Death of Child G, a teenage girl, in spring 2015 by suicide. Child G experienced problems at home and at school which escalated in the weeks preceding her death. She suffered from depression and had feelings of worthlessness and being unloved; there was conflict between herself, her mother and her siblings. She self-harmed and had one episode in hospital following an overdose. She was excluded from school when she and two friends stole craft knives from a classroom. Two days later she hanged herself in the garden shed. Lessons learned: the need for a coordinated approach to children and young people who self-harm; sufficiently robust safeguarding responses to self-harm and suicide ideation in teenagers; assessment as a dynamic process that should be updated as circumstances change; guidance around exclusion and vulnerable pupils in school. Recommendations include: to launch a campaign to raise awareness of self-harm and suicide ideation in children and young people; that agencies and CAMHS have sufficient tools, education and knowledge to assess risk and implement risk management plans for children and young people who self-harm; to ensure that the TAF/CAF model that supports early help for children is provided for families whose needs do not reach the threshold for statutory services; the LSCB should be assured that NHS England has informed all pharmacies in NHS England regarding selling of medication (Nytol) to children; to review processes for communicating available help to bereaved parents and their families.
      
    Serious Case Review No:  2018/C7258  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.           CHILD G  SUMMARY OF FINDINGS FROM SERIOUS CASE REVIEW  Author:  Jane Doherty Independent Social Work Consultant               2 1 Introduction 1.1. This is the overview report from a Serious Case Review (SCR) conducted by a Local Safeguarding Children Board (LSCB). The matter under review is the death of a teenage girl in Spring 2015, found suspended by the neck.   1.2. The case highlights the sad and premature death of a teenage girl and the challenges presented to the professional network when a child experiences mental health problems and difficult family relationships from a young age. 1.3. The following is a summary of the circumstances leading up to Child G’s death 1.4. Child G was experiencing problems at school and at home that had been escalating in the weeks immediately prior to her death. Of particular significance was a temporary exclusion from school just prior to her death when Child G and two friends stole craft knives from a classroom.  Later in the day, she provided the school with a forged note for a doctor’s appointment and truanted from school.  The following day, the school agreed with Child G’s father that exclusion from school for two days was appropriate. Two days later Child G went out to the garden shed and hung herself.  2 Arrangements for the Serious Case Review   After the death of Child G, LSCB took the view that the criteria for an SCR had 2.1been met. This is entirely consistent with the guidance in ‘Working Together’1 (WT) 2013.   In this case the following applies as abuse of a child is either known or 2.2suspected and the child died (5(2)(b)(i) and there are concerns about how organisations or professionals worked together to safeguard the child.    Regulation 5(2)(b)(i) in Working Together includes cases where a child died by 2.3suicide.   Working Together (2015) Chapter 4 Para 11 states a Serious Case Review 2.4should be conducted in a way which:  recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;                                                              1Working Together to Safeguard Children (Working Together) is the government’s overarching guidance on safeguarding.      3  seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings.   The purpose of the review is to;  2.5 Look at what happened in the case and why and what action will be taken to learn from the review findings  Identify actions that result in lasting improvements to those services working to safeguard and promote the welfare of children.  Provide a useful insight into the way organisations are working together to safeguard and protect the welfare of children.  Arrangements were made to appoint the independent people who are required 2.6to contribute to the conduct of SCRs. An Independent Chair and Overview Author independent from the LSCB were appointed.   The LSCB appointed a Review Panel to manage and oversee the review and 2.7met a number of times. The panel members were made up of senior representatives from those agencies that had worked closely with the family. These agencies also provided information to the review in the form of a detailed chronology and reports. The panel also included a lay member who provided further independent scrutiny and challenge.    The LSCB held a series of SCR Panel meetings, chaired by the Independent 2.8Chair, where all the agencies and the overview author contributed to the process of gathering and analysing the material provided.   Consultation and learning events were held during the course of the review to 2.9enable those practitioners who worked with the family to contribute to the overall findings and lessons from the review.  3 Comment on the limitations of the review   The review took longer than expected for a variety of reasons. First there were 3.1many changes of personnel within the LSCB and this caused disruption in terms of continuity of process. The LSCB now has permanent staff in post and the process in the latter part of the review has run much more smoothly.     4  Second, the original author for the overview report was unable to complete the 3.2piece of work and a new author was appointed. It then took time for the new author to absorb all of the material, meet with the practitioners and be satisfied that all the material was available in order to complete the task. It was not possible however, to meet all the practitioners as some had already left the relevant agencies.   Third, some of the information from agencies was incomplete and needed to be 3.3re-written and resubmitted for consideration by the panel even in the latter stages of the review period and this caused further delay.  4 Family Contribution   In line with expectations laid down in WT consideration was given to involving 4.1the family in the review process and family members were advised that the review was underway. As part of the review the Independent Author met with Ms A and Mr B, the contents of those consultations is detailed in Section 9.   5 Methodology used to draw up this report   This report is informed by: 5.1 The agency chronologies, IARs and other reports   Background information from agencies involved in the review  Panel discussions and analysis  Dialogue with IAR authors   Input from practitioners via individual consultations and the learning events held on the 7th March 2016 and the 16th September 2016.    The report consists of:  5.2 A factual context  Analysis of how the agencies worked together from the information provided in their IARs   Commentary on the family situation   Key themes and lessons learned  Recommendations  Contribution from the family      5  The review has been conducted and written with the benefit of hindsight, which 5.3often distorts the reader’s view of the predictability of events, which may not have been evident at the time.    It is important to be aware as Munro (2011) states just how much hindsight distorts our judgement about the predictability of an adverse outcome. Once an outcome is known we can look back and believe we can see where practice, actions or assessments were critical in leading to that outcome. This is not necessarily the case, and information often becomes much clearer after an event has occurred. The review is therefore sensitive to this ‘bias’.   In the learning and consultation events held during the course of the review 5.4practitioners described difficulties in their work associated with cuts resulting in a decrease in service provision. They particularly cited the reduction in the Referral and Assessment service that had been reduced from four teams to three and the lack of provision and support for practitioners in the Early Help service. CAMHS workers also described a reduction in resources due to internal efficiency savings that had resulted in a decline in services on offer.  These pressures are now being addressed by way of a multi-agency strategy that has been led by the local authority area, to further support the work of front line practitioners.    With the above in mind the review is also sensitive to pressures on agencies 5.5and the demands of the work that are sometimes overwhelming for even the most capable of workers.  It is therefore important to disseminate the learning and reflect on how the lessons from this review can help support better practice, rather than apportion blame to agencies or individuals.   6. Parallel Processes  6.1. The SCR is an independent process that takes place on behalf of the LSCB to inform partner agencies about the review and to learn lessons. The panel were however mindful of other processes that were conducted in relation to Child G’s death. These were mainly the internal inquiry report conducted by the local mental health trust and the Coroner’s Inquest into Child G’s death. The former was made available to the author to inform this review but not the latter.   The author was however aware of the considerable media coverage of the inquest in 2015.          6 7. Summary of Professional involvement          Brief Summary of information prior to 2012  7.1. As early as 8 years old Child G’s mother, Ms A expressed concerns with professionals about her challenging behaviour and as result the school made a referral to the Child and Adolescent Mental Health Service (CAMHS). She was discharged after neurodevelopmental issues were excluded. At the same time Ms A also requested help for Child G as she suffered from enuresis.   7.2. CAMHS assisted the family at that time by providing strategies and with help the situation improved over time.  During this time frame, 11 home visits were undertaken and Ms A was discharged in January 2010.  7.3. Child G’s enuresis was said to be associated with abdominal pains and it impacted on her social integration as she refused to go to sleepovers with friends because of it. Child G was seen by various medical practitioners and offered many treatments and suggestions as to how to deal with it. These included medication, renal ultrasounds and the use of an alarm. Some improvements were seen over time but the problem persisted into Child G’s teens.  7.4. From the information given covering this period of time the picture painted of the family is one of struggles with inconsistent boundaries and managing behaviour, coupled with distinct periods of improvements. Child G’s enuresis was better at times than others and this seemed to be pattern with Child G’s siblings who also suffered with similar problems.     Initial indications of Child G’s mental health (January 2012 – August  2012) 7.5. During this period Child G continued to receive services in relation to her enuresis and it is noted that there had been a recent increase in symptoms, possibly associated with her imminent transfer to secondary school. The paediatrician prescribed desmopressin (a medication to suppress urination at night - commonly used in children with problem wetting) for a 4 month trial period.  7.6. Towards the end of June 2012 Ms A’s GP prescribed her with Fluoxetine which is a medication to treat the symptoms of depression. However there was little exploration of her family life or cause of her depression.         7   Child G’s transfer to secondary school (September 2012 - August 2013) 7.7. In September 2012 Child G transferred to secondary school and by October had started to exhibit more pronounced symptoms of anxiety and low mood. Child G attended an appointment with the Consultant Paediatrician in relation to her bedwetting and the paediatrician was concerned about her low mood, flat affect and feelings of worthlessness. She was also suffering from headaches on a daily basis and expressed anxiety about her perception that she was at the bottom of her class.  7.8. Towards the end of that school term Child G did not attend an out-patient appointment for the Paediatric Bladder Department and was discharged. This was the 2nd appointment missed as she had also missed one earlier that term.  7.9. The Consultant Paediatrician however continued to see Child G into the New Year and remained concerned about her low mood. Child G’s bladder over activity had mostly resolved but the low mood and headaches persisted. Child G and Ms A had met with CAMHS but in the clinic it was very clear there was a lot of conflict between Child G and Ms A. The consultant also noted that there may be similar problems at home with Child G’s older sibling as they matched each other in strength of character. Their disputes were characterised by name calling and teasing and could get physical.  7.10. In the spring term of 2013 Child G continued to have regular sessions with a support teacher at school and was notably feeling more settled. In the sessions she rated home much lower than school. There were issues with peer relationships during this period but the school had no concerns about her academic progress and her term report stated as such.  7.11. By this time the referral to CAMHS had been picked up and an assessment was undertaken, the outcome of which was to offer Family Therapy. During the assessment it was noted that Child G ‘challenges everything’ and has a poor relationship with her siblings. She was said to struggle with social relationships at school and complained about not being liked by staff and peers. At the end of March 2013 Ms A attended CAMHS to discuss Non Violent Resistance (NVR) Parenting Group.   7.12. In the meantime Ms A was engaging well with the NVR course and attended the majority of the sessions.  She did however continue to experience the children’s argumentative and aggressive behaviour as very challenging and stressful.        8  Events leading to Child G’s death (January 2015 – April 2015)  7.13. Child G was seen at CAMHS in January 2015 to assess her difficulties sleeping and she was prescribed a 2 mg dose of melatonin to be used in conjunction with other techniques. This was to be reviewed in 4 weeks’ time and an appointment was to be set up to begin the ASD assessment.  7.14.  At the start of the academic term Child G requested to see the school counsellor again but this did not happen and there was no clear plan from agencies about the best way forward. It is significant that Child G only attended one further appointment at CAMHS.  7.15.  Ms A, Mr B and the two youngest siblings attended a Family Therapy session at CAMHS in mid-January. Child G was expected but did not attend and could not be contacted on her mobile. Tensions between the parents were evident during the session and adult themes were being discussed. In view of this the children were removed from the session with another worker and whilst they were out of the room the children disclosed being hit by both parents on a regular basis. When questioned further they became distressed particularly  when the worker suggested that she would discuss their concerns with their parents.  7.16.  It was agreed that CAMHS would speak to the parents about this the following week but not mention the disclosure. In the next session the parents spoke openly about discipline in the family home – on the back of this parents were informed of the children’s disclosures and that a referral would be made to Children’s Social Care.   7.17. CAMHS did not refer to CSC until a week later (some 2 weeks after the disclosure). Ms A acknowledged that what the children had said was true and was very upset about this.  She had spoken to the children about their disclosures and Child E told her that when she got cross it was ‘a bit scary’. Ms A reassured the children that she would try not to get cross. She was extremely unhappy with CAMHS having made the referral as she felt they should have used their judgment and understood that she was not harming her children.   7.18. CSC reviewed the information sent by CAMHS but took ‘no further action’ as it did not meet their threshold to progress to a referral. The family were offered services under ‘Early Help’ from the Targeted Family Support (TFS) but the family declined this service.      9 7.19. Child G was seen by CAMHS for her medication review later that month and as it was helping her to fall asleep more easily, her melatonin2 prescription was increased from 2mgs to 3mgs.  7.20.  At around the same time Child G attended an appointment with her care coordinator and disclosed that she had had what she described as a “breakdown” at school and her mother had to collect her. She said that she kept having thoughts of self-harm - particularly stabbing herself in the stomach although she was clear that she would not do this. She denied recent cutting but admitted punching and kicking walls. The care coordinator planned to call G’s mother to discuss; discuss with school and with the team doctor and consultant psychiatrist. The call to Ms A went unanswered but the clinician realised that Ms A was due in a few days later and so the plan was to discuss with mother then.  7.21. Ms A came to an appointment at CAMHS 3 days later to talk about Child G’s developmental history as part of the ASD assessment. Child G’s ASDQ score did not reveal anything significant in relation to communication difficulties. There are no records that the session where Child G described having had a ‘breakdown’ was discussed with Ms A. The practitioner concerned has confirmed that it was discussed but it is not clear if this then elicited some action in relation to this.      7.22. In mid-February Mr B attended a parenting session on his own and disclosed that he and Ms A had ‘lost faith’ in CAMHS since the referral to CSC had been made. They no longer wanted to attend the FTWs. The two younger children did not want to attend either.  7.23. About two weeks later Child G was discussed with the CAMHS team’s Consultant Psychiatrist.  The plan from this was to send the ASDQ to school, discuss with Ms A referring Child G to paediatrics for the ASD assessment and to refer Child G to CBT for OCD.  7.24. In the following weeks there were various communications between CAMHS and Ms A and Mr B. CAMHs agreed to offer Child G weekly appointments, as the situation within the family remained strained. Ms A was upset with how things were at home and agreed to come to an NVR session with Mr B.  7.25. The ASD assessment was still being completed and school had been asked to  fill in the ASQ to assist. Ms A was awaiting a review of Child G’s melatonin as she (Child G) had expressed some dissatisfaction with it. Ms A had also checked Child G’s arms and was concerned that she had been cutting again.                                                             2 Melatonin is found naturally in the body and can be used as a medication to help control sleep and wake cycles.      10 7.26. Towards the end of the term school sent a letter sent home commending Child G for receiving 20 Achievement Points this term. 7.27. Child G did not attend her next appointment at CAMHS.  7.28. At some point over the school holidays the family went to Italy leaving Child G with her PGM. Ms A reported to school that the family ‘needed a break’ from her.  7.29. In the new term Child G and two friends stole craft knives from the Design and Technology classroom.  Later in the day, she provided the school with a forged note for a doctor’s appointment and truanted from school.  7.30. Child G was initially tearful about the incident and said that she had truanted because she wanted space before her GCSE exam. Child G was unsure why she took the knife and said that it was a thoughtless act.  7.31. Mr B went to the school early in the morning to discuss the incident and truancy. He explained that the girls had stolen the knives to become ‘blood sisters’. 7.32. In the meeting the DoL and Mr B discussed CAMHS and he said Child G had missed an appointment because she was managing her own appointments. Mr B said that the Family Therapy at CAMHS had broken down and that the relationship between Ms A and Child G had been better since the overdose, at least initially, but that it had not lasted long. There was a discussion about the consequences of Child G’s behaviour and school imposed a two day fixed term exclusion with Child G siting her exam first.  7.33. The DoL spoke with Child G (with the Safeguarding Officer and Deputy Head Teacher) to explain the fixed term exclusion. Child G was interviewed (along with the friends involved). Child G showed no remorse and was described as ‘quite aggressive’ in some of her answers. She understood the consequences and appeared to accept them.  7.34. The following day while Child G was home from school having been excluded she spent the morning in her room studying. Ms A left the house in the afternoon to pick up the younger children from school and take them to an activity.   7.35. In the early evening Ms A tried calling Child G on the home number there was no answer.  She then called her husband to check on Child G.  He came home and went to the backyard shed and found Child G had hung herself.  He immediately called the police and an ambulance. He attempted to resuscitate her but was unable to and Child G died that night.      11  8. Analysis and themes from the review  8.1. The following information is an analysis from the information provided by agencies, panel discussions and consultation events with practitioners involved with the family.  This section identifies common themes throughout the multi-agency network surrounding the family.   Voice of the Child       8.2. Child G was described by those who knew her as a spirited girl who was bright and intelligent with a great sense of humour.  8.3. What is also apparent from the information gleaned from the review is that she was deeply troubled and despite many avenues of help offered, she was unable to overcome feelings of worthlessness and being unloved.  8.4. Research and themes from other SCRs where young people have taken their own lives suggest that they are ‘hard to reach’ or ‘lost young people’ who decline services, which are then withdrawn through lack of engagement. Child G did not fit this common pattern. She engaged willingly (most of the time) with various services and supports particularly in school. Her death was not precipitated by a single traumatic event as is often the case, but more a build-up of intolerable inner pain, the root cause of which we cannot know for certain. Practitioners who worked with her were deeply  shocked by her death.  8.5. In view of this it may have been beneficial for agencies to have had an agreed understanding of information to be shared with Child Gs parents and what information could be kept confidential. This is not an easy balancing act especially in view of different agencies threshold and policies. For example the issue of whether to discuss with her parents about herself harm seems to have been lost between CAMHS and school.  School believe that they were advised by  CAMHS not to discuss this with the parents and school were under the impression that this was something that they (CAMHS) would bring up in their regular sessions. When it wasn’t there was no further discussion to clarify what should happen next.  Interagency communication/CAF  8.6. There were a number of professionals involved with the family and the review has highlighted that inter agency communication was limited to specific periods of time particularly around times of crises. These were instances of  agencies communication with one agency rather than a more open, shared  exchange of information.     12 8.7. There was no established mechanism in the network surrounding the family to exchange information in a routine way. Given the long standing concerns about Child G’s low mood, her reported feelings of worthlessness  and tensions in her family relationships it would have been beneficial to have more robust lines of communication between professionals.   8.8. All professionals that came into contact with child G recognised that she was troubled and she talked openly to a number of professionals about her feelings. It also appeared that her anger towards her mother was openly displayed in various appointments and it seems from the information provided that professionals viewed this as more out of the ordinary than a normal developmental stage childhood.  There were various points when a more co-ordinated approach may have been beneficial particularly in the latter months of Child G’s life when her mental health began to deteriorate more significantly.  8.9. In terms of information shared between health professionals, the GP practice where Child G and the family were registered were pivotal but failed to take an active role in seeking services for the family. They received a wealth of correspondence e.g. from the paediatrician who was concerned about Child G’s mood and dynamics within the family and from the hospital when Child G overdosed on Nytol, and all of which was filed in the records but not acted upon.  8.10. Child G was never discussed in multi-disciplinary meetings within Primary Care and never flagged as a vulnerable child. Furthermore she was never invited to the GP practice and assessed after many problems were brought to their attention. The GP did not liaise with paediatricians or other providers of the secondary care that Child G was receiving.  By the same token, no agency contacted the surgery to gather information regarding the family and therefore the surgery had some information but by no means all of it. Several recommendations are made at the end of the GPs report as to how the GP surgery can make changes and improve their practice.    8.11. The Common Assessment Framework (CAF) is the nationally recognised mechanism by which Early Help is given to families and its advantage is that it can focus on services for the parents which ultimately benefit the child. The family received various interventions but each agency was focused on their own pieces of work and no multi-agency assessment was undertaken.            13  Suicidal ideation and Self harm  8.12. Suicide ideation and self-harm in young people is becoming an increasingly common problem.  Self-harm is generally seen as a coping strategy to help young people handle with life rather than end it. Child G often expressed this view – which she cut to relieve inner pain rather than an intention to harm herself.  Statistics do however show a strong correlation between self-harm and suicide, and according to Hawton and James (2005)3. ‘Young people who self-harm are at a higher risk of suicide than the general population’. Child G also on a number of occasions said that she felt that she wanted to ‘end it all’ or that ‘life was not worth living’ and this was explored with her in sessions but she rarely spoke of definite intent which compounded the view CAMHS held which was that Child G was not at high risk of suicide.    8.13. The National Institute for Clinical Excellence (NICE) provide guidelines4 for dealing with self-harm and more specific guidance for risk assessments and plans.  8.14. The guidelines which state that;    A risk management plan should be a clearly identifiable part of the care plan and should:  address each of the long-term and more immediate risks identified in the risk assessment  address the specific factors (psychological, pharmacological, social and relational) identified in the assessment as associated with increased risk, with the agreed aim of reducing the risk of repetition of self-harm and/or the risk of suicide  include a crisis plan outlining self-management strategies and how to access services during a crisis when self-management strategies fail  ensure that the risk management plan is consistent with the long-term treatment strategy.                                                             3 Hawton & James (2005) Suicide and deliberate self-harm in young people. British Medical Journal. 2005; 330;891-894   4 Self-harm in over 8s: long-term management NICE Clinical guideline [CG133] Published date: November 2011      14 8.15. The GP’s response to the evidence of self-harm was inadequate. They had been aware of Child G’s admission to hospital in November but their response was administrative and they added a code to Child G’s file. There was no professional curiosity on behalf of the GP practice and there were no attempts made to contact the family or assess Child G’s vulnerability. No assessment was ever made by the practice about Ms A’s own mental health and the difficulties experienced by Child G. Nor was there any exploration with her about how she was supported around her own difficulties. During the process of the review it has become apparent about the role that the church played and continues to play in Ms A’s life and how she has been supported by her friends there. There is little or no information in any of the information submitted about this important aspect of family life.  8.16. As a result of this review GP Partners have devised a new workflow system for managing children’s external letters for safety netting, actions or escalation as needed. These include keeping external documents up to date to ensure all letters are acted on, creation and monitoring of a database for safeguarding cases and alerts being placed on patient electronic records where there are safeguarding concerns. Audits are being planned to ensure external letters are acted on appropriately and alerts are placed on relevant records.  8.17. In addition a new policy specifying best practice procedures when GPs are notified that a patient has taken an overdose has been developed. It is intended that the new document will be incorporated into Safeguarding Children Standards for General Practice, for use by all practices.  8.18. Child G’s parents’ response to Child G’s self-harm was appropriate and they were very upset by the events that took place. They were not aware of the extent of the self-harm identified at the beginning of November but in relation to the overdose they were extremely upset. They were responsive to suggestions about risk and safety planning from CAMHS and appreciated the support offered to Child G in school.  Child G seemed to understand that her parents’ reaction meant they loved her and for a short time at least she took comfort from this. This was however short lived as the comments made by Child G in her session in mid-December that seem to suggest that she was again in state of turmoil. Local LSCB response to teenage suicides 8.19. This issue of teenage suicide was recognised and reviewed by a group of specialists. The aim of the review was to identify any common links between the deaths and to develop a strategy to deal with the incidences.       15 8.20. Most of the seven deaths occurred in 2014 or 2015 and the majority were white high-achieving young people and most died by hanging. Although there were no identified links between these young people the review thought the influence of both social media and the wider media was significant.  8.21. A US study of newspaper reports5 associated with suicide clusters in 13-20 year-olds showed that reports of suicides which were followed by clusters differed from isolated (single) suicides in terms of:   news appearing more frequently   being more often on the front page   having headlines which included the word ‘suicide’ or a description of the  method used for suicide   providing more detailed descriptions of the individuals and their suicide acts 8.22. We know that Child G used the Internet in relation to her self-harm and a few hours before she died she had conducted a Google search about death by hanging so the research also seems relevant here. There was extensive media coverage of Child G’s death after the inquest.  8.23. Further work developed by the cluster of specialists included;  Work with local press on reporting of teenage suicides.   Sharing good practice in suicide prevention between boroughs  Setting up a database to monitor teenage suicides and attempted suicides across the boroughs.   Work with schools in an effort to prevent suicide and to ensure that they are prepared for the risk of suicide in a pupil.   8.24. This is evidence of a thorough response by the LSCB and the work needs to be taken forward.                                                                  5 Gould, M. S., Kleinman, M. H., Lake, A. M., Forman, J., & Bassett Midle, J. (2014). Newspaper coverage of suicide and initiation of suicide clusters in teenagers in the USA, 1988—96: a retrospective, population-based, case-control study. Lancet Psychiatry. Advance online publication. doi: 10.1016/S2215-0366(14)70225-1     16    Management oversight and supervision 8.25.  Within their reports, agencies were asked to consider the question of supervision and management oversight. The majority are mainly silent on the issue of formal supervision and tend to focus on management oversight. Decisions were made at the right level e.g. staff at the school consulted with senior colleagues and decisions within CSC were made at a management level. They do not however describe the supervision process, its impact on how the work with the family developed and how decisions were made.  8.26. CAMHS is the only agency to clarify within their report that formal supervision was given to the care coordinator fortnightly but is critical of the fact that although it happened regularly it did not appear to be challenging or seek to evaluate the work that was taking place.   8.27. CSC has a strong culture of supervision in the majority of LAs but this family did not receive statutory services so formal arrangements were not in place.  8.28. Discussions were held among peers in MDT meetings particularly in CAMHS but agencies made little use of safeguarding advisors to discuss the family, promote reflection and take action to assist. This is particularly pertinent for school and the GP.  8.29. To address the issue of effective supervision in CAMHS the use of measures has been increased via Children and Young People’s Increased Access to Psychological Therapies (CYPIAPT), which addresses this to some extent.  8.30. CYPIAPT is a service transformation that is a national program improving the quality of CAMHs services. One important aspect of CYPIAPT is the regular use of patient reported outcome measures that are used to look at effectiveness of the work with service users, their carers / parents and in supervision. The local CAMHS joined CYPIAPT 3 years ago and since this time there has been an ongoing service transformation in line with the principles of CYPIAPT, including the use of patient reported outcome measures.      17 8.31. In general terms all GP practices in the local area have a Safeguarding Lead GP, who takes the lead for safeguarding in the practice. They are responsible for ensuring implementation of ‘The Safeguarding Children Standards for General Practice’, which covers safeguarding standards for training, communication, registration, employment and record-keeping in their practices. They receive supervision, training & support via a bi-monthly GP Safeguarding Leads meeting, which is led by Named Safeguarding GP and Designated Safeguarding professionals. Again little use was made of these mechanisms as the vulnerability of Child G was lost to them.  9. Contribution from the family          9.1. Ms A and Mr B chose to be interviewed separately but both were keen to contribute to the review. The overview author met with them along with the LSCB Business Manager in the months leading up to finalising the report. Their contribution was very valuable to the review and it is to their credit that they were able to be open and honest in the face of such tragic circumstances.   Ms A  9.2. Ms A acknowledged her difficulties with Child G from an early age, describing her as always being very lively, clever and finding it hard to fit into the narrow definition of their family. Child G always wanted to be different and found discipline hard to take and so would challenge her parents. Ms A found the sibling rivalry problematic and as she had grown up as an only child she found it hard to distinguish what was normal sibling rivalry and what was not. She was not prepared for how the children behaved towards each other e.g. fighting and swearing, as those things did not occur in her upbringing.  9.3. Ms A had welcomed the help from a range of CAMHS professionals but thought their approach in trying to empower Child G was wrong as it gave her too much responsibility whilst she was still a child. She thought it was wrong that Child G should manage her own appointments and this contributed to her not attending them. Ms A would have preferred to have known about the appointments so that she could remind Child G and encourage her to attend.  9.4. When Child G took an overdose this was a very distressing time for her to see how unwell she became in the hospital. She feels that although the doctors treated her medically she was left to cope alone with a sick child who was delusional and didn’t recognise her for several hours. Ms A stayed with her all the time but it was exhausting and she would have appreciated some support. Mr B was away at this time trying to get back from a business trip so this made it especially hard for both of them.        18 9.5. She expressed how upset she was at CAMHS when they made the referral to CSC. She was unaware of the response that the children’s disclosures of smacking would produce and feels that this may be down to different cultural expectations. She felt affronted at the suggestion that she and her husband might be abusing their children and felt that CAMHS knew her well enough by then to have used their judgement more sensitively rather than just following procedures. She described how much more disciplined her parents had tended to be and to a much older age. She was able to acknowledge however that her children found this mix of cultural expectations hard at times.  9.6. Ms A considered that the school had handled the exclusion badly and alternatives could have been considered given Child G’s vulnerability. She does however have every faith that Child G’s actions were the result of a ‘mad five minutes’ and that she did not intend to take her life. Child G had texted a friend not long before she died which indicated that she would return to school as planned the following day. She knows that Child G loved being at school and was doing very well there. Ms A is saddened that Child G couldn’t appreciate how clever and popular she was.   Mr B 9.7. Mr B’s main view of the services offered to Child G was that they were not at the sufficient level and therefore the plans made to assist her were not adequate to meet her needs. He believes that services underestimated the extent to which Child G needed help, for example he was surprised that she rarely saw and did not receive longer term treatment from a child psychiatrist. He felt that she seemed to connect with a particular psychiatrist she saw at this time and Mr B felt that it was unfortunate that she was not able to see this person for ongoing sessions.  9.8. Mr B further felt that professionals did not sufficiently impress upon him the gravity of the situation e.g. the overdose and Child G’s self-harming behaviour. He would like to have had it explained to him in much more serious terms. He feels then that he would have taken matters into his own hands and sought help privately for Child G. At the time he had couched it in terms of ‘teenage angst’ rather than a deep need in Child G to receive more targeted help. As it was he took their advice in terms of what professionals thought that Child G needed and this was not enough. He did acknowledge during the course of the interview that professionals had not considered Child G to be of high risk of suicide otherwise they would have acted differently. He also appreciated their attempts to help but as stated feels that they were not the right people to help her or his family.      19 9.9. Mr B’s view of the school exclusion was that it was badly handled. His recollection of that time was that he had agreed with the Head of Year that Child G would not be excluded but that an internal exclusion would be more appropriate. This was however overturned by the Head Teacher and that in turn crystallised for Child G that life was not worth living. He feels that this could have been avoided.  9.10. It would appear that the family have not received any help in terms of bereavement counselling and Mr B was unsure whether there was any help that could be reasonably given. He has been amazed and impressed by the resilience of his other children about how well they have dealt with the tragedy. At the time of Child G’s death he recalls being sent a bundle of leaflets but could not recall the nature of these. He was however unable to receive that kind of information and take it board at the time.        20 10. Lessons learnt and questions for the LSCB to consider  Co-ordinated approach to children and Young people who self-harm 10.1. Children who are experiencing difficulties are best helped by a range of professionals who know them and can provide different but complementary expertise. For Children In Need and Child In Need of Protection the structure exists for a core group of professionals or Team around the Child to meet together at regular intervals to plan the care for a child or family. There was no such embedded approach for children who fall below that threshold. Individually agencies working with Child G and her family did their best for them but were largely unable to make in roads into what were entrenched difficulties in the family. A more collaborative approach may have been beneficial.     10.2. It is clear that practitioners consulted during the course of this review appreciate the value of a more multi-agency approach both in terms of co-ordinated work and information sharing. The work in this case was limited to communication with one or two different agencies usually around significant events. The Board needs to be assured that practitioners are aware of the need to engage a number of agencies when children are identified as having additional needs. The use of the Lead Professional was not evident in this case and this was key missed opportunity for services to be fully co-ordinated.    10.3. It is incumbent upon practitioners across a range of services to ensure that the need for early help for children is identified and acted upon immediately. The benefits of this approach can be seen in collating information about the child’s needs and providing targeted services that address the concerns preventing them from escalating to statutory services.  10.4. The strategic work to address this referred to earlier in the report has recently been implemented but it may be necessary for the Board to monitor its effectiveness ensure that there are transition arrangements in place whilst the work is in its infancy.   Safeguarding responses to self-harm and suicide ideation in teenagers 10.5. Responses from CSC in relation to Child G and her family were insufficiently robust and decisions to take no further action were made on the minimum amount of information. It is not clear if the decisions made on the front door in relation to the referrals considered the history of past contacts  before making their judgements. What is known is that very little information was shared or sought before making the judgements.      21 10.6. Safe practice would indicate that judgements on the front door are made using all available information and that includes checks with those who are already involved with the family as well as the family themselves. There was limited evidence of this in this case.  The responses indicated a lack of training around the needs of children who self-harm and lack of awareness of research around child abuse and connection with self-harm. 10.7. There is evidence that agencies lack confidence in identifying and managing self-harm and that agencies most likely to come into contact with young people whom self-harm have different views on what steps to take. This is a concern given the increase in self harm and it appears that knowledge about how to recognise, support and manage it has not kept pace with this increase. This has impacted on staff considering self-harm as safeguarding issue and the LSCB needs to be confident that its workforce are competent at dealing with it and know where to access advice.  10.8. There was no professional challenge to the decision by CSC to NFA the referral. Information provided by CSC also commented that the decisions were appropriate given the circumstances indicating at that time custom and practice was to provide a service only to those children in urgent need of protection. The panel were satisfied that this is now being addressed.  10.9. Practitioners consulted described time constraints in the Referral and Assessment Service that inhibited them from being thorough in managing referrals on a day to day basis. Working well into the evening was usual in order get through the number of contacts that had to be dealt with. All but the most urgent of referrals are routed to “Early Help’ services, when a broader range of children may require a social work assessment.    Assessment as a dynamic process  10.10. Practitioners in CAMHS responded well to crises within the family but where they were not so robust was evaluating the work they were doing and assessing the impact of changing circumstances. For example the risk assessment in relating to Child G’s overdose and self-harming behaviour was not routinely updated or changed in response to particular events. Her seeming reluctance to speak to CAMHS between January and April 2015 was not considered as a factor that had heightened risk and her self-harming was not re-evaluated after herself described ‘breakdown’ in January that year.     22 10.11. Between January and April self-harm is rarely mentioned by agencies in the information provided to the review.  There was a particular need to review the work offered when parents began to withdraw from their services after the referral to CSC was made. Information provided by SLaM makes the point well when they state, ‘There was no formal review of the risk assessment or care plans to assess the impact of the CAF referral, even though this did not directly relate to Child G, to evaluate whether existing plans were still meaningful in  the context of the family’s reduced willingness to engage’.  10.12. Assessment of any type of risk is a dynamic process which analyses and responds to the changing nature and level of risk faced by the child. A good assessment will continually evaluate the impact of any services delivered, measure progress and note improvements or otherwise of the child’s lived experience. The advantages of a multi-agency assessment have been well rehearsed elsewhere and may have provided an additional safeguard to ensure that Child G’s ever changing needs were at the fore front of the ongoing work. 10.13. Since Child G’s death CAMHS have been working on implementing changes  to their working practices to try and improve their relationships with other agencies, particularly schools and school nurses.  Implementation of reflective practice sessions with practitioners will help strengthen the multi-agency approach to risk assessment.  Exclusions and vulnerable pupils  10.14. The review has found that the school did not have suitable guidance when considering the exclusion of vulnerable pupils and this led to insufficient consideration of Child G’s individual needs.  10.15. Although the school were well aware of Child G’s deteriorating behaviour and had placed her on the red flag list it is clear that there was never a consideration of using a CAF to try and delve further into the family history to try and resolve the issues before resorting to the exclusion. The reason for this may have been that Child G was not seen as a child requiring social care support; some of this probably relates to the fact that Child G was articulate, highly intelligent and came from a professional family.  A more child centred approach may have taken a broader view of her difficulties. The very act of stealing knives should raise alarm bells about what a pupil’s motivation may be or what they may be communicating by their actions.  10.16. The school have however taken this incident very seriously and now have systems in place to oversee more vulnerable pupils. The panel were satisfied with the measures put in place by the new senior management team in tracking students who needed more support.       23 11. Recommendations for the LSCB (to be read in conjunction with agencies recommendations and action plans) NB Questions that the Board may want to consider are in Appendix 1   1. The Local LSCB to be assured that the current work underway to develop the new MASH and Early Help is sufficient, sustainable and robust to ensure that children suffering with mental health difficulties receive the appropriate help. 2. Local LSCB to receive an updated report on the work undertaken by the specialists about deaths of teenagers by suicide and take appropriate action to continue this work. 3. In line with the above the Local LSCB to consider launching a campaign to raise awareness of self-harm and suicide ideation in children and young people.  4. The Local LSCB to seek assurances from education partners to ensure that exclusion policies contain guidance about students with additional vulnerabilities. 5. The LSCB to ensure that all partner agencies have guidelines for practitioners for how and when to assess Fraser Competence and when to share information  6. As part of their annual audit programme the LSCB should oversee an audit of multi-agency work that takes place below the statutory threshold. 7. The LSCB to ensure that agencies and in particular CAMHS have sufficient tools, education and knowledge to assess risk and implement risk management plans for children and young people who self-harm.   8. The LSCB should ensure that the TAF/CAF model that supports early help for children is provided to families whose needs do not reach the threshold for statutory services by a range of services.       9. The LSCB to review, and if necessary re-launch, their multi-agency escalation policy.  10. The LSCB to be assured that NHS England has written a letter to be sent to all pharmacies copying in NHS England regarding selling of medication (Nytol) to children.  11. A joint mental health protocol to be developed (or review and re-launch if one exists) between CAMHS and CSC to ensure consistency of thresholds and promote joint working. This strategy is already in development but the Board should be reassured that it is sufficient and clear in its expectations.  12. CDOP to review their processes in how they communicate available help for bereaved parents and their families.        24   Recommendations for individual agencies from the Overview Report   The local mental health trust to provide the LSCB Main Board with their risk management guidelines to ensure this is in line with the NICE guidance    Jane Doherty Independent Social Work Consultant  March 2017                                   25    APPENDIX 1  Questions the Board may want to consider  1. Is the expected multi-agency pathway in relation to self-harm clearly laid out to best support this group of children?   2. Is the training currently on offer meeting the needs of professionals who come into contact with young people who may self-harm or express suicide ideation?  3. Does the current review of Early Help services sufficiently address the area of childhood mental health  4. Neighbouring LSCBs – are schools in the surrounding area aware of their responsibilities for initiating formal Early Help services where required?   5. Is the Board confident that the current review of the MASH and Early Help services will match resource with demand? 6. Are there sufficient interim arrangements in place whilst the review is conducted?   7. How can the Board be assured that practitioners are confident in dealing with self-harm and suicide ideation in young people?   8. In view of decreasing resources available to services is the Board satisfied that the local commissioning  of CAMHS meets the identified needs of children living in its area?  9. How is the Board assured that there is a strong culture of reflective  supervision in all agencies?  