Ms I

Authors

• Maxine Naismith (MN), Head of Specialist Services, Adults & Health
• Dan Wood (DW), Superintendent Neighbourhoods & Partnerships, Leeds District Police

Background

The Local Authority were alerted on the 1st October 2019 of the strong possibility of a serious sexual assault against a vulnerable female adult who lacked capacity (Ms I). At that time the location and date the offence had taken place were unknown, and the offender was also unknown. 

The police were immediately made aware and a safeguarding strategy meeting took place. The meeting implemented a range of measures across all environments to mitigate risk during the police investigation. These measures included:

• A list of males (i.e. potential suspects) from all environments to be provided to the police to assist their investigation. 
• The placement of Ms I into a residential service away from the family home as a temporary initial safeguard, but with the arrangement of an independent female carer to go into Ms I’s home environment to enable her to return from the residential service as soon as possible. 
• Only female staff members to provide support when Ms I attended respite / day provision.

It was determined by medical investigations that Ms I had been a victim of serious sexual assault resulting in pregnancy and for her health, safety, and wellbeing, the Court of Protection agreed with an application made by Leeds Teaching Hospital that the pregnancy should be terminated. 

The police were able to utilise DNA testing to determine from the foetus that the offender was a staff member from a commissioned service. After being charged, the staff member pleaded guilty at a court hearing and was later sentenced at Leeds Crown Court to a lengthy custodial sentence.

Safeguarding Adults Board

Upon completion of a scoping exercise, the Safeguarding Adult Board agreed in September 2021 that a Safeguarding Adults Review should be undertaken under its Care Act 2014 Section 44 legal duties. Adult Social Care and West Yorkshire Police nominated two lead reviewers, Maxine Naismith (Head of Specialist Services) and Superintendent Dan Wood (Neighbours & Partnerships, Leeds District, West Yorkshire Police) to facilitate the Safeguarding Adult Review. In terms of the methodology, the two agencies were entrusted to scope the issues to be addressed in order to improve how both agencies worked together at the time and could work together more effectively going forward. 

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The Approach

The approach took two main forms. Firstly, it was important to consult with frontline practitioners from both agencies in terms of the areas of practice requiring further clarification and / or new approaches to enhance greater collaboration. This began in May 2022 with both agencies reviewing what took place in 2019 but also assessing how inter-agency working has evolved since then and how it currently operates. This reviewing led to the creation of a new joint protocol which is further referenced below. 

Secondly, the two reviewers met with the Shared Lives mother and sister of Ms I at the family home in October 2022 where Ms I was present. The purpose was to understand the desired familial level of involvement within the Safeguarding Adult Review process, to explain the reasons for the review and its purpose and to explore with Ms I and her family what worked well and what could have worked better in terms of their experiences of the safeguarding process / police investigation in 2019/2020. The family were also offered the opportunity to comment on the aforementioned joint protocol which had just been launched in September 2022.

This new protocol came about as a result of this review which considered the overall circumstances of the case once the offender in Ms I's case came to light. The review found that he had previously been investigated for a similar (albeit not quite so serious) offence which had taken place against a vulnerable adult female in a respite care setting in 2016. At the conclusion of that 2016 police investigation, the level of evidence in the case was such that no further action could be taken against the offender. 

The offender remained in his position of trust employment and, as we now know, went on to commit the offence against Ms I in 2019. It is clear from the records and practitioner accounts from the 2016 investigation that throughout it, and at is conclusion, liaison and information sharing did take place between the Officer in the case, the Social Worker and the respite care setting manager. 

We cannot definitively say that a different outcome in terms of the suspected member of staff remaining in a position of trust would/should have been arrived at in 2016 had a different approach or level of liaison taken place at that time. However this review has led us to further refine our inter-agency liaison to make it as robust as possible should this scenario ever arise again. This refreshed robustness in the new protocol takes four main forms: 

1. Police officers investigating crimes will formally alert Social Care at the earliest opportunity of cases involving adult victims with care and support needs and/or a learning disability, 
2. Police officers investigating crimes will alert Social Care at the earliest opportunity if, in cases involving adult victims with care and support needs and/or a learning disability, a named suspect is identified. Where the named suspect is known or suspected to be in a position of trust, this alerting will take the form of a formal referral to Social Care (rather than the officer just alerting the case social worker), 
3. Ensuring police officers, at the conclusion of such investigations, are confident and empowered to share with social care the absolute maximum level of detail permissible (in line with laws/regulations governing information sharing) in order for informed risk assessments to be made.
4. Ensuring such risk assessments at social care are, going forward, always made by Risk Managers to provide a higher level of scrutiny and consistency. 

To achieve this, the police and social care jointly designed a communication protocol for this exact scenario; this is provided at Appendix A. Superintendent Dan Wood personally briefed and trained all Safeguarding officers and sergeants at Leeds district in this adapted process and the form is readily available for them to access on internal systems.  As a result, this is now an established process.   

During the visit to Ms I’s home the reviewers were made to feel welcome and it was felt that this was an honest and transparent conversation in which all parties felt able to make their views known and to describe experiences in a frank manner. Ms I’s mother and sister were extremely articulate and unsurprisingly had amazing recall with regards to the tragic incident that had happened in 2019. 

A number of actions were taken away by both reviewers, some were joint actions and others organisation specific. At every point the family were contacted in terms of areas where they wanted to help strengthen and develop professional approaches, they were also interested to see the new joint working protocol and the action notes from the visit were shared with them to enable them to comment on factual accuracy or if there had been any misinterpretation of their views. A composite list of actions is included in Appendix B, further learning points have been undertaken and Appendix C contains further actions agreed with Ms I’s family which have either been actioned or are a work in progress.

An initial learning point was about the delivery of information to the family early on in the safeguarding process as they did not feel that either agency dealt with that as sensitively as they could have done. The family also reflected back a sense of both agencies each seeking to apportion responsibility or blame to the other for the safeguarding decisions or actions which were taken. They also commented on a sense of ‘panic’ across both organisations at times as opposed to a more professionally managed situation. The family also commented with regards to how a police officer seemed more concerned at times about how upset she herself was with regards to the serious safeguarding issue. 

In all these regards, both reviewers have reflected and considered how the initial stages in 2019 were handled and how they would be handled now in an equivalent situation occurred. The seriousness, sensitivity and complexity of the circumstances of Ms I’s case are (thankfully) extremely rare in occurrence, but we do as agencies need to be prepared to respond appropriately and professionally. 

On reflection, and based on feedback from Ms I’s family, it is imperative that the police and social care properly explain any decisions, how they have been jointly or independently made, and which agency has primacy for any initial safeguarding or investigative decisions/actions. It is vital that if a case of such sensitivity and complexity occurs again (which might require specialist provisions, legal advice etc) the practitioners involved escalate the circumstances to the relevant managers / senior managers – and both reviewers are confident this is now the case. The reviewers have reflected that if such a serious situation arose again, it would be beneficial for senior leaders in both police and social care to be involved in ratifying any initial strategy decisions, and we have committed to do this going forward. 

To cater for all these learning points above, staff training is being developed for both social care staff and police officers and Ms I’s family have been offered the opportunity to directly provide their lived experienced on training sessions for safeguarding police officers at Leeds so that practice can be improved, particularly with the aim of minimising trauma and better understanding of victim’s needs and vulnerabilities, along with a greater awareness of autism. This training is planned for 21st Sept and will be videoed to provide a training resources for further safeguarding teams. 

The family also had concerns with regards to the removal at the time of Ms I to a residential placement. Maxine Naismith reported back to the family that the Safeguarding and Risk Manager’s decision (supported by legal advice) had previously been reviewed by the Service Delivery Manager and at that time it was an extremely difficult decision to make on a very urgent basis. 

The family were very clear that they would have preferred Ms I to remain in the family home and for the Shared Lives father to have temporarily moved out. This was put to the Safeguarding and Risk Manager and at that time the decision was to remove Ms I as the safest option. Maxine Naismith as the responsible Head of Service had also met with the Safeguarding and Risk Manager and the Service Delivery Manager to explore the decision making and it was explained to the family that Adult Social Care could not say that it was completely the wrong decision at that time. 

The family shared their experiences at length and they are clear that the stress and anxiety which was caused at the time remains evident in Ms I’s behaviour now and was triggered by her removal from her home and subsequent introduction to multiple strangers. The family have impressed the need for gradual change in relation to an individual with learning disabilities and autism. The family have explained that the actual decision to Ms I from the family home is not so much the issue but how it was orchestrated. 

The family also felt that staff from another service were not under the same scrutiny as them; they point this out as nobody had been excluded at that time from suspicion. The family also felt that a member of that service accompanying Ms I to an alternative placement was not appropriate due to the aforementioned and that the staff did not have familiarity with Ms I’s routine or were they in a position to advise the staff at the alternative placement as to how to support Ms I into an unfamiliar environment. 

The family’s views are explicitly about the harm that they feel was caused by the method of orchestration and they felt that it was undertaken without expertise. This has very much been acknowledged by the reviewers and from an Adult Social Care perspective a reflective piece has been undertaken in terms of the sequencing of the removal and will form part of a Safeguarding Masterclass to improve practice and to ensure person centredness.

A lack of support for the family was also raised as they could not access any form of supportive counselling which was acknowledged as a gap. Since this time, Adult Social Care has offered to fund some counselling for the family with a provider of their choice that has a philosophy that they feel comfortable with. It is important to recognise that the family have clarified that the need for supportive counselling was exacerbated by what they describe as the mismanagement of the situation and lack of communication by both agencies.

The family also reported that they were (incorrectly) told by the police that they could not access Victim Support Services. Dan Wood has reviewed this aspect and concluded it must have been the error of an individual officer at the time. Current officer knowledge is very strong in how to refer victims to Victim Support so that they (and their families) can receive support, and we are confident this incorrect advice would not now occur again. 

Both reviewers explained the LSAB governance process which had led to their visit, a level of detail was provided and the family seemed positive about the obvious closer working between the two organisations and on that basis they did want to be part of the solution - the aforementioned training being one area. Approval was requested from the Chair of the Safeguarding Adult Board so that the family could contribute to this report in order that Ms I and her family’s voices could be heard.

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In Summary

Both Leeds City Council and West Yorkshire Police have been open and transparent in terms of their need to develop greater collaboration and this process has been instrumental in terms of considered reflection and positive learning. Both organisations feel in a more positive position and have a commitment to furthering greater collegiate opportunities. The tragic event has been hugely impacted via Covid in terms of the timescales of this process as ordinarily a meeting with Ms I’s family would have been held some years ago. This apology was made to the family and accepted as a consequence of the global pandemic. Both reviewers were made very welcome by the family and our thanks go to Ms I, her Shared Lives mother and sister and we are keen to strengthen the relationship with them with regards to the powerful arena of learning from people with lived experience and how we can integrate that into professional practice. The frontline staff involved in this review deserve recognition and appreciation and their embracing of this opportunity. The family also wanted to note the actions of a named Learning Disability Nurse at Leeds Teaching Hospital who impressed them during the period of the termination and they felt strongly that her skill and dedication should be recognised.

Both organisations have a commitment to further development opportunities and this is a continuum with regards to that journey.

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Guidance for police offers relating to investigations involving ADULT victims with care and support needs and / or learning difficulties where the suspect works in a Position of Trust

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This guidance mainly relates to cases where it is alleged that a professional or volunteer who works with ADULTS has:

·  Behaved in a way that has harmed (or may have harmed) an adult,  
·  Possibly committed a criminal offence against, or related to, an adult; 
·  Behaved towards an adult in a way that indicates she or he may pose a risk of harm to adults or 
·  Behaved or may have behaved in a way that indicated they may not be suitable to work with adults. 

If your investigation involves a person who works with CHILDREN, follow the LADO guidance instead. 

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BEFORE a suspect is identified:

If your victim is an ADULT with care and support needs and / or a learning disability:

• Send an email with the basic facts of the offence and your details as OIC to leedsadults@leeds.gov.uk 
  
  This allows Adult Social Care to correspond with you, e.g. tell you who the victim’s Social Worker is (if applicable) and contact you for more information if required. 
  
  You can also speak to their Contact Centre on (0113) 2224401 if required. 

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AS SOON AS A NAMED SUSPECT IS IDENTIFED:

• If your suspect is NOT in a position of trust then simply update Adult Social Care about the identified suspect in the routine way, e.g. liaise with the allocated Social Worker / Duty Social Worker by phone or their email address. 
   
• If your suspect IS in a position of trust (a professional or volunteer who works with adults) then send an email update containing the suspect’s details to: leedsadults@leeds.gov.uk. 

This ensures that any suspect in a position of trust will be appropriately considered (e.g. whether their access to other potential victims needs to be restricted while your investigation continues). 

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DURING YOUR INVESTIGATION
Liaise with the allocated Social Worker / Duty Social Worker by phone or their email address as required. 

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AT THE CONCLUSION OF THE INVESTIGATION

• If your suspect is NOT in a position of trust then simply update Adult Social Care about the suspect in the routine way, e.g. liaise with the allocated Social Worker / Duty Social Worker by phone or their email address.
   
• If the suspect in the investigation IS in a position of trust (a professional or volunteer who works with adults) then complete the template below and copy and paste it into an email to: leedsadults@leeds.gov.uk. 
  
  This will ensure that, whatever the outcome of the investigation, any person who was a suspect in a position of trust is appropriately considered. 

Please also paste the template onto an OEL entry on the occurrence(s) as a record of what you have shared. 

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Please note you can and should share relevant and proportionate information with Adult Social Care and this is permitted under the ad-hoc information sharing agreements of GDPR. Further guidance about information sharing is provided after the template.

Please also note: The actual template for use is held on internal systems, this list of headings for that template is illustrative: 

TEMPLATE TO NOTIFY ADULT SOCIAL CARE AT THE CONCLUSION OF AN INVESTIGATION ABOUT A 

SUSPECT IN A POSITION OF TRUST WHO WAS ALLEGED TO HAVE OFFENDED AGAINST AN ADULT VICTIM

Name of Officer in the case, contact phone number and email address

Niche occurrence reference number(s)

Offence type(s) investigated

Name, date of birth and address of VICTIM

Name, date of birth and address of SUSPECT

Employer of the SUSPECT in the Position of Trust and the SUSPECT’s work role / location

Brief summary of the offence / concern

Brief summary of the investigation actions

Outcome of investigation (choose one from the list below)

Choose an item.

Any other information / rationale relating to the outcome

Police view / rationale of any ongoing risk to the victim (or other potential victims) from this SUSPECT

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AD-HOC INFORMATION SHARING GUIDANCE (GDPR)

The Recipient 
Adult Social Care is a statutory agency and leedsadults@leeds.gov.uk is a secure email address you can send information to. 

The purpose and lawful basis for sharing  

GDPR defines the Law Enforcement Purpose as processing for the prevention, investigation, detection or prosecution of criminal offences, or the execution of criminal penalties, including the safeguarding against and the prevention of threats to public security.

The CODE OF PRACTICE ON THE MANAGEMENT OF POLICE INFORMATION 2005 defines the Policing Purpose as: 

• protecting life and property,   
• preserving order,  
• preventing the commission of offences,   
• bringing offenders to justice, and  
• any duty or responsibility of the police arising from common or statute law  

If you are sharing personal data for a law enforcement or policing purpose then you will have a lawful basis for sharing.  

Sharing information with Adult Social Care, if done proportionately, is likely to meet one of these purposes, e.g. preventing the commission of offences.  

What information needs to be shared?

Even with a lawful basis to share you must only share what is necessary, relevant and proportionate. 

If the sharing of necessary, relevant and proportionate information to Adult Social Care is for a policing purpose (e.g. to safeguard potential future victims against the commission of further offences), then even when a suspect has not been charged the information sharing will be justified and lawful. 

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(1) Ms I shared lives mother and sister explained they were unhappy about how the information had been delivered in terms of the serious safeguarding in respect of Ms I. This was explored and acknowledged. They explained about the joint visit between Adult Social Care (ASC) and West Yorkshire Police (WYP) and they were told that this was nothing to worry about. Ms I’s shared lives mother and sister report back that the handling of this was not done sensitively.

Action: Dan Wood (DW) and Maxine Naismith (MN) to consider further training for staff and the exploration for scenarios when sensitive information needs to be conveyed and the best approach to undertaking that.

(2) Ms I shared lives mother and sister clarified that they did not like the attitude of the Social Worker in general and her shared lives sister explained that when she wanted to back a bag for Ms I when she was being removed from the house she was told by the Social Worker that it is “not your business”. This was again acknowledged by MN.

Action: MN to discuss this with the Service Manager.

(3) Ms I shared lives mother and sister reflected that a level of blame between Adult Social Care (ASC) and West Yorkshire Police (WYP) was played out, this again was acknowledged by MN and DW and it was accepted that both organisations could have worked better together, DW and MN explained that they had undertaken a piece of work around improving and strengthening relationships, this was positively received by her shared lives family.

Action: DW to share the joint working protocol which has recently been launched as an action from the safeguarding adult review.

(4) The decision making around the removal of Ms I to live in a residential placement was explored, Ms I’s shared lives mother and sister struggle to understand why Ms I would not be left in the family home with dad moving out and her sister moving into Ms I’s home. MN explained that this particular decision making had been reviewed by the Service Manager along with the Safeguarding and Risk Manager and that on balance it was a decision taken very quickly and underpinned by legal advice. It was generally acknowledged that this was an extremely difficult decision by MN. MN has also met with the Service Manager to explore the decision making. MN upon reflection will meet with the Safeguarding and Risk Manager and convey back the shared lives family views and whilst MN explained that she could not say it was 100% the wrong decision at that time the family were so passionate about how they could have supported Ms I that a further conversation with the Safeguarding and Risk Manager would go some way to respectfully outlining the historical and current views of the family around the decision making via MN and Safeguarding and Risk Manager.

(5) With regard to another service: It was raised that male staff were still working with Ms I.
Action: MN will re-cap on the arrangements with that service internally with the Safeguarding and Risk Manager.

(6) Ms I’s shared lives mother and sister commented that the LGI staff were excellent and that the service that was received from a named learning disability nurse in particular was of high quality.
Action: MN and DW will comment on this as part of the Safeguarding Adult Review (SAR) report.

(7) A service provider’s 1:1 support: it was brought to MN’s attention that there were 8 different staff overall and some of them not knowing the circumstances. Plus a male from Adult Social Care arrived at the house to check that the carers were there.

Action: MN will reflect on this internally with Service Manager in terms of the lack of consistency, briefing and the ad-hoc visit by the male.

(8) A comment was made that the police officer seemed at times more concerned about how upset she was about the serious safeguarding issue, it was generally agreed that good practice would be around working out good ways of working with individuals into processes and not increasing their trauma. Ms I’s shared lives mother and sister commented on the fact that the circumstances at the time felt “panicked” as opposed to more professionally managed.

Action: acknowledged by MN and DW. This will be further explored by both agencies and it was agreed that Ms I’s shared lives mother and sister would form a part of supporting this, either in person or via webinar, etc. This will be taken forward.

(9) A comment was also raised about autism awareness in terms of communication and engagement from professionals, it was felt that this awareness should be tailored into relevant processes.

Action: DW to consider this for WYP. MN to re-look at the Organisational Development offer in ASC with regards to autism awareness as this should be core business.

(10) Ms I’s shared lives mother and sister commented upon that they are having further conversations with those two agencies that sat outside of this meeting.

Ms I’s shared lives mother and sister explained that they were told by the Police that they couldn’t access Victim Support as Ms I lacked capacity and therefore couldn’t access this. DW explained that this was not the case.

Action: DW to consider further training within WYP with regards to this aspect.

(11) The lack of support available throughout the process and since was raised. It was confirmed that Ms I’s shared lives mother and sister could not access Carers Leeds. This was acknowledged as a gap by MN.

Action: MN agreed to take away an action to consider how support could now be provided, albeit late in the day, Ms I’s shared lives carers to consider that.

(12) Ms I’s shared lives sister raised the issue of ASC hand delivering a letter around the need for confidentiality with regards to the case, this was delivered on the day of sentencing. MN fully acknowledged this and explains that she was sighted on this when it happened and had spoken to that individual about the inappropriateness and insensitivity of the action at that time.

(13) In addition, Ms I’s shared lives sister explained that when she attended Court she made it clear that she did not want to be engaged with however the Safeguarding and Risk Manager made a point of approaching her and sitting next to her which she reported as inappropriate.

Action: MN to reflect on this with the Safeguarding & Risk Manager.

(14) Ms I’s shared lives sister explained that following the emergency Court of Protection application, pro-life organisations had picked this up as a story and traumatised the family by posting about this. This was acknowledged. 

MN explained from a governance perspective that a scoping exercise had been gone through with organisations involved with MS I, this is usual safeguarding adult review process. Following this a decision is made whether the criteria for a Safeguarding Adult Review (SAR) is met. Essentially this is where either an adult has died and it is suspected that the death resulted in abuse or neglect or whether the adult is still alive and that it is either known or suspected that the adult has suffered serious abuse or neglect. It was concluded that in this case a dual organisation SAR was to be expedited as it had been identified that there were lessons to be learnt as to how ASC and the Police had at times not worked as effectively together as they might have. DW and MN explained that they are the Lead Reviewers for each of their organisations and also explained about the Task and Finish Group to date including the joint protocol of tighter working together and the joint briefings and training now in place. On the basis that Ms I’s shared lives mother and sister were keen to be part of the solution MN suggested that they contribute to the SAR report so that Ms I’s voice can be written large throughout that. This was seen as positive.

Action: MN to write to the Safeguarding Board Manager and the Independent Chair of the Safeguarding Board as to that direction of travel.

(13) MN briefed Ms I’s shared lives mother and sister on the extensive safeguarding process whereby every individual / family was written to pinpointing around the perpetrator’s shifts at the relevant resources. MN explained that very little leads came back through that but there was commitment to review other safeguarding incidents when E had been on shift, which meant a manual trawl of rotas. Further information came to light from 2015 in relation to a seaside visit. Whilst the dates did not necessarily match up originally in terms of this respite stay this was latterly identified pinpointed E to a safeguarding incident whereby a black male was alleged to have touched a women’s breasts and vagina. It was latterly the additional data of the seaside visit which was not originally available identified a link to E being on duty. Pinpointing this back historically MN explained that in all likelihood this was E. Ms I shared lives sister made a comment in relation to the fact that she strongly suspected the incident in relation to Ms I was not the first time that he had abused. This was reflected upon and whilst Ms I sister explained that she had no interest in the perpetrator she commented that she did hope his family were ok. It was raised that this additional information might be helpful to weave into the parole hearing.

Action: DW to seek clarity and advice on this.

(15) MN explained about the review of the Person in a Position of Trust policy and she agreed to email documents. MN and DW appreciatively thanked both Ms I’s shared lives mother and sister for positively welcoming them into the home and graciously working with them to improve future outcomes.

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Adult Social Care:

Social Workers Practice

The case notes were reviewed by the SDM and Team Manager, whilst there was nothing to support the comment made by the Social Worker has since been discussed with her and recorded in supervision. Lessons learnt from the delivery of sensitive information has been picked up in a service time out and explored in some detail.

In terms of the male who visited, this was directly addressed with him as this was a lack in terms of full preparation and interrogation of case notes. He acknowledges that he should have looked at the case file in a level of detail, this is acknowledged as poor practice on his and the service’s part and again a reminder was sent across the service with regards to reviewing case notes thoroughly before visiting or carrying out reviews. This has also been followed up by the service Manager. It's impossible to give 100% guarantee that this would not happen again but the practice note / reminder will be visited annually.

Commissioned Provision

Sadly on occasion there is inconsistency in terms of micro-commissioned services, with the current scarcity of workforce unfortunately this is a more increasing scenario. We acknowledge that a service provider said 2-3 carers and then 7. Since this time we have put in a monitoring system so that Social Workers can check in regularly in terms of the consistency and regularity of service. A practice note has since been circulated by the SDM in terms of reminding staff to check the delivery of support plans within the first 2-3 weeks and then at 6-8 week review.

Autism Awareness Training

Awareness of more detailed autism training is part of the mandatory ASC OWD offer. This has been strengthened by a piece of new training “Neurodiversity Awareness Training” and the Learning Disability service has commissioned 3 sessions which will ensure than 90 people are trained with 30 people on each session. To strengthen this all staff have been enrolled onto the Tier 1 Oliver McGowan Training, which is mandatory.

Query wider service roles in the SAR

Neither of two named service providers are in scope within this SAR. Any complaints would need to be directed to their complaints procedure or the Leeds City Council as commissioner. The Regulatory Body is CQC.

Lack of Access to Carers Leeds

This has been followed up with the relevant Commissioner, Carers Leeds provide support to unpaid carers, the clarification was that that another organisation would be the support for Shared Lives carers. The family have confirmed that they have been having conversations about the practice and lack of support at the time.

Quality Assurance Framework

In terms of driving up practice standards, a QAF is being developed and case file audits have already started in terms of the identification of good practice and areas where practice needs strengthening, this approach will provide professional assurance to Adult Social Care and wider partners.

New Safeguarding Practice Guidance

A piece of work is underway with a view for completion November / December 2023, chaired by the Head of Service for Specialist Services. The guidance will clarify practice at every point within the safeguarding process and policies and will also clearly frame the roles and responsibilities of all practitioners. The policy guidance will be in line with trauma informed guidance and practice.

POLICE

New Protocol 
As described above, the new joint protocol is embedded which provides guidance and confidence to police officers to share information at all stages of an investigation involving vulnerable victims and suspects in a position of trust.

Training
The family of Ms I have agree to provide their Lived Experience in a training input on 21/09/23 to two teams of Safeguarding Detective Sgts/Constables. The session will be videoed for future use by other internal safeguarding teams. 

Parole Process
Dan Wood has provided detail to the family of Ms I to support them in the future potential parole process of the offender in this case.  

Officer involved

The officer involved in the initial stages in 2019, who the family reflected seemed more upset about the impact on herself, no longer works in a safeguarding role. 

Victim Support
Within the police, knowledge of the agency Victim Support is strong and officers are aware that individuals do not have to be a direct victim to seek support. I can only assume this was erroneous advice on the part of an officer in 2019.   

Escalation
This joint review has brought about greater collaboration between the two agencies. I am confident that if a case occurred now that involved the sensitivities and complexities such as that of Ms I, rapid escalation would occur within both agencies to ensure that professionals of the commensurate level would have the necessary discussions. 

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