Death of a 12-year-old child by suicide in 2020. Learning includes: wider consideration of issues relating to children electively home educated (EHE), children from the Jehovah's Witness faith, child and adolescent mental health services (CAMHS) and triage arrangements and information sharing in tertiary hospitals. Recommendations include: consider how to engage local faith communities to undertake a proportionate Section 11 process to provide assurance to the safeguarding children partnership on the effectiveness of those arrangements; the local authority EHE team continue to lead the work on improving the identification and assessment of children who are electively home educated and ensure the voice of the child is included; engage with the Department for Education in the development of local guidance for schools on children electively home educated; request the National Safeguarding Practice Review Panel considers the recommendations from the Independent Inquiry into Child Sexual Abuse (IICSA) report and its final report on the safeguarding arrangements within religious faiths to ensure they are addressed and implemented at a national level; alert the National Child Safeguarding Practice Review Panel, and contact all child death review leads, to raise awareness of the need for child death review processes requiring referrals to the coronial process to be explicit about any potential safeguarding concerns.
      
    Serious Case Review No: 2022/C9517  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.    1        Local Child Safeguarding Practice Review  Child A        2   CONTENTS  Item Page  1. Introduction    3  2. Process for conducting the review   4  3. Family History and Agency involvement    5  4. Family views   6  5. Findings & analysis  - School’s responses to children of Jehovah’s Witness faith and Elective Home Education - Elective Home Education arrangements  - Jehovah’s Witness faith and safeguarding arrangements - Information sharing from tertiary hospitals   8-12   6. Analysis and Recommendations   13          3   1 Introduction  1.1 A Local Child Safeguarding Practice Review (LCSPR) was commissioned following completion of a Rapid Review process, submitted to the National Child Safeguarding Practice Review Panel in July 2020. The Rapid Review requires all agencies to undertake a review of their records and to submit a timeline, analysis and summary of agency involvement. This review involves the tragic death of a 12 year old child, referred to as Child A in this report, by hanging. 1.2 The case was referred to the Safeguarding Children Partnership’s Case Review Group (CRG) as the tertiary hospital, where the child had been treated and subsequently died, had raised some safeguarding concerns. These related to Child A’s weight, access to food, parental presentation and concerns shared by parents in relation to a sibling who had previously self harmed and described suicidal ideation.  1.3 As a result, there was a joint Section 47 child protection investigation undertaken by the Local Authority and Police. This took place and ran concurrently to the early stages of this Practice Review. The outcome of this investigation was that there were no child protection concerns, but sibling was assessed and began to receive a Child and Adolescent Mental Health Service (CAMHS).  1.4 The CRG and Independent Reviewer were unable to evidence any concerns regarding abuse/neglect relating to Child A through the review process. However, it was agreed by the CRG that this review offered a broader opportunity to use the lens of this family to consider any local or national learning around safeguarding for children electively home educated and from a particular faith. This was because Child A was electively home educated as was the sibling and the family were also a member of the Jehovah’s Witness faith. 1.5 Therefore, this review has been undertaken in a proportionate way to ensure the key learning is identified to support improvements in policy and practice. It is deliberately not detailed about the family but provides a brief summary of the family circumstances and key agencies’ engagement with the family. 1.6 The purpose of a LCSPR, as confirmed in the current statutory guidance, Working Together to safeguard children 2018: Chapter 4 is clear that the focus is on learning, not holding individuals or agencies to account.     4  2  Process for conducting the LCSPR  2.1 The CRG acted as the review Panel and first met in October 2020 to discuss the Rapid Review learning and scope the Terms of Reference (TOR).  The Independent Reviewer attended this meeting. The Independent Reviewer is an independent safeguarding consultant, experienced Local Safeguarding Children Board and Serious Case Review (SCR) Panel chair and SCR/LCSPR reviewer, fully independent of the commissioning Safeguarding Children Partnership and its partner agencies. 2.2 It was decided that sufficient detail had been provided by all agencies into the Rapid Review process, so agency reports were not requested. However, it was agreed it would be helpful to request that the schools attended by both children be asked to consider their involvement and their responses to children from the Jehovah’s Witness community. In addition, it was thought useful to inform both the Section 47 assessment process and the practice review to understand the Jehovah’s Witness faith community and their safeguarding arrangements to inform the local Safeguarding Children Partnership. Consequently, an expert was commissioned to provide information to specific questions developed by the Reviewer and the Panel. 2.3 The Terms of Reference initially set out the following areas, which were felt to require further focus:  • The safeguarding implications of Elective Home Education (EHE) for children and the effectiveness of the current system to identify any concerns.  • How much do practitioners understand the EHE arrangements /policies/operational delivery?  • To consider how mainstream schools respond to /adapt to the inclusion of children who are Jehovah’s Witnesses and any learning for the wider school/education community.  • The potential impact of the family’s religion as Jehovah’s Witnesses and how this is responded to by the Safeguarding System. • How effective are the safeguarding policies of the Jehovah’s Witness organisation and how would potential concerns around parenting be managed/responded to? • To consider the learning from other published SCRs/LCSPRs, which have involved children home educated, and any wider national learning and the impact for learning for the commissioning Safeguarding Children Partnership.  5  2.4 The CRG then met in January 2021 and considered the expert opinion on safeguarding arrangements in the Jehovah’s Witness faith and the reports prepared by the schools and agreed further actions to be undertaken by the Reviewer. At the March 2021 CRG meeting, it became clear at this meeting that there were additional issues identified in relation to the tertiary hospital and how information about their safeguarding concerns had been fed into the differing statutory processes. As a result, the CRG formally requested an agency report from the tertiary hospital to address specific issues identified through the practice review process. 2.5 Following the discussion on the school’s reports, it was decided it would be helpful to meet practitioners in order to progress the learning from this review process and to understand the issues facing front-line practitioners in relation to elective home education and the opportunities and challenges about the ‘system’. A meeting was therefore held with the Reviewer and four practitioners from the Local Authority Elective Home Education team and the Safeguarding in Education team in February 2021. 2.6 The contribution of family members is an important part of the review.  It was agreed that both parents of Child A would be informed of the review and invited to contribute their thoughts and experiences on all agencies that had been involved with the family. The reviewer kept the family informed of progress by letter and then made contact in June 2021 and was able to have a helpful lengthy virtual meeting with Mother.  3.  Family History and Agency involvement  3.1  The family are White British and comprised of parents, Child A and sibling. The family are Jehovah’s Witnesses and the children were electively home educated. The family had only been known to Children’s Social Care through it’s “front door” following a referral by the General Practitioner to CAMHs in relation to the older sibling in January 2020. There was concern around low mood, incidents of self harm and suicidal thoughts. The assessment concluded that the CAMHS threshold was not met and sibling was signposted to a counselling service, the local college counselling service and the provision of a number of “apps”.  3.2  The older sibling became electively home educated from the end of Year 7 and Child A from the end of Year 5. They had routine contact with the Local Authority home education service. This comprised annual phone calls to discuss and agree education provision was suitable, the offer of attendance at a Drop In and a Home Visit if requested by the family. A Home visit was not requested, and  6  the education of the children was deemed suitable. Therefore, the contact with this family didn’t include face to face contact or home visits. Child A sibling had begun to attend a local college on a one year part time home education programme. The college also provided counselling and high levels of support.  4. Family Views  4.1  The reviewer had a very helpful discussion with mother who was able to identify a number of areas of learning although generally her overall experience of local agencies was very positive. However, she felt that access to CAMHS for Child A sibling was not the most constructive experience in January 2020 as the assessment was done over the phone and sibling had felt unable to disclose the detail of their suicidal ideation. Sibling was signposted to other support services but then was fortunate enough to receive excellent counselling and support from the local college.  4.2  Mother also identified the lack of NHS services/counselling for parents of children who have died to support their mental health. The Child Death review nurse helpfully facilitated this service from local charities but that seemed to be purely good fortune that they were flexible enough to offer a service. Mother described the current support from CAMHS and the Adult counselling service as very positive. 4.3  Mother reflected on their experience at the tertiary hospital, where Child A was admitted and died. This was clearly a highly distressing period and occurred during the Covid pandemic, which obviously impacted on the family and the service. However, her reflection was informed by the positive experience they had received as parents when Child A had been a very seriously ill baby at another tertiary hospital. At that time she said they felt nurtured and supported and this contrasted significantly from the experience at the tertiary hospital where Child A died.  4.4  Both parents received the medical notes from the tertiary hospital, which were released by the Coroner’s office. They were very concerned at the statements included in the notes around their presentation and Child A’s weight, which had not been shared with them directly. Mother felt the staff were influenced by the initial Police and Children’s Social Care investigation and that their experience with some of the staff made sense when she had subsequently read the medical notes. They had been allocated a Liaison Officer from the nursing team but although father had found that helpful, Mother said she felt the interaction appeared judgemental and punitive.   7  4.5  Mother described the statement made by nursing staff that the parents had been “absent” and not with Child A but described the “instruction” from nursing staff apparently at the request of Children’s Services that one parent needed to return home and remain with sibling. Ironically mother said this meant sibling had to leave their friend’s home where sibling felt nurtured and return home to where the incident had taken place, which caused distress. This also coincided with the hospital Covid policy at that time for only one parent to be present on the ICU. Mother felt alone and unsupported, there was no food outlets open in the hospital, so she had to go outside to find food. Mother stated the notes described her spending little time with Child A but she felt that nursing staff were always with Child A and she felt “often in the way”. Mother said she had however had a more positive experience with some nursing staff. She wondered if they might have been short staffed due to Covid but said that the ICU itself was not near capacity. 4.6  A significant point made by mother was that both parents were asked, once it was confirmed that there was no likelihood of survival for Child A, if they would agree to organ donation. They considered but decided against it based on what they believed would be Child A’s wish. Mother then described being told almost immediately that they would then turn off the life support and that the room they had been using to sleep in would be no longer available to them. On reflection Mother felt that might explain what she felt to be a judgemental atmosphere. Mother described being told information and trying to absorb that to share with her husband and felt that her reactions were then judged as not demonstrating emotion. Overall mother described a significant lack of compassion. 4.7  Mother described the local Police/Children’s Social Care involvement as very positive, compassionate and non-judgemental. She described the child death review nurse as a “lifesaver” who had helped them navigate their way through the processes/systems and provided significant emotional support. 4.8  In discussion around the decision to electively home educate the children, mother was positive about all the schools attended by the children and how they had positively “accommodated” their Jehovah’s Witness faith. Mother described sibling as having difficulties for some years with concentration and they hoped it would improve over time. However there had not been improvement by the end of Year 7 and decided that home education might be beneficial and better suited. This was a positive experience for sibling who was then was able to join a programme at a local college enabling sibling to spend 2/3 days a week in college. This structure has been very beneficial for sibling. 4.9  Mother stated that they had then discussed removing Child A from school to home educate and had initially planned to do this at end of primary school and  8  had discussed this with the Head. They thought that there was no real advantage to waiting and so removed Child A at the end of Year 5. Mother stated Child A was not socially isolated but had only one real friend at school but a number of children from the Jehovah’s Witness faith were home educated locally and there was a great deal of contact with those children. Child A was functioning a year ahead academically. Mother described the support from the Local Authority as also being a positive experience with supportive contact and advice and had no comments about areas of improvement. 4.10  Mother wanted to make the point that although at the inquest, the cause of Child A’s death was suicide, the Coroner had explained in court this was a relatively new requirement to come to a conclusion on the “balance of probabilities”. If this inquest had taken place previously, it would have had a likely outcome of an “open verdict”. Mother’s view was confirmed by the assessment undertaken by Children’s Social Care that suicide intention was not clear.  5. Findings   School responses /arrangements for children from the Jehovah’s Witness faith 5.1  Agency reports were requested from all three schools attended by the children and they provided reports and analysis facilitated by an independent consultant, which were thorough, helpful and reflective. Specific questions were developed by the CRG and the Reviewer and addressed key questions of how were the schools aware of, and sensitive to, the needs of children of Jehovah’s Witness faith in their work, and knowledgeable about the child’s faith and the implications of this in terms of inclusion and access.  5.2  The summaries in the report broadly identified that practice had been robust but in terms of improvement, it would be helpful to create systems for better communication with specific faith groups and improve staff understanding of specific beliefs and practices. Their proposals included all schools to promote open discussion with parents and child at the point of admission and introduce individual planning for children from specific faiths and to develop and promote child -focussed feedback on their lived experience as a child of a specific faith at the school. It was identified that when a child leaves a school to become electively home educated and the school do not have the opportunity to gather the child’s views and wishes directly, this should be seen as a potential additional vulnerability alongside any additional vulnerabilities such as isolated lifestyle, family systems or faith with the EHE service.  9  5.3  All the schools were clear they had significant concerns around the current systems in place regarding home education.  One school concluded “It allows children to become invisible and removes avenues of support for their parents.  With the current increase in EHE across the country, alongside the increase in mental health concerns we need some robust adaptations made to legislation and support available if a decision is made to educate at home.  We would welcome the opportunity to support these actions”.  Elective Home Education (EHE) in the local area 5.4  Following receipt of the agency reports, the Reviewer met with representatives of the Local Authority Elective Home Education Team and the Safeguarding in Education team to consider the findings. This was an opportunity to reflect on the school’s reports, current arrangements and consider opportunities for improvement. A number of actions were identified to help raise the profile of elective home education within schools, to update the existing Elective Home Education policy to be clearer and more explicit about roles and responsibilities and expectations, to ensure multi-agency pathways were clear, to develop guidance and to consider better ways to hear the child’s voice. 5.5  Action was subsequently taken to raise the profile and understanding of EHE with all Designated Safeguarding Leads (DSL) in schools including the independent sector which included devising enhanced training, which is now embedded in DSL training and the link to the online ‘off-rolling’ form is included in this training. The EHE Team have also sent an update through the twice-weekly Covid schools message board. In addition, the EHE team created and shared a template exit letter for schools to use with parents, which very clearly signposts to EHE services, and responsibilities.  5.6  The Reviewer provided comments on the EHE Policy, which have been incorporated into a revised Policy published in March 2021. This included a clearer definition of responses from the EHE team when children are classified as vulnerable/non vulnerable. Work is ongoing on how to include the potential social isolation of children into the “vulnerable” criteria. 5.7  Two working groups were established, one focussing on developing pathways of communication between the EHE team and Health (GP/paediatrics/dentistry/School Health) and social care. Training and resources for all frontline practitioners across these services is being developed to ensure the right information about potentially hidden children is identified and shared.  5.8  The second working group is focussed on working with headteachers from primary, secondary, special and independents schools to co-devise a guidance document for schools on EHE processes which ensure best practice in  10  safeguarding EHE children. The EHE team is keen to work in partnership with school leaders to create a workable document which ensures consistent practice and gives clear pathways of communication and clear definition of processes for informing and updating the EHE team about children who off roll from school to EHE, and communication with parents. The Reviewer has raised this work with the National Panel and suggested it might be helpful to have Department for Education (DfE) representation on this working group. DfE has subsequently confirmed their agreement to joining the working group. 5.9  In order to address concerns around how to better hear the child’s voice in the process of children becoming home educated, the initial parent pack sent out to parents has been redesigned, with a young person voice section at the top. Routine reports have also been recalibrated to put a young person voice section at the top to support the changes in culture/relationships/parental trust by making explicit the belief that the voice of the child should be heard. In addition, the educational psychology service has allocated time to support with the development of an EHE young person voice. Additionally, work to develop an exit interview for/by schools with children, is ongoing. 5.10  The Local Authority has made good progress from a sound base on developing its local response to elective home education. The national focus on elective home education and the current perceived legislative restrictions to enable these children to be known about and seen continues and has been recently a specific focus of work for the National Child Safeguarding Review Panel. Work was commissioned to consider safeguarding referrals of children electively home educated and the outcome has been shared with the Secretary of State and Children’s Commissioner. The Education select committee have also undertaken an inquiry in 2021 to which the national panel provided evidence. There are therefore recommendations in this review both locally and nationally.    Jehovah’s Witness Faith 5.11  There was no evidence that there were safeguarding issues in relation to Child A, the subject to this review, related to their faith. However, the review provided an opportunity to consider the effectiveness of the safeguarding arrangements in the Jehovah’s Witness faith and if there was a need for local or national improvement. 5.12  The CRG commissioned an “expert” report on the Jehovah’s Witness faith and with the Reviewer developed specific questions for which responses were received. The Reviewer also undertook an analysis of the current worldwide Safeguarding Policy used within the Jehovah’s Witness faith (Dec 20).  11  5.13  Neither of these documents provided the Reviewer or the CRG with assurance around the process of response to referrals, the checks/training of leaders/staff and the management of safeguarding referrals and allegations. The reviewer therefore undertook to research the national work currently being undertaken in relation to the Jehovah’s Witness faith by the Charity Commission and the national Independent Inquiry into Child Sexual Abuse (IICSA). 5.14  The Reviewer wrote to and had helpful discussions with the lead investigator from the Charity Commission. The Charity Commission investigation has been ongoing since 2014 and they provided evidence to the IICSA in 2020 of their concerns primarily around safeguarding policies and procedures. They have commissioned a number of independent safeguarding reviews of arrangements within the Jehovah’s Witness faith. The delay in their investigation has been mainly due to a number of lengthy Judicial Review legal challenges from the Jehovah’s Witness faith, two of which are still ongoing. It appears unlikely that this investigation will be resolved in the near future.  5.15  The current national Independent Inquiry into Child Sexual Abuse (IICSA) was established in 2015. It undertook a thematic inquiry in 2020 into the “current child protection policies, practices and procedures in religious institutions that have a significant presence in England and Wales including non-conformist Christian denominations, the Jehovah’s Witnesses, Baptists, Methodists, Islam, Judaism, Sikhism, Hinduism and Buddhism“. The public hearing into this investigation concluded in August 2020 and an investigation report was published on 2/9/21.  5.16  The IICSA Inquiry involved up to 2 days of specific focus on the Jehovah’s Witness Faith in 2020.  There were around 48 documents submitted, which mainly included statements on behalf of the Jehovah’s Witness faith setting out their policies and other statements in response including from the Police and victims in individual cases.  5.17  Statements were provided to the Inquiry of a number of individual cases where there was evidence of deliberate decisions by a number of Elders to not refer a case of child sexual abuse and of delay by Elders in referring cases of the suspected abuse of children. Statements describe the Jehovah’s Witness safeguarding policy/procedure as “confused” as Elders are not “required” to report abuse to statutory authorities and can compromise Police positions by talking to parents. This review is concerned that the Jehovah’s Witness safeguarding policy does not provide assurance or sufficiently clear guidance to members of the Jehovah’s Witness faith and this is impacting on children not receiving sufficient safeguarding and protection from abuse/neglect. 5.18  The IICSA Inquiry was published on 2/9/2021. It is very detailed in outlining current arrangements and their concerns about the Jehovah’s Witness faith’s  12  safeguarding arrangements. It reflects the issues already highlighted in relation to safe recruitment, safeguarding training and responding to allegations of abuse. The Report makes two recommendations, the first in relation to child protection policy, procedures and training: “All religious organisations should have a child protection policy and supporting procedures, which should include advice and guidance on responding to disclosures of abuse and the needs of victims and survivors. The policy and procedures should be updated regularly, with professional child protection advice, and all organisations should have regular compulsory training for those in leadership positions and those who work with children and young people.” The Report concludes that broader issues will be addressed in the IICSA Inquiry final report in 2022. 5.19  The Reviewer also contacted the National Child Safeguarding Practice Review Panel to request further information on whether they are aware of other SCRs/LCSPRs or Rapid Review processes involving children from the Jehovah’s witness faith. The response was that this had not been identified as an issue so far in the work of the Panel.  Information sharing - Tertiary Hospital  5.20  Through the process of this review, concerns became apparent at the inconsistent and at times inaccurate information shared by the tertiary hospital into the different statutory processes, which follow the sudden unexpected death of a child. The CRG decided at its meeting in March 21 to request an Individual Management Review (IMR) from the tertiary hospital. The IMR was received in early May and there was a consensus that the IMR report did not fully address the questions posed. There was limited analysis of the issues and no learning identified for the tertiary hospital. As a result, CRG did not feel assured on the effectiveness of the tertiary hospital processes to share information with other agencies and the impact this may have on decision making. They wrote again to the local Safeguarding Children Partnership in May 21 to request further analysis of the key points identified by the Safeguarding Children Partnership and the resulting learning for the tertiary hospital. 5.21 CRG were primarily concerned that there didn’t appear to be a collective shared and agreed view from all the health practitioners involved in the care of Child A about their concerns of potential abuse/neglect.  There was evidence of contradictory statements specifically about the child’s weight. The medical opinion on whether Child A was malnourished or just of slight build was unclear and, as the child was not weighed at any point or subject to a post mortem examination, there was no evidence.   13  5.22  The response from the tertiary hospital in July 2021 appears to have recognised that there was learning to be gained from this incident and they have identified six areas of specific learning. One specific local learning relates to the need to ensure that when referrals from the lead clinician following a child death are made into the Coronial process that there is an explicit requirement for the clinician to state if there any safeguarding concerns. This is to enable the Coroner to make an informed decision on the need to undertake a post mortem or any other specific actions. The Safeguarding Children Partnership have recognised that it would be helpful for this to be a national learning and recommendation from this Review. The Safeguarding Children Partnership have also strongly suggested that the local Clinical Commissioning Group Designated Nurse and Designated Doctor monitor progress against these areas of learning.   6. ANALYSIS and RECOMMENDATIONS  The death of Child A is desperately sad and tragic for the family and this review, and local multi-agency investigations, have not identified any concerns around abuse or neglect. However, the death led to a decision to undertake this review which has enabled wider consideration of issues relating to children electively home educated, children from the Jehovah’s Witness faith, CAMHS triage arrangements and information sharing in tertiary hospitals and has developed proposals for local and national learning.  1. The Safeguarding Children Partnership consider how they can engage local faith communities to undertake a proportionate Section 11 process to provide assurance to the Partnership on the effectiveness of those arrangements. 2. The Local Authority Elective Home Education team continue to lead the work on improving the identification and assessment of children who are electively home educated and ensure the voice of the child is included. 3. The Safeguarding Children Partnership engage with DfE in the development of local guidance for schools on children electively home educated. 4. The Safeguarding Children Partnership to request the National Safeguarding Practice Review Panel considers the recommendations from the IICSA report and its final report on the safeguarding arrangements within religious faiths to ensure they are addressed and implemented at a national level.  14  5. The Clinical Commissioning Group Designated Nurse and Designated Doctor support the tertiary hospital to consider the learning and review their arrangements to share information with other agencies. 6. The Safeguarding Children Partnership seeks assurance from CAMHS regarding the robustness of the triage of CAMHs referrals.  7. The Clinical Commissioning Group consider the current commissioning of bereavement services to parents following the death of a child to enable a consistent and appropriate response to the need. 8. The Safeguarding Children Partnership should alert the National Child Safeguarding Practice Review Panel and contact all Child Death Review Leads to raise awareness of the need to ensure that all Child Death Review processes require referrals into the Coronial process to be explicit about any potential safeguarding concerns.   Alex Walters  June 2022  