Sam and Chris Gould: Failures made after twins reported sex abuse

Sam Gould (left) died in September 2018 and her twin sister Chris died a few months later

Police and other agencies made failures after twin sisters, who went on to take their own lives, reported sexual abuse, reviews have found.

Sam and Chris Gould, from Fulbourn, Cambridgeshire, died by suicide four months apart, aged 16 and 17.

Reviews found agency responses at the "critical juncture" after the girls reported abuse were "fragmented".

Both police forces involved in the dropped investigation said they had made changes after the twins' deaths.

In May 2016, Chris, then 14, disclosed she and Sam had been sexually abused from about the age of six into their teenage years, and named the alleged perpetrator.

Hampshire Police investigated the case, but at the time the girls were struggling with their mental health and did not wish to give video evidence.

The case was then closed, but the separate case reviews said it appeared police guidance had not been followed and "alternative ways of giving evidence should have been explored".

Sam died at home in September 2018, while Chris died in January 2019 while she was an informal patient at a mental health unit.

The reviews added: "The absence of joint planning between the two police forces involved, and the lack of multi-agency partnership working, suggested that the importance of seeking justice over time was not recognised.

"This was a critical juncture. The response by services at the time was fragmented and very shortly professionals and services from across the multi-agency network withdrew in a misguided belief that they had no ongoing role."

The author of the reviews, Bridget Griffin, said learning from the cases was "substantial" and that she hoped, if changes were made, "children will be less likely to take their own lives and be better supported to reach their potential".

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Chris and Sam's parents Jane Cannon and Ian Gould are now fighting for change following their daughters' deaths

Police told children's services they were taking no further criminal action two months before telling Sam, Chris and their parents, the reports also revealed.

The girls' mother, Jane Cannon, said: "We waited months... only to be told 'Oh, we decided not to take any action a few months ago - didn't anyone tell you?'. We were left in limbo. It was an appalling situation to be in."

Their father, Ian Gould, added: "After they told us, it was actually only two weeks after that that Chris had a suicide attempt."

Sam and Chris, pictured on holiday in Turkey with parents Jane and Ian

The serious case reviews also found:

• Hampshire Police asked Cambridgeshire Police to contact people who Chris had spoken to about the abuse "but there is no evidence that this was taken forward"

• Communication and joint working between Sam's school, children and adolescent mental health services (CAMHS) and the local authority was "ineffective"

• Children's services often took no further action when a referral came in, which seemed to stem from a lack of clarity about their role and a misunderstanding of legislation

• There was a "missed opportunity" to understand "Sam's internal world", when she was pulling out her hair and eyelashes at a young age and had displayed sexually inappropriate behaviour

• Sam's three months without having a care coordinator, aged 16, was key to why there was "little communication and no joint work" between her school and CAMHS during that period

The reviews also raised concern around the "considerable variation" nationally on whether services were available for the diagnosis and treatment of borderline personality disorder in adolescence, despite "sound evidential basis" for it.

Sam and Chris were each other's best supporter, their parents said

In a statement released after the reviews' publication, Ms Griffin said her reports "highlight the pernicious impact of child sexual abuse (CSA) on children and young people".

"The serious case review does not state with any certainty, either way, that were the multi-agency services in place, the girls would still be with us today," she said.

"What we can say with a degree of certainty is that had the CSA not taken place both Sam and Chris would very likely not have suffered mental health difficulties and therefore may never have taken their lives."

Among their 11 recommendations, the reviews state the Cambridgeshire and Peterborough Safeguarding Children Partnership (CPSCP) should request a national review about multi-agency service provision to children at risk of harm as a result of their mental health needs.

It should also raise its concerns with government over the burden of proof in child sexual offences cases, and "facilitate a dialogue" over the approach to borderline personality disorder.

• Why the twins who had everything 'fell apart'

Mr Gould said: "Time and time again, serious case review after serious case review, inter-agency working comes up as a key element in the failings, and yet nothing happens; it carries on the same.

"We are determined to make sure the recommendations go forward and that real action comes from them."

Cambridgeshire Police's Assistant Chief Constable Vicki Evans said the force had since "strengthened our approach and responses to the investigation of childhood sexual abuse".

"We adopt a holistic approach, which recognises strength in jointly working with our partner agency colleagues throughout the course of an investigation, and signposting to support services. We are committed to embedding the learning from these serious case review," she added.

Chris and Sam were "normal, healthy, happy children", their mother said

Hampshire Police said it would review the report's recommendation about working with other agencies "particularly where complainants live in another force area, and consider whether there are any further measures we can take".

A statement added: "Following the girls' tragic deaths, we carried out an internal review of the investigation, and changes to some internal processes regarding how these cases are graded and allocated have already been made."

Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) has since introduced a CAMHS crisis team and a new home treatment team.

A spokesman said: "We welcome the findings of the serious case reviews... and we will continue the improvements already made to our services, working with partners to ensure all learnings from the reviews are acted upon."

Carol Anderson, chief nurse at Cambridgeshire and Peterborough Clinical Commissioning Group (CCG), said it was "committed to making further improvements on the basis of the recommendations, building on the changes that we have already implemented".

Chris and Sam pictured at the London Olympics

Cambridgeshire County Council said it has since worked alongside health partners to review support to young people and their families prior to admission and upon discharge and revised its Education Health and Care Needs Assessment policy.

A spokeswoman said: "The loss of any child is profound, and we cannot even begin to imagine the grief experienced by Sam and Chris' parents, family and friends."

She said the authority welcomed the reviews' "thorough, detailed and thoughtful analysis" and they had taken forward recommendations in both reports.

"We continue to work with our partners to improve best practice and information sharing in cases such as these.

"The importance of our responsibilities, support and advocacy for young people in challenging and vulnerable situations is very much at the forefront of our service," she added.