The Croydon Safeguarding Children Board (CSCB) review of support for vulnerable adolescents was launched following the deaths of three teenagers in less than a month during summer 2017 in the London borough. All had been known to social workers by the age of two.
The review, which comes nearly 18 months after the borough's children's services was rated "inadequate" by Ofsted, was subsequently expanded to include 57 other young people in Croydon.
They were all also known to children's social care, with many at risk of violence, abuse and exploitation.
A key aim was to better understand the lives of vulnerable young people and improve their support, with a lack of early support seen as a key failure.
If such support had been in place at an earlier stage their life chances could have improved and problems could have been addressed before they escalated, says the review.
Often this group of vulnerable children did not meet the threshold for support despite the need for targeted help. As a result, problems around substance abuse, child sexual exploitation, as well as crime and gang affiliation, continued to escalate, the review adds.
In addition, 42 per cent had been exposed to domestic abuse, 28 per cent had been homeless and 70 per cent had been referred to child and adolescent mental health services.
Support across social care, health, education and criminal justice agencies was too focused on managing crisis rather than addressing the root causes of problems.
"Had early intervention services been available from a young age, or targeted support been provided earlier, complemented by a holistic family plan, it is reasonable to conclude that children might have achieved better outcomes," states the review.
- Analysis: Serious Violence Strategy - experts advocate earlier interventions
- Analysis: Experts look to public health model to tackle surge in youth knife crime
It adds: "The multi-agency response was reactive, and sometimes could be described as crisis management. As the risks and vulnerability grew, behaviour was more serious, more violent and more frequent; agencies struggled to meet their needs and to effectively engage families to keep children safe.
"The child protection framework and criminal justice enforcement and interventions were applied. However, these interventions were ineffective as agencies continued to primarily address the presenting crisis and issues. Engagement of the children dwindled, and they seemed to lack the motivation to change."
The cases of the three teenage boys that sparked the review, included a 16-year-old looked-after child who was riding a moped with two others on board when he crashed and died.
Another involved a 15-year-old who was subject to a child protection plan and died from multiple stab wounds in a gang-related incident. The third was a 17-year-old who died after taking a highly toxic drug.
There were two further deaths among those involved in the review - both 17-year-old boys who died from stab wounds in October and December 2017.
Among the 23 girls and 37 boys involved in the review, 71 per cent are from a black, Asian and minority ethnic (BAME) background. Black boys of Caribbean heritage and white girls of British heritage were the two largest groups.
Some BAME families interviewed suggested that they may have been better supported if they were white.
The review states: "Children and parents who were spoken to as part of the review were unhappy with the multi-agency response and questioned if the boys had been white, would more have been done to assist them?"
Failures to support vulnerable young people in school are also detailed.
It emerged that primary schools have "limited interventions", other than exclusions, to address challenging behavior. A total of 19 of the young people had been excluded at primary school all of whom went on to receive a criminal conviction.
"Overall, there were poor transitions between primary and secondary school, behaviour deteriorated throughout secondary education with over half of the children being made subject to fixed term exclusions, managed moves, and placements in pupil referral units or alternative education provision," adds the review.
Croydon Council says that the review's findings will "shape every aspect of care for children and young families".
A preventative approach to support is being put in place through local early help services, which were introduced this month.
The council has also launched a targeted service to support vulnerable nine- to 14-year olds, called Safe and Well. A Violence Reduction Network, which involves a range of agencies looking to tackle the root cause of crime, is also being developed.
CSCB independent chair Di Smith, said: "In Croydon, the learning will be invaluable as we go forward, as a strong and cohesive partnership, to take a preventative approach to youth crime, strengthening families and to helping our young people make positive choices.
"We hope this review will also be of some value to other areas facing similar issues both here in London and beyond."
Ofsted handed Croydon's children's services an inadequate rating in September 2017 after finding "weak managerial oversight at all levels".
A monitoring visit by the inspectorate last summer found that the pace of improvement was too slow and too many children were not having their needs met.