Every child death is a tragedy, but a fourteen year old boy shot while standing in a street is particularly sad. Chris, a boy of Caribbean heritage was killed in Newham in 2017. It’s not clear if he was the target of the bullet shot from a passing car, but it is known that he was involved in “gangs” dealing drugs, and that he was vulnerable. The murder is still unsolved. I read Nicky Hill’s serious case review after Charlie Taylor, Chair of the Youth Justice Board tweeted that it was essential reading. It is.

As in Lord Carlile’s searingly critical report on the Edlington Boys (who nearly killed two boys), the report tracks difficulties back to early childhood, and cites numerous missed opportunities to intervene. A few observations on the report:

1. Unlike many boys who get involved in “gangs” and get exploited, Chris had a loving, supportive family who often asked for help from agencies. Neither he nor they were “hard to reach”; Chris’s mother sought help and wasn’t given it, and was offered help she didn’t want. A year before Chris’s death children’s services made one visit to their home to offer Families First – a programme of intensive family support to help with school attendance and progress and with changing behaviour. The family felt that Families First would not really help Chris since his challenges were outside the home. They turned down the offer and weren’t offered anything else.
2. Chris had ADHD and conduct disorder, the stigma of which he felt even as a child. Without medication he found it difficult to control his behaviour, and this affected his ability to settle at school. The contrast between his primary and mainstream secondary school are stark. His primary school provided him with extra help:”staff knew Chris very well and responded well to meet his needs. For example, he would work at the desk kneeling and writing rather than use a chair and this was fully supported by staff. To support Chris’s ability to self-soothe when agitated, he was allocated and chose calming and safe places across the school to calm down”. Transition to secondary school is often the start of a decline in behaviour and happiness, and was the case with Chris.”There is little evidence that his SEND (special educational needs and/or disabilities) needs were fully understood or met in this new setting”. He acted out, was excluded several times and was sent aged 13 to a Pupil Referral Unit, where he met boys who led him into criminal activity and exploitation.
3. Chris was involved in lots of crime from the age of 12, but was not charged in most cases. The only crime for which he got a conviction was possessing a knife. But he was also said to have committed a serious sexual assault, to have ordered a large Rambo knife and a bullet proof vest, and to have been pressured into dealing drugs (£600 worth were flushed down the loo by his mother). Its OK that he was not formally dealt with for every offence, but they should have been used as a serious indicator of need.
4. When the system needed to act urgently, it seemed incapable of doing so. Chris’s mother realised he needed to move outside Newham, so he could get away from the men who were exploiting him. She asked her housing association to rehouse the family, but they never did. The process started, requests were made and emails sent, but nothing actually progressed. At one point she was so desperate she sent Chris to live with uncles in South London.
5. Governance matters. Newham youth offending service is in the local authority, but is part of the community safety department rather than children’s services. This structure is not recommended (the youth offending team is usually part of children’s services), but persists in some councils. In the case of Newham, reading between Nicky Hill’s careful lines, I think this split was disastrous. Chris was seen as a youth offending problem, rather than as a vulnerable child who needed support to survive and thrive. He flitted on and off the radar of children’s services and they never appeared to make him a priority; for instance “Whilst there was a clear referral made, by the Tunmarsh School to Children’s Social Care, outlining several examples of harmful sexual behaviour, it does not appear that any assessment or planning took place to respond to this”.
6. Bureaucracy matters if we are to learn lessons. The minutes of crucial Multi-agency Risk and Vulnerability Panel meetings about Chris were so poor Nicky could not work out what was discussed or what the outcomes were – minutes “did not include any detail on the sign off process or whether they were ever agreed as an accurate reflection of what was discussed and agreed”. A well written set of minutes makes the heart sing. Without them, many meetings may as well not have happened.
7. Chris lacked a consistent figure outside the family who could offer him challenge and support. There were professionals with whom he developed good relationships (primary school teachers, a YOT case worker, youth workers) but he needed someone he could rely on for years rather than months. He was always “teachable”.
8. We need a new model of safeguarding for teenagers which acknowledges that the family is often not the source of abuse. Children’s services are so beleaguered and overwhelmed by (young) child protection cases that they scarcely even have time to take on adolescent cases, let alone completely change the way they work. But if children involved in serious youth violence, drug dealing and extremism are to be protected from exploitation and from harm, there is no alternative but to develop a multi tentacled way of safeguarding, using outreach, and focusing on peers and potential exploiters. This is what is urged in a joint inspectorate report published this week. It makes for alarming reading – Inspectors found that some partners do not have a grip on the scale of criminal exploitation in their area and they “call for a ‘culture shift’, so that front line staff both recognise the signs of criminal exploitation, and see children as victims despite their apparent offending behaviour”.

Nicky Hill makes a series of important recommendations but, above all, she encourages a change of attitude – that professionals need to challenge themselves and reflect whether interventions and talk are necessarily making a difference.

“Despite hundreds of professional hours provided by a multitude of people, discussion at dozens of meetings over several years and provision of multiple forms of support (albeit with limited intervention), little changed for Chris and risk was not effectively managed…Poor quality assessments and reviews were regularly confused with intervention and activity with progress. It does not appear that professionals paused to consider fundamental questions such as ‘what are the underlying risk factors here?’ ‘What needs to change and why?’ ‘What does good practice look like and are we seeing it?’ ‘Is what we are doing working and if not, why not?’ ‘What do we need to do differently?’”

Chris slipped through the cracks in services. His death probably couldn’t have been prevented, but it was not an accident. I suspect the same could be said of every incident of serious youth violence.