Organisational, Organised and Complex Abuse

In 2024, following learning from a local review, the NSCP has widened this definition to include harm caused by systemic failures in the management of organisational settings to provide adequate care for children. Organisational Abuse: occurs when there are systemic failings within an institution, such as a school or care setting, which result in the neglect or harm of children. This form of abuse often arises from poor leadership, poor management, lack of accountability, lack of governance, or a failure to adhere to safeguarding standards, leading to an environment where children's needs are not properly met, even if individual acts of abuse are not easily identified.

Organised Abuse: Organised abuse refers to situations where multiple abusers, often acting in concert, exploit their authority or institutional positions to target children. This type of abuse can involve networks of abusers who collaborate to groom, recruit, or harm children across various settings, including within families, communities, or institutions.

Complex Abuse: Abuse involving one or more abusers and a number of related or non-related abused children. The adults concerned may be acting in concert to abuse children, sometimes acting in isolation or may be using an institutional framework or position of authority to recruit children for abuse. 

Such abuse can occur both as part of a network of abuse across a family or community and within institutions such as residential settings, boarding schools, in day care and in other provisions such as youth services, sports clubs, faith groups and voluntary groups. The Safe Network has launched an online hub to help protect children from abuse in faith settings. There will also be cases of children being abused via the use of electronic devices, such as mobile phones, computers, games consoles etcetera which access the Internet.

Although in most cases of complex and organised abuse the abuser/s is an adult, it is also possible for children / young people to be the perpetrators of such harm, with or without adult abusers.

Each investigation of complex and organised abuse will be different, according to the characteristics of each situation and the scale and complexity of the investigation. All will require thorough planning, collaborative inter-agency working and attention to the needs of the child victim/s involved.

The investigation of complex abuse requires specialist skills from both police and social work staff which usually involves the formation of dedicated teams of professionals and will need consideration of the needs for victims for therapeutic services. The consequent legal proceedings may add to the timescales of such investigations.

Some investigations become extremely complex because of the number of places and people involved, and the timescale over which abuse is alleged to have occurred. In these circumstances a specialist Investigation Management Group (see Section 7, The Investigation Management Group), as well as a Strategic Management Group (see Section 6, The Strategic Management Group) may be set up. 

The complexity is heightened where, as in historical cases, the alleged victims are no longer living in the setting where the incidents occurred or where the alleged perpetrators 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.

The confidentiality of the 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 the agency, unless absolutely necessary.

In cases of organisational harm resulting in neglectful care being provided for children, the investigation will need to involve professionals who understand the regulatory context of the setting and are able to advise on progression of the investigation where a Section 47 is not the appropriate statutory framework. In cases related to an education setting this will be the relevant Group Manager from NCC Education, Skills and Learning Directorate. In cases of early years settings this will be the NCC Group Manager for Early Childhood Services. The NCC Group Manager for Commissioning will also need to be invited where an organisation is commissioned by NCC to provide services to Nottinghamshire children.

The single and most important consideration is the safety and well–being of any children and young people involved. As such the emphasis must be given to the safeguarding of children and young people as the primary consideration.

The strategic case management response must also recognise and address any racial, religious, cultural, language, sexual orientation, gender and/or special needs of any child, young person or other individuals involved.

This procedure relates to disclosures made by children or by people who are now adults but are disclosing information about things that they believe and/or allege happened to them when they were children.

The procedure should also be used when there is an emerging picture of organisational harm where concerns may be coming from professionals and carers, rather than directly from children.

In reconciling the difference between the standard of evidence required for child protection purposes and the standard required for criminal proceedings, emphasis must be given to the protection of the children as the prime consideration.

A victim support strategy and protocol should be established at the outset. Support will be required in pre-trial, trial and post-trial periods if the case/s proceed to court. Minimum periods for contact should be established. It is clear from experience in research about complex investigations that many victims and families feel strongly that it is important that they remain in contact with the same staff throughout the investigative process.

The early identification of circumstances requiring the instigation of these procedures is critical. All professionals should be alert to the requirement to consider whether a case requires consideration under these procedures and promptly discuss any concerns with their organisation Designated Safeguarding Lead (DSL), Designated Safeguarding Practitioner or named safeguarding practitioner and promptly highlight this as part of any referral process. Professionals should consult their own agency whistleblowing procedures if they feel their concerns are not being addressed within their own organisation or by other agencies.

Sometimes concerns do not constitute threshold for services when considered individually, but when considered as a whole show a picture of concern about the care being provided by an organisation.

A referral should be immediately referred either to the Police (if urgent) or the Multiagency Safeguarding Hub. In non-urgent cases that are already open to Nottinghamshire Children’s Social Care the social worker responsible for the case should be contacted at the earliest opportunity. The action outlined in this procedure will NOT delay an immediate action required to be taken by the Police and Local Authority in the discharge of their responsibilities under Working Together to Safeguard Children 2023.

The LADO should be informed and immediate consideration should be given to the way in which any media interest in the referral will be treated. The LADO may receive the information initially and identify a range of concerns not meeting LADO threshold regarding individuals but raising concerns regarding an organisation. In this situation the LADO will remain involved with a waiting brief pending individuals being identified.

If there is any suspicion that any managers currently employed by a social care agency are implicated or a member of the police, the matter should be referred to a senior officer outside the manager's area of responsibility. Response to organisational, organised or complex abuse requires thorough planning, good inter-agency working and attention to the welfare needs of all those involved.

Partner organisations response requires commitment from all organisations involved to work together in partnership to ensure that all relevant information is shared, and that appropriate action is to minimise the risk posed by potential perpetrators to children and vulnerable adults.

Organisational, Organised or Complex Abuse strategic case management should be undertaken as a co-ordinated and agreed response between the statutory safeguarding partners. The partnership Senior Leadership Group must be notified by the partnership business unit of the concern resulting in this procedure being started. It is for the SLG partners to determine who should attend the strategy meetings but the individuals must be at sufficient seniority to have decision-making authority on behalf of their organisation.

A Strategy Meeting should be arranged to take place as a matter of urgency to assess the need for future action to be taken and, in particular, whether a criminal investigation should take place. 

The Strategy meeting, chaired by the Group Manager Strategic Safeguarding and Independent Review, must take place within one working day of the receipt of the referral or within 24 hours of the identification of a suspected pattern of organisational abuse and be formally recorded.

The nominated senior staff in children's social care, including the LADO, and the police should attend the meeting. The meeting must involve senior staff from health, education and other agencies as required and, where necessary, must ensure coordination across local authority boundaries.

The Strategy discussion/meeting must carefully note:

• An assessment of the information known to date:
  • The children named;
  • The children who may be in current contact with possible abusers;
  • Children who were, but no longer are, in contact with possible abusers;
  • Possible victims who are now adults.
• Decide what further information is required at this stage;
• Arrange for its gathering;
• Establish if / to what extent complex abuse has been uncovered;
• Undertake an initial mapping exercise to determine the scale of the investigation and possible individuals implicated as well as prepare:
  • Witnesses to be interviewed prior to the interviews of children;
  • Multiple and simultaneous interviews.
• Consider a plan including resource implications, for investigation to be presented to the management and resources strategy group;
• Consider any immediate protective action required.

A strategic decision will need to be made by senior managers from the involved agencies as to whether the social work input into the enquiries/investigation can be managed in the conventional way or whether a specialist approach is required for example from a dedicated team outside the service.

This will usually depend on the number, geographical spread and age range of potential interviewees, as well as whether those implicated are foster carers or employees of any member agency.

Where the Strategy Discussion confirms that the investigation will relate to complex and organised abuse, it will appoint a multi-agency Strategic Management Group (see Section 6, The Strategic Management Group) to oversee the process. 

Where a member of staff of any agency is implicated in the investigation, his or her line manager must not be a member of the Strategic Management Group.

To ensure a co-ordinated response the Strategic Management Group will be chaired by a senior officer in Children’s Social Care or Nottinghamshire Police or the Integrated Care Board. If needed this will be agreed by SLG

It is a primary responsibility of this group to ensure that the welfare of children and any vulnerable adults are paramount at all times.

A Police Gold group may be held in parallel with the Strategic Management Group process, however, this should be by agreement between the NCC Director of Children’s Services and Nottinghamshire Assistant Chief Constable (ACC) as an additional requirement.

Where a Strategic Management Group is established the membership must comprise of senior managers that are able to commit to decision making and resources on behalf of their organisation. The Strategic Management Group must have the following core membership that should remain constant through the strategic case management response process (although there may be a need to add or co-op in other personnel as the strategic case management progresses):

• Notts County Council and/or Nottingham City Council Children and Families Service Director;
• Nottinghamshire Police Detective Superintendent for Public Protection;
• Nottingham City and Nottinghamshire Integrated Care Board Assistant Director of Nursing and Safeguarding.

The Strategic Management Group will:

• Complete the mapping process started by the Strategy Discussion as set out in Section 5, The Strategy Meeting;
• Establish ownership of the strategic lead in the investigation;
• Decide the terms of reference and accountability for the investigating team, including the parameters and timescales of their enquiries/investigation;
• Agree an initial safeguarding response, investigative, communication and support strategy;
• Bring together a team of people with the necessary training, expertise and objectivity to manage and conduct the criminal investigation and/or Section 47 Enquiry and/or organisational abuse investigation on a day to day basis. NB: Line managers or colleagues of any person implicated in the investigation must not be involved and the involvement of any person from the workplace under investigation must be considered with particular care;
• Decide whether there is a need for an independent team to investigate the allegations, for example, the NSPCC, particularly where the alleged perpetrators are foster carers, prospective adopters or members of staff employed by a member agency of the Safeguarding Children Partnership;
• In cases of greater scale and complexity, appoint an Investigation Management Group (IMG) (see Section 7, The Investigation Management Group);
• Ensure that appropriate resources are deployed to the investigation including access to legal and other specialist advice, resources and information;
• Consideration of any cross boundary issues and planning of appropriate liaison and sharing of resources;
• Relevant communication with Regulatory Bodies;
• Ensure that appropriate resources are available to meet the needs of the children and families or adult survivors, including any specific health issues arising from the abuse;
• Ensure the investigating team are themselves supported with personal counselling if necessary and that issues of staff safety are addressed;
• Ensure that suitable accommodation and administrative support are available for the investigation;
• Ensure that an appropriate venue is available for interviews and the interviews are conducted in accordance with Achieving Best Evidence Guidance;
• Liaise as necessary with the Crown Prosecution Service at an early stage before arranging services for a child in need of counselling or therapeutic help so that the help can be given in a way which is consistent with the conduct of the criminal investigation;
• Agree a communications strategy including the handling of political and media issues, and communication as necessary with the Regulatory Authority;
• Consider the communication and support arrangements for the affected children, families, settings, professionals and community;
• Ensure that records are kept safely and securely stored and a high level of confidentiality maintained at all times. The governance for the sharing of information, to ensure that safeguarding teams secure full access to records from all partner organisations affected, individuals holding important information and to commit all those involved to providing the necessary support to obtain records from any relevant organisations. Timescales for the key stages of the safeguarding response, investigation and support;
• Hold regular strategic meetings and reviews, which must be recorded, to consider progress, including the effectiveness of the joint working, the need for additional resources and next steps.

In cases of considerable complexity and scale, an Investigation Management Group will be appointed.

Membership of this group should include representatives from children's social care and LADO, the police, designated health professionals and the local authorities legal services, with other agencies being invited to participate as appropriate.

The tasks and functions of the Group will be subject to the terms of reference agreed by the Strategic Management Group (SMG), and will include the following:

• To provide a forum where professionals can meet, exchange information and discuss the implementation of the agreed investigation strategy;
• To ensure a consistent strategy for interviewing victims within and outside the council’s area;
• To keep the SMG informed of resources and any shortfalls;
• To ensure a consistent and appropriate inter-agency approach to support victims and their families;
• To co-ordinate the inter-agency response to families and provide consistent information;
• To ensure information is shared appropriately with other agencies not represented on the SMG or the IMG;
• To ensure clarity of roles and responsibilities for staff involved in the investigation. Investigators will have full access to all records and key information;
• To ensure that relevant intelligence is passed between agencies and to the police Major Incident Room (MIR).

The Waterhouse Inquiry report has noted the importance of adequate referral of information about suspected abusers. It is probable that an investigation will identify individuals who are suspected abusers but against whom prosecutions are not brought – the MA process will be relevant and will inform disciplinary processes. If a suspected abuser is working with children in a childcare position, or in the education service, evidence and information should be shared to support disciplinary proceedings and to enable, where appropriate, the referral of suspected abusers to the Disclosure and Barring Service (DBS) and the relevant regulatory bodies.

At the conclusion of the enquiry/investigation, the Strategic Management Group must evaluate the investigation, identify the lessons learned and prepare an Overview Report with recommendations and an Action plan for the Safeguarding Children Partnership, highlighting any practices, procedures or policies which may need further attention and require either inter-agency or individual agency action plans.

There must be a clearly defined exit strategy not only in relation to closure of the safeguarding response and investigation, but also with regard to any children, young people and families who may require on-going support at the conclusion of any criminal trial or investigation.

If a potential perpetrator is working or volunteering with children, young people or vulnerable adults the case should be referred to the NCC LADO Team and, in conjunction with these procedures, managed through the NSCP Managing Allegations Against those who work or volunteer with children Procedures.

At the conclusion of the safeguarding response and investigation each partner should take time to reflect and consider if there needs to be a fuller review, with a view to identifying any learning and recommendations as a result. In some circumstances the criteria may be met for a serious incident notification and rapid review.

The Strategic Management Group should have a final meeting where concluding information and debriefing can be shared. The Strategic Management Group must evaluate the safeguarding response, investigation and support and where relevant an overview report should be compiled with the support of the NSCP and any good practice and areas for development identified and disseminated accordingly. The storage and security of material relating to the investigation should be agreed.

Allegations Against Staff or Volunteers Procedure

College of Policing: Managing Complex Child Abuse Investigations