Death of a 16-year-old girl in 2017 by suicide. Carys and her sister lived with their mother and stepfather and his two children. Carys experienced anxiety and was in receipt of mental health services. Early in 2017 Carys and her sister disclosed to their mother that their stepfather had been sexually abusing them; he was arrested and has subsequently been convicted for the offences. Following the disclosure and investigation, but before the criminal trial, Carys took her own life. Ethnicity or nationality not stated. Learning focuses on issues around: initial responses to disclosures of child sexual abuse; use of child sexual abuse pathways and associated support; responses to the mental health needs of Carys; education settings being identified as key safeguarding partners; sharing of adult safeguarding information and concerns; accurate record-keeping by professionals; follow-up for children not brought to health appointments. Recommendations to the Safeguarding Children Board include: to require an audit of strategy meetings to ensure participation from partners is sufficiently inclusive, follow up is occurring as necessary and effective information gathering and sharing is taking place; ensure rigorous promotion of the role of the Sexual Assault Referral Centre to ensure victims of sexual abuse, including nonrecent abuse, are being offered holistic support; explore ways to widely promote existing pathways and opportunities to respond to mental health issues in children and young people, including the policy to manage self-harming and suicidal behaviour; request assurance from health partners that missed health appointments for children are subject to robust and consistent follow up.
      
 Title:  Serious case review: SCR Child I: Carys. LSCB: Kent Safeguarding Children Board Author: Amanda Clarke Date of publication: 2020  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1 KSCB Child I SCR Final Report 24th January 2020       Kent Safeguarding Children Board Serious Case Review   SCR Child I Carys           Published  24th January 2020   2 KSCB Child I SCR Final Report 24th January 2020  Introduction  1. The young person to whom this review relates will be known as Carys to protect and respect the child’s and family’s identity. The name has been chosen in consultation with Carys’ family.   2. This Serious Case Review (SCR) was commissioned by the Independent Chair of Kent Safeguarding Children Board (KSCB) in July 2018, in agreement with the recommendation of the KSCB Case Review Group that the circumstances surrounding the death of a child met the criteria for a serious case review. The case originally came to the attention of the KSCB Case Review Group in March 2017 following Carys’ tragic death.  It was initially felt that this case did not meet the criteria for a serious case review, however, this decision was reviewed following information obtained whilst undertaking analysis around other teenage suicides in Kent. As a result, it was agreed by the Independent Chair, that a SCR would be undertaken.  3. Carys died in 2017, age sixteen years. Circumstances leading to her death are outlined below in the circumstances and history section of the report.   The Serious Case Review Process  4. Legislative frameworks and guidance1 in place at the time of Carys’ death were considered when the KSCB made the decision to undertake a serious case review. It was known or suspected at the time that Carys had suffered abuse and her death was as a result of suspected suicide.   5. The methodology used for this review was based on the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). This is a formal process that allows practitioners to reflect on cases in an informed and supportive way. Documenting the full history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for local safeguarding children boards (LSCB) to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken of the case is not the focus of the reports which centre on identification of learning themes and improving practice.  6. The opportunity to conduct serious case reviews in this, and other ways, is as a result of the change in statutory guidance following The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011. Munro suggests that local safeguarding children boards should use any learning model which is consistent with the principles in the Working Together to Safeguard Children Guidance: Learning and Improving, HM Government 2015, which was the guidance in place at the time the review was commissioned.     7. However, because a review has been held, it does not mean that practice has been wrong, and it may be concluded that there is no need for change in either operational policy or practice. The role of the LSCB is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to  1 Working Together to Safeguard Children (Department for Education 2015, and Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006, which sets out the functions for LSCBs.  3 KSCB Child I SCR Final Report 24th January 2020  inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These may be included in the final review report or in an action plan as appropriate.   8. Following notification of the circumstances of the death of Carys, and agreement by the Independent Chair of the KSCB to undertake a SCR, a review panel (to be known as the Panel) was established.  The Panel was chaired by a lay member of the KSCB and included representation from relevant organisations within Health Services, Children’s Social Care, Education and the Police.  9. Amanda Clarke, an independent reviewer from Derbyshire, (the Reviewer), was commissioned to work with the Panel and to lead the review. Amanda Clarke has no professional connection to Kent, or the organisations involved in the case.  10. The Panel identified the review timeframe as the two years leading up to the death of Carys. The Panel had agreed this was an appropriate period to review services relating to Carys and her family, on the understanding that historical information would be considered and shared where relevant, and to provide context.   11. All relevant agencies reviewed their records and provided timelines of significant events and analysis of their involvement for the identified review timeframe. These were considered by the Panel and provided opportunity for Panel members to raise questions and clarify understanding of the circumstances of the case and of the separate services provided. The agency timelines were merged and used to produce an interagency timeline. This was carefully analysed by the Reviewer with the Panel and informed of the areas of interest that required further exploration and consideration. The process also allowed for the identification of the key practitioners to be invited to attend a learning event in order to understand the detail of the single and interagency frontline practice in this case.    12. The practitioners’ learning event was held in April 2019 and was attended by nine professionals. Most practitioners attending had had direct involvement with Carys. Those attending who had not worked directly with Carys were able to provide the position and perspective of the service delivered to the family.  13. The Reviewer facilitated the learning event2 assisted by the Chair of the Panel. Notes were recorded by the Kent Safeguarding Children Board team.  14. Prior to the practitioners’ learning event the Reviewer met with the mother of Carys. The views and thoughts of mother are included below and were shared, as relevant, with professionals at the learning event.  15. Due to the timing of the serious case review being two years after the death of Carys it must be acknowledged that the memories and opinions about the case of both family and professionals may have been influenced by subsequent events which have occurred. The Reviewer has taken this point into account when considering the findings of the review.    2 The event was organised in line with Welsh Government guidance (Child Practice Reviews: Organising and Facilitating Learning Events, December 2012) 4 KSCB Child I SCR Final Report 24th January 2020  16. Following the practitioners’ learning event and family meeting, the Reviewer collated and analysed the learning to date for discussion with the Panel. Practice issues and themes originally identified by the Panel were re-examined in the light of the findings of the review. In reviewing the findings, the Panel considered what could be done differently to further improve future practice. A draft report was provided to the Panel in June 2019, in advance of the Panel meeting in July 2019. Further enquiries were made after the draft report had been considered and the report was updated.   17. The report contains learning themes and recommendations for the Kent Safeguarding Children Multi-agency Partnership KSCMP), which has replaced the LSCB, to consider in developing an action plan to ensure learning from the case is embedded in future practice.    Circumstances and history resulting in the review  18. Carys was sixteen at the time of her death. During her early childhood she had lived with her mother, (to be known as Mother for the purposes of the overview report), and her sister, (to be known as Sister), who was two years younger than Carys. They had lived together elsewhere in the country some distance from Kent. For much of their childhood, Carys and Sister did have contact with their birth father, (to be known as Father), including after Mother and Father had separated. When Mother, Carys and Sister moved to Kent, Father remained living some distance away in another part of the country. The context of the family’s life prior to the move to Kent has been considered by the Panel.     19. When Carys and Sister were of primary school age, Mother married a man in Kent. (This man is to be known as Stepfather throughout the overview report). Mother and Stepfather had two children, (to be known as the Half Siblings). Carys and Sister were still in primary school at the time and all four children lived together in Kent in the care of Mother and Stepfather.  20. In early 2015, Stepfather worked in a pub in a neighbouring county. An allegation of sexual touching was made against him by a female colleague who was a young adult at the time. Stepfather denied the allegations and after a police investigation it was decided there was insufficient evidence to charge him with any offences. Whilst the investigation was ongoing information about the allegations was not shared by the investigating police force with Kent Police or Kent children’s services. Mother was aware of the allegation as she had to collect Stepfather from the police station after his arrest.   21. In early 2015, Carys was engaged in weekly mindfulness sessions at school which was a service available to a small number of students. Carys’ need for the sessions stemmed from anxiety relating to exams and performance.   22. Around the same time, Carys was referred to the rheumatology department at a local hospital due to pain in her knees and legs. She was not brought to an orthopaedic appointment which was offered.    23. At the start of spring 2015, Carys saw the GP for “emotional concerns” relating to a poem she had written called ‘The A to Z of Dying’.  A referral was made by the GP to the child and adolescent mental health service (CAMHS) as a result, with Mother completing the required consent form which was sent to her after the referral was received by CAMHS. Two 5 KSCB Child I SCR Final Report 24th January 2020  appointments were offered as the first was not convenient but CAMHS recording shows Carys was not brought to the appointment.  24. Around the same time and over the summer period through 2015, Carys was not brought to hospital rheumatology and orthopaedic appointments.  25. Early in 2016, Carys attended a GP appointment at the same practice as in 2015. She reported having low mood, feelings of being socially isolated and sleep difficulties. She was asked about and denied having suicidal thoughts, and also denied any sexual or physical abuse taking place. A PHQ9 questionnaire3 was completed with a score of fourteen. The notes made at the appointment state counselling was being arranged by Mother through school. Other counselling service details were provided by the GP.    26. Soon after, in early 2016, a counsellor for Carys was arranged via school. The reasons recorded for the request related to Carys feeling ‘angry, friendless and sad’. Carys engaged well with the counselling sessions.   27. Carys joined the school sixth form at the start of the autumn term in 2016. At this point a second set of weekly counselling sessions commenced for her in school.  28. Early in the new school term 2016, Carys attended her GP with Mother. She had changed GP practices in the summer of 2016. At the appointment, Mother raised a number of issues for Carys including friendship difficulties, worries about going out and meeting people. The notes showed the GP thought Carys seemed happy and content during the appointment. Carys was advised to continue with the counselling at school.  29. At the end of autumn 2016, Carys chose to conclude the counselling sessions at school. She had not attended all appointments. The counsellor noted that Carys seemed to have lost weight and this was discussed with her. The counsellor also discussed the weight observation with the school’s special educational needs coordinator (SENCO), resulting in the SENCO contacting Mother to talk about Carys’ weight. Mother described Carys as wanting to eat more healthily which is why she had lost weight.   30. Around the end of autumn 2016, Carys attended the GP for a routine complaint. The contraceptive pill was prescribed to treat a medical issue, not for use as contraception. Carys told the GP she was not sexually active. Carys’ mental health was not discussed.   31. At the end of 2016, Carys started to express a wish to leave school sixth form and to start work as an apprentice in her job role, which she had been doing part time around her school hours. Discussion took place between school staff and Mother, with Carys being encouraged by school to continue in sixth form. She was advised to think through options over the Christmas break, but Carys made the decision to leave school just before Christmas 2016.     3 The Patient Health Questionnaire PHQ-9 is a 9-question instrument given to patients in a primary care setting to screen for the presence and severity of depression. A score of 10-14 is considered as moderate depression severity with suggested intervention as make treatment plan, consider counselling, follow-up, and/or prescription drugs. 6 KSCB Child I SCR Final Report 24th January 2020  32. Early in 2017, Carys attended a GP appointment regarding her increasing anxiety which included having difficulty speaking to people particularly at work. She was signposted by the GP to local services.   33. On the same day she had attended to see the GP, later in the evening Carys and her Sister disclosed to Mother that Stepfather had sexually abused them both, at different times over a period of years. Stepfather had already left the address at the time of the disclosure as a result of an argument with Mother that same evening.   34. Mother immediately called the police to report the sexual abuse. A telephone discussion, referred to as a strategy discussion,4 took place during the night between a children’s social care out of hours senior practitioner and a police detective. It was agreed the threshold for a section 475 investigation was met and that a joint visit would take place in the morning. There was no previous concerning information regarding either Stepfather or Mother on record from the local checks undertaken in the night.  The next morning there was no follow up strategy meeting to include other multi-agency professionals.  35.  A joint police and social work visit took place the next day to the family home. Stepfather had been arrested by that time which had removed any immediate safeguarding risks. As part of the joint investigation, both girls and Mother were spoken to separately. Information provided from the family included that the sexual abuse by Stepfather started first with Carys. It was thought that this stopped when Carys told her Mother that she thought he had tried to photograph her whilst she was in the shower with the camera on his phone. The ongoing sexual abuse to Carys was not disclosed at the time Carys spoke to Mother about the alleged shower photograph. Stepfather had said she was mistaken about the photograph, causing Carys to doubt herself about what she thought had occurred.   36. It is believed the sexual abuse by Stepfather then started with Sister. Neither knew of the other’s abuse until just before the disclosure in 2017, and it was apparent that Carys felt guilty for being unable to protect her Sister from Stepfather.   37. The professionals involved in the initial joint visit discussed options with the family about making a referral to a local counselling service based in Kent for children and adult survivors of sexual abuse, in order for additional support to be offered.    38. The safety of the younger Half Siblings was considered, and enquiries made with them at their primary school. Mother requested that she should be able to inform the school of the Sister (at that point also the ex-school of Carys). This was agreed by the professionals involved but did not immediately happen.  39. Later, on the same day as the joint visit to the family, Carys attended an appointment to see the GP. Notes made by the GP state that Carys had been advised by Mother “to try to get some medication to help her with difficult circumstances”. Carys did not disclose to the GP about the abuse but mentioned some difficulties at home making her more anxious. Talking  4 The purpose of a strategy discussion or meeting is to determine whether there are grounds for a section 47 investigation (see below) 5 A section 47 enquiry means that children’s social care must carry out an investigation when they have reasonable cause to suspect that a child is suffering, or likely to suffer significant harm 7 KSCB Child I SCR Final Report 24th January 2020  therapies were explored and a note made to review in a week; the GP notes are unclear as to type of review should take place. No prescription for medication was given.  40. One week after the disclosure of abuse by the girls, children’s social care records show a decision that the outcome of the section 47 investigation was “no further action required” as the children were not judged to be at continuing risk of harm. The child and family assessment would be continued and completed by the social worker.   41. Two weeks after the disclosure had been made, a visit by the social worker to the family home was cancelled by Mother as she had another appointment. The visit was rearranged for the following week.  42. A few days after the cancelled appointment with the social worker, Mother informed the school where Sister was a student and where Carys had recently left, that the girls had alleged sexual abuse against Stepfather. The school had been unaware of the abuse and the joint investigation until this point.   43. The rearranged social work appointment was cancelled by Mother on the day of the appointment as she had just left another meeting at the police station and did not have time that day to fit in another appointment around other commitments. A new date was planned for the following week, which would be one month after the disclosures were first made.   44. The appointment between the social worker and Mother took place at the family home and all four children were seen. The visit was short due to the family having to go out. On the same day, Mother attended an appointment at school to discuss support for Sister; school records demonstrate counselling and early help support were options explored.   45. Around two days after the social worker’s visit to the family, Mother stated another appointment had been arranged at her request. Mother says she telephoned the social worker asking for help as she had found a note at home written by Carys indicating she (Carys) had self-harmed and was having thoughts about further self-harm and suicide. Mother said the appointment was cancelled on the day by the social worker. Mother said she was told all appointments had been required to be postponed due to an imminent Ofsted inspection of the local authority for which preparation was required. Another appointment was not formally agreed, but records show there was an intention to plan another convenient date. The social worker cannot be certain of the reason why the visit was cancelled and cannot recall being told by Mother that there was self-harm and a note.     46. One week after the cancelled appointment, Mother found a parcel at home which had been ordered by and delivered to Carys. Mother thought the parcel contained legal highs6 and related paraphernalia. Mother spoke to Carys via a text message immediately after finding the items. Later that day Carys died by taking her own life. In the note found at the scene where  6 New psychoactive substances (NPS) are often incorrectly called 'legal highs'. NPS, such as mephedrone (meow meow) and spice, used to be available to buy legally in shops and online. Since the Psychoactive Substances Act came into effect on May 26 2016 it has been illegal to supply any NPS in the UK for human consumption, www.nhs.uk/live well/ healthy body/the effects of drugs   8 KSCB Child I SCR Final Report 24th January 2020  she died, Carys apologised to her Mother and said she had ordered the items which had been found “to find a way to handle the pain”.   47. British Transport Police managed the investigation into the death of Carys including initial contact with the family.  48. In 2018 after a criminal trial, Stepfather was convicted of sexual offences against Carys and Sister. At time of writing he is currently serving a prison sentence.      Family Involvement  49. Involvement of significant family members in a review process is important to gain an understanding of the family’s experiences of the services offered to them. Specifically, in this case, Mother and Sister were asked to provide their views relating to services provided during the review timeframe to Carys and Sister, and the family as a whole.   50. Mother met with the Reviewer in March 2019, with a follow up meeting taking place in July 2019. Sister at the time of writing this report, felt unable to contribute, and this choice is respected. A summary of the views of Mother is given below. Other comments are included in the analysis section of the report where relevant. Views reflect the personal opinions and memory of individuals who have contributed.   51. The valuable insight into Carys’ and the family’s experiences, from Mother’s own perspective, was shared with the Panel at draft report stage. Account was taken of the views when finalising the report and formulating recommendations, and the Reviewer is grateful for the contribution from Mother.  52. A decision was made by the Panel not to ask for participation by Father due to his limited involvement with the family in the period leading to Carys’ death. The Panel also decided that Stepfather should not be offered the opportunity to contribute.    53. Mother described Carys as “funny, lively, artistic and quick witted”. She went on to describe how she thought from about age thirteen Carys became “withdrawn, quiet, with a low opinion of herself”.   54. She described a normal, busy family life in Kent prior to the disclosures being made, but that her own relationship with Stepfather had started to deteriorate before the girls spoke to her about the abuse.   55. Regarding specific feedback about services received before the disclosures were made, Mother was positive about the counselling service facilitated by the school. She said Carys had “liked the counsellor”.   56. Mother was very satisfied with the service received from the investigating police officer who became involved with the family after the sexual abuse had been disclosed. Mother said the officer had “built trust, had been supportive and had always been available, including throughout the criminal trial of Stepfather and after the death of Carys”.   9 KSCB Child I SCR Final Report 24th January 2020  57. Mother was positive about the “professionalism and understanding” shown by the British Transport Police who worked with the family in the immediate period after the death.  58. Mother felt that children’s social care “had a focus on risk of harm only and offered no other support even when support was requested”. Mother said, “apart from providing love to her daughters, she didn’t know what else to do to support them with what they were going through”. She said she felt “lost” and needed guidance about how to respond.  59. When Mother found the note from Carys about a week before she died, she recalls she contacted the police officer and the social worker who were both involved in the case. Mother said the police officer took details and gave advice. Mother said she asked the social worker for support about what to do and asked if she, (the social worker), would visit, which is when the appointment was made. She said she was very disappointed and angry when the arrangement to meet was cancelled, and particularly when, as she recalls, this was due to inspection preparation.        60. Mother said she mentioned the note to a GP she saw when attending for an unconnected medical issue with one of the other children. She said the GP, in her view, “was more concerned with patient confidentiality (of Carys) but did give general advice to contact children’s social care”. A check of records has found no evidence of the discussion during any appointments around the relevant time for the other children.  61. Mother said she received “good support” from the Half Siblings’ school after the abuse became known. She was grateful for the “supportive and thoughtful” response of the Sister’s school when she informed them of the sexual abuse allegations and after the death of Carys.   62. Mother was clear, in her opinion, that Carys was not using illegal or other substances, (including ‘legal highs’). She said the parcel she discovered just before Carys’ death was a “complete shock”.   ANALYSIS: Practice and Organisational Learning  63. Carys, Sister and family had received services from a number of agencies during the timeframe of the review. Information from all sources, including from the practitioners’ learning event and contributions from Mother, have highlighted areas of good practice, and also provided an opportunity for wider learning to emerge about the ways in which services work together. The following, in no order of priority, is an analysis of the issues identified:  Initial responses to disclosures of child sexual abuse     64. Both girls disclosed sexual abuse to their Mother at the same time. From initial information shared it was quickly apparent that the last episode of abuse had occurred sometime prior to the disclosures being made and therefore, immediate forensic evidence opportunities were not available. Mother acted appropriately regarding the protection and support of her children by reporting the allegations promptly to the police and by asking Stepfather to leave.   10 KSCB Child I SCR Final Report 24th January 2020  65. The disclosures occurred after normal office hours and out of hours services were required to become involved. A strategy discussion took place during the night which was within a few hours of the allegations being reported to police. The telephone discussion was between children’s social care and police to determine whether a Section 47 investigation was required and to plan next steps. This was in line with local guidance at the time. An appropriate decision was reached that criteria was met for a joint investigation, which would commence in the morning.  Due to the timing of the discussion, (in the early hours), other partners, which guidance in Working Together 20157 suggests should normally be represented at strategy discussions, for example, health services and education, were not involved.   66. At the time of the incident (in 2017), and with arrangements in place at that time, expected practice would have been for a follow up strategy discussion to have occurred in office hours in order that other agencies could contribute and all available information regarding the children and family could be considered. This would have ensured information sharing and the most effective multi-disciplinary response and subsequent action could be planned, including where enquiries may take place, the need for medical examinations and additional support for the family being properly explored. The procedures suggest subsequent strategy meetings should lead to “a final discussion involving all participants of the first strategy discussion to agree outcomes”. In the response to the disclosures from Carys and Sister, there was no further formal discussion either between the original participants or including other key partners.  Local guidance has been reviewed and amended, and follow up strategy meetings do occur.    67. Records show that an allocation discussion, to determine who would manage the case, took place within children’s social care the morning after the disclosures were reported. Clear actions were recorded, with a joint investigation visit to take place that day by the police (Police Protection Unit, now known as Vulnerable Investigations Team (VIT)) and children’s social care. Key information from health and school involvement with the girls was not known at this stage for reasons explained above.   68. The inclusion of an education representative at a follow up strategy meeting would have ensured that information could have been shared regarding Carys’ school counselling and other recent, relevant information about Carys and Sister. The girls’ school would have also then been made aware of the disclosures in a timely way and been able to arrange to offer support from the school and school nursing service. Health professionals were not able to provide any input meaning valuable health information could not be shared, in particular regarding Carys’ mental health.    69. The joint investigation which commenced at the home with both girls and family the day after the disclosures were made met expected requirements in terms of information gathered about the allegations being made and assessment of future risk of harm.   70. Mother was satisfied with the professionals’ initial sensitive approach.  It was mother’s opinion that the social worker’s primary focus was on risk. Within any section 47 investigation, there is a requirement for all involved, but particularly children’s social care, to consider risk of  7 68. Working Together 2015, states children’s social care, police and health professionals should as a minimum participate in strategy discussions. Other relevant professionals may include a child’s school or nursery and any other health services which the family are receiving. 11 KSCB Child I SCR Final Report 24th January 2020  ongoing and future harm. In this case the risk was around Stepfather; professionals needed to be sure that the relationship between Mother and Stepfather would not be resumed which would enable his possible contact with the children.   71. The social worker and police worked together to assess the risk and there is evidence the social worker discussed risk with a line manager. Children’s social care were satisfied that Mother was a protective factor and was acting appropriately to safeguard the children. Within one week of the disclosures, the social care record showed a decision of “no further action (NFA) taken; concerns were substantiated, but the children were not judged to be at continuing risk of harm”. The decision was that the child and family assessment8 which had commenced as standard practice, would continue and be concluded within agreed timescales.    72. A local counselling service was suggested to Mother on the first day that the joint investigation commenced, which was appropriate. Mother said at the time she didn’t know what support the girls needed or wanted and didn’t immediately act upon the suggestion. It is known that Mother encouraged Carys to attend the GP within 24 hours of the initial disclosure and an appointment took place. GP recording shows Carys spoke of “issues at home”. Advice about talking therapies was provided by the GP to Carys; (GP responses will be explored later).   73. With a decision being made quickly that there was no continuing risk of harm, and despite the ongoing child and family assessment, there is limited evidence to indicate additional holistic support was offered to Mother and the family. A positive professional relationship and rapport was developing between the investigating police officer and the family as this was the period when Stepfather was in custody and police enquiries were continuing.    74. Within the month following the disclosures, appointments were made, then shortened or postponed by both Mother and the social worker. As a result of appointments not taking place, limited additional information, current or historical, was gathered by children’s social care about the family to inform the assessment and other decisions being made regarding further support which might be required.   75. There is no evidence of enquiries by children’s social care with key professionals who had been involved with the family before the disclosures or regarding Carys, including when her mental health appeared to deteriorate in the last weeks prior to her death. Enquiries with other agencies can still be undertaken even when there are difficulties in seeing families themselves, as in this case. Such information gathering and sharing is an expectation during a child and family assessment but did not occur. For the assessment of Carys, the information and history within her health records would have been significant.    76. The primary school of the Half-Siblings was contacted by the social worker after the disclosures were made, but there was no contact by children’s social care with the school of Sister and Carys until after the death of Carys. After respecting the wishes of Mother who  8 2.1.4. The purpose of a child and family assessment is to gather sufficient information about the child and family to understand its needs and make decisions about:  •The nature and impact of the concerns or needs described in the referral and what intervention or support is necessary; •Whether the child meets the criteria for ongoing services as a ‘Child in Need’, Kent and Medway Safeguarding Children Procedures 12 KSCB Child I SCR Final Report 24th January 2020  wanted to talk to the school herself about the abuse, there should have been a timely follow up with senior school staff to check the disclosure information had been shared and to make enquiries to inform the ongoing assessment. This would have identified that support had been facilitated by school for Carys in the recent past for her mental wellbeing. The school would have also been best placed to provide general background information about both girls who had been known to many staff for a long period. It is important to remember that outside of the immediate family setting, schools are normally the service with the most consistent contact with children and therefore, often have useful and current information to share.   77. The information not shared due to education and health information not being considered at the out of hours strategy discussion, and there not being a follow up strategy meeting could have assisted in providing a better understanding of any additional support required. Mother’s request for urgent help to children’s social care after she had found the note from Carys a week before she died is not recorded as having occurred and the social worker does not recall the request. This is explored further in responses to mental health needs of Carys below.  78. Recommendation - The KSCMP should require an audit of strategy meetings, convened both in office hours and out of hours, and should include subsequent strategy meetings, to ensure participation from partners is sufficiently inclusive, follow up is occurring as necessary and effective information gathering and sharing is taking place.  79. Recommendation - Integrated Children’s Service should review the practice of completing agency checks within the assessment process and ensure future audits of the quality of assessments include audit of the timings of when agency checks were requested. Assurance should then be provided that child and family assessments are being completed efficiently informed by enquiries with key professionals and agencies, considering information both current and non-recent, and must include the voice of the child.   Use of child sexual abuse pathways and associated support   80. Since 2016, the local area has had a Sexual Assault Referral Centre, (SARC), to offer free support and practical help to anyone aged 13 or over who has experienced sexual violence and/or sexual abuse. The SARC offers professional help to those reporting sexual abuse and in particular can ensure any healthcare needs are met and medical examinations facilitated. Due to the nature of the service, a holistic range of services is available or can be linked in, including for emotional support.  81. There is an expectation that the SARC will be used for all sexual abuse cases reported to the police and associated multi-disciplinary pathways exist in the area, including for child sexual abuse. The Reviewer found, however, that use of the SARC was inconsistent. There may still be an assumption by some professionals that the SARC is predominantly for medical examinations and evidence gathering from victims reporting recent sexual abuse, which is incorrect. The Kent and Medway Pathway for Child Sexual Abuse Medicals (under 18 years), May 2017 states “it is important to note that although the purpose of an examination is to look for signs which might support or confirm sexual abuse, it is also a holistic examination which serves to ensure the health and wellbeing of the child, to reassure and help begin the therapeutic process”.   13 KSCB Child I SCR Final Report 24th January 2020   82. The sexual abuse reported by Carys and Sister, who were both over 13 years at the time, was non recent and as such, there were no obvious forensic evidence opportunities. The use of the SARC, although available at the time, was not considered and neither girl was medically examined.   83. The Reviewer was told any child who is a victim of possible child sexual abuse should have the opportunity of a child sexual abuse examination. Non recent allegations also merit a child sexual abuse examination so the child or young person can be reassured if there are no physical findings. Other relevant sexual health screening can take place at the same time.   Both Carys and Sister should have been offered an examination, and if health services had been represented as part of the strategy discussion this would have been recommended. Clients and parents find the examination beneficial physically and emotionally as their voice has been heard by a medical professional.  84. The Independent Sexual Violence Advisor (ISVA) service should always be offered as part of the outcome of the examination. The local area does have ISVAs for children and adults. ISVAs are specially trained to look after the needs of victims with care and understanding. They work closely with partners involved in sexual abuse cases.   85. There is no indication that an ISVA, a service available at the time, was considered as a resource to offer to the family, and therefore, Carys, Sister and the wider family did not have the opportunity to receive specialist support. The expectation that an ISVA acts as a single point of contact for victims and families may have alleviated pressure on other professionals had a trusting relationship been developed between an ISVA and the family. An ISVA, if allocated, could have managed queries and requests from the family which were being directed at involved professionals with other core responsibilities. An ISVA may have also established a rapport with Carys and Sister which may have enabled the identification of significant concerns as they developed, and for an appropriate response to be provided.     86. Due to the services of the SARC not being utilised, other support provision readily available within the SARC, was not offered to the family. This would have included support for the mental wellbeing of the girls, and Mother, who were all traumatised by the abuse and what this meant for them as a family and for their future. Signposting had taken place during the initial joint investigation to a local counselling service, and this was offered again by the police as the enquiries progressed, but Mother declined the service as she was unsure what the family needed in terms of help. If similar support had been available at the same time and in the same setting, as would have been within a SARC if the consultation had taken place there, the family may have been more likely to access the specialist support being offered.      87. A review of the services offered to Carys, Sister and their family after the disclosures of sexual abuse has provided an opportunity to examine what support provisions were and are available locally for victims of sexual abuse and how the available services link and work together. In addition, the Review has examined the awareness of professionals of the existing support and pathways and how these can be used for better outcomes for those affected.    88. The Ending Violence against Women and Girls Strategy 2016- 2020, HM Government March 2016 highlighted, “the human cost of violence, (including sexual violence), against women and girls is high, with experiences of abuse having serious psychological, emotional and physical 14 KSCB Child I SCR Final Report 24th January 2020  consequences”. It is tragically clear what the human cost of being a victim of sexual abuse was for Carys, and for her family.  89. Provision of services was a key priority within the government strategy, with an expectation that local partnerships would respond robustly to meet local needs. In times of austerity, it is vital that existing services for victims of child sexual abuse are being used effectively and to their full potential. Services, such as the SARC, do exist in Kent and it is important that all professionals responding to disclosures of sexual abuse by children and adults are fully aware of the local offer.  90. Recommendation - The KSCMP and relevant partners should ensure rigorous promotion takes place of the role of the SARC, including clarification of expectations as to when the centre must be used and raising awareness of associated pathways, to ensure victims of sexual abuse, including non-recent abuse, are being offered holistic support.  91. Recommendation - The KSCMP and relevant partners should explore opportunities to raise awareness of the role of Independent Sexual Violence Advisors, their availability and to ensure the role of ISVAs is included in the child sexual abuse pathway.   Responses to the mental health needs of Carys   92. There is evidence from information in the review timeframe that Carys had mental health needs prior to the sexual abuse being formally disclosed, and during the course of the investigation. Both she, and Mother on her behalf, requested professional support for mental health related issues from school and the GP service, but neither service received a specific disclosure of sexual abuse. Once the sexual abuse disclosures had been made, help was requested again from the GP service, but abuse was not mentioned explicitly. Mother also stated that she requested support from the police and children’s social care who were fully aware of the disclosures from both girls, but due to inconsistent record keeping this cannot be formally confirmed. Recording is discussed later in the report.  93. There is limited evidence that professionals trying to support Carys with her mental wellbeing spoke to other professionals, (either within their own organisation or externally), in an attempt to coordinate an effective response.    94. Carys had received counselling which had been facilitated by the school in response to anxiety, exam related stress and general wellbeing. Mother said Carys spoke positively about the school counsellor. There is no information to suggest that Carys disclosed self-harm or suicidal thoughts to the counsellor, and there was no requirement for formal self-harm and suicide pathways to be used.   95. Carys had left school six weeks before the sexual abuse disclosures were made, but Sister was still attending the same school. The school was made aware of the sexual abuse by Mother three weeks after the disclosures were made, the delay and circumstances have been explored earlier.  96. As a result of school not being contacted by professionals aware of the disclosures of abuse in a timely way, no support plan was put in place for Sister, and the school were unaware of the 15 KSCB Child I SCR Final Report 24th January 2020  need to offer any wider support to the family. Once informed, the school did discuss options for Sister with Mother and offered timetable amendments and other practical options.   97. With regard to the counselling facilitated through school for Carys before the disclosures were made, both Carys and Mother discussed the counselling arrangements with GPs who saw Carys throughout the review timeframe. There was, however, no enquiry with the school about the type of support being offered and whether this could be enhanced through the GP service. The Reviewer was told that it was unlikely for liaison to take place between GPs and schools under such circumstances.  GP responses to Carys are examined below.    98. Within the review timeframe, Carys attended five GP appointments for mental health related issues over a two year period. There was a change of GP provision during that period, with Carys registering with a different GP practice in the summer of 2016. Therefore, the first two appointments of the five took place in Practice 1, with the other three appointments occurring in Practice 2. Both practices were in the same geographical area of Kent.  99. The first attendance in Spring 2015 was when Carys had written a poem titled ‘the A to Z of dying’. Emotional and behavioural difficulties were discussed and the referral to CAMHS made by the GP was considered as appropriate. Checks have been made and there is no record that Carys was brought to the CAMHS appointment. There was no documented follow up from the GP with Carys or Mother as to why the CAMHS service was not utilised. This will be discussed later.  100. Nine months later, Carys attended the same GP practice seeing a different GP for low mood, sleep difficulties and feeling socially isolated. The notes show an enquiry was made by the GP relating to abuse and suicidal thoughts and no disclosures were made. It is positive that the school counselling offer was discussed. There is no recorded evidence that the concerns in the previous appointment were revisited or that the missed appointment with CAMHS was queried which would have been an opportunity to explore links between how Carys was feeling at the time compared to when seeking help before.   101. The GP notes state a review would take place in two weeks with a CAMHS referral to be considered then, but the status of the review and how this would occur was not clear in the records, and no review occurred.    102. After a further nine months, (which was after the move between GP practices), Carys attended an appointment at Practice 2 where anxiety about school and not wanting to go out was discussed. Mother also queried autism spectrum disorder for Carys, but there was limited supporting evidence. The school counselling was discussed and encouraged. Again, there is no evidence in notes that the previous two GP appointments, albeit in a different practice, but for related mental health issues were explored.   103. Carys attended a GP appointment at Practice 2 two months later for an unconnected medical complaint. She saw a different GP, but there was no reference to the last recent attendance or a record that a check on how she was feeling mentally was made.   104. In early 2017, Carys attended Practice 2 for worsening anxiety. The appointment was with a GP not seen before, and there was no recorded reference to previous attendances. It is now known that later the same day, Carys and Sister made the disclosures of sexual abuse to 16 KSCB Child I SCR Final Report 24th January 2020  Mother. The next day, Carys returned to Practice 2 and saw the same GP as the previous day. GP notes state Mother had suggested Carys request some medication to help with what was described as “issues at home”, but the sexual abuse was not mentioned specifically. There is no evidence that the subsequent appointment, only a day after the last, was thought worthy of additional scrutiny by the GP who saw Carys. Advice and signposting to support was provided and a note was made to review in one week. The review did not take place. Carys was not seen by a GP again before she died.   105. One week after the last appointment, Practice 2 received a request from the police to access the medical records of Carys with her consent as part of the sexual abuse investigation. This is a routine request made by the police to GPs. A note was entered on the records of Carys, but no further action is recorded as taken by Practice 2 to follow up with her as a patient in view of her age, history and recent attendances.    106. The summary of GP attendances above indicates a regular need for GP support relating to Carys’ mental wellbeing. Each appointment appears to have been managed in isolation, with no evidence of consideration of or reference to even the last appointment and advice or treatment provided.   107. Some GP follow up processes at the time required improvement. The referral to CAMHS which was made in 2015 by a GP in Practice 1 was not followed up, despite the Practice being informed that the referral, made so promptly in response to an identified mental health concern, had not been taken up by the patient and family. Reviews with Carys were highlighted as needed by both Practices on two separate occasions but did not happen. It is unclear for that time period what mechanism was in place for GP follow up to occur when it was documented as required, and who was responsible for ensuring this happened.   108. It is significant, that even when formal notification of sexual abuse of Carys was received by Practice 2 from the police, there was no process to ensure a patient’s records would be checked and follow up offered if considered relevant.   109. Overall the ongoing mental health needs which Carys and her family recognised as requiring clinical support, were not collectively assessed by professionals working within either GP practice. As such, no pattern of continuing and/or worsening mental health issues was identified for Carys. Furthermore, there was no consideration of collaboration with other professionals from the health community or other partners, to explore different approaches to help Carys with, what is now known to be escalating mental health concerns.       110. Recommendation - GP Practices 1 and 2 in the case of Carys, must provide evidence that a robust review and follow up process is in place and being used for children and young people attending as patients with mental health needs.  111. Recommendation - The CCGs and other relevant health partners must issue a reminder to raise awareness to all GPs of the importance of ensuring GPs are examining the circumstances of previous recent appointments in order that any emerging concerns and patterns of behaviour may be identified.   112. The police became involved with Carys, Sister and family once the disclosures had been made. It is good practice that during the initial joint investigation, the police and children’s social care 17 KSCB Child I SCR Final Report 24th January 2020  working together offered to organise support from a local specialist counselling organisation. Other opportunities for support which might have been available had the SARC facility been used were discussed above.   113. The lead officer in the case became a trusted professional for the family, especially Mother, who spoke highly about the officer’s work on the case regarding Stepfather. In addition, the officer was seen as an emotional support for Mother, including when the letter was found in which Carys wrote about self-harm and suicidal thoughts. After the death of Carys, such was the trust which Mother felt with the officer, she requested the same officer remain involved in the enquiries being made on behalf of the coroner.    114. During investigations into serious crimes such as sexual offences, it is vital that trusting professional relationships are developed between victims, survivors and their families with the officers allocated to lead enquiries. Families have to open their lives to sometimes intrusive, but necessary scrutiny about very sensitive issues, and as a result, can often feel dependent on the officers who are seen as working on their behalf.   115. Mother sought the support of the police officer on discovering her daughter’s mental health was declining when a note was found from Carys detailing self-harm and suicidal thoughts. The officer gave general advice and recalls she was told by Mother, that she (Mother) had requested a meeting with the allocated social worker to discuss the note’s content and seek support. Carys herself had told Mother she would not speak to any professionals about what she had written, therefore, any other face to face support which the officer might have offered to Carys could not be provided.   116. As the mental health concerns for Carys were presented later, and in addition to the main disclosures of sexual abuse, the pathway for responding formally to the information about self-harm and suicidal behaviour was not considered by any of the professionals already involved.  There was no consideration for signposting to services which might have provided a more urgent response, such as via 999 or attendance at the accident and emergency unit.     117. Specialist police officers, like many professionals working in safeguarding, are not clinicians, counsellors or therapists. They do, however, often develop strong bonds with children and families, resulting in them regularly being the first point of contact for all requests and queries about a family’s circumstances. Multiple and unconnected requests can often be made simultaneously to officers by family members, and officers involved, as in this case, want to respond to support victims and their families.   118. Senior police managers should be aware of the additional demands placed on lead investigators by some families who feel they have nowhere else to turn. Officers themselves need to be aware of roles and boundaries and be aware of what they are professionally qualified to manage and when to refer on for specialist support and to use agreed guidance/ pathways. The involvement of Independent Sexual Violence Advisers (ISVAs) in sexual abuse cases to support families was explored earlier and must always be considered as beneficial in sexual abuse investigations.    119. In this case specifically, which has been extended with an unsuccessful appeal against conviction by Stepfather, an exit strategy will be required for the officer and family to ensure all are appropriately supported when contact ends.   18 KSCB Child I SCR Final Report 24th January 2020   120. Recommendation - Kent Police must provide assurance to KSCMP that exit strategies for lead investigators and family liaison officers are considered and developed in the initial planning stages of all complex enquiries, with officers encouraged to ensure relevant signposting to other appropriate support providers occurs and planned exits take place when investigations are complete.  121. As with the police involvement in the case, the children’s social care involvement commenced when the disclosures of sexual abuse were reported. Appropriate support was offered during the initial joint visit with signposting to specialist services. Mother and the family at the time were understandably distressed and unsure of what support they might need.  Mother remains firm in the view that she felt children’s social care were exiting the situation from an early point due to the risk to the family being removed, in that Stepfather was no longer having contact with any of them.    122. The need for a plan of support for Carys in terms of her mental health was not identified due to the service history within education and GP records not being collated and analysed to inform the child and family assessment. This meant there was no real sense generally of the mental health concerns which were known for Carys meaning identification of a pattern of mental health deterioration was not possible.    123. It is difficult to analyse the children’s social care response to the letter written by Carys detailing more significant mental health concerns which Mother says she found a week to ten days before the death. This is due to differing recollections of the circumstances and limited case recording. Recording is discussed later in the report.  124. Mother’s recollection is that she spoke to the allocated social worker about the note and a meeting was arranged but was subsequently cancelled due to inspection preparation.  This was one week before Carys died. The social worker’s recall of this part of the case is different and there is no record of why the meeting was arranged or cancelled. It has been confirmed an Ofsted inspection did take place around the time of Carys’ death.   125. Whichever recollection or circumstance is accurate, it is confirmed that the appointment between Mother and the social worker was cancelled and not rearranged. Cancellation of appointments is discussed below.    126. The response to Carys and her evolving mental health needs was affected by the limited partner engagement at the out of hours strategy discussion, the absence of any follow up strategy discussion with other partners and the subsequent lack of information gathered about Carys and her family to inform the child and family assessment.   127. By not being aware of the recent history of Carys’ mental health needs, there was no opportunity for an effective plan to be developed to offer appropriate support to Carys. Furthermore, circumstances for Carys after the disclosures were made, were rapidly changing, with her needs escalating to crisis point. There is limited evidence that the overall impact of the abuse on the mental health of Carys, or her Sister, was considered or revisited. Assessment of the girls’ mental wellbeing, and focus on the needs of the children generally, after the initial management of the disclosure did not seem to occur.    19 KSCB Child I SCR Final Report 24th January 2020  128. Individual agency responses to the mental health needs of Carys and specific practice areas have been explored above. Whilst there is an assumption that all professionals will understand and empathise with those affected by child sexual abuse, and may have received some training in children’s mental health, it is vital that with the demands of service delivery they do not lose sight of existing research which links child sexual abuse with low self-esteem and mental health conditions9. Carys exhibited characteristics such as anxiety, self-harming and thoughts of suicide during the timeframe of the review and especially in the later months before her death.  129. It is encouraging in the local area that several multi-disciplinary training and awareness opportunities are available through the Kent Safeguarding Children Board including Youth mental health first aid courses and Youth suicide awareness and prevention workshops. Guidance is available online at Self harming and suicidal behaviour, chapter 2.2.47, Kent and Medway Safeguarding Children Procedures.   130. Kent Safeguarding Children Board has commissioned a thematic review of teenage suicides and an associated learning programme has been developed with Kent County Council Public Health.  131. Recommendation - KSCMP should explore ways to widely promote existing pathways and opportunities to respond to mental health issues in children and young people, including the policy to manage self-harming and suicidal behaviour.    Education settings being identified as key safeguarding partners  132. Before Carys left her sixth form setting, a few months before she died, the school had played a key role in responding to her mental health needs. For Sister, the school also responded well, as highlighted by Mother after she had brought the sexual abuse disclosures to the attention of school staff and through the support provided to Sister and Mother when the sad death of Carys had occurred. The school involvement in the case has been referenced throughout the report. It is accepted that education settings for any child in attendance are the service with most regular contact with children, outside of the family unit.   133. Keeping children safe in education, Department for Education, September 2018 is statutory guidance for schools and colleges. It is clearly stated within the document that “schools, colleges and their staff are an important part of the wider safeguarding system for children”. However, schools can only contribute to safeguarding processes when they are made aware of safeguarding issues and invited to share relevant information. Senior representatives from Carys and Sister’s school expressed disappointed at not being involved in the safeguarding response to the family.     9 The Independent Inquiry into Child Sexual Abuse (IICSA) Interim Report, April 2018, found participants in the Inquiry who were survivors of abuse reported the most common issues were depression, lack of trust in authority, thoughts of suicide, anxiety, self-harming and attempted suicide. Participants in the same IICSA report also shared “it is important that all professionals realise that supportive and positive responses from families, friends, caregivers and professionals have been found to help recovery”. 20 KSCB Child I SCR Final Report 24th January 2020  134. Education settings must be enabled to contribute throughout a whole safeguarding process. It should not be the responsibility of families, particularly in times of crisis such as when disclosures of abuse have been made, to remind professionals that it may be useful to involve a school in order that history and context of support which may have been previously received can be considered. Furthermore, those leading safeguarding processes must professionally challenge unrealistic requests from families that agencies, including schools, will not be informed of evolving safeguarding issues.   135. The Reviewer was told that an Education Safeguarding Service is available through The Education People which is owned by Kent County Council. All schools and Early Years Settings in the county are able to contact the service to seek support advice and guidance, on any safeguarding issue, including making referrals, escalation of concerns and multiagency working.    136. It is clear that education settings in Kent are recognised as having a significant role to play in keeping children safe. However, involving every individual school and college in an area in local safeguarding children board and other strategic processes is not possible. Having representation from different education levels may assist, but there is still a challenge in how pertinent information can be cascaded through to each setting and how requests and issues can be fed back. In Kent there is an Education Representative Forum of the KSCMP, which is made up of key representatives from across the sector.    Sharing of adult safeguarding information and concerns    137. Towards the start of the review timeframe in early 2015, an allegation was made against Stepfather by a young adult female. The allegations were of a sexual nature said to have occurred at the workplace where both parties were employed, which was located in a neighbouring police force area to where Stepfather, Carys and the family lived. Stepfather’s case was managed by officers from the neighbouring police force to whom he denied the allegations. Mother said she was made aware of the arrest by Stepfather on his release. At that time the disclosures of Carys and Sister had not yet been made to Mother or any professionals.  138. Due to insufficient evidence, Stepfather was not charged with any offences relating to the alleged workplace incident. No information about the allegations was shared with the home local authority where Carys and family lived and therefore, no assessment of risk to Carys and siblings was undertaken.   139. The position regarding information sharing, particularly about unsubstantiated concerns, was explored by the Panel and by practitioners at the learning event. There was no formal requirement at the time for a sexual abuse allegation made by an adult against another adult to be shared with another local authority or for enquiries to be made about the alleged perpetrator’s own family under those circumstances.   140. The allegation of sexual touching against Stepfather was made by a female in her late teens. If the information about the concern had been shared, the Reviewer was told that, on being 21 KSCB Child I SCR Final Report 24th January 2020  received at the ‘front door’ of the home local authority at the point the investigation was ongoing, it is unlikely that a visit to the family would have taken place.   141. The Reviewer was told the detail of the referral would have been recorded and agency checks would have been completed about the family. Such checks at that time would probably have not led to further face to face assessment with the family as no similar or related concerns were known about them.   142. There was also no record of information or intelligence being shared between the two police forces involved. The police area responsible for investigating the alleged incidents by Stepfather on the work colleague did not share intelligence / information with the police area where Stepfather and the family lived, which was a separate, but neighbouring police force area. The police officer who investigated the sexual abuse of Carys and Sister said she was unaware of the other allegation made against Stepfather during her initial involvement with the family.   143. It is accepted that the sharing of the information between police forces of Stepfather’s alleged behaviour and subsequent arrest would not have led to any earlier police contact with Carys or Sister. However, such information about Stepfather would have been useful to the officer in the case investigating the girls’ allegations, including in the initial stage of the enquiries.   144. Best practice is for police intelligence about suspects, whether charged or not, and especially when relating to sexual offences, to be submitted and shared across borders when necessary. This is particularly relevant when suspects live and work in different police areas as local police intelligence recording systems may only relate to one police area. It is important that all police areas have the capability to research when required known suspects of alleged sexual offences living within in a specific locality but the submission of intelligence on uncharged / unconvicted suspects will depend on capacity. Other factors such as the severity of alleged circumstances may also have a bearing on what is considered necessary intelligence to be shared.  145. In Kent now robust arrangements exist regarding the triage and management of adult safeguarding concerns. A central referral unit is co located within Adult Social Care with arrangements in place for continual multi agency liaison and investigation, including the consideration of wider safeguarding concerns and risks. Assurance was provided that identified risks to others would be actioned with information and intelligence shared where relevant.  146. The current arrangements for adult safeguarding of the neighbouring police area where responsibility was held for the investigation of the workplace allegation were described as similar to those of Kent Police.   Record keeping by professionals  147. All professionals working with children and families should be aware of the necessity for accurate records to be maintained. Documenting contacts with children and families is essential to ensure other professionals becoming involved are able to obtain a clear 22 KSCB Child I SCR Final Report 24th January 2020  understanding of the child’s journey from records, including assessments undertaken of any health and social care needs, risks identified, and services provided.   148. To ensure effective partnership working, contacts between multi-disciplinary professionals should also be recorded on each agency’s own recording system and in accordance with individual agency standards and expectations.    149. Records were examined of all agencies involved with Carys and family for the period agreed as the timeframe of the review. The review of records in this case has demonstrated that not all professionals were recording as expected and record keeping was inconsistent. This has presented challenges to the Reviewer and Panel in trying to determine an accurate picture of services provided.   150. There were recording gaps within children’s social care records relating to significant contacts between Mother and the service. Kent County Council has clear policy and guidelines for children’s services recording10.   151. There was inconsistent recording in GP notes of whether Carys, as an older child, was accompanied by an adult in GP appointments. In some appointments this was clearly recorded, but in others not. Other child and adult reviews have identified this omission in GP recording of patients being accompanied as a learning theme.   152. Linked to the expected practice of accurate recording is the expectation that different professionals becoming involved in the case will familiarise themselves with the previous service history recorded as provided to the child. It was discussed earlier that some GP contacts with Carys were managed in isolation. If GPs had taken the opportunity to read and properly reflect upon the previous GP interaction with Carys when she was at the next appointment, a more informed assessment of her health and social needs may have been made.   153. Professional familiarisation of at least the recent chronology of involvement, if on record, is especially useful and necessary when a child is required to see different professionals from the same service, such as GPs. Furthermore, families may often request additional urgent support or have a new query to which other professionals have to provide a response. Both examples occurred in the case of Carys, and the records had either not been fully completed, or were not read sufficiently to inform the next intervention.  154. Recommendation - The KSCMP should receive assurance and a commitment from all partner agencies that their record keeping meets single agency standards and requirements in order that an accurate picture of relevant contacts and services provided to families can be easily accessible to inform decisions and actions about ongoing involvement.   10 All relevant contacts with children, their families, colleagues, professionals or other significant people must be recorded in the same way, i.e. who was present or seen, the relevant discussions, actions or decisions taken and by whom, and the reasons for decisions. This includes conversations, phone calls, visits, letters, emails, assessments and reports. The options that have been considered and the child and the family’s preferred choices and the reasons why an option has been chosen if agreement could not be reached, Kent Children's Services Procedure Manual, 3.1 Recording Policy and Guidelines, para 5.3. 23 KSCB Child I SCR Final Report 24th January 2020     Follow up for children not brought to health appointments     155. During the review timeframe, Carys was referred once for specialist assessment by CAMHS. This was in Spring 2015 after Carys attended the GP for writing a poem about dying. It is now known that Carys had been sexually abused by Stepfather by this point.  156. After the first appointment offered was changed at the family’s request, Carys was not brought to the rearranged appointment for reasons unknown. Mother said she recalls taking Carys to the appointment, but there is no record of this. The GP, as the referrer, was informed by CAMHS of the non-attendance. There is no evidence that the referral was followed up by the GP service after being notified that Carys was not brought to the CAMHS appointment. When Carys attended the GP for other mental health related concerns nine months later, the opportunity to explore the earlier non-attendance to CAMHS was not taken. The management of concerns in isolation, and lack of follow up has been explored above.    157. At the time, all children within the family were involved with universal services only, therefore, there was no known evidence to suspect that the reason for Carys not being brought to a health appointment was due to neglect, as is the position in some ‘was not brought’ scenarios. The reason for the non-attendance of Carys to CAMHS in 2016 remains unknown, but the only follow up which could have been reasonably expected at that time was by either CAMHS or Carys’ GP, as no other additional services were involved with the family.         158. It is positive that there is now a procedure for Managing missed appointments/non-attendance/was not brought for adult and children’s health appointments, NELFT, September 2017. The procedure outlines the expected action to be taken when an individual is not brought to an appointment, with additional considerations for children and young people and when the missed appointment is for mental health related concerns.   159. Another positive to note locally is the mind shift demonstrated by Panel members and practitioners attending the learning event that children should be assessed as ‘was not brought’ instead of ‘did not attend’ when they miss health appointments. Children are reliant upon another person, usually a parent/carer, to bring them to an appointment. Missing, or not being brought to appointments, is seen as a recurring feature in many serious case reviews, both locally and nationally, and it is encouraging to see local professional opinion and practice about this issue is changing.  160. Throughout the timeframe of the review, which was before the current Managing missed appointments, procedure was introduced, Carys was not brought to some other health appointments for non-mental health issues. As with the CAMHS appointment, no or limited follow up occurred as a result.  161. It is important that now a procedure for follow up is in place, that the process is followed and different services within the health community work together to ensure children are able to receive the specialist treatment that health professionals have assessed as being required.    24 KSCB Child I SCR Final Report 24th January 2020  162. Recommendation - The KSCMP should request assurance from Health partners that missed health appointments for children are subject to robust and consistent follow up, as set out in the local Managing Missed Appointments Policy, to ensure children are receiving the treatment they require and any emerging safeguarding concerns relating to the child’s non-attendance may be identified and appropriately actioned.      Impact of inspections on children, families and staff   163. An Ofsted inspection of Kent County Council’s children’s services11 took place throughout the three week period in 2017, which included when Carys died. Mother told the Reviewer an appointment she had with the social worker to discuss Carys’ mental health was cancelled due to preparation for the imminent inspection. Mother’s recall of the cancellation is different to that of the social worker.   164. Inspection processes, including preparation for inspection, are resource intensive and create pressures across all levels of staff. It is acknowledged that many organisations involved in safeguarding children will be subject to rigorous inspection and audit regimes.  165. However, the impact of cancelling or delaying case work, for any reason, including for inspections, can have serious consequences on families and should be avoided.   Suicide prevention  166. An inquest into the death of Carys recorded a verdict of suicide. Statistics regarding numbers of children and young people known to have taken their own lives can be difficult to collate. However, what is known is that the five-year annual average suicide rates among 15 to 19 year olds in England and Wales were previously in decline, but have started to rise in recent years12.  167. Suicide ideation and self-harm in young people is becoming an increasingly common problem.  Towards the end of her life, information did surface regarding Carys having suicidal thoughts and that she was self-harming. Research does suggest that “young people who self-harm are at a higher risk of suicide than the general population”, Hawton and James (2005).  168. The Kent Safeguarding Children Board has taken the positive step of commissioning a thematic review into deaths of young people believed by suicide in the local area. Information and findings from this serious case review will feed into the overview report from that thematic review.    169. It is important that local suicide prevention strategies and action plans engage a wide network of stakeholders in reducing suicide. The Suicide prevention strategy (2015-2020) for Kent and Medway combines actions by local authorities and public health, mental health and health  11 Inspection of services for children in need of help and protection, children looked after and care leavers, March 2017. 12 There were 115 suicides where death was recorded as by intentional self-harm, and a further 28 deaths by undetermined intent of 15 to 19 year olds in 2016, How safe are our children? The most comprehensive overview of child protection in the UK 2018, Bentley, H. et al (2018) London: NSPCC 25 KSCB Child I SCR Final Report 24th January 2020  care services, primary care, police, community and voluntary agencies, schools, colleges and others.   170. The National Institute for Health and Care Excellence (NICE) and Public Health England issued Preventing suicide in community and custodial settings13 in September 2018 which is intended for a number of organisations and services including local safeguarding boards and health and wellbeing boards. Any local response relating to suicide prevention should take account of this guidance.  171. Recommendation - The KSCMP should collaborate with Public Health and other local strategic bodies to ensure a proactive and effective approach to suicide prevention within Kent is continuing and takes account of national guidance.   Concerns relating to the use of new psychoactive substances (NPS)  172. Whilst the review process was well underway, information not previously shared, came to the attention of the Reviewer that Carys had ordered and taken delivery of a parcel containing new psychoactive substances (NPS) which are commonly referred to as ‘legal highs’. Mother said she asked Carys about this and despite initially denying any knowledge of the parcel Carys did say in the note found after her death that she had ordered the NPS.   173. The Reviewer and Panel have endeavoured to explore the link between Carys and the misuse of dangerous substances. There is no evidence prior to the parcel being found on the day of her death which suggests Carys was in any way involved or using any substances including NPS. There is no indication that services or professionals working with Carys prior to her death had knowledge or suspicion that Carys was even considering using NPS or any other substance. Mother of Carys said she was not aware that Carys had ever considered using dangerous substances until she found the parcel. No other information has been submitted to the review to suggest dangerous substances were a contributory factor in Carys’ death.   174. The words in the note left by Carys at the time of her death reflect the desperation that Carys felt at that time. She admitted and apologised that the parcel and contents belonged to her but “needed a way to handle the pain”. It has been established with as much certainty as is possible, that Carys did not have the opportunity to use the NPS she had ordered. However, her actions to seek out unorthodox ways to help deal with the challenges she faced could suggest that she was not receiving the appropriate, coordinated support which was needed.      Conclusion  175. The circumstances in any serious case review are tragic. The findings of the review into the sad death of Carys have identified areas of learning for all agencies involved which if acted upon will improve practice and provide better support to young people and their families.    13 A guideline which covers ways to reduce suicide and help people bereaved or affected by suicides- nice.org.uk/guidance/ng105, 10 September 2018 26 KSCB Child I SCR Final Report 24th January 2020  176. The absence of a strategy meeting with all relevant agencies represented to share information about previous and ongoing involvement with Carys and her family, led to concerns being managed in isolation based on a limited assessment of a child’s and family’s needs. Limited coordination of support meant the pre-existing and escalating mental health needs of a child sexual abuse survivor were not identified.   177. However, it is recognised that some professionals worked hard to support Carys and Sister after their brave disclosure of sexual abuse and continued to offer support to the family after the death.   178. Reviewing practice always provides an opportunity to reflect on ways in which services can be developed and further enhanced. As a result of the significant incidents which occurred in the lives of Carys, Sister and their family, the following recommendations for Kent Safeguarding Children Multi-agency Partnership and its partner agencies have been made based on the learning from the case.     Recommendations  The following recommendations for Kent Safeguarding Children Board have been made based on the learning from the case.  1. The KSCMP should require an audit of strategy meetings, convened both in office hours and out of hours, and should include subsequent strategy meetings, to ensure participation from partners is sufficiently inclusive, follow up is occurring as necessary and effective information gathering and sharing is taking place.  2. Integrated Children’s Service should review the practice of completing agency checks within the assessment process and ensure future audits of the quality of assessments include audit of the timings of when agency checks were requested. Assurance should then be provided that child and family assessments are being completed efficiently informed by enquiries with key professionals and agencies, considering information both current and non-recent, and must include the voice of the child.  3. The KSCMP and relevant partners should ensure rigorous promotion takes place of the role of the SARC, including clarification of expectations as to when the centre must be used and raising awareness of associated pathways, to ensure victims of sexual abuse, including non- recent abuse, are being offered holistic support.  4. The KSCMP and relevant partners should explore opportunities to raise awareness of the role of Independent Sexual Violence Advisors, their availability and to ensure the role of ISVAs is included in the child sexual abuse pathway.  5. GP Practices 1 and 2 in the case of Child I (Carys) must provide evidence that a robust review and follow up process is in place and being used for children and young people attending as patients with mental health needs.  6. The CCGs and other relevant health partners must issue a reminder to raise awareness to all GPs of the importance of ensuring GPs are examining the circumstances of previous recent 27 KSCB Child I SCR Final Report 24th January 2020  appointments in order that any emerging concerns and patterns of behaviour may be identified.  7. Kent Police must provide assurance to KSCMP that exit strategies for lead investigators and    family liaison officers are considered and developed in the initial planning stages of all complex enquiries, with officers encouraged to ensure relevant signposting to other appropriate support providers occurs and planned exits take place when investigations are complete. 8. KSCMP should explore ways to widely promote existing pathways and opportunities to respond to mental health issues in children and young people, including the policy to manage self-harming and suicidal behaviour.  9. The KSCMP should receive assurance and a commitment from all partner agencies that their record keeping meets single agency standards and requirements in order that an accurate picture of relevant contacts and services provided to families can be easily accessible to inform decisions and actions about ongoing involvement.  10. The KSCMP should request assurance from Health partners that missed health appointments for children are subject to robust and consistent follow up, as set out in the local Managing Missed Appointments Policy, to ensure children are receiving the treatment they require and any emerging safeguarding concerns relating to the child’s non-attendance may be identified and appropriately actioned.     11. The KSCMP should collaborate with Public Health and other local strategic bodies to ensure a proactive and effective approach to suicide prevention within Kent is continuing and takes account of national guidance.  