Investigating Complex (Organised or Multiple) Abuse
Scope of this chapter
This chapter outlines the key points in relation to investigating complex abuse cases, which may be organised or have multiple victims or perpetrators may be historical in nature and cover more than one Local Authority area. The arrangements as described set out the subsequent role of Children's Social Care, Health or the Police where there are concerns about a child or children.
Related guidance
Complex and organised (or multiple) abuse may be defined as abuse involving one or more abusers and/or a number of related and/or unrelated children, and can take place in any setting. The adults concerned may be acting with others to abuse children, sometimes acting in isolation or may be using an institutional framework or position of authority such as teacher, coach, faith group leader or be in a celebrity position to access and recruit children for abuse.
Whilst in most cases of complex and organised abuse the abuser is an adult, it is also possible for children and young people to be the perpetrators of such harm, with or without adult abusers.
Complex abuse often encompasses different forms of abuse. It does NOT mean "complicated" abuse or difficult cases. Complex abuse cases however may cross Local Authority and Policing areas and involve a large number of agencies.
Complex abuse can occur both as part of a network of abuse across a family or community, and within institutions such as residential homes, health settings or schools and other provisions such as youth services, sports clubs, faith groups and voluntary groups. There will also be cases of children being abused by the use of electronic devices including mobile phones, computers, games consoles, which all access the Internet, and particularly social networking websites.
Particular consideration needs to be given to children and young people who may be involved in organised crime and their vulnerability to complex abuse ensuring that there is partnership discussion at an early stage.
Such abuse is profoundly traumatic for the children and families who become involved.
For situations where an adult discloses non-recent child abuse the Strategy for Survivors of Non-Recent Abuse in Childhood should be consulted in addition to the Adults who Disclose Non Recent Abuse Procedure, to ensure that vulnerable adults are adequately supported.
The timing, coordination and extent of any action to safeguard the children involved, make arrests, potential victim or witness approaches, research enquiries (effectively with all relevant agencies) and evidential searches, could, if not properly considered, have a detrimental effect on both the safeguarding arrangements, disruption and prosecution of the alleged offenders.
It is not always obvious at the outset that a single investigation may become part of a complex child abuse investigation. It is most likely that concerns about possible complex child abuse will emerge during the initial, single investigation.
If there is suspicion of complex abuse, whether current or historical, practitioners must immediately consult their Manager and inform the named professional/designated person for child protection within their own agency. Where there are concerns or allegations relating to staff, volunteers or carers, this should also be referred to the Local Authority Designated Officer (LADO) (see Allegations Against Staff, Carers and Volunteers Procedure).
In some circumstances a practitioner may be concerned about possible conflict of interest or other sensitivities, in which case they may raise their concern directly with an appropriately senior and/or independent manager. They may find further guidance within their agency about "Whistleblowing"/"Speaking Up" or further information from the Public Interest Disclosure Act 1998.
Chronologies and genograms should be developed by agencies to aid the process of information sharing. Section 47 Strategy Discussions should be held at an appropriate level involving the Police, Social Care and Health, and advice should be sought from a Child Protection Manager. Where the situation is unclear an initial Strategy Meeting, chaired by a Child Protection Manager, may be held to evaluate the information.
Information and intelligence available at the beginning of the concern about complex abuse may be limited. It is therefore extremely important that the changing analysis of what is known and what is not known is explicitly considered by the partners involved with the case. Detailed discussion between the Police, Children's Social Care, Health and other agencies is key to the identification of complex and organised abuse.
Action required to safeguard children must always take priority, with clear timescales set and leads identified.
The following issues should be considered to inform the decision as to whether the complex abuse procedures are applicable, and at what level:
- Number of potential allegations currently highlighted;
- Seriousness and type of allegations;
- Potential for the investigation to cross boundaries for the agencies involved;
- Number and types of locations identified (e.g. homes, premises, institutions or locations in the community referred to);
- Number and identities of potential victims (and any special needs);
- Number and identities of potential witnesses (and any special needs);
- Time parameters of the concerns raised about alleged offences and when they were reported;
- Number and identities of potential suspects (and any special needs);
- Potential for the number of victims, witnesses, locations, scenes or suspects to increase;
- Potential for media interest and its impact on the victims, safeguarding arrangements and the investigation;
- Possible links to other investigations, including historical investigations.
If the criteria above are considered and the outcome is that a complex investigation is required, the child protection or other relevant manager must ensure that this is brought to the attention of:
- Head of Quality Assurance / Safeguarding (Children's Social Care) and Assistant Director for Early Help and Children’s Social Care in Derby City or in Derbyshire, the Head of Child Protection and Assistant Director for Early Help and Safeguarding;
- Detective Superintendent (Public Protection);
- Designated Nurse / Doctor for Safeguarding Children (Health).
The plan of action will:
- Ensure that initial action has commenced so that the child or children involved are safe and a referral made to Children's Social Care if this is outstanding;
- Share information and ensure the relevant level of Strategy Group is convened to manage the investigation;
- Consideration must be given to safeguard any adult at risk identified within the investigation.
Complex abuse investigations will be overseen and co-ordinated by a strategy group of an appropriate level:
Gold - when allegations are both serious and significant, requiring active criminal and safeguarding investigations; serious implications for local communities and partner organisations; likely to attract significant media attention; requiring commitment of significant resources for the investigations or victim support.
Silver - when allegations are both serious and significant, requiring active criminal and safeguarding investigations, and there are barriers to a joint investigation or significant on-going risks.
Bronze - when allegations are both serious and significant, requiring effective cross-agency co-operation in the investigations which are progressing appropriately.
The strategy group will need to consider and continuously review the above levels, plus as applicable:
- Dynamic risk assessment of suspect's current access to children;
- Dynamic risk assessment regarding vulnerability of any potential victims or witnesses;
- Securing and retaining documents;
- Historical information;
- Whether a community impact assessment is required and whether consultation is required with an independent advisory group to clarify this;
- The potential for parallel care and /or family proceedings are likely or current, and whether disclosure by parties involved in the proceedings may be sought in relation to the complex investigation;
- Provision or funding of a multi agency support strategy for victims and/or witnesses;
- Use of analysts to present information (for example association between parties involved, timelines, chronologies); and
The following must be agreed at the outset:
- Strict confidentiality is of the utmost importance and relevant information must only be shared on a need to know basis;
- A robust understanding should be established about the specifics of the principles around "need to know" and how this may change over the duration of the investigation and be subject of review as the case progresses;
- That a child centred approach is maintained with the focus of activity remaining on the welfare of individual children;
- Support for vulnerable adults making a non-recent disclosure; see Strategy for survivors of non-recent abuse;
- Discussion about potential conflict between action needed to safeguard children and action needed to pursue a complex criminal investigation should be explicitly discussed as an agenda item at all strategy meetings;
- The strategy should be subject of on-going review as the changing nature of a complex investigation will mean that the arrangements for sharing information and decisions made about priorities will be dynamic and change as the picture of what is known and not known becomes clearer;
- Except where the child is in imminent risk of significant harm, the timing for the removal of the child should be agreed following consultation, including legal opinion, as part of the agreed multi agency strategy with the welfare of the individual children being the first consideration;
- Where there are indications that the abuse may involve more than one to how those other areas are informed and involved;
- Arrangements for the immediate protection and secure storage of relevant records;
- Clear media statement/ communication strategy agreed;
- Determine timeline for chronology for each organisation’s involvement;
- There may be on occasions the need to escalate the level of the strategy group depending on the seriousness of the case and new information that comes to light as part of the investigation.
Notification to the Safeguarding Children Partnership may be appropriate, but only following consultation of senior members of the investigating team and involved partners (to ensure case disclosure to the Partnership does not impact on the investigation). The Partnership will require the findings to be presented at the conclusion of the enquiry, in order that any learning can be addressed.
In historical child abuse cases where the victims are adults, a referral to the Local Safeguarding Adults Board may be required.
It is the role of the Designated Professionals in Health to inform the relevant Integrated Care Board Chief Nurse and NHS England Area Team for information.
Consideration must also be given to whether the concerns about the complex abuse meet the threshold for notification to Ofsted, DfE, HMCI, CQC and other regulatory bodies.
Each investigation of complex and organised or multiple abuse will be different, according to the characteristics of the situation and the scale and complexity of the enquiry. However, all require thorough planning, good inter-agency working, and attention to the welfare needs of the children victims or adult survivors involved.
Investigation of complex abuse require specialist skills from Police, Social Work and Health which usually involves the formation of dedicated teams of professionals and will require consideration of the needs of victims for therapeutic services (further detail in section 7).
Investigation of complex and organised abuse can be time-consuming. Some investigations can become extremely complex because of the number of places and people involved, and the timescale over which the abuse is alleged to have occurred.
Undertaking enquiries into complex abuse can be challenging for practitioners and an individual should not undertake the enquiry in isolation. The strategy meeting should recognise the need to ensure multi-agency co-ordinated working and good supervision.
The complexity of investigation is increased where, as in historical cases, the alleged victims are no longer living in the setting where the incident occurred or where the alleged perpetrator(s) are also no longer linked to the setting or employment role. These will all need to be taken into consideration when working with a child or adult victim. When the victim(s) is unable to provide a full statement, careful consideration should be given to how to proceed to ensure that other children, who are in contact with the alleged perpetrator(s) currently, are also protected.
Strategy Groups may be convened in order for appropriate information to be shared and the plan agreed. It is not the remit of Strategy Group(s) to direct investigations. These meetings are minuted and these may be revealed to the prosecution should criminal proceedings be undertaken.
The confidentiality of information relevant to any Section 47 enquiry and criminal investigation must be strictly maintained by those involved and must not be disclosed to others, including others within any agency unless absolutely necessary.
The function of this group is to set policy and strategy and secure the funding and resourcing necessary for the investigation. The Gold Strategy Group will have the following core membership, which will be constant throughout the investigation; however, there may be a need to add other personnel during the investigation process:
- Chair (to be senior representative of the Police;
- Strategic Director (Early Help and Children's Social Care) (Derby) / Director Early Help and Safeguarding (Derbyshire);
- Detective Superintendent (Public Protection Unit);
- Senior Investigating Officer (Police – if different);
- Independent Chair of the Safeguarding Children Partnership;
- Executive Safeguarding Lead for the Integrated Care Board (Chief Nurse);
- Designated Doctor;
- Designated Nurse Safeguarding Children;
- Head of Quality Assurance (Children's Social Care) (Derby)/ Head of Child Protection (Derbyshire);
- Other agencies as appropriate:
- Education;
- National Probation Service;
- Adult Social Care;
- Senior representation from Adult Safeguarding Board;
- Voluntary and Independent Sector Organisations;
- Chief Nurse / Deputy Chief Nurse / Executive Safeguarding Lead from the Health agencies;
- Comms (Any relevant organisations as appropriate).
If there is the possibility of any national consequences arising from the investigation, consideration should be given to whether national agencies should be involved in the Gold Group (for example: National Police Chiefs' Council; CEOP; CPS Policy, DfE, CQC, NHS England).
The frequency of meetings for the Gold Group will depend on the individual circumstances of the case and should be set out in the terms of reference. During the evolution of the investigation, membership of the group may vary to include other agencies on a case dependent basis.
Detailed minutes of the meetings, the actions raised and the results of previous actions raised should be recorded and retained.
Each agency must ensure that they comply with their agencies individual GDPR arrangements and documents/records should be retained for as long as necessary in line with guidance from the Independent Inquiry into Child Sexual Abuse (IICSA).
Agree Terms of Reference
The Strategy Group should review the information and any revised and updated information and intelligence that led to the decision that a complex investigation was required. The Gold Strategy Group should agree the terms of reference for the complex investigation, clearly identifying:
- Areas of responsibility;
- Lines of accountability and communications;
- How the investigation team will have full access to records and individuals who hold relevant information;
- The membership of the Silver Group and areas of responsibility for on-going management of the investigation;
- The membership of the Bronze Group and areas of responsibility for the on-going services being delivered to safeguard children and witnesses.
The Gold Strategy Group has explicit responsibility to ensure that the arrangements put in place to safeguard the children and witnesses subject of the unique complex investigation are clearly understood and acted upon by those in the Silver Group.
Key areas that require clarity include:
- Arrangements for the Joint Investigation;
- Multi agency assessments of the capacity and informed consent of the children to make decisions about either what has happened to them, or their on-going involvement in the safeguarding arrangements and investigation;
- How this affects the decision making of agencies about the methods needed to carry out the criminal investigation balancing the use of overt or covert policing methods alongside the need to ensure that the investigation methods will not compromise the safety of the children;
- How the information sharing arrangements will be reviewed so that the essential principle that information is shared on a 'need to know' basis so that there is no confusion about any restrictions that may change and evolve as the investigation progresses and the information that will be required on a day to day basis to help agencies safeguard the children;
- Contingency plans for both the on-going investigation and safeguarding arrangements so that there is flexibility to ensure that welfare of both victims and witnesses are safeguarded;
- Development of a media strategy/communication strategy;
- Key issues that may be unique to the circumstances of the complex investigation that set out potential circumstances that might jeopardise plans to gather evidence and alternative action that might be taken to ensure that abusive behaviours are never the less disrupted and further abuse prevented;
- To ascertain/ identify the need to commission specific services in order to support the victims.
The Gold Strategy Group is responsible for setting out an exit strategy that reflects the evolving nature of the Police investigation, criminal proceedings and the on-going responsibilities of the agencies towards the welfare of the victims and witnesses. This will need to include the involvement of the Crown Prosecution Service.
The uniqueness of any complex investigation and on-going services for the children mean that the exit strategy will need to consider not only these generic issues, but also additional factors that will be relevant and not set out below:
- How the police investigation and on-going criminal proceedings will impact on children involved in the case and how the witness support arrangements will be linked with the on-going support provided by universal and specialist services;
- How any future allegations will be managed linked to the case;
- Document storage;
- Management of the media;
- Civil Litigation;
- Management of information to the multi-agency workforce.
Complex child abuse investigations are time consuming, resource intensive and costly. The Gold Strategy Group will need to regularly review the balance between the on-going investigation, the welfare needs of the children involved and that the potential outcomes benefitting the children in the specific case.
Measuring the anticipated success of a complex investigation may include the following factors:
- The number of children protected;
- The number of incidents where abuse has been stopped;
- The number of children who are protected from abuse by disruption tactics;
- The stability of the children before, during and after the investigation in respect to where they are living, their health needs, education needs and other outcomes that are affected by the circumstances of the case;
- The number of perpetrators arrested, charged and convicted;
- The number of people barred from working in a position of trust with children;
- The success of family and civil proceedings in preventing perpetrators having access to children, as well as providing compensation to the victims of abuse.
The Gold Strategy Group is responsible for providing sufficient information either during or at the end of the complex abuse investigation to the Child Practice Review Panel so that decisions can be made, and reviewed, about whether a Child Practice Review or Multi Agency Learning Review is required arising from the circumstances.
The Chair of the Gold Group would be responsible for capturing the key learning points from this process in order to disseminate across the Multi Agency Partnership.
The function of this group is to implement the policies and strategies of the Gold Strategic Group (if in place) and have an operational focus and perspective at management level to the investigation that ensures that the case management arrangements safeguard the children effectively.
The group should comprise of multi-agency representatives who are at a senior level where they can share information, represent, update and quality assure case management arrangements:
- Chair (unless otherwise identified) Head of Quality Assurance / LADO (Derby) / Head of Child Protection (Derbyshire);
- Detective Superintendent;
- Senior Investigating Officer or deputy Senior Investigating Officer;
- Designated Doctor;
- Designated Nurse Safeguarding Children;
- Head or Deputy Head of Service (Children's Social Care)(Derby) / Assistant Director Early help and Safeguarding (Derbyshire);
- Relevant Team Managers (Children's Social Care);
- Other agencies as appropriate:
- Senior school representation for each child or young person (or a representative to liaise with all);
- National Probation Service;
- Voluntary and Independent Sector Organisations;
- Named professionals from relevant health provider/s;
- Representative from the Safeguarding Children Partnership;
- Representation from the Adult Safeguarding Board.
The Gold or Silver Groups, if in place, will assess the size of the investigation to decide whether a Bronze Group is required. Where investigations do not require groups at a Gold or Silver level, the Bronze Group will co-ordinate all aspects of the investigation. If the investigation runs into any barriers, or becomes more complex, Silver Group may be convened as a one-off or to meet regularly and take on the lead of the investigations.
Meetings will be chaired by a Child Protection Manager; membership will include all relevant front line staff involved in the investigation or working with the family, and/or their managers.
Meetings will need to be co-ordinated with any other relevant meetings, e.g. Child Protection Conferences, core groups or LAC reviews, to avoid duplication.
Frontline staff attending Bronze Group meetings need to keep their managers/Named/Designated professional informed of the case and plan of action and receive regular case supervision.
Where there are a large number of families/children involved consideration should be given for one Children's Service's Locality to coordinate the work. This will help to ensure continuity and consistency and also to prevent missed opportunities occurring.
Robust Genograms/Ecomaps must be completed to identify children in households, possible perpetrators and how they are connected to assist the work that needs to be undertaken.
The need for Safety Plans will be developed at the earliest opportunity, and should include both adults and children. These should include robust risk assessments that are reviewed and updated within agreed timescales.
Each organisation should identify an agency lead to ensure effective co-ordination, and communication. This includes making sure there is clarity of roles and responsibilities to ensure timescales are adhered to for the work to progress, be completed and to prevent unnecessary drift. The Social Care Lead should be a Team Manager.
Identifying intervention and support including any specialist services should be responded to at the earliest opportunity and not at the end of investigations/ assessments, e.g. children's advocacy and/or counselling.
Decision making should be clearly recorded and provide a rationale for actions and decisions taken. Updating chronologies for all agencies is crucial and must be completed in a timely manner.
Case discussed at Bronze Meeting level can be escalated to Silver or Gold command depending on the level of concerns/new information obtained.
A Senior Investigating Team will be identified to include appropriate officers from the Police, Children's Social Care, Health and other appropriate agencies to be responsible to offer guidance and advice and the maintenance of day to day multi-agency strategies.
The Police will identify a Senior Investigating Office (SIO) to be responsible for the conduct of the criminal enquiry.
The Senior Investigating Team will identify and allocate resources required to undertake intervention and investigation. It will be necessary to consider the following:
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Staff selection |
Gender, race, training, experience, specialism in respect of the different aspects of the functions of:
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Accommodation |
Location, size, securing, individual agency space. |
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Management systems |
Police computer (HOLMES), administrative support - incident staff, briefing strategy - investigation teams. |
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Critical alerts |
On victims and witnesses known at the time of the commencement of the operation and plans for those who will emerge as the investigation proceeds. |
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Interview facilities |
Location, recording/playback equipment, family support needs, accessibility - disability, transport. |
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Medical facilities |
Gender, staff, experience, training, location, record keeping, joint examination protocol. |
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Media strategy |
Manage through Derby and Derbyshire Safeguarding Children Partnership: identify lead, agree protocol, collective responsibility, regular staff briefing, press liaison personnel. |
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Needs of children/family |
Timing of intervention, maintenance/support needs, therapeutic support (during and/or after investigation), pre-court preparation/support, post-court support, and follow-up after 'outcome'. |
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Staff Support |
Administrative, debrief and ongoing support of staff, post-investigation debrief. |
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Post-Investigation |
Write-up for Senior Investigation Team and Derby and Derbyshire Safeguarding Children Partnership, post-outcome - debrief staff, address needs of children/families, implications for the future. |
At the conclusion of the investigation, the Group should assess its handling of the process and identify lessons for conducting similar investigations in the future.
The role of the SIO is extensive and is set out in detail in the national guidance on Managing Complex Child Abuse Investigations.
All partners involved in Silver Group should be familiar with the guidance Sections 5 to 8 of the national guidance so that they are able to discuss in an informed manner the arrangements for the investigation. These arrangements should include (dependent on the case):
- The terms of reference for the scale and nature of the case;
- Staffing issues (Selection, Welfare and Training);
- Multi Agency Working;
- Initial Risk Assessment;
- File Examinations and Retention;
- Joint Investigation;
- Links with Crown Prosecution Service;
- Potential Witness Identification;
- Witness / Victim Approach and Protocol;
- Further Risk Assessment;
- Forensic Strategy;
- Suspect Strategy;
- Victim and Witness Care and Support;
- Counselling and Therapy.
During an investigation it is probable that individuals will be identified who are suspected abusers although against whom prosecutions are not brought. If the suspected abuser is working with children in a childcare position, with adults at risk of abuse or neglect, consideration needs to be made for a referral to LADO or PIPOT. Evidence and information should be shared to support any outstanding HR/professional body processes to enable where appropriate the referral of suspected abusers to the Disclosure and Barring Service (DBS) and relevant regulatory bodies.
At the conclusion of the enquiry/ investigation, the strategic management group must evaluate the investigation, identify lessons learned and if appropriate, prepare an Overview Report with recommendations and an action plan for the Safeguarding Children Partnership. The purpose of this report would be to highlight any practices, procedures or policies which may need further attention and require either multi-agency or single agency action plans.
This work is very challenging for practitioners and support and supervision is essential. Each agency should have a supervisory system in place that is accessible to the professional and reflects practice needs.
If differences of opinion exist between practitioners or agencies regarding the management of the case, the Escalation Policy should be followed.
Last Updated: May 10, 2024
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