arrest until mental health issues considered to be resolved. Liaised with EIP and the CAMHS psychiatric forensic service. NHS Trust- Adult Mental Health Services Children s Services NSPCC West Mercia Probation Trust New College Responsible for Justice Liaison Service via which the referrals to CAMHS and the Early Intervention Psychosis (EIP) teams were made. Undertook an initial assessment of REYNOLDS and arranged a multi-agency professionals meeting. REYNOLDS did not have any other contact with adult mental health services until his arrest in In view of the age of the offender and actual and potential victims, responsible for safeguarding issues relating to them all. Called three safeguarding meetings, focused largely on REYNOLDS and the two females who appeared in the altered images recovered by REYNOLDS parents. At the time of the 2008 offence the NSPCC ran a project working with adolescent sex offenders, to which REYNOLDS was referred by YOS. Provided a shortened programme of work linked to the final warning work plan and some continued support to REYNOLDS following the withdrawal of all other agencies from the case. No direct role in the case but included as key information passed to them by YOS, at the termination of the case via YOS records. Both REYNOLDS and his 2008 victim, Alison, were students at the college at the time of and following, the 2008 offence. They were given responsibilities within the agreed safeguarding action plan to both monitor REYNOLDS behaviour and to protect possible victims. RESTRICTED 5

8 5. Chronology of Events The following provides a combined chronology of contacts by all agencies involved in this review with REYNOLDS from January 2008 until May 2013, based on information provided in individual agency reviews. Date Event Reviewing Manager Comments REYNOLDS contacts fellow student Alison, via social network and asks her to help him with a college media project. She goes to his home where he attempts to strangle her. Later arrested on suspicion of Sec 47 assault, admits offence after questioning and bailed to 29 th Feb 2008 REYNOLDS later acknowledges that he used the excuse of the project as a conscious ploy; otherwise he thought Alison would not go to see him. Described by NSPCC at a later date as pleased with himself for inventing this ruse. One of the interviewing officers opined that REYNOLDS needed to be seen by a psychologist or doctor. This was not recorded by, or acted upon, by the custody officer REYNOLDS is told that he can contact the Justice Liaison, (JLS) mental health service. A written statement was obtained from Alison but no medical examination was undertaken and no photographs of Alison s injuries were taken. No section 18 search was undertaken of REYNOLDS address to seek supporting evidence or information REYNOLDS contacts HC3 of JLS HC3 visits REYNOLDS and parents at the home, after a lengthy meeting with REYNOLDS he meets the parents and they inform him that they have found computer images of adult women being strangled on pornographic sites, on REYNOLDS computer. Also two altered images, one of REYNOLDS plus girl in their school uniform and two of slightly older school girls. Girls (later identified as Jennifer and Lucy) with nooses drawn around their necks. Meeting to initiate assessment of REYNOLDS. HC3 does not share information re images with police. RESTRICTED 6

9 15/ Faxed request from HC3, to Children and Adult Mental Health Service (CAMHS) for an urgent psychiatric assessment of REYNOLDS. Referral recorded as the 15 th in JLS record and 18 th in CAMHS. CAMHS respond promptly with an appointment Home visit to REYNOLDS by Dr C and HC5; Community Sister. HC1 of Early Intervention Psychosis team also planned to attend but unable to do so, due to ill health. Assessment completed including discussion with REYNOLDS both alone and with parents, offence discussed and internet images plus images of friends. Parents concerned re images, REYNOLDS found him using the sites two years ago, altered images found a week ago. Follow up appointment agreed for at Centre and letters sent to REYNOLDS general practitioner, HC3, HC1 and Drs A and Dr E of Forensic CAMHS Later, Dr C calls Dr A; consultant forensic psychiatrist to CAMHS for advice (Forensic CAMHS, NHS Trust). Dr A advised that the two girls in the pictures needed to be identified and they and their families made aware that they should not spend time alone with REYNOLDS. Also advised the college should be told REYNOLDS should not be alone with female students or staff and that the police should be made aware of photos. Dr A advised no need to admit to hospital but risk needs to be carefully managed in the community. Dr C phoned REYNOLDS to tell her of advice from Dr A and requested that REYNOLDS try and identify the girls and also contact the college and the police in response to the advice given REYNOLDS and bring images to the police from REYNOLDS REYNOLDS assessed as significant risk to others, having progressed from viewing images to harming an individual, he was prescribed medication for moderate depression. Care plan agreed with REYNOLDS and parents is to continue the medication for depression and seeing REYNOLDS as an outpatient in order to keep him under review. Prompt response to referral, clear assessment, care plan all in place promptly and some relevant other health professionals informed. No contact outside of health re case. Additional, specialist forensic advice appropriately sought by Dr C. The decision to place responsibility on REYNOLDS to deal with the various aspects of risk management rather than CAMHS taking direct responsibility to contact relevant others in order to ensure management of what they have acknowledged as a significant risk, is inappropriate and not in line with CAMHS Service policy which required the information to be discussed direct with senior colleagues or via a multi-agency setting. The police being made aware of these images was dependent upon RESTRICTED 7

10 bedroom as already shown to HC3 and make them aware of the use of sexually violent pornography. Police create a detailed intelligence log to go on the system for future reference. REYNOLDS parents and not upon the professionals who should have been liaising with them directly. Despite now being provided with this information and bearing in mind the nature of the offence which had brought REYNOLDS to police attention, REYNOLDS was never questioned about them by the police, the computer was not viewed, no searches were made nor was there any specific liaison with agencies working with REYNOLDS. Despite existence of log; no checks were carried out therefore no connection was made with it in 2011 when REYNOLDS comes to the attention of the police and there are linked concerns Planned consultation between HC5 and REYNOLDS took place with no additional concerns raised HC1 of EIP team and HC3 (JLS) made a home visit to REYNOLDS for the purposes of assessment Represents good follow up on case and provision of support for family by CAMHS. Represents good follow up by the EIP team following HC1 s absence at first meeting. HC1 s assessment is that there is no immediate indication of psychosis. HC3 completes interview for assessment of REYNOLDS Planned consultation with Dr C takes place with REYNOLDS and his r attending. Some improvement in REYNOLDS mood but still low will continue with medication. No evidence of psychotic symptoms. Roles of various professionals in managing the risk posed by REYNOLDS explained to REYNOLDS and his and they were notified that HC3 had called a Multi-Agency Professionals meeting for the next day. Also agreed that a consultation would be arranged with a male colleague for REYNOLDS to discuss sensitive issues re images and sexuality. Focus on depression but awareness of other outstanding concerns. Referral to Dr as no psychologist within team and it was considered useful for REYNOLDS to see a male colleague. Again relevant health professionals updated after consultation and prompt follow up in setting up meeting with Dr D. Next appointment with Dr C on RESTRICTED 8

11 Later, appointment with male colleague, Dr D, arranged for and summary letters sent to REYNOLDS general practitioner, HC3, Dr A, HC1, Dr E, Dr D and REYNOLDS parents Later, CAMHS and police receive report written by HC3 in respect of REYNOLDS Children s Services records indicate that a social worker met with Jennifer at her college. A detailed background report which also indicates concerns re REYNOLDS interest in harmful sexual behaviour, that he is a potential risk and the need for a thorough assessment and the use of a multiagency approach to managing REYNOLDS. No further information exists regarding this visit which is recorded on the case file of REYNOLDS and it is clear from the sequence of events, that the identity of neither of the two girls was known at this stage. It seems probable that this meeting has been mis-dated as it is clear that Jennifer and her were invited via a college tutor to meet a social worker at her office at some point following identification of the girls in the photographs but the date is unknown Multi-agency professionals meeting held. Attended by HC3, Dr C for CAMHS and ED1,,,. Also representatives from the police (Pol2) and the colleges attended by REYNOLDS and Alison focus on REYNOLDS mental state and vulnerability and how to address this. A plan was made of how to manage the risk in the community and how to identify the two girls in the photos. Police indicated that a file was being prepared for CPS but a reprimand was the likely outcome and that if he did appear in court, the likely outcome would be referral to those agencies with which he was now involved. First multi-agency meeting where risk issues and REYNOLDS health issues were addressed together. YOS, as the lead criminal justice agency likely to work with REYNOLDS were not invited although not actively involved at the time. Records indicate that CAMHS recorded this as a MAPPA meeting and understood it to be such although this was not the case. A CPS file was not being prepared at this time as no decision had been made to refer the case to them. RESTRICTED 9

12 Children s Service holds a strategy meeting chaired by r ED1. Pol3 of police public protection unit attends and indicates Pol2 will take the file to CPS the next week to see if any further action is to be taken but she is of the view it will be a reprimand. Focus on safety of girls in altered photos. Now identified as Jennifer and Lucy in photo of two girls; both seventeen years old. Girls in third image with REYNOLDS not known but believed to be Jennifer and ; REYNOLDS. No discussion re; Alison despite the fact she was the direct victim of REYNOLDS and they continued to attend the same college. Also, limited discussion of REYNOLDS himself, his risk and potential for future harm although as a seventeen year old he also falls within the safeguarding remit. Police and HC3 of the view that Jennifer and Lucy should not be told of the images due to the distress it may cause them and the impact on REYNOLDS. The social worker disagreed with this view and it was decided it needed to be established via Dr D, if REYNOLDS had contact with the girls. J2, evidence review manager for the police, reviews evidence file and advises further bail to mid March for YOS input into the case. The record indicates she spoke to Pol5, YOS police officer, who had suggested further bail and asked for the YOS submission report to be sent to him for consideration. Meeting timely and appropriate. Chair of the meeting had also been at the professionals meeting so some scope for continuity. Attendance based on that at the earlier professionals meeting, minus CAMHS, the key agency working with REYNOLDS. YOS again not included. Membership was made up of chair and minute taker, social worker; police PPU, HC3 and tutors from the two colleges attended by Alison and Jennifer. Notes indicate limited attention paid to any wider risk which REYNOLDS might pose, other than to the two girls in the picture and his. There was no discussion about REYNOLDS himself and the nature of his behaviour and potential to offend further although some limited measures identified to monitor his behaviour. This meeting missed a key opportunity to respond to the wider risk issues in the case although they would reasonably have fallen within the scope of the meeting and Alison s situation was not considered at all. The restricted membership and narrowing of focus for this meeting prevented the development of a coordinated and fully informed approach across all the agencies involved. In line with Police procedures at the time. The case was dealt with by the evidence review manager who determined that the case did not meet the criteria for referral to the CPS, based on the offence under investigation Children s Services, Chair of Strategy meeting, notified by police that a final warning is being considered for REYNOLDS. Also; REYNOLDS bail date to be set back as Pol5, YOS YOS plan to involve NSPCC in the case via their adolescent sex offender project as part of the work to be undertaken during voluntary contact following the proposed final warning. RESTRICTED 10

13 police liaison officer on leave and because NSPCC need to be involved Letter to Dr C from Dr B, forensic psychiatrist to CAMHS, with appointment for REYNOLDS at the Centre on CAMHS receive notes of professionals meeting; action points for them are to continue treatment for depression, outpatient reviews and seeking forensic advice as required. Letters from Dr B to REYNOLDS and to his parents re appointment for the Social Worker attends New College to meet with REYNOLDS parents and a college tutor. Aim is to look at risk REYNOLDS may pose to his, to identify the girls in the altered image with REYNOLDS (confirmed as Jennifer by REYNOLDS ) and the steps to be taken by the college to protect female students, who it is felt are at risk from REYNOLDS. Parents view is that REYNOLDS is not at any risk from him and social worker agrees home visit on the , to access more clearly. Home visit by social worker to REYNOLDS family cancelled due to an emergency in another case.. Meeting at college agreed as part of action plan from meeting on Planned visit to home appropriate in order to fully assess risk to, rather than relying on parent s perspective. Whilst the original decision to undertake this visit was appropriate in terms of assessment and risk management, it was never rescheduled and there is no further contact with REYNOLDS parents or concerns re, beyond this point from Children s Services REYNOLDS and attend the As REYNOLDS mood is recorded as Centre for consultation with Dr C and improved the frequency of contact HC1. REYNOLDS reports his mood is reduces and only his GP and HC1 improving and also now able to (who was in attendance) are kept discuss accessing pornography. informed of developments in the case. REYNOLDS more open; re feelings The watch and wait scheme involves and viewed as establishing a good regular monitoring of REYNOLDS in relationship with HC1. HC1 considers order to identify any evidence of that REYNOLDS is not showing psychosis. CAMHS records indicate RESTRICTED 11

14 symptoms of psychosis and therefore places him on the watch and wait scheme. Next appointment with Dr C is for the Summary letter re consultation sent to HC1 and REYNOLDS GP. Children s Services hold a second strategy meeting, again chaired by the ED1. HC1 also invited on this occasion but unable to attend. Focus again only on named victims/potential victims. Discussion re contacting Jennifer and Lucy to tell them of photos and the attack on Alison. Social worker again of the view this should be done but police disagree, It was agreed they should be told REYNOLDS had photos of them but not of the amendments he had made to them or the attack on Alison. Also enquiries to be made about the nature and extent of their contact with REYNOLDS. It was reported at this meeting that Pol5 (YOS) wanted the case to be referred for charge and court, rather than a reprimand. HC1 expressed the view that the NSPCC would not be able to work with REYNOLDS but it is unclear why she made this comment. REYNOLDS attended police station and re bailed to REYNOLDS meets with forensic CAMHS team. REYNOLDS has consultation with Dr D at the Centre. Further appointment arranged for he will be seen by HC1 a number of times a year for the next few years although in reality; contact with the EIP team was formally ended on the 6 th June Meeting originally called as a Resolution meeting to discuss the outcomes of the meeting on the 8 th Feb. No subsequent evidence that actions re; and Lucy were followed up or that actions from previous meeting were reviewed. YOS was not invited but an initial contact was made to establish availability. Dr C from CAMHS was not invited. No indication that HC3 was invited although he had actions to complete from the previous meeting. Again, no clear multi-agency perspective due to limited membership of the meeting and a narrow focus only in regard to protection of three girls. No consideration of longer term management bearing in mind likely decision to issue a final warning. Little reference to Alison. Police reluctant to engage fully with the potential future victims despite being within their remit to do so, as they are concerned it will alert anxiety in the girls. Some of content of meeting taken from individual IMRs as notes limited in content. Bailed pending work by YOS police officer in response to proposed final warning. Record of meeting received by CAMHS on 16 th May Follow through by CAMHS on plan for REYNOLDS to speak with a male psychiatrist re images and sexuality. RESTRICTED 12

15 Police notified by REYNOLDS that five youths had been to the house saying they wanted to speak to REYNOLDS. They were sent away but said they would return. The group included Alison s. Dr D sends written memo to Dr C summarising his meeting with REYNOLDS on the 4th. REYNOLDS says he is no longer accessing pornography on the internet and is deeply ashamed and embarrassed by what happened. Children s Services record notes that Alison has reported to the college that she is still getting smirks and distressing comments from REYNOLDS at college. The youths were clearly not making a social call and their action indicated some form of threat to REYNOLDS but no action taken by police in response to call from. No evidence that HC3 asked him to check if REYNOLDS had contact with Jennifer and Lucy, as agreed in the first strategy meeting. No evidence that these concerns, reported by the victim Alison to her tutor, were ever responded to by either Children s Services or the college. They would suggest that REYNOLDS reported shame and embarrassment as recorded by Dr D on behalf of CAMHS, is not to be relied upon but the lack of interagency engagement means that this was never explored and REYNOLDS self reported behaviours were not challenged by agencies working with him in order to clarify risk Pol5 was unavailable and therefore Pol4 (YOS) undertakes ASSET review of REYNOLDS. He also completes the Final Warning Assessment Update and indicates that REYNOLDS is suitable for a final warning with an agreed programme. REYNOLDS is assessed as medium risk of harm. The programme to include continued contact with CAMHS, victim empathy course with a letter of apology to Alison and a consequence of offending course. REYNOLDS has apparently already agreed to these conditions. Whilst it was clearly recognised further work was needed with REYNOLDS and a programme agreed with him, the effect of the final warning was that this was largely undertaken on a voluntary basis, with very little control should he choose not to co-operate. The period of formal contact with REYNOLDS was also very short, with three months voluntary engagement with YOS (maximum allowed) resulting from the outcome during which to undertake the majority of the work. REYNOLDS was interviewed by Pol4 for the purposes of this assessment. REYNOLDS provided further detail of his sexual arousal from extreme pornographic images; including the alterered images of both RESTRICTED 13

16 Jennifer and Lucy. In line with guidance on final warnings Alison should have been contacted during the process but no contact was made. It is unclear if the police sought her consent to contact in line with agreed procedure but the indications are that they did not. Date unknown Jennifer and her are asked by a college tutor to attend social workers office. She asks about contact with REYNOLDS and tells them he is not allowed to contact her. Children s Services holds its third strategy/resolution meeting. No note taker was available and the social worker in the case took notes. This meeting took the form of a resolution meeting but the decisions and actions leading to the closure of the case are not known. Later entries in the record indicate New College were tasked with completing a Team Around the Child (TAC) and Common Assessment Framework (CAF) in respect of REYNOLDS. REYNOLDS responds to bail with his parents and is issued with a final warning by Pol1 & YOS Pol4. REYNOLDS told to continue consultation with DR s C and Dr D. CAMHS and Children s Services notified. This meeting is not recorded but reported by Jennifer during the 2013 investigation. It seems the information offered was very limited and is unlikely to have been sufficient to ensure that Jennifer could protect herself. Notes were never submitted by the social worker, despite reminders from her line manager and the Chair. She subsequently left the service. As a result there is no formal record of this meeting or the reasons why the decision was taken to close the case. One of the attendees took notes indicating that there was a detailed discussion over the final warning and the associated legal implications. This meeting effectively represents the end of Children s Services involvement in the case although it would seem that at this point in time the issue of REYNOLDS comments to Alison, consideration and assessment of wider risk issues in relation to REYNOLDS and the safety of his other two known potential victims, remain unresolved. Longer term management of risk following the three month warning period is not considered. The final warning has come more than three months after the incident to which it relates, during which time Children s Services have effectively closed the case. No detailed or up to date risk assessment is in place and no multi-agency planning for the future has taken place. RESTRICTED 14

17 REYNOLDS attends the Centre to see Dr C with. REYNOLDS reports mood back to normal but agreed medication will continue to July/Aug. Dr C suggested REYNOLDS attends next consultation in one month s time. Dr C s notes from this meeting indicate that REYNOLDS has been placed on the Risk to young people register for five years YOS allocate REYNOLDS to J3, who discusses risk with his line manager. In the discussion mention is made of a referral to MAPPA when more information has been obtained. YOS health worker contacts Dr C at CAMHS to clarify their involvement in the case. Dr C confirms REYNOLDS is on medication for depression and that a MAPPA meeting took place two months previously. YOS worker J3 calls Criminal Justice Liaison Service for notes of professional s meeting. REYNOLDS attends Centre for second consultation with Dr D. They agree that no further contact is required. REYNOLDS fails to attend meeting with YOS. J3 calls REYNOLDS re a missed appointment on the 17 th. J3 decided no formal warning is needed for the absence. Depression appears to have responded well to treatment and frequency of contact reduces. Source of comment re register appears to be from REYNOLDS. YOS may have made reference to the PPRC register but Children s Services records indicate it was never acted upon. Discussion took place reference MAPPA referral but it was decided that the case was not eligible for MAPPA consideration. YOS records are incomplete and have no further information about the nature of the discussion. The MAPPA meeting was in fact the Professionals meeting called by HC3. YOS are seeking out relevant information on the case but do not take the initiative in ensuring a multiagency approach. No evidence of contact with Children s Services. As before, REYNOLDS indicates he is no longer using pornography and is embarrassed and ashamed by what occurred. No clear record of planned meeting in YOS files but record of follow up, the next day. It is assumed this was a supervision meeting with J3. In fact a formal warning was not an option in respect of voluntary contact J3 meets with REYNOLDS and his. They discuss referral to the Only recorded evidence of direct parental involvement in work by YOS, RESTRICTED 15

18 NSPCC in terms of concerns re sexually harmful behaviour and how risk can be reduced. other than calls re missed appointments Telephone call from YOS to REYNOLDS to confirm he has an appointment with J3 the next week. Caller also checks out with the if there are any immediate concerns REYNOLDS meets with J3. Again discuss referral to NSPCC and risk issues. REYNOLDS agrees to intervention and says he wants to understand the reasons for his offending. Also discuss family dynamics and how REYNOLDS can manage risk. J3 records it as a good session. J3 calls NSPCC, specialist youth sex offender project, to discuss referral of REYNOLDS. Dr D sends a letter to Dr C confirming he has no plans to see REYNOLDS again, unless requested to do so. REYNOLDS attends to see Dr C at the Centre with both parents. CAMHS record indicates REYNOLDS parents were disappointed at REYNOLDS recent truancy from college and that REYNOLDS was less engaged than previously in the session. No evidence of psychotic symptoms. No information on record re the nature of the risk issues discussed or how they will be responded to. NSPCC first record of contact from J3 is on the 19 th May 2008 CAMHS aware of truancy but it seems YOS are not or if they are, there is no response to it or consideration of it in the context of overall behaviour and there is no direct liaison at this stage with the college by any agency. In the absence of college records it is not clear how they responded to the truancy REYNOLDS attends YOS who undertook a mental health Screening Questionnaire Interview For Adolescents (SQUIFA) with him. REYNOLDS does not score highly. Diary entry by J3 indicates medication for depression appears to be making REYNOLDS happier and is working well. J3 is of the view that the depression is not directly linked to REYNOLDS behaviour but this has yet to be dealt with and will be picked Mental Health questionnaire automatically prompted by scoring mechanism on ASSET. Low score means no further assessment is required re mental health. RESTRICTED 16

19 up by the NSPCC. Dr C calls YOS as she has some concerns re referral to NSPCC project. According to YOS record this is on the basis that Dr C thinks his behaviour was depression related and that he has already been involved with a number of different professionals. CAMHS receive a fax from Dr B summarising a risk assessment of REYNOLDS, undertaken by herself and HC1 on the 29 th February. Dr B reports that REYNOLDS is able to accept full responsibility for his acts, to demonstrate empathy for his victims and to show remorse. Dr B suggests further work with REYNOLDS to enable him to increase his understanding of what happened and his awareness of the risk factors would be useful. Dr B comments it seems clear that REYNOLDS and his family are receiving appropriate multidisciplinary inputs to this end Dr C requests faxed letter is forwarded to HC3, HC1 and YOS. Children s Services integrated service manager SC1, receives an e mail from ED2, student support co-ordinator at REYNOLDS college, to say they were tasked by the Resolution meeting on the 20 th March, to manage REYNOLDS behaviour in college and to convene a Team Around the Child (TAC) meeting and to start work on the Common Assessment Framework (CAF). The college have begun the process but wish to question the approach as they are not able to support/manage REYNOLDS other than during college hours. Call indicates there is some liaison and information exchange between CAMHS and YOS but not as part of any clear or co-ordinated multi-agency process. It is also my understanding that DR C did not think his behaviour was depression related but rather that his depression was behaviour related. Dr B s final comment indicates a clear multi-disciplinary approach to working with REYNOLDS and addressing risk issues is in existence but I understand this is intended in the context of mental health services only. Dr C does ensure up to date info is shared with YOS who are now involved in the case and that HC3 is updated. YOS subsequently pass the report to NSPCC. Dr B s view that REYNOLDS accepts full responsibility for the acts and is able to empathise is not subsequently shared by the NSPCC and does not fit with his apparent taunting of Alison but due to the lack of multi-agency liaison, all these elements were not considered together. This provides the only indication of the content of the third strategy/resolution meeting, for which no notes exist. The college response is some two months after the meeting. RESTRICTED 17

20 SC1 s ED2 and the assistant team manager YOS, to advise that YOS are the lead agency for REYNOLDS and therefore there is no need for the college to proceed with the CAF/TAC work. A specialist assessment undertaken by YOS and safeguarding would override the TAC/CAF approach Prior to making this decision, there is nothing to indicate that SC1 liaised with either YOS or Safeguarding but assumed that the assessment would have taken place. There is also nothing to indicate that, in the absence of a co-ordinated, multiagency approach, that the process would have served any constructive purpose if it had been completed. This appears to be the last contact that any of the agencies had with REYNOLDS college NSPCC records that an initial consultation took place with J3 regarding REYNOLDS referral to their specialist adolescent sex offender project- the Sexually Harmful Behaviour Service. J3 is concerned that he cannot complete the required work in the timescale available to him. J3 agrees to send relevant information. This includes further details of previous allegations of animal cruelty. Entry in record indicates information provided includes notes of multi-agency meeting where it was agreed REYNOLDS can return to the same college which Alison attends. The key areas of work are identified as 1. Assess the behaviour and sexual component 2. Victim empathy work and letter of apology 3. Analysis of potential risk in the future. The concerns re animal cruelty emanate from HC3 s report. On the basis of his interview with REYNOLDS, HC3 himself has no evidence to support the concerns re animal cruelty but has reported that REYNOLDS told him the police have concerns. The police have no record to support this. REYNOLDS had already returned to college at the time of the first multiagency meeting and this was not a decision of the meeting. The plan of work seems appropriate and to recognise the need for a clear assessment of risk but this is now some five months after the offence and two months after the final warning was issued. Throughout the proceeding five month period there appears to have been little focused work in respect of his actual or potential victims or the management of wider risk, other than expectations placed upon the college which he attends, to monitor his attendance and an instruction to him to avoid contact with the victim, in addition to responsibilities placed on his parents to restrict his computer use and monitor his behaviour. J3 provides extensive and appropriate information to the NSPCC. It includes RESTRICTED 18

21 a report for the CPS prepared by Pol2 which has not been referred to elsewhere by any of the agencies involved REYNOLDS has contact with YOS. REYNOLDS says he sees the victim at college but has been told not to contact her. He says that the college report his behaviour to his and he signs in and out of college, as per risk plan. J3 advises REYNOLDS not to make contact with Alison or to attempt a clumsy apology. NSPCC receive written referral from J3. Record clarifies work plan. Indicates there will be eight to twelve sessions with him. Focus is to explore sexual element of case, motivation and triggers. Case entry indicates J3 is working with REYNOLDS for three months but anticipates REYNOLDS will need an extended period of work. The plan referred to is from the multiagency professionals meeting. REYNOLDS comments appear to be accepted at face value. There does not seem to be any liaison between YOS and the college despite the fact his victim is also attending the same college. The issue of the victim s complaints against REYNOLDS are not known by YOS but might have become apparent had there been contact with the college and would then also have called into question REYNOLDS presentation of his behaviour and attitudes. Unclear why there has been a one month delay between the initial consultation with the NSPCC and their receipt of the referral. At this point in time YOS contact is due to terminate in eight days time on the 26 th June at which point there will be no formal liaison point for the NSPCC with any other agency, although the final warning guidance states that there should be regular liaison and review between YOS and any third party undertaking work on their behalf. 18/ Joint meeting between the NSPCC, YOS and REYNOLDS. REYNOLDS is collected from home and taken to the meeting by J3 of YOS who also meets the at the house and records that he seems supportive. REYNOLDS is told about the project and indicates he will attend voluntarily. YOS advise the NSPCC worker HC4 that in one of the altered photos REYNOLDS appears with the victim of his offence. He is unable to clarify the situation regarding the alleged animal NSPCC have logged this meeting as taking place on the 18 th and YOS, on the 19 th. This is J3 s fifth and final meeting with REYNOLDS. There is no evidence that he clarifies the situation regarding animal cruelty so it is unclear to the NSPCC if this is valid information although it would be relevant in terms of assessment. The victim referred to in the photo is Jennifer, not the direct victim of his attack; Alison. YOS records indicate there is limited further contact with the RESTRICTED 19

22 and cruelty but says he will investigate further. Two appointments are agreed with REYNOLDS for the 2 nd and 9 th July. REYNOLDS final warning formally closes.(contact with YOS) Later, REYNOLDS contacts NSPCC and cancels appointment scheduled for but agrees to attend on REYNOLDS consultation with Dr C, CAMHS, is cancelled by his due to school commitments. Agreed with that REYNOLDS will now stay on medication until re-scheduled meeting on REYNOLDS cancels the first appointment and confirms the second but does not keep it. REYNOLDS calls HC4 in response to message left by her the previous day. REYNOLDS says he forgot their last appointment and not fussed about meeting but will meet if she wants them to. Records indicate there was a discussion about REYNOLDS options to engage with the Service and he decided that he wished to be contacted after the school holidays in mid September. NSPCC. The case is handed over to the NSPCC to manage. No forward planning has been considered in respect of risk and no further multiagency meetings have taken place. I understand that a final ASSET assessment was completed by J3 indicating REYNOLDS as high risk. With effect from this time NSPCC are effectively the key agency working with REYNOLDS as CAMHS contact has reduced in frequency in response to his improved mental health. NSPCC have no links established with other agencies in the case and YOS have closed the case. At the point where the NSPCC become actively involved in the case with a planned focus on offending, REYNOLDS appears to become disengaged and contact with other agencies is withdrawn. Future entries make clear that REYNOLDS did not attend the NSPCC again until December REYNOLDS has now opted not to be contacted until September. NSPCC records do not indicate that this information was shared with YOS nor that HC4 discussed the situation with her line manager. REYNOLDS had agreed to attend on a voluntary basis, he is clearly disengaged with the process and there is no process in place to hold him to account to undertake the agreed work. The record indicates that YOS will be contacted if REYNOLDS fails to engage and possibly the college but no contact is made with them. At this point in time, no work has been done with REYNOLDS on his motivation to commit the offence against Alison. The NSPCC record indicates that REYNOLDS was not contacted until RESTRICTED 20

23 November and seen in December REYNOLDS was the subject of an assault. This was reported to the police and it was investigated but witnesses were reluctant to provide statements, so no prosecution followed REYNOLDS meets with Dr C at the Centre. His mood is now improved and it is agreed he will stop the medication. REYNOLDS also says he no longer wants to access the pornographic sites. Dr C is told by REYNOLDS that he is no longer involved in YOS but is due to start attending regular meetings with the NSPCC in December. The notes indicate REYNOLDS parents were encouraged to start trusting him more, as appropriate for a person of his age. Notes on meeting sent to REYNOLDS GP and his parents. Next appointment set for REYNOLDS case reviewed by HC4. REYNOLDS has previously indicated he is having second thoughts re the work with NSPCC and as a result has had a break from contact. The record indicates that YOS will be informed if REYNOLDS decides not to engage and YOS have advised them that he is not a candidate for MAPPA NSPCC record indicates that HC4 s manager reviews the case for the first time and confirms that direct work with It is assumed that this assault followed on from the previous unwelcome visit to the family home, which was also reported to the police but not investigated. Alison was one of the witnesses to the assault but she chose not to co-operate. Police believed was behind the assault but lacked evidence to pursue a prosecution. There is no indication that information about the attack on REYNOLDS was shared with other agencies. Notes of the meeting are not sent to NSPCC and no contact made with them. It is interesting that REYNOLDS reports his contact with NSPCC will commence in December as this is not recorded by the NSPCC as agreed, although in reality this is when he is next seen. Some conflict in terms of measures put in place to protect Jennifer and Lucy in terms of control and monitoring by parents and Dr C s view that he needs to be trusted more. Measures do not appear to have been monitored by anyone. REYNOLDS had already disengaged but YOS have not been informed. The basis of the view that REYNOLDS is not a candidate for MAPPA is unclear. For the purposes of MAPPA the final warning would be viewed as a conviction and the offence is a category three offence, the offence was concerning, even if not formally referred a consultation with the MAPPA co-ordinator may have been appropriate. This is five months from the date of initial consultation and four months from the date of first contact with RESTRICTED 21