A SERIOUS case review following the death of a former pupil at a South Lakeland school revealed there were concerns she was being exploited ‘criminally and sexually’ during absences from a care home in Cumbria.

Maziellie MacKenzie, known as Mazie, was found hanged in woodland near Heysham Barrows, Lancashire, on June 23, 2018.

The 14-year-old attended Ulverston Victoria High School, Walney School and Furness Academy, Barrow.

A report by the Cumbria Safeguarding Children Partnership, which is responsible for ensuring organisations work together to safeguard children, outlined steps which could be taken in future to better protect youngsters in care.

The 30-page report said Mazie was taken into care in 2016. It was then that she disclosed extensive alleged sexual abuse from multiple perpetrators from the age of seven, the report said.

While living at a privately-owned children’s home in Cumbria between July 2017 and March 2018, Mazie was reported missing on more than 20 occasions.

The report said: “During her absences there were concerns that she was being exploited criminally and sexually.

“Child CH would often return from a missing episode under the influence of alcohol/drugs and showing signs of sexual abuse.

“She provided the names of individuals who she stated she had sex with, on one occasion admitting she had sex with an adult man to pay off a cannabis debt.”

While at the children’s home, Mazie also disclosed alleged historic sexual abuse.

A spokesman for Cumbria Constabulary said no arrests were made in relation to allegations of abuse made by Mazie.

In February 2018, the children’s home informed the local authority that it could no longer care for Mazie.

The report said she was ‘targeted by those who sought to exploit her vulnerabilities and unhappiness.’

She was eventually moved to a privately-owned specialist unit in North Yorkshire.

It was expected she would spend around 12 months there.

“Child CH was seen at a number of acute hospitals in Yorkshire due to self-harm incidents and following Child CH’s allegation that she had taken an overdose of stockpiled melatonin tablets (although this was believed to be untrue),” said the report.

The specialist unit determined the ‘risk of serious injury or fatality’ to Mazie was too high for it to be able to manage her safely.

She spent 13 days as an inpatient in hospital with staff providing 24-hour support.

From May 29, Mazie was an inpatient at a specialist mental health hospital in Lancashire.

Her place at the North Yorkshire specialist unit was retained ‘in the hope that she would return following assessment at the hospital’.

However, notice was later given that the unit did not feel it could provide adequate supervision with Mazie’s continued levels of self-harm.

The report said: “On the day that Child CH died there had been no concerns about her mental state or behaviour.

“She had left the unit twice previously during the day without concern or incident.

“She ‘ran away’ from staff and the other children during a very local escorted trip out of the hospital in the early evening.

“Lancashire Police were informed and staff members looked for Child CH in the local area.”

Mazie was found in a woodland area around four hours after she went missing.

She could not be resuscitated.

The report highlights a number of issues related to Mazie’s care through her life.

It states: “This serious case review shows what many others before it have found; that systems are complex and that both individual professionals and their agencies often struggle to negotiate an individual case through these systems.

“This is particularly difficult across different geographical areas.”

For example, on the day Mazie went missing the report says Lancashire Police was not aware the teenager ‘was in hospital in their area and they had no information on their systems regarding the previous involvement of police in other areas, the ongoing investigations, and her history of going missing.’

It added: “The reality of moving placement meant that Child CH was often cared for on a daily basis by those who did not know her well or have a good understanding of her history.”

The recommendations were as follows:

1 - The learning from this review should be disseminated widely.

2 - This report should be shared with the other local safeguarding children boards where Child CH lived during the time-frame considered by this review. A request should be made for feedback on any actions they propose to take in this matter.

3 - The Cumbria Local Safeguarding Children Board (CLSCB) to write to the Departments of Health and Education to state the need for the reform of systems nationally, which ensure that children are at the heart of service delivery whatever their needs, diagnosis, placement, or home address. This issue should also be highlighted to the Independent Child Safeguarding Practice Review Panel.

4 - The CLSCB should request assurance from Cumbria County Council and the Clinical Commissioning Group on the commissioning arrangements for placements for children who require stable and safe care, which provide management of risky behaviours alongside therapeutic input.

5 - The CLSCB should write to the Department of Education and OFSTED about the challenge in finding placements for children with significant risks and vulnerabilities, and the need for flexible bespoke packages of accommodation, care and support for these children that are based on the child’s needs and are not provision-led. They should be specifically asked to review the registration requirement for bespoke placements to ensure they can provide support in a timely way.

6 - That the CLSCB requests an update from the Cumbria Children’s Trust Board regarding progress of the action plan regarding Child X [the subject of a previous review].

7 - The CLSCB must assure itself that information about children looked after, including up-to-date risk assessments, health and social care plans, an up-to-date photograph, and contact details for family and associates are shared with a placement or hospital when a child moves or is an inpatient, so it can be utilised by all partners if a child goes missing or requires emergency assistance.

Question for the CLSCB: How can professionals be supported to ask themselves if they have the confidence to respectfully challenge other professionals if they believe that a child’s needs are not being met by existing multi-agency plans?