Death of a 16-year-old girl due to Diabetic Ketoacidosis in 2015. Review focuses on the concerns around the management of her illnesses both in the home and by professionals and services. Dawn was born in 1999 and had a twin sister and younger brother. The family are Black (Caribbean) British, and had been known to Children's Social Care. Dawn's sister was taken into care after living with her father. Dawn had four significant health problems which needed careful management to avoid her becoming ill. In December 2015 Dawn was found collapsed at home following a short period of illness. Key findings and learning include: safeguarding needs were not assessed by any of the agencies involved; there was a lack of professional curiosity around siblings and parental neglect; child's voice not sought or heard; lack of understanding of how the family's cultural beliefs impacted on their attitudes; comprehensiveness of assessments, including risk; information sharing between health agencies. Recommendations include: health providers should provide assurance about how they manage and co-ordinate the care of children and adolescents with complex health needs to ensure that safeguarding issues are not missed; develop flagging systems across agencies which identify children and adolescents where other children or young people in the family are looked after; develop a system for regular liaison between children's services in different areas, where children in families of concern live between parents and across areas.
      
 Title:  Serious case review: Dawn. LSCB: Medway Safeguarding Children Board Author: Tracey Sparkes Date of publication: 2018  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.                                   Medway Safeguarding Children Board    Serious Case Review Dawn   Author: Tracey Sparkes  March 2018    2 Contents   Page 1. Introduction 1.1  The circumstances that led to this review 1.2  Scope, timescale and terms of reference for the review 1.3       Specific issues to consider in the review of this case 1.4       Methodology  3 3 5 5 2. Background information 2.1        Dawn 2.2  Dawn and her family 2.3  Dawn’s health and its impact on her life 2.4  Dawn’s younger years and contact with Children’s Services 2.5        Dawn’s contact with other agencies during the timeframe for the review  7 8 10 12 13 3. Findings and Learning 3.1  Summary of themes identified 3.2. How did the quality of assessment and decision making affect this         case?  Identifying opportunities to assess how well Dawn was safeguarded from serious harm  Undertaking risk assessments at times of change  Including Dawn’s voice in assessments  Including assessments of the family  Over-reliance on telephone assessments  Over-reliance on incident focused and location focused assessments 3.3 Did agencies work together to safeguard Dawn? 3.4  Was neglect considered as a feature of this case?  14 14  15 17 18 20 21 22 23 25 4. Summary of key learning and recommendations 29 5. Appendix A: A summary of agency involvement during the timeframe  for the SCR 33   3 1.   INTRODUCTION   1.1  The circumstances that led to this review 1.1.1 This case concerns the death of a 16-year-old girl with known complex health needs. The cause of her death was Diabetic Ketoacidosis.i  1.1.2 Following her post mortem in May 2016, the Designated Safeguarding Manager at Medway Council referred the case to the Medway Safeguarding Children Board (MSCB). In June 2016, an MSCB Serious Case Review (SCR) screening panel considered the case and concluded that the threshold for a SCR had not been met. This was due to the lack of clarity around a causative link to neglect, although neglect was clearly evident in the period surrounding her death. The local panel agreed that this could be dealt with better under a Lessons Learned Review.   1.1.3 In August 2016, the National Panel of Independent Experts on Serious Case Reviews took the view that evidence of neglect was clear through the lack of appropriate parental care and a SCR should be undertaken.  1.1.4 The MSCB SCR Screening Panel met to reconsider the case in September and agreed to undertake a SCR. 1.2  Scope, timescale and terms of reference for the review 1.2.1 The prime purpose of a Serious Case Review (SCR) is for agencies and individuals to learn lessons to improve the way in which they work both individually and collectively to safeguard and promote the welfare of children. This involves a focused examination by all relevant organisations and professionals as to their involvement with the child and family concerned. Regulation 5 of the Local Safeguarding Children Boards (LSCBs) Regulations 2006ii sets out the requirement for LSCBs to undertake reviews of serious cases where:  (a) Abuse or neglect of a child is known or suspected; and  (b) Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board Partners or other relevant persons have worked together to safeguard the child.                                                              i Diabetic Ketoacidosis is the biggest medical emergency related to diabetes. It's also the most likely time for a child with diabetes to die. It occurs when the body is unable to use blood sugar (glucose) because there is not enough insulin. Instead, it breaks down fat as an alternative source of fuel. ii Regulation 5; CHILDREN AND YOUNG PERSONS, ENGLAND (2006) The Local Safeguarding Children Boards Regulations    4 1.2.2  Working Together to Safeguard Children (2013)iii led to a new approach to multi-agency working to safeguard children. It streamlines previous guidance and clarifies the children’s workforces’ responsibilities in regards to safeguarding children. It also aims to ensure that the needs of the child and not processes are the key focus of safeguarding practice. 1.2.3 Working Together (2013) also provided new guidance for undertaking a SCR, which requires that they should 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;   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.iv   1.2.4 Working Together to Safeguard Children was updated in March 2015 to include a definition of ‘seriously harmed’ following concerns that some LSCBs were failing to make appropriate decisions on what constituted serious harm. This is as follows:  Seriously harmed includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:  a potentially life-threatening injury;  serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development.  1.2.5 The purpose of this review is for agencies to recognise, respond to and action the learning highlighted by this SCR. Its purpose is not to try and second-guess the judgments and decisions that various people and organisations made at the time of the events examined by the review. Hindsight can severely distort the clarity of information that was available and underplay the impact of time pressures, and the other influences and dilemmas that confront people dealing with a complex interplay of different factors.  1.2.6  The report aims to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible depth and range of learning required from a SCR.  1.2.7 The review covers an 18-month period between just after Dawn’s 14th birthday until her death when she was 16. This timescale was chosen to provide greater detail of Dawn’s life                                                            iii HM Government (2013) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children iv Ibid; page 67   5 and management of her health care by not limiting the review to the immediate timescale preceding her death.  1.3 Specific issues to consider in the review of this case 1.3.1 In this case, the following key lines of enquiry have been identified as (but not limited to):  How did the quality of assessment and decision making affect this case?  Were opportunities for referral to children’s services acted upon? Were these followed up? How?   How were Dawn and her parent’s ability to manage her conditions assessed?   Was Dawn assessed and her health needs managed as a child or an adult? How was her poor self-management addressed?   Were assessments (including health and social care) holistic and reflective of the whole family as well as Dawn’s presentation history?   How was Dawn’s lived experience considered in any assessment made? (Child’s voice)  How were the impacts of Dawn’s illnesses considered throughout her life?   How did agencies assess and mitigate risk during any assessments for the whole family and not just the child who was the focus at the time? Did they take account of historical issues?   What was known about the family structure and relationships?   Was the impact of mother moving out of the country considered?   What was Dawn’s experience of being cared for?   What did agencies know about father’s family?   How was culture considered?    Did agencies work together to safeguard Dawn?   Was neglect considered as a feature of this case? 1.4 Methodology 1.4.1 LSCBs may use any learning model for the SCRs that they commission, which is consistent with the principles in the guidance. The Medway LSCB agreed to undertake a review using an analysis of the case through Individual Management Reviews (IMRs) of the agencies that were involved with Dawn between March 2014 and December 2015. The IMRs were also used to present a combined chronology of events and interventions during those 22 months and to identify any themes in terms of practice and response.    6 1.4.2 This review was commissioned in November 2016 and presented to the MSCB in September 2017.  1.4.3 An independent author, worked with a core SCR Panel, with representatives from the following agencies:   Medway Council – Children’s Services  Dawn’s College   Kent Police  Medway NHS FoundationTrust  NHS Medway Clinical Commissioning Group (CCG) The MSCB Business Manager and Learning and Development Officer were also members of the SCR Panel and the Board provided administrative support. The Chair of the Dawn SCR Panel was the Head of Service for Safeguarding and Quality Assurance within Medway Council, who also had no direct involvement in the case. 1.4.4 The review process included:  5 meetings of the Review Panel;   Panel review of IMRs produced by:  o Medway Council Children’s Services o Queen Elizabeth Hospital (QEH) (Greenwich and Lewisham NHS Trust) o Medway Adult’s Social Care (summary only) o Valentine Health Partnership o Medway GP o Dawn’s College o Oxleas NHS Foundation Trust o Guy’s and St. Thomas’ NHS Foundation Trust o Kent Police (summary only) o Greenwich Social Care (summary only) o Sussex Partnership NHS Foundation Trust – Kent and Medway CAMHS (summary only); and o Dawn’s School (summary only)  Panel review of drafts of the SCR report. 1.4.5 Dawn’s father was invited to contribute to the SCR process through a face-to-face meeting with the SCR author, but he did not respond to the invitation. The MSCB also tried to contact Dawn’s mother who we understood lived abroad, but she did not respond.      7 2.   BACKGROUND INFORMATION  This section of the report is designed to provide a picture of Dawn and her life. It is split into five sections:   Dawn  Dawn and her family  Dawn’s health problems and their impact on her life  Dawn’s younger years and contact with Children’s Services  Dawn’s contact with other agencies during the timesframe for the review 2.1  Dawn   2.1.1 Dawn was born in 1999. She had a twin sister and a younger brother, who was born in 2002. The family are Black (Caribbean) British.  2.1.2 Dawn had four significant health problems which needed careful management to avoid her becoming ill. She was diagnosed with sickle cell disease when she was 10 years old andv diagnosed with diabetesvi when she was 12. At the same age, Dawn was diagnosed with narcoplexy with cataplexy.vii She was also overweight.  2.1.3 The seriousness of Dawn’s medical conditions was highlighted when, in July 2015, she was admitted to hospital with Diabetic Ketoacidosis. While there, she developed a serious infection and a sickle cell crisisviii and was admitted to intensive care. Dawn remained in hospital for more than two weeks.  2.1.4 Towards the end of her life, Dawn presented a confused picture in terms of how she was dealing with her illnesses. We are presented with the picture of a teenager who was not coping, either physically or, emotionally.                                                             v Sickle cell disease is a serious group of lifelong conditions which are inherited (genetic). It affects the red blood cells in the blood and can cause pain, acute chest problems, infection and anaemia. vi Diabetes is a lifelong condition that causes a person's blood sugar (glucose) level to become too high. The hormone insulin, produced by the pancreas, is responsible for controlling the amount of glucose in the blood. There are two main types of diabetes:  type 1 – where the pancreas doesn't produce any insulin  type 2 – where the pancreas doesn't produce enough insulin or the body's cells don't react to insulin. Treatment is by insulin injection and/or tablets. vii Narcolepsy is a neurological disorder that causes persistent sleepiness and additional symptoms such as brief episodes of muscle weakness known as cataplexy, vivid, dreamlike hallucinations, brief episodes of paralysis when falling asleep or upon awakening (sleep paralysis), and fragmented nighttime sleep. viii Sickle cell crisis is a severe attack, which causes pain because blood vessels can become blocked or the defective red blood cells can damage organs in the body.    8 2.2  Dawn and her family  2.2.1 Dawn’s family situation was complicated. Her parents were separated and there is a history of the children in the family moving between their mother, father and aunt. Dawn’s own experience of moving was as follows:   At the end of 2013, when she was 14, Dawn moved to live with her aunt in Bristol for approximately 6 months. It is noted that she moved there by informal family arrangement due to difficulties in her relationship with her mother.    By April 2014, Dawn was back living with her mother in London but spent time with her father in Medway. Dawn’s father was not involved in her health care at this time.  On discharge from hospital in August 2015, Dawn went to live with her father as her mother moved abroad. She remained living here until she died. As a result of these moves, Dawn attended four different schools between 2007 and 2014. 2.2.2 At the time of her death, Dawn lived with her father, brother and grandmother in Medway. At this time, Dawn’s grandmother had some apparent mental health issues and had been diagnosed with schizoaffective disorder for which she took medication.   2.2.3 In 2014, Dawn’s twin sister, was accommodated in Medway, under Section 20 of the Children Act 1989 ix. This was when the twins were 15 years old. She had been living at her father’s house and her living arrangements with her father had deteriorated and she was considered as  being at risk of harm. Neither parent was able to provide her with effective parenting at the time. Dawn and her brother were living with their mother. Dawn’s twin has lived in foster care since then.   2.2.4 A member of Dawn’s extended family potentially posed a risk to children.  The genogram below describes the family relationships.                                                           ix Section 20 of the Children Act 1989  is about the Local Authority’s duty to provide a child with somewhere to live because the child does not currently have a home, or a safe home:   Dawn 16 years 1999 Mother Twin Sister 1999 Paternal Grandmother Father Paternal Uncle Brother 2002 Maternal Aunt Mother’s New Partner  2.3  Dawn’s health problems and their impact on her life  2.3.1 As previously mentioned, Dawn had four significant health problems: diabetes, sickle cell disease, narcolepsy and obesity. She had been living with these conditions since she was 10 and 12 years old. As well as being significant in themselves, the conditions impacted on each other. This meant that her medical needs and the management of them were very complex. Her life was defined by this complex multiple diagnosis and the varying and often overlapping symptoms of the illnesses would have meant that it was not always possible for Dawn, her family and professionals to understand what was causing them. 2.3.2 Dawn’s health problems affected her everyday life. Diabetes is a long-term condition that can have a major impact on the life of a child or young person, as well as their family or carers. The National Institute for Health and Care Excellence (NICE) recognises this and recommends that health services:  Offer children and young people with type 1 and type 2 diabetes and their family members or carers (as appropriate) timely and ongoing access to mental health professionals with an understanding of diabetes because they may experience psychological problems (such as anxiety, depression, behavioural and conduct disorders and family conflict) or psychosocial difficulties that can impact on the  management of diabetes and wellbeing.x   2.3.3 Having diabetes meant that Dawn and her parents needed to be careful about what food she ate, pricking her finger to check her blood sugars up to four times a day and either taking tablets and/or giving herself daily injections. The tablets she took often made her feel unwell. Dawn would have needed to be particularly careful if she had an infection or vomited as these could affect her blood sugar levels. 2.3.4 Dawn also had sickle cell disease, in which people do not generally have sickle cell crises, which can lead to clogged arteries and chest problems. However, sickle cell disease combined with diabetes can be more serious. Sickle cell disease can cause infection and abdominal pain, both of which Dawn experienced. Sickle cell disease can also cause death of tissue in the spleen and changes to her spleen were noted when Dawn was admitted to hospital in July 2015.   2.3.5 Living with sickle cell disease meant that Dawn would have needed to be alert to avoiding anything that may trigger a sickle cell crisis, such as drinking plenty of fluids to                                                            x NICE Guideline NG18 Diabetes (type 1 and type 2) in children and young people: diagnosis and management. [2004, amended 2015]     11 avoid dehydration and avoiding getting cold. Her sickle cell disease had been well controlled until she experienced a crisis while in hospital in July 2015. 2.3.6 Dawn’s diagnosis of narcolepsy with cataplexy led to a very disturbed sleep pattern. Dawn’s secondary school reported that Dawn would be very tired in school and occasionally fell asleep in the school toilet. When this happened in April 2014, the school rang Dawn’s mother who said that Dawn’s medication was due to be reviewed and that Dawn had stopped taking it as it caused her to hear voices. In May 2014, Dawn told the Special Educational Needs Coordinator (SENCO) at school that her sleep pattern was “all over the place.” In August 2015 Dawn’s mother told the Community Paediatric Nurse, who was worried about Dawn’s slow responses over the phone that these were typical for Dawn when she had been sleeping beforehand. Slow verbal responses can also be an early sign of uncontrolled blood sugar levels. Dawn’s symptoms were so complex that they could have been caused by more than one of her illnesses. 2.3.7 Dawn was also overweight. The school nurse had discussed a healthy diet in May 2014 and the Paediatric Diabetic Nurse referred her to a dietitian in September 2014. Dawn’s mother reported that she would encourage Dawn to exercise. In March 2015 mother contacted the Paediatric Diabetic Nurse herself as she was concerned about Dawn’s weight. She was advised about diet and exercise. In July 2015, Dawn saw a dietitian and joined a gym but was not motivated to go due to her exams. 2.3.8 In April 2014, Dawn’s year 10 teachers were concerned about her processing skills as she could be vague and withdrawn. The school could not determine whether this was due to her processing skills, for which she saw a speech and language therapist, or because of her complex medical needs. However, the impact of all these health problems on an adolescent’s life cannot be under-estimated. Dawn would have needed to develop skills and confidence to manage her complicated and potentially life threatening illnesses. Her numerous periods of sickness led to a high number of missed school days, which would have impacted on her education, development of friendships and therefore life plans and potential. It is not known what impact this would have had on her psychological wellbeing, social learning and self-esteem at an important transition phase of her life. 2.3.9 There is evidence that neither Dawn and/or her parents managed her medical conditions very well in the following ways:  Her diet was not being controlled: In July 2015, following Dawn’s admission to hospital, her mother reported that Dawn may have had too much sugar. Dawn reiterated this by saying that her mother had taken her to the cinema and allowed her to eat popcorn, eat desserts and drink fizzy drinks a few days before her hospital admission.   The use of medication to control Dawn’s diabetes was erratic. Dawn had stopped taking her tablets prior to her hospital admission because they led to side effects of bloating and abdominal pain. On her discharge from hospital in August 2015, the hospital diabetic nurse had explained the importance of taking her medication as prescribed. However, in her father’s police statement following Dawn’s death, he said that he allowed Dawn to manage her own medication, and was aware that she had stopped some or all of it. He also described “borrowing” two of his brother’s diabetic   12 (Metformin) tablets for Dawn a few days before her death because she had run out of hers. Dawn told the Paediatric Diabetic Nurse that she had been self-medicating with insulin after her discharge from hospital. Although prescribed for night time only, she had been taking it 3 to 4 times during the day.  Dawn’s father did not take her to either of the two outpatient appointments arranged when she lived with him in the month before her death. He also did not get her registered with a GP until November 2015 (one month before she died), even though she had lived with him since August 2015 and although both the college and Dawn’s community health team had contacted him on a number of occasions to remind him to do so. He did not return a number of calls from the Paediatric Diabetic Nurse about how they were managing Dawn’s diabetes. 2.3.10 Dawn had been ill in the days leading up to her death. Four days before she died, she saw a locum GP, who prescribed antibiotics for a chest infection. She also had a flu immunisation at the GP surgery in the week before her death. On both occasions, there was a lack of consideration about the complexities of Dawn’s medical conditions and their impact. On the day before she died, she had no energy, felt hot and was vomiting.  2.3.11 On the day she died, Dawn was last seen by her brother at around 4.00pm when she was asleep. She had been asleep all day.  Dawn’s father returned from work around 6.50pm and found Dawn on the floor at home with no signs of life. Both father and the ambulance crew attempted resuscitation but it was not successful. The cause of Dawn’s death was Diabetic Ketoacidosis. Her post mortem examination stated that death was due to natural causes. 2.4 Dawn’s younger years and contact with Children’s Services  2.4.1 Although, it is outside the timeframe for this SCR, the following information provided by Greenwich Children’s Social Care after her death provides some context for the case. Throughout this period, Dawn was living with her mother in the Royal Borough of Greenwich. 2.4.2 In 2005, when Dawn and her twin sister were six years old, they disclosed sexually harmful behaviour from a cousin. The outcome at that time was no further action. 2.4.3 In 2006, when they were 7 years old, there is a record of physical abuse towards the twins from their mother; they were hit with a belt and made to stand with their arms in the air for extended periods of time as forms of punishment. The outcome was to place the children on a Child in Need Plan. This was stepped up to a Child Protection Plan in early summer the following year and back to a Child in Need Plan in December 2007. 2.4.4 A referral was made to Greenwich Children’s Social Care in 2010, when the twins were 11 years old and their brother was 8. The reported concerns were that the children were left home alone while their mother was at work. 2.4.5 When she was 13, her mother self-referred due to difficulties managing Dawn’s behaviour. She disclosed slapping her. The outcome was that services were offered but declined as the extended family were involved. No further action was taken. A few months later, Dawn’s mother self-referred for the same reason and described hitting   13 Dawn on her back. Her mother asked Dawn’s father to take her, which he did. This made school attendance difficult for Dawn. The outcome was that she was stepped down to a Team around the Child (TAC) service. 2.4.6 At 14 years old, the Police were called to an argument between Dawn and her mother. Greenwich Children’s Social Care offered support but no further action was taken. 2.4.7 When they were both 15 years old, information from Dawn’s twin sister was passed from Medway Children’s Services to Greenwich Children’s Social Care that their mother was intending to leave Dawn in their father’s care and emigrate abroad. Dawn’s mother assured Greenwich that this would not happen and that Dawn would be joining her. The assessment was therefore not continued. 2.5 Dawn’s contact with other agencies during the timeframe for the review 2.5.1 The main agencies involved with Dawn during the timeframe for this SCR were health agencies. When she died, Dawn had lived in Medway for only four months. Although the family were known to Medway Adult Social Care, Medway Children’s Services and Kent Police, Dawn was not. Appendix 1 describes the involvement of agencies with Dawn and/or her family during the timeframe for the review.      14 3.   FINDINGS AND LEARNING  3.1   Summary of themes identified 3.1.1 The report considers the issues agreed as the focus for the SCR in terms of the findings of the review and the learning from the review. To reiterate, the timeframe for the review is March 2014 to December 2015.The findings and learning are detailed below. 3.1.2 The main themes identified in this Serious Case Review are:  Recognising neglect  Child’s voice not sought or heard  Comprehensiveness of assessments, including risk  Adolescents with chronic health conditions and their complex management  Sharing information between health agencies 3.1.3 The questions posed by the panel were:  How did the quality of assessment and decision making affect this case?  Did agencies work together to safeguard Dawn?  Was neglect considered as a feature of this case? These are addressed in turn in this section of the report. 3.2. How did the quality of assessment and decision making affect this case? 3.2.1 Working Together (2015) states that: A good assessment is one which investigates the following three domains: …  • the child’s developmental needs, including whether they are suffering, or likely to suffer, significant harm;  • parents’ or carers’ capacity to respond to those needs; and • the impact and influence of wider family, community and environmental circumstances.  3.2.2 The guidance goes on to say that: Where a child has other assessments it is important that these are coordinated so that the child does not become lost between the different agencies involved and their different procedures.xi                                                             xi HM Government (2015) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children; page 22   15 3.2.3 The overall finding is that Dawn’s case raises a number of lessons for agencies, which could have led to a more comprehensive assessment of her overall needs. These are:  Identifying opportunities to assess how well Dawn was safeguarded from significant harm;  Undertaking risk assessments at times of change;  Including Dawn’s voice in assessments;  Including assessments of the family;  Over-reliance on telephone assessments; and  Over-reliance on incident focused and the impact of the location of all siblings on assessments. 3.2.4  Identifying opportunities to assess how well Dawn was safeguarded from serious harm  Working Together (2015) states that: Seriously harmed includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:  a potentially life-threatening injury;  serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development. During the review period, Dawn’s safeguarding needs were not assessed by any of the agencies involved. Sometimes, they were unaware of her history. However, there are also examples of a lack of professional curiosity. 3.2.4.1 There is a history of physical abuse and disclosure of sexual abuse in the family. Although Dawn had been subject to a Child Protection Plan and a Child in Need Plan earlier in her childhood, this information was not known by any of the agencies involved with Dawn during the timescale for the review. There are no flagging systems in health services for children for whom there have been previous safeguarding concerns or where other children in the family are Looked After. For example, there is no chronology of Dawn’s family history on the community nursing records, the Medway GP was not aware of any previous safeguarding concerns having not received her records and Dawn’s college also had no access to any records about Dawn’s family history.  3.2.4.2 Even without this information, health and education services did have concerns about parental neglect but lacked professional curiosity to explore and escalate these concerns, despite having evidence for this. (This is discussed further under key question 3). 3.2.4.3 Medway Children’s Services lacked professional curiosity for assessing Dawn’s safeguarding when they assessed her siblings. It was clear that neither her mother or her father had been able to parent her twin sister adequately. The focus had been on her siblings; there was a lack of questioning about their sister.  3.2.4.4 In March 2014 and November 2014, Medway Children’s Services undertook a Child and Family Assessment in respect of Dawn’s twin sister, who was living  with their father at the time. There were concerns about Dawn’s father’s ability to protect her from the risks   16 presented by an extended family member. The Child and Family Assessment concluded that the risks were considered to be sufficiently understood and safety measures were put in place. Dawn and her  brother were listed as family members in the assessment and it was noted that  there were sound safety measures in place for them. As her sister was in Medway and Dawn and her brother were in Greenwich it was assessed that there was less of a risk to Dawn and her brother. Medway Children’s Services knew that Dawn’s sister could not live with their mother either, as their relationship had broken down. In the later assessment Medway Children’s Services identified that Dawn’s sister could not remain living with their father and was also unable to live with her mother as their relationship had broken down. They did not question whether, given that neither parent could adequately parent Dawn’s sister, whether this meant there was also a risk to her siblings in the care of their mother in the Royal Borough of Greenwich. 3.2.4.5  Dawn’s safeguarding could also have been assessed in October 2015, when the Kent and Medway NHS and Social Care Partnership Trust made a referral to Medway Children’s Services following an allegation that their grandmother had assaulted Dawn’s brother. By this time, Dawn did live in Medway and professionals were aware of previous assessments of her twin sister and brother. Contact with Dawn’s father ascertained that he was taking appropriate steps to protect Dawn’s brother from their grandmother. No concern was raised about Dawn at this time and she was not seen or spoken to.  3.2.4.6 Kent Police also missed an opportunity for assessing Dawn’s safeguarding at this time, when they received the allegation from Dawn’s brother that he had been assaulted by his grandmother. This was not considered as a child protection crime and, although it is noted that Dawn was believed to be present, neither she nor her brother were thought to be at risk. There is no Child Protection marker on the file and safeguarding is not mentioned in the police crime report. There is nothing in the notes to indicate that this incident was ever discussed with, sent to or reviewed by Medway CRU or Medway CST. No safeguarding referral was made as a result of this incident. When responding to incidents of domestic abuse, police officers are required to record the details of all the children who may be affected by the abuse under the Domestic Abuse, Staking and Harassment and Honour Based Violence checklist (DASH).xii 3.2.4.7 Guy’s and St Thomas’ NHS Foundation Trust missed an opportunity to assess Dawn’s safeguarding in August 2015, before her transfer to QEH. Dawn’s mother told a nurse that she was concerned about Dawn’s father’s ability to care for her when she left to go and live abroad as he had barely been involved in her care or medical problems. It is noted that this information was passed onto the QEH and that it is recorded that the plan was to contact Dawn’s sibling’s social worker. There is no evidence to confirm whether this happened  or what the relevance of this contact would have had. The diabetic team at the QEH met with the family to explain the management of Dawn’s illnesses and also spoke to the parents about Dawn’s mother’s departure. This provided an opportunity to further explore family relationships and the impact of separation from her mother on                                                            xii Richards, L. Domestic Abuse, Stalking and Harassment and Honour Based Violence (DASH, 2009) Risk Identification and Assessment and Management Model     17 Dawn. However, this did not happen, even though the hospital staff also had experience of Dawn and her mother’s relationship being challenging. There was an over-optimism about the family’s ability to cope with such complex needs and impact of her main carer leaving the country. Within the Paediatric Department at QEH, there is a weekly psycho-social meeting, attended by senior medical and nursing staff and members of the hospital safeguarding team. There is no record of Dawn being discussed at such a meeting, despite these warning signs.  3.2.5  Undertaking risk assessments at times of change There were various points in the timeframe for this review where Dawn’s situation changed significantly and where a risk assessment would have helped the agencies involved identify escalation points. 3.2.5.1 The most significant is when parental care shifted from her mother to her    father immediately following her admission to hospital with a life-threatening   condition. The National Institute of Clinical Excellence (NICE) Guidelinexiii    states that:   After a child or young person with known diabetes has recovered from an episode of DKA, discuss with them and their family members or carers (if appropriate) the factors that may have led to the episode. Advise children and young people who have had an episode of DKA and their family members or carers (if appropriate) how to reduce the risk of future episodes. In particular, advise them of the importance of managing intercurrent illnesses.    3.2.5.2 Although the family was involved in planning Dawn’s care on discharge, and QEH and Oxleas Community NHS Trust were informed that her mother would be moving abroad, a home visit to see Dawn at her father’s house was not arranged. Neither was there a formal competency assessment of his ability to manage Dawn’s diabetes nor an ongoing assessment of his abilities as a care giver for her health needs. Neither did the hospital or the community trust arrange a home visit when Dawn’s father missed the first  two outpatient appointments with the diabetic clinic and said he was sorting  out appointments with the sickle cell disease and narcolepsy clinics after her discharge from being so seriously ill in hospital. He also failed to engage in telephone conversations with the Community Paediatric Diabetic Nurses.                                                             xiii NICE Guideline NG18 August 2015   18 3.2.5.3 There is no evidence of any risk assessments of Dawn as a vulnerable young person who was required to manage complex health needs. No one health person or agency had an overall view of her health needs. As discussed previously, risk assessments, including the family history, environment and impact on siblings would have led to a more complete picture of Dawn’s situation when her siblings’ safeguarding needs were assessed.   3.2.6 Including Dawn’s voice in assessments  There are very few recordings of Dawn being asked about her own views and feelings.  3.2.6.1 We get most of our sense of who Dawn was and what she wanted from her time at school. She was described as vague and withdrawn at school, possibly because she started late in year ten or because of social communication  difficulties or her medical needs. The school helped her develop strategies to  help her engage. In April 2015, Dawn told her pastoral manager that her sleep pattern was “all over the place” and the school responded by drawing up a revision timetable with her. Dawn also told her pastoral manager that she did not want her mother contacted about health problems as she felt she became stressed and annoyed at the situation. She told school she had been staying with father and other relatives as well as with her mother. She said she wanted to go to the prom and end of key stage 4 tea party but did not attend.   3.2.6.2 There are very few recordings of Dawn being asked about her own views and feelings about her medical situation. Although there are several references within the Community Diabetic Nurse’s records about Dawn’s unhappiness with her weight, her wishes and views are not documented. There are no community health records of her being offered appointments to be seen on her own without a parent to ask how she was feeling or about the support available at home.  3.2.6.3 In particular, there are no records of Dawn being asked  how she felt about her diabetes, her mother moving abroad, going to live with her father or having a twin sister in Local Authority care. There are no recorded assessments of the new family composition once her mother had moved and how this may have affected Dawn.   3.2.6.4 These issues might have been raised through Dawn’s contact with the psychologists attached to the medical teams whose care she was under. However, Dawn was not referred to a psychologist within the diabetes team although it is noted that she saw a psychologist about her diabetes when she briefly lived in Bristol. The QEH IMR states that possibly there may have been  a role for a psychologist. The fact that she was not referred is contrary to the NICE Guidance on psychological and social issues of children and young people with diabetes, which states that:      19 Diabetes teams should be aware that children and young people with type 2 diabetes have a greater risk of emotional and behavioural difficulties. Be aware that children and young people with type 2 diabetes have an increased risk of psychological conditions (for example anxiety, depression, behavioural and conduct disorders) and complex social factors (for example family conflict) that can affect their wellbeing and diabetes management.  Diabetes teams should have appropriate access to mental health professionals to support them in psychological assessment and the delivery of psychosocial support. Be aware that a lack of adequate psychosocial support has a negative effect on various outcomes, including blood glucose control in children and young people with type 2 diabetes, and that it can also reduce their self-esteem. Offer children and young people with type 2 diabetes and their family members or carers (as appropriate) emotional support after diagnosis, which should be tailored to their emotional, social, cultural and age-dependent needs.xiv  3.2.6.5 Towards the end of her life, Dawn presented a confused picture in terms of how she was dealing with her illnesses. Dawn obviously could not manage and health professionals did not act on this. There is a lack of evidence that she was asked if she could cope and then how she was coping. We are presented with the picture of a teenager who was not coping, either physically or, with hindsight, emotionally. In the absence of a record of Dawn’s voice, the reasons for this are unclear.  3.2.6.6 For example, Dawn did not tell the college about her medical conditions when she registered although diabetes 2 was noted in her learning agreement and Dawn had told her tutor about her diabetes and sickle cell disease but not the detail. The college soon identified concerns about her health as she was spending so much time in the toilet, describing crippling constipation followed by a sudden urgency to use the toilet. She would email the teachers from the toilet to let them know she was too unwell to attend lessons. Dawn said she felt she was losing out on lesson time. Her attendance rate was 67% due to illness.    3.2.6.7 When she was admitted to hospital in July 2015, Dawn told a doctor that she had been taking her diabetes medication erratically over the previous six months and described that she had been eating sugary foods and drinking sugary drinks. It is noted that, as a teenager, Dawn was expected to be able to manage her medication and diet. However, because Dawn’s voice was not considered as part of the assessment, no-one asked why she was not managing her medication and diet appropriately. It is suggested in the hospital notes that it was because teenagers with diabetes want to be normal.                                                             xiv NICE NG18: 2015 - Psychological and social issues    20 3.2.6.8 Dawn was present at the family meeting, when she was discharged from hospital. However, there is no record about whether she was asked how she felt. Dawn’s feelings about her family situation at the time were not taken into consideration or questioned, although her father was asked and said that he did not think she was reacting to her mother’s imminent departure.   3.2.6.9 No-one asked Dawn how she felt she could manage her medical conditions once her mother had left the country. There is no evidence that people questioned her response to this parental abandonment and lack of family support in the context of the  seriousness of her medical conditions.  3.2.6.10 After being discharged from hospital in August 2015, Dawn was prescribed both insulin injection and tablets to get her levels back on track. During a call with the Community Diabetic Nurse in November 2015, it became clear that, although she should have stopped the insulin, she was medicating herself with spare insulin that was kept at home because the tablets were having an effect on her stomach. This was how Dawn coped with the side-effects of her medication as they were so difficult to manage and were affecting her education and  life. 3.2.7 Including assessments of the family  There is considerable evidence that all health agencies involved with Dawn tried to engage with the family. However, despite concerns raised in the notes, for example that the mother was emigrating and the father had not yet registered Dawn with a GP, there is no evidence of any holistic assessments of how the family functioned and the impact this may have on Dawn. 3.2.7.1 Medway Children’s Services carried out Child and Family Assessments in November 2014 and in January 2015. These focused on Dawn’s twin sister and brother respectively. The potential reasons for this have already been discussed: Dawn did not live in Medway at the time and a risk assessment of Dawn would have been associated with her local parent (her mother at that time).   3.2.7.2 It is now apparent that Dawn’s mother often provided inaccurate information to professionals. For example, in October 2014 Dawn told the school nurse that she had signs and symptoms of high blood sugar (she was very thirsty and was passing urine often) but her mother disputed this, although it is not recorded why. Another time was when Greenwich Children’s Social Care planned to assess Dawn’s safeguarding following concerns raised by her twin sister that she was going to live with her father. An assessment of Dawn was arranged but then cancelled because Dawn’s mother told the social worker that Dawn would be going to live abroad with her and her new partner and that she would not be leaving her. Dawn’s mother told her school that Dawn had gone abroad with her but moved back as she missed her friends. In fact, Dawn did not leave the country with her mother.   3.2.7.3 There is no evidence that any questions were raised during medical assessments of ethnicity or culture and how this may have had an impact on Dawn’s and her parents’ decision making about her diabetes. The QEH IMR states that there was no specific   21 consideration of culture in this case but that QEH catered for a very diverse population and has one of the largest sickle cell clinics for children in London. Oxleas NHS Foundation Trust note that questions regarding ethnicity and culture appear to be lacking in assessments, and consideration was not apparent in how this may have had an impact on Dawn and her parent’s decision making about her diabetes management. 3.2.7.4 Although it is not possible to generalise and - in the absence of such a cultural assessment - to know whether these findings applied to Dawn and her parents. A number of studies have shown that the perception of African-Caribbean people about diabetes are influenced by memories of growing up in the Caribbean and that knowledge and understanding of diabetes is sometimes poor. There is also evidence to show that insulin treatments are feared and diet, or tablet-controlled diabetes can be seen by some as a mild form that does not warrant serious concern.xvxvixviiTherefore, it is not known whether Dawn’s parents’ apparent understanding when talking to professionals, yet failure to sometimes take her condition seriously, was due to the impact of their culture on their perception of diabetes and sickle cell disease or disguised compliance to keep professionals at bay. However, what is clear is that the way they responded to Dawn’s health problems did not reflect the seriousness of her conditions.  3.2.8  Over-reliance on telephone assessments Living out of the area led to a heavy reliance on telephone consultations between the Community Diabetic Nursing Team, Dawn and her parents throughout the period of this review.  3.2.8.1 When she lived with her mother, Dawn’s diabetes care was jointly provided by the Paediatric Diabetic Team at QEH and the Community Paediatric Nursing Team at Oxleas NHS Foundation Trust. Both provide this service for children living in Greenwich, which is where Dawn lived when she was first diagnosed. When she moved to live with her father in August 2015, he insisted that Dawn was not transferred to a local service in Kent but that she carried on under the care of the two Greenwich trusts. The trusts                                                            xv Brown, K et al; (2007) The British Journal of General Practice: Health beliefs of African–Caribbean people with type 2 diabetes: a qualitative study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2078187/ xvi Harrison, G. (2014) Journal of Diabetes Nursing: Health beliefs of black and minority ethnic groups and the implications for diabetes care. http://www.thejournalofdiabetesnursing.co.uk/media/content/_master/3909/files/pdf/jdn18-9-362-8.pdf xvii ScHARR Public Health Collaborating Centre; Prevention of type 2 diabetes: Interventions to reduce risk factors for prediabetes among UK adults from black and minority ethnic groups. https://www.nice.org.uk/guidance/ph35/evidence/review-2-interventions-to-reduce-risk-factors-for-prediabetes-among-uk-adults-from-black-and-minority-ethnic-groups-435069757      22 agreed to this to ensure continuity of care after Dawn had been seriously ill and because the trusts had good relationships with Dawn and her family.  3.2.8.2 The level of assessment and engagement that can be achieved through a telephone call rather than a face-to-face discussion seems unreliable, given Dawn’s history of not attending appointments, her medical emergency in July 2015 and the fact that health agencies knew that her mother, who had been more involved with Dawn’s diabetes, was emigrating. Telephone consultations were practical for the Community Diabetic Nursing Team as Dawn lived out of  their area. The decision to provide continuity is understandable. However, with hindsight, it is clear that Dawn would have benefitted from a local team who could see her face-to-face. It should be noted that the Trust did recognise this as an issue and, in October 2015, Dawn’s father agreed to ask his local GP if Dawn’s care could be transferred.  3.2.8.3 Although she moved in with her father in August 2015, Dawn was not registered with a GP until November 2015. Her father did not take her to the diabetic outpatient appointments in September and October 2015. This was not escalated as a reason to undertake a home visit, even if she did live out of area. The community nurses continued to rely on accounts from Dawn and her father about her blood sugar levels and no one checked these in person. 3.2.8.4 There are a number of other occasions where face-to-face consultations would have provided a better assessment of Dawn’s situation. For example, on a phone call between the Community Diabetic Nurse and Dawn in August 2015, Dawn reported that she was well and happy to be home from hospital (she had just moved in with her father). The notes state that Dawn’s responses were slow and the nurse needed to repeat questions and advice several times. The nurse raised this with her mother, who said it was typical of Dawn, especially when she had just woken up. However, this can be a sign of problems with blood sugar levels. 3.2.8.5 Further examples are on 21st August 2015, when Dawn told the Community  Diabetic Nurse that her legs felt shaky and on 17th November 2015 as she was concerned about her levels increasing and the side effects of her medication. Dawn also said she was confused as she had 4 – 5 different glucose monitors for measuring her blood sugar levels. The nurse advised her to only use one  machine and asked Dawn to ask her father to urgently call the nurse. Despite Dawn’s recent hospital admission and the fact that she was clearly not managing her diabetes very well, a home visit was not made.  3.2.9  Over-reliance on incident focused and location focused assessments  This case presents a number of individual assessments that were not joined up to present a complete picture of the situation. This meant that practitioners were unable to see emerging patterns as they were focusing on the immediate issue and not seeing patterns. For example:  3.2.9.1 When they were contacted about Dawn’s grandmother’s attack on her brother, Kent Police investigated this as common assault. Due to the age of the victim, an intelligence report was submitted by the Public Protection Unit (PPU) but there is no record of a referral being made to Children’s Services by Kent Police.   23  3.2.9.2 Oxleas NHS Foundation Trust’s IMR states that it can now be seen that there were similarities between Dawn’s symptoms prior to her first admission with Diabetic Ketoacidosis and the symptoms she was reporting in the weeks leading up to her death. However, the Community Diabetic Nurses did not pick up these similarities.  3.3 Did agencies work together to safeguard Dawn? 3.3.1 The 2003 enquiry into the Victoria Climbié case states that: The support and  protection  of children cannot be achieved by a single agency…Every service has to play its  part. All staff must have placed upon them the clear expectation that their primary responsibility is to the child and his or her family.xviii 3.3.2 The Dawn SCR Panel identified how agencies worked together as one of the key areas to examine in Dawn’s case. The SCR Panel specifically asked:  Did agencies communicate effectively and share information to safeguard and promote the welfare of Dawn? Was information sharing timely? Are there any current procedures / polices that restrict the sharing of information in a timely way?   How was lack of family and Dawn’s engagement managed? Was disguised compliance identified as a factor and, if so how was this managed?   Describe the opportunities for agencies to safeguard and promote the welfare of Dawn. Were any opportunities missed by any of the agencies involved? Were concerns acted upon appropriately?   Were practitioners aware and sensitive to the needs of children in their work and appropriately trained in what to do if they had concerns about a child’s welfare?   Did all agencies working with Dawn understand the needs of her illnesses and the diabetes care pathways? How was this acted upon in practice?  3.3.3 There are some good examples of joint working on this case, although this was also hindered by having different service providers and systems issues. There was also a lack of information sharing across organisational and geographic boundaries. Agencies could have worked better together to safeguard Dawn by sharing their assessment information and concerns with each other. The number of health agencies involved with Dawn added to the complexity of working together to safeguard Dawn. 3.3.4 Examples of good multiagency working in this case include the Community Paediatric Diabetic Nursing Team working closely with the Paediatric Diabetic at QEH, Medway Children’s Services passing on their concerns about Dawn as a result of their involvement with her twin sister and QEH contacting Dawn’s Medway GP to tell him about her treatment plan for diabetes.  3.3.5 However, there were also barriers to agencies communicating effectively and sharing information to safeguard and promote Dawn’s welfare, some of which were outside the control of the individual agencies involved. These include:                                                            xviii Lord Laming (2003) The Inquiry into the Victoria Climbié case   24  Information about previous safeguarding concerns and the current family situation were not shared. For example, Medway Children’s Services was unaware of the family history, a chronology of Dawn’s family is not available on the community nursing records, the Medway GP was not aware of any previous safeguarding concerns and Mid Kent College also had no access to any records about Dawn’s family history.  It takes 6 – 8 weeks for the transfer of clinical records from one GP to another. This means that, as Dawn was only registered with the Medway GP for a month before she died, the Medway GP did not have access to Dawn’s previous medical records during his involvement with her. He did have some information, however. The Consultant Diabetologist faxed the new GP her treatment plan on December 2nd 2015 so he knew what medication she was taking for her diabetes and the Community Diabetic Nurse rang him to describe their input. However, the GP did not know that Dawn had been recently admitted to hospital with Diabetic Ketoacidosis.   There was a lack of information about the management of Dawn’s conditions when she lived in Bristol.  There was difficulty sharing written information between QEH and the Community Diabetic Nursing Team due to the use of multiple record keeping systems and lack of access by the hospital team to the community records.  Dawn’s family lived in split households in different areas. The family did not always notify agencies or register them with a GP when the children moved. There was a lack of information sharing across boundaries.  There are problems managing sibling groups placed in different authorities on the information systems used.  3.3.6 There are other examples where agencies could have worked better by sharing information:   In January 2015, Oxleas NHS Foundation Trust arranged for Dawn to have a Speech and Language assessment as the school had expressed their concerns about her ability to process information. This assessment took place in February 2015 and strategies were recommended to support her memory and understanding. However, this information was not shared with the Community Paediatric Diabetic Team, despite the fact that they were part of the same Trust. There is no evidence that Dawn’s information processing skills were part of any assessment about her ability to manage her diabetes.   A multidisciplinary team meeting was planned when Dawn was in QEH in July 2015 as the team was concerned that her mother was moving abroad and that Dawn would be moving in with her father, with whom she had little contact. This meeting was deferred due to Dawn’s deteriorating medical condition and admission to Paediatric Intensive Care Unit at Guy’s and St Thomas’ Hospital. It was never reconvened.   There is also no record of QEH sharing information about Dawn’s care with the school nurse. 3.3.7 Although there are some examples of agencies sharing their concerns about Dawn’s safeguarding with other agencies, this did not always happen. This report has already   25 discussed the lack of escalation by health and education about their concerns about non-engagement of the parents. 3.3.8 There are also examples of reliance on other agencies to intervene. For example, although Guy’s and St Thomas’ NHS Foundation Trust passed on their concerns to QEH about Dawn’s mother moving away and her father being unable to care for her, they relied on the QEH to take this forward.  3.3.9 There were many health professionals from different organisations involved in Dawn’s care. This is likely to have made the health arena seem complex to other professionals and affect engagement and communication. In this case, there was no one health organisation identified as having an overall view of Dawn’s health. If there had been, patterns of parental engagement and lack of management of her conditions may have been identified.   3.4  Was neglect considered as a feature of this case? 3.4.1 Working Together (2015) defines neglect as:   The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:  • provide adequate food, clothing and shelter (including exclusion from home or abandonment);  • protect a child from physical and emotional harm or danger;  • ensure adequate supervision (including the use of inadequate care-givers); or  • ensure access to appropriate medical care or treatment.  It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.xix  3.4.2 In their thematic review of neglect in 2014, Ofsted reported that “nearly half the assessments did not take sufficient account of the family history. Even in those cases where the family history was recorded, this was not always analysed in terms of patterns of previous abuse and neglect.”xx 3.4.3 Neglect is one of Medway Safeguarding Children Board’s six strategic priorities for 2017 – 2020. Neglect has been identified as one of the key areas to examine in Dawn’s case. Specifically, whether neglect was ever considered to be a factor either during Dawn’s life and after her death and how this impacted on her situation.                                                            xix HM Government (2015) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children; page 93 xx Ofsted; March 2014: In the Child’s Time – Professional Responses to Neglect   26 3.4.4 Overall, as Dawn’s death was due to natural causes, parental neglect was not deemed to have caused it. However, neglect is a feature of this case. Throughout her childhood, Dawn had absent parents who kept professionals at bay and did not appropriately support their daughter with her complex medical needs. This was not fully explored or escalated by the agencies who were in contact with the family at the time. For example, in the initial police report in October 2015, potential neglect was mentioned. However, as the full circumstances of the family were not known at that time, the investigation did not proceed on a criminal basis.  3.4.5 Dawn’s post mortem result was that she died of natural causes, specifically Diabetic Ketoacidosis. This led to a decision that no further action would be taken by Kent Police; as there were no grounds for any criminal investigation. Dawn was not known to Medway Children’s Services during the timeframe for the review.  3.4.6 However, there are many examples of parental neglect during the timeframe for this report. Dawn had chronic medical conditions which needed careful management. She was not sufficiently supported by the adults with parental responsibility for her. She ran out of medication, was not registered with a GP for some time and her parents appeared not to understand her medical needs, despite the fact that she had recently been hospitalised with life-threatening symptoms of her illnesses. 3.4.7 Dawn’s essential health needs were not given sufficient priority by her parents or by the health services working with her. However, it is not apparent in any of the reports reviewed for this SCR that this was considered when Dawn was alive. The evidence for this is as follows:  Dawn’s mother decided to move abroad in August 2015, even though her daughter had recently been seriously ill and in intensive care. Dawn’s mother informed QEH, the community diabetic nurses and the school that she was moving. Records show that professionals were concerned about Dawn’s father’s ability to manage her complex medical needs but this was not referred to Children’s Services.  Dawn’s father did not register his daughter with a local GP when she went to live with him. This was despite her moving to his home straight from hospital, when she had only just been discharged from intensive care with Diabetic Ketoacidosis. He had been told that she needed to be more careful with her medication for diabetes. The Children’s Community Diabetic Team contacted Dawn’s father four times by telephone and once by letter to remind him to do this and to highlight that Dawn was self-medicating with insulin and got no response. This was not escalated when there was no response.  Dawn attended Mid Kent College for less than two months before she died. During that time, she missed many lessons because she would spend a great deal of the day on the toilet. The college had no access to Dawn’s previous records and Dawn had not told them that she had diabetes when she had registered. The college also contacted Dawn’s father on numerous occasions in the two months Dawn was at college. He assured the college that he would register Dawn with a GP but did not. This was not escalated. Dawn finally registered herself with a local GP in November 2015.   27  There were numerous occasions when either parent failed to take Dawn to her medical appointments. These include two missed appointments at the diabetic clinic following her discharge from hospital in July 2015. Although these were recorded as Child Was Not Brought (WNB), rather than Did Not Attend (DNA), this was not escalated, despite the fact that the relationship between child maltreatment and non-attendance at appointments (and family disengagement from services more generally) has assumed importance as a safeguarding issue.xxi   When she was admitted to hospital in July 2015, Dawn told a doctor at QEH that her mother had taken her to the cinema and allowed her to eat popcorn and desserts and drink sweet fizzy drinks. This was not challenged.  As a teenager, Dawn would be expected to have a degree of self-management. However, the record of a telephone discussion between the Community Diabetic Nurse and Dawn’s mother in August 2015 show that Dawn was self-medicating incorrectly. These concerns were not escalated, despite the fact that she had so recently been in hospital with Diabetic Ketoacidosis, Dawn’s mother was known to be emigrating and the father was not present on the call. 3.4.8 After Dawn’s death, and with the benefit of hindsight, we now also know that:  Dawn’s father did not check whether Dawn had sufficient tablets and admitted to giving her some of his brothers’ diabetes medication when she ran out.  On the day that she died, Dawn told her father that she felt ill and he said he would make her an appointment with the GP. He did not do this as he said he was too busy at work. 3.4.9 At this time, only health and education agencies were in contact with Dawn. Although the parents’ behaviour was all documented by the individual agencies at the time, not one incident triggered anyone to question whether Dawn was being neglected and whether she should be referred to Children’s Services. Possible reasons for this are that Dawn’s parents engaged with health professionals when they saw them face-to-face and seemed to understand the seriousness of her health condition. An example of this is the meeting the diabetic nurse had with Dawn, both parents and her brother after she had been discharged from hospital in August 2015 and just before her mother moved abroad.     3.4.10 No-one asked whether there was an over-reliance of her parents on Dawn’s abilities to manage her medical conditions, even though agencies were aware that her father was difficult to contact and her mother was absent. 3.4.11 Dawn was at college for insufficient time for the college to escalate any concerns they had about neglect.                                                               xxi Aria, L, et al: The unseen child and safeguarding: ‘Did not attend’ guidelines in the NHS.  http://dx.doi.org/10.1136/archdischild-2014-307294    28 4. SUMMARY OF KEY LEARNING AND RECOMMENDATIONS  The main themes identified in this Serious Case Review are:  Recognising neglect  Child’s voice not sought or heard  Comprehensiveness of assessments, including risk  Adolescents with chronic health conditions and their complex management  Sharing information between health agencies The report makes the following recommendations: 1. Led by the CCG, health providers across Medway should provide assurance to the MSCB about how they manage and co-ordinate the care of children and adolescents with complex health needs to ensure that safeguarding issues are not missed. This should include:    Applying clinical pathways in line with NICE Guidelinesxxii;  Being explicit about how safeguarding and/or parenting concerns are escalated and how the organisations ensure that this always happens;  Did Not Attend/Was Not Brought policies and what action is taken in such circumstances;  How the health organisations ensure that the children and their parents understand and are competent in managing their conditions;   How the child’s voice and psychological needs are considered as part of the assessment; and  A policy for the use of telephone consultations; when these can be used and in which circumstances they should always be avoided. Include a risk assessment as part of the policy to guide staff in their decision-making about the use of telephone consultations.   2. Led by the CCG, health providers should work together to identify a lead agency where multiple health agencies are involved in the care of children and young people with complex health needs. This agency should co-ordinate information and act as the main link between the health and other agencies if they also become involved with the child.  3. Children’s Social Care to set up a working group (to include the safeguarding leads of health organisations) to develop flagging systems across agencies which identify children and adolescents where other children or young people in the family are Looked After. The group’s role will be to clarify accountability and identify systems in place to enable this to happen. It will also consider ways of ensuring that GPs also receive this information and develop a common understanding of the terminology across agencies. MSCB will set up the initial meeting for this to happen.                                                            xxii NICE Guideline NG18 Diabetes (type 1 and type 2) in children and young people: diagnosis and management. [2004, amended 2015]    29 4. Children’s Social Care to develop a system for regular liaison between Childrens’ Services in different areas, where children in families of concern live between parents and across areas. The aim of this would be to ensure consideration is given to all the children in the family so that the boundary is the family and not the local Council area.   5. When responding to incidents of domestic abuse police officers are required to record the details of all the children who may be affected by the abuse under question 10 of DASH. Training and awareness is required to ensure Police Officers conduct a DASH risk assessment when attending incidents of assault or abuse within an extended family setting  6. MSCB to hold a multi-agency event for agencies to discuss the theme of adolescents with complex health needs. The aim of the session should be to raise awareness of specific conditions, such as diabetes and sickle cell disease, develop an understanding of different cultural attitudes to chronic illness and improve confidence amongst non-health staff. Evaluate the impact of the event and how learning has been assimilated and used. In addition, the Individual Management reports of the agencies involved with Dawn include a number of agency specific recommendations. Medway LSCB will monitor progress through their Learning Lessons sub-group. Single agency recommendations identified through their own review of Dawn’s case, are as follows:  Queen Elizabeth Hospital, Woolwich  Complete family and social histories should be obtained on all patients and families  Where there is a significant and worrying change within the family, a further complete record should be made of the family’s social circumstances  Sharing of information: Alterations to patients’ management should be recorded and available to be seen by all relevant clinical staff. In the context of this case, the further development and use of a shared IT system for diabetic children is considered important.  Improving communication flows with Greenwich Children’s Services  Oxleas NHS Foundation Trust  To raise awareness of adolescent neglect for children with complex health needs: o Develop a bespoke training/embedded learning day on Recognising Adolescent Neglect to be made available to all services involved in Dawn’s care e.g. PDNs, SNs, CAMHS, SALT. To also include the wider practitioners, from the Diabetic MDT from L&G NHS Trust. The learning event will incorporate the use of chronologies to assist analysis and the identification of themes and emerging risks o Oxleas Level 3 Safeguarding in house training to be reviewed to include key learning from the case.  To ensure a stronger focus on safeguarding within the MDT Operational policies: o The terms of references for the 6 – 8 weekly MDT to be reviewed to include discussion of complex cases o LGHT MDT members to have access to Oxleas RiO, the electronic record system.   30 Oxleas NHS Foundation Trust also presents in its IMR a list of lessons it has learnt from this case and changes it has already made:  Working practices have changed since Dawn’s death; weekly case discussions are held amongst the PDN team and documented for audit purposes.  The PDN’s Standards of Practice in respect of ‘Did Not Attend’ appointments (DNAs) have been updated to include consideration to potential safeguarding issues at an earlier part of the pathway; an escalation process has been developed and implemented around DNAs whereby no response to letters or correspondence is also included.  A standard has been developed within the PDA’s Standards of Practice that sets out the process for updating parents of any relevant health changes  The PDN’s Standard Operating Procedures around the transfer of care with guidance has been reviewed and updated  A safeguarding supervision session was delivered, with a focus on referral thresholds  Training has been completed for the children’s’ specialist nursing teams, which included the PDN staff to assess as Frazer Guidelines and Gillick Competence and consent to treatment. College  Ensure that all information regarding previous school history is captured upon application to the College:  If a medical condition/health issue is indicated, the College to ensure that a request for more information is made both to the parent/carer and the previous school.  To improve existing record keeping practices. Medway Council Children’s Services  Strengthen the requirement for social workers to seek consent to assessment from both parents, including when they live in separate households, and to engage both parents in the assessment process. Where there are children resident in separate households, the assessment should include a profile of the needs of all children and the relationships between them in order to fully understand the parenting capacity required. If consent is not provided or obtained, the analysis must consider the impact on the assessment conclusion. Guy’s and Thomas’ NHS Foundation Trust  Improve the knowledge of family history/dynamics. This will be through education and development of clinical staff. Audit a sample of case records to determine quality of social history taking.  Ensure safe transfer of care when patients move addresses through education and development of staff. Assess how this is done across the Trust through auditing patient medical records who have been transferred to another provider  Raise awareness of non-compliance with treatment/medication as a potential indicator of neglect. Valentine Health Partnership (Greenwich General Practice)   31  Administrative staff will now always forward any notification of a missed children’s outpatient appointment to the child’s usual GP.  Once notification of an ITU admission is received by the practice, the patient will be called by the clinical assistant to check on their progress and to offer a GP follow-up appointment. Medway GP  To improve awareness of safeguarding concerns for GP multi-disciplinary teams  Review of Practice Safeguarding Policy and Procedures in conjunction with MSCB policies and procedures.  To ensure training is up-to-date to ensure compliance with CQC recommendations for caring for young and vulnerable families.  To ensure timely transfer of medical notes for early identification of vulnerabilities.       32 Appendix A:  Table 1: A summary of agency involvement during the timeframe for the SCR  Agency Involvement Dates Eltham Hill School Dawn joined halfway through Year 10 April 2014 –July 2015 Greenwich – Children’s Social Care Child and Family Assessment begun as Dawn’s twin sister expressed concerns about Dawn’s living situation. Family visited and told the social worker that Dawn would remain living with her mother until she finished her education. Child and Family Assessment therefore cancelled. October 2014 – 24th December    Kent Police No involvement. Kent Police were involved when Dawn’s younger brother accused his grandmother of hitting him.  Medway Council – Adult Social Care Dawn not known to Adult’s Services during the period of the review. Her grandmother has been known to the service since 2003, mainly due to her mental health concerns.  Medway Council – Children’s Services Dawn not known to Children’s Services during the period of the review. Her twin sister’s case was open to Children’s Services at the time – she was placed with a long term foster carer.  Medway GP – The Sunlight Centre Dawn’s GP when she lived with her father November 2015 -  December 2015 Mid Kent College Dawn was at college here for ten weeks before she died. She left the course early. September 2015 - November 2015   33 Guy’s and St Thomas’ NHS Foundation Trust Treated Dawn for her sleep disorders. Sleep study, diagnosis medication and review Three episodes of care between November 2011 and December 2015 Oxleas NHS Foundation Trust The Trust’s Diabetic Paediatric Nurse Specialists and a multidisciplinary team comprising consultant Paediatrician, a dietician and a psychologist provided care for Dawn regarding her diabetes.  September 2011 –December 2015 Queen Elizabeth Hospital, Woolwich (Lewisham and Greenwich NHS Trust)  The local acute hospital when Dawn was living with her mother. Dawn was under the care of the Paediatric Diabetes Service for children resident in Greenwich and the Sickle Cell team Dawn was an inpatient here when she was admitted with Diabetic Ketoacidosis. January 2009 – November 2015 Sussex Partnership NHS Foundation Trust – Kent and Medway CAMHS Dawn was not known to the service but her twin sister was.  Woolwich GP - Valentine Health Partnership Dawn’s GP when she lived with her mother (for most of her life) Between March 1999 – September 2014 and again between September 2014 – July 2015   