Inspection of Greater Manchester Police and its safeguarding partners’ approach to investigating allegations of child criminal and sexual exploitation

Foreword

Child sexual abuse and exploitation have a devastating effect on children and their families. Children are among the most vulnerable people in society. Children should grow up in loving, caring families and reach adulthood unharmed. But many children sadly don’t. They are abused within the family environment, are coerced into criminal enterprises or exploited for sexual gratification. Some children, such as children who have experienced adversity or who go missing from home, face increased risks.

These things are well known. Public services, including the police, have a shared responsibility to look for the warning signs, be alert to the risks and act quickly to protect children.

Victims often live with the trauma of child sexual exploitation for a considerable time or for life. People who experience sexual abuse and exploitation can be female or male. Many victims and survivors may reach adulthood before they feel they can tell someone about their experience and ask for support. Many other victims never disclose what has happened to them. It shouldn’t be underestimated how complex and challenging these crimes are to prevent and investigate. And the police can’t tackle them alone. They require good quality investigations, effective leadership and partners working together.

In July 2017, the BBC broadcast a documentary, The Betrayed Girls, about child sexual exploitation in Greater Manchester. In September 2017, the Greater Manchester mayor, Andy Burnham, commissioned an independent assurance review of the effectiveness of multi-agency responses to child sexual exploitation in Greater Manchester. In January 2020, June 2022 and January 2024, the review team published each of its three reports. These reports focused on three local authority areas of Greater Manchester, and the past approaches to child sexual exploitation practices and investigations.

In July 2024, following publication of the final report from the independent review team, the Greater Manchester mayor commissioned His Majesty’s Chief Inspector of Constabulary to inspect Greater Manchester Police and its safeguarding partners’ approach to investigating allegations of child criminal and sexual exploitation. Our commission focused on the current and ongoing provision for investigating allegations of child criminal and sexual exploitation.

To support our inspection, we drew on the experience of specialist advisers from Ofsted and the Care Quality Commission (CQC) for the peer review inspection activity. And we had support from the Child Sexual Exploitation Taskforce’s Hydrant Programme for the Greater Manchester Police investigation activity. We thank them for their support.

We found that since 2019, when the force started to review its non-recent child sexual exploitation investigations, Greater Manchester Police has improved its understanding and approach to investigating allegations of child criminal and sexual exploitation. The force has specialist officers within a child sexual exploitation major incident team who are dedicated to investigating multi-victim multi-offender, non-recent child sexual exploitation.

There have been several inquiries and inspections by His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services’ and other organisations about child sexual abuse and exploitation. All of them reference that the police, law enforcement bodies, government departments and child protection agencies need to work together effectively, to protect children from harm and bring offenders to justice.

In October 2022, the Independent Inquiry into Child Sexual Abuse (IICSA) published its report. It made 20 recommendations. The inquiry gave victims and survivors an opportunity to share their experiences and make suggestions for change, via the Truth Project. The project, which concluded in October 2021, listened to the experiences of over 6,000 victims and survivors of child sexual abuse. These helped inform the inquiry’s final recommendations.

In December 2023, we published our report ‘An inspection of the effectiveness of the police and law enforcement bodies’ response to group-based child sexual exploitation’. We found that police services across England and Wales have taken steps to improve their response to child sexual exploitation. Police forces know more about the wider context in which cases of child sexual abuse occur. We found that when specialist officers – with the right training and skills – took charge of investigations they were of a better quality. We made nine recommendations and identified one area for improvement to support police forces. We are pleased to find that Greater Manchester Police has implemented all force-specific recommendations and the area for improvement. We are currently reviewing all forces’ progression against the published recommendations and the area for improvement.

In December 2024, we published our ‘Greater Manchester – National child protection inspection’ report as part of our national rolling programme of inspections. This assessed how effective the force was at safeguarding children, including children who are victims of child sexual and criminal exploitation. We found that the force’s leaders had strong oversight and understanding of its performance and the quality of service it provides to the public. And the force is good at working with partner organisations to safeguard children. It is adequate at responding to children at risk of harm and at investigating offences. But we found that the force needed to improve how it records information about children. This would help it to assess risks more effectively. And it should improve how it investigates online child exploitation. We also identified that the force should make sure its officers and staff in high-risk roles understand the well-being support available to them and encourage them to use it.

Reflecting on our findings from this commission, we can’t help but be encouraged by how the force has improved its practice. The improvements have been secured by the hard work and contribution of various parties. These begin, not least, with the experiences of victims and survivors themselves. They include the public service leaders, partners and practitioners whose job it is to safeguard people and investigate these crimes. They also include third sector support organisations, the Greater Manchester voluntary community, faith and social enterprise sector, and other individuals in Greater Manchester. Collectively, their evident dedication and willingness to challenge organisational and societal norms have secured these improvements. For that they should be thanked.

Executive summary

For a number of years, Greater Manchester Police and its safeguarding partners have been scrutinised about how they keep children safe from sexual and criminal exploitation.

In 2017, Greater Manchester Combined Authority (GMCA) and the Greater Manchester mayor commissioned a series of independent reviews about the safeguarding provisions in the past and the investigation of criminal exploitation in several local authority areas of Greater Manchester. The review findings were published in January 2020, June 2022 and January 2024.

In 2022, Chief Constable Watson QPM made an unequivocal apology to victims of child sexual exploitation for how Greater Manchester Police had handled child sexual exploitation investigations and let vulnerable victims down. The apology came with a commitment: “We are committed to leaving no stone unturned to bring these offenders to justice, no matter the passage of time, through our dedicated Force CSE [child sexual exploitation] unit.”

On 10 July 2024, the mayor commissioned His Majesty’s Chief Inspector of Constabulary to carry out an inspection of the force and its safeguarding. Its primary focus was the force’s current and ongoing investigation provision and how the force and safeguarding partners have learned lessons and made improvements through its peer review programme. This report sets out our findings in relation to that commission.

How effective is the Greater Manchester Complex Safeguarding Programme peer review process at improving the partnership approach to child criminal and sexual exploitation?

The peer review programme, introduced by GMCA in 2018, aimed to reassure leaders about multi-agency responses to child exploitation.

All Greater Manchester local authority areas agreed to peer review child sexual and criminal exploitation cases. The partners agreed seven complex safeguarding principles. They supported peer reviews by providing access to case files and skilled staff to carry out the reviews.

The ongoing intention is for results from the reviews to inform and improve their work and reduce the harm from child sexual and criminal exploitation. The peer review programme methodology continues to develop.

Our inspection found that the peer review programme largely meets its objectives. It is focused on the work of the complex safeguarding teams. The programme works alongside other activities to tackle and quality assure safeguarding responses to child exploitation.

We found areas of good practice, and we highlighted areas for development to GMCA.

Overall, we have clearly seen that the Greater Manchester complex safeguarding peer review programme contributes positively to multi-agency practice to reduce the risk of child exploitation. This has been highlighted in this report as innovative practice.

Areas of good practice

Greater Manchester partners commission and support a proven and well-researched approach to peer reviews. Resources and capability for effective peer reviews are generally in place. Improved outcomes for vulnerable children are achieved through Greater Manchester partners’ strong governance and oversight.

Peer review methodology includes an analysis of the contribution each partner makes in practice. Reviewers evaluate the outcomes of partnership work to reduce exploitation risk, identifying practice strengths and aspects that need to improve.

Peer reviewers present their findings clearly to the district partners. The Greater Manchester complex safeguarding hub (GMCSH) team identifies themes from the peer reviews and publishes these to highlight and promote learning.

Peer review findings are drawn directly from the outcomes of practice. This analysis provides direct evidence of its effectiveness. Leaders and managers use peer review information alongside other quality assurance and performance systems.

Greater Manchester partners use peer review findings to implement best practice. Peer review learning is included and prioritised in the content of training materials, through each organisation’s systems. Policy, practice guidance and staff training is updated without delay.

Areas for development

We found that the quality of peer reviews varied according to the practitioners’ skills. The case file reviews and analysis the GMCSH team completed were consistently good. But some of the district peer reviewers are less experienced in this work. We found some examples of inconsistency between the district reviewers’ and the GMCSH team’s analysis. We also saw that children’s social care case audits and analysis was consistently better than those completed by health and police service district peer reviewers.

Use of different case file audit tools for children’s social care, health and police records meant that the peer reviewers didn’t record and evaluate sector-level information consistently. Specifically, we saw that the police audit tool isn’t aligned to the seven complex safeguarding principles and it doesn’t support the analysis of trauma-informed practice. The force has since told us that it is now piloting a new assessment tool, which all peer review partners are using.

Greater Manchester partners should apply their processes more consistently. This would maintain the integrity of the peer review process and improve consistency of the district peer review findings. The partners would benefit from training a group of multi-agency peer reviewers and introducing quality assurance and moderation processes. A standardised case audit template would improve the way the programme collects and analyses multi-agency case file information.

The GMCSH team collated detailed peer review findings for each district as either strengths or areas for improvement. At the end of each peer review, they presented this evaluation in a meeting with the district multi-agency partners. This analysis of the four district cases was immediately helpful to local safeguarding practice. But the GMCSH didn’t include all the district-level detail in presentations to the wider partnership. For example, a type of online exploitation risk found in one child’s review wasn’t identified to other districts.

Peer reviewers should improve their evaluation of cases by including contributions from children, their families and carers. Their views can make insightful contributions to understanding the effectiveness of the Greater Manchester specialist safeguarding partners’ work to tackle child exploitation. The partners told us they are developing methods of gathering this sensitive information.

An oversight process for making and monitoring peer review recommendation outcomes would improve consistency and provide evidence about the programme’s effectiveness.

How effective is the force in carrying out its investigative strategies in relation to operations Bernese, Green Jacket, Sherwood and Exmoor?

Our inspection found that the force has made significant improvements to how it understands and investigates child sexual exploitation.

The force has a dedicated team to investigate serious and complex multi-victim or multi-offender child sexual exploitation. The team was introduced in 2021 and renamed the child sexual exploitation major investigation team (CSE MIT) in 2023. The dedicated team of 98 investigators and police staff is a significant commitment by the force to investigate the missed opportunities in non-recent child sexual exploitation investigations.

The force has good strategic and operational leadership and governance arrangements in place for investigations carried out by both the CSE MIT and local district investigators. This includes the force requesting and welcoming constructive challenge from national advisors and subject matter experts. The chief officer lead who chairs the governance group provides clear direction and guidance to investigators.

Force strategies provide clear direction for the investigation of child exploitation. The CSE MIT has a comprehensive victim and survivor strategy, which is in accordance with College of Policing and National Police Chiefs’ Council (NPCC) guidance. The CSE MIT senior investigating officers work with statutory and non-statutory partners who provide professional support and advocacy to victims and survivors. The force prioritises victims’ and survivors’ wishes. The progress of the investigation is also taken at the victim’s pace to support their well-being.

Police and partner organisations across the vulnerability sector work together to identify and support victims and survivors. Victims may live with the trauma of sexual exploitation for long periods of time before they tell someone and ask for support. Others may have never asked for such support. Investigators and partners share information to identify individuals who may have been a victim of child sexual exploitation. They make carefully considered decisions about approaching a potential victim. Investigators also pay close attention to the person’s wishes.

A multi-agency approach is also taken with suspects and vulnerable locations for child sexual exploitation. The force and its partners are good at managing suspects and locations identified during investigations and through intelligence. They use a perpetrator risk assessment tool to categorise the risks from suspects. Suspects and locations are then managed using a range of tactics to disrupt criminal activity and interventions to keep vulnerable people safe.

How effective is the force’s approach to the 74 potential victims and survivors of child sexual exploitation identified through the work of the independent review team?

In its January 2024 report, the independent review team identified 74 children as potential victims and survivors of child sexual exploitation. These children’s circumstances were known to the police and children’s services between 2003 and 2013. All are now adults. The police’s historical contact with the children was between 11 and 20 years prior to the inspection.

Our inspection team viewed all force records about the 74 individuals from either the first date the initial information was reported or the date when a potential victim was identified by investigators (whichever was earliest).

We reviewed all available information held on force systems. We found that some of the 74 children had disclosed offences of child exploitation. And some individuals told officers that they hadn’t been sexually exploited. The audit included an assessment of how the investigators had dealt with multi-victim or multi-offender child sexual exploitation investigations at the time the offence or incident was first reported and what action investigators had since taken.

In some cases, we identified failings in the way the force initially supported victims and survivors and carried out investigations. For example, police personnel and partners frequently used victim-blaming language and this went without challenge. These failings will have resulted in the irrecoverable loss of confidence and trust in the police and safeguarding services for some victims and survivors. The force didn’t offer some survivors the support they needed and deserved. We also found that the recording of crime historically was poor. As a result some victims’ cases weren’t adequately investigated.

The chief constable has given an unequivocal apology to victims and survivors, for the treatment they received at that time.

Since the initial victim and survivor engagement, we found that the force had made considerable effort to work with and support victims and survivors of child sexual exploitation.

The force introduced dedicated child sexual exploitation investigators who reviewed the force’s historic approach to child sexual exploitation offences. This included those incidents and cases relating to the 74 individuals.

We found that the force had revisited the information and the quality of service it had provided to all 74 children. It identified missed opportunities to support victims and survivors and investigate their crimes. It had also developed its policy for identifying, assessing, supporting and approaching victims and survivors.

We found that dedicated child sexual exploitation investigators had retrospectively recorded some of the crimes the force had failed to initially record.

Investigators recontacted the vast majority of the 74 potential victims to offer support and gain their trust and confidence to support a police investigation. The force received a varied response. Some victims and survivors didn’t want to tell the police about any crimes that had happened to them. Officers left their contact details and information on how victims and survivors could access the support available. They made sure the person was aware they could change their mind at any time. Other individuals reported crimes to the police and accepted the victim support services they were offered.

It was clear that the force had tried to rectify the missed opportunities it had identified and the times when it had let down victims and survivors. Its more recent work with people who had potentially been sexually exploited as children was more victim‑focused. However, for some individuals who had been let down by Greater Manchester Police at the initial contact stage, the force was unable to rectify the issues they had experienced.

The inspection found that the force had been trying to provide a better service to those who have been, or may have been, traumatised by child sexual exploitation.

Innovative practice and areas for improvement

During our inspection, we found four areas of innovative practice, which we have highlighted within chapters 1 and 2. There are also a number of areas in which the force could improve.

Introduction

Background

The Greater Manchester city region has a population of approximately 2.9 million people. It spans a mostly urbanised area of 493 square miles with ten local district councils: Bolton, Bury, Manchester, Oldham, Rochdale, Salford, Stockport, Tameside, Trafford and Wigan. These district councils collaborate through the Greater Manchester Combined Authority (GMCA).

The elected mayor chairs the GMCA as a strategic partnership arrangement between the district councils, public services, businesses and the communities. These partners work together to regenerate and improve the economic situation of the city region. They are responsible for policing and security, regional transport and providing communities with health, education and social care services.

The district councils, Greater Manchester Police and the Greater Manchester Integrated Care Board are responsible for safeguarding and promoting the welfare of all children across the districts. These Greater Manchester partners follow the national multi-agency arrangements in the statutory guidance ‘Working Together to Safeguard Children 2023’.

The threats of harm to children caused by child sexual exploitation and child criminal exploitation are being increasingly recognised. The national media has repeatedly reported on several non-recent high-profile incidences of organised child exploitation in the Greater Manchester region. This commentary included highly critical accounts from victims, survivors and locally-based practitioners about Greater Manchester safeguarding services. Communities and their representatives also voiced serious concerns. They strongly challenged Greater Manchester Police and the mayor about the effectiveness of the multi-agency arrangements to safeguard children from exploitation.

In September 2017, the mayor commissioned an independent assurance review of the effectiveness of multi-agency responses to child sexual exploitation in Greater Manchester. In January 2020, June 2022 and January 2024, the review team published each of its three reports. These reports focused on three local authority areas of Manchester and the historic approach to child sexual exploitation practices and investigations.

Following the publication of these reports, the mayor commissioned His Majesty’s Chief Inspector of Constabulary, under section 54(2BA) of the Police Act 1996, to inspect Greater Manchester Police and its safeguarding partners’ approach to investigating allegations of child criminal and sexual exploitation, and supporting victims and survivors.

About us

His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services’ independently assesses the effectiveness and efficiency of police forces and fire and rescue services to make communities safer. In preparing our reports, we ask the questions that the public would ask, and publish the answers in an accessible form. We use our expertise to interpret the evidence and make recommendations for improvement.

Our commission

Inspection of Greater Manchester Police and its safeguarding partners’ approach to investigating allegations of child criminal and sexual exploitation.

Our terms of reference

In terms of reference agreed with the mayor, he asked us to examine how the force and its safeguarding partners learn lessons and make improvements from peer reviews of child exploitation investigations. He also requested assurance that four ongoing investigations into non-recent child sexual exploitation cases are effective.

These investigations cover a 12-year period from 2002 to 2014:

• Operation Bernese – an investigation into the death of a child in 2003;
• Operation Green Jacket – an investigation into alleged child sexual exploitation between 2004 and 2005;
• Operation Sherwood – an investigation into 11 cases of child sexual exploitation in Oldham between 2011 and 2014, as identified in the 2022 independent assurance review; and
• Operation Exmoor – an investigation into non-recent child sexual exploitation in Rochdale.

Finally, the mayor asked about the effectiveness of the force’s approach to the 74 victims and survivors of child sexual exploitation who were identified through the work of the independent review team (previously appointed by GMCA).

In this inspection – with necessary advisory support from Ofsted, the Care Quality Commission and the Hydrant Programme – we addressed the following questions:

• How effective is the Greater Manchester Complex Safeguarding Programme peer review process at improving the partnership approach to child criminal and sexual exploitation?
• How effective is the force in carrying out its investigative strategies in relation to operations Bernese, Green Jacket, Sherwood and Exmoor?
• How effective is the force’s approach to the 74 victims and survivors of child sexual exploitation, who were identified through the work of the independent review team (previously appointed by Greater Manchester Combined Authority)?

Methodology

Our inspection took place between October 2024 and February 2025.

We developed a methodology to inspect the three areas of the commission. This identified the standards and characteristics of good performance, in accordance with relevant legislation and national guidance for England and Wales.

We carried out inspection activities to gather evidence and assess how the force and its safeguarding partners meet the identified standards. These included:

• 114 case file reviews (including 40 peer review audits) – we audited files for single and multi-agency cases and investigations;
• 27 interviews and discussions with police personnel and staff from other safeguarding agencies – we held strategic and operational interviews with leaders and practitioners, and we held focus groups and did reality testing with personnel from the force and its statutory and non-statutory safeguarding partner organisations; and
• 70 document reviews – we examined reports, strategies, policies, data, training material, guidance, meeting minutes and other relevant written materials.

In October 2024, we held a stakeholder meeting. We asked leaders and frontline staff from Greater Manchester local victim and survivor organisations, who are part of the Greater Manchester voluntary community, faith and social enterprise sector, and national organisations about the services available for victims and survivors. Attendees at the meeting provided their views and experience, which gave us valuable insight. We thank them for their support.

1.  How effective is the Greater Manchester Complex Safeguarding Programme peer review process at improving the partnership response to child criminal and sexual exploitation?

As part of this inspection’s terms of reference, the mayor asked us to consider the effectiveness of the Greater Manchester Complex Safeguarding Programme peer review process at improving the partnership approach to tackling child criminal and sexual exploitation.

The inspection specifically examined:

• the effectiveness of the peer reviews that the force and its safeguarding partners carry out;
• the effectiveness of peer reviews in identifying learning (such as good practice and areas where the partnership could make improvements);
• how the force and its safeguarding partners share and report learning from peer reviews;
• how peer reviews contribute to other partnership scrutiny and accountability processes; and
• how the force and its safeguarding partners use learning from peer reviews to improve how they approach child criminal and sexual exploitation.

For this inspection, we use the term ‘Greater Manchester partners’ to include: the Greater Manchester Combined Authority (GMCA), Greater Manchester Police, the ten regional local safeguarding children partnerships, and the Greater Manchester Integrated Care Board. We refer to the local partnerships as ‘districts’.

Summary of findings

During this inspection, we found many examples of good practice including:

• a proven and well-researched approach to peer reviews;
• strong governance and oversight;
• effective methodology, including analysis of partner contributions and evaluation of partnership work;
• clear presentation of findings to district partners and more widely;
• learning incorporated into continuing professional development, quality assurance and performance systems; and
• using insights to update policy, practice and guidance.

However, we also found some areas for development. These included:

• the quality of peer reviews varied, depending on the practitioners’ skills;
• use of different case file audit tools by children’s social care, health and police records which led to some inconsistent records and evaluation;
• some inconsistent processes in how partners collected and analysed case information;
• not all learning was shared with the wider partnership;
• a lack of contributions from children, their families and carers; and
• no oversight process for making and monitoring peer review recommendations to provide evidence about the effectiveness of the programme.

Strategic leaders and practitioners strongly support the Greater Manchester complex safeguarding programme peer review process. They continue to develop the methodology by incorporating learning from the previous rounds, alongside other national research findings.

The programme should be expanded to include other sectors, such as education. This would reflect the increasingly integrated nature of multi-agency work to protect children from exploitation, as referenced in the statutory guidance ‘Working Together to Safeguard Children 2023’.

Peer reviews are focused on the work of the specialist complex safeguarding teams (CSTs). But the findings apply equally to non-specialist practitioners who work closely with vulnerable children and their families. Their work to prevent the escalation of child exploitation risk also benefits from peer review learning.

The Greater Manchester partners should maintain the accuracy and consistency of the programme’s findings. A standardised case audit template would improve the collection and analysis of multi-agency case file information. Training a cohort of multi‑agency peer reviewers and introducing quality assurance and a moderation process would improve consistency. Including feedback directly from the children and their families would enhance the analysis of each case.

The peer review process has a clear commitment from Greater Manchester strategic safeguarding partners to review and reflect on cases to identify and improve multi‑agency practice. It has support from both strategic leaders and practitioners. The programme is positively affecting how partners and practitioners improve multi‑agency practice to reduce the risk of child exploitation.

Background

In 2018, GMCA leaders wanted reassurance about the multi-agency responses to child exploitation. They agreed to start a city region-wide peer review programme of child sexual exploitation and child criminal exploitation case files.

This programme continues. Experienced safeguarding practitioners in the Greater Manchester Complex Safeguarding Hub (GMCSH) co-ordinate it. They use the learning from each review, alongside insights from academic organisations such as Research in Practice, to strengthen the programme’s methodology.

The GMCSH adapted the methodology to allow the reviews to continue safely during the pandemic. This flexible approach also allows the programme to continue alongside activities, such as inspections of service providers, which can reduce organisations’ capacity to carry out the peer reviews.

Strategic leaders from all the districts and sectors actively support the programme by allowing access to their case file records. They also provide skilled staff with the time to complete the process.

This inspection is focused mainly on the latest process, dated 2022/23. We are aware that the Greater Manchester peer review programme methodology has developed and continues to do so. We haven’t commented on the new methodology as it was still being developed at the time of our inspection.

The 2022/23 Greater Manchester peer review process

The Greater Manchester partners collectively agreed to using seven complex safeguarding principles, which we quote below. These principles are the foundation of the peer review process. They are:

1. Young people should be at the centre; their developmental needs and their strengths must drive “our” response.
2. Exploitation is complex; therefore, the response cannot be linear or simple.
3. No agency can address exploitation in isolation, collaboration is essential.
4. Knowledge is crucial.
5. Communities and families are valuable assets and may also need support.
6. Equip and support the workforce, effective services require resilient practitioners.
7. Context matters, young people need a holistic approach.

The 2022/23 programme completed four child exploitation case reviews for each district. This gave a regional total of 40 cases.

The case file selection for the peer reviews involved the districts working closely with the GMCSH peer reviewers. This joint selection process made sure that the reviewed cases included:

• children of different genders, ages and cultural heritage;
• children with disabilities;
• children who had experienced sexual and/or criminal exploitation; and
• three statutory safeguarding partners’ services.

The GMCSH team reviewed two case files for each district. A team of practitioners from the police, children’s social care and health services from another partner district reviewed two other case files. The combined results of the four individual reviews contributed to each district’s peer review report. It took about eight weeks to complete each district peer review.

Each peer review process started by completing individual health, police and children’s social care audits on the children’s case files. Peer reviewers used agency-specific audit frameworks. They then jointly assessed and combined their findings for each case audit.

The peer reviewers then held a reflective discussion meeting with the multi-agency practitioners involved with the child’s case. The purpose of this meeting was to feed back the peer review findings to the practitioners. This process helped the practitioners reflect on the strengths of their practice and where improvements could be made to outcomes for the children.

The GMCSH staff organised the district peer review findings into themes of strengths and areas for improvement. Districts had an opportunity to review the evaluation. Once findings were agreed, the information was presented to the reviewed district’s partnership strategic complex safeguarding meeting.

As the programme progressed, the GMCSH reported the emerging high-level themes to the Greater Manchester partners. The GMCSH later compiled these themes into a final thematic overview.

Methodology

His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services’ (HMICFRS) national child protection inspection team completed this aspect of the inspection. Specialists from Ofsted and the Care Quality Commission (CQC) advised our inspectors.

We structured the inspection to cover five key activity areas of the peer review programme:

• strategic governance;
• identifying learning;
• communicating learning;
• performance and quality assurance; and
• improving practice and outcomes.

Document reviews

We reviewed the Greater Manchester peer review programme documents, covering process arrangements and the evaluation summaries. We assessed the individual audit records of the 40 children’s cases that formed the basis of the programme. We evaluated the documents of each district’s peer review. We also saw, as at October 2024, the district position statements about the progress of their workstreams following the peer review process.

Interviews and focus groups with key staff and leaders responsible for CSTs

We visited five districts: Bolton, Manchester, Rochdale, Salford and Trafford. In each district we held three focus groups with multi-agency professionals:

1. Managers in the district safeguarding board complex safeguarding subgroup.
2. District managers responsible for performance, quality assurance and training.
3. District frontline practitioners and supervisors from the CSTs.

We also separately interviewed the local children’s social care services assistant directors with responsibility for the district CST, the local health service leads for the CST, and the local peer reviewers from police, children’s social care and health services.

Additionally, we interviewed strategic leaders and the specialist practitioners associated with the GMCSH and the management of the peer review programme.

Strategic governance

Resources and support for peer reviewers is good, but more training would be beneficial

The Greater Manchester partners consistently support qualitative reviews of multi‑agency arrangements for child exploitation. Leaders value this detailed information because it helps them to understand the effectiveness of their service provision.

GMCSH staff design, plan, co-ordinate and evaluate the peer review programme. This small but experienced multi-agency team includes social work managers, a health service safeguarding professional, a detective sergeant and an analyst. These experienced practitioners have clear line management from the GMCA.

There is strong governance in place. One of the region’s directors of children’s social care services has oversight of the peer review programme and the GMCSH team.

The GMCSH reports its work to the Greater Manchester complex safeguarding executive. This strategic meeting involves the GMCA and senior leaders from health, police and local authority areas. Together these partners provide the resources and capability for the GMCSH team of peer reviewers.

Locally based services also assign district-based social workers, police officers and health practitioners to the peer review programme. These local practitioners complete two multi-agency case file reviews in another district. At the same time, the GMCSH team completes two other case file reviews in that district. These four case file reviews together form the basis of each district’s peer review.

The GMCSH staff guide and support the district peer reviewers. This includes an initial briefing about the programme and advice as they complete their reviews. But no formal peer reviewer training is provided. District peer reviewers from each of the services told us they valued the support. But specific training for the role would have helped them work more efficiently and consistently within the programme.

Some reviewers felt they didn’t have the knowledge and skills to peer review the work of another district team. One district reviewer was new to the role with no previous experience of case file auditing, so relied heavily on colleagues for advice throughout the process.

Several of the district peer reviewers told us that they weren’t assigned enough time away from their existing responsibilities to complete the peer review process. But because they valued the process they used their personal time to make sure the work was finished. They said that time limitations meant that they weren’t always able to thoroughly assess and evaluate the information about the case.

Strategic leaders, GMCSH and district peer reviewers also acknowledged that the peer review programme hadn’t fully included the direct accounts and experiences of the children, their families and carers. This was because the 2022/23 programme didn’t include the time and resources needed to sensitively gather this information. Instead, the peer reviewers relied on case file records and practitioners’ notes from their reflective discussions with families.

The methodology for the peer reviews is based on well-researched, relevant and focused criteria and practice

In 2019, GMCSH staff started carrying out child exploitation regional peer reviews. Previously, some of the Greater Manchester districts had completed local peer reviews. The GMCA provided Greater Manchester safeguarding partners with an opportunity to develop a regional peer review programme. Safeguarding partners recognised the advantages of using shared methodology and standards to achieve a consistent evaluation of services.

GMCSH staff work to actively improve the peer review programme methodology. This involves evaluating previous experiences of their reviews, understanding existing operating models and incorporating validated academic research, such as from Research in Practice. The GMCSH team uses flexible approaches to adjust to the reality of the operating environment and continue the programme. For example, to continue work safely, the team adapted the methodology during the pandemic. Staff ask for feedback from local practitioners and strategic leaders. The team also introduced reflective discussions, which was identified as effective practice in national research.

Strategic leaders told us they have confidence in the peer review programme. They provided examples of learning and impact resulting from peer reviews, such as the use of specialist nurses in the CSTs. They also told us about a change in Greater Manchester Police policy so that a child’s local CST investigates even when the child is involved in offences in another district. This means all risks to the child are fully considered and understood. In our interviews and focus groups we also saw and heard evidence of learning implemented from peer reviews.

Practitioners and strategic leaders we spoke to said that the peer review process has a proven record of improving operational practice and arrangements for tackling child exploitation.

The GMCSH team continues to develop the programme methodology. At the time of our inspection, Manchester and Wigan districts were holding workshops to help design the next stages of the peer review programme. These workshops are an opportunity to learn from previous programmes and to implement new and improved models of practice, such as the partnership reflective tool endorsed by Research in Practice, the Children’s Society and Bedfordshire University.

There are some ineffective processes within the peer review methodology

We found some commonality between the social care and health file case audit formats. But the police and health peer reviewers use their own service-specific case audit formats.

Children’s social care reviewers use an audit tool that is aligned to the seven complex safeguarding principles. Health service reviewers use a similar audit process. In contrast, the police audit tool was adapted from another review format and didn’t directly support the evaluation of the seven principles. It also wasn’t based on trauma‑informed practice. This means each service’s audit is recorded and evaluated differently. This creates inconsistency in how the three services gather and evaluate information from their records.

The force has since told us that it, along with its partners, is now piloting a new assessment tool. This should improve consistency to maximise learning.

Positively, the district peer reviewers told us that being part of the review team had improved their skills. It had also helped them better understand child exploitation in their district and across the region. They particularly valued the reflective discussion as an opportunity to learn about the challenges of working with different communities and organisations.

There is good governance and evaluation of the peer review programme

The GMCSH has actively developed the peer review methodology. This is because the strategic partners agree the programme contributes positively to improving sector‑wide practice to reduce the harm from child exploitation.

The district safeguarding partners use peer reviews alongside other systems, processes and activities to evaluate the outcomes of their services that support and protect children harmed through exploitation. This complements the Greater Manchester partners’ other quality assurance processes, such as completing themed single or multi-agency case file audits.

There is clear and effective governance of the programme. This includes scrutiny by elected officials. The peer review results are reported to strategic leaders and operational managers. This means that local multi-agency quality assurance, action planning and performance management processes are also informed by peer review findings.

The GMCSH team provides the overall programme evaluation. Together with the district peer reviewers they evaluate findings in each district and present these to the districts’ strategic leaders as strengths and areas for improvement. The district partners are responsible for acting on this information.

The ten Greater Manchester district CSTs provide services to about 650 children with recognised complex safeguarding needs. The types of exploitation risk these children face vary between sexual and criminal abuse. A child’s demographic characteristics and location can affect risk and vulnerability, and this can also change over time. There are clearly many other children across the region who also face heightened risk from exploitation, but the peer reviews only include children who were receiving services from the CSTs.

The 40 cases forming the 2022/23 peer review sample provide reasonable evidence from which to draw conclusions. The programme’s evaluation clearly supports the GMCSH to provide a valuable region-wide overview of how effectively CST practitioners work together to help children.

The GMCSH thematic oversight report combining all the districts’ thematic findings was circulated throughout the Greater Manchester partnership. The evaluation identified many practice strengths, for example:

• clear evidence of strengths-based and trauma-informed practice;
• positive working relationships between the CST and locally based social workers; and
• good examples of transition planning for children who want to continue to be supported post-18.

It also included areas for reflection to improve practice, for example:

• inconsistent recording of reflective supervision and joint supervision with locally based teams or other key workers;
• the need for better use of peer mapping and disruption (used to understand children’s connections and relationships with other children, so practitioners can identify other children at risk and intervene to support and protect them); and
• the presence of victim-blaming language in some records.

All the Greater Manchester partners included peer review findings in their action plans. This helped them to monitor their work to improve service efficiency and outcomes for children.

The peer review programme would benefit from a standardised quality assurance programme

The peer review programme has a limited quality assurance capability. The personal knowledge and experience of the GMCSH team is integral to maintaining the programme’s integrity. These experienced practitioners guide district-based colleagues in applying the methodology and evaluating the findings.

But the programme doesn’t have a formal quality assurance process. This means there could be inconsistencies between the case reviews in each district’s peer review programme and in the interim and final presentations. For example:

• in Bury, the analysis of the first district peer review contained much greater detail than appeared in the subsequent district presentations;
• in Wigan, peer reviewers found that local managers had already completed a review of the selected case files before they started the work; and
• in Rochdale, the final peer review feedback session only dealt with the two GMCSH-reviewed cases.

Overall, the quality of the reviews completed by the GMCSH staff and district peer reviewers was inconsistent.

Audits of social work were mostly good. Some were adequate and others of a very high standard, with comprehensive analysis that clearly identified practices that help children.

The GMCSH manager told us that their team actively advises on, and quality assures, the work of the district peer reviewers. But the programme would also benefit from having standardised training and detailed instructions for all those involved. For example, the initial peer review feedback identified the use of victim-blaming language in one of the cases. The district then reviewed the case and found that the language recorded on the file was a direct quote from the child victim, rather than being inappropriately used by a practitioner.

A quality assurance and moderation stage would help guarantee a consistent standard in the quality of audits.

Identifying learning

The peer review process methodology is outcome-focused and identifies learning from CST practice

The selection process for peer review cases makes sure that opportunities for learning are gathered from a range of multi-agency responses. This includes cases involving children of different genders, ages and cultural backgrounds, and from a range of practitioners and service providers. The reviewers who select cases take care to include different types of exploitation. This means that the outcomes of the process apply to the widest possible range of cases.

After completing the individual reviews, the reviewers discuss and evaluate their findings together. These discussions help identify issues in single and multi‑agency working. This is also an opportunity for the GMCSH team to gather feedback about the peer reviewers’ own experience of each district to inform future programme development.

The reviewers’ discussion prepares them for a reflective group evaluation meeting with the multi-agency practitioners, the supervisors who were involved in the case and the GMCSH team. These carefully managed discussions are structured around the seven complex safeguarding principles. This encourages participants to recognise practice strengths, such as the positive contributions psychologists from the trusted relationships service make to trauma-informed plans. It also helps identify aspects to improve, such as the use of inappropriate or victim-blaming language in some records.

We saw evidence of an occasion when a police peer reviewer identified the need to change force policy to improve consistency in how the force dealt with children who had been arrested. The new force policy provides for a more child-focused approach for these children, managed by the local CST which has a better understanding of their vulnerabilities.

We found that peer reviewers tended to emphasise the responsibilities of children’s social care over those of other practitioners. But they did identify positive collaborative work to support children. For example, peer reviewers recognised the benefits of closer working with education and health services. And they consistently identified how specialist nurses working closely with multi-agency CSTs had led to better access to health record information and specialist health provision for the children.

In another example, the GMCSH health specialist evaluated and circulated peer review findings to the regional health complex safeguarding meetings. They also compiled a health service overview at the end of the programme. This helped strategic leaders and local practitioners to understand and improve their contribution to complex safeguarding arrangements.

One district used feedback from the children and parents to help evaluate the practice that had resulted in effective interventions.

Analysis of peer reviews clearly identifies both practice strengths and areas for improvement

The GMCSH team presents peer review findings and recommendations to the local district complex safeguarding leaders. The recommendations mainly focus on areas for reflection. The districts are responsible for their local action plans and responding to recommendations. The evaluated peer review information helps the district CSTs understand where their practice worked well and where changes are needed.

Some of the findings are specific to a service. Each partner organisation is responsible for making sure peer review findings are included in their own governance, learning and development and performance management arrangements.

Practitioners told us they saw strategic leaders responding positively to the information in the reviews. The CST practitioners and their managers said that co-located multi‑agency teams provide a more effective response to children affected by exploitation. Organisational leaders had strengthened some of these teams because of the peer review findings. For example, in some districts, additional specialist staff were co-located or worked more closely together. This included closer alignment with specialist safeguarding nurses, speech and language practitioners and trusted‑relationship psychologists.

We found that district action plans reflected the peer review analysis and focused mainly on areas for improvement. There isn’t a clear and consistent methodology for either recording peer review recommendations or for managing the action plans. Some districts incorporated peer review recommendations into their existing plans and others held these separately.

An oversight process for making and monitoring peer review recommendation outcomes would help to improve consistency and provide evidence about the effectiveness of the programme.

Communicating learning

The peer review findings are accessible to all stakeholders

Reflective discussion involves multi-agency practitioners, their managers and the peer reviewers. This means practitioners and managers actively contribute to their own learning with direct reference to the evaluation of the outcomes of their work.

Some district partnerships challenge sections of their peer review feedback. They use their professional relationships with GMCSH staff to agree final versions of the district peer reviews. This relationship is vital because it provides the confidence needed to make changes to current practice. The district information is collated and the main themes are used within regional briefings and training materials.

But the programme doesn’t include a process for effectively communicating the specific learning points from each peer review more widely. Only the local partnerships receive this detailed information. For example, an online threat to a child seen in a single-case review wasn’t included in wider communications.

The health service has efficient arrangements to circulate these findings quickly across health networks. The GMCSH compiles and circulates a condensed thematic presentation at the mid-stage and in their final evaluation of the programme. But this doesn’t include every learning opportunity.

The Greater Manchester partners organise complex safeguarding practitioner and manager forums. GMCSH managers attend these meetings and provide updates about the peer review findings. GMCSH supports professional development with a range of events to share learning from peer reviews and wider learning about other forms of harm within the community or peer groups. This dynamic approach mirrors the evolving risk and keeps professionals regularly updated. This activity underpins consistent safeguarding practice messages across all local authorities in Greater Manchester.

Communication of peer review findings throughout the partnership is improving practice. For example, specialists have reported that following the sharing of review findings there has been an increase in referrals from both GPs and emergency departments. This demonstrates that the Greater Manchester partners are effectively communicating peer review findings.

Greater Manchester partners publish and promote the learning from peer reviews to their workforce and more widely

Members of the GMCSH team report peer review findings to their organisations’ governance meetings. Senior managers and team leaders told us that they use this information to review and make changes to improve practice. For example, after the Bolton peer review, the police increased the use of their powers to disrupt child exploitation perpetrators. And health professionals improved the use of flags (markers) for exploitation risk on some children’s records, where appropriate.

Greater Manchester partners promote the peer review findings locally and more widely. National organisations, such as the NWG Network, recognise the positive benefits of the Manchester peer review model. The GMCSH actively communicates with many voluntary sector organisations, academic establishments, and individuals and groups of people with lived experience of exploitation. It regularly updates these partners about the peer review findings to maintain a joint understanding of best practice.

The GMCSH uses a range of activities to communicate peer review learning. Members hold and attend conferences, discussions about findings (known as challenge events) and practitioners’ forums. They work closely with the regional education sector through the designated safeguarding leads network. The designated safeguarding leads are seen as vital partners, as they represent:

• local authority schools;
• higher education organisations;
• academies;
• independent schools; and
• alternative education providers.

Practitioners and managers told us about ‘weeks of action’. During these weeks, the partnership carries out activities across Greater Manchester to share findings from peer reviews and raise awareness more widely about issues relating to exploitation.

Greater Manchester partners also use the programme findings to raise awareness in the wider community, such as businesses working in the night-time economy. The police and local authority licencing personnel work closely with those who provide hotel, fast food and transport services. This leads to practical co-operation which helps the community protect children and disrupt offenders.

Performance and quality assurance

Peer review findings inform safeguarding, child protection and community safety governance processes

The peer review programme isn’t an additional or regional performance management framework. Instead, the review findings contribute to the other systems, processes and activities that Greater Manchester partners use to oversee the effectiveness of their responses to child exploitation. The programme complements these other quality assurance processes, such as themed single or multi-agency case file audits.

The GMCSH thematic analysis of the peer reviews is integral to its own action plan. The team publishes the action plan to present the findings and support strategic leaders in prioritising work for their teams. For example, at the time of our inspection, the action plan included information about maintaining an appropriate professional culture to make sure that victims are never blamed for their situations.

The GMCSH executive team makes sure information from the peer review programme reaches all other regional safeguarding service partners. GMCSH understands the information is relevant for all partners and all levels of service provision. This approach means the programme’s latest findings effectively support local practice improvements.

For example, the Oldham complex and contextual safeguarding subgroup produces and oversees the district exploitation strategy and action plans. This subgroup uses peer review findings to determine what activity needs to be prioritised.

Some districts now use the seven complex safeguarding principles in their local quality assurance processes. In Salford, the principles form the basis of quarterly multi-agency practitioner audits.

The partnership provides the peer review findings to individual practitioners and their managers. This helps them to identify good practice and areas that need action, along with timescales for the action to be completed.

The Greater Manchester partners use the peer review findings to identify and address gaps in service provision

Each local district decides its own complex safeguarding strategy and action plan. There isn’t a regional format. We found that districts used different sources of information for their plans. Some districts only included local partners’ information and their individual peer review feedback. But other districts included wider thematic peer review findings.

Some districts mainly created actions for children’s social care services. Actions for the health and police services were much less prominent. And some districts didn’t include actions to build on strengths identified in the GMCSH thematic evaluation. So those plans focused only on the areas for improvement.

The peer review process identifies negative and positive thematic findings. This encourages approaches that can strengthen service provision. Greater Manchester partners should consider including the practice strengths in their action plans. For example, to help improve consistency in when services should refer children to the national referral mechanism (NRM). Reviewers identified this in one case file study, which resulted in local action to improve the knowledge and understanding of the NRM for practitioners and their strategic leaders. This approach benefits children who need timely NRM referrals.

We found evidence that findings from peer reviews lead to improvements. For example, the 2019 peer reviews identified the benefits of a consistent health service capability within the CSTs. The reviews confirmed that co-locating health specialists in multi-agency teams provided children with better access to health services. Strategic leaders responded positively, and specialist health practitioners are now operationally co-located within eight of the ten district CSTs.

In Manchester, six-weekly CST audits, based on the peer review processes, inform multi-agency governance arrangements. This activity reassures the partners’ leaders about the quality and effect of work to address any emerging concerns. For example, concerns about the adultification of some groups of children or unconscious bias against sections of the community. The partners have extended this practice to improve other ways they work together. For example, the local authority used information from the case file audits to make changes to the policy for responding to reports of missing children.

We heard that independent scrutineers in local safeguarding also use findings from peer reviews to check that Greater Manchester partners are working together effectively to improve outcomes for children who have experienced exploitation.

Improving practice and outcomes

Greater Manchester partners use the peer review findings to identify and prioritise the most effective practice to safeguard children

Greater Manchester partners collectively recognise the unique opportunities the peer review programme provides to identify and share learning. The partners will continue to develop the programme so that it remains relevant across all the districts and services.

The peer review findings are based on real and recent multi-agency practitioner practice and experience. Frontline staff and their managers know which arrangements and practices most effectively help children who have been exploited. These practitioners work quickly, dealing with complex risks and children with specific vulnerabilities. They told us they valued the peer reviews, because strategic leaders listened to the results and acted to strengthen the CSTs’ capability.

Greater Manchester partners use the learning to improve best practice and consistency across the CSTs. For example, we saw districts using the ‘working to increase safety in exploitation’ (WISE) assessments that were developed using national academic research and practice experience across Manchester.

WISE methodology changes the focus of professionals from mainly assessing risk, to understanding safety and stability. This approach emerged from a growing recognition that risk assessment tools and checklists didn’t include the complex needs of children who have experienced exploitation. It means practitioners and children co-design each assessment to assess risk, focus on strengths and build relationships which support them to achieve their goals.

The peer review findings also prompted the safeguarding partners to support more effective transitional safeguarding for children approaching adulthood. Earlier peer review findings in 2020 identified the need to improve school inclusion arrangements for children with complex safeguarding needs.

Some of the district peer reviews highlighted that speech and language therapists and people who work with parents made positive contributions to work with children who had experienced exploitation. These specialists are now increasingly deployed within the CSTs.

The Greater Manchester partners make sure that learning from peer reviews is included without delay in policy and practice

The peer review findings show that trusted-relationship psychologists contribute positively to CST work. In districts where these psychologists worked closely with other practitioners, they were more effective in communicating with children and their families. They provide advice in joint supervision and in planning interventions which keep children safer.

As a result, strategic leaders have increased the number of trusted-relationship psychologists. They now work as core members of the region’s CSTs. Practitioners told us this work is leading to a better understanding of children’s needs and an improved multi-agency response to meet these needs.

Joint supervision of CST cases, although not yet in place across all teams, is increasingly part of routine work. This supervision is case specific and always includes input from children’s social care, health and police. It now also involves other services such as youth justice, the voluntary sector and even housing officers. This change in practice directly links to the seven complex safeguarding principles. It is a holistic approach and keeps the child at the centre of responses.

In the peer reviews that we examined we found the need for records to be clear, current and accessible to practitioners. This was the case not only for the CSTs, but also for other partners in operational response roles. CST managers told us that they consciously check records to prevent duplication and make sure the information is clear and accessible. They have also improved recording of chronological information about children’s lived experience, so that practitioners understand the effect historical events may have on the child.

Greater Manchester Police responded to peer review findings about the excessive workloads of complex safeguarding officers. Leaders reviewed and redefined the team’s terms of reference, providing consistency across the force area. They reassigned non-recent investigations and those reported by vigilante group activity. Leaders told us that complex safeguarding officers now have more opportunity to respond effectively. And they are charging greater numbers of suspects of child exploitation.

Greater Manchester partners use peer review findings to update their training

A range of training helps practitioners from all organisations and voluntary groups to respond effectively to child exploitation. In 2023/24, the GMCSH included peer review findings when it updated its core training package ‘Understanding Exploitation’.

Weeks of action across the region are designed to increase public and professional awareness of exploitation and harm outside the home. In October 2023, the GMCSH presented its evaluation of the peer review themes to 409 participants attending a multi-agency learning event. In March 2024, a further 769 participants received this training. The GMCSH team has received positive feedback from participants about this training.

Greater Manchester partners promote and prioritise trauma-informed practice. The peer review themes from local children’s cases provide a real-life context, which makes the training more effective.

The peer review reflective discussions have highlighted themes around trauma, language and children’s identity. Many attendees at the training said the discussions improved their understanding of trauma-informed approaches. These approaches include being professionally curious, empathetic, patient and non-judgmental when dealing with child exploitation.

In our 2024 national child protection inspection, we found that Greater Manchester Police acted to improve its child-centred services. The force had trained officers, staff and their supervisors not to use victim-blaming language.

Health service meeting agendas include training and professional development. The complex safeguarding nurses lead specific local training about the effects and consequences of victim-blaming language. This has led to strengthening the focus on the voice of the child. The complex safeguarding nurses use their practice experiences to provide context and understanding for other colleagues. For example, they trained emergency department staff to recognise the signs of exploitation. These staff now know to offer these children a safe place when they attend the emergency department without a parent or are accompanied by a non-parent adult.

Each district uses the peer review findings to identify training needs. In Bolton, the CST staff recognised that a lack of parental understanding of the risks to their children was affecting the effectiveness of joint work with families. They designed an open evening to inform the community about the risks of child exploitation, and held a free raffle to incentivise attendance. This helped to secure good attendance by families and resulted in a worthwhile session. At the end, one parent felt able to disclose to the organisers that their child was currently being exploited.

In Stockport, peer reviews highlighted a gap in service provision for parents. The CST, supported by the learning and development team, created a contextual safeguarding parenting programme for parents. This local initiative is based on an accredited programme which supports parents to meet the needs of adolescents. This is a positive response to a recommendation from the peer review programme.

Conclusion

Strategic leaders and practitioners strongly support the Greater Manchester complex safeguarding programme peer review process. They continue to develop their methodology by incorporating learning from the previous rounds, alongside other national research findings.

The programme could be expanded to include other sectors, such as education. This would reflect the increasingly integrated nature of multi-agency work to protect children from exploitation.

Peer reviews are focused on the work of the specialist CSTs. But the findings apply equally to non-specialist practitioners. These practitioners work closely with vulnerable children and their families. Their work to prevent the escalation of child exploitation risk would also benefit from peer review learning.

Greater Manchester partners should maintain the accuracy and the consistency of the programme’s findings. A standardised case audit template would improve the collection and analysis of multi-agency case file information. Training a cohort of multi‑agency peer reviewers, and introducing quality assurance and a moderation process, would improve consistency. The analysis of each case should be enhanced by including feedback directly from the children and their families.

However, we have clearly seen that the Greater Manchester complex safeguarding peer review programme contributes positively to multi-agency practice to reduce the risk of child exploitation.

2.  How effective is the force in carrying out its investigative strategies in relation to operations Bernese, Green Jacket, Sherwood and Exmoor?

As part of this inspection, the mayor asked us to consider the effectiveness of Greater Manchester Police in carrying out its investigative strategies in relation to operations Bernese, Green Jacket, Sherwood and Exmoor.

The inspection specifically assessed whether:

• the force has allocated enough personnel with the necessary skills and experience;
• the force’s strategies to support victims and survivors are consistent with national guidance, such as guidance from the National Police Chiefs’ Council (NPCC) and the College of Policing, and the Code of Practice for Victims of Crime (‘the Victims’ Code’);
• the force’s strategies to manage suspects are consistent with national guidance (such as guidance from the NPCC and the College of Policing) and take account of risks that suspects may pose to the public; and
• the force makes victims and survivors aware of the support services available to them, regardless of whether those organisations operate independently of the criminal justice system.

Summary of findings

We found that Greater Manchester Police has made significant improvements in how it understands and investigates child sexual exploitation. It has resourced a dedicated team to investigate complex and serious child sexual exploitation. These investigations involve some of the most vulnerable people. Force leaders have requested and welcomed constructive challenge from national advisers.

Greater Manchester Police has a strong multi-agency approach to investigating child sexual exploitation. The force introduced its child sexual exploitation major incident team (CSE MIT) to investigate missed opportunities in non-recent child sexual exploitation cases. It has committed significant resources to support these investigations. And it is working closely with local safeguarding partner organisations and victim support services. The force also works with national organisations that provide advice, support and guidance to victims and survivors. This approach makes sure it is operating in accordance with national guidance and with practice advice for senior investigating officers (SIOs).

The CSE MIT is well resourced, with 98 dedicated police officers and police staff. At the time of our inspection, we found there were ten vacant posts on the team. But the force had brought in additional officers and staff to cover these vacancies and provide additional resourcing to support the ongoing court cases.

We also found that the force hadn’t yet provided some of the CSE MIT police staff with appropriate training and accreditation. This had limited their role on the team. The force is aware of this and is working to provide the training.

We found that the force has good strategic and operational leadership and management of multi-victim multi-offender child sexual exploitation investigations. It has a governance and performance structure to help force leaders regularly review the strategic management of these complex and serious crime investigations.

The assistant chief constable lead for protecting vulnerable people chairs a multi‑agency child sexual exploitation (CSE) gold group. Members of the force sit on this group, together with local safeguarding partners and representatives of national organisations. The CSE gold group reviews force performance and demand levels, and discusses any identified risks within multi-victim multi-offender investigations.

The CSE MIT also has governance meetings to review the progress of child sexual exploitation investigations. Its SIOs provide updates to the CSE gold group.

Senior leaders have commissioned several problem profiles, to make sure they understand the nature and scale of offences and issues affecting children, including child sexual exploitation. These problem profiles support leaders in making sure the force has sufficient resources to tackle its priorities and risks. The force has also developed an overarching vulnerability strategy which is now in place.

The force uses national guidance to inform its strategies and plans. It has a comprehensive victim strategy which puts victims’ wishes at the centre of every investigation. This strategy has a clear multi-agency approach to the identification of, and potential contact with, victims and survivors of child sexual exploitation. It highlights the importance of identifying the victim’s needs and providing appropriate professional specialist support, for example by an independent sexual violence adviser (ISVA). The CSE MIT also uses victim care packs to support the victim and assist the investigation, which we have highlighted as innovative practice.

The force occasionally pauses contact with potential victims of child sexual exploitation that investigators have newly identified. This is due to the capacity of the CSE MIT, which balances ongoing demand with additional criminal justice trial commitments. We were reassured to see that the multi-agency CSE gold group discusses these pauses, alongside appropriate risk assessments and safeguarding.

The force completes effective investigations into child sexual exploitation and treats it as serious and organised criminal activity, using specialist tactics where appropriate. This brings together two major areas of policing: serious and organised crime (SOC) and vulnerability.

The force has good processes to assess threat, harm and risk during the initial stages of an investigation. And it monitors this ongoing risk carefully, taking into consideration any updated information on its own and partner organisations’ systems.

It has effective systems to make sure investigators follow all reasonable lines of enquiry. While in the past access to information on partner systems has been problematic, the force has now resolved this. It has agreed a memorandum of understanding with one local authority and is working towards this being replicated with all Greater Manchester local authorities for consistency across the force area.

We found that the force effectively manages potential suspects it has identified. It uses a multi-agency perpetrator risk assessment process. The CSE gold group monitors any suspects that have been categorised as high-risk, until that risk is lowered. Officers arrest suspects as soon as possible, in accordance with the perpetrator strategy. And district staff manage perpetrator risk locally.

The force and its safeguarding partners put a flag on their relevant systems for every identified perpetrator. This supports prompt information sharing and helps identify any escalation of risk. Hydrant Programme peer reviewers told us that they haven’t seen this shared responsibility approach taken elsewhere.

The force has worked with its safeguarding partners to develop a communications strategy. The designated lead for communications is part of the CSE gold group. They work with partner organisations to prepare information for the public. All public communications consider and prioritise the needs of victims. This is to enhance trust and confidence and encourage victims and survivors of child sexual exploitation to contact relevant organisations for support.

The force monitors a range of criminal justice and non-criminal justice outcomes for its child sexual exploitation investigations. It told us that its investigators have so far approached over 130 people whom they believe may be victims of child sexual exploitation and offered them specialist support. The force also told us that officers have arrested over 170 suspected offenders and submitted several criminal justice files to the Crown Prosecution Service. This has resulted in charges being brought against many of these suspects.

Background

In March 2021, Greater Manchester Police restructured its investigative resources for non-recent multi-victim multi-offender child sexual exploitation and formed a CSE unit. It had recognised the need to expand its capability in addressing the challenges of these serious complex investigations. It understood it needed to provide a consistent, victim-focused approach to child sexual exploitation, led by a dedicated specialist unit.

In 2023, it renamed this unit the CSE MIT. This team is now part of the force’s serious crime directorate. The CSE MIT’s main function is to investigate opportunities that the force may previously have missed. It works with its safeguarding partners to support victims and survivors and, if they wish, pursue a criminal justice outcome.

Investigators concentrate on three areas of Greater Manchester – City of Manchester, Oldham and Rochdale. This mirrors the focus of the three reports from the independent review team, published in 2020, 2022 and 2024.

The CSE MIT has two objectives:

• to investigate large-scale child sexual exploitation investigations that have been risk assessed as requiring CSE MIT involvement; and
• to support district-led large-scale and complex child sexual exploitation investigations, by carrying out peer reviews and with governance support.

There are 98 police officers and police staff in the CSE MIT. A detective superintendent leads the unit, supported by two detective chief inspectors who carry out the SIO role. The unit is divided into four syndicates, each with a detective inspector, team of investigators and support functions, such as analysts and indexers.

The CSE MIT uses the Home Office large major enquiry system (HOLMES) to record all information relating to each investigation. This uses major incident room standard administration procedures (MIRSAP) to identify and link evidence, and record lines of enquiry and actions.

The CSE MIT syndicates are investigating five major non-recent child sexual exploitation cases:

• Operation Bernese – an investigation into the death of a child in 2003;
• Operation Green Jacket – an overarching investigation into child sexual exploitation in South Manchester between 2004 and 2005;
• Operation Sherwood – an investigation into 11 cases of child sexual exploitation in Oldham between 2011 and 2014, as identified in the 2022 independent assurance review;
• Operation Exmoor – an investigation into non-recent child sexual exploitation in Rochdale; and
• Operation Lytton – an investigation into child sexual exploitation in Rochdale between 2002 and 2006.

Strategic leadership and governance

Force strategies provide clear direction for the investigation of child exploitation

To provide a consistent governance approach, the force has appointed a single gold commander to oversee all its child sexual exploitation investigations. This includes current cases being investigated by district staff and non-recent cases being investigated by the CSE MIT.

The force’s strategies for child sexual exploitation investigations align with national guidance, such as the Hydrant Programme guidance for SIOs. They are also consistent with legislative developments, such as the Victims’ Code.

The detective chief superintendent force lead for protecting vulnerable people is responsible for 21 force policies and strategies within this portfolio. He reviews these documents according to a set timescale, in consultation with interested parties that include stakeholders and partner organisations such as Greater Manchester Combined Authority (GMCA), the local authorities and relevant charities and staff associations.

The force has also developed a vulnerability strategy for the 14 strands of vulnerability defined by the College of Policing. This strategy defines the force’s victim-centred, suspect-focused and context-led approach to vulnerability. The force has now put this strategy in place, following the publication of the new Vulnerability Knowledge and Practice Programme (VKPP) national vulnerability and public protection strategy. Officers and staff have also received vulnerability training.

The force works closely with national teams who provide guidance on investigating child sexual abuse and exploitation

The Hydrant Programme is part of the NPCC child protection and abuse investigation portfolio. It works with UK forces, along with partners and stakeholders across the vulnerability sector, to make sure there is a co-ordinated policing response to child sexual abuse and exploitation. Since October 2022, the Hydrant Programme has been responsible for gathering child sexual abuse and exploitation data nationally in the child protection abuse investigation database for UK police forces.

The Hydrant Programme works closely with the force to support its child sexual exploitation investigations. Programme representatives sit on various governance groups, including a multi-agency gold group for all multi-victim multi-offender child sexual exploitation investigations. The force’s assistant chief constable lead for protecting vulnerable people chairs this group. It meets quarterly and holds additional meetings when a gold decision is required. The CSE MIT detective superintendent provides updates. The membership includes adult and child social care, the National Association for People Abused in Childhood (NAPAC) and district staff.

Hydrant Programme advisers directly support the gold commander, making sure the force complies with national practice. In addition, staff from the College of Policing’s VKPP visit the force quarterly to advise district commanders about their responsibilities under the government’s statutory ‘Working Together to Safeguard Children’ guidance.

The chief executive officer of NAPAC told us the force welcomed constructive challenge. This continues to be the case, despite changes in personnel. She has visited many forces in her role. In her view, “GMP’s approach to non-recent child sexual exploitation is excellent practice nationally”.

The child sexual exploitation major incident team has a comprehensive victim strategy

As part of our inspection, we reviewed the force’s child sexual exploitation investigation strategies, including the CSE MIT victim strategy. This had been updated in September 2024. This strategy makes sure investigators respond to, manage and support victims in a consistent way across individual cases. This is in accordance with College of Policing and NPCC guidance.

The victim strategy provides best practice guidance to staff investigating major non-recent child sexual exploitation investigations. It is underpinned by an ethos of wanting to ‘get it right’ for victims and survivors. It contains clear direction on:

• approaching victims (including using multi-agency risk assessments in advance) and victim self-referrals;
• taking initial accounts from victims;
• assessing victim needs;
• managing victim contracts, ongoing contact and expectations;
• safeguarding, including signposting victims to appropriate support services;
• how to manage digital evidence, third party material and the disclosure of victim criminal behaviour;
• making best use of tier 5 interview advisors; and
• exit strategies (supporting victims as an investigation draws to a close).

The strategy also includes guidance on the use of appropriate language and the impact of using victim-blaming language.

The victim strategy doesn’t include the use of pre-recorded cross-examination evidence

As part of achieving best evidence (ABE), Section 27 of the Youth Justice and Criminal Evidence Act 1999 allows for video-recorded interviews to be presented in court as evidence in chief. Section 28 of the Act extends this to include pre-recorded cross examination of victims and witnesses.

This applies to vulnerable complainants of a crime (commonly referred to as victims or survivors) and witnesses, regardless of offence including:

• all child witnesses
• any witness whose quality of evidence is likely to be diminished because they:
  • are suffering from a mental disorder
  • have a significant impairment of intelligence and social functioning
  • have a physical disability or are suffering from a physical disorder.

The CSE MIT victim strategy doesn’t mention pre-recorded cross examination. However, we found the force does use pre-recorded evidence when appropriate. During our inspection, we recommended to the force that it reviews the victim strategy and updates it to include the use of pre-recorded cross examination in accordance with the legislation.

The force has an effective communications strategy for child sexual exploitation investigations

Since December 2023, the force has had an internal and external communications strategy for child sexual exploitation investigations. This includes how it updates people who aren’t directly involved in an investigation. The force prepared this strategy in consultation with its partner organisations and other important stakeholders. The force told us it is keen to identify an external ambassador to support the communications strategy but hasn’t yet been successful in finding a suitable independent person.

The force initially communicates significant events to police personnel and staff within partner organisations, and then to the public. Stakeholder engagement is clearly mapped out in the overarching communications strategy. This means that staff across the organisations hear news directly, rather than via the media.

If the force anticipates any negative coverage, it makes sure to inform staff as early as possible. This helps the workforce to support the communications strategy with consistent messages to the public. In addition, the force uses a bulletin to update staff and partners twice a year.

The force is keen to make sure all external communications reinforce public trust and confidence. In particular it wants to reassure victims and survivors that it places them at the centre of investigations.

It issues regular updates about each stage of a live investigation, such as releasing details of arrests and convictions for each of the ongoing operations. These updates always generate feedback from the community. We saw evidence of victims and survivors coming forward as a direct result of this communication.

The force’s head of communications is directly responsible for all media communications about child sexual exploitation. We saw examples of several press stories, communicated via press releases, social media and the force’s external website. The force also consults with external partners, such as Saint Mary’s Sexual Assault Referral Centre (SARC) and NAPAC, who offer support and guidance with media releases where appropriate.

In addition, each individual investigation in the CSE MIT has its own communications strategy. The relevant local authorities and mayor’s office approve these. The CSE MIT detective superintendent and the two SIOs keep these documents under review and update them after significant events – such as the arrest or charge of suspects, or when a case is listed at court. However, the stakeholder engagement aspect of each individual strategy is very similar. We encourage the force to re-examine these strategies to make sure stakeholder engagement is bespoke to each operation.

In October 2024, the force took part in introducing the ‘When you are ready’ campaign. This campaign encourages adult victims and survivors of child sexual exploitation to get support. It is a collaboration with the national child sexual exploitation taskforce, the Hydrant Programme, the Tackling Organised Exploitation (TOEX) Programme and the College of Policing’s VKPP.

Police personnel understand force strategies and policies about tackling child sexual exploitation

The chief constable and his leadership team are keen to make sure all force personnel understand that child sexual exploitation, child protection and organised crime are force priorities. He or the deputy chief constable have personally spoken to every supervisor about this. In addition, the force uses ‘Giants’ events (internal officer and staff communication and engagement events, hosted by the chief constable in person) to share briefings across the force.

The force uses a performance management framework to assure itself that investigators are following investigations policy. We spoke with some investigators about the child sexual exploitation cases they were leading. They had a clear understanding of force strategies and policies for investigating child sexual exploitation. These policies are easily available on the force intranet.

The detective superintendent from the CSE MIT risk assesses each new child sexual exploitation investigation as soon as it is reported. Based on this, he decides whether it can be managed at district level or whether CSE MIT resources are required. Any requirement for specialist resources or support is discussed at a gold meeting.

District staff investigating child sexual exploitation would benefit from further training on force strategies

At the time of our inspection, the force told us they had 59 ongoing multi-victim multi‑offender child sexual exploitation investigations. Of these, 46 were managed by district investigators.

The CSE MIT SIOs carry out peer reviews to support these district investigations. They advise the district detective superintendents directly about each case. The reviews make sure district investigators understand and follow force strategies for child sexual exploitation investigations. This includes victim and offender strategies, assessing and managing risk, completing lines of enquiry and effective resourcing.

However, partner organisations who support victims and survivors, told us that district investigators’ understanding and compliance with victim strategies can vary. They highlighted that investigations in the CSE MIT are always victim-led. But this isn’t always the case at district level. And investigators don’t always consider the survivor’s needs well enough.

The force should consider including a refresher on victim strategies in future continuing professional development (CPD) sessions for district investigators. And it may wish to include a focus on the role of ISVAs and other organisations that support survivors.

There are also benefits to including lived experience in development training, where this is managed sensitively and appropriately to the person’s experience and needs.

Senior leaders promote the importance of effective, high-quality child sexual exploitation investigations

Senior leaders were keen to stress that tackling child sexual exploitation is a priority for the force. Throughout our inspection, we saw evidence to support this.

Senior leaders told us there is a clear line of governance from the chief constable to frontline personnel. This is achieved via an effective governance framework, clear messaging and personal leadership. For example, in May 2024, the chief constable attended a specialist conference reinforcing the public message that the force was putting victims and survivors at the centre of its child sexual exploitation investigations, with a focus on “getting it right, first time”.

The personal leadership and support from the chief constable and his team was particularly important following publication of the independent review team’s third report in 2024. This report was critical of the force’s previous actions in relation to non‑recent child sexual exploitation. The force fully accepted those findings. But the report negatively affected the morale of officers and staff working on non-recent child sexual exploitation investigations. The chief constable visited the CSE MIT to talk with staff which provided much-needed reassurance.

By creating a major incident team dedicated to child sexual exploitation, and ring‑fencing its budget, force leaders have sent a clear and effective message to staff, partners and the public about the importance of investigating non-recent child sexual exploitation cases.

An assistant chief constable is responsible for all areas of policing that deal with vulnerability. Her policing background includes child protection, which means she has an in-depth understanding of this area. The force has also increased staffing levels across all ranks that specialise in vulnerability. And officers and staff we spoke to were aware who the force lead for child sexual exploitation was.

The chief officer team meets three times a week to discuss performance. Child sexual exploitation and child protection feature heavily in these meetings. Once a month, senior leaders hold their chief superintendents to account for performance, and this includes child sexual exploitation and child protection. At district level, commanders take responsibility for child sexual exploitation investigations that are managed locally.

Senior officers in the child sexual exploitation major incident team provide effective leadership and governance

The detective superintendent and SIOs in the CSE MIT provide effective leadership and governance. They chair weekly briefings. A detective chief inspector also chairs a monthly performance and governance meeting into non-recent investigations.

Every six months, the team completes a thorough review of each investigation. And, at regular intervals, a multi-agency gold group meets to consider each investigation. We reviewed minutes from these gold group meetings and found they were well written and contained sufficient detail and evidence of actions being progressed in a timely manner.

Resourcing

The force’s child sexual exploitation investigation major incident team is well resourced

In October 2024, the force told us there were 59 live multi-victim multi-offender child sexual exploitation investigations, of which 13 were being managed by the CSE MIT.

Cases that are too serious or complex for districts to manage are referred to the CSE gold group to decide which team should continue the investigation with support from the CSE MIT. The CSE MIT detective superintendent provides peer review support to districts for any investigations that remain with them.

Each child sexual exploitation investigation is risk rated according to whether the suspects are pending arrest, on bail, deceased, out of the country or of no current known risk. At the time of our inspection, the force told us that in these active investigations there were 714 victims and survivors, and 1,099 suspects.

The force has more than 300 officers investigating child sexual exploitation offences, including the CSE MIT. This shows the importance the force places on investigating both current and non-recent child sexual exploitation offences.

We found that the force’s CSE MIT is well resourced. The force has ring-fenced the funding for this team and has protected its staffing levels. This means it won’t divert resources from this team to cover shortfalls in other areas of policing. As far as we are aware, Greater Manchester Police is the only force in the country to have dedicated a major incident team for investigating child sexual exploitation and this level of resourcing dedicated to investigating non-recent cases. The only other child sexual exploitation investigation of this size is Operation Stovewood in South Yorkshire, which is led by the National Crime Agency.

The force has an effective structure for managing the nature and scale of these child sexual exploitation offences.

The CSE MIT has a staffing level of 98 posts. At the time of our inspection, there were 10 vacant posts. However, 107 personnel were working from the office, as additional resources are brought in as needed (such as when preparing for trial). The staffing includes a detective superintendent, two detective chief inspectors, four detective inspectors, detectives and police staff investigators, analysts and staff to manage the various requirements of a HOLMES investigation.

The assistant chief constable monitors staffing levels before every gold group meeting. We saw evidence the force has maintained continuity of leadership within the CSE MIT. When SIOs have moved on, the force has replaced them with either another officer from the team on promotion, or someone with a child protection background.

Senior leaders told us that the force fills vacancies when they arise, rather than leaving posts open. However, officers and staff said that the force is increasingly relying on investigators from other teams to cover these vacancies temporarily, and it hasn’t replaced staff who have left. This included essential staff to support the HOLMES roles. They told us that this is partly due to funding constraints and partly due to difficulties with recruitment.

Some of the workforce told us that there is a perception that the CSE MIT isn’t a good place to work, due to the pressure and negative media attention. This means that detective sergeants and detective inspectors are covering essential roles in addition to their supervisory duties.

We recommend that the force reviews the HOLMES staffing levels and capability and addresses these shortages. In addition, colleagues from the Hydrant Programme, who assisted with this review, have recommended that the force provides a dedicated intelligence support team in the CSE MIT. This would include analysts, researchers and intelligence officers as well as relevant supervision. This additional capacity would significantly improve the efficiency of these non-recent child sexual exploitation investigations.

The child sexual exploitation major incident team has the skills and capabilities to complete effective investigations

At the time of our inspection, the CSE MIT was responsible for five major child sexual exploitation operations, plus each of the investigations linked to these operations. Staff in CSE MIT told us that while workloads are high, they are manageable. Each operation is managed via the HOLMES system which records every action in the investigation. The CSE MIT supervisors allocate resources to each investigation based on risk. They told us that the force’s digital and forensic departments provide excellent support.

The CSE MIT also has dedicated specialist support from the Crown Prosecution Service (CPS). In England and Wales, the CPS has an organised unit for child sexual abuse cases. Lawyers in the unit told us that they view the CSE MIT structure as a best practice model. They agreed that the relationship between the police and the CPS lawyers is very good, and there are face-to-face meetings when necessary, including with the assistant chief constable.

Taken as a whole, officers and staff in the CSE MIT have the skills and capabilities to complete child sexual exploitation investigations. Police forces use a structured development programme called the professionalising investigations programme (PIP). This has a tiered structure depending on the level of investigation skills required. In the CSE MIT the detective superintendent and both detective chief inspectors are trained to PIP 3 level (major investigations) and the four detective inspectors are working towards this.

However, there are 13 police staff investigators in CSE MIT who aren’t trained to the level required to do their job. This means that those personnel who do have the necessary authorised skills, are covering several roles and supporting the wider team. Others are capable but unable to assist. Upskilling staff was one of 33 recommendations made by the Hydrant Programme in 2020. We have reiterated this as an area for improvement. See the ‘Training’ section later in this chapter for more information.

The force provides well-being support in several ways but needs to do more to make sure personnel access this

Supervisors in the CSE MIT hold regular reviews with officers and staff. These include an assessment of workloads, welfare and any support needed. Supervisors spend a lot of time emphasising the importance of welfare with staff and officers on the CSE MIT.

The force provides welfare support in several ways, including via HR, occupational health and staff associations. Staff can also access support from the Police Treatment Centres, The Ben Fund and other providers of well-being resources.

The force has promoted the Helen Bamber Foundation Trauma Informed Code of Conduct to officers and staff. This is designed for professionals working with survivors of human trafficking and modern slavery.

Due to the nature of the investigations, occupational health considers the child sexual exploitation investigator role as at high risk of direct or indirect psychological risk. Repeated exposure to trauma can negatively affect well-being, leaving people feeling desensitised and fatigued. If members of the CSE MIT need psychological support, this can be arranged very quickly via occupational health. There are also psychologists on the resilience hub (who are there to assist with understanding victim behaviour) who can provide support if necessary.

However, we found that none of the investigators had ever been given a psychological questionnaire or assessment, or offered enhanced psychological support. We recommend that the force offers CSE MIT investigators enhanced psychological support as standard. It may wish to include this as part of a well-being strategy to make sure the workforce receives the support it needs.

The force has a team of specially trained interviewers which assists the child sexual exploitation major incident team

The force has a team of officers and staff who are trained to a higher level of interview skills. These trained interview advisors carry out this work alongside their full-time role. A tier 5 co-ordinator manages this team.

The tier 5 co-ordinator works with the SIO for CSE MIT cases, to advise on suspect, witness and victim interview strategies. Their involvement starts as soon as the investigation is allocated to that team. If asked, the co-ordinator can arrange for a member of their team to complete an interview strategy, to support CSE MIT and district investigations. The co-ordinator will also dip-sample video interviews to make sure the standard of interviews is high. They then provide feedback and support to assist with learning.

The force should review the support provided by the child sexual exploitation major incident team PIP 4 investigator

The PIP structured investigation development programme includes the use of PIP level 4 investigators. These investigators are trained to strategically manage highly complex investigations. When responding to a high profile or complex incident, the gold commander may wish to use a PIP 4 investigator to support the investigation and provide updates to the gold governance group.

A PIP 4 investigator is a competent decision-maker and can provide advice or review support as required. The gold commander for any major investigation should clearly set out their responsibilities and remit at the outset.

In 2019, the CSE gold group assigned a PIP 4 investigator to the CSE MIT. We found that, at the start of investigations, the PIP 4 investigator met regularly with the SIOs, providing the necessary advice and support. But as the investigations progressed – and as the SIOs became more experienced in this type of complex crime – the meeting frequency decreased. This shouldn’t happen. The involvement and responsibilities of a PIP 4 investigator should continue unchanged, unless directed by the gold commander.

As part of our review, we talked with the SIOs about some of the complexities and challenges of these non-recent child sexual exploitation investigations. For example, the CSE MIT has experienced problems getting information from the local authorities (see the ‘Investigations’ section later in this chapter for more information). The PIP 4 investigator could have helped to resolve this.

Support for victims and survivors

The force prioritises the wishes of victims and survivors

Greater Manchester Police works closely with the Hydrant Programme, Saint Mary’s SARC, NAPAC, charities and organisations that are part of the Greater Manchester voluntary, community, faith and social enterprise sector. Force representatives are part of several strategic boards and groups in the wider Greater Manchester vulnerability sector. This all supports the force’s aims of prioritising the needs and wishes of victims and survivors and improving the service it offers.

In the earlier section on ‘Strategic leadership and governance’, we discussed the force’s use of victim strategies. There is an overarching strategy and a bespoke strategy for each operation and each victim. The strategies include contingency plans for different scenarios.

A specially trained tier 5 interview advisor in the CSE MIT provides guidance and supports each interview strategy. At an early stage, investigators complete a victim needs assessment, which also identifies the victim’s wishes. They include this in a victim care pack which they then give to each victim (see the example of innovative practice later in this chapter for more information).

There is a strong multi-agency approach to investigating child sexual exploitation

The force now has a strong multi-agency approach to investigating child sexual exploitation. Several of its teams work in the same location as colleagues from partner organisations, including teams at district level. The CSE MIT includes representatives from children’s social care services. The team works closely with various voluntary sector organisations that support victims of sexual abuse and assault. And it now has a constructive relationship with the local media. This aims to establish trust and confidence in victims, including those who have yet to come forward.

The force works closely with Saint Mary’s SARC, which is based at Saint Mary’s Hospital in Manchester. This SARC was the first to be established in the country. And it is the largest, employing 19 ISVAs who work across Greater Manchester.

The force has a victim risk register document, dated June 2024, which a detective inspector from the CSE MIT prepared with representatives of Saint Mary’s SARC. It details an agreed process to refer victims to support services, share information and jointly assess risk. It clarifies roles and responsibilities for both Greater Manchester Police and the SARC. It also includes agreed risk indicators that can be used to guide risk assessments and prioritisation. Saint Mary’s SARC manages this register and is responsible for chairing a multi-agency meeting every four weeks, to review each victim. This review includes those survivors who prefer not to be involved in the investigation.

It was positive to note that Saint Mary’s SARC provides support to victims regardless of where they live in the country.

The police and partner organisations work together to identify and support victims

The force and its partner organisations view victims as their priority. They manage victim care jointly. Investigators consider each victim individually when assessing non‑recent child sexual exploitation cases.

Before taking a decision to contact a potential victim for the first time, investigators consult with specialists from a variety of partner organisations. This includes Saint Mary’s SARC, children’s and adult social care, and victim support and advocacy groups. This multi-agency group considers all available information to decide the right time to contact a potential victim. Investigators told us about a range of measures they consider when reviewing when and how to approach a potential victim.

If necessary, in addition to the initial information sharing, a formal strategy meeting is held. CSE MIT investigators always make contact in person. Investigators also pay close attention to the wishes of the potential victim. They are careful to make sure the individual understands what an investigation would involve, how long it might take, and what to expect from the criminal justice process. They also make sure the person is aware that they can change their mind at any time.

When the CSE MIT was initially set up, GMCA provided additional funding for crisis workers through Saint Mary’s SARC. This was very effective in leading to more victims being willing to work with investigators. Victims viewed these crisis workers as separate to the police and social care, which helped create trust. This intervention was an excellent victim-centred safeguarding approach for victims.

Unfortunately, the crisis worker role is no longer funded. Now, if a potential victim has additional needs, or if they are already working with a partner organisation – such as Saint Mary’s SARC, the NHS or social care – the relevant practitioner will attend the initial visit with the police to provide support.

The force could still make further improvements to its approach to victims and survivors

The Hydrant Programme also highlighted the victim care packs as innovative practice. However, to avoid using victim-blaming language, the force should rename the victim disengagement form (an agreement the victim signs to indicate they no longer wish to engage with the ongoing investigation).

In addition, when we reviewed the victim strategy, we found that it didn’t mention victim personal statements. While these may be considered a routine part of any investigation, it is still necessary to highlight their importance in all victim strategies.

The advice in the strategy about victim contracts included an overview of the effects of witness collusion and of victims’ social media use. The focus should instead be on victims’ rights, as detailed in the Victims’ Code.

The strategy also included advice about statutory referrals to children’s services, implying that consent is needed in all cases. The force should review its victim strategy to make sure it reflects up-to-date guidance.

Finally, the force uses psychologists from the trusted relationships service when developing strategies for working with children at risk of child sexual exploitation. But at the time of our inspection, it wasn’t using this expertise when working with adults who were children at the time of the offence. This is a missed opportunity. The force should consider reviewing its use of trusted relationship psychologists to include adult victims of non-recent child sexual exploitation.

The force has a clearly defined strategy for supporting victims when it concludes an investigation, but it could be improved

We reviewed the force’s approach to supporting victims when investigations, and court cases, come to an end. The force has a clearly defined ‘step-down’ strategy (also known as an ‘exit strategy’ or ‘transition process’) that is bespoke to each victim and survivor. This is done in partnership with victim support organisations. It includes making referrals to organisations that can provide ongoing support for victims of child sexual exploitation.

When a decision is taken not to continue with an investigation – whether this was by the CPS or the CSE MIT – the officer in charge of the case will visit the victim to tell them in person. This means they can explain the reasons for the decision and answer any questions. The officer also gives the victim a letter from the SIO explaining the decision, that they can refer to later. This helps victims to process the information in their own time.

Representatives from organisations that support victims of child sexual exploitation told us that district investigators could improve how they use the step-down strategy. For example, officers can put victims in touch with third-party support services by:

• Providing a victim or survivor with information about support services which allows the victim to decide whether to make contact.
• Making a referral for the victim to another organisation which can make contact, although this often means the victim has to share their experience again, which can be retraumatising.
• Completing a handover by personally introducing the victim to the new organisation so the victim is reassured that the new organisation understands their history and is in the best position to support them.

The force should make sure that, in appropriate cases, investigators complete a full handover to the organisation that will be supporting victims and survivors in the longer term.

Effectiveness of investigations

Child sexual exploitation major incident team investigation strategies are closely aligned to force strategies and policies

Each investigation by the CSE MIT has clear strategies for victims, perpetrators and external media communications that are closely aligned to the force’s overarching strategies. This means the force has established clear terms of reference. These documents include a risk assessment for each case. Supervisors review the strategies at each stage of the investigation.

Within each of the main investigations there are specific investigations, each with its own operational name. Each of these specific investigations is in respect of one victim. This allows the police to submit prosecution files to the CPS as soon as possible, rather than wait for all the linked cases to be ready. The force introduced this approach in consultation with the CPS.

The force has effective systems for assessing the threat, harm and risk for victims during the initial stages of a child sexual exploitation case

A new victim or survivor can be identified in several ways, through investigation work, referrals or reports.

Researchers often identify additional potential victims as part of work on non-recent child sexual exploitation investigations. And the force also receives referrals from partner organisations. In many cases, survivors identified in these ways may not even realise they were a victim.

Greater Manchester Police and its partner organisations in the CSE MIT review each potential new victim and complete a risk assessment. This is based on a careful review of each organisation’s information systems. As the investigation progresses, the team continues to review this risk assessment.

Reports about potential victims are also made to the force contact centre or in person to a police officer. This information can come from a member of the public, an organisation or via a Crimestoppers report.

Survivors can also self-refer online or by phone. Call handlers in the force contact centre manage all new calls for service about child sexual exploitation. They complete an initial threat, harm, risk, investigation, vulnerability and engagement (THRIVE) risk assessment and decide which resource to allocate. If an offence has taken place, this is recorded on force systems and allocated for an investigation as per force policy.

Districts manage all new reports of child sexual exploitation. The district detective superintendent is responsible for reviewing all new multi-victim multi-offender cases and assessing the risk they pose to children, using a red, amber, green assessment. They then decide which specialist resources are needed, such as CSE MIT or SOC. In the initial stages of an investigation, the SIOs in the CSE MIT complete a peer review of each red-assessed new child sexual exploitation case. However, the districts manage the risk for any victims who live in their local area.

The force intelligence bureau and district intelligence units support the force in its approach to tackling child sexual exploitation

The force intelligence bureau produces a monthly intelligence pack related to risks of child sexual exploitation and child criminal exploitation. Analysts base this on data from the vulnerability tracker, which monitors young people at risk of child sexual exploitation in each district. Each child is risk assessed into low, medium and high-risk categories. Where known, the tracker also records demographic data. The intelligence pack includes demand trends and analysis of county lines, adult and child exploitation, sexual offences, organised immigration and modern-day slavery. It also includes a comparison of this information with nationally available data in other force areas. This helps the force review its threats and manage the demand.

We reviewed the September 2024 pack. The data pack showed that there had been a 28 percent increase in intelligence related to child sexual exploitation and a 10 percent decrease in recorded crimes since August 2024. Between January and September 2024, there had been a 25 percent decrease in child sexual exploitation incidents compared with the same period for 2023. The briefing pack includes details of hotspot areas, such as Piccadilly Gardens in Manchester city centre.

The force effectively assesses and manages suspect risk

We reviewed the latest version (version 4) of Greater Manchester Police’s perpetrator risk assessment for Operation Green Jacket. It developed this in consultation with partner organisations. The SIO reviews and updates this assessment regularly. In 2023, the force developed the assessment to include a red, amber, green rating in each of the four categories:

• Group 1 – awaiting assessment
• Group 2 – assessment complete
• Group 3 – identified as suspects
• Group 4 – filed.

Perpetrators in groups 1, 2 and 3 who are known to the force but haven’t yet been arrested are rated ‘red’. Perpetrators in group 3 who have been arrested and are on police or court bail or released under investigation (RUI) are rated ‘amber’. And perpetrators in group 4 who are either deceased or considered no risk to children are rated ‘green’. The force monitors those suspects who are circulated on the Police National Computer and are believed to have fled the UK.

The CSE MIT keeps each group under review. And the CSE gold group reviews and directs police activity for all ‘red’ suspects. A detective inspector from the operation chairs a fortnightly meeting with children’s and adult social care where all parties review the available information from their systems.

In 2024, the Hydrant Programme reviewed the Operation Green Jacket perpetrator risk assessment. They highlighted it as “effective practice”. At the time of our inspection, the force based risk-level decisions on the national decision model. This is an effective model for making decisions. It also considers the welfare of suspects and their families. This can often be forgotten but is a clear responsibility for the force.

The multi-agency risk management group meets daily to review all information systems (police and partner organisation) and take action, as necessary. We were told about an example of a young person attending hospital with a cut that a doctor thought might be an injury inflicted in a stabbing. Additional research raised concerns that the young person might be at risk of child sexual exploitation. The various organisations were then able to take appropriate action to safeguard them.

Once a perpetrator is identified in a child sexual exploitation case – whether dormant, active or suspect – their details are entered on the force’s computer systems. A permanent child sexual exploitation flag is placed against their name. This means if operational officers and staff come across these perpetrators for any reason and check force computer systems, it will trigger a warning on the police system. The district risk management focus groups review these triggers every morning. And the district safeguarding units and force intelligence bureau teams also review these incidents as needed.

Investigators told us that some partner organisations were initially reluctant to flag perpetrators on their own systems when the information related to non-recent allegations. However, following legal advice, they have now updated their processes.

The force also checks the Disclosure and Barring Service for details of any person suspected of being involved in child sexual exploitation.

The force has effective processes for assessing and disseminating information about potential suspects

The force manages suspects and offenders via its gold command process. District teams are responsible for managing perpetrators in their local area and are supported by CSE MIT supervisors. Detective superintendents from the districts and CSE MIT work together via the gold meetings. This brings the districts together with the CSE MIT in an effective working relationship. Representatives from the CSE MIT also attend the districts’ complex safeguarding review of suspects.

The force takes a multi-agency approach to managing perpetrators. It holds regular meetings with representatives from partner organisations to discuss effective ways to manage and disrupt these offenders. These meetings mean that the force can consider a wider range of information when assessing risk and deciding what action to take. District teams also manage these disruption tactics, such as sexual risk orders, and record them on the force agency and partner management information system (APMIS).

Before arresting a suspect, the CSE MIT holds a strategy discussion with partner agencies. There are further strategy meetings as the investigations develop and when a suspect is charged. These meetings mean that investigators can review all available information – in addition to their own research and intelligence pack – and partner organisations can put appropriate safeguarding in place. For example, in one case, this led to a suspect’s children being placed on a child protection plan at the time of his arrest.

The child sexual exploitation major incident team investigates suspects and makes arrests as soon as possible

As with its approach to victims and survivors, the force takes a multi-agency proactive approach to identifying suspects and locations for child sexual exploitation. For example, having identified Piccadilly Gardens as a potential location, the force and its safeguarding partner organisations introduced Operation Luka. Multi-agency patrols now work in the area, to identify potential perpetrators and support potential victims. We mentioned this operation in our national child protection inspection of Greater Manchester Police.

The force has a suspect strategy in place for every child sexual exploitation suspect. The tier 5 interview advisor writes these strategies, in consultation with a psychologist where required. We reviewed a suspect strategy written in September 2024. It provided guidance on ABE practice for staff working on non-recent child sexual exploitation investigations. The main objectives were:

• Safeguarding children from further abuse – the strategy refers to bespoke multi‑agency risk management policies for named and identified perpetrators, with referrals as required to relevant partner agencies to manage current safeguarding concerns.
• Declaration of suspects – it clarifies that the SIO and deputy SIO are responsible for designating a person as a suspect and it reminds officers to obtain tier 5 interview advice.
• Establishing the suspect’s safeguarding – it explains the importance of completing a safeguarding interview and considers self-harm risk assessments, safeguarding measures and referrals for additional support; this includes completing ongoing assessments for suspects who are released under investigation.
• Investigating deceased suspects – the strategy outlines how to complete a proportionate investigation to establish the involvement of other victims and suspects, links to other perpetrators, assess the risk to children, safeguard and learn any lessons to prevent future offending.

The force gives clear direction to arrest suspects as soon as possible in appropriate cases. The CSE MIT considers the circumstances of arrest as part of the perpetrator strategy and uses the appropriate arrest power. The team arrests suspects as soon as possible, to secure evidence and mitigate risk, using tools such as bail conditions.

As well as writing suspect interview strategies, the tier 5 interview advisor will also prepare written disclosure for solicitors if the SIO requests this.

The force is effective in making sure all reasonable lines of enquiry are followed throughout the investigation

The CSE MIT manages its non-recent investigations on the HOLMES computer system. The police typically use HOLMES to generate actions for investigators to complete. (An action is any activity that, if pursued, is likely to establish facts, preserve material or lead to the resolution of the investigation). HOLMES was originally designed to be used in faster-paced major inquiries, such as homicides. But its use for complex multi-victim multi-offender investigations is in line with MIRSAP. It means the SIO and deputy SIO can easily monitor all actionable lines of enquiry and make sure they are followed. Any actions that aren’t completed must be agreed by a sergeant.

The force has effective oversight of these investigations. The assistant chief constable chairs a CSE gold group which meets as often as required, and reviews each CSE MIT case. In addition, the SIO and deputy SIO closely monitor all investigations, reviewing each one weekly and monthly. Line managers also supervise each investigation closely to identify priority actions. The CSE MIT SIOs maintain oversight of cases being managed by district staff, via the peer review process.

Information sharing by partner organisations within the child sexual exploitation major incident team is very good

There is effective information sharing between partner organisations in the CSE MIT, such as the ISVAs from Saint Mary’s SARC, to support victims.

For example, we saw evidence that when a new potential victim is first identified, each of the organisations reviews its own systems to find out what information is available about the person. This information is then used to build up a profile for the potential victim and assess the level of risk. This risk assessment considers all available information. And all partner organisations agree the final decision. The team completes a victim needs assessment and the victim care pack. The partner organisations then put safeguarding measures in place to support the victim and assign an ISVA. A referral is made to an ISVA for victims in all CSE MIT investigations, although the victim can later choose not to receive this support.

This multi-agency approach continues throughout the investigation, with regular meetings to discuss each case and review the risk. Where appropriate, these meetings are formalised as strategy meetings and all partner organisations are involved.

At district level, effective information sharing takes place via the multi-agency safeguarding hubs (MASHs). This is a two-way process, with the police and partner organisations all sharing relevant information to safeguard victims and survivors.

Access to third party information is improving, but more work needs to be done

As part of any investigation, the police need to gather evidence from a variety of sources. Where material is held by a person, organisation or government department other than the investigator or prosecutor, it is called ‘third party material’. With child sexual exploitation offences, this material is often held on partner systems, such as local authorities’ (social care) systems.

The force has experienced problems accessing this third-party material. As we set out in ‘Both sides of the coin’, our 2020 inspection report on the police response to vulnerable people in county lines drug offending, there are often problems with joint working. As part of that inspection, we made a recommendation for the Home Office to clarify the legal position and to address barriers to information sharing which undermine effective partnership working for law enforcement purposes.

The force works with ten local authorities across Manchester. Each has its own agreement (memorandum of understanding) about what information it will share with the police. Some are willing to share all available information and do so promptly and without redactions. Others will only do so in accordance with strict rules on what can be included. This has led to significant delays in investigations and in the preparation of evidence for court.

Operations Green Jacket and Bernese have been particularly affected by these delays. Material provided by Manchester City Council took many months to arrive and was so heavily redacted that some pages contained only a few words. This made it impossible to assess the evidential value of the information.

The force, local authority and CPS have now agreed a new memorandum of understanding and process. There is now a dedicated point of contact at the council who can review the information requests. Investigators can view and assess unredacted documents remotely. This is far more efficient and effective but means investigators have had to start the process again.

The non-recent child sexual exploitation investigations are lengthy

The force’s investigations into non-recent child sexual exploitation offences have, by necessity, been lengthy. The longest running, Operation Lytton, has lasted nine years so far.

Various factors have contributed to the length of these investigations. One of these is the sheer scale and complexity of a multi-victim multi-offender operation, with potential new victims being identified all the time. Other factors include the delays in accessing information held by some local authority partners. There have also been delays in getting expert witness statements, such as from doctors.

Importantly, the force has made sure to progress each inquiry at the victim’s own pace. This has sometimes meant waiting until the person was ready to talk about what had happened to them. The force has been keen to make sure the victim is always at the centre of its child sexual exploitation investigations. For this reason, investigators on the CSE MIT are careful not to push people too quickly.

Identifying learning

There is a strong learning culture and desire to improve practice

The force fully accepts that it made mistakes in the past. It has taken positive and effective steps to learn from these mistakes and improve how it investigates recent and non-recent child sexual exploitation. This has included reviews from external organisations, such as the Hydrant Programme and the independent review team. And there are now internal review processes to make sure there is a consistently high standard across all child sexual exploitation investigations. At all levels, the force’s governance and performance arrangements have an audit and quality assurance element.

We saw evidence the force and its partner organisations have a strong learning culture. All personnel we spoke with showed a desire to learn and improve. The force’s organisational learning board monitors learning and records how effective it is. Learning is also recorded on a strategic document and the force keeps this updated with developments. In the year before our inspection, the force introduced an exploitation improvement board. This meets quarterly to examine how the force can reduce vulnerability and improve child sexual exploitation investigations.

Greater Manchester Police makes sure it is aware of developments by other police forces, so that it can update its processes to include good practice. For example, it closely monitors learning from Operation Stovewood, which is the National Crime Agency’s investigation into child sexual exploitation in South Yorkshire. The force consults with national policing and other organisations, such as Saint Mary’s SARC, NAPAC, and victim support and advocacy charities, to help it continually improve its services. And it works with partner organisations to share learning at a local, regional and national level.

Representatives from the force, GMCA and other partner organisations, take part in a number of strategic groups. These include the gender violence board and the domestic abuse steering group. These meetings help all parties review practice, share learning and make improvements. The head of protecting vulnerable people also meets with charities and third-sector organisations to listen to feedback from victims and survivors of child sexual exploitation.

The force works closely with the Hydrant Programme to review and shape its approach to child sexual abuse and exploitation

In February 2020, at the force’s request, a team from the Hydrant Programme carried out a peer review of Operation Green Jacket. The force asked the review team to assess:

• how the investigation was aligned to good practice;
• the effectiveness of governance;
• governance, leadership and partnership working;
• resourcing;
• victim, witness and suspect strategies; and
• media and communications engagement.

The initial investigations in 2004 and 2005 didn’t adequately safeguard children or disrupt offenders. But the Hydrant Programme review team found, as we have in this inspection, that Operation Green Jacket was demonstrating a considerable commitment to learning from past mistakes and, where possible, was rectifying errors. And substantial resources had been committed to Operation Green Jacket and other complex child sexual exploitation operations. The team noted that historical context is important. When these offences happened, multi-agency partnership work for child sexual exploitation investigations was rare and victim-blaming language was openly used.

The team made 33 recommendations. These recommendations were comprehensive and covered areas such as various strategies, policies and processes to support investigations. The force then created a plan to monitor the implementation of any changes made because of these recommendations.

We viewed a document, dated April 2021 and written by the SIO for Operation Green Jacket, that summarised the results. The force had addressed each of the recommendations made. It put new governance, strategies, processes and policies in place, including making sure victims were at the centre of each investigation.

As part of our inspection, we reviewed evidence that showed the force pursues investigations and will target potential perpetrators and locations, based on a wider assessment of the evidence.

The force has also applied this learning and good practice to other operations. And, in 2021, it held CPD events across the force to share the good practice.

The force has various review processes to evaluate its approach to investigating child sexual exploitation

In addition to the Hydrant Programme reviews, the force completes multi-agency peer reviews, as discussed in Chapter 1. Senior officers oversee and review child sexual exploitation investigations through the gold meeting structure. And the PIP 4 adviser supports the SIOs and reviews their decisions.

The CSE MIT detective superintendent reviews investigative strategy and resource levels. Supervisors review all child sexual exploitation investigations and hold weekly 1-2-1s with investigators. The reviews consider progress made, strategies and outstanding lines of enquiry, as well as any welfare needs victims and survivors have. The SIO also reviews complex cases with the head of CPS to identify learning and make changes to working practices.

CSE MIT staff and officers told us that this review process works both ways, as supervisors also listen to feedback and make improvements. For example, when a decision is taken not to continue a child sexual exploitation investigation, a letter is given to the victim to explain the reasons. The CSE MIT introduced this process after finding victims didn’t always recall or absorb information from an in-person visit. However, these visits sometimes took place before the letter was ready. Following feedback, the team improved the process to make sure the letter is always ready by the time of the visit.

Managers from the CSE MIT also regularly review child sexual exploitation investigations carried out by district personnel. We saw evidence that the team in the vulnerability governance unit shares learning from these peer reviews with officers and staff across the force as needed. This is done directly as well as via the force’s training department and ongoing CPD events.

Training

The force is aware of the training needs in the child sexual exploitation major incident team, but should do more to address them

Greater Manchester Police maintains good oversight of all areas of child sexual exploitation investigations, including staffing levels and training needs. It has a skills matrix which identifies gaps in accreditation in the CSE MIT. Supervisors review training needs in their one-to-one meetings with the team. The force has a plan to address any gaps in accreditation. For example, there is a plan in place to train more staff to do ABE interviews with victims and witnesses.

However, we found that there are various training needs in the CSE MIT. There is a persistent national shortage of detectives, which is causing problems for forces across England and Wales, including Greater Manchester Police. The force has recruited police staff investigators to work alongside detectives in the CSE MIT. It would like all these police staff investigators to be trained to PIP 2 level. This is necessary for anyone investigating serious and complex investigations, such as multi-victim multi-offender non-recent child sexual exploitation.

But, at the time of our inspection,13 staff investigators hadn’t yet completed their PIP 1 training. A further 11 police staff investigators were working towards their accreditation and 20 retired detectives returning as police staff investigators were accredited.

The force is working with staff associations to encourage them to support the plan to train police staff to cover PIP 2 investigator roles.

The force doesn’t have a process for assessing the existing skills of these retired detectives (such as a background in safeguarding and previous accreditation for ABE interviewing). These investigators are therefore unable to contact survivors and witnesses and must rely on colleagues to do so. In the meantime, they can only carry out research functions, which isn’t the most efficient use of these resources.

Likewise, there are team members waiting for disclosure training, specialist child abuse investigation development programme (SCAIDP) courses, and HOLMES training. Some of the formal roles on the HOLMES major incident room team were vacant at the time of our inspection. This means that members of the CSE MIT who are already accredited – including detective sergeants and detective inspectors – are covering these essential roles in addition to their supervisory duties. This isn’t an efficient or effective use of these resources.

The force provides effective training for officers and staff who investigate reports of child exploitation

Greater Manchester Police provides effective training for officers and staff who investigate reports of child sexual exploitation. In 2021, it introduced the first investigators course solely focused on child sexual exploitation. The CSE MIT provides CPD, with content that includes learning from peer reviews. Officers and staff have also been trained to understand the contextualised behaviour of survivors of child sexual exploitation. The force supports this training through continued work with survivors.

The force has arranged for officers and staff to receive fully immersive training on child sexual exploitation from a company called Near-Life. The training involves interactive video software to give officers and staff the opportunity to take on the roles of both officer and investigator in a simulated case. The force has provided a two-day child sexual exploitation SIO course which included presentations from representatives from the Hydrant Programme and NAPAC.

The NHS resilience hub has given resilience training to members of the CSE MIT. The training covered:

• fear, stress and survival;
• anxiety and trauma;
• vicarious trauma;
• interviewing traumatised witnesses; and
• self-care and resilience in teams.

The feedback from this training was overwhelmingly positive, with 100 percent of attendees finding it informative and useful.

The force provides other training covering a wide range of relevant subjects, as required. CSE MIT members have received Think Victim training, for all ranks from investigating officer to detective chief inspector. And there has been training on the victim strategy, including the victim care packs, victim approaches and victim risk register.

District staff have also been given various briefings, including one on the child-centred policing strategy, covering prevention and engagement, alternatives to arrest / pre‑custody, custody, and post-custody and investigations.

In March 2023, the force held a workshop as part of a week of action. Speakers from outside the force attended the workshop and gave presentations and training on a range of topics such as:

• child exploitation issues in Greater Manchester schools;
• county lines awareness;
• grooming;
• practice principles for dealing with child exploitation;
• Catch 22 (Greater Manchester Victims’ Services); and
• disclosure.

In May 2024, the force and Manchester City Council held a ‘learning from best practice’ multi-agency conference and training event, with the aim of:

• learning from national and local best practice for victim voice, victim safeguarding, offender disruption and investigations;
• sharing learning from previous child sexual exploitation investigations and safeguarding practices;
• enhancing collaboration and partnerships to achieve excellence in tackling child sexual exploitation; and
• learning from the Greater Manchester Resilience Hub and trusted relationship work and how this supports workforce well-being.

The force makes good use of continuing professional development

The force holds regular CPD events for all its teams, to share learning from a variety of sources. This includes learning from the Hydrant Programme, the CSE MIT, partner organisations, such as Saint Mary’s SARC, and themes identified by peer reviews. For example, a peer review identified that, due to unclear terms of reference, district staff were focusing on safeguarding rather than investigative opportunities. The CSE MIT held a CPD event for district staff to clarify police and partner organisations’ roles. The force also includes any learning from national best practice.

During our inspection we saw various examples of CPD that the force has run for the CSE MIT and district investigators. This included:

• lessons from non-recent child sexual exploitation inquiries, including Operation Stovewood and Operation Green Jacket;
• themes and conclusions from the Independent Inquiry into Child Sexual Abuse and Greater Manchester Police peer reviews;
• a case study of Operation Lytton;
• understanding the roles and benefits offered by various specialist teams, including the SARC, SOC, CPS, VIPER, occupational health well-being support and the district intelligence unit;
• using preventative orders such as sexual harm prevention orders; and
• input on victim strategies and investigation tactics.

The serious and organised crime team contributes to district continuing professional development days

The SOC investigation team gives regular input into district CPD days. This helps local officers and staff better understand the team’s role, the tactics it uses and how to access these resources. This has become more important now that the force is using SOC tactics to support investigating vulnerability and sexual exploitation.

As a result, district teams now know to record all child sexual exploitation disruption activity on APMIS, so that this information can help guide SOC activity. The force told us that as a result of the CPD input, the number of entries on APMIS about child sexual exploitation increased from 250 a month to 1,300 a month. The force now has a record of 27 organised crime groups, 6 priority individuals and 4 vulnerabilities shown against child sexual exploitation.

The SOC team told us that feedback on the last two CPD events has been very positive, with 87 percent and 90 percent satisfaction ratings from attendees. Members of the SOC team adapt the sessions according to need, particularly around awareness raising. A recent event included a staged information release exercise documenting a real incident that demonstrated how SOC resources could assist at the various stages of an incident.

Outcomes

The force monitors both its criminal justice and non-criminal justice outcomes

The force and the CSE MIT closely monitor the outcomes of child sexual exploitation cases. The force measures these via its performance framework, which forms part of regular governance arrangements. The CSE MIT detective superintendent and the force’s PIP 4 adviser complete regular reviews of all child sexual exploitation cases. These reviews record details of the victims and survivors, the perpetrators and the outcomes of each case.

For example, the review stated that Operation Lytton has resulted in over 90 arrests and 37 suspects being charged with over 300 child sexual exploitation offences. This includes 120 offences of rape.

In 2023, one criminal justice trial took place as a result of Operation Lytton. Five defendants were convicted. Between them, they received 71 years imprisonment. At the time of our inspection, there were a number of criminal justice trials scheduled for 2025 involving multiple defendants. In total, the CSE MIT and the earlier child sexual exploitation multi-victim or multi-offender investigations have resulted in 42 convictions and over 430 years imprisonment for offenders.

In addition to reviewing criminal justice outcomes, such as results at court, the force records non-criminal justice outcomes. These include the number of victims and survivors it has offered support to via a specialist service.

We also saw evidence that the force uses its performance management framework to monitor compliance with strategies for investigating child sexual exploitation. Its corporate development branch and public protection governance unit complete audits of operational practice, including at district level. They also review compliance with the Victims’ Code of Practice and authorised professional practice (APP). Results of these audits are reviewed at the force public protection governance unit meetings and by the deputy chief constable.

In accordance with recommendation 5 of the report from the Independent Inquiry into Child Sexual Abuse, and several of our recommendations, the force records demographic data, such as the age, gender and ethnicity of potential victims and suspects, and any disabilities they may have. It has a range of intelligence products that support its approach to investigating child sexual exploitation. These include a strategic assessment and specific problem profiles. Together, these products provide detail on emerging threats and potential child sexual exploitation risks. These threats are scored using the MORiLE risk assessment system, and the force then assigns the most appropriate resource.

The force takes steps to continuously improve its outcomes relating to child sexual exploitation

The force’s approach is now significantly different to how it – or any police force – historically responded to child sexual exploitation. Partner organisations are also included in its learning. And it actively gathers feedback from safeguarding and victim support partners, such as satisfaction surveys requested from the ISVAs at Saint Mary’s SARC.

The force has developed a very effective working relationship with the CPS. CPS support used to come locally from the complex case unit, but this has transferred to the national organised child sexual abuse unit. Despite this change, both Greater Manchester Police and CPS lawyers spoke very positively about the working relationship.

The force can easily access legal advice from the national unit. And the legal professionals have a good understanding of the complexities involved in these non‑recent child sexual exploitation cases. They have attended the CSE MIT to talk with staff about procedures and timescales. This has clarified expectations and processes on both sides. CPS lawyers have also given a presentation at a force CPD event.

In 2024, the force introduced a quarterly exploitation governance group to bring together two areas of policing: vulnerability and SOC. The head of protecting vulnerable people chairs this group. It includes the heads of the force’s investigative assets, such as for vulnerability, crime and SOC, and representatives from the north‑west regional organised crime unit.

As discussed in the section on training, the force is increasing its use of SOC tactics to support vulnerability investigations. Members of SOC have attended CPD sessions for protecting vulnerable people to provide input about SOC tactics. This has helped to bridge the gap between these two areas of policing and supported improvements in both investigations and safeguarding.

SOC members have also attended training events at district level to improve awareness of SOC resources and tactics. District staff now have a better understanding of how SOC resources and tactics can be used in vulnerability investigations. This means they are more confident in requesting these resources, or in asking for assistance.

The force intelligence bureau produces a monthly intelligence summary pack about child sexual exploitation, child criminal exploitation and adult exploitation. It includes data from the force’s vulnerability tracker. This looks at trends in the demand the force experiences from reactive and proactive policing work for child sexual exploitation. The intelligence summary helps the force review and manage the threat of child sexual exploitation.

Conclusion

Greater Manchester Police has made significant improvements in how it investigates child sexual exploitation. It has effective governance, leadership and investigative strategies in place. This provides the best possible chance for successful outcomes. As the operations progress, criminal justice outcomes may be reasonably expected.

We found the force and its dedicated workforce are actively looking for, supporting and listening to victims and survivors of child sexual exploitation.

Force leaders have made it clear that vulnerability is a priority. The workforce understands the importance of child sexual exploitation investigations and providing support to victims and survivors. This message is reinforced internally to the workforce and the force’s safeguarding partners, and externally through official communications. These communications aim to increase the trust and confidence that victims and survivors of child sexual exploitation can now have in the force and its safeguarding partners. The force hopes that, when they are ready, more victims and survivors will ask for support.

The force has fully accepted it made mistakes in the past. It has developed a leadership and governance structure that makes sure there is appropriate oversight for multi-victim and multi-offender child sexual exploitation investigations. Support and challenge from national bodies strengthens this.

The force has a dedicated CSE MIT investigation team. Since it was set up, this team has grown in experience and expertise. Its leaders are open to support and feedback from peer review. But we found that the force needs to review its resourcing and training for the team. At the time of our inspection, there were vacant posts on the CSE MIT and various training requirements.

We found those working within the CSE MIT are passionate and committed to their work and the support they offer to victims and survivors. Investigators work closely with specialist partner agencies to offer appropriate support to victims. They investigate offences at the pace that the victims require to support their well‑being.

It shouldn’t be underestimated how complex and challenging these crimes are to prevent and investigate. We found clear evidence that the force has introduced detailed and effective victim and offender strategies to support its dedicated investigation provision. This has contributed positively to its ability to carry out effective investigations of non-recent multi-victim multi-offender child sexual exploitation.

3.  How effective is the force’s approach to the 74 victims and survivors of child sexual exploitation, who were identified through the work of the independent review team (previously appointed by Greater Manchester Combined Authority)?

As part of this inspection, the mayor asked us to consider the effectiveness of Greater Manchester Police’s approach to the 74 victims and survivors of child sexual exploitation, who were identified through the work of the independent review team (previously appointed by Greater Manchester Combined Authority).

The inspection specifically examined:

• how the force approached information it received about potential victims;
• the force’s investigative policies and strategies for information on potential victims;
• whether the force considered the wishes of victims and survivors;
• the criminal justice outcomes for victims and survivors;
• other, non-criminal justice outcomes for victims and survivors (such as restorative justice, where the force recognises the abuse and victims and survivors have an opportunity to share their experiences, or where suspects have died and proportionate investigation takes place); and
• the provision of, and access to, support services for victims and survivors, regardless of whether there is a positive criminal justice outcome.

Summary of findings

The independent review team identified a cohort of 74 children it considered likely to have been sexually exploited between 2003 and 2013.

The 74 identified children are all now adults. The incidents and investigations took place between 11 and 20 years ago. We found that the force had since reviewed its response to the initial incident reports and referrals. It had revisited the information and crimes to assess the quality of service provided to the potential victims. It then contacted all 74 individuals to offer them support from victim support organisations. The force also hoped to gain their trust and confidence for a police investigation.

We found that the force had records of the 74 people which pre-dated when the independent review team identified them. The force records show that 48 of the 74 individuals had disclosed criminal offences of child sexual exploitation. But 13 of the 74 stated that they hadn’t been sexually exploited and a further 13 people didn’t disclose offences or wish to engage with the police.

There may be a variety of reasons why some of the individuals felt that they couldn’t disclose criminal offences or support a police investigation. Some of those people who didn’t report criminal offences provided evidence as a witness in other investigations.

We started our audit of force records from the date the initial information was reported to the police, or the date when a victim was identified by investigators (whichever was earlier). We then audited all available information held on police systems for that individual.

We reviewed how the force and investigators dealt with multi-victim multi-offender child sexual exploitation at the time these offences were first reported, and how they deal with them now. We found a marked improvement. The force now has a specialist dedicated investigation team – the child sexual exploitation major incident team (CSE MIT). And it has developed its policy for identifying, assessing, supporting and approaching potential victims and survivors of child sexual exploitation.

We found that between 2003 and 2013, when the police identified potential victims, received referrals or incidents were first reported, police personnel and some safeguarding partners commonly used victim-blaming language. This went unchallenged.

We also identified failings in some of the initial victim and survivor engagement and investigations. This led to some individuals losing confidence in police and safeguarding services. We found there were occasions where potential victims weren’t assessed as vulnerable, and therefore they weren’t offered the support they needed and deserved.

We identified that the force didn’t always record a crime when these child sexual exploitation offences were first reported. This meant that it also didn’t investigate these offences. We found that the dedicated CSE MIT has since reviewed those historical incidents and referrals and recorded some of those crimes retrospectively. But our audit still identified some crimes for which there was no corresponding crime record on force IT systems.

In 2022, Chief Constable Watson QPM gave an unequivocal apology to “victims who in the past had been let down when they needed our help in the most traumatic and horrific circumstances”.

When the force made further contact with the 74 individuals, through the dedicated investigation teams, it was more sensitive, structured and considered. The force and its safeguarding partners completed an assessment for each potential victim and survivor before making contact. In each case, this multi-agency assessment reviewed whether, and how, that contact should be made. Any contact included an offer of support for that individual.

Some of the 74 individuals didn’t tell the force about any crimes that had happened to them or accept the support that was offered. Investigators always left their contact details, with information on how to access the support available. And they made sure the person was aware that they could change their mind at any time.

We found that in 60 of the 74 individuals’ cases there had been an effective investigation. In cases where we would have expected the force to have offered support to potential victims and survivors, we found evidence of this in 58 of 64 cases both during and after the investigation. Support wasn’t expected in ten cases as the individual wasn’t a victim or a witness. We found that overall, the force had provided an appropriate level of service to 64 of 74 individuals.

Our audit identified that the force’s dedicated child sexual exploitation teams are still actively investigating offences reported by some of the 74 individuals. Specialist officers and victim support agencies continue to support some of these individuals during criminal investigations. We found that this support has remained in place throughout any criminal justice procedures.

The force and its safeguarding partners continue to support other potential victims and survivors from this cohort about their traumatic experiences of child sexual exploitation.

Background

In January 2024, the independent review team published its third and final assurance review report: ‘The review into Operation Span and the investigation of non-recent child sexual exploitation in Rochdale’. This part of our commission relates directly to that report.

The report focused on the sexual exploitation of children in Rochdale between 2004 and 2012. The review team specifically considered the allegations made in 2017 by Sara Rowbotham (Rochdale crisis intervention team co-ordinator) and Maggie Oliver (former Greater Manchester Police detective constable).

It considered the effectiveness of safeguarding approaches to children at risk from child sexual exploitation. This covered the period from 2004 to the conclusion of Operation Span and the overlap with Operation Doublet (both being Greater Manchester Police investigations).

The review’s terms of reference didn’t extend beyond December 2013. The review team examined records held by the force and Rochdale Council. Its assessment focused on two questions:

• Was there a significant probability, from the information on the files, that the child was being sexually exploited?
• Could the review team provide assurance that this abuse was appropriately addressed by either Greater Manchester Police or Rochdale Council?

The team judged the response in line with the procedures that were in place at the time. The team reviewed 111 cases and concluded:

“We believe there was a significant probability that 74 of the children we considered were being sexually exploited. Of these 74, we found that we could only provide assurance that three of them were appropriately protected by the protective agencies. There were serious failures to protect the children in 48 cases.”

Thereafter, the report refers to these 74 children as “our cohort of 74 children”. The cohort of 74 children had come to the attention of the police and/or social services between 2004 and 2013. This was 11 to 20 years prior to the review taking place. All are now adults.

There were seven criminal trials following police investigations into child sexual exploitation in Rochdale, taking place in either 2013, 2016 and 2023. These trials included nine victims who were included in the cohort of 74 children. The review team acknowledged this in their report.

Methodology

The force provided remote access to its record management systems, to help our inspectors to review and audit the relevant case files and information. These systems included the Home Office Large Major Enquiry System (HOLMES), the force intelligence systems, and its legacy database and search tool.

We needed access to the legacy database because some of the investigation records dated back to 2004 and the force has since changed its record management systems. The force also provided officers to help our inspectors with this research and answer any queries.

We developed an audit workbook to record information across five categories:

• reporting and initial assessment
• investigation
• outcomes
• victim and survivor care
• overall summary.

This methodology allowed us to collate and evaluate a range of information. We could then assess the effectiveness of the force’s approach to the identified potential victims and survivors.

Audit findings

The force didn’t always take timely or appropriate action to mitigate risks during initial reporting and assessment of child sexual exploitation offences

Our audit identified that the cohort of 74 individuals first had contact with the force between 2003 and 2013. During initial contact and investigation, the police and some of their safeguarding partners had let these individuals down. In most of these cases, dedicated investigation teams have since reassessed the details. Investigators have made further contact with the potential victims and survivors, to offer support and try to gain their trust and confidence for a police investigation.

We found that the force received the initial information in different ways, including from:

• child protection referrals;
• intelligence referrals from safeguarding partners;
• police-generated information; or
• calls to the force contact centre.

It is important that police personnel record all contact and respond in a timely way. When receiving a new report, the police should, along with their safeguarding partners, take a structured approach to assessing threat, harm and risk. This allows officers and staff to try to reduce the identified risks and keep people safe. They should also consider the needs and vulnerabilities of the people involved and record any safeguarding action taken.

We found that in 62 of the 74 cases the force provided a timely response to the incident or information received. In some cases, information had been received that the person may have been a victim of, or a witness to, child sexual exploitation but there were delays in speaking to them as a potential victim. At times this led to a lack of recognition of the risk to individuals, resulting in ineffective investigations.

We found that in less than half (35) of the cases the police held a safeguarding strategy meeting with their safeguarding partners to review and identify risk.

In 69 of the 74 cases, there was a structured approach used to assess risk. In three of those risk assessments, the force hadn’t identified or recorded all apparent risks.

We found that the force had taken appropriate action to reduce risks and provide necessary safeguarding in 58 of the 68 cases that we assessed as requiring such action.

In 6 of the 74 cases, individuals stated that they hadn’t been a victim of sexual exploitation.

In some cases, the force didn’t record a crime on its system. For example, it didn’t always identify or record a crime when it received an intelligence report about potential child sexual exploitation crimes. In these cases, the force didn’t carry out an investigation or put safeguarding in place for the potential victim.

The force reviewed its initial investigations to make improvements

We assessed that in 60 of the 74 individuals’ cases, the force had carried out effective investigations. There were various reasons for us deciding an investigation was ineffective, including:

• a crime wasn’t recorded therefore no investigation took place;
• an initial decision to take no further action and later approaches to engage with a potential victim were unsuccessful; or
• investigators not pursuing all reasonable lines of enquiry.

According to the National Crime Recording Standards 2024/25 (PDF document), a crime should be recorded if reported by a victim, unless there is credible evidence to prove that it hasn’t happened. In some instances – particularly where the offences were non-recent at the time they were reported – the force had failed to do this initially. It also failed to investigate those offences when first reported.

We found that dedicated child sexual exploitation investigators had subsequently reviewed each incident and referral, and recorded crimes for investigation in almost all cases. Of the 68 incidents or crimes recorded by child sexual exploitation investigators in the force’s review, we found that on 15 occasions there were delays in allocating the investigations. And on 18 occasions there had been unjustified delays in investigations. For example, there had been delays in speaking to a potential victim or the initial historic investigation had been closed and then a review team had carried out a reinvestigation of the crime.

We found that child sexual exploitation investigators had reviewed the available information, in consultation with their safeguarding partners, and made a decision on whether or not to contact the potential victim again. In one case, they decided not to make an approach. We reviewed the records of these decisions. We found that in almost all cases the force had made a record of the policy decision whether to recontact a person. Investigators had then revisited potential victims to ask for their support for an investigation and offer support services. In some of these cases, the potential victim didn’t wish to support a police investigation.

Child sexual exploitation is one of the most serious offences. It has a significantly negative effect on people. Therefore, the pace of any investigation must consider the needs and well-being of the potential victim. The police often need to interview the individual several times to get detailed evidence. Safeguarding partner organisations will often provide support in these serious cases. It was positive to find that investigators considered the wishes of the victims and survivors in nearly all cases.

We identified that 48 people disclosed criminal offences to officers and 26 people didn’t disclose any criminal offences. These 26 occasions where the person didn’t disclose offences, fell broadly into two categories:

• There was little information or intelligence to suggest that the person had been groomed or sexually exploited, and they stated that they hadn’t.
• There was significant information which would suggest that the person had been sexually exploited. However, the police may have been unable to provide the reassurance and confidence for the potential victim to report offences at that time.

There could be many reasons for this lack of trust. For example, it may have been due to previous experience of the police, threats or perceived threats from perpetrators, or a lack of understanding about the significance of what had happened to them. It may also have been that the individual wasn’t ready to report offences and for an investigation to take place.

Positively, we found that in 50 out of 56 cases investigators had identified a suspect for the offence. And in 45 of these 50 cases, officers had arrested or interviewed the identified suspect. The five suspects not arrested were named in referrals or intelligence submissions to the police, but a potential victim didn’t disclose a criminal offence.

There have been criminal justice outcomes for some of the identified victims and survivors

The outcome of a child sexual exploitation case will vary depending on several factors. This includes the wishes of the potential victim and survivor. In our audit we identified three categories of outcomes sought by potential victims and survivors:

• a criminal justice outcome (23 individuals)
• access to dedicated support services for victims and survivors (13 individuals)
• no further contact with the police or support for a police investigation (38 individuals).

We considered whether the outcome of the case was appropriate to the nature of the incident. We found that in 62 of the 74 individuals’ cases there was an appropriate outcome. In general, the cases we assessed as not having an appropriate outcome were those cases when the potential victim had been let down by the force at the initial contact stage. And further contact from the force had been unable to rectify the issues experienced by individuals.

The force had pursued a criminal justice outcome in 18 cases, of which, at the time of our inspection:

• fifteen resulted in a criminal conviction;
• two had resulted in the defendant being acquitted; and
• one was still an ongoing criminal case.

In 14 cases, the police decided to take no further action. And on four occasions the Crown Prosecution Service (CPS) decided to take no further action. The police challenged two CPS decisions, which led to suspects being charged and convicted. In one of these cases this resulted in the conviction of five offenders who were, in total, sentenced to 26 years imprisonment.

It is important that investigators make a record of the appropriate reason for closing a crime, known as a recorded outcome. We found that in 68 of the 74 cases there was a clear reason recorded for the outcome of incidents or investigations.

The force made an offer of victim and survivor care to most of the potential victims of sexual exploitation

Victims and survivors of child sexual exploitation very often need support from specialist professionals. During our audit, we assessed whether the force and investigating officers had considered and recorded the offer of support from specialist victim services. This can be from an independent sexual violence adviser (ISVA), from children’s services or adult social care, or from local voluntary sector organisations that provide access to support, and professional and pastoral care.

We found that in 58 of 64 cases, the force had provided support or made a referral to one of its safeguarding partners. In ten cases, the potential victim hadn’t wished to engage with officers. In all 58 cases, where support was provided or a referral made, this support was appropriate. In these cases we found that there was evidence of continued support to potential victims and survivors during and after the investigation.

Where the force offered ISVA support, this was accepted in 29 of the 41 cases. And, in 20 of 25 cases when the individual declined this support, the force offered it again at a later stage. The force has since moved to an opt-out ISVA service. This means every potential victim and survivor of child sexual exploitation in CSE MIT cases is allocated an ISVA for support, unless they decide that they don’t want this support.

Overall, we found that the force had historically provided a poor level of service to some victims and survivors. This resulted in a loss of trust and confidence in the police investigating their crimes.

However, there was clear evidence that the force, via its dedicated specialist child sexual exploitation teams, had reviewed those cases. Investigators had revisited potential victims and survivors, sometimes on multiple occasions. They had tried to gain their trust and confidence to support investigations and to provide victim and survivor support services.

We found that overall, the force had provided 64 of 74 potential victims with an appropriate level of service. There were ten cases in which the force hadn’t provided an appropriate level of service. They were generally cases where the force hadn’t recognised the individual as a victim at the initial time of referral or report and further contact had been unable to rectify the issues potential victims had initially experienced.

It is possible that some potential victims who have lost trust and confidence in the force may be willing to speak with investigators from another force. Greater Manchester Police may want to consult with other forces and consider this approach.

Conclusion

The force has made considerable efforts to engage with and provide support to the identified cohort of 74 people. They form part of a much larger group of potential victims and survivors of child sexual exploitation, which the force has approached to identify criminal offences and offer professional victim support.

We examined the cohort of 74 individuals who were likely to have been sexually exploited before 2013. We audited all available information held on police systems and found that on many occasions, the initial approach by officers wasn’t effective in either mitigating identified risks or investigating the incidents. The force had missed opportunities to offer support to potential victims and survivors.

Since that time, the force has set up several dedicated operations to review its non‑recent multi-victim multi-offender child sexual exploitation cases. It has identified potential victims from incident reports, referrals received from safeguarding partners, and information received during linked investigations. Investigators reviewed all available information to identify missed opportunities to support potential victims and survivors and pursue lines of enquiry. Where possible, the force has actively pursued investigations and continues to do so.

The force set up these dedicated child sexual exploitation operations before it established the CSE MIT, as discussed in chapter 2 of this report. These operations also started many years before the independent review team identified the cohort of 74 individuals whom they assessed as likely to have been sexually exploited before 2013. In our audit we found that the force had included all 74 individuals in its review.

We found that the force revisited the circumstances for each identified person and on all but one occasion revisited these potential victims. Where appropriate, investigators arranged access to support services for potential victims and asked for their support in pursuing any identified criminal offences. They left contact details for both police and support services, should the victim wish to ask for support or have further discussions with the police.

The review and revisit to potential victims and survivors was met with a varied response. Some had lost trust and confidence in the police and the force wasn’t able to redress their experience. They didn’t want further contact and they didn’t want the police to take any action on their behalf. Some wished to access professional support. And others wanted the police to investigate the offences that had happened to them.

It was clear to us that the force has for many years been trying to provide a better service to those who have or may have experienced sexual exploitation.

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Inspection of Greater Manchester Police and its safeguarding partners’ approach to investigating allegations of child criminal and sexual exploitation