Suicide of a 14-year-old Black British girl in the Summer of 2014 while living in foster care in Kent. Child J had a history of suspected emotional, physical, sexual abuse and neglect and complex mental health needs including suicide ideation, self harm and an eating disorder. Child J suffered acute and chronic bereavement after her mother's death from a long term illness and a series of other losses, including a breakdown in her relationship with her older half-brother and changes in foster carers. Child J was supported as a Child in Need before being looked after by the local authority when her family were unable to care for her. She also received adolescent acute and community mental health services. Issues for learning include: the significant impact of bereavement, transitions and loss on Child J; the need for J's history and the impact of her experiences to be taken into consideration in risk assessments and continuity of planning and treatment arrangements; the need for agencies to be clear about their understanding of the legal concept of parental responsibility and when young people can make decisions; care planning for looked after children in receipt of mental health services; the importance of Child J's diaries and whether practitioners had sufficient professional curiosity about their content and how this could have been raised with her; and social media and pro-anorexia or 'Pro-Ana' websites. Poses a series of questions for consideration by Lambeth Safeguarding Children Board based on the findings of the review.
      
 Title:  Serious case review: Child J: overview report. LSCB: Lambeth Safeguarding Children Board with Islington and Kent LSCBs Author:  Date of publication: 2016  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.                                  Lambeth Safeguarding Children Board with Islington and Kent LSCBs Serious Case Review Child J   Agreed February 2016 Following endorsement at a Joint LSCB in December 2015        Contents Page        Statement by the Chair of Lambeth Safeguarding Children Board Introduction Executive Summary Key Lessons: Headlines Family details J’s profile Timeline and analysis of agency and multi-agency assessments and support J’s voice – including the diary, Facebook and issues of hindsight Family and Carers’ Voices Learning and Conclusions – including learning from the NHS Health Overview Report Appendices 1 2 4 5 11 12 13 48 48 54 70     Lambeth Safeguarding Children Board  Olive Morris House, 18 Brixton Hill, Brixton, London SW2 1RD       Statement by the Chair of Lambeth Safeguarding Children Board I welcome this report into the tragic death of this young person. The SCR was commissioned by my predecessor in conjunction with the Chairs of Islington, Kent, Southwark and Wandsworth Local Safeguarding Children Boards. We extend our condolences to J’s family, friends and carers and to those practitioners who worked closely with her to help and support her and who developed trusting relationships and affection for her. The purpose of an SCR is to seek to understand what happened and why it happened in the context of local safeguarding systems rather than solely the actions of individuals. It is to ensure that agencies are held accountable for their services and their systems and processes in safeguarding children and how they work together as a multi-disciplinary system. An SCR also aims to enable LSCBs, through a single case, to test the effectiveness of local and national safeguarding children procedures, protocols and working arrangements. Lessons from the review will be used to improve workers’ and agencies’ understanding of self-harm by young people and support improved co-ordination across mental health and social care services. This report was endorsed at a joint LSCB Meeting in December 2015. A separate Action Plan will be required by each LSCB in response to the questions raised by the Review. Lambeth LSCB will publish its Action Plan in early 2016 alongside the SCR. At the time of endorsing the SCR it is noted that the Inquest into J’s death has not yet been completed. Lambeth SCB will publish any learning from the Inquest alongside the SCR and the Action Plan.   Paul Curran Independent Chair Lambeth Safeguarding Children Board February 2016 Page 2     Introduction J was 14 years old when she took her own life in the summer of 2014. At that time, she was looked after by Lambeth Children and Young People’s Services and had recently moved to live in a new foster home in Kent. Immediately prior to the move to the foster home J had spent four months as a voluntary in- patient in an adolescent psychiatric unit, as a result of a crisis in early 2014 when it was assessed that there was a high risk that she would seek to seriously harm herself or take her own life. The Lambeth Safeguarding Children Board (LSCB) convened a meeting of relevant agencies and recommended that in the circumstances of J’s death an SCR was required.  The Independent Chair of Lambeth SCB endorsed this. The Terms of Reference were negotiated with other LSCBs which had an interest in the review. It was agreed to focus the review on agency and multi-agency assessments and interventions to support J and her family from the time of the referral as a child in need in November 2011, when J’s mother was dying, to July 2014 when J herself died. Agencies in undertaking their own Internal Management Reviews were asked also to review the background of J’s care up to October 2011 in order to understand her history, life experience and resilience. The key LSCBs were Lambeth, Kent and Islington, where J had lived; and Southwark and Wandsworth, where J was temporarily placed while in the care of Lambeth Council (Sec 20 Children Act 1989). Some health services had also been provided in Camden for her mother – but these had been commissioned as part of her residency in Islington. This report sets out a brief summary of priority lessons, describes the key phases of J’s life through a timeline and analyses the multi-disciplinary and single agency responses to J during these phases, as a child in need, and the challenges of working with a young person who has chronic and acute emotional health problems with developing suicidal ideation. Alongside the timeline a commentary is provided which also includes some lessons which derive from a specific event or issue and which do not necessarily form a part of the overall priority lessons. The key lessons and the thinking behind them are then discussed in more detail. The SCR Panel has raised some questions for LSCBs to think about in relation to the lessons and to consider in formulating an Action Plan. The analysis of the work undertaken to support J and her family and carers seeks to understand what the practitioners working alone or together at the time can have known, or could be reasonably expected to know, at the time that the decisions and actions for her care were taken. As part of this SCR, and in parallel, NHS England commissioned a Serious Incident Review, co-ordinated by the Lambeth Clinical Commissioning Group to cover all the health agencies which were involved. Its findings are included in this review. Information for the report was provided from a chronology of agency contacts with J and her family or between agencies by the key agencies involved. This was used to create the Timeline for analysis. Stakeholder agencies provided Independent Management Reviews (IMRs) describing and analysing their agency involvement and work in a systemic way. The Terms of Reference for those IMRs is included in the Appendices. A Serious Case Review Panel with two Independent Reviewers and representatives from the key agencies who had not been part of the service delivery or direct management of the case reviewed all the material. Where necessary the Panel sought clarification about information or actions.  Page 3   When the priority lessons had been identified these were shared with the practitioners and immediate managers who had worked with j and who had been responsible for the case through a Practitioners’ Learning Workshop. This was to ensure that the Panel’s thinking reflected the practitioners’ experience, understood the context in which they were working, was proportionate and not over influenced by hindsight. Interviews with the two Independent Reviewers were held with J’s Aunt and J’s foster carers in order to understand their perspective. The attempt to contact J’s half-Brother was unsuccessful. These interviews and the Practitioners’ Learning Workshop enabled corrections and changes to be made to the final draft of the report and the correction of some misunderstandings or gaps. J’s Aunt also made some comments on seeing the final report as it was about to be published and it was agreed to amend some information and to include additional comments about her perspective.  The Independent Reviewers would like to thank J’s Aunt, foster carers and the practitioners for taking part, sharing their views, and contributing to the learning in a non-defensive and helpful way.        Bridget Griffin and Malcolm Ward Independent Reviewer and Independent Chair SCR Panel February 2016   Page 4    Executive Summary   J had challenging experiences as a child in a family where there was a history of complex relationships and emotions, separations, parental mental and physical ill-health; and alleged abuse. She experienced acute loss (age 12) through the illness and death of her single-parent mother who was in hospital for six months, before being discharged home to die.  J entered a period of acute and then chronic bereavement and further losses as she moved from care by one relative by running away to another relative; and then was accommodated by the local authority. Throughout the period from before her mother’s death to her time in foster care there was evidence in her writings of suicidal thinking, examples of these writings first became known to professionals after her Mother’s death. In January 2014 J was admitted as a voluntary patient to psychiatric hospital care in an adolescent unit, as a result of what was assessed to be active planning to take her own life. A few months later, when she was assessed to be safe to be discharged she transferred to a different long-term foster home outside London. These transitions from autumn 2011 to summer 2014 are characterised by moves across service-delivery boundaries, adding to the difficulty of meeting her emotional needs at a key stage in her development as an adolescent. She began to show increasing signs of pre-occupation with weight and eating control, self-harm, and suicidal ideation and suicide attempts. J’s Aunt sought help from services with these matters. J was of concern to universal agencies (schools and GPs) and specialist services as a child in need, a child in need of protection, and finally as a looked after child and as a child in need of specialised adolescent acute and community-based mental health services. Multi-disciplinary services co-ordination and case planning were essential to her support and care as a child with highly complex needs. This was complicated by moves across local authority and health provision boundaries.  J was a seen as a bright, articulate and seemingly resilient child; at times appearing to cope, at times avoidant of help. She was able to express her thoughts and feelings clearly, but did not always choose to do so. At times she made statements which were not true and at times she deliberately masked her thinking and behaviours. At times J wrote down her thoughts in ‘diary’ notes. These were not in formal printed diaries and were initially sporadic; not all are dated. At times they were in books, such as a birthday book, or in notebooks or on single sheets of paper. J’s Aunt has stated that she shared the content of one of the books with practitioners in Islington and Lambeth; the writing pre-dated J’s mother’s death. Later some single pages of J’s writings were shared with staff in Lambeth. It was known that J used writing and drawing a lot and she was encouraged to do this. However, the full detail of the volume of writing, the content and the possible significance as an aid to understanding J was not known at the time. The concerns raised in the pages that were known about were not shared across services at the time, or over time as teams of workers changed. Nor were their contents considered as part of key mental health risk assessments or referred to specialists for consideration. Some practitioners were aware that J was writing in notebooks but felt that they could not look at these as a parent might because of her right to privacy. After her tragic death it came to light that J had committed a great deal of her thoughts, feelings, hopes and desperation to notebooks over many months, while she was experiencing acute emotional difficulties. J’s diaries have given this review what may be a unique hindsight into a young person’s thinking and voice, but which were not available to the practitioners who sought to help and protect her at the time. If the writings are an accurate reflection of J’s thoughts rather than fantasy they show a young person of extremely low self-esteem, feeling alone, rejected and unloved, pre-occupied with her body image and the need to lose weight; and experimenting more and more with suicidal thinking and behaviour. They also show what appears to be influence by specialist websites for people with pre-occupation with anorexia. It is not clear if J, herself, accessed such websites or whether she learned of these through peers, possibly in the adolescent in-patient unit.  Page 5   A serious case review should avoid hindsight and seek to learn from what information was available and known or what could have been known to practitioners at the time that they made their assessments and plans. Some analysis and discussion of J’s diaries is included in this report as they raise important questions about helping young people who are troubled with thoughts about eating, weight loss, anorexia, self-harm and suicide for front line practitioners for whom these areas are less familiar.    Key lessons: Headlines  The sections in these headlines are discussed more fully in the body of the report.   Bereavement, Transitions and Losses  The eco-map in the appendix illustrates the number of losses experienced by J over 2 years and 7 months. Losses included in this map include losses of attachment figures or key people all-be-they a family member, a peer group, a carer, or a professional with whom J had a relationship; as can be seen these are significant. During this time J was entering adolescence, transitioning to secondary school, and moving home across administrative boundaries. The significance of these compounded losses and transitions were not held in mind by the multi-agency professional group at the time they were working with J, it was only when this review brought together the information that the significance of these losses and transitions was thought about. These were important factors that impacted both on the services that were provided and most importantly on J’s emotional world. It was the view of the Panel that this warranted greater thought and consideration in understanding J and planning for her needs; especially when that planning itself included further losses of significant relationships as she moved.       Questions for Safeguarding Children Boards: How is attachment theory and how are transitions and losses understood by those agencies responsible for the assessment of a child’s needs across a range of service provision and how might improvements be realised? How can Boards work with all relevant agencies in order to improve transitional arrangements for children moving across geographic boundaries? What are the particular challenges and how might these be addressed? How does the system ensure that practitioners can hold these things in mind and translate them into practice? For Looked After Children how would foster carers be supported in understanding and supporting patterns of loss? Page 6    Assessments and Treatment (including risk assessments and continuity of planning and treatment arrangements)  Over time it was established that J had a very ‘poor psycho-social history’, even in the early days of planning, this psycho-social history was recorded across agencies and professionals but did not appear to adequately feature in treatment or assessments. A picture of poor and ambivalent emotional attachments and possible emotional abuse and sexual abuse as a child even before her mother’s death. She was in grief and experiencing complex bereavement, the continued losses of significant people, including family, carer, friends and professionals after her mother’s death probably compounded this.  However, J appeared as a bright, articulate and resilient child, possibly masking her emotional need; she was seen in the in-patient unit as guarded and intensively private not trusting staff and being more open until towards the end of her stay.  In assessing the care and support arrangements for J it is not clear her history and the impact of her experiences were fully taken into consideration or the abilities required in those who may have to care for her. In a period of neglect after her Mother’s death this was not assessed as a child protection matter. Allegations of sexual abuse were not followed up, using the agreed procedures. When it was feared that J may self-harm or take her own life while in her first foster placement good risk assessments were undertaken and reviewed to mitigate against dangers of hanging, cutting or ingestion. For the second foster placement such written risk assessments of the environment were not put in place by the placing authority on the un-checked assumption that the independent fostering agency would do this. At the time of that transition from the in-patient unit to the second foster home it was understood by non- health professionals that the risk of suicide or self-harm had greatly diminished. It was known that some risk remained but the significance of this was not fully understood by the second foster carers. They had some experience of working with young people with mental health difficulties but this was beyond their experience. The risks should have been clearly spelled out and a check done to ensure that they were properly understood by carers and non-health workers.  Discharge Planning from the Adolescent In-Patient Unit J was an in-patient in a specialist adolescent psychiatric unit for several months where she had intensive supervision and support and was at times, in the initial period, on close watch for self-harm. She appeared better on discharge but there was no smooth transition of treatment plans for her.   She was moving from a total care and support environment to a new family, and to a different set of community services which had not been consulted about local provision and were not aware that she was transferring to their care or of the level of her need until some time after she had arrived. The agreed plan was that, until local community mental health services were in place in her new community, J would receive services from Lambeth mental health services after discharge from the in-patient unit. No direct service was offered.  Non-health workers looked to the mental health specialists to guide them in seeking appropriate arrangements for J’s care and were re-assured that the risk of self-harm or suicide had lessened. For tier 3 community CAMHS and tier 4 inpatient CAMHS with knowledge of assessing suicide and self-harm J was not an unusual child in terms of the population of patients that they see. For non-health workers J was a complex and needy child and outside their usual experience. In communication between these two systems it is important to ensure that there is understanding in the use of language and perception, especially in relation to risk.  Health workers must understand their responsibilities for ensuring that non-health workers and carers (or family) understand levels of risk and how they may Page 7   be mitigated. Where there has been risk but it is assessed to have gone or receded there must be a clear contingency plan put in place, to support the identification of any relapse. All agencies must understand the additional duties to support and safeguard looked after children.       Understanding the legal concept of Parental Responsibility and when young people can make decisions  At times there was confusion in understanding about J’s legal status after her Mother’s death, what the role and responsibility of a testamentary guardian1 is, the responsibility and rights of someone with parental responsibility, and whether J should be subject of a care order or not. J was thought to have been ‘Gillick’ competent based on her age but no assessment was done of her actual competency to make important decisions given her life-experience and vulnerability. The Children in Need processes or Looked After Children processes should have established these as early as possible.                                                                  1 A testamentary guardian is appointed by a parent, who holds parental responsibility, to assume parental responsibility for a child on that parent’s death. It is usually done through a will. It is governed by section 5 of the Children Act 1989.   Questions for Safeguarding Children Boards: Relevant boards should ensure a clear understanding from commissioners and providers of mental health services (including CAMHS tier 3 & 4 provision) in relation to the range of therapeutic interventions for children with complex needs such as J’s in order to effectively plan for future provision.  LSCBs should consider what generic training and support should be in place for practitioners and managers outside child and adolescent mental health services in understanding self-harm and suicidal ideation and behaviour in order to strengthen them in offering support to family and carers or workers in universal services.  Questions for Safeguarding Children Boards: LSCBs should seek assurance that staff, including those in universal services, are aware of the legal aspects of parental responsibility and the significance of knowing who can make decisions for a child and when young people may be able to make decisions for themselves. Page 8   Care Planning (Child in Need, Looked After Reviews, Care Programme Approach & Multi-Disciplinary Work)  J was a child who, by the very nature of being a Looked After Child within tier 3 and tier 4 mental health provision, was extremely vulnerable, with complex emotional social, physical and mental health needs. There was a need for all professionals to work together to share information and bring together multi-disciplinary expertise in order to plan for J whilst an inpatient, and in planning for her future care and discharge. The statutory processes that are in place were not robust enough and did not achieve successful co-ordination, and this mitigated against achieving an overall care planning approach that met J’s complex needs.  Positive attempts were made to co-ordinate the two formal planning and review processes for Looked After Children and children in receipt of mental health services through the Care Programme Approach (CPA) – this review questions whether more should be done to bring these two systems closer together more formally and to ensure that professionals across disciplines have greater understanding of each other’s cultures and perspectives. A question has also been raised about the need for community based CAMHS psychiatry to be more directly involved with in-patient psychiatry as part of the CPA.      Management Overview & Leadership  J was a child with complex, Tier 4 mental health, needs who by the nature of her Looked After Child (LAC) status and her acute and chronic mental health needs, required the provision of a range of multi-agency services and specialist resources. This presented challenges both to the practitioners and carers working closely with J. Her needs resulted in the provision of expensive specialist resources. The SCR Panel expected that a child with such needs who presented such challenges to services would have been the subject of higher management scrutiny and monitoring and that practitioners would have received equally close supervision and reflective challenge. Initially the SCR Panel found evidence of reflective supervision, which it thought to be essential in this case, to be sketchy. However, feedback from practitioners and managers showed this to have been more robust and responsive. Some of the reflective supervisory thinking about J to support some of the frontline practitioners was undertaken within agencies rather than conjointly across agencies in a Team Around the Child Approach. A question arose about the reflective supervision for Independent Reviewing Officers how are the IROs supported in analysing and escalating complex cases which cross services?  Questions for Safeguarding Children Boards: Relevant boards should review how care planning for a child who is LAC and an in-patient of a Tier 4 establishment can be achieved to ensure a joint multi-disciplinary approach where the child’s holistic needs both whilst an in-patient and when planning for discharge can be effectively realized; and examine how, in circumstances when there are gaps in discharge planning arrangements/transition, these concerns can be successfully escalated to senior management and resolved prior to discharge. It is recommended that a joint multi-disciplinary working group is established to progress and it is further recommended that the work of this group is shared more widely to enhance national learning on this issue. Page 9        J’s Diaries A question which the Panel has raised and believes is important for learning to prevent serious self-harm in future similar cases is whether J’s diaries became a place for J to rehearse and acclimatise herself to self-harming and suicidal thoughts. J appears to have become de-sensitized to normal psychologically healthy barriers to survive, which may have counter-acted thoughts to harm herself or take her own life. It is clear that J thought about ending her life on repeated occasions over a protracted period. The continual detailed mental pre-occupation about anorexia, self-harm and ending her life through her writing, without supportive challenge from carers or practitioners, appears to have psychologically prepared her for the final event. The Panel questioned whether more could have been done to work with J to help her share her diaries and her thinking. Not all staff were aware that J kept diaries or journals. Some staff did hold back from looking at them or discussing them with her for fear of breaching her rights. The Panel considered whether practitioners had sufficient professional curiosity about what J was writing and how this could have been raised with her.      Consulting with J and establishing her views  This lesson links to and further develops those above. Whilst J was consulted with about her views on a number of occasions, in respect to making key decisions about her care the ‘Gillick competency’ test was applied. Gillick competency applies only to the issue of young people being competent to make a decision, without parental consent, about medical treatment. It was the view of the Panel and the Lead Reviewers that the application of this as a blanket approach to  Questions for Safeguarding Children Boards: LSCBs should be aware of what the current arrangements for supervision (reflective management) within agencies are; and what the joint-arrangements are when a child is receiving services across agencies? Are these the subject of regular quality assurance audit and challenge? Is reflective supervision currently being provided within agencies and how are outcomes being evaluated? Are current training programmes sufficiently promoting the knowledge base and skills of practitioners in understanding the impact of a child’s psychosocial history and in providing services to children with such complex needs? Are Agencies aware of which cases should be the subject of senior management scrutiny and review, and where needed, intervention in order to resolve any barriers to joint working?  Questions for Safeguarding Children Boards: Given the learning in the case how will relevant Safeguarding Boards seek to address the importance of holding a child’s writings such as diaries in mind when working with children and young people such as J. Do current professional training programmes address how this might be done? Is there a need to issue specific guidance in this area/amend existing policy/procedure to reflect the importance of this issue? How can professional curiosity be encouraged in a way to engage and work in counselling young people? Page 10   assessing J’s ability to make informed decisions about her care was misleading. It was their view that J’s competency to give agreement was variable - as it depended both on the question being asked and J’s needs at that time. Overall, it was felt that undue weight was placed on J’s ‘Gillick competency’ and that there were times when decisions needed to be made by someone who acted with parental responsibility (as a ‘reasonable parent’ would) and, as a result, on occasions make decisions that did not concede to J’s wishes. It is clear in hindsight from her diaries that J’s competency to make important decisions was often compromised.      Social Media/Internet Access  From J’s diaries and from agency records it appears probable that J used the internet or was aware of the content of ‘Pro-Ana’ anorexia web sites; she also used Facebook. Information from J’s diaries and from agency records, some of which was known to those seeking to support her at the time, raises questions about how professionals understand young people’s use of social media and possible negative but powerful influences, such as the ‘Pro-Ana’ websites. Given local safeguarding children policies about safe use of the internet a question arises as to how J was being guided on the appropriate use of the web in order to help her make more informed sense of the information that she was accessing and in her safe use of social media sites.     Questions for Safeguarding Children Boards: How widespread is the use of the ‘Gillick Competency Test’ used in relation to assessing a child’s ability to make informed decisions that have a fundamental impact on the care the child receives/how decisions are influenced/made? How will this be addressed so that the question of a child’s competency to make decisions is based on a solid understanding and appreciation of a child’s individual needs and informed capability? Could the assessment of capability used within the adult Mental Capacity Act be a useful way to inform LSCBs how this issue might be successfully addressed?  Questions for Safeguarding Children Boards: What knowledge and training do staff in different services have about the use of the internet to access websites and their risks, and how are staff equipped in understanding the use of social media sites to inform assessments and to safeguard children from harm? How are LSCB e-safety policies and procedures being applied? Page 11     Family details     Maternal Grandmother Maternal Grandfather Maternal J’s Aunt (1) Maternal J’s Aunt (2) DOB: June’58 DOB: Sept ‘65 Mother’s boyfriend Mother’s Partner Mother Mother’s Partner  Father of J DOB: Sept ‘59 DOD: NOV ‘11 Father of Brother DOB: Jan ‘61 DOB: NK DOB: NK J J’s half Brother DOB: Sept ‘99 DOB: Oct ‘91 DOD: July 2014  Page 12    J’s profile  Who was J?   J was a Black British young woman of African Caribbean heritage, her mother was Black British and her father was thought to be Nigerian. She was born in north London and spent her early years at home with her older half-Brother in the care of their mother. When J was 12 months old the Mother and children moved to the Midlands, returning to north London a year later where the family remained for J’s childhood until her mother’s death. In her early years J attended a childminder and local nursery, and later a nearby primary and secondary school. Whilst at school J was observed to be a bright child who did well, in her first secondary school she exceeded expected grades, she was noticed to be an avid reader. From her diary entries, and from observations made by various professionals, it was clear that J was creative with a particular flair for, and enjoyment of, art and fashion design. She was noticed to take pride in her appearance and many of her drawings were of fashionable items of clothing and accessories. In November 2013, when J was thirteen, her diaries reveal her hopes for the future and show she had an interest in photography, in learning a musical instrument and attending Art College. She enjoyed a number of peer relationships with both boys and girls although appeared to have had no close long term friendships. J was articulate and was thought to be resilient, she engaged well in meetings and in conversations with professionals. However, those that knew her well also felt she was ‘closed’ and did not often reveal her inner world. She was reluctant to talk about her experiences in depth and although she attended various therapeutic sessions was reluctant to engage and was clear that she did not want bereavement counselling. At times she made statements about her experiences which were known to be untrue.   J’s life and events, her family care and services provided to support her  The Timeline presented below has been compiled from confidential chronologies provided by the agencies involved in J’s and her family’s support. They comprised universal services (health and education), local authority children in need and looked after children services, community child and adolescent mental health services, a hospital emergency service, police, in-patient adolescent mental health services and an independent fostering. The table concentrates and comments on the information that was available at the time to the agencies which provided the relevant services, or information that could have been available.  The SCR Panel in reviewing J’s history analysed the information and identified key phases and transitions. Some general comments are made on J’s needs, assessment, support and intervention, use of procedures and available research and best practice.  The most important over-arching lessons and themes are identified separately in the Learning and Conclusions section of the report.      Page 13   Time Line J’s Journey  Phase Event / Actions Implications and Analysis Phase 1 Background and early history       J: Birth to 11 years  Sept 1999 J’s Birth  J born to in Islington, N London. It is understood her mother was a single parent. She had an older half-Brother. Later (for a few years) there was said to be a step-father.  The Aunt said he was only a boyfriend.  In late 2000 Mother was diagnosed with myasthenia   The family history, reviewed in retrospect and hindsight from the point of J’s death suggests there was a problematic bonding and attachment between Mother and J, from an early age. A family history was taken by workers in the first core assessment.       Early child hood and parental care  April 2002 J 2 years 7 months Records document J’s mother struggling to meet the emotional needs of her two children when J was 2 years old. During a home visit the health visitor noted Mother presenting as “extremely stressed”, she had difficulty managing both children’s behaviour – particularly J, and was worried that she could not meet J’s emotional needs. There was concern that Mother was experiencing a “manic episode”, Agency records state that she was distressed by the break-up of her relationship with J’s father (but it was not reported if he had been resident in the home). It is J’s Aunt’s view that this is incorrect.   An application was made for a nursery place for J, Mother was referred for counselling services and a referral was made to Children’s Social Care. The Health Visitor made an urgent referral to the GP for who saw Mother the following day. The GP referred Mother to a psychiatrist. Within weeks the psychiatric view was that Mother was more stable, she had placed J with a childminder 5 days per week and was appropriately responsive to J’s needs.   Children’s Social Care undertook an assessment but decided that no services were needed.  This brief psychiatric involvement, including medication, ended in summer 2002.   Mother had clear mental health needs. History of maternal mental health difficulties from Mother’s own adolescence. The multi-agency response to the mental health episode in 2002 was appropriate by health visitor, GP, mental health services and social care.  There was no clear picture of Mother’s partners – it is understood that she may have had three different partners – the fathers to her two children and a boyfriend -  but this is not clear.        J herself later made a historic allegation of sexual abuse by her mother’s boyfriend which would have taken place in this period. J also alleged later that in this period her Mother had told J to kill herself.   Page 14  Phase Event / Actions Implications and Analysis  2003 – 2007 J   4 – 7 years     Mother later described variable moods and depression throughout this period – see next entry.  Little is known of J’s primary school years and her educational or social progress.       Summer 2007 J Almost 7 years  In summer 2007 Mother was re-referred to psychiatric services by the GP after concern by Mother’s employers about her health. Mother described variable moods, listlessness, and depression, thoughts of dying, periods of low energy and periods of energetic mood over the previous three to four years. This resulted in various possible diagnoses, including: manic depressive illness, hypomania, bi-polar disorder and cyclothymia. Mother reported symptoms worsening after the birth of J, and psychiatrists noted mother identified a clear link between her relationship with her own mother and her relationship with daughter, J. J’s Mother was described as angry with her mother and of “not having a relationship with her”.   Mother later associated an increase in her own depressive symptoms when J reached 4 years old; which was the age Mother told professionals of having been separated from her mother and placed in (private) care.    There is no record of J’s or her half-Brother’s needs being considered as part of the assessment of this episode.           This memory is probably incorrect as Mother was placed in a residential nursery at six months. Her older sisters were in a neighbouring and linked children’s home and had regular contact with her. J’s Aunt believes this to have been a private arrangement made by their mother.  It is possible that J’s Mother’s first ‘memories’ would be from the age of three or four years hence her association of this with J at three or four years.   Towards the end of this period J was preparing to transfer to Secondary School - her Mother’s physical health was deteriorating.  Phase 2 Recognition of J as a child in need, Early Assessment and Support J aged 11 years 10 months to -12 years  April 2011 to early November 2011    Mother was diagnosed with pancreatic cancer and admitted to hospital in April. She transferred hospital for specialist care in the summer. Additional health concerns were myasthenia gravis, pernicious anaemia, asthma and hypertension.   J visited her regularly in hospital. J and her half-Brother were  The SCR Panel’s view was that this period was critical. It was an opportunity for Partner Agencies to come together, to share information and plan together for J’s needs.     Page 15  Phase Event / Actions Implications and Analysis  Mother’s illness, decline and death supported in the family home by relatives.  J’s Aunt visited the Mother daily in the hospital, supported J in her visits to the hospital and after the Mother’s return to the family home.  J transferred to secondary school in September.  Mother returned home in October with support from family and the Palliative Care Team.   The Palliative Care Team visited Mother at home, in order to complete an assessment to determine the services to be provided. A number of concerns were identified. These led to a referral to Children’s Social Care:  Mother’s diagnosis of pancreatic cancer  Differences of opinion between various family members about Mother’s needs and J and her half-Brother’s needs  Concerns, expressed by relatives about the half-brother’s ability to care for J and concerns about J’s future guardianship.  Mother’s relationship with J which was noted to be tense.        Referrals to children’s services and to the GP for the half-Brother were appropriate and timely.  12 years 1 month A parallel letter was sent to the GP, from the Palliative Care Team, outlining the referral to Children’s Services and the need for J’s half-brother to be provided with counselling therapy/ bereavement support ‘particularly in taking on a caring role for J so soon after mother’s death’.  The Palliative Care Team understood that Mother refused to allow J to be told of her impending death.     The Palliative Care Team visited regularly   Eight days after the initial visit by the Palliative Care Team Mother died at home.   J was aware that her Mother was acutely ill but professionals believed that J was not told that her Mother was likely to die as her Mother did not want this. This prevented pro-active work to support J with her mother’s impending death. J’s Aunt’s view is that J was aware that her Mother was dying at the time and confirmed this after her Mother’s death.   Page 16  Phase Event / Actions Implications and Analysis Phase 3 Recognition of J as a child in need, Early Assessment and Support J aged 11 years 10 months to -12 years     November 2011 to May 2012  J’s school informed Children’s Social Care that J was posting messages on Facebook saying she was alone at home crying. The school worked sensitively with J to help share the news with other pupils about her mother’s death. A social worker discussed this with J on the phone and was re-assured that J was managing the loss. J returned to school (her new school) in late November.  A social worker was appointed to support J and her half-Brother. J was recognised as a child in need and the primary task was to support the half- Brother in securing the tenancy to the Mother’s home and in claiming benefits. A Family Support Worker was appointed to assist with this alongside the social worker.    Acute bereavement, loss, poverty – neglect  In December a Children in Need Meeting summarised the recent history and noted that the half-Brother (18) – now J’s carer was ‘experiencing a lot of problems (financial)” and “seemed quite depressed”.  Add:  J’s Aunt has stated that she visited the home regularly throughout the period of the Mother’s illness and after her death. Visiting at least three times per week and often daily. She also cared for J in her own home in S London at weekends and in school holidays.   A further Children in Need Meeting in mid-January identified as positive that J and her half-Brother had returned to live in the family home. However, basic furniture, an oven and household equipment was needed and it was “unclear how half-Brother will adapt to role of guardian and manage the care of J”.    J’s Aunt has stated that J and her half-Brother never lived in his accommodation but both remained resident at the Mother’s  There were a number of CIN meetings in this period.  J’s emotional difficulties were becoming clearer, her eating difficulties were identified. “The amount of tasks which were undertaken during the core assessment prevented or distracted (the SW) from carrying out a detailed assessment of J’s needs” (Islington IMR)  There were questions about the ability of J’s half-Brother to care for her and meet her needs; and there were concerns about the home environment. As the half-Brother did not claim the necessary benefits, they were living in poverty; there was a lack of food, warmth and a shortage of essential furniture and equipment in the home, including no oven and for a period only one bed. The half-Brother had some of these items but there were delays in arranging their transfer to the family home. The Core Assessment did not explore in depth whether the half-Brother had the capacity to take on the role of caring for J, as her guardian; “Tasks are completed efficiently by social workers but the wider question of the capacity of ** (J’s brother) to care for J is lost” (Islington IMR). It was questionable to leave some of the tasks to J’s half-  Page 17  Phase Event / Actions Implications and Analysis address throughout her illness and death.  It was noted in social care supervision in early April that the half-Brother was finding it hard to cope consistently, as a result it was planned to convene a Family Group Conference to see if any other family members might be able to Care for J.  The referral for a Family Group Conference was made in early May; attempts to hold the Family Group Conference were unsuccessful as Family Members, except J’s Aunt, did not wish to attend. It was also noted in this supervision that it would have been punitive to use safeguarding / neglect procedures to tackle the apparent neglect and that moving from the half-Brother would be a further loss for J. It was noted that progress was slow.  School referred J to the ‘Friendship Group’, a CAMHS support service in February. However, when J met with the psychologist from the Friendship Group in mid-May she declined to talk about her Mother’s death and the social worker agreed to refer J to a CAMHS Tier 3 service.  J attended a number of Anxiety Group sessions run by CAMHS at the school, initially she engaged but then disengaged from these sessions.    Later, after this period, it was alleged that the half-Brother may have been abusing J during this time; this was not alleged to or known by workers in this period. Nor has subsequent evidence been found to substantiate it. J herself later said to staff that her half-brother had not abused her. It was J’s Aunt’s view that J had later said that the half-Brother had looked at J oddly and made her feel uncomfortable.  Brother who was not coping and at times reluctant to engage with the workers: “J’s basic needs were not being met”. When it became clear that the half-Brother lacked the capacity to care for J, the social work team did not look at alternatives. “(The SW) was tenacious in her attempts to contact him (half-Brother) …. However, in focusing on (half- Brother) and the urgency of the situation with regard to finances and accommodation, the full extent of J’s needs was overlooked…..These concerns were never put to (half-Brother) as they might have been if he were her parent. They were not considered at a strategy discussion where one might reasonably conclude that there may have been a possibility that she would be assessed as suffering significant harm.   The involvement of mental health practitioners/services commenced. J was referred to CAMHS Tier 2 and accessed this support through school. This was the first time her mother’s death was formally raised by professionals with J (some 5 months after Mother’s death). J was reported as reluctant to talk about her mother’s death. She was later referred to Tier 3 CAMHS.  Summary and Comment: There was a lack of focus on J herself in both phases 2 and 3 and on the cumulative effect of neglect of her emotional needs. “There was an assumption that she was in a supportive loving family with good attachments. However, J’s early life was without sufficient support and attachment and what was there fell away after the death of her mother. The thinking that her half-brother would be able to meet her needs was flawed. As a result, there was no one who truly understood J’s inner world and no one who tried to do this.” (Islington IMR).  There was little direct therapeutic work with J - although she did have the Support Group at school, but its primary focus was not for work with young people with such complex emotional problems.  It has been noted that minutes of CIN Meetings were not circulated.   Page 18  Phase Event / Actions Implications and Analysis Phase 4 A period of transitions J aged 12 years (almost 13 years)  Mid-June 2012 to end of August 2012   Late one evening J ran away to her Aunt in Lambeth following an argument with her half-Brother.  J’s Aunt agreed to take her in.    All the services required for J had to be re-assessed and re-initiated in south London. “The SW referred the case to Lambeth and carried out some excellent work …to ensure that J received the support services which had started to be put in place in Lambeth” (Islington IMR).  Change of carer, home, transfer from Islington, disengaging with talking support, concern about J’s emotional well-being  J told the support Group at school (Islington) that she was worried about having to move schools, but remained at the Islington school until the end of term. A few weeks later she was noted to be low in mood and disengaged and told the group that she was having flashbacks and stated: “someone might find out my secrets”.   End of July Referral from Islington Children’s Social Care to Lambeth Children’s Social Care. The Core Assessment noted the history and J’s low self-esteem, “caused by her relationship with mother”, which was described as “temperamental”, and identified Mother speaking to J in an abusive manner. J was reported to be “crying all the time” and writing on Facebook saying she was alone. The half-Brother was described as not being emotionally available to J. The unstable caring arrangements were noted. The referral noted concerns about J’s emotional wellbeing, eating difficulties, low mood and challenging behaviour at school.  Lambeth Children’s Social Care did not accept the case and so no services were offered.   Islington Children’s Social Care closed the case in August as there was no further role for them. Islington also advised J’s Aunt where she should seek assistance in caring for J, if needed.   J continued to be offered the support of the CAMHS Friendship Group at school. She was observed to be low in mood and starting to disengage from the group. She was worried about the impending change of schools. (J’s Aunt had not told J at that time that she may change school)  The clinical appointment for a CAMHS Tier 3 service was made for the end of August in Islington, after she had already moved to south London. J did not attend the appointment with Islington CAMHS in late August. Islington CAMHS initiated the transfer of J’s case.  The Islington referral and core assessment provided to Lambeth Social Care seen as part of this Review described the loss, that J’s half-Brother had not been managing well and that there had been financial problems. It was made because of concerns about whether the new arrangement with J’s Aunt was viable, given her previous reluctance to care for J. It raised concerns about J’s Aunt being able to manage J’s behaviour, which she found difficult at times. Questions were raised about J’s emotional stability and behaviour at school and J’s reluctance to accept therapeutic support. There were no safeguarding concerns and no mention of risk of self-harm. The key areas where it was thought that J needed continued support as a Child in Need were the possible unstable care arrangement and J’s emotional well-being. The referral was received by Lambeth but no services were offered, the reason for this is unclear: “The referral of J as a CIN with unstable care arrangements, recent loss and bereavement issues should have triggered an Initial Assessment ……..this would have been expected  Page 19  Phase Event / Actions Implications and Analysis practice…there is no rationale recorded on the system as to why this did not meet the CIN threshold” (Lambeth IMR). clinical appointment for a CAMHS Tier 3 service was made for the end of August in Islington, after she had already moved to south London. J did not attend the appointment with Islington CAMHS in late August. Islington CAMHS initiated the transfer of J’s case.  The Islington referral and core assessment provided to Lambeth Social Care seen as part of this Review described the loss, that J’s half-Brother had not been managing well and that there had been financial problems. It was made because of concerns about whether the new arrangement with J’s Aunt was viable, given her previous reluctance to care for J. It raised concerns about J’s Aunt being able to manage J’s behaviour, which she found difficult at times. Questions were raised about J’s emotional stability and behaviour at school and J’s reluctance to accept therapeutic support. There were no safeguarding concerns and no mention of risk of self-harm. The key areas where it was thought that J needed continued support as a Child in Need were the possible unstable care arrangement and J’s emotional well-being.     The referral was received by Lambeth but no services were offered, the reason for this is unclear: “The referral of J as a CIN with unstable care arrangements, recent loss and bereavement issues should have triggered an Initial Assessment ……..this would have been expected practice…there is no rationale recorded on the system as to why this did not meet the CIN threshold” (Lambeth IMR). Summary and Comment on Phase 4: Despite J’s high level of needs there was no continuity of support or care. J had now lost her mother, her home and the professional support services with which she was familiar.      Page 20  Phase Event / Actions Implications and Analysis Phase 5 CIN Assessment and Planning (Lambeth)        J aged 13 years  Sept 2012 to March 2013       Transfer from Islington to Lambeth CAMHS     Disclosures of alleged historic & recent sexual and emotional abuse  J’s Aunt enrolled J in a summer play scheme over the summer holidays so that she would meet local young people.  J started at a new school in Lambeth  In early September Islington CAMHS sent a summary to the GP, suggesting referral to CAMHS in Southwark. (This should have been Lambeth)  In mid-September Islington CAMHS contacted J’s new school – J was reported to be on the waiting list to see a counsellor but consent was required from J’s Aunt to refer to Lambeth CAMHS.  The same day Islington CAMHS contacted J’s Aunt by phone to gain consent to refer to Lambeth CAMHS – during that conversation J’s Aunt alleged to Islington CAMHS that:  J was sexually abused by Mother’s ex-boyfriend  J had described emotional abuse by her Mother including being given a plastic bag and told to put it over her head to kill herself.  J’s half-Brother and J were observed to be on the same bed and half- Brother was masturbating next to J whilst she was sleeping. (J’s Aunt has said that she did not report that he was abusing J or that he was masturbating but that he should not have been on the bed with J and was behaving oddly. It was not clear that J was asleep. J designed a thank you card for her Aunt referring to saving J.   J was reported to have described her half-Brother as viewing her in a sexual way and of being ‘emotionally unkind to her’.     The SCR Panel’s view is that this is as an important phase as J was experiencing a number of transitions and her significant emotional needs were becoming clearer.  Insufficient information about J was transferred from J’s school in N London to her new school, this was despite a wealth of information being held by the school and a considerable amount of work and commitment to J: “(There was) ….no transition planning with the receiving school. This is remarkable poor practice and would be likely to contribute to the vulnerability of a child moving to a new borough to a new school at a time in her life when she was bereaved and disadvantaged”. (Education IMR).  The Islington School Nurse Service was informed of J’s needs a few days prior to her move (this was a 7-month delay). No handover with the School Nurse in Lambeth took place.  During this period the following emerge: o Historic and recent allegations of sexual abuse o J’s level of emotional suffering/risk was clearer. Risk of suicide identified by CAMHS / Aunt had raised a number of concerns o J’s previous history becomes clearer, indicating early trauma: including possible child sexual abuse as a young child and emotional abuse. o The extent of self-harm was emerging. o J’ voice is noted but - she does not want to talk about her past as it is “too painful”. o J said that she felt like an “empty box”, “feels nothing”.      Page 21  Phase Event / Actions Implications and Analysis Islington CAMHS advised J’s Aunt to contact Lambeth Social Care and also referred this to Lambeth Social Care by email the same day, recommending a police investigation.  This was good practice   Lambeth Core Assessment as a child in need started J’s Aunt rang Lambeth social care and left a message, Lambeth social care returned her call and left a message. Two days later J’s Aunt attended the Lambeth Social Care office and repeated her concerns. Lambeth Social Care noted the concerns and directed that a social worker should gather information and speak to J, no timescales were agreed. There was no Strategy Discussion or sharing of information with the police. J’s Aunt stated that she showed J’s birthday book, containing wishes to self-harm, to a Duty Worker in this meeting, but there is no record of this.  One of the allegations of sexual abuse/sexually inappropriate behaviour towards J was recent: There should have been sharing of information with the Police Child Abuse Investigation Team in a strategy discussion to agree a section 47 enquiry and how J would be interviewed. “It would have been expected practice to initiate a Sc47 enquiry…. there is no rationale recorded as to why the procedures were not followed” (Lambeth IMR) Achieving Best Evidence procedures should have been considered. None of which happened and no consideration was given as to whether either of the two men alleged to have abused J may be a risk to other children. This was a failure to follow the agreed London Child Protection Procedures.      First anniversary of Mother’s death Islington CAMHS referred J to Southwark CAMHS which decided to screen for psychosis and Post Traumatic Stress Disorder. However, J and her Aunt wished to be seen by Lambeth CAMHS not Southwark.  A week after the allegation of sexual and emotional abuse a Lambeth social worker visited J and her Aunt at home. J repeated her allegations about sexual abuse. J’s Aunt queried why the half-Brother had been allowed to care for J. J’s Aunt gave social care the identifying details of the mother’s ex-boyfriend.  J showed pictures she had drawn of her Mother depicted as a devil, of being inappropriately touched by mother’s ex-partner, J putting a plastic bag on her head (with her mother standing beside her smiling), of self-harm (cutting and pills), of how she wanted to kill herself, and of her mother’s funeral when J is smiling (she is happy that her mother has died).  The social worker concluded that J had suffered significant harm in her mother’s care and was concerned “that she is withholding     This was a second occasion in which consideration should have been given to gathering information with the police under a section 47 child abuse investigation, but it did not happen: “There was considerable delay in speaking to J and there is no reason given for this delay…. this would have impacted on J negatively as having disclosed she would need reassurance people were taking it seriously and the disclosures about **** (mother’s boyfriend) have been lost” (Lambeth IMR).   Page 22  Phase Event / Actions Implications and Analysis all that may have happened to her”. A core assessment was recommended by the social worker and agreed by the Team Manager.  Lambeth CAMHS involvement              January 2013  Joint work CAMHS / children’s social care In November Islington CAMHS referred J to Lambeth CAMHS, noting a history of the death of J’s mother, “emotional and sexual abuse”, and “unusual experiences of having thoughts in her head that are not coming from her …. has described events that are not real and like a dream”.  Lambeth CAMHS appointed a CACS co-ordinator, with a view to refer to a psychiatrist.  J did not keep the first appointment, was seen at the end of November, but was reluctant to talk. Appointments were offered to J’s Aunt and J to complete an assessment.  In a CAMHS session, in November 2012, involving the CAMHS CACS coordinator and J’s Aunt, reference was made to mother’s death, but J was said to report that she does not want to talk about her Mother’s death.  In mid-January The CAMHS CACS Care Co-ordinator contacted the social worker who shared the history of maternal mental health and concerns about J’s Aunt’s current stress. J’s Aunt had described disagreements with J and J “not wanting to talk about the past as it is too painful”. J was described as “depressed sad/low in mood”. The need for a referral to psychiatrist is noted but no immediate psychiatric input or oversight is recorded.   J made regular visits to see the CAMHS CACS Coordinator with her Aunt. However: “there was an incomplete CAMHS assessment and a Child and Adolescent Brief Risk Assessment which was also acknowledged as incomplete…. this resulted in unclear management plans throughout Child J’s contact with Lambeth CAMHS” (CAMHS IMR).  J’s Aunt stated that she asked for bereavement counselling for J.  J’s Aunt disagrees with this statement, saying that she was committed to J and wanted help for her.    The first joint work in Lambeth – information sharing between Lambeth CAMHS and Lambeth children’s social care.    Relationship between J and her Aunt deteriorating Lambeth Children’s social care noted that the relationship between J and her Aunt was deteriorating.  The social care record noted that J’s Aunt described J as “unhappy/having thoughts of self-harming” “and has self-harmed in the past”. The record noted that J’s Aunt had stated that J kept a diary “that is full of negative thoughts”.   J’s Aunt disagrees with this statement, saying that she was committed to J and wanted help for her.  There was a delay in completion of the Core Assessment which was out of timescale. J was a child in need – there was not yet a clear assessment of her needs or how to respond to them.   Page 23  Phase Event / Actions Implications and Analysis Decisions were made by social care: ‘to complete Core Assessment, the social worker to take J to CAMHS appointment, the possibility of a family group conference to be explored, case to be transferred to Family Support Social Work Team’. The alleged sexual abuse was not included in these decisions.  There was increasing evidence that the family care arrangement was under great strain and was fragile.     Complex grief reaction  In mid- February in a joint meeting with the CAMHS worker and her social worker J said she was not going to share all her thoughts and feelings. She did raise concern about own mental health (hearing voices, talking about having psychic powers, seeing auras, feeling worried that she may have bi-polar or be schizophrenic).” Feels like an empty box, feels nothing, difficulties sleeping, low mood, self-harm, feels aggressive/angry towards others”.  There were no reported manic or hypomanic episodes and no current evidence of intent or plans to self-harm. It was decided to discuss the concerns with a psychiatrist and consider a meeting with J, J’s Aunt, social worker, CAMHS Coordinator and the psychiatrist.  The complexity of J’s emotional needs and the fragility of her situation were not being fully recognised by staff; compared to other children her needs were not seen to stand out. The alleged sexual abuse was not being dealt with and the ability of J’s Aunt to meet J’s complex emotional needs was questioned by social care but not discussed with J’s Aunt.  J’s Aunt felt that the depth of her commitment to J was not fully taken into account.   It is the view of the SCR Panel that J was suffering from a complex grief reaction to her mother’s death, coupled with possible early childhood trauma, J’s bereavement was not included in the treatment provided.   Psychological input recommended  At the end of February in a CAMHS review (J not present) A psychiatrist noted “2+ years of low mood worsening over the last year. Complicated grief reaction, irritability, mood swings, suicidal ideas and plans, impulsivity, and difficult interpersonal relationships. Low mood for most of each day over the previous two weeks. Occasional death wishes and suicidal plans”.   Psychiatrist recommended: psychological treatment; but medication was not required at that time.     J was seen by a psychiatrist in late February and towards the end of March.   Whilst under the care of Lambeth CAMHS J reported perceptual disturbances such as hearing voices and seeing images for a number of years, alongside odd feelings. She also described occasional suicidal ideas or plans – but at the time of the psychiatric review she denied any thoughts of harming herself or ending her life. She did not meet the criteria for diagnosis of depressive or anxiety disorder, bipolar affective disorder or psychosis.     February 2013  Throughout February both Children’s Social Care and CAMHS noted that J’s Aunt was struggling to care for J, J’s Aunt was anxious about her own complex and deteriorating health – a view was formed that Social Care noted:  The relationship with J’s Aunt was deteriorating. J’s Aunt was associating her own poor and deteriorating physical health with J’s behaviour and it was thought that there may be some risk to J  Page 24  Phase Event / Actions Implications and Analysis J may be at risk of physical harm.  as a result of this.  …. the response lacks some urgency Re: risk assessment, care planning/ contingency planning, given the possibility of imminent placement breakdown, ” (Lambeth IMR).    J’s Aunt has stated to this review that she wanted more support for J as time went on and that she felt undermined in her caring role.  She has stated categorically that the risk of physical harm to J was never raised by her or discussed with her.   March 2013   J’s writings / diary entries   In early March three separate pages of J’s writings/diary were scanned into the Children’s Social Care record – Lambeth Children’s Social Care chronology summarises them:  “Nov 2012: J feeling unwanted, low self-esteem. (Dated the day before the anniversary of Mother’s death).  Mid Feb 2013: feeling rejected by mother, hearing voices after mother’s death, physical abuse by mother in the past, seeing no point in living, unable to be happy. Not mattering to many people. J reported attempts to poison herself by inhaling fumes/drinking nail polish.  Late Feb 2013:  feeling unwanted, feeling there is no future”.   It is not stated how or when these separate diary pages came into children’s social care’s possession, they are not referred to in the running case notes, but stored in a document storage section of the electronic record as scanned copies.  There is no indication how their contents were used, the contents were later shared with CAMHS but advice was not sought through clinical supervision in relation to risk assessments. “The diary notes seen on 4/3/13 indicate how damaged J is and the level of risk to self……some of these entries re attempts to kill herself/self-harm are concerning and it is unclear how they were followed up” (Lambeth IMR).   Staff who worked with J and her carers later were unaware of the existence of these writings. Phase 6 Planning for J as a child in care     J aged 13 years  March 2013     Breakdown of care arrangement with  At the end of the first week of March it was agreed by Social Care that J should be accommodated (section 20 Children Act 1989); Social Care noted that J’s Aunt had said that she could no longer manage J.  The search for a foster carer was started.   J was looking forward to moving to a foster placement but had idealized expectations of her future placement. The family finding  J’s Aunt has stated to this Review that J coming in to care was a shock to her, she disputes that she requested this. But she has said that it was possibly a time for J to make a fresh start and possibly be adopted and get away from her troubled feelings. She thought that J had an idealized view of foster care and that J’s wishing to be in care was not challenged.    Page 25  Phase Event / Actions Implications and Analysis J’s Aunt  Planning Sc20 Care  referral noted a history of “moderate mental ill health” and recent self-harming. The need for planned placement/not an emergency placement, due to risk of feelings of rejection. A week later J met prospective carers and felt very positive about moving to them. However, the placement did not go ahead; the reasons were unclear. The Placement with J’s Aunt was becoming increasingly difficult. There was concern about J’s Aunt not being able to meet J’s needs and the possible impact of another change of carer on J’s emotional health.  J’s Aunt said that she had felt rejected and undermined by J being taken into care and subsequently she stood back as she was hurt.   This period of time offered an early opportunity to plan for J’s complex needs in care. J had a complex life story. The pieces/chapters needed to be held in mind to understand her needs and make effective plans. There were apparent aspects of resilience, although the notes from the diaries that were seen indicated that J’s inner world was characterised by thoughts of self-harm and suicidal ideation. It was not clear, given J’s history, that there had been an assessment of her ability to form and manage emotional attachments, such as those that a foster home may require. J had idealised expectations; careful placement planning needed to avoid future disruption (if possible) and offer security but this did not happen.   CAMHS assessment   The following week in a medical review at CAMHS. J’s was described as anxious and upset, although not meeting the criteria for major depression/anxiety. “J has clear idealised expectations of foster care which may pose hurdles and hurt”.  J met her prospective carer and felt positive about moving to her.  The incomplete assessments in CAMHS “…… resulted in unclear management plans throughout J’s contact with Lambeth CAMHS. In addition, gaps in assessment and formulation were not recognised or remedied. And so as J moved into LAC and then the private service her needs as an adolescent LAC with emotional and mental health vulnerability were not explicitly assessed and met in a coherent care plan.” (CAMHS IMR).  Phase 7 J became a Looked After Child (CIC)     Age 13 years and 6 months   March – April 2013        J moved from her Aunt to foster care under section 20 Children Act in the third week of March  J was noted to have felt rejected and hurt on moving from her Aunt although putting on an ‘upbeat face’.  J’s Aunt said that she learned of the planned move by text and  This period offered the next opportunity to plan for J’s complex needs as a child in care. There was confusion about the status and role of testamentary guardians. It seems that no formal care agreement was signed with the testamentary guardians. It is not clear why not, although this did not invalidate the care arrangement.   It is unclear to the SCR Panel how J was matched to this carer and  Page 26  Phase Event / Actions Implications and Analysis         Planning change of key workers  packed J’s belongings for the same evening. J did not say goodbye to her. She was also hurt by what had happened and how it had happened.   The Aunt states that she was not asked to sign any papers and did not receive copies of care plans, reports or reviews for J. She felt that it was all taken out of her hands and that she was not kept informed. Although invited she did not go to the first LAC Review (or subsequent) as a result of the way she felt she had been treated.   As a result of becoming looked after her CAMHS care was due to transfer to the Children Looked After Mental Health Service (CLAMHS). Her social work responsibility was also due to transfer to a different team.  what planning took place to prepare J for the move, however this placement proved to meet her needs well. J      J’s change of status from child in need to becoming a ‘looked after child’ meant that she would require a change of social worker (& supervisor) and from CAMHS to CLAHMS workers. The SCR Panel questioned whether these were systemic losses for a child who had already lost several key relationships. (See section on transitions and eco-map of losses).    Looked After Review J’s first statutory Looked After Child Review was held in mid-April. An improvement in mood (although variable) was noted in the new foster placement (‘very happy and very sad’), “low self-worth, struggling with low mood for a long period of time, struggles with her identity and reported as pleased her mother died, reported variable relationship with peers at school”. Care Plan: legal team to be contacted to resolve issue of no-one acting with Parental Responsibility for J. It was expected that J would remain in care long term.  J’s Aunt did not respond to requests to have face to face contact with J. She has stated that this was because she was feeling hurt and rejected. This period offered the next opportunity to plan for J’s complex needs as a child in care. There was confusion about the status and role of testamentary guardians. It seems that no formal care agreement was signed with the testamentary guardians. It is not clear why not, although this did not invalidate the care arrangement.   It was being recognised that J had acute needs. J’s future care would require effective inter-agency partnerships; particularly between social care, foster care, CLAMHs and school. The IRO appropriately recommended legal advice should be sought with the view to initiating Care proceedings.  The social worker recognised that J could seem resilient, but importantly noted that this may mask her internal world. This was a good observation by the SW but without a complete CAMHS assessment or input by a psychological/psychiatric it was difficult for the SW to conclude what J’s inner world was like.   Page 27  Phase Event / Actions Implications and Analysis Phase 8 Transfer of services between services / teams     J   13 years and 7 months   April -  May 2013  Looking after J in placement   Towards the end of April, a month after J moved to the foster home, the foster carer reported concern about J’s emotional wellbeing, J was at times “very low” and “not seeing the point in living”. The carer requested counselling for J. She was advised to contact CAMHS. The social worker noted that the Foster Carer may need additional support in caring for J. The Carer was advised to continue to risk assess the environment to safeguard J. The Social worker informed CAMHS of the Carer’s concerns and requested support for the Carer.    In these early weeks of placement, vital information was coming together to inform partners of J’s needs and future plans. There were significant concerns about J’s emotional wellbeing. There was good information sharing and a recognition that the Carer needed specialist advice and support to care for J.   Risk Management  A few days later the CAMHS worker advised the social worker of a conversation with the Carer about the Carer’s concern about J’s low mood, negativity, difficulty in functioning, and wanting to die. A Risk management plan for J in placement was agreed (including removing tablets, ligatures etc.) The CAMHS worker suggested J is “at high risk”. Discussion within CAMHS resulted in advice that “this is a pattern that is not inconsistent with previous episodes of low mood”.  Close support was offered to the Carer and she was linked to a Mentor (Carer) and given numbers to contact her own social worker or other workers out of hours. The fostering service undertook detailed risk assessments and supported the Carer in securing items which J might use to harm herself by hanging, cutting or ingestion. This was good practice.         Therapeutic Support  At the beginning of May, the CYPS Core Assessment was concluded. It provided comprehensive information and noted J’s early years and poor attachments. The allegations of historic child sexual abuse were noted.   Transfer of case from CAMHS to CLAMHS (Child Looked After Mental Health Service). Plan: ‘J to continue to receive art psychotherapy’.   In these early weeks of placement, vital information was coming together to inform partners of J’s needs and future plans. There were significant concerns about J’s emotional wellbeing. There was good information sharing and a recognition that the Carer needed specialist advice and support to care for J.   The risk of suicide was felt to be high, and some discussion with the carer took place in terms of risk management by CAMHS and by CSC (This was good).  However, the CAMHS risk management plan was incomplete. Risks were discussed at an internal CAMHS meeting but it was advised that this current period of low mood was consistent with previous  Page 28  Phase Event / Actions Implications and Analysis episodes of low mood: “her needs as an adolescent looked after child with emotional and mental health vulnerability were not explicitly assessed and met in a coherent care plan” (CAMHS IMR). It was not clear why there was no psychiatric input / advice to this case at this stage. It is noted that the CAMHS IMR identifies difficulty in the provision of psychiatric cover due to staffing gaps.  Whist J engaged well with the art psychotherapy there is no evidence that any other therapeutic support was offered. The services provided were of a high standard but J had complex needs, she was regarded as high risk of suicide by those that knew her best (FC/SW/CAMHS).  Overall, the service response to J by CAMHS did not appear to meet her needs   May 2013  Referral to the Police of the alleged sexual abuse The Social Worker contacted the Police Child Abuse Investigation Team (CAIT) about one of the allegations of Child Sexual Abuse made against mother’s ex- partner (Previously recorded in entries in Sept 2012) CAIT advised that there was no role for CAIT “as no disclosure by J”. Advised contact with the safer neighbourhood team.  Within days, following a decision in supervision the social worker talked direct to J about the allegations. J confirmed the details of her Aunt’s report and that she wanted to make a statement to police about her mother’s ex-boyfriend having sexually abused her, when she was a young child. This additional information was provided to the Police including details of the alleged abuser. The Police Child Abuse Investigation Team concluded that the allegation constituted a possible sexual offence but there was insufficient information to take the matter further.  This referral to CAIT was eight months overdue: “There are no explanations for the reasons for the delay recorded on file or acknowledged by the manager, it is clearly out of timescales” (Lambeth IMR). The referral did not include the allegations against J’s half-Brother this was a significant omission. A discussion between the police and the SW took place. “This discussion did not meet the criterion set out in the London Child Protection Procedures and decision was reached that this was a single agency (CSC) matter. J was a Lambeth LAC and her allegation was one of sexual abuse therefore the police should have initiated and led a criminal investigation in parallel with an LCS(CSC) initiated and led Sec 47 Children Act 1989 enquiry.” (Police IMR).  This did not happen.   J was spoken to directly by the social worker, she said she had been affected by what had happened and was keen to make a statement, this was passed on to the police but this was not progressed by CAIT: “This was a lost chance to develop the limited disclosure made a referral. The decision to proceed by means of a single agency investigation directly impacted on J’s opportunity to make and evidential statement” (Police  Page 29  Phase Event / Actions Implications and Analysis IMR).  J was disappointed by this lack of progress of her allegations and the SCR Panel’s view was that the likely impact was that J felt she was not believed. There was no consideration as to whether either of the alleged perpetrator may have previously been or continued to be a risk to other children. The allegations against J’s half-Brother remained unknown to the police until after J’s death.    J’s low mood By mid-May, eight weeks into the placement, the Carer was struggling to cope with J’s low mood and the impact on her own two children. The new CLAMHS worker met with the Carer’s supervising social worker and agreed to offer support to the Carer when needed.  Looked After Child medical. J’s ongoing emotional and psychological problems noted.    Case responsibility transferred to the LAC SW Team  This was appropriate and shows good linking between the Carer’s support social worker and the CLAMHS worker although the treatment plan remains unclear and there was still no psychiatric input / oversight.  This medical was robust and appropriate although health recommendations outlined in the IHA health plan were completed, this was not communicated to parties and there was a: “lack of formal assessment of risk of suicidal intent as part of the health assessment process” (Health IMR).  A new social worker and supervisor were allocated.  Phase 9 Early parenting of J by the Local Authority / partnership responsibilities      J aged 13 years and 9 months  Mid-June to Early July 2013    Awareness of suicidal thinking      The Carer reported concern about J having suicidal thoughts. The School described J as exhibiting behaviour that is manic and irrational. CLAMHS advised attendance at Accident & Emergency for a mental health assessment.  The Psychiatric assessment at A&E resulted in a diagnosis of depression (long term) and noted: “she was clearly depressed and had very little insight into triggers as well as what relieving factors are there to help and seems to be in a state of continuous helplessness”. The risk to self was concluded as moderate; medication/hospital admission possibly being required in the future.  J’s risk of suicide heightened. Appropriate contact was made with the on duty A&E psychiatrist which dealt with the immediate risk.  It is the view of the Lead Reviewers that this visit to yet another professional in an unfamiliar environment potentially could have been avoided if a community psychiatrist had been seeing J. The assessment completed by the on duty psychiatrist was of a high standard, clearly outlined J’s needs and how to manage risks at home and for the first a clear management plan is recorded on multi-agency files. There was a recommendation for J to be offered Cognitive Behavioural Therapy (CBT)  Page 30  Phase Event / Actions Implications and Analysis        J at high risk A 3 step management plan was given to J and the Carer. Art therapy was noted and Cognitive Behavioural Therapy (CBT) was recommended due to the severity and long standing nature of the depression, ongoing community management.    On seeing this comment the Aunt stated that this is how J had been before coming into care.   The Carer continued to report continuing difficulties in caring for J.  CLAMHS placed J on ‘high risk’ case list and set up weekly appointments for J with the CLAMHS Care Coordinator. Over the next two weeks J attended these with her Carer.   Supplementary information provided to this review states that the taking therapy subsequently undertaken by the CLAMHS Care Coordinator with J was within a framework of CBT; alongside group sessions for young people who hear voices, attendance at a local art project, and an offer of a referral to a bereavement project.    “(There was) a view that J’s difficulties and risk factors were related to psychosocial stressors rather than mental health risk. (There was) a greater need to understand the impact of both on this young woman” (CAMHS IMR).  Phase 10 Care Planning / Corporate and Partnership Support    J aged 13 – 14 years  July to November 2013  Long-term  Care Planning   The second Looked After Review was held in early July. The need to progress legal proceedings to gain a Care Order so that the Local Authority could hold Parental Responsibility was recommended (this had not progressed since the first LAC review) and the need for J to be seen by a psychiatrist in the community was also noted. The long term care plan was confirmed as long term fostering in the current placement.  The recommendations to pursue care proceedings and for psychiatric overview whilst appropriate lacked follow up.   The IRO engaged J well and sought to understand J and to establish her views. The involvement of the IRO service and the impact of the LAR process is detailed at the end of this report.   Responding to risks  The Art Therapist highlighted two additional areas of concern in regard to two incidents shared by J in the art therapy group, both related to J reporting that she may seek to harm others. In one J claimed to keep scissors for protection (alleging that she was ‘almost sexually assaulted on the street’ and managed to avert assault by holding the scissors to the man’s throat’). J’s school the school had no knowledge of incidents described by J. This information was shared with CLAMHS, this constituted good information sharing. However, these statements were not followed up/investigated.  Good inter-agency communication.      The GP received a letter from paediatrician requesting blood tests to explore J’s tiredness and to test for ‘haemoglobinopathies’, symptoms noted of myasthenia gravis and requests neurology  These medical checks were progressed but the results were not communicated to professionals involved in J’s day to day  Page 31  Phase Event / Actions Implications and Analysis   Risk assessed as reduced  referral, ophthalmology review, audiology check(tinnitus) and ENT assessment (recurrent nose bleeds). In early August J and her Carer attended two further appointments with the social worker and CLAMHS co-ordinator. J was noted to be brighter in mood, looking forward to the summer holidays and no concerns were identified. The risk assessment plan was reviewed and confirmed and the carer was advised to take J to A&E to see a psychiatrist if she was concerned.  care.  The foster carer engaged very well with CLAMHS and followed through on the advice she was provided. She showed ongoing commitment to J despite the obvious challenges. “It was unclear where the clinical senior oversight was in this case” (CAMHS IMR).    Planning for J’s Long Term care      Responding to allegations At a social work visit, J was advised of care proceedings and became visibly distressed about the thought of possibly having to return to the care of her family. She spoke about her low moods/difficulty in sleeping and mood swings, that she was unable to control. J was sorry for her Carer ‘who is finding J’s moods difficult’, and said; ‘on two occasions her Carer broke down and started crying because she did not know what to do about J’s low moods’.  J continued to express the need for her previous allegations to be investigated.  At the end of August J raised concern that an old friend was in contact with her mother’s ex-boyfriend and was concerned for her friend’s safety (she was also upset that her own allegations about sexual abuse had not been followed up).      J’s disclosures still had not been the subject of investigation, this was now almost a year after she first made her allegations. This was significant for J. The SW followed up these statements with J but there was a confusion about the information held on file about the alleged perpetrator, and there was no further follow up.   J reluctant to continue in therapeutic work   Matching J to long term carers   In early September J did not want to continue attending meetings with the CLAMHS Care Coordinator as she felt she did not have a good relationship with co-ordinator, and did not find sessions helpful. J was referred to the bereavement project, ‘voice collective group’, art project as alternatives. At the end of September, the Local Authority Placement Panel confirmed that a permanent long term foster placement should be sought for J.  J was able to express her views about continuing to attend CAMHS however her views were not explored and so remained unheard “(There was) …no evidence of exploration with J about why she did not want to engage in one to one work” (CAMHS IMR). Attempts to identify an appropriate permanent placement and to match J to carers took place 6 months later. J was just 14 and it was important that some form of permanency was arranged for her – there had not been an assessment of J’s attachment and her ability to form emotional attachments within a family. Hence plans for J’s  Page 32  Phase Event / Actions Implications and Analysis future remained unclear.  Therapeutic support Low mood, fragile behaviour – stress on the Carer At the beginning of October J started the ‘Voice Collective Group (a therapy project)’. Over the next three weeks J spoke about how to manage her voices/coping strategies.  In early October J’s bouts of low mood and fragility of behaviour are discussed with J and her Carer during a home visit; although overall the placement is reported to be going well.  The significance of J possibly hearing voices was appropriately shared with CAMHS, but there remained no psychiatric overview. Information available suggested the foster carer was providing a good level of care to J and was committed to her. However, she was struggling with J’s care. J is aware of this and the inference that her behaviour impacted on adult’s health/wellbeing (her Mother had blamed her for this in the past).   J’s legal status Legal advice was received that the Local Authority did not require Parental Responsibility as J was seen to be ‘Gillick competent’. It was suggested that J’s half-Brother and J’s Aunt should be asked ‘to renounce their Parental Responsibility’. It is not clear how this competency was assessed or whether it was based on age alone or whether her vulnerability and actions were taken into account. Gillick competency is not a relevant test to apply in these circumstances. The Looked After Review had made recommendations about care proceedings but this was not pursued, the reason is not clear.  Poor food intake At the end of October beginning of November: There were concerns about J’s poor food intake and vomiting/gastroenteritis diagnosed at A&E (although there was some confusion over whether this was a physical illness or a symptom of J’s emotional difficulties).   Family Group Conference and long term planning  J was told by her social worker that family members had pulled out of a planned Family Group Conference (FGC) to explore if any member of the family could offer a home to J.  (J’s Aunt has stated that she was unaware of this).    The decision to proceed with a FGC was questionable. It is unclear why return to family care was being considered, it was assessed that J’s testamentary guardians were unable to meet her needs and the previous LAR had confirmed J’s care plan to be long term fostering. It is unclear why a FGC was being pursued. It does not appear that consideration was given to whether sharing this information with J would be harmful to her in compounding existing feelings of rejection/being unloved. Staff advised the Independent Reviewers that the advice they were given was that the FGC must be undertaken as a precursor to Care Proceedings as the Court would require this.  Page 33  Phase Event / Actions Implications and Analysis The view taken here is that the Local Authority should have been prepared to demonstrate to the Court why this was not in J’s best interests, rather than slavishly follow procedure.  In mid-November the Local Authority confirmed J’s care plan to be long term fostering.  In the same meeting J’s social worker raised a question with J about her low food/liquid intake. J talked about wanting to lose weight. J showed the social worker her Facebook and pictures of her family. J asked about future placement plans. She spoke about the current placement being “boring” and requested a placement change. The social worker noted on file “I have the feeling that J’s cultural needs are not being fully met. J is a very creative young person and likes to be stimulated”. A previous review had confirmed the care plan to be long term fostering in the Care of FC1. The comments on file about the placement not matching her cultural needs/not providing sufficient stimulation were simplistic, this was a good placement where J’s most pressing needs in relation to stability and safety were being met.   Response to therapeutic support The CLAMHS co-ordinator continued to meet the Carer and J, there were further concerns about J’s eating. In a meeting at the end of November J was seen to be low in mood and did not want to attend talking therapy as “no-one understands” and “she does not find this helpful”.   This was the third time J expressed her views on her meetings with CLAMHS. “(There was) …no evidence of exploration with J about why she did not want to engage in one to one work” (CAMHS IMR).    Phase 11 Planning for J’s care as a long term child in care     J aged 14 years 3 months  December2013 –  early January 2014   Concerns about eating  In early December J’s third Looked after Review took place. The possibility of J having an eating disorder was raised. A recent 3-day fast was described. J was also described as eating continuously and then making herself sick; she was described as “closed” and of recently feeling down. A possible referral to a psychiatrist recommended and care proceedings recommended.  The recommendations to pursue with Care proceedings and for psychiatric overview whilst appropriate, lacked follow up. The IRO engaged J well and sought to understand J and to establish her views. The involvement of the IRO service and the impact of the LAR process is detailed at the end of this report.  J’s family confirms that none of them can care for her   J attended the Family Group Conference and heard her family members stating they could not look after her, although promises were made by some family members to have contact with her. Given that the plan has already been confirmed as long term fostering the value of this meeting is questionable and the impact on J hearing this in the FGC was not considered. It is the view of the Panel that this increased J’s sense of being alone.   Page 34  Phase Event / Actions Implications and Analysis   J’s Aunt described holding back as she felt inhibited by the circumstances and had had no indication that J may wish to return to her.       Adoption is ruled out.   Response to growing concerns  In Art Therapy, J’s mood was very flat; she spoke about the need to lose weight/to exercise and spoke about “wanting to go up for adoption”. J discussed adoption with her social worker and she was told this was unlikely given her age.  The CLAMHS coordinator continued to meet with J and her Carer up to Christmas and in one session focused on J’s eating. J “wants to be a size 6 and will not eat until she has achieved this”. The Carer expressed serious concerned about J’s low mood and J’s eating, the Carer was advised by CLAMHS “to take a step back”, as there were no immediate concerns about J’s health. Just before Christmas J avoided a meeting with the CLAMHS Coordinator as she did not want to talk. She was reported as being teased at school by peers as she had a crush on a girl.  The art therapy provided was of a good quality it was consistent and J engaged well communication by the Art Therapist with the multi- agency group was excellent.    J faced final rejection from her family and her hopes of a substitute family (through adoption) were challenged. The impact on J of these two issues coming together were not considered.  The Designated Nurse for looked after children contacted the social worker concerned about the pattern of J “binge eating and starvation”. J spent Christmas Day with a cousin and family. A few days later J’s Carer reported J was eating more sensibly, contact with maternal family had been positive; and J was “in a better mood. J also spent New Year’s Eve night with wider family.    Response to growing concerns At the end of the first week of January the Carer reported that J was “very low in mood”; she was concerned about J’s emotional welfare. The social worker spoke with J who ‘had nothing to live for, no family, and no friends and could not see past the day’. The social worker contacted CLAMHS for advice.       Page 35  Phase Event / Actions Implications and Analysis   The CLAMHS coordinator proposed to seek advice from the psychiatrist on “whether further intervention is required”.  The school expressed concern about J’s behaviour and her low presentation, J was unable to make plans or see past the end of the day. CLAMHS informed the social worker that the risk was “not regarded as high enough to warrant urgent discussion with psychiatrist”. Discussion with a psychiatrist was planned for the following week.  “There was poor team discussion on high risk cases”. Formulation and risk assessment plan remained incomplete and the lack of psychiatric overview and management in the community remained ongoing: “It was unclear where the clinical senior oversight was in this case” (CAMHS IMR). Phase 12 J’s first (known) active suicidal intention / behaviour and admission to in-Patient Unit J aged 14 years and 4 moths  Early January 2014   The following day the Carer found J in her bedroom with the window open and dressing gown cord tied like a noose. J was taken by the Carer and social worker to A&E and was seen by the on duty psychiatrist.  J was angry she had been found out. She confirmed she had been planning suicide for some time and had self-harmed by using the blade of a pencil sharpener. J spoke about having researched various methods of suicide, on the internet. She spoke of her plan to go out with her friends on the Saturday evening for dinner (“last supper”), before committing suicide. She spoke about a previous attempt in Feb ’13, and of self-harming in October ’13. She had feelings of hopelessness about the future and worthlessness, reported feeling secluded and cut off from her family. It was concluded that J was at high risk of suicide. She was admitted to a paediatric ward overnight, 1:1 supervision provided.  The A&E psychiatric assessment noted deliberate self-harm from the age of 6/7 years, a history of emotional abuse and sexual abuse by mother’s boyfriend.  J’s first (known) active suicidal intention/behaviour and admission to In- Patient Unit.        This was the second time J was seen by a psychiatrist on an emergency basis, it is a good assessment and clear.  “There was a poor handover from consultant psychiatrist to successor (Inpatient unit) and there was a confusion about responsibilities” (CAMHS IMR).   J’s Aunt states that she was not informed until late evening of the concern.  Page 36  Phase Event / Actions Implications and Analysis Clinical observation was “severe depressive episode with psychotic features, suicidal ideation, strong and ongoing (chronic background of severe abuse and traumas)”. Medication, CBT and group therapy recommended.   Phase 13 J’s early weeks in the In-Patient Unit J aged 14 years and 4 moths   Mid-January – Mid March 2014  Children’s social care agreed to retain the foster placement for six weeks, while J was in hospital  On being informed that J was in hospital J’s Aunt indicated that she wished to exercise her role as Guardian; as a result, the Local Authority decided to initiate care proceedings.  This was appropriate.     This was appropriate (albeit delayed)   The In-Patient Unit noted that J reported possible auditory and visual symptoms and likely symptoms of Post-Traumatic Stress Disorder. She also reported previous bulimic behaviour. She had previously had thoughts of drowning herself or taking overdoses.  Initial presentation was severe depressive episode with psychotic feature, in addition strong suicidal ideation (chronic) – with no current urge - a background of severe abuse and traumas; and low self-worth.  The aim of the admission was to clarify diagnosis; to manage current levels of risk; to stabilise her mental state and ensure appropriate follow up and community support.  She was seen for individual therapy on a weekly basis. J thought that talking was pointless and planned to kill herself by any means possible. Safety measures were put in place.    Page 37  Phase Event / Actions Implications and Analysis She was diagnosed with severe depressive episode without psychotic symptoms and Post-Traumatic Stress Disorder. J agreed to receive medication in discussion with the psychiatrist.  At the end of January, it was noted that after a long period of low mood and suicidal thoughts, J’s mood had improved, J had started to talk of past traumas/flashbacks. She was not taking offered medication (to assist sleep) but was attending Cognitive Behaviour Therapy (CBT) and Dialectical Behaviour Therapy (DBT) sessions.  The Care Programme Approach Meeting due at the end of January was cancelled (as the psychiatrist was on sick leave). It is not clear what alternative arrangements were for CPA Meetings in the absence of the Psychiatrist.   February 2014  By mid- February J was engaging in therapy sessions, although engagement was noted to fluctuate. Her feelings were predominately of shame, guilt, anxiety and sadness. She was frequently observed to react negatively when her Foster Carer or J’s Aunt did not visit as frequently as she would like, although both maintained phone contact with J and visited J on the ward. Regular risk assessments were undertaken and J systematically attended ward rounds and weekly reviews with her key worker was prescribed medication for depression and mood disorder (to reduce her risk of impulsive behaviour). J did not engage well with therapeutic work offered. “There was no in-depth understanding of J’s history…and there was no attempt to undertake a full family assessment”. J was found to engage “only minimally in key work sessions and groups and was found to be “guarded throughout her admission” (Inpatient Unit IMR).  J’s Aunt stated that she was unable to care for J long term and agreed to the Local Authority taking legal proceedings. J’s Aunt spoke of her own emotional health problems and of J’s mother “starving J, then force feeding her”- as reported by J.  A ‘Looked after progress meeting’ took place in mid-February where it was confirmed that a Foster Placement would be sought for J.      LAR progress meetings have no formal status or authority. Given that the decision was to look for an alternative foster placement, this constituted a change in care plan, procedures dictate that this should have led to a formal LAR.  There were no minutes of this meeting and community CAMHS were not in attendance.  This is not good practice.  Page 38  Phase Event / Actions Implications and Analysis  J’s Aunt stated that she was unable to care for J long term and agreed to the Local Authority taking legal proceedings. J’s Aunt spoke of her own emotional health problems and of J’s mother “starving J, then force feeding her”.  The SW visited regularly, this was good practice.  The Local Authority commenced seeking a new long term foster placement on the understanding from advice by the in-patient unit that this was the most appropriate form of care for J.   March 2014  At the beginning of March J went on day leave to her Foster Home but returned in low mood feeling “unwanted”. When talking about a new foster family J was optimistic but also spoke about feeling that “she avoids getting attached to people as she predicts they will just leave”.  Throughout March 2014: J’s mood was changeable on the ward, she spoke about wanting to kill herself and hearing ‘a voice’. Her relationship with food was variable; she had very low goals, she felt unwanted by her foster Carer (‘she thought she would be there until 18 years’). J was taking prescribed anti- depressant and sleeping medication.  J’s mood temporarily improved after two male patients were admitted; she had emotional feelings for one of the young men. But her mood quickly deteriorated and attempts at self-harm were identified.     Phase 14 Planning for J’s discharge from the In-Patient Unit to long term care    14 years 6 months   Mid-March to Mid-May 2014  Children’s social care commenced the search for a suitable long term foster placement. J had requested to be placed “with a lesbian couple preferably with pets”.  J was placed on red risk due to staff finding that J had attempted to drink cleaning fluid and staff had found a knife in  J has lost another attachment with a significant adult (foster carer 1) and at this point no future placement has been identified. She had packed her belongings and these had been moved into storage. J was in limbo, the impact of this on J did not appear to be given the required attention. J’s Aunt stated that she was not informed about this.   Page 39  Phase Event / Actions Implications and Analysis her room.  March 2014 During March a Looked After Child Health Review Assessment (RHA) was completed. A number of the recommendations, from previous assessment were believed to be outstanding, including the CLAMHS assessment, blood tests, ophthalmology, neurology, and ENT appointment and dental reviews. This RHA identified that a significant number of recommendations from the HA a year previously were outstanding, as it was believed no action had been taken by GP/LAC Nurse/ LAC Doctor to progress. The recommendations were reassigned to the SW, this was inappropriate. In fact, the recommendations had been progressed by the GP, but there had been no communication about this with key professionals. Planning for  J’s future At a second “LAR progress meeting” J’s recent self-harm of cutting and drinking shampoo was identified Scored ‘abnormal’ in all domains of emotional and behavioural development in Strengths and Development Questionnaire (SDQ). It noted that a careful discharge plan was required. The meeting noted that J was “sad that placement with her Carer was coming to an end” and noted “J does not want to go into residential care, insisted on placement with a single female carer”.  J was noted on ward to be very sad and low, about the change of foster placement, showing anxious and volatile behaviour, “hiding in corners”, not attending DBT or CBT.  The meeting noted the need for a careful discharge plan; this was appropriate. However, the meeting had no formal status or authority and it did not link with the CPA, this was a missed opportunity to achieve robust integrated planning. The decision to pursue another foster placement appears to have been taken in discussion with a number of professionals however there was a lack of sufficient consideration of J’s attachment profile/psychosocial history in making this decision: “No one professional sought to gain in depth information relating to child J’s early childhood experiences” (In-patient IMR). April 2014   Care Programme Approach Meeting at the beginning of April. J had very low self-esteem and depressive episodes. The Consultant felt that the current volatile behaviour was linked to anxieties about her future placement. Medication was not having an impact. Consultant was recorded as saying DBT may be of benefit in the future. J was reported as handing a note to nursing staff about “things they do not know about her past…the friend, the drug phase, the actions and the plans” (details unclear). J was reported as not feeling suicidal at present, but she continued to ‘disassociate’ when distressed.  Later in April the social worker visited potential foster carers but – neither set was deemed suitable as a result of the needs of other children in placement. It is noted that medication was not having an impact and that J had not fully engaged with therapies offered. J’s current difficulties were being linked to social anxieties. The note J passed to staff was concerning, but was not the subject of further investigation.       It is not clear how this competency was assessed or whether it was  Page 40  Phase Event / Actions Implications and Analysis Final Legal Advice was that Care Proceedings were not required for J as she was “Gillick competent”. based on age alone or whether her vulnerability and actions were taken into account. Gillick competency is not a relevant test to apply in these circumstances. The LAR had made recommendations about care proceedings but this had not yet been achieved, as a result of the social worker’s workload.  Planning for J’s future At the end of April, the Care Programme Approach Meeting noted J’s mood fluctuated. At times, she was tearful and angry; at other times, bright and engaging. There were periods of distress, making self-degrading comments about herself; she had been overheard planning to abscond. A risk management plan was put in place. J was no longer reporting feeling suicidal, she continued to disassociate when distressed, and appeared confused as to her whereabouts. She was said to be internalising her feelings. Medication was not effective. Going to visit a FC placement, confused about what she wants’. J was thought to be going through a dip due to high anxiety about a new placement, feelings of hopelessness and abandonment.   J had spoken to staff ‘about being in a cult/gang, when she saw some horrible things and that they tried to make her jump in front of a train’. This was not the subject of curiosity or investigation   Residential care was considered at the meeting but was felt to be a last resort, only if a foster placement could not be found. Residential care was felt ‘not to be ideal for J’ and that ‘any residential placement would need to ensure it met J’s emotional health needs’.  J was noted to be have frequent phone contact with her half-Brother and her Aunt. Her Aunt also visited regularly, but a fraught relationship between J and her Aunt was noted by staff. The Aunt has stated that this was on one occasion only as J was cross with her for telling staff that J had been bullying other residents.  J was told of the Foster placements which were not going ahead,  The quality of professional discussion and decision making on this issue is questionable. The question about J’s attachment profile (her ability to form appropriate relationships and manage in a family) and the risks of a future family placement breakdown do not appear to have been considered. The primary issue at this point was the need to manage the risks in a placement. There does not appear to have been a discussion about a hierarchy of needs and there was no consideration about whether a secure order might be required.  Page 41  Phase Event / Actions Implications and Analysis she appeared ‘visibly upset almost demoralised’, and then disengaged from communication. May 2014  Identification of new foster home and risk assessment At the beginning of May, a prospective independent foster home in Kent was visited by the social worker, only the foster father was at home. The following day the Independent Fostering agency confirmed that both Foster parents were agreeable to J’s placement. The Foster Agency noted the need for a thorough risk assessment given J’s history.      This was appropriate but was not provided or, later, effectively chased / escalated.    May 2014   In Mid-May the Ward Round noted J was anxious about the new placement. Her mood was changeable, she was ‘chaotic’, ingesting soap, dismissive when asked about feelings; had erratic eating (purging /binging); and had a dissociative episode in a CBT session (‘incoherent, speaks about seeing images of a group doing things to children and fears the group will come to get her. Feeling unwanted’). Her observation level was increased to every 30 minutes. Risk stated; ‘as in previous meetings’.  At the same time The Social Care Supervisory Decisions were: care proceedings to be initiated. It was noted that there was no current contact with J’s Aunt or half-Brother. J’s Aunt says that this was not correct as she was visiting J two to three times per week at this time.   Plans for J to be introduced to the Kent foster family were confirmed.  Notes from The In-Patient Unit indicate that J was not responding to therapy, medication appeared to be the only consistent treatment. At this time, it was felt that the medication was not effective. Both the implications of this and the treatment plan were unclear.  J’s worrying statements about seeing images were not the subject of curiosity or investigation.  Risk assessment/discharge/ transfer of care/ consideration of alternative placements (such as secure/residential) were not discussed.   There was no written risk assessment in relation to this overnight stay.   J went to stay in the foster home for two nights. On return to the In-Patient Unit J told the staff that the ‘leave had gone really well’.  The Fostering Agency requested a risk assessment from the In-Patient Unit and was advised that ‘a verbal (oral) risk assessment had been provided to the foster carers’.  Whilst it is understood the Foster Mother was told of the risks she did not understand the seriousness of these risks and the risks were not sufficiently articulated in a risk management plan.  The lack of a risk assessment was critical. It is unclear how decisions could be made, in relation to whether carers are able to keep J safe,  Page 42  Phase Event / Actions Implications and Analysis  A few days later the Ward round noted ‘Risk details as before….. J has told a peer she will kill herself on discharge…. No concerns from nursing team, observation every 30 mins. Nursing staff report mood fluctuation ‘from extremely low to excitable within a short space of time. J denied suicidal thoughts; has the appearance of anxiety but does not identify with this’. Two days later J went to the new foster placement in Kent, for a period of extended leave without this risk assessment. The significance of J informing a peer she will kill herself on discharge is noted in records held at the in-patient unit, this is not the subject of interrogation and does not impact on discharge planning. The statement of ‘risks as before’ is ambiguous: this is a critical time in planning for J’s safety on discharge.  There was no viable risk assessment completed in relation to this extended leave.  The In-Patent Unit requested that Lambeth CLAMHS referred J to the local CAMHS team in Kent, where J would be placed and J’s discharge from the In- Patient Unit was planned for six days later. Given that it was planned that J is to be discharged 6 days later, this request to transfer care back into the community was late, The Panel’s view is that Kent CAMHS should have been consulted as part of the planning as soon as the Kent foster home was identified, Kent CAMHS should have been invited to the planning meetings.  It is also noted that Kent County Council was not consulted about this placement as it should have been.  The In-Patient Unit was concerned that throughout J’s placement there had been no direct community psychiatrist involvement from Lambeth CAMHS.  Phase 15 Transfer of J’s care to a new foster placement and community    J 14 years and 8 – 10 months  End of May to July 2014    J is discharged      J returned to the In-Patient Unit for the Care Programme Approach Meeting which was also the discharge meeting and was discharged to the new foster placement the same day.   The Unit noted: J has not self-harmed for several weeks. Been quite guarded since admission and not wanted to talk about her previous traumatic experiences, therefore this is still a need for this to be addressed in the community.  This was a critical period involving the transfer of care/risk into the community and the transfer of day to day care to new carers/new agency: “At no time either at admission or discharge was there a consultant psychiatrist psychiatric discussion/liaison” (In-patient IMR).  Although towards the end of her stay in the in-patient unit J was thought to be more trusting of staff she had not fully engaged in therapy to address underlying trauma. This coupled with a previous  Page 43  Phase Event / Actions Implications and Analysis                              The Plan was for the Foster Carers to contact CAMHS if concerned. Early warning signs /relapse indicators discussed were discussed with the Foster Mother (Foster Father did not attend the discharge meeting) but were not put in writing.  entry stating that medication was no longer effective suggests that J was being discharged with no effective treatment in place to address her long standing depression and no follow up secured.  No check had been done that the Kent CAMHS had been notified of J’s placement or needs or the risk. This was contrary to NICE Guidance on transfer of cases. It would have been good practice for the Kent CAMHS to have been invited to and attended the CPA Meeting.  This was not appropriate – the risk assessment and actions to be taken should have been put in writing in a risk assessment (such as the one used with the first foster carer) and a check that the Carer/s fully understood what was being asked. No written plan or actions were passed to the Fostering Agency. There was no contingency or relapse plan in place. Although the Carers had some previous experience of young people with emotional health issues it was not clear that they had experience of this kind of behaviour or understood what to look out for or how to handle J’s moods or behaviour. They did not understand that there was still a risk of suicidal behaviour.  J’s early days of placement and transfer of care and services  The Lambeth Social worker visited the following day.  The Foster Carer said the move had gone well; she noticed days when J’s mood had been low, relationships with the other foster children were noted to be good. J was on anti- depressant and anti-anxiety medication and reported as compliant with taking medication. J requested her belongings, which were in storage, from the previous foster home.  The social worker understood that Kent CAMHS had been notified of J’s placement although application for funding from Lambeth CLAMHS to Kent CAMHS had not been made and still required progression before treatment in the community could start.    It was good practice for the SW to visit so soon.  J had been placed with no local CAMHS provision, no school place and inadequate risk assessment/risk management plans. “There was an unreasonable delay in making a referral to (the local) CAMHS and barriers to the referral were not escalated through senior clinical management lines…. her needs as an adolescent Looked after child with emotional and mental health vulnerability were not explicitly assessed in a coherent care plan” (CAMHS IMR).  “The foster family had no direct experience or training that covered working with inpatient mental health services or in caring for young people who had a recent history of depression/suicidal ideation and  Page 44  Phase Event / Actions Implications and Analysis self- harm. This should have prompted a greater degree of support and guidance” (Fostering agency IMR). There was an assumption in this IMR that this guidance should have been provided through the in-patient unit, this did not happen and the support provided to the foster carers by the fostering agency was inadequate.  There should have been a follow up visit by the ‘host’ CAMHS to J 7 days after discharge, this did not happen and was unacceptable.  First week of June The Foster Mother registered J with the GP immediately and went, without J, after a few days to ask for repeat medication as J had been discharged with only 5 days’ medication. She handed over a handwritten pro-forma discharge note from the In-Patient Unit, which had minimal information. The GP gave two weeks’ medicine and insisted on seeing J before prescribing more.   This was good practice        The In-Patient Unit Care Programme Approach Review/Discharge planning notes (from the meeting at the end of May) were faxed to the social worker a week later. They reported ‘J brighter in mood since new placement found, engagement in groups superficial since admission, not discussed previous traumatic experiences, needs community follow up support, had suicidal thoughts previous week but did not act on these. Unclear if improvements due to medication or environmental factors. Contingency plan: warning signs noted. Particular risks identified as self-harm suicide ligatures self-neglect (restricting diet/purging)’.  The Social Care Deputy Practice Manager visited the placement and observed the placement to be ‘going well’. Social work supervision – noted that the referral to Kent CAMHS should be completed by the end of June; J was noted to be settling well.  This delay was not acceptable and the risk management plan was insufficient in managing the risks and in guiding the foster carers.   Practitioners in Kent were being asked to take important clinical decisions without sufficient background or a true understanding of risk. There was too much reliance on the foster carers to hold the risk.  The absence of a robust risk management plan was not identified and the lack of continuity of mental health services was not recognised as a potential area of concern.  Mid-June 2014  The Foster Mother returned with J to the GP. J’s recent in-patient care was noted, she was reported as settling in well after two The GP acted appropriately and supportively – but the 6-day delay in faxing the referral to Kent CAMHS was not acceptable. However, it  Page 45  Phase Event / Actions Implications and Analysis weeks and to be taking her medication regularly. The GP noted a positive relationship between the Foster Carer and J. No concerns were reported, although occasional bingeing and fasting were mentioned. J was chatty and seen to be open. She reported no suicidal ideation or self-harm since the move to the foster home. The GP agreed to follow up the referral to Kent CAMHS (although this was not in fact done until six days later). He offered ‘open door’ to return for support if necessary. was not the GP’s responsibility to make this referral as the GP did not have all the required information. Mid-June 2014 Three days later the social worker visited the placement and noted that the placement was going well. The need for a school place was identified, the local school had said the Local Authority (Lambeth) needed to complete the application for a school place. It was noted that there was currently no support social worker from the Fostering Agency.  The same day the LAC Review was held and noted: ‘J remains concerned about body image. Settled in well, and relates appropriately in the household’, noted not to be in school, ‘appeared happy in placement’. The Health needs previously identified by Designated Nurse for Looked After Children was not discussed.  The Care plan recommended was: ‘J to remain in LA care under Sc31 at current placement’, care proceedings recommended. Diagnosis of clinical depression noted. ‘CLAMHS to start work with J on 31/7/14’. It was noted that no placement agreement was in existence as meeting has not been held. J had been in Kent for three weeks and was not in school. A school placement would have added additional support, structure and safeguarding for her.    The LAR was again recommending Care proceedings, this has been repeated from J’s first review, contrary to the IRO regulations there has been no escalation of this delay to senior managers. Despite the previous meeting stating the need for robust discharge planning, the absence of such planning was not the subject if escalation by the IRO.   The sense of urgency of a young person being discharged from four months as a psychiatric in-patient was lost. This referral was urgent and should have been given much higher priority, there was an 8-day delay in sending the appointment letter. The SCR Panel’s view is that the referral to Kent CAMHS should have been completed before J’s discharge from the In-Patient Unit and Kent CAMHS should have been invited to the discharge meeting. Part of the reason for the delay was awaiting receipt of discharge reports from the In-Patient Unit and consulting with J. These delays were unacceptable.  In mid-June Kent CAMHS received the referral letter from GP and screened the request as a non-urgent referral. Three days later they accepted the referral and offered a routine appointment.   In the third week of June the Fostering Agency visited to support    Page 46  Phase Event / Actions Implications and Analysis the Carers and noted that a risk assessment had still not been completed.  The same day the Local Authority social worker and Fostering Agency met to complete the Placement Agreement. It was noted that it ‘should have taken place prior to Looked After Review to determine delegated authority and remit of placement’. It was also noted that a new Agency Supervising social worker had not yet been allocated. The Local Authority social worker was to visit every 4 weeks.    The purpose of Placement Planning meetings is to identify the needs of the child and the action that needs to be taken, in the immediate future, about these needs by carers, support workers and others. These delays were unacceptable and compounded the lack of support/ guidance provided to these carers. The Agency should have escalated the issue of the lack of a written risk assessment. The gap and change in support workers possibly impacted on this. Delay in local CAMHS support Four weeks after the start of the placement the Lambeth social worker received the CLAMHS referral from Lambeth to the Kent CLAMHS with the required history, discharge summary and documentation and forwarded it the same day. The CLAMHS Co-ordinator had first contacted Kent CAMHS before J left the In-Patient Unit. Kent CAMHS provided a referral form and requested details of the GP and a discharge summary from the in- patient unit. The day after J’s [permanent move to Kent Lambeth CLAMHS asked the Lambeth CCG Commissioner to ensure that funding would be provided for J as a non-Kent child. The required information was emailed in the last week of June but not accepted by email – hence it was sent by the social worker by fax. July 2014  At the beginning of July, the Fostering Agency visited the Carers. This delay in providing routine support to the foster carers was not acceptable.  Mid-July 2014  A few days before her death J telephoned her first foster carer in the evening. During the conversation J said that everything was ‘fine’. She thanked the carer for looking after her and said ‘if not for you I would not be alive’.   The Aunt reported that J had also said this to her.  The day before J’s death  The newly appointed independent fostering agency supervising social worker visited J and the Carers in order to support them. The Lambeth social worker visited the same day. J was seen to be in a positive mood and talking about her future education.  It was learned after J’s death from J’s Aunt that on this same day there was a telephone conversation between J and her Aunt in the       This is hindsight and was not known until after J’s death.   Page 47  Phase Event / Actions Implications and Analysis late afternoon, they had spoken for an hour. J had been animated, was positive about visiting her new school that day, there was nothing in the conversation that suggested that J was planning to take her life. J offered to send her Aunt a wool or rag doll that she had made or to send her rock candy, but J’s Aunt declined this.   That evening the Foster Carers went out for the evening for a family celebration leaving their adult daughter (an approved carer) to care for J and the younger foster children. It is understood there was a minor disagreement between J and the adult in the household.   J’s death The following day J was found in the early afternoon, hanging by a belt from a pole which was fixed into her bedroom wall as a clothing rail. Resuscitation was not attempted; it was concluded J has been dead for some time. She was not discovered earlier as her Carer was allowing her to sleep in.  The risk assessment had not identified the risk of hanging, hence the presence of a fixed solid clothing rail (a scaffold pole) in J’s bedroom had not been identified as a risk. It remains unclear whether J had been taking her prescribed medication.      Page 48   J’s Voice J’s diaries  After J died her diaries were discovered. During the course of this Serious Case Review these diaries were made available to the Lead Reviewers. The diaries that have been seen start in September 2012, and end just before J died in July 2014. An earlier diary was made available to the Independent Reviewers by J’s Aunt which has entries which pre-date J’s Mother’s death. There are references to J’s ‘dairies’ in agency records. J’s Aunt gave J a number of large notebooks to use as diaries in which to write down her thoughts. J’s first foster carer was aware that J was writing in a ‘notebook’. J’s Aunt and the first foster carer expressed concern about the content. Staff at the In-Patient Unit were also aware that J wrote in notebooks and also encouraged her to keep a diary – although the Review has been advised that the books recovered after J’s death were not part of any therapeutic work at the Unit. The full significance of these diaries was only fully realised after J’s death.      The pages reveal neatly written accounts of J’s inner world and include many sketches, lyrics from songs or lines from poems. They provide a moving account of a child’s inner world, a world that was increasingly marked by hopes and struggles of finding love; and meticulous recordings detailing food and fluid intake, plans of weight loss, and relentless self-denigration. On many occasions J clearly stated that she wanted to be anorexic, and there are a number of references to ‘Pro-Ana’ (assumed to be Pro- Anorexic websites - see below). There are many references to suicidal ideation, and to self-harm. Whist J was living with her foster carer (foster carer 1) in Lambeth these references are not significant but it is acknowledged that not all diaries covering this period were available to the Lead Reviewers. The entries relating to anorexia ‘Pro Ana’ and self-harm increase in intensity over her period as an in-patient. Whilst in her foster placement in Kent (foster carers 2) J’s diary entries reveal that her thoughts of self-harm and suicide were ongoing.  Family and Carers’ Views  J’s Aunt and half-Brother and her Foster Carers were invited to meet the Independent Reviewers to share their perspectives on the support that J was offered and that they were offered to assist them in caring for J. The invitation to the half-Brother was returned from the address where he had been living and he was not seen. The summaries provided here are taken at face value. J’s Aunt was seen with a friend who also knew J. The Carers were seen with their support social workers.      Page 49   J’s Aunt  J’s Aunt described a background where she and J’s Mother had grown up in ‘private’ care themselves as children, resulting in complex family dynamics. Until her Mother’s illness and death J had been more distant from the wider family in south London. J’s Aunt became more involved when J’s Mother was dying. She had been unaware that she was to be designated as Guardian alongside J’s half-Brother. She was not advised of the legal implications of this or of the responsibilities and rights it involved in carrying Parental Responsibility. She thought that she had 50% guardianship only and she remained unclear about her status as a testamentary guardian until she met with the lead reviewers as part of this review.  J’s Aunt described being fully involved on a daily basis when her sister, J’s Mother, went into hospital in April 2011. She visited the hospital daily and then called in each evening to check on the well-being of J and her half-Brother, returning on the night bus to south London in the early hours. She told the lead reviewers that she did not initially want to care for J after J’s Mother’s death as she had observed J’s behaviour which was difficult; but she but supported J and her brother by visiting them frequently to offer practical support and provide resources. She had J to stay with her in south London for weekends and half-term. She was aware that J’s half- Brother was finding it hard to cope and although she attended child in need meetings she did not understand the plans of the school or children’s social care, she felt excluded and like an onlooker at the meetings that she attended.  She had sight of some diary entries that pre-dated J’s Mother’s death which were worrying and contained suicidal thoughts. She said that she passed this to the social worker at a meeting at the school (Islington social care has no record of this but states that J’s Aunt told them of the concerns). When J was living with her she gave J some notebooks to write down her thoughts and J would sometimes leave them open for her to see, J also gave her notes or hand-made cards; examples were to apologise to or thank her Aunt.   When J ran away to her Aunt’s home J’s Aunt took her in, but she was not sure if she would be able to cope with J’s behaviour. However, she made a bedroom for J and supported her in moving to a school nearer to her home, and communicated with the school about J’s background and circumstances. She spoke about outings they would have together and how her adult sons and their families would occasionally entertain J for the day, weekends and half-terms. J’s Aunt had no financial support for J for the first few months whilst she was living in her care.  When the lead reviewers asked whether J would accept affection she replied saying J could accept cuddles or would want to hold her Aunt’s hand at times; but she would often regress and J was often clingy and anxious when they were out of the home together.  Increasingly J would also ‘explode’ at home and her J Aunt would talk with her. J was self-denigratory, describing herself as ugly, saying she wished to be dead and that no-one loved her; she described her mother as evil and of abusing her. J’s Aunt encouraged her to talk but the explosions continued from time to time – occasionally J would ‘glaze over’ and when asked what the matter was would say ‘nothing’. J would often write things down on sheets of paper or in books and leave them out for her Aunt to read. J’s Aunt continued to be worried about what J wrote and about J’s behaviour, on one particularly memorable occasion she recalled that one morning, the day after a CAMHS session, she asked J if there was anything wrong; J spoke about trying to kill her Mother with bleach, and being glad that her Mother was dead, wishing that she was herself dead, and saying that she hated her Aunt and would kill herself - before running out of the house. J’s Aunt sought help from Lambeth social care duty service that day by going in to the office. She said that she showed a manager J’s diary; J’s Aunt was concerned about what J was writing, she was worried that J would harm herself or kill herself or would run away. Page 50    J’s Aunt felt that when the social worker started working with J, J started to shut her Aunt out; and that J wishing to go into foster care came from the conversations between the social worker and J. J’s Aunt had not wanted J to be accommodated but it seemed J increasingly wanted this and so her behaviour became more difficult, making it harder for J’s Auntie to manage. She had not wanted J to be accommodated and so did not co- operate with the family finding and described being hurt that J was going in to foster care. She said she learned about the planned move to the foster home by text, which made her angry. When J moved - there were no goodbyes. Thereafter, she remembered being invited to the first Looked After Review meeting but not to subsequent meetings. She said she felt shut off, ‘left high and dry’, treated as if she was a ‘criminal’, and was angry about this. There was no contact between J’s Aunt and J whilst J was in foster placement 1; she thought that J would contact her when she was ready.  She attended meetings at the In-Patient Unit and visited J regularly but felt that J had put barriers up to people and the staff could not push past those barriers. ‘J shut down and would have none of it.’ In her view Staff would deal with the new issues and current behaviour but did not seem to get to the underlying problems.  J’s Aunt did not feel that she could say that she would take J back as J had not asked to go back to her. She did not feel as if she was being consulted, she had to remind staff that she had ‘part-guardianship’. She was concerned that J was to be placed in the country away from London on discharge but felt re-assured that the foster carers had previous specialist experience in dealing with mental health problems.  She had no face to face contact with J after J moved to Kent, support for this was being arranged, but she did have phone contact with J.  The day before J’s death she rang J. J talked about wanting to buy some turquoise steps that she had seen for her room and a scarf. J wanted her Aunt to have some knitted toys that J had made or some rock candy. In retrospect J’s Aunt wondered if J was bequeathing her things.  Foster Carer 1  J’s first foster carer was a single parent of African heritage, with several years’ experience of fostering for the Local Authority. She described J as very intelligent, attractive, artistic, clever with crafts; and smart dressing, with an eye for design and colour.  J had had emotional problems from when she was little. J had described feeling unloved by her mother; and that her half-Brother could not cope with her. During the placement J had wanted contacted with her Aunt but felt that this was not reciprocated. (J’s Aunt, on learning this as part of the review said that she was not told this at the time.) The Grandmother occasionally telephoned the foster carer and J spoke to her on the phone.  J had contact with her wider family in the summer for a family event including the foster carer and spent Christmas Day with her family but did not feel part of the family. She also went out for the night with family members at New Year, which J found a better experience. J found the Family Group Conference traumatic. She felt that no-one wanted her. She was increasingly unhappy after New Year 2014. Her mood changed frequently. Page 51    The Carer felt very well supported by her fostering-support social worker who she could contact in emergencies. She also had a very good link and felt well-supported by J’s social worker, who she thought was a very good social worker for J. The Carer was well-supported by the CLAMHS Co-ordinator and was able to ring her between the weekly sessions which the Carer attended with J.  When J moved to the In-Patient Unit she continued to visit J – initially five days a week and later three days per week and occasionally took J out. There were good risk assessments and reviews by the fostering support social worker (instigated by the Head of Service) looking into J’s self- harming behaviour and what actions were required to prevent her harming herself. Sharp items and the washing-line were removed and chemicals were locked away.  J’s mood swings were extreme one minute up and the next down. J had said to the Carer –‘one day I will do myself in’ and ‘there is no point being alive; ‘I have no dad, no mum and no family’’. The Carer felt that J trusted her and talked to her easily.  The school was helpful and made allowances for J’s behaviour; the Carer could talk with them as needed. J could be panicky in crowded places, and around her peers and had few friends. She became close to the Foster Carer’s daughter.  Caring for J was full-time - she had never had a child like J before but hoped that by encouraging J and talking to J about her own (at times adverse) experiences that she would be able to help J. There were times when J was pretending. J would say ‘everything is okay’ when it was not and would say that there are things that the In-Patient Unit did not know.  J would draw on paper. One example was an A3 sheet of paper which she discussed with the Carer where J drew pictures and talked about having no-one and suicide. J drew pictures of people with tears and said that that was how she felt. That is when she went to the hospital for the first A&E psychiatric assessment.  J did not use the computer much but did use Facebook to keep in touch with her half-Brother and old friends. J would sleep early but slept poorly. J ate well, was tall and slim, ran and jogged; and had a good body but was worried about her weight.  After J had been in the In-Patient Unit for several weeks this foster placement came to an end J cried and was screaming about losing her place in the foster home. But the Carer was clear that she could not offer all that J needed through one to one surveillance, as she had been asked to do on a possible home visit, as she had her own children to care for. She was also worried that J would hang herself in the foster home.  The Carer felt that she had all the help she needed, including mentoring from a more experienced Foster Carer, and could not have asked for more. She undertook additional training in suicide and loss which she found helpful. The fact that the CLAMHS Coordinator was based in the same building as the social work services was also helpful. Her own older daughter was a great help.  The Independent Reviewers were impressed by this Carer and what she offered J and believed that what was described by the Carer and by the social workers was a developing attachment between J and the Carer. Page 52   Foster Carers 2  The Carers have over 11 years’ experience of fostering 37 children. In their view J was the most intellectual and creative child they have ever fostered. They believed (in retrospect) that they had not been given enough information about J. They understood at the time that she had depression, which they thought from previous experience that they would be able to deal with. Their initial concern when they first learned about her was rather that she was a young black girl being placed in an area where there are few black children.  When they were first sent information about J they spoke with their link-worker and then the Lambeth social worker met with them and the Foster Mother also spoke with the keyworker at the In-Patient Unit a couple of times. They asked questions about J and as a result thought that they could try to meet her needs. They learned that J had been ‘cutting her arm’ and that her depression was linked to her body image.  From the Discharge Meeting at the hospital the Foster Mother understood that there had been no new incidents – but later has wondered if the hospital held things back. She would have liked a one to one with the Psychiatrist to learn more about J.  They were both clear that they did not understand at all that there was a risk of suicide. Both Carers were shocked on learning from the Independent Reviewers that the reason for J’s admission to the In-Patient in January had been what was seen as a serious risk of suicide. They said that they had not known this. They thought that J’s behaviour had been assessed as a ‘cry for help’ not as a concern that J would seek to take her own life. If they had known that they would not have offered the placement as they would have been concerned about the possible impact on their two foster children. They were clear that they would have put the other children’s needs first.  The first contacts with J in Kent and in London went well before J moved to their home permanently.  No specific risk assessment was done for the foster home specifically for J. The Carers had removed razor blades from the bathroom as they knew J had cut herself; they thought to do that from previous experience that they had had. They had not been asked to do so or think about other areas of possible harm, such as rope or chemicals or medicines.  J was concerned about her weight and dieting but she was not starving herself and ate well. J had no access to the internet at home – except on her phone, to use the internet on the computer she had to go to the library.  When the Foster Mother went to the GP to get the repeat prescription the script had not been sent through by the In-Patient Unit and so she had to contact the Unit to ask them to send it to the GP. When she took J to see the GP for more medication, J was more concerned about her height, she wanted to grow taller, like her Mother, and she was worried about a curve in her back; the GP re-assured her. The Foster Carer did not remember if the GP asked specifically about self-harming thoughts or behaviour.  J took the medication twice a day. The Foster Mother kept the medication and gave it to J to take, watching her most of the time; it did not occur to her to Page 53   check that J was swallowing it, as she was not advised to check that J had actually swallowed it. J did not like the medication as she thought it affected her sleeping. J ‘clicked’ with the other two foster children quickly, especially the older one who was nearer her age. They bought her a bike so that she could go out with the other girls and J decorated it in a very colourful way.  J was not in school and so J and the Foster Mother spent the days together while the other children were at school. J would write stories, poems and songs, and draw. The three children played together and got on well. J was very creative and would make things – especially rag dolls. She played the guitar, liked to paint old furniture, and was interested in clothes and trinkets from second hand shops. J chose colourful clothes or materials which she would use for her handicrafts or accessorising. They never went to furniture shops with J and had no knowledge of the ‘steps’ which J had referred to in her phone conversation with J’s Aunt. They believed J to be settling in well. J described it as a ‘fresh start’.  J kept in contact with old friends through her phone, she liked YouTube and used FaceBook to speak to her half-Brother, who, J said, was unhappy that she was in foster care as he should have been looking after her.  The Carers felt well-supported. They had fostered for eleven years and know a number of staff in the Independent Agency – as some of them have previously been their link-workers. Although they did not feel that they needed it, the Agency rang every Monday to check how the weekend and previous week had gone for all the children.  When their link-worker left suddenly they did not feel worried as they did not think there were any difficulties and they could contact the Agency if they needed to, with confidence. There was always someone they could talk to, if needed. They were visited by one of the Agency’s staff before the new link- worker was appointed.  The Lambeth social worker visited each week after J was placed, except for one week when a different Lambeth worker visited. The Carers thought this was helpful. They could also have called her if they needed to.  The day before J died, the Lambeth social worker met J and the Foster Mother at the prospective school which J would start in September. The meeting went well. J was very pleased that she would not have to repeat a year, having missed so much school. J described this as her ‘happiest day’. J declined a visit back to London the following week with her social worker. That evening she wished to make cakes for the Foster Father as it was his birthday.  They were unaware that J had rung her previous Carer or her Aunt in the few days before she died. They did not know that J had kept diaries until after her death when the diaries were found among her belongings; although she shared her other story writing, pictures and songs with them.  When asked what they thought Agencies could learn from J’s tragic death the Foster Carers (2)  said:  ‘Give full information – all the information you have got. Don’t put roses on things.’  ‘Do what you say you will do and get things done.’ Page 54   ‘Did they think about the other children? When placing a child, like J, think about the other children who are already in the home.’  Learning and Conclusions – including learning from the NHS Health Overview Report  The purpose of a serious case review is not to blame but to seek to understand ‘what happened, and why, and what action will be taken to learn from the review findings’2. The review should also be proportionate. Such understanding must review the actions undertaken by agencies within the agency context, the systems, knowledge and skills that were in place to inform the assessments made, and the actions taken, including any systemic dynamics which were not intrinsic to the case management but which may have impacted on it. Where responsibility is shared across agencies Local Safeguarding Children Boards and their Member Agencies will want to know how effective the multi-agency information sharing, joint assessments and co-working have been and whether agreed local policies and protocols have been used and are fit for purpose.  In the analysis above the table of commentary has evaluated the work done at the different stages of J’s journey from both individual and multi-agency perspectives. Those lessons do not need to be repeated here.  J was in a unique position. She had lost her mother in tragic circumstances and her family was unable to care for her. Her needs were complex and, over time, became more compounded. The moves across administrative boundaries complicated this and increased difficulties in understanding her needs and responding to them. She was also entering adolescence. For staff in Tier 3 and 4 mental health services she was not unusual, for staff in non-health services she was a complex child.  Her ‘journey’ through the child in need and safeguarding systems was mixed. She was identified as a child in need prior to her mother’s death and received support. Assessments of her family’s ability to meet her needs were insufficient and did not recognise when she had become a child in need of protection as a result of acute physical neglect, which she concealed. Although her emotional needs were being seen, the depth of those needs does not appear to have been fully recognised, nor that they were not being met (and possibly could not be met) through her wider birth family. She was experiencing emotional neglect, requiring protection services. Transition from one geographical area to another was not well-managed or co-ordinated across services between Islington and Lambeth – perhaps because it was thought her family would manage this. She continued to be a child in need but was not, initially, accepted as such by Lambeth Children’s Services – a transitional child in need meeting covering health, CAMHS and schools would have been beneficial to ensure that J’s history and unusual needs were known and well understood and that there was a smooth transfer of co-ordination of the help she needed. When both historic and current allegations of possible sexual abuse were made, a formal section 47 child protection assessment led by a strategy discussion or strategy meeting should have taken place and information should have been shared and sought from key agencies who were supporting J. This was delayed and did not follow national or local guidance.                                                             2 Working Together to Safeguard Children, 2015 page 72  Page 55   When it was clear that J’s Aunt could not continue to care for J and concerns were noted that J may be self-harming, there was information sharing across services but a lack of co-ordination. There was also confusion about her legal situation and whether she was ‘competent’ to make decisions for herself, simply because of her age – regardless of an assessment of her capability or the impact of her continual experiences of loss and feelings of rejection. When J showed the need for more specialised child and adolescent mental health services these were provided but there was a lack of co- ordination. She was offered different forms of therapy and the opportunity to speak about her losses but declined this. Workers who were not from specialised mental health services looked to the specialists to work with J and advise them. Other processes such as Looked After Review processes appear to have become compromised by deference to CAMHS. As a looked after child there was drift in planning and lack of a timely needs assessment to secure J’s future and appropriate care arrangements. When J needed fourth tier specialist and in-patient mental health input other systems recognising her status as having no parent and needing longer term planning had a lower status. More was needed to ensure that the systems worked closely together. J’s behaviour was increasingly risky – but much was hidden from those seeking to protect her; and when glimpses of J’ self-denigrating, self-harming and suicidal thinking did emerge her denials were readily accepted.    Risks were considered when J was being prepared for discharge from the in-patient unit the transfer to a new family in a new area. Risk of relapse was not spelled out. The SCR Panel’s view is that the transfer was too speedy. J required a whole new range of service providers and these were not in place or coming in to place when she moved. Staff had known that there needed to be a risk management plan in place and that J would require local mental health services. Actions should have been taken to put these in place before her move and to involve those services in the discharge planning and preparation for her care. She was moving to an area where she was unknown.    Such lessons as these are not new, there is no new or magic solution. Appropriate policies and procedures are already in place but pressures, lack of co- ordination and information sharing impacted by other non-case related agency dynamics distracted from J’s needs. Although unique in many ways J was like many other children in need. The Review Panel questioned whether the severity and uniqueness of her losses and her situation were missed as she seemed, on the surface, like many other children in the looked after system.    J’s Aunt had mixed feelings about offering to care for J but supported her extensively in the period before J’s Mother’s death and after when J was in the care of her half-Brother. When J ran away to her Aunt, her Aunt took her in and intended to offer J a home for life; but wanted more specialist help for J from psychological services as she thought that J was very troubled. She loved J, provided a home, sought services for her, supported her in change of school and attending CAMHS. However, J’s Aunt felt rejected by J when J went into care and so stood back; becoming involved again when J was admitted to the in-patient unit. J ’s Aunt did not feel listened to or supported by services in her concerns about J.   The foster carers in Lambeth and Kent offered J affection and good family care, and made good quality relationships with her. But it was asking a great deal of such families to manage the potential risks that J posed to herself without greater understanding and training or experience of self-harming behaviour or an understanding of eating disorders and poor self-image.  J’s diaries, with the benefit of hindsight, show that she was probably more troubled and self-denigrating than could have been known by those working with her at the time.  Page 56   Over-arching themes and lessons  A range of lessons have been identified during the process of this SCR. The methodology used to conduct this review has allowed senior agency representatives to take lessons back into their respective agencies as they have emerged, and to implement action plans in response to these service/agency/team specific findings. Some of the lower priority lessons are included in the Timeline. In line with relevant SCR guidance in relation to proportionality, key priority lessons for relevant Safeguarding Children Boards are detailed below. They represent the most important overarching lessons for LSCBs and multi-agency partners.  Bereavement, Transitions and Losses  The eco-map in the appendices depicts J’s significant losses, estrangement, or the ending of a relationship (denoted in white); as can been seen these are significant. The number of times J moved home is not included in this eco-map. J moved home several times between the ages of 12 and 14 years. She moved from her home with her mother and half-Brother to the home of her maternal Aunt; and then moved to the home of foster carer 1; from there she moved to the in-patient unit.  Whilst there she lost her home with foster carer 1 and her belongings were put into storage. Her final move was to the foster placement in Kent. Overall J’s transitions across service boundaries were poorly managed by the services involved; the transfer of information was either consistently delayed or not transferred at all, communication between professionals was fragmented and this led to gaps in service provision and further delays. All of J’s moves were characterised by a change in the professional network; each new encounter with professionals invariably led to J telling the story of her life again.  During this time J was moving into early adolescence, the particular social and emotional challenges of adolescence do not have to be repeated here. There was no comment on the impact on J of these multiple losses and transitions during this critical developmental period, and there did not appear to be an understanding of their possible impact. This included an apparent difficulty in understanding dynamics of attachment and loss, and how these would affect her ability to make future relationships, such as in a future (foster) family.  Attempts were made to discuss her losses and bereavement, in particular the death of her Mother, but J was reluctant to engage in these.      Questions for Safeguarding Children Boards: How is attachment theory and how are transitions and losses understood by those agencies responsible for the assessment of a child’s needs across a range of service provision and how might improvements be realised? How can Boards work with all relevant agencies in order to improve transitional arrangements for children moving across geographic boundaries? What are the particular challenges and how might these be addressed? Page 57   Assessments and Treatment  J’s psychosocial history included complex bereavement, possible physical emotional and sexual abuse, significant losses, possible attachment disorder and multiple transitions. She was a child who had no significant attachment figure, her behaviour revealed the depth of her sadness and her diaries recorded her relentless self-loathing. Many professionals spoke to J and heard her life story, her behaviour including self-harm and suicidal ideation were known about, the recordings in her diaries, whilst largely unknown, were ‘unsurprising for a child with such a past’. J was clear that the joint sessions she had at CAMHS with her carers were not helpful; ‘talking did not help’. Whilst she engaged in the art psychotherapy that was provided, this was not sufficient to address her significant mental health needs Whilst J was an in-patient, medication was regarded as the most effective consistent treatment she received. Despite this being the only form of treatment at discharge, during the latter part of her stay, there was confusion over whether medication was effective. When J went to live in Kent, in the absence of CAMHS provision, medication was the only treatment received for her mental health difficulties. There was confusion over how her medication was supervised by the foster carers in Kent, poor record keeping at the placement. There was poor communication from the in-patient unit at discharge.     Understanding the legal concept of Parental Responsibility and when young people can make decisions J was unusual to services as she became an orphan and by her late Mother’s will was placed under the guardianship of her half-Brother and an Aunt. J’s Aunt did not understand the significance of this role, that it carried legal Parental Responsibility (PR) and what rights and responsibilities are inherent in that role, notably that she had the right to act independently of her nephew who also had PR. She states that she was not advised what being a Testamentary Guardian meant.  Practitioners also seemed to be unclear about J’s legal status. This confused thinking about who could make decisions for her and whether she should have been made the subject of Care Proceedings. J became a Looked After Child under section 20 of the Children Act. J’s Aunt and half-Brother continued to hold Parental Responsibility for her until her death. In terms of treatment options, it is not clear if agencies other than the Local Authority understood the significance of this.  J was thought to have been ‘Gillick’ competent based on her age but no assessment was done of her actual competency to make important decisions given her life-experience and vulnerability. The Children in Need processes or Looked After Children processes should have established these as early as possible.  Questions for Safeguarding Children Boards: Relevant boards should ensure a clear understanding from commissioners and providers of mental health services (including CAMHS tier 3 & 4 provision) in relation to the range of therapeutic interventions for children with complex needs such as J’s in order to effectively plan for future provision. LSCBs should consider what generic training and support should be in place for practitioners and managers outside child and adolescent mental health services in understanding self-harm and suicidal ideation and behaviour in order to strengthen them in offering support to family and carers or workers in universal services. Page 58        Care Planning (Child in Need, Looked After Reviews, Care Programme Approach & Multi-Disciplinary Work)  The reasons for J coming into care are not fully clear. J’s Aunt has stated that she had not. felt able to care for J initially following the Mother’s death because of her own health and J’s behaviour; but had been actively involved in supporting the half-Brother as J’s carer in practical and emotional ways. and had been concerned about his maturity, his ability to care for J practically and emotionally and his own needs and bereavement. She was in contact with and went to CIN meetings with Islington staff. When the arrangement with J’s half-Brother broke down, J ran away to her Aunt, who accepted the task and sought to care for J and make arrangements for her education, health and emotional needs – including seeking appropriate psychological help for J for bereavement. She had planned to offer J a home to adulthood and considered that she might adopt J (although this was not discussed with social care staff). However, she found J increasingly hard to manage and sought additional help, as well as raising concerns about alleged sexual abuse. She was concerned about the content of J’s writings, which J regularly left out for her to read. J’s Aunt wanted psychologists to get to the bottom of J’s problems but increasingly found J’s behaviour at home hard to deal with and felt that over time J became alienated from her, becoming increasingly attracted to the idea of foster care. It is J’s Aunt’s view that she did not ask for J to go into care but she allowed J to go into care as that is what J wanted and that J pushed for this. J’s Aunt felt rejected by J. Children’s social care believed J’s Aunt to be at the end of her tether and wishing J to be accommodated. It is not clear to the Review Authors that diversion from care and supporting the family was fully explored.  There were a number of meetings where J’s needs were discussed and plans were made for these needs to be met. The most critical of these care planning forums were J’s Looked after Reviews (LAR’s), and whilst an in-patient the Care Programme Approach meetings (CPAs).  Looked after Reviews  In testing how the care system worked to support and plan for J statutory Looked after Reviews played a key role. The IRO Handbook provides statutory guidance for Independent Reviewing Officer’s (IRO) and local authorities on their functions, in relation to case management and review of the care provided to Looked after Children. There are two clear and separate aspects to the function of the IRO: chairing the child’s review; and monitoring the child’s case on an ongoing basis. In exercising both parts of this role the IRO handbook outlines the responsibilities of the IRO in relation to a wide range of areas focusing on the inclusive nature of reviews, including but not exclusive to; “facilitating consultation with a wide range of parties, promoting the voice of the child; ensuring that plans for looked after children are based on a detailed and informed assessment, are up to date, effective and provide a real and genuine response to each  Questions for Safeguarding Children Boards: LSCBs should seek assurance that staff, including those in universal services, are aware of the legal aspects of parental responsibility and the significance of knowing who can make decisions for a child and when young people may be able to make decisions for themselves. Page 59   child’s needs.” J was the subject of 4 Looked after Reviews and had the same Independent Reviewing Officer throughout; this was good practice and allowed J to have a consistent figure in her life who was able to hold her history in mind. It is clear that J engaged with her IRO, and that the IRO was committed to understanding J and to establishing her views. This review found that whilst the IRO made important recommendations in relation to care planning, when these recommendations were not implemented there was no effective response, this is not an unusual finding and has been the subject of government attention and research. Escalation and challenge are clearly important tenets of the LAC system, the absence of which compromises effective care planning for children (see below).  Care Programme Approach The Care Programme Approach (CPA) was introduced in 1990 to provide a framework for effective mental health care for people with severe mental health problems. Its four main elements are to put in place systematic arrangements for assessing the health and social needs of people accepted into specialist mental health services, the formation of a care plan which identifies the health and social care required from a variety of providers, the appointment of a care co-ordinator to keep in close touch with the service user, and to monitor and to co-ordinate care, to provide regular review and, where necessary, to agree changes to the care plan. Whilst J was an inpatient she was the subject of three CPA meetings attended by the Lead Psychiatrist, CAMHS and key workers within the in-patient unit. The first scheduled meeting was cancelled and for the second there were no minutes.  Joint planning  The most critical care planning period was when J was an in-patient, and whilst an in-patient two LAR Progress meetings were held chaired by the IRO and three CPA Meetings chaired by the Lead Psychiatrist.  Despite the key principles of these statutory planning forums being very similar these meetings were held in parallel and key players were not present and it was the absence of robust, timely, integrated care planning between the statutory planning forums that had the most significant impact on how effective planning was not achieved. Research of available government guidance, research and literature looking at how the CPA and LAR processes integrate in order to form a coherent planning approach to the care and discharge of a child from a Tier 4 in-patient establishment revealed nothing of significance. The IRO handbook makes brief reference: ‘In relation to children admitted to a psychiatric unit, whether as a voluntary patient or as a result of a compulsory admission under the Mental Health Act 1983 the IRO will need to be satisfied that the local authority is fulfilling its responsibilities and that appropriate plans to meet the child’s needs and planned outcomes are in place before discharge’. In relation to CPA guidance: ‘Ensuring effective communication between service users (including families), health providers and other involved agencies using the Care Planning Approach so that families and professionals are fully involved in the treatment and discharge process and that timely and appropriate community services are available upon discharge’. So whilst these references are remarkably similar there is no specific guidance in relation to ensuring an integrated approach to a child who is the subject of both statutory processes. In a sense it could be argued that the separate guidance sits in its own furrow and application of the guidance in practice mirrors this silo approach, as seen in this case.  Roles and responsibilities of the multi-disciplinary group  The separate nature of the planning meetings affected how the different roles and responsibilities of the multi-disciplinary group and services were understood, this led to assumptions being made characterised in two important ways. From the perspective of staff at the in-patient unit, whose expertise Page 60   was in mental health not in working with a looked after child, the unique position of a child looked after by the local authority did not seem to be fully understood (ref: In-Patient IMR) and so the unique challenges of J’s care status were not appreciated. Equally for Children’s Social Care staff, whose expertise is in looked after children not mental health, the purpose of J’s admission to the in-patient unit was not understood. There was a sense that J ‘was admitted for treatment in a highly specialist residential unit and when the time came for discharge she would have received the appropriate treatment’. These assumptions had a direct impact on planning for J’s future placement.  On advice from the in-patient unit it was understood that J would be best placed in a foster family rather than a residential unit. The first foster placement had been a good one and there was evidence of attachment behaviour and good management of risk but it was seen as short term only and was not seen as suitable for J’s long term needs. The carer who was committed to J also felt that she could not manage the level of risk that she had experienced previously in caring for J and that it would not be right for her family.  J was deemed well enough for discharge and was described as wanting to go as well as becoming anxious about where she would be discharged to. Unlike other young people she had no family to return to. In seeking a new foster family for J it seems her complex attachment history and needs and the possibility of a continued or reversion to a level of high risk of self-harm and suicidal thinking were not fully considered or included in the family finding. It was good practice that the in-patient unit and social care discussed the suitability of possible families that were put forward. However, there was a lack of robust, informed professional debate and challenge about the type of specialist placement J might require, and what was realistic in a foster family. The transition arrangements were poor and the risk management plans were inadequate.      Management Overview and Leadership  J was a child with a complicated psycho-social history, with a history of possible emotional, physical, sexual abuse and neglect, complex mental health needs, and was a looked after child. In Lambeth initially there was no multi-disciplinary co-ordination or management overview to support front line practitioners in understanding the complex needs of a child such as J. Case recordings in Children’s social care reveal a ‘surface deep’ level of supervision and guidance. Initially from Lambeth Children’s Social Care perspective J was not a remarkable child, there were many other children catching the attention of senior management, and J was seen as being cared for by her family, which could be argued to be sufficient. The referral from Islington did not trigger that J was a  Questions for Safeguarding Children Boards : Relevant boards should review how joint-care planning for a child who is LAC and an in-patient of a Tier 4 establishment can be achieved to ensure a joint multi-disciplinary approach where the child’s holistic needs both whilst an in-patient and when planning for discharge can be effectively realized; and examine how, in circumstances when there are gaps in discharge planning arrangements/ transition, these concerns can be successfully escalated to senior management and resolved prior to discharge. It is recommended that a joint multi- disciplinary working group is established to progress and it is further recommended that the work of this group is shared more widely to enhance national learning on this issue. Page 61   priority Child in Need. From the perspective of CAMHS; case recordings reveal that equally J was not a child whose presentation was remarkable. This suggested to the SCR Panel that the significance of J’s history and the seriousness of her presentation was not understood in a reflective way. There also appeared to be some drift and delay in the early management of the case within Lambeth.  J was in an establishment that was an exceptionally high cost resource equally independent fostering provision is a high cost resource, this in itself suggested that J’s case warranted the attention of senior management. Instead the front line practitioners were largely left to go it alone and this resulted in assessments, care planning and decision making that in the absence of close reflective supervision, and senior management guidance failed to comprehend the complexities of J’s needs.  It has been noted that in Lambeth children’s social care at the time that this case was being managed there were several changes in senior management and leadership. Systems to monitor high priority cases were not as effective as previously or as now. Teams were under pressure and there were changes in staff. The Looked After Team which took over responsibility for J’s care after she was accommodated was better staffed with a strong team identity but had to take on work for other services such as the court team.       J’s Diaries  A number of professionals perceived J to be a resilient child whilst others correctly identified that J was reticent and avoidant about expressing her thoughts and feelings; she appeared at times to be ‘coping well’, but this was sometimes thought only to be ‘surface deep’. On occasions when J was asked about her feelings she gave positive views, denying suicidal thinking, even in the final weeks up to her death. Some practitioners were aware that J wrote a diary or wrote in notebooks. The content of a few pages had been seen and were worrying. Carers expressed concern about some of the entries which indicated risk and suicidal or self-harming ideation. Other practitioners working with J later were unaware of the worrying content of the earlier pages which had been shared. Some knew that she was often writing in books but felt inhibited from discussing her writings and diaries with her.   Questions for Safeguarding Children Boards: LSCBs should be aware of what the current arrangements for supervision (reflective management) within agencies are; and what the joint-arrangements are when a child is receiving services across agencies? Are these the subject of regular quality assurance audit and challenge? Is reflective supervision currently being provided within agencies and how are outcomes being evaluated? Are current training programmes sufficiently promoting the knowledge base and skills of practitioners in understanding the impact of a child’s psychosocial history and in providing services to children with such complex needs? Are Agencies aware of which cases should be the subject of senior management scrutiny and review, and where needed, intervention in order to resolve any barriers to joint working?   Page 62   The question asked by this SCR Panel was whether it would have been appropriate or ethical for practitioners to have read these diaries at the time (one practitioner told us that they saw such a notebook but held back from looking at it on grounds that it would have breached J’s rights, even though as a parent herself she may well have done so). J was in care; the Local Authority was acting as her parent. Given the acute nature of J’s mental health concerns would it have been appropriate to have read J’s diary, if it had been accessible– what would a reasonable parent have done? Legal advice to this SCR is that it would not have been legal to have accessed J’s diaries without her permission.  J’s permission was not sought and this becomes the central issue as, despite a number of professionals knowing about her dairies or writings, there was little thought or reflection about their significance as an important part of understanding J’s inner world - their possible significance in assessing her mental state, and the risk of self-harm, and suicidal thinking was not fully available.        J’s Voice: Establishing J’s wishes and feelings through consultation  Multi-agency case recordings, and Independent Management Reports completed as part of this Review, showed that J was consulted fully and that her wishes and feelings were ascertained in a number of different areas. In line with requirements J’s views were regularly ascertained as part of her Looked After Reviews. Areas included, but were not exclusive to, her wishes and feelings in relation to her current and future placements and her views in relation to CAMHS support. When decisions were being made about whether to pursue a Care Order, legal advice was that J was ‘Gillick’ competent – ‘Gillick Competence’ now more usually referred to as ‘Fraser Guidelines’ - applies to contraceptive advice. 3J was felt to be ‘Gillick competent’ and this appeared to be an important consideration in deciding that the Local Authority did not need to secure parental responsibility for J. This view of J being ‘Gillick competent’ appeared as a feature throughout the involvement of the multi-agency group and appeared to be applied in relation to all decisions upon which J was consulted. There was no test of J’s ability, such as there might have been under the Mental Capacity Act if she had been over 16 years of age. The advice that she was Gillick competent seems to have been based solely on her age rather than an assessment of her mental and emotional capacity, the impact of what had happened to her, her developmental experiences, and her losses.                                                                 3 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/legal-definition-child-rights-law/gillick-competency-fraser-guidelines/  Questions for Safeguarding Children Boards: Given the learning in the case how will relevant Safeguarding Boards seek to address the importance of holding a child’s writings such as diaries in mind when working with children and young people such as J. Do current professional training programmes address how this might be done? Is there a need to issue specific guidance in this area/amend existing policy/procedure to reflect the importance of this issue? How can professional curiosity be encouraged in a way to engage and work in counselling young people? Page 63     Social Media/Internet Access  Between November 2011 and January 2014 a number of references can be found in case records relating to J’s use of Facebook. J talked to her social worker about communicating with friends/family members on Facebook. Her use of Facebook was rightly the subject of concern when pupils raised concern about her wellbeing with members of school staff as J was expressing suicidal thoughts and intentions shortly after her Mother’s death. Later J’s Aunt raised concerns about J communicating with an older man and posting a photograph of herself in what was felt to be inappropriate clothing. On these occasions professionals correctly reported their concerns for J’s safety and wellbeing. However, apart from recording the information within the case narrative, there appeared to be no further curiosity or management overview of the possible significance of J’s use of social media or of the potential safeguarding action that may have been needed.   J’s diaries reveal she was aware of the content of Pro-anorexic – ‘Ana’ web sites with some regularity. It is not known if J accessed these sites herself or whether she gained the information from peers who had eating disorders in the in-patient unit. Whilst this was not known to professionals at the time, it is the view of the panel that given J’s known preoccupation with her food and fluid intake and with her body image, knowledge of these websites and the dangers they pose would have provided the opportunity to have explored these issues with J more fully and to put in place clear advice and safeguarding measures to protect her from the risks these sites pose.  Useful research into the use and risk of such websites is: Virtually anorexic: Where’s the harm by Dr E Bond, University Campus Suffolk4                                                                 4 www.ucs.ac.uk/virtuallyanorexic  Questions for Safeguarding Children Boards: How widespread is the use of the ‘Gillick Competency Test’ used in relation to assessing a child’s ability to make informed decisions that have a fundamental impact on the care the child receives/how decisions are influenced/made? How will this be addressed so that the question of a child’s competency to make decisions is based on a solid understanding and appreciation of a child’s individual needs and informed capability? Could the assessment of capability used within the adult Mental Capacity Act be a useful way to inform LSCBs how this issue might be successfully addressed?  Questions for Safeguarding Children Boards: What knowledge and training do staff in different services have about the use of the internet to access websites and their risks, and how are staff equipped in understanding the use of social media sites to inform assessments and to safeguard children from harm? How are LSCB e-safety policies and procedures being applied? Page 64   Additional Findings  There are a number of findings relevant to single agencies. These issues are covered in corresponding IMR’s and the expectation is that these issues are the subject of further exploration and action by the relevant agencies responsible. The additional findings mentioned in this section have been selected for attention by relevant safeguarding boards either because of their particular significance or because they affect more than one safeguarding partner.   Investigation of sexual abuse allegations  J made a disclosure about sexual abuse; she was consistent in making this disclosure and was keen for it to be the subject of investigation. A concern about possible inappropriate sexualised behaviour towards j had also been reported. There was delay in progressing these enquiries and when the police were contacted a decision was made not to progress to a joint investigation. As noted in the timeline this was not appropriate practice; the disclosure and allegation were left unexplored and unresolved and it was only after J died that these were the subject of investigation. This was poor practice and in all likelihood left J feeling she was not believed or heard       Discharge arrangements (including risk assessments)  Lead responsibility for overseeing these arrangements was held jointly by the in-patient unit and CAMHS. The In-Patient Unit held a particular responsibility for ensuring risk assessments were well documented, robust and clearly articulated and understood. This did not happen and was poor practice. Whist the unit also held lead responsibility for the transfer of J’s general care, within this role they were reliant on other professionals fulfilling their responsibilities. This included responsibility held by CSC to arrange for J’s schooling, responsibility by CAMHS to visit J 7 days after discharge and to transfer care to the local CAMHS team to ensure J was provided with a timely appropriate response, and responsibility by the fostering agency to ensure the carers were appropriately trained and supported. Given J’s history the Panel believes that the arrangements should have been in place before J moved or very soon after.    Questions for Safeguarding Children Boards: It is understood that in response to findings from recent serious case reviews action has been taken to improve the practice in this area. Relevant Boards are recommended to request an update on the progress in this matter and keep under review.  Questions for Safeguarding Children Boards: Relevant Boards should request a progress report from the in-patient unit detailing how these lessons will be taken forward in the future and maintain an overview of progress. Relevant Boards, with Commissioners, should examine how in the future the duties of multi-agency partners in this area will be scrutinised and challenged to enable these arrangements to be satisfactorily fulfilled. Page 65     Looked after Reviews and the role of the IRO  As part of this review the minutes of J’s looked after reviews were scrutinised. As previously identified, there were a number of recommendations made by the IRO that were not taken forward by the Social Work team. The recommendations that were taken forward related only to those that have a performance indicator attached (e.g. Personal Education Plan, dental and health checks). The LAR’s consistently made a recommendation that a Care Order should be pursued, this was started but not achieved. There was no escalation or challenge to the Local Authority when this did not happen and this is contrary to statutory guidelines. In addition, the LAR documents, that include the minutes of the meeting and the Social Work report, were c o n f u s i n g .  Outdated information had been cut and pasted from previous reviews, and there were large sections of the form that were left blank. This meant that the document as a whole did not provide a comprehensive picture of J and her needs and had implications both in terms of planning and meeting J’s needs.       Community Psychiatric Management and Leadership (CAMHS)  There was no consistent community psychiatrist taking an active role in the care and treatment of J whilst she was living in the community, on admission to the in-patient unit, and on discharge. The lack of management overview and leadership in a number of agencies is identified above and does not need repeating here. It is understood that there were a number of staffing problems in the community CAMHS team and it was the view of the Panel that this contributory factor, whilst understandable, from the perspective of J was not acceptable; the absence of a community psychiatrist had a significant impact on the way J’s mental health needs were assessed and her care managed.      Questions for Safeguarding Children Boards: Relevant Boards are recommended to audit Looked After Review Arrangements to identify whether this is a common feature of LAR’s. Firstly, in relation to the possible barriers that may exist in IROs fulfilling their statutory responsibilities in challenge and escalation and secondly in relation to the quality of LAR documentation.  Questions for Safeguarding Children Boards: Relevant boards should challenge the agencies responsible for the commissioning and provision of this service on this matter and receive regular updates on how changes will be made and sustained. Page 66    Matching J’s needs to carers  During J’s life as a child in care J was matched and placed with two foster families. It was not possible to identify the practice based decision making process showing how J was matched to carers as no documentation could be found that showed adequately how these decisions were reached. Neither of these placements was made in an emergency, and so there was time to consider J’s needs and follow a practice based process of matching her needs to carers. That said, J’s placement with her first foster carer was a good placement where it seemed that J’s emotional needs were understood, and from her diary entries J felt settled and able to plan for her future. J’s second placement after discharge was secured through an independent fostering agency. Whilst it is understood there is a process in place that was followed in respect to the identification of such placements, it was the view of the Panel that whilst the carers were well meaning and provided a comfortable family home for J it was not possible to understand how the match had been made. J was a black child, these carers were white and lived in a predominately white area. It is understood that current guidance on matching no longer emphasises the need to provide a racial or cultural match. However, given this placement was likely to become J’s long term placement it was the view of the panel that the lack of regard for J’s racial and cultural identity in making this match was poor practice. J did not have regular contact with birth family members and had no contact with members of her community in a way that would enable her racial and cultural identity to be promoted. It was understood that the family were chosen partly on the basis that they had experience in caring for children of J’s age who were emotionally troubled. This was naïve; J required a placement with carers who were trained and experienced in caring for children who have significant mental health needs and in providing care to children who self- harm and have suicidal ideation. As identified in the relevant Independent Fostering Agency IMR, the carers did not have this experience or training. As raised earlier in this report the original question of what type of placement J required was not the subject of satisfactory interrogation and so the decision to pursue a fostering placement was questionable. It may be that there are foster placements available that are able to provide care to children in such difficult circumstances, but in this case failure to match J with carers in this way placed both J and the carers in a difficult and arguably untenable situation.       Lessons from the NHS Health Agencies Overview  As part of the SCR process NHS England undertook a parallel review from a health perspective. Each Agency which provided services to J completed an Independent Review using Root Cause Analysis; those reports were also made available to the SCR Panel. The NHS appointed two Independent Psychiatrists to advise that review, which was led by the Designated Doctor and Designated Nurse of the Lambeth CCG. The review analysed the Agency Reviews and interviewed some of the key practitioners.  Questions for Safeguarding Children Boards: How will relevant Safeguarding Boards review how current matching processes are completed both with internal fostering placements and with placements made through independent providers in circumstances such as J? What possible steps can be taken to assist those responsible for making these critical matching decisions? Page 67    The Findings from the Health Overview Report are summarised here:  Good Practice Points   The Palliative care team delivered end-of life care in challenging circumstances; they made a holistic evaluation of the material and emotional needs of J and her brother after mother’s death and rapidly sought to involve appropriate agencies.   There was good handover of care between Islington and Lambeth CAMHS services   There was appropriate provision of Tier 3 community CAMHS service, in which J. actively engaged. The art therapy offered was clearly planned and adequately supervised and appropriate recommendations for future work were made. There was good transition to the CLAMHS service once she became looked after.   LAC Health assessments were holistic and of high quality and an outreach service was provided when J was an inpatient in hospital.   Child J had skilled and comprehensive medical assessments when she presented at both acute hospitals emergency departments.   The Priory hospital provided appropriate individual and group work. They had good awareness of child J’s traumatic background, and her reluctance to talk about this. Regular risk assessments were conducted, and CPA meetings, chaired by a consultant, took place at appropriate intervals. J. formed a good relationship with her key nurse, who worked closely with the SW and foster carer in planning J’s discharge, including the provision of a safety plan.   The Kent GP responded quickly arranging follow up mental health care and medication for J when she was brought to the practice.   Care and Service Delivery Problems  1. Clinical leadership Although individual practitioners worked hard to address J’s needs, effective clinical leadership was not established within all of the community mental health services who worked directly with child J. There was an absence of consistent case management oversight and supervision by a consultant psychiatrist or other senior clinician, despite J. being identified as a high risk case and having known safeguarding concerns. This resulted in no clear care plan being in place for J prior to her hospital admission. There was little evidence of a coordinated and integrated approach to the delivery of her care, including the monitoring of her medication and no regular review of her mental state or risk level. The care co-ordinator in CLAMHS appeared to be working largely in isolation.  Page 68   1.1    There was no senior community CLAMHS clinician/consultant psychiatric liaison with the inpatient team whilst J was an inpatient. This was particularly significant as J. posed a significant risk and was on psychopharmacological treatment. It contributed to the lack of effective discharge planning and missing responsibility for who was going to see J for her 7-day post discharge review. This lack of involvement was not effectively challenged or escalated by the clinical lead of the inpatient unit.  2. Discharge planning The professional responsible for J’s care in hospital and discharge was the inpatient consultant psychiatrist (known as the Responsible Clinician). The time after discharge would be stressful and difficult for Child J. Child J had been in hospital for a significant length of time and was going to be discharged home to a new geographical area and to a new foster placement.  Before discharge, a care plan should be made under the Care Programme Approach (CPA) which will look at how to meet her needs. Given J‘s  level of complexity and risk, the agreed discharge plan was insufficient and fell below expected standards. The discharge appeared to take place very rapidly once a foster placement had been identified which may have affected the ability to recognise or resolve some important issues. There were no clear arrangements put in place for the 7-day post discharge follow up for J. There was no confirmation of allocation and transfer of her care and management to a community CAMHS consultant. There were plans for Child J’s social worker to see her weekly after discharge. However, it was inappropriate for her social worker alone to review her considering her significant psychiatric diagnosis, on-going medication and assessed risk of self-harm.  Additionally, there was no clear timescale to register J with a Kent GP (which was essential before her care could be transferred to Kent CAMHS), or specifically allocate this important task to a member of the professional network. It is unclear why the referral by Lambeth CAMHS to Kent was significantly delayed. However, Lambeth CAMHS agreed to be available for consultation until the Kent CAMHS transfer. It is noteworthy that J did not have any contact with a CAMHS clinician following her discharge from hospital in the 8 weeks before her death.  3. Communication - Co-ordination and Communication  3.1 Communication between adult and children’s services Adult services (e.g. palliative care team, district nursing) could have made links with children’s service providers (e.g. school nursing) to support child J. There is a lack of easy lines of communication between adult and children’s services working in the same community.  3.2 Communication between community health providers There was an absence of communication and discussion between the community clinicians who provided first line support to child J (GP, school nurse, community child mental health services, and LAC Health services), so a holistic view of her needs was not formulated or shared.  High quality LAC health assessments were undertaken, with clear recommendations, but responsibility for following up on health tasks (e.g. between paediatrician and GP) was unclear.   Page 69   4. Supervision  The need for effective supervision is a key lesson from this review. Staff who are in the front line of practice must be well supported by effective supervision. Supervision of workers carrying out child and family assessment is essential, as the assessment can have far reaching effects on the planning of care and the assessment of need and/or risks.  Children at high risk of adverse outcomes require especially robust supervisory and management support in order to ensure: reflective practice, challenge, adequate recording, prevention of drift, timely caseload transfer, and effective communication between health agencies and other agencies. However, the purpose of supervision is ultimately to ensure that the child’s safety and welfare is given paramount consideration at all time.  5. The Voice of Child J  The health professionals who worked with Child J (universal services, LAC Health, A&E, Tier 3 & 4 mental health services) were sensitive and supportive of her needs. Her views and wishes were well captured in the clinical notes; these generally informed the work that was undertaken with her. However, when she voiced her impression that the anti-depressant medication was not being effective, there is no evidence of this having been taken into consideration.  6. Commissioning of Child and Adolescent Mental Health Services  NHS England Case Managers maintain an overview of patient pathways and are responsible for quality monitoring of contracted and hosted providers (i.e. the specialised commissioning contract is held by one NHS England region but the service is located elsewhere) NHS England Case Managers are not usually directly involved in decision-making for the majority of discharges but may be involved if the issues are particularly complex or there are difficulties in making progress. The difficulties in effectively managing J’s discharge were not highlighted to the NHS England case manager and they were not approached to support her discharge directly. This was a missed opportunity. Additionally, NHS Lambeth CCG was not approached by the local CAMHs service seeking funding authorisation.      Lambeth Safeguarding Children Board February 2016   Page 70   Foster carer Lambeth  Appendices                                                                      Foster Carer’s Daughter CAMHS Coordinator  Mental health professional Islington (FG) A&E Psychiatrist  Foster siblings  GPs  School Teacher/staff Lambeth  Mental health practitioner Lambeth (VC) Maternal Cousin and Family KCH Psychiatrist LAC Doctor  Independent Fostering Agency SW Supervising SW (FC) Lambeth  Peers Islington In-Patient Therapists  LAC Nurse CLAMS Coordinator In-Patient Psychiatrist Art Therapist Islington  Art Therapist  Lambeth  SW 1 (CIN) Islington SW 2 (CIN) Lambeth Independent Reviewing Officer (IRO) Foster Carers Kent Half Brother  J  SW 3 (LAC) Lambeth  Peers:  In-Patient Unit Peers Lambeth  School Teacher/Staff Islington In-Patient  Key Worker & Nurses Foster siblings Lambeth  osfot Maternal Grandmother   Maternal Aunt  Wider family members  Mother  (Deceased)  Page 71   Appendix 2     Terms of Reference and Methodology  The Terms of Reference for the SCR were agreed between the Independent Chairs of Lambeth, Islington and Kent LSCBs – in discussion with the Chairs of Southwark and Wandsworth LSCBs (as some of the services provided were in their areas).  Terms of Reference of the Review - All agencies involved with J across Islington, Lambeth, Southwark, Wandsworth and Kent LSCB areas are asked to check if they offered services to J in the period January 1999 to July 2014 and, if so, to secure their records and undertake an Independent Management Review (IMR) of their assessments of J’s needs and the services offered.  - The local LSCBs are asked to liaise with their local Partners on this.  - Agencies should notify the Lambeth Safeguarding Children Board of their involvement with J and her family, compile a summary chronology of those key contacts, including relevant inter-agency contacts and note, in summary, the content and outcomes of those key contacts.  Chronologies – Scope: For the period January 1999 to November 2011 only significant events (i.e. not all events) or information should be noted about J’s development and care and any concerns about her welfare or behaviour, including from antenatal services, primary care, community health, early years services, schools, social care or housing. Other agencies may become identified in this process and the Lambeth SCB should be notified.  For the period from October 2011 a more detailed chronology should be compiled indicating key contacts with J, her family members or carers or inter-agency communications, summarising the content and outcome of the contact or communication and who was involved from the agency by role e.g. SW1, HV1, GP2, etc. The chronology should be confidential and should not identify an individual by name – only role.   Independent Management Reviews (IMR) Using the agency chronology, agency records and conversations with relevant practitioners, each agency which had contact with J or her family is asked to compile an IMR. This should be undertaken by a suitably qualified and independent practitioner who is able to analyse the agency involvement and provide a review which comments on the agency practice and any lessons arising from the review. The review should be endorsed by a senior manager of the agency who did not have direct involvement in the management of the case.      Page 72   The Agency IMRs should note and review: - the key and priority practice episodes (these will be drawn from the agency chronology); - the agency’s involvement, commenting on the work undertaken and use of LSCB and agency policy and procedures, or accepted best clinical/professional practice, in use at the time; - the agency’s and inter-agency assessment of J’s needs, including her developmental needs, her emotional needs, and ethnic and cultural needs; and any risk identified, including signs or disclosures of neglect or abuse; - analysis of the planning and management of transitions for J, including specialist advice/support; - the direct work undertaken with J and her family members – how J’s views and wishes were ascertained and how her family’s views and wishes were ascertained; - inter-agency information sharing and co-operation to meet J’s identified needs; - the decisions, actions taken and timescales, noting any gaps, errors and successes and why these occurred; - the views of the practitioners involved and any management or supervisory oversight of the work, seeking to understand the work undertaken by what was known at the time, not through hindsight, but noting any gaps; - the agency systemic context in which the work was undertaken and any factors intrinsic to the agency, or external to the case, which may have impacted on the work. - The IMR should note the key lessons, including concerns and good practice, which have been learned as a result of the agency independent review and any recommendations to be taken as a result within the agency, or by the home LSCB or by other bodies; and whether the agency has accepted such internal recommendations as formal actions. - Non-health agencies should compile their IMR using the principles above.    SCR Panel - Lambeth SCB appointed a panel of senior and experienced practitioners, with experience in safeguarding, to draw together the learning from the IMRs and Health Overview and to comment on the work undertaken. - The SCR Panel members were independent of the line-management for this case. - Two independent lead reviewers were appointed to support the process and author the final report. - The Panel was commissioned by the Lambeth SCB Chair. - None of the Panel Members had direct involvement in the management of the case up to the point of J’s death. - The Panel are able to co-opt specialist advice, as needed. - The Panel had the authority to invite the agency IMR authors to further discuss their IMRs and findings.  Participation by family members and carers - J’s Aunt and brother will be advised at an early stage of the review, its purpose, how it will be conducted and how they may be involved; including by direct conversation with agreed SCR Panel members, probably the independent lead reviewers. - Consideration should be given to seeking early clarification of the allegations made by J’s Aunt of possible neglect and abuse. Page 73   - Consent is not required for access to agency records about J or her mother, who are both deceased. There should be no need for access to records about her J’s Aunt or brother, but if it is decided that this may be needed consent will be sought. - Both sets of foster carers will be advised of the review and should be consulted as part of their agency IMRs, but they will also be invited to make direct representation to the SCR Panel, should they wish to do so in writing or in a meeting with the Lead Reviewers.  Governance The SCR Panel Chair will hold responsibility for informing the LSCB Chair/s of any emerging findings which require attention before the SCR is completed. Governance meetings will be convened twice during the course of the Review to inform the LSCB Chairs and DCSs of the emerging findings and to present the draft review before its completion.   3. Membership of SCR Panel Malcolm Ward, Independent Chair / Reviewer Bridget Griffin, Independent Reviewer Dr Alison Barnwell, Designated Doctor, Lambeth CCG Dr Sarah Bernard, Consultant Child and Adolescent Psychiatrist, Named Doctor for Safeguarding Children, South London & Maudsley NHS Foundation Trust Patricia Denney, Asst Director, Safeguarding Children and Quality Assurance, Kent County Council Lisa Humphreys, Asst Director, Lambeth Children’s Social Care Russel Pearson, Specialist Crime Review Group, Metropolitan Police Service Lesley Ward, Manager, Next Steps Fostering Avis Williams-McKoy, Designated Nurse, Lambeth CCG Lara Wood, Islington Children’s Services Vanessa Wright, Quality Improvement Lead, Priory Healthcare Paul Maddocks, Specialist Crime Review Group, Metropolitan Police Service stepped down from the Panel for personal reasons.  None of the Panel Members had had any direct involvement in the case. The Panel was supported by Rupinder Virdee, Sandra Fernandes, Andrea Watkins and Maria Burton of the Lambeth SCB.    Page 74   4. Independent Management Reports Received Central and NW London NHS Foundation Trust Guy’s and St Thomas NHS Foundation Trust – Lambeth Community Health Services and Looked After Children Health Services Islington Council – Children’s Social Care Islington Council – Early Years’ Services Islington Council – Schools and Young People’s Services Islington GP Service Kent GP Service Lambeth Clinical Commissioning Group Lambeth Council – Children’s Social Care Lambeth Council – Education Services Metropolitan Police Next Steps Fostering NHS England OFSTED South London and Maudsley NHS Foundation Trust (Mental Health/CAMHS) Sussex Partnership Foundation Trust (Kent CAMHS) The Priory Group (Independent Mental Health Provider) Kent Community Health NHS Trust, Kent County Council – Children’s Services and Kent Police confirmed to the SCR Panel that they had had no involvement with J prior to her death.  5. Bibliography Bond; Virtually Anorexic – Where’s the harm? A research study on the risks of pro-anorexia websites; University Campus Suffolk; 2012 Meltzer, Lader, Corbin, Goodman and Ford; The mental health of young people looked after by local authorities in wales: Summary Report Welsh Assembly/Office of National Statistics; 2004 Ougrin, Tranah, Stahl, Moran and Asarnow: Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: Systematic Review and Meta- Analysis;  Journal of the American Academy of Child and Adolescent Psychiatry, Vol 54 Numb 2 February 2015 Self-harm and suicide in children and young people – Reconstruct Research Service (www.reconstrict.co.uk) Undated  Page 75   Suicide: Learning from serious case reviews, NSPCC 2014 Independent Reviewing Officers’ Handbook, DfE, 2010  https://www.gov.uk/government/publications/independent-reviewing-officers-handbook  Young Minds - has a range of useful leaflets, articles and information about childhood and adolescent suicide and self-harm http://www.youngminds.org.uk   Published by Lambeth Safeguarding Children Board February 2016 