Death of an adolescent girl by hanging, in the early summer of 2011. FJ became known to agencies four months before her death when she disclosed a history of self-harming to mother and GP. FJ took a significant overdose of over-the-counter medication in the months preceding her death, resulting in an eight day in-patient hospital stay. Issues identified include: inadequate exploration of FJ's 'inner world'; lack of professional challenge; and insufficient importance attached to FJ's indications that she would self-harm if returned home and mother's indications that she could not guarantee FJ's safety. Makes various interagency and single agency recommendations, covering: police, educational psychology services, leisure services, child and adolescent mental health services (CAMHS), children's services, GP, community health and NHS services.
      
 Title:  Serious case review: Child FJ: executive summary. LSCB: Wolverhampton Safeguarding Children Board Author: Fergus Smith Date of publication: 2013  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                                                                                                                                            1           WWOOLLVVEERRHHAAMMPPTTOONN  SSAAFFEEGGUUAARRDDIINNGG  CCHHIILLDDRREENN  BBOOAARRDD    SSEERRIIOOUUSS  CCAASSEE  RREEVVIIEEWW      CCHHIILLDD  FFJJ      EEXXEECCUUTTIIVVEE  SSUUMMMMAARRYY      PPUUBBLLIICCAATTIIOONN  DDAATTEE  0044  NNOOVVEEMMBBEERR  22001133  1 INTRODUCTION  1.1 CIRCUMSTANCES PRIOR TO DEATH 1.1.1 FJ lived with her mother and other siblings. Her parents were separated though her father owned a house nearby and remained actively involved. All family members are White British and practicing Christians. 1.1.2 Some eight months before she died, FJ had begun to exhibit some difficult behaviour at home and her mother considered that she was the victim of some ‘cyber bullying’. 1.1.3 One evening in the early Summer of 2011, the parents found their daughter hanging from a wardrobe with a ligature around her neck.  An ambulance was immediately summoned and FJ was transferred to hospital where life was formally pronounced extinct. FJ was then aged thirteen. 1.1.4 In the months preceding her death, FJ had:  Taken a significant overdose of over-the-counter medication   Some two weeks before she died, cut her wrist to an extent that required minor medical treatment 1.2 INITIATION OF THE SERIOUS CASE REVIEW 1.2.1 The then relevant statutory guidance (Working Together to Safeguard Children 2010) required a ‘serious case review’ to be initiated if a child has died (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in that death. Its purpose is to:  ‘Establish what lessons can be learned about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children  Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result and  As a consequence, improve intra and inter-agency working and better safeguard and promote the welfare of children’ 1.2.2 On 12.07.11 the chairperson of Wolverhampton’s Safeguarding Children Board (William Anderson) accepted the recommendation of the standing serious case review sub-group that a serious case review should be conducted into FJ’s death. Ofsted (the relevant regulatory body) and the Department for Education were immediately notified of that intention. 1.2.3 Serious case reviews are not inquiries into how a child died or who is culpable. Those matters are for Coroners and criminal courts respectively. The local Coroner has opened and adjourned an Inquest into FJ’s death. 1.3 INVOLVEMENT OF LOCAL AGENCIES 1.3.1 The following agencies were identified as having or likely to have information and opinions of relevance to the serious case review:  FJ’s school   Wolverhampton City Council Communities Directorate Safeguarding Service Health & Wellbeing: Wolverhampton City Council Communities Directorate Children and Families Division –Children’s Social Care (Child Protection & Family Support); Social Inclusion Multi Agency Support Team (MAST) (including educational psychologist and parent support adviser)  Black Country Partnership Mental Health Foundation Trust hosting the Child and Adolescent Mental Health Service CAMHS   (‘mental health practitioners’, ‘specialist practitioner’, consultant psychiatric and psychotherapeutic input and its ‘Crisis Team’)  Wolverhampton City Council Communities Directorate: Safeguarding Service Health & Wellbeing, & Children and Families Division: Children’s Social Care (child protection and family support)  Royal Wolverhampton Hospitals NHS Trust (in-patient paediatric, children’s liaison and school nursing services)  West Midlands Police (jointly investigating alleged abuse, attending when FJ was missing and on the night of her death)  Wolverhampton Primary Care Trust (commissioning GP services) 1.4 REVIEW PROCESS 1.4.1 Because there has been no concerns about her before FJ began secondary school the panel formed the view that it should explore the period from her move to her new school in Autumn 2009 to her date of death in 2011. 1.4.2 Members of the serious case review panel were as follows:   Ms Nicki Pettitt (independent chairperson)  Wolverhampton City Council Health & Wellbeing Directorate, Head of Service Safeguarding  Wolverhampton City Council: Health & Wellbeing Directorate, Deputy Head of Service Safeguarding  West Midlands Police: Detective Chief Inspector Public Protection Unit  Wolverhampton City Council: Deputy Head of Child in Need & Child Protection Children and Family Division – for part of review  Wolverhampton City Council: Head of Child in Need & Child Protection Children and Family Division – for part of review  Wolverhampton City Council: Learning & Skills Directorate  Black Country Partnership Mental Health Trust: Consultant Psychiatrist   Youth Offending Team: Operations Manager   Designated Senior Nurse Safeguarding Children Wolverhampton  Royal Wolverhampton Hospital NHS Trust: Consultant Paediatrician & Designated  Doctor for Safeguarding Children Wolverhampton  Senior Inspector Education   District Senior Educational Psychologist   Staffordshire & West Midlands Probation Trust   Youth Organisations Wolverhampton: Co-ordinator  Safeguarding Children Board Training co-ordinator 1.4.3 The need for independence was recognised. No panel member had prior involvement with FJ or her family; the panel was chaired by an experienced independent person and the overview report drafted by an experienced author also with no connection with agencies or professionals involved. Each individual management review submitted was drafted by a suitably qualified individual with no line management or supervisory responsibility. 1.4.4 The independent chairperson Ms Pettitt is a General Social Care Council-registered freelance social work manager who qualified in 1989. The overview author is Fergus Smith of CAE (www.caeuk.org) who has thirty seven years post-qualification experience of social work, is the author of over twenty ‘Personal Guides’ to family and criminal law and is the co-author, author or chairperson of approximately forty serious case reviews. 1.4.5 The panel met on six occasions and devoted a further day to completion of a comprehensive action plan to ensure effective implementation of the changes identified as necessary during the serious case review. 1.4.6 FJ’s family was involved in formulating the terms of reference, updated during the course of the review (when some specific issues raised by them were also addressed). Following their acceptance by Wolverhampton’s Safeguarding Children Board, the parents were taken through the recommended changes. Sincere thanks are owed to the family for contributing at what remains a very difficult time for them all. 1.4.7 Both the family and staff affected by FJ’s death were offered support in coming to terms with the loss of this talented and much loved child. 1.4.8 Panel members were acutely aware of the ease of identifying FJ’s family and the potential harm to other vulnerable members by intrusive Media attention. On psychiatric and legal advice, the panel recommended that, following receipt of a response from Ofsted, only an executive summary should be published. This recommendation was accepted by Wolverhampton’s Safeguarding Children Board and this summary omits all identifying details. 1.4.9 It includes unchanged, conclusions, lessons learned and recommended improvements for local service (the majority of which have, as at June 2013 been completed).                                                                                                                                    5 2 AGENCIES’ CONTACT, CONCLUSIONS & LESSONS LEARNED 2.1 AGENCIES’ CONTACT 2.1.1 Until some four months before FJ’s death there had been no professional or parental awareness of any mental health difficulties or of any self harming.  FJ then revealed to mother and her GP a history of self-harming. An immediate referral was made to the Child & Family Service of the Child & Adolescent Mental Health Service (CAMHS). The school also offered pastoral care and the services of an educational psychologist were engaged. 2.1.2 From that point on, several agencies were involved.  2.1.3 FJ went missing on one occasion following a row at home and her diary entry at that time indicated an intention to kill herself. 2.1.4 A scheduled appointment with CAMHS was consequently brought forward and a conclusion drawn that FJ’s continuing contact with an educational psychologist was sufficient. 2.1.5 Further family support was provided by Children’s Social Care and a Multi Agency Support Team. In the period to Easter, there was a good deal of liaison between involved professionals, though Children’s Social Care closed the case at this time. 2.1.6 In late Spring, FJ took a significant overdose of Paracetamol and Ibuprofen. In what was regarded by medical and other professionals as a deliberate attempt to kill herself. FJ was admitted to the children’s ward and spent eight days as an in-patient during which time there was some effective and some less effective liaison between paediatric, psychiatric, psychological and social care services. 2.1.7 The possibility of a transfer to a residential adolescent unit was considered but on her eighth day and without the benefit of a pre-discharge meeting, FJ was prescribed standard medication and discharged home to the care of her mother with ongoing support to be provided by the CAMHS Crisis Team.  2.1.8 The responsible psychiatrist wrote to the GP to advise of FJ’s return home and to request prescription of specified medication. FJ returned to school and was provided with substantial and valuable levels of support from staff there and from the involved educational psychologist. 2.1.9 In the middle of her school’s Summer term FJ informed her psychologist that she had had ‘slit her wrists’ and that voices had told her to do so. The psychologist initiated practical arrangements for the relatively minor treatment required and liaised with FJ’s psychiatrist and GP. 2.1.10 A multi-agency meeting at which FJ’s pattern of self-harm and attempted suicide could have been explored, would have been justified at this stage. 2.1.11 Some two weeks before FJ’s death, the treating psychiatrist changed her medication to a less orthodox one. Expert advice has confirmed that the choice was a reasonable one, but no rationale for it was included in the  letter to the GP nor was any written information for parents provided as required by the National Institute for Health and Clinical Excellence (NICE) guidelines1. It anyway seems likely that FJ would not have experienced the full benefit of the new medication before her death about two weeks later.  2.1.12 The General Pharmaceutical Council has confirmed that its code of practice indicates that some doubts raised earlier by a local dispensing pharmacist as to the choice of the less orthodox medication, should have been raised by him directly with the psychiatrist. 2.1.13 Finally, a more detailed analysis is provided in the full report of some confusion on the night of FJ’s death, between Police and Ambulance Services centring on which hospital JF was to be taken to and its location.  2.2 CONCLUSIONS 2.2.1 Professionals involved appear to have approached their respective tasks in a conscientious and predominantly sensitive manner and most of the services provided were properly planned and efficiently and effectively delivered. 2.2.2 It is not possible to conclude that FJ’s tragic death was preventable by any simple alternative actions of professional staff.  The evidence did though indicate she would further self-harm. If best practice had prevailed at all times, the risk of further attempts at suicide would probably have been better identified and more consistently evaluated. This in turn would probably have led to a more effective collaborative effort to keep her safe.  SUB-OPTIMAL PRACTICE 2.2.3 There were a number of examples of individual sub-optimal practice: Children’s Social Care  A failure by Children’s Social Care in February to seek further contextual information e.g. agency checks prior to completion of its core assessment  A muddle about which member of the Family Advice & Support Team was to be allocated  An apparent failure to circulate clear purpose, membership or outputs of a nonetheless useful ‘child in need’ meeting in March  A failure to provide formal notification of case closure in April  A muddle in May about whether Duty & Assessment or the Family Advice & Support  Team should raise a referral                                                  1 NICE Guidelines Depression in Children & Young People number 28 September 2005  CAMHS  Insufficient weight placed by ‘consultant psychiatrist 2’, ‘mental health worker 2’ and by the ‘specialist practitioner’ on what FJ was saying  ‘Consultant psychiatrist 2’s’ failure to convene a pre-discharge meeting   ‘Consultant psychiatrist 2’s’ failure to initiate a dialogue with his paediatric peers during FJ’s period in hospital  ‘Consultant psychiatrist 2’s’ failure to sufficiently involve the educational psychologist  An apparent failure to adequately brief parents on what to do to keep FJ safe, to brief the GP or to  provide written information to the family on prescribed medication or to record the rationale for the switch to the unorthodox Mirtazapine     Community Services  A failure at the Health Centre to pass on to the correct location notification of FJ’s overdose in May  A school nurse’s failure to follow up her (belated) notification of FJ’s hospitalisation  Police  On the night of FJ’s death, poor communication between Police and Ambulance Dispatch centres, some officers of both services and the family SYSTEMIC ISSUES 2.2.4 Retrospective analysis of the effectiveness of the efforts made has also highlighted the following more systemic weaknesses that transcend individual agencies.  Hearing the child’s voice 2.2.5 The reasons for FJ’s anxieties about home, her mother and what they represented do not emerge from available records. From the first assessment in March through to her discharge without a shared acknowledgment of her stated intention to self-harm again, coupled with all GP consultations being in the presence of mother, there was insufficient exploration of FJ’s inner world. 2.2.6 Though she was clearly ambivalent about her family, there was a consistency in the anxiety associated with it which was insufficiently recognised, explored or shared amongst involved professionals. 2.2.7 In the view of the overview author, FJ was as clear as she was able to be that a return home would lead to a further suicide attempt. 2.2.8 Observations of FJ’s instability of mood should not have offered as much reassurance about reduced risk as they did. 2.2.9 It is reasonable to conclude that there was undue optimism amongst the CAMHS staff who dealt with FJ after her initial assessment on the day of her hospitalisation. Such optimism also served to diminish the proper concerns of those who had heard FJ’s voice more clearly e.g. the consultant psychotherapist and educational psychologist. Practical arrangements for collaboration 2.2.10 Whilst there were many examples of sound inter-agency work, there were  ‘system failures’ within the practical arrangements for collaboration:  A faxed confirmation of the phone referral from the hospital apparently not being received by Children’s Social Care’s Duty & Assessment Team  CAMHS’ mistaken reassurance about the current Family Advice & Support involvement when the hospital rang that agency   A collective failure, albeit some individuals recognised the need, to ensure a pre-discharge meeting when FJ was in hospital  The failed notification to the school nurse about FJ’s admission  (a result of an erroneous address held by the hospital and compounded by an individual failure to forward the message)  The fact that no written information was readily available to inform and facilitate the required briefing of GP and of parents with respect to the switch to Mirtazapine  Record keeping & effective information sharing 2.2.11 A number of weaknesses in record keeping and information sharing seem to extend beyond the individuals involved and are probably systemic:  The insufficient core assessment ‘completed’ in February – it seems likely that such a mistaken approach was not a ‘one-off’ and may have been accepted practice  The absence of any agreed notes of the professionals’ meeting in early March which it is suspected may not be a ‘one-off’  The absence of standard elements for the child in need meeting in March (agenda, output notes kept / circulated) which again may well be more than a one-off failure  Absent, poor quality or seriously belated records of contacts especially by several CAMHS staff   The joint failure to ensure notes made by CAMHS staff at hospital are accessible at that location and at CAMHS  CAMHS failure to offer the school directly or via the psychologist, guidance on how to respond to FJ on her return  Sometimes illegible handwriting in some records of hospital staff  Confident challenge 2.2.12 There were occasions when a professional became aware of a need to improve the plan or approach being adopted at the time but did not do so:  The educational psychologist’s acceptance (even though she was the nominated ‘lead professional’) that there was no pre-discharge meeting  ‘Consultant paediatrician 2’s’ acceptance that the February child protection enquiries adequately resolved any safeguarding concerns she had prior to FJ’s discharge  The community pharmacist’s failure to make direct contact with the prescribing psychiatrist in spite of his concerns about the choice of medication  2.2.13 Though the reasons for respective actions may have differed, the implication for future practice is that, without regard to profession or rank within it, any individual who forms a view that an existing proposal or plan is not in the best interests of a child has an obligation to articulate that view. 2.2.14 Having initiated a challenge and failed to effect change, a responsibility remains to reflect on any counter arguments and (if the individual still believes change to be required) escalate the concerns through available channels.  BEST PRACTICE 2.2.15 There was also good practice evident in this case of which the most commendable examples were the:  Efforts of the ‘pastoral lead’ in an academic environment unused to addressing such significant emotional needs  Educational psychologist’s commitment and willingness to be contacted at any time if FJ required it  Joint approach adopted at the point of FJ’s admission to hospital of the consultant psychotherapist and psychologist  Response of the practice nurse and receptionist in attending FJ’s home and waiting with her for an ambulance to arrive 2.3 FJ’S WORLD 2.3.1 Professional records and parental descriptions offered ‘external’ views of FJ’s world. Panel members sough to piece together and develop a coherent account of the expressed and implied wishes and feelings of FJ herself. The full report provided significantly more detail, much of it personal in nature. In essence, whilst apparently showing only limited signs of depression, FJ emerged as feeling lonely, helpless and stressed in the face of high levels of pressure from within her family. Observation of self-inflicted scarring on arms and abdomen by the GP and hospital respectively suggest also that FJ had found coping with her life more difficult than was obvious to others. 2.4 LINKS TO RESEARCH 2.4.1 Two sources of research potentially add to the learning arising from this tragic case. The first is the series of biennial analyses of completed serious case reviews published by the Department for Education (previously Department for Children, Schools and Families and before that the Department for Education and Science). The second source is the narrower and more specific knowledge-base derived from academic studies of self-harm and suicide in adolescents. Both are explored in the full report that has informed the Local Safeguarding Children Board’s responses. 2.5 LESSONS LEARNED Voice of child & mother 2.5.1 The feelings and opinions of daughter and mother were insufficiently heeded in this case by CAMHS staff. Though FJ’s mood state seemed to vary she was fairly consistent in offering verbal and non-verbal indications that she would self-harm or worse if returned home. 2.5.2 Similarly, and although insufficiently captured in CAMHS’ records, there seems little doubt that mother had clearly expressed doubts about whether she could keep her daughter safe if she returned home from hospital. 2.5.3 Mother has consistently recalled saying to ‘consultant psychiatrist 2 ‘I can’t be responsible for that thing’ [sic] [a reference to her self-harming daughter and the plan that she return home]. If that was indeed the expression used, the choice of words and its meaning required thorough exploration.  2.5.4 The practical result of assuming an ill-briefed mother could ensure acceptance by an increasingly reluctant FJ of the prescribed medications was to establish a further ‘battle-ground’ and risk further inflaming an already fraught relationship. Need for an holistic view 2.5.5 Any assessment of medical, psychological or social need or risk requires a holistic view of the child in her/his personal and social setting. For specialists in any given field to see ‘the whole child’ necessitates drawing upon information gathered and provided by others including the child. To ensure that such shared information is of value, it must be a complete, accurate and timely account of the results of professional contacts.  2.5.6 Though there were no examples of any deliberate refusal to share information, nonetheless there was insufficient information exchange. Key practitioners should have sat down together to compare, contrast and explore all that they knew during, or at worst after FJ’s hospitalisation. Had they done so, a clearer picture of the risk of suicide by FJ was more likely to have emerged. 3 RECOMMENDATIONS 3.1 INTRODUCTION 3.1.1 Mindful of the Department for Education research report2 that focused on recommendations from serious case reviews, the panel sought to minimise their number and maximise their specificity and achievability. 3.1.2 The panel has though found it necessary to formulate the following recommendations, most reproduced from individual management reviews (when necessary modified to render them more specific, measurable, achievable, realistic and timely) some identified by the overview author and/or health overview authors. These have been divided into those requiring action by:  Wolverhampton’s Safeguarding Children Board or  The agency specified 3.2 WOLVERHAMPTON LOCAL SAFEGUARDING CHILDREN BOARD 3.2.1 The Safeguarding Board should:  Seek from Wolverhampton’s Children’s Trust Board details of the local provision for minimising amongst children and young people, self-harm and suicide and a reassurance as to the relative effectiveness of that provision  Write to each member agency and ask them to issue a written reminder to all staff (and ensure their training programmes address) a): the need in law and best practice to include non-resident parents (especially, though not just those with parental responsibility and who are actively involved) in all assessments of need, planning and delivery of service and - b): the obligation of all professions without regard to discipline or rank within it, to offer respectful challenge to colleagues.  Write to Wolverhampton PCT and ask that it remind all local community pharmacies of the professional expectation to make direct contact and query any proposed prescription which appears to the pharmacist in question not to be in the patient’s best interests. 3.3 SCHOOL  3.3.1 School 1 should review its outdated child protection policy so as to ensure it is rooted in the current 2010 version of Working Together to Safeguard Children.                                                  2 A study of recommendations arising from serious case reviews 2009-2010 Brandon etc al DFE RR157 3.3.2 School 1 should seek from Children’s Social Care and partner agencies a simple description / illustration of the respective roles of local agencies and the established multi-agency infrastructure e.g. Common assessment Framework, lead professional, child in need meetings etc. 3.3.3 The school’s management team should reflect on why teaching staff did not  involved the school nurse at any point and initiate in consultation with the Community Health Service any required organisational changes. 3.3.4 So as to achieve one of its key objectives in the 2011/12 School Development Plan (provision of effective training for pastoral staff in dealing with students who present with complex mental health issues, and the need to resource on-site counselling) a clear plan should be formulated with timescales and arrangements for monitoring progress and evaluation. 3.4 WEST MIDLANDS POLICE 3.4.1 ‘HQ Public Protection’ should instruct officers engaged in missing persons co-ordination duties to record all actions undertaken after a missing episode within retrievable police systems (the systems are already in place; Periodic dip sampling of systems will enable supervisory checks. 3.5 EDUCATIONAL PSYCHOLOGY SERVICES 3.5.1 Detailed plans should be prepared to improve the awareness of parents, schools and young people of self harm and the importance of early intervention. 3.5.2 Policy and procedural guidance for Children’s Social Care and MAST staff in relation to their respective responsibilities for overlapping areas of work should be developed. 3.5.3 A clear policy should be developed and supported corporately, for cover arrangements for staff absence in MASTs when casework involves significant levels of risk. 3.5.4 Multi-agency guidance on how staff should respond to suicide attempts and to self- harm should be developed. 3.5.5 Training to support the dissemination of the above guidance should be rolled out. 3.5.6 Practical arrangements need to be put in place so that messages can be left for educational psychologists. 3.6 LEISURE SERVICES 3.6.1 Youth services should be developed so as contribute to targeted work with those who self harm and those at risk of suicide. 3.7 CHILDREN’S SOCIAL CARE 3.7.1 In order to help achieve the delivery of planned help and measured outcomes to children and young people, social workers in the department should receive training in evidence-based approaches to assessment. 3.7.2 The Core Assessment should be redesigned to ensure social workers:   Gather information from available sources including the use of assessment tools, such as those provided in the Framework for the Assessment of Children in Need and their Families, (DH, 2000) and  Create a comprehensive chronology of salient information. 3.7.3 Policies and procedures about the management of s.47 enquiries should be well understood by the Duty & Assessment team, so should be reviewed at intervals of no more than three months as an agenda item in team meetings and supervision.  3.7.4 Recruitment of permanent staff should be achieved with minimum delay to avoid having a high ratio of agency staff in the department [completed]. 3.7.5 Induction processes in the Children and Family Support department should be reviewed and an inductions pack written and issued for new staff and supervising managers. 3.7.6 Departmental policy guidance should be updated to require that where forms are designed to be copied to service users and ask for service user signatures, practitioners must provide copies and gain those signatures or record why they have failed to do so. 3.7.7 Departmental policy guidance should be updated to require that key partners; specifically children, their families and referrers are written to when case responsibility is to transfer or close. 3.7.8 A memo should be sent by the Assistant Director of Children & Family Support, to all of the department’s staff supporting the Wolverhampton Safeguarding Children Board guidance ‘Children who Self Harm’: Practitioners’ supervision notes should record that they have read and understood that guidance. 3.7.9 A set of good practice exemplars for case note recording should be created and circulated to staff as an aide memoir. 3.7.10 Procedures for the ‘Resource Allocation Panel need to be amended to enable it to be able to become aware of and address ‘inter-panel’ events. 3.8 CAMHS 3.8.1 All CAMHS staff should attend record-keeping training. 3.8.2 The Deliberate Self Harm Assessment procedure should be strengthened to ensure that working practices between the hospital services and the CAMHS are robust, that there is consistency of record-keeping practices and that the explicit requirements for discharge planning are clearly defined (action plan provides details). 3.8.3 All electronic written details (in the form of e-mail information-exchange on case management relating to individual’ children’s needs) must be inserted into individual records which inform and evidence on-going case management within and across agency sites and are reflected as such within agreed standards of record-keeping and practice (action plan provides details). 3.8.4 A professionals’ meeting must be convened for all ‘high risk’ cases in which Children’s Social Care is not involved (action plan provides details). 3.8.5 Relevant enquiries regarding existing service involvement should be made by the CAMHS with key agency sites e.g. Community Children’s Nursing Service / Children’s Services, Local Authority following acceptance of a referral for service assessment of a child’s mental well-being, the details of which are to be fully documented.  3.8.6 When involved in care provision, the CAMHS should directly engage in multi-agency integrated service activities (Common Assessment Framework / Child in Need / Child in need of protection planning), ensuring that documentation is maintained which effectively informs on the progression and effectiveness of care delivery (action plan provides details). 3.8.7 All high risk cases must be brought to ‘peer meetings’ and key staff should receive minutes of those meetings. 3.8.8 A protocol should be developed for a high risk child wishing to disengage from service delivery (action plan provides details). 3.8.9 If a child is identified as a high risk suicide, the member of staff undertaking the initial assessment should be involved in subsequent assessments and case discussions. 3.8.10 A process should be developed to give staff guidance on ending a clinical session (action plan provides details). 3.8.11 All direct consultations with children should include an appropriate level of discussion with regard to:  Their perspective on their needs   Their opinions on care planning and needs’ management and   Their impression regarding the impact on their well-being as a result of service intervention  All of which should be accurately reflected within the records as maintained. 3.8.12 Safeguarding supervision needs to be embedded into practice by means of a review of existing clinical supervision and new arrangements made explicit. 3.8.13 Staff should undertake any required safeguarding children training as indicated by a review of the current in-service mandatory training. 3.8.14 In all cases of self-harm of children there must be robust multi-disciplinary liaison and in relevant instances a pre-discharge planning meeting must be convened. 3.8.15 Staff support should be offered in an appropriate and timely manner following the death of a child and its form determined by the results of reflection amongst and questioning of staff. 3.9 HOSPITAL  3.9.1 When children are in-patients hospital staff should ensure that their referrals to safeguarding services have been responded to before discharge and that they are included in any child protection discussions, strategy meetings and child protection investigations that take place. 3.9.2 In complex cases admitted to the ward for any length of time one named      consultant paediatrician should take overall responsibility to ensure     consistency rather than handing over care to the ‘out of hours’ consultant      even if overall care is with the consultant child psychiatrist. 3.9.3 If there are child protection concerns about children on the ward consideration should be given to involving a consultant community     paediatrician with expertise in this area at the outset. 3.9.4 When the CAMHS team considers that there is a suicide risk, senior hospital staff should ensure that parents have been given advice about keeping the young person safe and that their concerns have been addressed before discharge from the ward.  3.9.5 In all cases of self-harm of children there must be robust multi-disciplinary liaison and in relevant instances a pre-discharge planning meeting must be convened.  3.9.6 The hospital need to complete an exercise so as to verify that all details held of local liaison links are correct and introduce an expectation that all professional agencies which are known to be involved with a child-patient are informed of her/his admission and discharge. 3.9.7 All entries into the hospital records should be legible, signed with name and designation or registration number clearly stated and dated with the time for in-patients. 3.9.8 The Deliberate Self Harm Assessment procedure should be strengthened to ensure that working practices between the hospital services and the CAMHS are robust, that there is consistency of record-keeping practices and that the explicit requirements for discharge planning are clearly defined.  3.9.9 All direct consultations with children should include an appropriate level of discussion with regard to:  Their perspective on their needs   Their opinions on care planning and needs’ management and   Their impression regarding the impact on their well-being as a result of service intervention  All of which should be accurately reflected within the records as maintained. 3.10 COMMUNITY HEALTH 3.10.1 The systems and practice of information shared between the acute and community health services on presentation of children and young people with self-harming behaviour in the A & E should be reviewed. 3.10.2 The system and practice of collaborative working between the school and the school nursing service in the context of physical and emotional concerns for the welfare of individual children should be reviewed. 3.11 GP SERVICES 3.11.1 When there are concerns about a child and s/he is referred to another agency, there should be systems in place to ensure that the child attends the appointment and that the referrer is kept informed about the attendance. 3.11.2 When a health professional visits a patient this should be fully recorded as should the actions taken even if the care is passed onto another e.g. ambulance crew. 3.11.3 There should be specific recording of when and in what way the children’s wishes and feelings were ascertained and taken account of when making decisions about the provision of services. 3.11.4 All direct consultations with children should include an appropriate level of discussion with regard to:  Their perspective on their needs   Their opinions on care planning and needs’ management and   Their impression regarding the impact on their well-being as a result of service intervention  All of which should be accurately reflected within the records as maintained. 3.11.5  ‘Primary Care Services’ should be reminded of their responsibilities to identify vulnerable children without reliance on carers to pursue actions in response to their dependents’ health needs. 3.12 PRIMARY CARE TRUST 3.12.1 The Primary Care Trust or its successor organisation (Clinical Commissioning Group) should develop guidance to support the completion of independent management reviews with regard to Primary Care Service provision and which takes account of the management of serious case review requests for health information relating to adults. …………………………………………     SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 1 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome 1 MAST staff to be actively involved in improving the awareness of schools about self harm and the importance of early intervention. Social Inclusion  Review of the MAST training that is currently provided to educational providers, including school governors, to ensure that self-harm and suicide prevention is appropriately included in training programmes.  District Senior EP DSEP convened Psychology Service Special Interest Group to plan materials and training for schools. Guidance completed. Training and information in place.  Completed 31.10.12.   An increased awareness of the needs of these vulnerable students within school.  2 Development of youth services contributions to targeted work with self harmers and those at risk of suicide Social Inclusion  Referral pathways to be developed.  Training needs analysis of youth service staff to be undertaken to gauge their current and future capacity to undertake this work.  Training plan to be devised and implemented. Head of Social Inclusion and Head of Youth Service  Referral pathway and Training agreed between DSEP, Head Social Inclusion and Head of Youth Service. Completed 31.12.12 Head of Service agreement on an integrated approach involving Youth Worker and other Children & Family Support  staff as an outcome of the Youth Service re-organisation when Youth Workers will be deployed to area teams.  Youth Service staff given access to materials used to brief Children & Families staff. 3 Preparation of Policy and Procedures guidance for Social Care and MAST staff in relation to their respective responsibilities for overlapping Social Inclusion  Develop a specific policy and procedure for relevant staff.  Launch the policy and procedure at Head of Social Inclusion and Head of CIN/CP Materials developed into C&FSS Policy Guidance. Completed 31.12.2012 Presentation on self-harm delivered to Children, Young People and Families staff as part of staff briefings. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 2 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome areas of work. Joint Children’s Services event.  4 MAST staff to ensure that all child in need, and CAF plans should have clear detail and instructions about cover arrangements when the key worker/lead professional is absent.  Social Inclusion  All MAST staff to be informed of this expectation through management supervision and team meetings.   Regular audits of plans to monitor this expectation. Deputy Head of SI  Cover arrangements agreed and incorporated into Policy and Procedural guidance. Completed 31.12.2012 Policy established and in place.  5 Specialist Core assessments must provide a balanced analysis of the child’s story. Children’s Social Care Commission training to be delivered by the organisation - Child and Family Training in Evidence informed approaches to assessment.   Head of Workforce Development and  Head of Children in Need and Child Protection Child & Family Training was commissioned in November 2011 and is  Now embedded using in-house trainers and provides the underpinning methodology for social work assessments in the city. Assessing Parenting and the Family Life of Children is part of our induction programme for new social Completed  November 2011  A systematic and evidence-based approach to specialist assessments. This will result in practitioners providing   improved analysis and more helpful plans being created with children and their families. It will help embed a good practice culture of analysis and critical thinking in the department. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 3 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome workers. 6 Core Assessment pro forma on Care First should be redesigned to ensure it  encourages the gathering of information from all available sources and the completion of comprehensive chronologies Children’s Social Care Business Change Manager will be employed to consult with practitioners to review Wolverhampton Children’s Social care forms. Care First User Group (CFUG) chaired by Head of Looked After Children Development of New forms began in summer 2012 and were introduced in June 2013 and are being used by all social workers Completed  June 2013.  A pro forma which is easy to read and helps tell the child’s story. The needs of Children and their families will be better understood and help offered will target those needs. 7 Recruitment of permanent staff should be achieved with minimum delay to avoid having too high a ratio of agency staff in the department. Children’s Social Care All agency filled posts will be recruited to. Head of Children in Need and Child Protection When vacancies arise in social work posts they are recruited to without delay. The recruitment process is supported by robust HR processes.  Completed  July 2012 A stable and highly motivated workforce    8 Induction processes in the department should be updated and reviewed, identifying key policies and procedures in regular use and which require staff to demonstrate that they have read and understood them. Children’s Social Care An induction pack will be written and issued for new staff and their supervising managers to follow. The departments Child Protection policies and procedures will be reviewed and updated paying close regard to those available from the Head of Children in Need and Child Protection And Policies and Procedures Officer The induction policy, including the employee checklist, has been updated annually.  Completed August 2012 Confident staff with: not only a clear understanding of their own department’s roles and responsibilities but also a clear understanding of other key partners’ roles and responsibilities. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 4 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome WSCB TriX online manual. 9 Copies of assessments and plans must be evidenced as having been received by service users and other agencies. Children’s Social Care  Departmental policy guidance will be updated, to require that where forms are designed to be copied to service users and which ask for signatures that practitioners do so or record why they have failed to do so.  Monthly auditing will include monitoring of this expectation.  Head of Children in Need and Child Protection And Policies and Procedures Officer  Department’s policies and procedures have been updated and staff forums utilised to embed responsibilities/ expectations.  Social Workers record that service users have received assessments and plans on the Electronic Social care record. Monthly audits/thematic audits address information sharing.   Completed – December 2012.      Children and their families will be able to check out their understanding and relationships will be enhanced. 10 Key partners to always be informed when case responsibility is to transfer or close. Children’s Social Care  Departmental policy guidance will be updated to require that key partners and most specifically children and their families and referrers are written to when Head of Children in Need and Child Protection And Policies and Procedures Department’s policies and procedures have been updated and remain under regular review. Most recent update October Completed  14.10.13        Well informed Children,  Families and key partners. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 5 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome case responsibility is to transfer and close.  Team meeting minutes and individual supervision records will record that practitioners have discussed and understood the importance of this communication standard.   Monthly auditing will monitor compliance of this expectation.  Officer.  Head of Children in Need and Child Protection       Head of Children in Need and Child Protection 2013   Since December 2011 Information sharing with partners is addressed within minutes..     Since March 2012 Monthly audits/thematic audits address feedback to partners regarding significant change/transfer.     . 11 Children’s Social Care to ensure that there is an improved understanding by all staff of good practice in working with children and young people who self harm or threaten suicide.  Children’s Social Care  The Head of CiN and CP in Children and Family Support will write a memo to all of the departments’ staff supporting the WSCB guidance in section 5 sub section 19, Children who self -Head of CIN & CP Memo sent out to all staff outlining good practice Completed  08.12.12 Department staff to be given the opportunity to reflect on issues of self harm in supervision and as a team, particularly when they are in the role of lead professional.  SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 6 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome harm.   Practitioners’ supervision notes will record that the memo has been discussed. 12 Quality of case recording must be improved.  Children’s Social Care  A set of good practice exemplars for case note recording will be created and circulated to staff.   Auditing will monitor the effectiveness of this approach.  Head of Children in Need and Child Protection  New Carefirst forms contain links to good practice exemplars.  Quality of recording monitored via monthly audit and supervision. Completed   08.08.13  Consistent clear case note recording standards across the department. 13 Provision of on-site counselling for students presenting with complex mental health issues. School 1 Seek governor approval for an increase in staffing. Ascertain level of need in order to determine amount of time required. Consider location for counselling service once established. Set protocols for student access to the counselling service.  Headteacher / Deputy Headteacher  Report completed and as a result, Counsellor employed by school 1 morning a week since October 2011 and 2 mornings a week from January 2012 In addition Counselling Psychologist attached to the school for 1 day a Completed  30.03.12  An additional resource is available for students and staff in school.  Students and staff are able to access appropriate support to address specific needs.    SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 7 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome week ( from MAST 5) from September 2012 – July 2013. This service is well used by students. Referrals are made via Pastoral Leaders and students 16 years and over self- refer.   14 Provision of training for pastoral staff in dealing with students with complex mental health issues. School 1 Identify appropriate trainer. Book training.  Deputy Headteacher Pastoral Leaders’ Training Day off site took place 16th January 2012. Included  all Pastoral staff , 2 Learning mentors and School counsellor. Completed  16.01.12   Staff feel more confident and better equipped to support and address the needs of students with complex mental health issues.    15 Provision of parent support classes. School 1 Plan parent support classes to provide parents with greater insight into social networking sites in order to understand how cyber bullying happens, their Headteacher / Deputy Headteacher E-safety bulletins have been a feature of the termly school newsletter since September 2012. School has put in Completed September 2013.  Parents feel better informed and better equipped to deal with these issues.    SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 8 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome responsibility to protect their children from it and how they can do so. Plan parent support classes on how to deal with issues of adolescent mental health, supporting parents to know how to address these issues. place Parental sessions  for 2013/14 academic year including  e- safety and cyber bullying (and adolescent mental health. In addition school has run ‘drop ins’ for parents to discuss any pastoral issues with a member of the SLT. 16 ‘HQ Public Protection’ should instruct officers engaged in missing persons co-ordination duties to record all actions undertaken after a missing episode within retrievable police systems (the systems are already in place and it is not onerous for officers to complete this task. Periodic dip sampling of systems will enable supervisory checks. West Midlands Police Missing persons coordinator practices to be revised to direct officers to appropriately record actions undertaken in a format which is readily available Force Lead Officer A new Force Policy on the Management, Recording and Investigation of Missing Persons was introduced in June 2013. It includes electronic recording on the COMPACT system of tasks and updates to be completed in the same tour of Completed  June 2013 An improvement in the ability of officers to retrieve relevant information in a timely way.    A more effective missing persons policy will be available to officers.        SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 9 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome duty. Missing enquiries are supervised by an Inspector and have an identified Officer in the Case. Debriefs following/ misper– absent episodes are recorded on COMPACT. All entries are searchable and retrievable.            Bold italic is additional entry from HOR review of IMR Action Plan details                                                                                                                          AP No Recommendation /  Issues Agency Source Specific  Actions Responsible Lead  Progress to Date Status including date for completion Outcome 17 To review the systems and practice of information shared between the acute and community health care services on presentation of children and young people with self-harming behaviour in the A & E department Community Services  CLHVS, A& E staff, CAMHS, SN service 1. Response from CLHVS 2. Review notification procedure -form and timeliness 3. Standard operating procedure  CLHV Pathways developed in partnership with Alcohol Liaison Nurse, Aquarius /Birmingham and Solihull Mental Health Trust (new providers since April 2013) and are working well.   Named Completed  July 2013 Improved Identification of need for young people presenting at A&E departments as a result of self-harming behaviour.  Improved service delivery to these young people.  SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 10 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome Emergency Department[ED] Sister attends the alcohol steering group which monitors pathways.  Verbal notification to services made by Paediatric Liaison Nurse.  Independent Domestic Violence Advisor[IDVA] based in ED from October 2012 Specific training delivered to ED staff by Lead Nurse for Safeguarding Children with resultant improved  training compliance.  18 To review the system and Community 1. Review SN attached System reviewed. Completed Form and function of SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 11 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome practice of collaborative working between School 1 and the SN service in the context of physical and emotional concerns for the welfare of individual children Services  School 1 & SN service  communication channels  2. Agree future systems of communication for urgent and non-urgent issues to School 1   School nurse  (SN) now attends weekly for ‘drop ins’ for students. Students needing access to SN identified by Pastoral Leaders and referred to SN by Deputy Head. SN also delivers health sessions in PSHCE at KS3 – this has been ongoing for the last 4-5 years continues to be so. The Drop-in sessions provided by school nursing service is audited 6 monthly with positive findings 31.01.12  Drop-In sessions are understood by pupils and school staff Regular information-exchange takes place between health and education staff with regard to the health and well-being of pupils. Posters available in schools advertising school nurse drop ins School nurses advertise service during assemblies. Annual working together agreement completed with school nurses and individual schools.   Safeguarding procedures followed and escalated appropriately.    SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 12 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome 19 Where there are concerns about a child and the child is referred to another agency, there should be systems in place to ensure that the child attends the appointment and that the referrer is kept informed about the attendance GP Review the records systems operated by GP practices which enable acknowledgement of all correspondence as received.  Ensure systems are robust. Review the systems operated by GP practices which flag the need for referral follow-up. Ensure systems are robust.  SC Commissioning Lead WCPCT Named GP for SC Letter sent to all GP’s and practice managers to ensure that each practice reviews its systems and procedures. Feedback to ensure that this occurred was received. Completed 30.9.13 Records systems are robust which ensure all correspondence is available to inform on-going care provision. Staff are alerted to the need to follow-up on referrals via established record-keeping systems. Named GP reports activities into the JHSCC Training events have been held across the city to highlight this issue and the named GP has circulated information to support the process. 20 Where a health professional visits a patient this should be fully recorded as should the actions taken even if the care is passed onto another eg ambulance crew  GP Details to be forwarded to all GP Practices which inform on the expectation of record-keeping practices with regard to individual episodes of care provision. Expected record-keeping standards to be included in content of SC Training events for GP Practice staff . SC Commissioning Lead WCPCT Named GP GMC guidance sent to all practice managers and GP’s as well as a series of safeguarding training sessions detailing this issue and embedding this within practice  Completed 30.06.12 Awareness-raising exercise is completed regarding record-keeping requirements. SC training programmes include information on record-keeping standards Named GP to report activities into the JHSCC   SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 13 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome 21 There should be specific recording of when and in what way the children’s wishes and feelings were ascertained and taken account of when making decisions about the provision of services. Refer to Rec. HOR 6 GP Details to be forwarded to all GP Practices which inform on the expectation of record-keeping practices with regard to individual episodes of care provision Expected record-keeping standards to be included in content of SC Training events for GP Practice staff SC Commissioning Lead WCPCT Named GP All GP’s and practice managers sent the GMC guidance and a series of Safeguarding training sessions undertaken to fully embed this within their practice.  Completed 30.06.12 Awareness-raising exercise is completed regarding record-keeping requirements. SC training programmes include information on record-keeping standards have been undertaken and area core part of the ongoing safeguarding training programme for the GP’s. GMC guidance has been circulated and highlighted to all GP’s and practices  Named GP  reports activities into the JHSCC    HOR 1  Primary Care Services’ are to be reminded of their responsibilities to identify vulnerable children without reliance on carers to pursue actions in response to their dependents’ health needs. HOR For GP  / Primary Care Services Details to be forwarded to all GP Practices which inform on responsibilities for identifying and attending to the needs of individual children  Practice expectations are SC Commissioning Lead WCPCT Named GP Letter sent to all practices regarding this action and asking for assurance from practice managers.  Completed 30.09.13 Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 14 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome to be included in content of SC Training events for GP Practice staff  practice requirements. Named GP  reports activities into the JHSC    HOR 6 All direct consultations with a child should include an appropriate level of discussion with regard to: their perspective on their needs,  their opinions on care planning and needs’ management and their impression regarding the impact on their well-being as a result of service intervention,  all of which should be accurately reflected within the records as maintained. HOR For GP  / Primary Care Services Details to be forwarded to all GP Practices which inform on responsibilities for identifying and attending to the needs of individual children  Practice expectations to be included in content of SC Training events for GP Practice staff SC Commissioning Lead WCPCT Named GP Letter sent to all practices regarding this action and asking for assurance from practice managers.  Series of Safeguarding training sessions held across the city for Gp’s and their practice staff to ensure that this is addressed within all consultations with children and young people   Completed September 2013 Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on practice requirements Named GP to report activities into the JHSCC   SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 15 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome  22 When children are in-patients the hospital staff should ensure that their referrals to safeguarding services have been responded to before the child is discharged. Acute Trust This will be included in child protection audit.    Re-distribute  the ‘Management of Concerns’ Flow chart  6-monthly reports on referral activity to continue which includes detail on referral tracking and outcome.  Ref Overview Report: The hospital is to complete an exercise to verify that details of local liaison links are correct and introduce an expectation that all professional agencies which are known to be involved with a child-patient are informed of his/her admission and discharge. Named Doctor for Safeguarding in hospital.  Des Dr SC DSNSC   DNSNC NNSC      SC Strategic Lead RWHT  Following a multiagency task and finish group an updated Self Harm policy has been written and ratified by the providers. The policy will be audited in Feb 2014 to ensure that it is working well for all providers. Finding will be reported through Joint Safeguarding Children Committee [JSCC] and to Commissioners.           Completed  31.07.12        Safeguarding procedures followed and escalated appropriately.  Training for ED staff  to covers specific requirements of CAMHS patients.    23 Where there are child protection concerns regarding Acute Trust To discuss at peer review child protection Designated Doctor Flow chart redistributed to all  Completed  Ward staff have a full understanding of SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 16 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome children on the ward consideration should be given to involving a consultant community paediatrician with expertise in this area at the outset.  departmental meetings   Re-distribute  the ‘Management of Concerns’ Flow chart  Ensure that practice expectations are included in content of SC Training events for hospital staff Safeguarding   Des DR SC DSNSC    Des Dr SC DSNSC NNSC  staff. Discussed at CP peer review meetings and embedded within the safeguarding training for paediatricians and paediatric nursing staff in all session 2013.       31.03.12           safeguarding children flow chart and of need to involve community paediatricians as required 24 When the CAMHS team considers that there is a suicide risk, senior hospital staff should ensure that parents have been given advice about keeping the young person safe and that their concerns have been addressed before discharge from the ward.  Acute Trust To include in Discharge planning meeting   Refer to Rec HOR 2 Clinical Director  Discussed at CP peer review meetings and embedded within the safeguarding training for paediatricians and paediatric nursing staff in all session 2013.     Completed - 30.04.12 Discharge planning meetings involving parents / carers is routine practice pre-discharge 25 In complex cases Acute Trust Refer to Rec HOR 2 Clinical Discharge Completed – Discharge planning SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 17 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome consideration should be given to holding a multi-disciplinary discharge planning meeting. Director planning meetings involving parents / carers is now routine practice pre-discharge and if this does not occur then clear rationale for the absence of a meeting is documented in the notes. This is embedded within training and the self harm policy.  June 2012 meetings involving parents / carers is  routine practice pre-discharge 26 All entries into the hospital records should be legible, signed with name and designation or registration number clearly stated. and dated with the time for in-patients. Acute Trust Staff to be issued with name and designation stamps with GMC/NMC nos.     Practice expectations with regard to standards of record-keeping are to be re-issued Directorate manager        Medical Director /  Chief Nursing Officer All medical staff have received their name stamps     Standards re-issued.  Completed        Completed  30.06.12 Standardised documentation / record keeping policy followed in in-patient, out-patient and Emergency department areas.  Quarterly  audit process in place which shows improvement in compliance. Trust audits 10 sets of case notes per month against NHSLA HOR 2 The Deliberate Self Harm Assessment is to be strengthened to ensure that HOR  For Hospital Review and revise the existing procedure*  Clinical Director RWHT Record keeping has been explicitly covered Completed 30.06.12 Discharge planning meetings held for CAMHS patients who required SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 18 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome working practices between the hospital services and the CAMHS are robust, that  there is consistency of record-keeping practices and that the explicit requirements for discharge planning are clearly defined.  Services Formulate a monitoring  activity / audit of practice tool  Complete 6 monthly audit and report into the JHSCC  *ref Overview Report In all cases of self-harm of children there must be robust multi-disciplinary liaison and in relevant instances a pre-discharge planning meeting must be convened  Deputy Chief Nurse RWHT within the safeguarding children training.  A joint self harm policy has been written and ratified for use by BCPFT and RWT and is explicit in the expectation of record keeping and pre discharge planning meetings.   enhanced care packages HOR 6 All direct consultations with a child should include an appropriate level of discussion with regard to: their perspective on their needs,  their opinions on care planning and needs’ management and their impression regarding the impact on their well-being as a result of service intervention,  all of which should be accurately reflected within the HOR  For Hospital Services Details to be forwarded to all relevant hospital sites which inform on responsibilities for identifying and attending to the needs of individual children  Practice expectations to be included in content of SC Training events for hospital staff Clinical Director RWHT  Deputy Chief Nurse RWHT Safeguarding training delivered specifically for ED medical and nursing staff and Children’s Directorate staff on in-service study days – high 90% compliance Work continues to refine person centred care plans and user satisfaction Completed 30.06.12 Records of patients reflect improvement in recording of care planning   SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 19 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome records as maintained. strategy design for autumn 2013. Monitored through JSCC annual schedule of work.   27 All CAMHS staff to attend Record keeping Training     A more robust system be developed to ensure all contacts are inputted into case files in a safe and timely manner ie. electronic system. CAMHS  Learning and Development (L&D)  Review existing training arrangements and adjust according to need. Report submitted to management on numbers of staff attending training Random Case file Audits Discussions to take place in team meeting around how to ensure safe transferral of notes until a more robust system in place. Service Manager CAMHS team managers L & D Discussions taken place by NNSC with Service Manager who has disseminated to staff areas of concern. Random file audits are taking place.  Specialised training has now been delivered for all relevant staff. Issues around appropriate input of contacts and safe transferral of notes have been discussed and made priority by staff.  Notes that are written on the ward are now Completed  30.04.12  Good Practice in line with NMC / Trust Record Keeping Policy   SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 20 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome scanned, with a copy filed into the Child and Family notes, ensuring mirror copies maintained within both.  28 A professionals meeting is called for all high risk cases where Children’s Services are not involved  Refer to Rec. HOR 5 CAMHS    Raise staff awareness of Common Assessment Framework (CAF) Monitoring of number of meetings that occur.  Minutes documented accordingly in case file CAMHS team managers Staff have now completed or are booked on CAF training (some still those awaiting due to sessions being fully booked) The Deliberate Self Harm Policy has been amended to ensure multi-agency discussion takes place prior to young person being discharged from hospital. Policy has been agreed by RWT/BCPFT.  NNSC continues Completed  30.06.13 CAF is utilised by Health professionals where Children’s services are not involved thus ensuring co-ordinated service delivery. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 21 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome to be informed via virtual fax of each self-harm admission to hospital. 29 All High Risk Cases to be brought to Peer Meetings. Key members of staff involved in the case should receive the minutes. CAMHS     All staff involved in a child’s case should meet to discuss views on levels of risk, especially when there are inconsistencies around levels, or risk changes from high/low in a short period of time. Minutes of Meetings documented in both case file and Peer meeting file.  Random case audits to identify high risk cases and monitor their discussion. Service Director  All high risk cases discussed at weekly meeting which NNSC attends. Safeguarding issues are explored whether or not family known to CSC. Staff have received training regarding CAF process, NNSC/CAF co-ordinator offer refresher sessions. Staff are aware of internal escalation process and BCPFT Escalation Policy- this is monitored by the safeguarding links and NNSC at the Completed  Dec 2011 Improved risk assessments and monitoring of activity to ensure children & Young People’s needs are being addressed. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 22 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome Crisis Team Meetings. 30 Protocol to be developed for when a child has been identified as high risk but wishes to disengage. This should stipulate that these children and their families are offered 2 weekly contact, even by phone call, and reviewed after following 3 months. In the case of a medicated child specific arrangements need to be made to carefully monitor adverse reactions in line with NICE guidelines. All correspondence to the GP needs to clearly state how and why decisions are made around the prescribing of medication. Refer to Rec. HOR 8 CAMHS   Protocol to be developed and distributed to all staff.  Audit to be completed of identified high risk cases and their care plans Audit of case notes   Service Director Process in line with NICE  guidelines has been informally developed and disseminated to staff via email,  Process now ratified into service policy. High risk cases reviewed at weekly Crisis meetings and medication monitored in line with NICE guidelines.  Included in Self Harm Policy. GP letter shares any information in relation to medication regime changes. Completed  February 2012 A Protocol is in place and embedded to inform CAMHS staff of their responsibilities when Children disengage from CAMHS intervention.    31 When a child is identified as a high suicide risk the member of CAMHS  Guidelines to be incorporated into Service Director These guidelines have now been Completed  October 2012 There is clarity regarding actions to be taken SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 23 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome staff undertaking the initial assessment (Deliberate Self Harm Protocol) should be involved in subsequent assessments and case discussions.    Should there be a variance in perceived risk between the initial assessment and the subsequent 2nd opinion, the clinicians involved should discuss together the concluding plan of care.   Refer to Rec. HOR 2  Deliberate Self Harm Protocol. Audit of case files to ensure consistency of care Assessors invited to Peer meetings in high risk cases – this can be monitored through attendance list of Minutes. Staff conducting high risk assessments to ensure they are familiar with previous/on-going assessments by reading case notes and/or direct contact with each other. incorporated into the Self Harm Policy ( agreed by RWT/BCPFT)  Initial assessors are invited to attend weekly meetings and contribute to case discussions.  The escalation process has been disseminated to ensure staff are aware of where to take concerns should they feel perceived variance in risk needs addressing further.   regarding children who are identified as being at high risk of suicide. 32 Process to be developed which will give staff guidance and enable them to end a session should they feel intimidated or the session exceeds the time allocated CAMHS  The purpose and content, including time allocated, to be clearly explained to child and family before session begins. A contract agreeing to these terms to be signed by all involved. Awareness sessions to Service Director Team Mangers The F2F letter that is sent out clearly stipulates the time allocated and purpose of the meeting.  Staff re-iterate this at the beginning of each session to ensure Completed  30.06.12 The effectiveness of increased clarity around times of sessions regularly monitored with any exceptions discussed within supervision. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 24 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome ensure staff are confident in assertion techniques. YP/and or parents understand the purpose and content of consultation 33 Safeguarding Supervision to be embedded into practice CAMHS  Safeguarding Review the existing Clinical Supervision arrangements and guidance for staff Arrangements and expectations of practise to be made explicit Service Director NNSC  It has been agreed that Clinical Safeguarding Children Supervision be integrated into existing Supervision Policy. Completed June 2012 SGC supervision takes place during internal clinical supervision and this covers the support they require.    NNSC to offer additional support and advice when required, on both a 1-1 level, or   by group discussion through our safeguarding link forums.   A more robust system underway to ensure external supervision available on request 34 Staff to undertake mandatory Safeguarding Children   training CAMHS  Learning and Development  NNSC   Review the existing in-service mandatory training and adjust according to need. Accommodate needs, ensuring expectations of required levels are clear. Team Managers L & D NNSC  Mandatory training passports have been developed through L & D to advise staff on required levels, act as on going Completed September 2013  Mandatory Safeguarding Training is embedded and available to all relevant staff. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 25 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome records and contain action plans for those whose training is outstanding. 35 Staff Support should be offered appropriately and timely following the death of a child. CAMHS     Staff questionnaire/reflective exercise to understand individual needs and requirements and accommodate accordingly.  To review existing processes and explore ways to enhance, including external support. Service Director Team Managers NNSC Support is offered by NNSC and CAMHS Managers to staff. This is  available on an    Individual and group reflection basis.   Completed 31.03.12 Timely support is available to staff and the outline of this is embedded in policy and procedure. HOR 2  The Deliberate Self Harm Assessment is to be strengthened to ensure that working practices between the hospital services and the CAMHS are robust, that  there is consistency of record-keeping practices and that the explicit requirements for discharge planning are clearly defined. Refer to Rec. 5 HOR  For the CAMHS Review and revise the existing procedure*  Formulate a monitoring  activity / audit of practice tool  Complete 6 monthly audit and report into the JHSCC  *ref Overview Report In all cases of self-harm of children there must be Dir C & YP BCPFT   The Deliberate Self Harm Assessment has been strengthened and completed through Task and Finish Group. Deliberate Self Harm Policy has been agreed by BCPFT/RWT. Completed 30.06.12 Deliberate Self Harm Assessment is effective and it’s effectiveness is measured via regular audit. SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 26 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome robust multi-disciplinary liaison and in relevant instances a pre-discharge planning meeting must be convened HOR  3 All electronic written details (in the form of e-mail information-exchange on case  management relating to individual children’s needs) are to be inserted into individual records which inform on and evidence on-going case management within and across agency sites and reflected as such within agreed standards of record-keeping and practice. The opportunity should be taken to make reference to information-exchange via SMS. HOR For the CAMHS  Refer to CAMHS Rec. 1 Management of e-mail information exchange with regard to record-keeping practices is to be made explicit and incorporated into existing policies and procedures Dir C&YP BCPFT The BCPFT Information Governance Lead has reviewed current Record Keeping Policy to include these forms of communication.  Completed 30.06.12 Records are fully informed on case management details which involve e-mail exchange.  Expectations of record-keeping practices are explicit with regard to the use of e-mail information-exchange  Relevant record-keeping audit activities to be reported into the JHSCC   HOR 4 Relevant enquiries regarding existing service involvement are to be made by the CAMHS with key agency sites (eg Community Children’s Nursing Service / Children’s Services, Local Authority) following acceptance of a referral for service assessment of a child’s mental well-being, the details HOR For the CAMHS  Existing policy and procedural documents are to be reviewed and revised to accommodate the need for enquiry with key sites.  Local audit tool to be developed by which to monitor activity Dir C &YP BCPFT NNSC meets with staff (link/crisis team meetings) to ensure that appropriate liaison with relevant agencies is made. This has been included within updated Completed  30.06.13 Liaison and networking practices are enhanced.  Practice expectations are explicit.  Audit activity is to be reported into the JHSCC.   SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 27 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome of which are to be fully documented. Deliberate Self Harm Policy. HOR 5 When involved in care provision, the CAMHS is to directly engage in multi-agency integrated service activities (Common Assessment Framework / Child in Need / Child in Need of Protection planning), ensuring that documentation is maintained which fully informs the progression and effectiveness of care delivery.  HOR For the CAMHS  Refer to CAMHS Rec. 2 Existing policy and procedural documents are to be reviewed and revised to accommodate the need for practice expectations with regard to engagement in integrated multi-agency activities  Local audit tool to be developed by which to monitor activity Dir C &YP BCPFT NNSC has highlighted need fro CAMHS to engage in multi-agency fora via link meetings etc. Staff are booked onto, or attended,  Case Conference training. CAF training is embedded in service NNSC reports number of CAF’s raised/Conference invites/attendance into JHSCC Completed 30.06.12 Practice expectations are explicit.  Engagement in integrated activities is enhanced.  Record-keeping practices are robust  Audit activity is to be reported into the JHSCC.   HOR  6 All direct consultations with a child should include an appropriate level of discussion with regard to: their perspective on their needs,  their opinions on care planning and needs’ management and their impression regarding the impact on their well-being as a result of service intervention,  HOR For the CAMHS  Details to be forwarded to all relevant CAMHS sites which inform on responsibilities for identifying and attending to the needs of individual children  Practice expectations to be included in content of SC Training events for CAMHS staff Dir C&YP BCPFT Responsibilities have been forwarded to relevant CAMHS staff and are re-iterated via training programme. Impact to be Evidenced within records/supervisioCompleted 30.06.12 Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on practice requirements Activities to be reported  into the JHSCC  SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 28 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome all of which should be accurately reflected within the records as maintained. n notes. Quarterly audits to be presented to Care Governance Meeting.  Relevant corporate record-keeping audit activities to be reported into the JHSCC.   HOR 8 Existing systems and practices with regard to the prescribing of medication by the CAMHS and the associated care packages supplied by the service are to be audited with reference to compliance with NICE guidelines.    HOR For the CAMHS Comprehensive audit to be undertaken with regard to level of compliance with NICE guidelines   Dir C&YP BCPFT All high risk cases and care plans are reviewed weekly and medication monitored in line with NICE guidance.  Completed 30.06.12 Status of local practices as compliant with national guidelines is explicit. Findings inform local action plan for on-going service development Audit activities to be reported into the JHSCC.     Supplementary Recommendation   HOR 7 Guidance is to be produced by which to support the completion of Independent  Management Reviews with regard to Primary Care Service provision and which takes account of the management of Serious Case Review requests for health information as HOR Production of guidance to support process with regard to IMR of GP / Primary Care Services   Awareness-raising of IMR process within GP SC Training events Dir. Primary Care Services WCPCT  Des Dr SC DSNSC IMR process now included within the training of GP’s for safeguarding children training Dec 2012, Jan 2013, Feb 2013  Completed 30.09.13 Explicit guidance available to support the IMR process  Effective and efficient engagement in the SCR process by GP Practices  Activity is to be reported SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 29 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome relating to adults.  SCR subgroup has   developed IMR training for all agencies therefore no longer need full guidance specifically for Health professionals .  into the JHSCC and the SCR Sub-committee WSCB.            AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome  Overview Report Recommendations  OR 1 Wolverhampton Safeguarding Children Board should seek from Wolverhampton Children's Trust Board details of the local provision for minimising among children and young people, self harm and suicide and a Overview report  A formal request to be made by the Chair of the WSCB to the chair of the WCTB for information.  Report from the WCTB to be Head of Safeguarding    Chair of the Sub group –  Public Health has been requested to provide an update on source provision for YP + Self-Harm – Completed October 2013 The WSCB to be informed of local provision of services to this vulnerable group.  A policy and procedure will be available to all SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 30 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome reassurance as to the relative effectiveness of that provision. considered by the Quality and Procedures Best Practice sub-group of the WSCB, who will then formulate a multi-agency policy and procedure for all staff who may work with children and young people who self harm or threaten suicide.  Head of CIN and CP.  Health and Wellbeing Board now responsible rather than CTB  Letter re-sent to H&W Board in view of changes in Health economy.  Self-harm Policy remains outstanding. agencies which will be based on local provision and will ensure best practice in this area.   OR 2 Wolverhampton Safeguarding Children Board will write to each member agency and ask them to issue a written reminder to all staff (and ensure their training programmes address) a): the need in law and best practice to include non-resident parents (especially though not just those with parental responsibility and actively involved) in all assessments of need, planning and delivery of service; and  b): the obligation of all professions without regard to discipline or rank within it, to Overview report  Letter to be written, and to include the request that evidence of the impact of this request will be monitored through regular auditing and management oversight of case records.   WSCB Quality and Performance sub-group to request regular updates on audits of practice in this area.  Head of Safeguarding         Chair of the Quality and Performance sub-group.    Embedded in all relevant WSCB training and requested for inclusion in all partner agency training.    Information only report to WSCB in November 2013.  Information added to QA windscreen  - 30 Completed March 2013                All staff to be reminded of expectations of good practice in assessment and planning.       Managers to monitor this issue and address practice issues.  SCR FJ AGENCY IMR – INTEGRATED ACTION POINTS  Action Plan Updated  25 October 2013 31 AP No Issues\ Recommendation Agency Source Specific Actions Responsible Lead Person Progress to Date Status including date for completion Outcome offer respectful challenge to colleagues  October 2013 OR 3 Wolverhampton Safeguarding Children Board will write to Wolverhampton PCT and ask that it remind all local community pharmacies of the professional expectation to make direct contact and query any proposed prescription which appears to the pharmacist in question not to be in the patient’s best interests Overview Report Letter to be written. Head of Safeguarding  SC Commissioning Lead WCPCT  Letter re-sent to CCG since the demise of PCT in April 2013. Completed October 2013 Awareness-raising exercise is completed regarding practice requirements.  SC training programmes include information on practice requirements  Evidence of completed action is reported into the Quality & Assurance Committee, WCPCT  