Death of a 7-year-old boy, in 2018 at his maternal grandparents home where he had been living with his mother and sibling. His mother admitted killing Child R and in January 2019 was found not guilty of murder by reason of insanity. Learning includes: a disconnect between the help provided to adults and help to children in the family; the impact of mothers physical and mental health conditions on her children was not fully explored or understood; indications that the children were being adversely affected by their home situation were not fully assessed. Recommendations: need for practitioners to think family and identify barriers that prevent these principles being implemented in practice; mental health providers should communicate the outcome of their assessments including non-engagement back to GPs; adult mental health services should revise their clinical assessment model and training to include a risk assessment of the impact on children where a parent has a mental illness; child mental health services should ensure that assumptions are not made about the actions of other professionals in making safeguarding referrals and always consider at the point of triage whether a child may be at risk of harm; need for effective two-way information sharing between statutory and non-statutory providers to facilitate the most effective help to children and their families.
      
 Title:  Serious case review: Child R. LSCB: Essex Safeguarding Children Board Author: Jane Wonnacott Date of publication: 2020  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.                                Serious Case Review Child R   December  2020  Jane Wonnacott  Lead Reviewer   MSc MPhil CQSW AASW  Director, Jane Wonnacott Safeguarding Consultancy Ltd      ESCB SCR Child R Report  Page 2 of 32 Contents  1 INTRODUCTION ........................................................................................................... 3 2 THE REVIEW PROCESS ............................................................................................. 4 3 CASE SUMMARY ......................................................................................................... 5 4 REVIEW FINDINGS .................................................................................................... 11 5 SUMMARY OF RECOMMENDATIONS ..................................................................... 24 6 APPENDIX ONE – TERMS OF REFERENCE ............................................................ 27 7 APPENDIX TWO – PRACTITIONER DISCUSSIONS ................................................ 32        ESCB SCR Child R Report  Page 3 of 32 1 INTRODUCTION 1.1 Child R, aged seven, died in 2018 at his maternal grandparents’ home in Essex. He had been living in the home with his mother and nine-year-old sibling. Mother was arrested, admitted killing Child R and in January 2019 was found not guilty of murder by reason of insanity. She was given an indeterminate hospital order.  1.2 At the time of Child R’s death, records showed that Mother had a long history of physical and mental health problems and was an open case to mental health services. As a child had died as a result of abuse by a mental health service user the case met the criteria for both a child serious case review and an independent mental health homicide investigation by NHS England.1  1.3 Prior to their move to Essex in November 2016, Mother and the children had lived with her ex-husband in Southend. Much of their contact with agencies had been whilst living in Southend, and Essex and Southend Safeguarding Children Boards discussed who should lead the serious case review process. It was agreed that as the children had resided in Essex at the time of Child R’s death the review would be led by Essex, with Southend agencies contributing to the review and joining the review team.  Although some of the learning has general applicability beyond the local area, most recommendations focus on either services in Southend or health trusts that work across both local authority areas.  1.4 The decision to carry out a serious case review took place after new statutory guidance came into force in 20182 and prior to new partnership arrangements for safeguarding children being in place in Essex and Southend. Arrangements for initiating this review and publishing the report have therefore remained with Essex Safeguarding Children Board but it is important that the final recommendations are considered and responded to by both Essex and Southend Safeguarding Children Boards/Partnerships. 1.5 The focus of this serious case review is Child R. Due to the circumstances of his death many of the recommendations of this review relate to the way in which risks to children can be recognised by practitioners working with adults with physical and mental health problems. This may inadvertently result in the voice of Child R being lost within the review process and this is not the intention of this review. The main picture given though records and from discussion with family and practitioners is of a child who was loved by his extended family and was a happy boisterous child within school. There were ways in which family circumstances can now be understood to have had an impact on him and this is explored here relevant in the body of this review report.  1.6 The investigation by NHS England focusses in more detail on the NHS services provided to Mother and can be accessed separately, however it should be noted that  1 NHS England Serious Incident Framework (March 2015)  https://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incident-framwork-upd.pdf 2 HM Government (2018) Working Together to Safeguard Children   ESCB SCR Child R Report  Page 4 of 32 the two reviewers have worked closely together in finalising the findings and recommendations of this review. It is therefore important that both reports are considered together when planning a response to this review.   Recommendation One This report and the findings from the NHS England investigation should be considered by Essex and Southend Safeguarding Adult Boards/Partnerships and the expectation is that there will be joint planning in response to this report and the NHS England independent mental health homicide investigation.    2 THE REVIEW PROCESS 2.1 An independent lead reviewer was commissioned to carry out the review on behalf of Essex Safeguarding Children Board. An initial meeting was held by the lead reviewer with the family including Maternal Grandfather, Maternal Grandmother, the father of Child R, Maternal Aunt and Child R’s sibling. 2.2 In order to avoid duplication, terms of reference3 were jointly agreed with the independent investigator from NHS England and the independent reviewers worked together throughout the review. This has resulted in two separate reports that have been informed by the other with continuity in the recommendations made for the health agencies concerned.  2.3 The terms of reference stipulated that the start date for the detailed chronology should be the point that Child R started school in September 2015 and finishing on the date of his death. Agencies were asked to identify any significant information prior to this date. This is included in this report and has proven to be important in contributing to the final analysis.  2.4 Agency chronologies were received from:  ➢ Essex Partnership University NHS Foundation Trust (EPUT)  ➢ Essex Police ➢ Local Council ➢ Southend University Hospital NHS Foundation Trust (SUHFT) ➢ NHS Southend Clinical Commissioning Group - CCG (GP services) ➢ North East London NHS Foundation Trust ➢ Southend Early Help ➢ Southend Education  ➢ Open Door ➢ Southend Adult Services   ➢ Southend Housing  ➢ The Advocacy Service Provider ➢ South Essex Advocacy Services  3 See Appendix One for full terms of reference   ESCB SCR Child R Report  Page 5 of 32 2.5 Mental Health services also carried out a Serious Incident Review and this was made available to the serious case review. Reports were also received from psychiatrists who provided expert evidence for the criminal proceedings.  2.6 As well as the meeting with family members at the start of the review, the independent reviewers have also met with Mother. The review team are very grateful for the contribution of the family and their views have informed the findings set out in this report.   2.7 The review included discussions with practitioners who had been involved with the family and a list of those who contributed can be found in Appendix Two of this report. A final draft was shared with all those practitioners who had contributed in order to check for factual accuracy and enable a multi-agency discussion of learning from the review process.  2.8 The final report was shared and checked for accuracy with Child R’s family prior to publication.  3 CASE SUMMARY  3.1 Mother reported a long history of physical problems associated with fibromyalgia stretching back to childhood. After her marriage and the birth of her two children she is described as spending two years in bed, being unable to leave the home on many occasions and needing to use a mobility scooter. Mother and Father separated in 2012, Father later returned to the home in Southend to care for his children due to the severity of Mother’s physical impairments. 3.2 The following table summarises key contacts with the family up until the two weeks prior to Child R’s death. This is followed by a more detailed description of the events leading up to the fatal incident    Services for Mother Services for Children Feb 2014 Mother was seen by Therapy for You (IAPT)4 and scored high on all three assessment tools but was discharged from the service as she did not attend the next two appointments. A subjective interpretation of the scores noted that she was frustrated with her physical/medical condition and perceived lack of support from medical professionals.  Feb 2014 Six days after the IAPT assessment Mother was seen in the Emergency Department of Southend General Hospital having taken an overdose and was referred for a mental health assessment. She was discharged to   4 IAPT is Improving Access to Psychological Therapies and is an NHS service designed to offer short-term psychological therapies to people suffering from anxiety, depression and stress.   ESCB SCR Child R Report  Page 6 of 32 GP care and referred to outpatient psychiatry and psychotherapy services. She was then assessed by the mental health clinical assessment service and the assessment noted no risk to the children. Mother was referred back to the GP as it was considered that she had appropriate help in place via IAPT. There was no further consideration by the GP of any implications for Mother or the children as a result of her disengagement from IAPT.  Oct 2014 Father referred Mother to Southend Adult Social Care due to her physical ill health and mobility problems. He also mentioned depression. This resulted in an occupational therapy assessment which focused mainly on her physical problems and adaptations needed to the home.  Jan 2015  Child R’s sibling (age six) was referred to Child and Adolescent Mental Health Services with symptoms associated with anxiety. Following an assessment and five sessions, the symptoms were noted to be improved. The assessment was thorough, included a genogram and noted Mother’s overdose although there was no communication with the sibling’s school. March 2015  The school referred to Family Action5 for family support and a support worker started home visits. The school’s view is that risks at this time were managed by Father living in the home but would increase if he left. April  2015 An advocate was working with Mother and made a referral to Southend Adult Social Care for a holistic assessment. After a home visit the social worker recommended direct payments so that Mother could source her own support, but this was turned down by the allocation panel who advised reablement. After visits by the reablement team Mother reported some improvements.  Sept 2015 Father was planning to move out and the case was closed to reablement in September 2015 as Mother was described as “not compliant with the assessment”. The record notes that Mother was given the access teams number for when father moved out as she would need help with the children.  Child R started primary school.  Family Action liaised with the pastoral support worker at the school regarding concerns about the family and discussed the possibility of the referral to young carers. The school did not feel this was needed whilst Father was at home.   5 A voluntary organisation offering support to families.   ESCB SCR Child R Report  Page 7 of 32 Mother continued to receive specialist health services for physical health problems. During this period there were further signs that Child R was becoming anxious. Jan 2016  Family Action closed the case. Father was not happy with this outcome, but the school supported the decision and were positive about the children’s behaviour and capacity to form friendships.  March 2016 Essex Police received an allegation from a neighbour that she had been assaulted by Mother. The decision was to manage this via a Community Resolution, but this was not progressed as Mother could not be located and engaged with. The case was therefore closed. It is the view of Mother’s advocate that this allegation was part of a pattern of harassment by neighbours and that the assault was precipitated by the neighbour.   Mother saw the GP and started taking medication for anxiety. Father also visited the surgery to report that Mother might need counselling for depression and panic attacks. He was given contact details for Therapy for You.6  April /May 2016 In an e-mail to her advocacy worker Mother said that she was worried that Child R’s sibling’s anxiety symptoms had returned.    Records from this time indicate that Mother had moved temporarily out of her flat in Southend and was staying with family in Essex due to harassment by neighbours. Her advocate contacted the GP to request support with housing and asked Essex Police (verbally and in writing) to give details of the harassment. After inquiries to establish whether this fell into the category of hate crime the conclusion was that it was not a matter requiring further police attention.   Father made a referral to Southend Adult Social Care for another assessment which was passed to the locality team. Father told the school he was concerned about Child R’s “anger issues” in and outside the home and that his sibling was “petrified of him”. The school did not recognise this behaviour as there were no problems in school other than normal boisterousness. The next week Mother contacted the school to say she was keeping Child R off school for the rest of the week after a teacher spoke to her about his behaviour as “she was worried it would exacerbate her illness.” From the school’s perspective they had not raised any significant concerns. A referral was made to Southend Early Help Service with the consent of Father. June/ July 2016  Mother was back in the home in Southend and an assessment by Adult Social Care confirmed that Mother met the criteria for support under the Care Act 2014. A social worker from Southend Early Help Team was allocated to the family. In agreement with Mother the visit was deferred until September.  Sept 2016  In September, the early help social worker contacted Mother, but she was living in Essex with her sister. The children were living with their father in  6 Therapy for You is a free NHS counselling and talking therapies service for people in South Essex.   ESCB SCR Child R Report  Page 8 of 32 Southend. Mother told the social worker that she planned to return to Southend and explained about her mental health problems and being in debt. As Mother was living out of area and Father did not want any support the case was closed to Southend Early Help Service. Oct 2016 Mother’s fibromyalgia improved– she had accessed holistic support via an on-line group. It seems that many of the physical symptoms improved and she was no longer using a wheelchair or in permanent pain.  Nov 2016 A Southend Borough Council housing worker interviewed Mother with the advocacy worker to assess whether she was homeless. This decision rested on whether it was unsafe for Mother to return to the flat. After obtaining information from the early help worker and the police, the decision was that Mother was not homeless.  Around this time the children moved in with Mother to her parents’ home in Essex. They remained at the same Southend school. Feb-April 2017 Mother made two calls to Essex Police. The first was to report the theft of three vehicle batteries from the side of her parent’s house and the second to report a burglary in progress. On the second occasion, the police call taker noted that mother was not making sense and there were concerns about her mental health. Maternal Grandfather commented to police officers that he thought mother was becoming paranoid. There is nothing in police records to indicate that the welfare of the children was considered at this time. There is a note that a referral was made to “social services” for the “mental health team” to make contact with Mother.      Maternal Grandmother took Mother to the emergency department at Southend Hospital reporting hallucinations for three years. Mother was assessed by the Rapid Access Interface and Discharge Team (RAID and a referral was made to the Essex Support and Treatment for early Psychosis Team (ESTEP) for a full assessment. Following this assessment, the decision within ESTEP was to carry out a further assessment in order to establish whether Mother met the criteria for the team. Following further contacts from the family expressing concern that mother’s mental health was deteriorating, an assessment was organised at home with the Consultant Psychiatrist from ESTEP. As a result, Mother was started on anti-psychotic medication.     ESCB SCR Child R Report  Page 9 of 32 April 2017 Mother was allocated a care coordinator from ESTEP who saw her regularly. The care coordinator told this review that her role was to gather further information, build up a therapeutic trusting relationship and keep medication under review. The care coordinator also worked on relapse prevention. The children were not seen by the care coordinator (at Mother’s request) but there was nothing that alerted the care coordinator to any concerns about parenting. There was also no evidence of fibromyalgia. Maternal Grandmother declined a carers assessment. Father asked the school to keep an eye on the boys as Mother was having problems “hearing things”. July 2017 Mother stopped taking her antipsychotic medication for a short time and her paranoia returned. She commented to her mental health worker that her children were a protective factor influence on her self-harm.  Aug /Sept 2017 Mother had resumed medication but did not wish this to be increased – some paranoid thinking persisted.   Around this time Mother was declared bankrupt. She was also refused a place on Southend’s housing register as there was information on file that she assaulted a neighbour whilst living in her Southend flat. This was followed up by the advocacy service who pointed out that the information regarding the assault was wrong. Advocacy support then ceased as this was a Southend service and Mother was living in Essex. Mother was given details of a local advocacy service should she wish to access it.   Mother mentioned to her care coordinator that Child R (age 7) was wetting the bed. The advice from the care coordinator was to talk to the GP about this issue.  Father took Child R to the GP and spoke of his violent behaviour and short attention span during the past year. He was described as punching his sibling in the head leading to an A&E attendance. He was also noted as seeing Mother hit Father, and that Mother had severe mental health issues and was thinking of putting him in foster care. This consultation resulted in a referral to children’s mental health services (EWMHS)7. Following a desktop triage, Child R was deemed not to meet the threshold for a service from EWMHS and advice was given to self-refer to a local counselling service (Open Door) A letter to this effect was sent to the GP and Mother. Oct 2017 Mother told a psychologist about stressors including Child R’s violent behaviour towards his brother and that he was having counselling.  Mother referred Child R to Open Door for counselling. Nov 2017 Mother had stopped taking her medication and reported no worsening of symptoms. The plan was for relapse prevention work. Maternal Grandmother was monitoring.   Jan - June 2018 Mother was seen regularly by the care coordinator who focused on relapse Child R was seen by the Open Door service for counselling. Mother attended the first session and Father the second.   7 Emotional Wellbeing and Mental Health Service. This part of North East London Foundation Trust.   ESCB SCR Child R Report  Page 10 of 32 prevention work. In April Mother’s condition was noted in the records to be stable.  From the school’s perspective they thought Child R’s behaviour at this time was that of an ordinary boisterous child.   3.3 Mother and her family have described her becoming increasingly unwell in the two weeks before the incident. They describe her pacing up and down at night and saying that “they are all going to kill us”. Around this time, Mother also believed that the brakes on her car had been tampered with by the garage who had replaced her windscreen. Maternal Grandmother telephoned the mental health team and described her concerns including that Mother was having the same thoughts as before in relation to conspiracy theories and thinking everyone was against her.  As her usual care coordinator was not in, her call was discussed within the team and a mental health worker attempted to call Mother on three occasions, but she did not answer the phone. Maternal Grandmother was informed, and it was agreed that the usual care coordinator would call as soon as she was back at work.   3.4 Three days later Maternal Grandmother called the mental health team to ask whether a scheduled appointment with the care coordinator the next day would go ahead. When informed that the care coordinator was on holiday but someone else could visit, the records note that Maternal Grandmother said that it was not necessary for anyone else to visit. Maternal Grandmother’s recollection of this conversation is different: she recalls being told that here was no one else available. 3.5 The family recall Mother feeling very unwell in the evening three days later and asking Maternal Grandmother to take her to hospital. They arrived at hospital just after midnight and were referred to RAID (the Rapid Assessment and Interface Discharge service) who see all mental health patients who present in the emergency department. A student mental health practitioner, who was nearing the end of her training, took a full history and concluded that the main need was for Mother to start her anti-psychotic medication again. In their opinion there were no overt symptoms that required immediate referral for a Mental Health Act assessment or to stay in overnight for consultant review in the morning. As it was night-time no consultant was on site to prescribe the required medication and Mother was therefore advised to see her GP in the morning for a prescription. It was not common practice for GPs to be automatically notified of a hospital attendance although in some cases a call was made if medication needed changing. This was not thought to be necessary in this case.    3.6 The following morning (Friday) Mother booked an emergency appointment with the GP and attended an appointment accompanied by Maternal Grandmother at 8.59am. The records show that she asked for sleeping tablets and anti-psychotic medication. The GP had no information from the hospital to confirm what medication should be prescribed. The GPs examination concluded that Mother was objectively not depressed and there was no evidence of formal thought disorder. The GP told the review that they would never initiate anti-psychotic medication without psychiatric   ESCB SCR Child R Report  Page 11 of 32 advice and in the absence of a letter from the hospital they searched for the most recent letter from her psychiatrist which had been received two months previously. Although some GPs may have refused to prescribe without a letter from the RAID team the GP decided to do so as there was a letter on file describing Mother as having “transient psychosis”. In the light of this he prescribed her usual anti-psychotic medication plus medication for sleep. He agreed to review in four weeks or sooner of she was unwell. The GP told the review that Mother did not appear unwell and he was reassured that she attended with Maternal Grandmother and had a network of social support. 3.7 The hospital mental health liaison team sent an e-mail to the community early intervention team and Maternal Grandmother called the mental health team the same day, told them about the hospital visit and that they had collected a prescription from the GP and the medication. Maternal Grandmother confirmed that Mother had taken the first dose although Mother has told the review that she did not take any as she did not feel it would work. Maternal Grandmother is recorded as confirming with the team that she was willing to wait for a visit from the usual care coordinator when she returned from holiday.   3.8 On Monday morning Mother killed Child R.  4 REVIEW FINDINGS 4.1 The overarching finding of this review is the disconnect between the help provided to adults and help to children in the same family. Some of this is structural, some is linked to the right of adults to confidentiality and some of the issues stem from knowledge and skill gaps in recognising the impact of adult issues on their children. This latter issue applied to practice in both adults and children’s services. In summary: ➢ The impact of Mother’s physical and mental health conditions on her children was not fully explored or understood by those working with her. (Finding One) ➢ Indications that the children were being adversely affected by their home situation were not fully assessed when concerns about their wellbeing were considered by community health services, child mental health services and practitioners providing early help services to the family. (Finding Two) 4.2 There are also specific lessons regarding the management of Mother’s mental health condition immediately preceding the incident. (Finding Three)  4.3 The need for practitioners to “Think Family” cuts across all of the findings. This is an approach which was first articulated in 19988 following a study into fatal child abuse  8 Falcov, A.(Ed) (1998) Crossing Bridges: Training resources for working with mentally ill parents and their children. Brighton: Pavilion Publishing   ESCB SCR Child R Report  Page 12 of 32 and parental psychiatric disorder9 and has subsequently been updated, developed and evaluated10.  It focuses on the dynamic interplay in relationships between adults and their children and calls for joint working between practitioners working with adults and those whose focus is the child. This case demonstrates that challenges remain in putting this into practice from both adult’s and children’s services perspectives as well as the need to think widely about services that need to operate from a Think Family perspective. In this case the findings below identify that adult advocacy services, housing, schools and early help providers are all important elements of a whole family approach 4.4 Within Southend Borough Council a Family First Protocol has been in place since 2015 and contains a common set of principles which include “improves the identification of children in need and in need of protection through increased understanding of the impact of adult problems on a child’s life”. Discussion with practitioners indicates that further work is needed to translate this protocol into day to day practice and decision making.  4.5 Training initiatives such as that planned by Southend Adult Social Care in safeguarding young people and new supervision frameworks in children and adult services as well as the work of the Practice Unit11 could provide a vehicle for developing practice in this area of work. However, given the overarching findings of this review, a thorough appraisal of any barriers to implementing a Think Family across Health, Children’s and Adult’s Services in Essex and Southend would seem necessary. This must include the role of schools and other early help services for children where parents have mental health or physical health problems.   Recommendation Two Southend Safeguarding Children Partnership and Essex Safeguarding Children Board should work with practitioners in all partner agencies to: a) Agree the principles of a Think Family approach and disseminate these to all providers through staff development and training initiatives b) Identify any barriers that prevent the principles being implemented in practice and take steps to mitigate their impact.   Finding One The safeguarding system needs to support practitioners who work with adults to understand the impact of parental issues on children and encourage appropriate information exchange and joint working across services.  9 Falcov A (1996) Department of Health Study of Working Together Part 8 Reports: Fatal child abuse and parental psychiatric disorder. London: Department of Health. 10See for example SCIE guide (2009) and evaluation report (2012) https://www.scie.org.uk/publications/reports/report56.pdf 11 The Practice unit was launched in January 2019 and provides support and challenge to social work and social care practitioners.   ESCB SCR Child R Report  Page 13 of 32 4.6 There are examples within the records of those agencies working with Mother of situations where more consideration should have been given as to the way in which her mental and physical health problems were impacting on her children. This should have led to a planned approach across services.  Mental Health Issues 4.7 Adult mental health services should have been in a good position to explore whether Mother’s symptoms and behaviour could negatively impact on the children and if necessary, liaise with Children’s Social Care. There is no evidence that this happened even when there were indications that the children were involved in her delusional belief system and Mother was open about her worries about Child R’s violent behaviour, disclosed that he was receiving counselling and that his brother had also been in receipt of help the past.  In fact, her children were generally referred to in positive terms as a protective factor.   4.8 When Mother took a significant overdose in 2014 this was six days after her assessment by IAPT (Improving Access to Psychological Therapy) which had noted high scores for severe depression and anxiety, indicating that active treatment was warranted. The mental health assessment by the Rapid Assessment, Interface and Discharge (RAID) team at the point of the overdose identified her children as being a “protective factor” – she loved them too much to attempt suicide again. This assessment concluded that there was no risk to the children although there is little information as to how the impact of her condition on the children was analysed. RAID’s assessment assumed that Mother was being seen by IAPT, but this did not happen as IAPT were not notified of the overdose and discharged her from the service as she did not attend. The GP was not aware that she had been discharged from IAPT so could not assess the implications of the whole picture at this stage.  4.9 Mother again referred to the children as a protective factor when working with her care coordinator in the Essex Support and Treatment for early Psychosis team (ESTEP). Where children are understood to be protective in relation to adult mental health, best practice would be to make sure that the assessment includes a second stage which includes an analysis of what this means for the child and consideration as to whether contact should be made with services for children. The need for a more sophisticated assessment of any potential risk is supported by an overview of lessons from previous serious case reviews which comments: Children should never be considered a protective factor for parents who feel suicidal. In some cases, professionals inappropriately viewed the child as a protective element who could help to reduce the parent’s risk of self-harm. This belief significantly increases the risk to the child.12  12 NSPCC 2015 https://learning.nspcc.org.uk/media/1349/learning-from-case-reviews_parents-with-a-mental-health-problem.pdf    ESCB SCR Child R Report  Page 14 of 32 4.10 There are indications that Mother’s mental health condition was impacting on her children and that they were involved in her delusional belief system but there is limited evidence that this was considered by practitioners. For example, during the eighteen months before the incident she described to mental health practitioners a belief that her children were being “spiked” and that neighbours were trying to kill her and her family. The investigation report by Essex Partnership University Trust also comments that Mother had referred to her ‘children not being bullied at school because of her’ and that this rather odd statement should have been explored further to assess whether her children were included in her delusional system. It is also of note that Mother told the school that she had kept Child R at home for the rest of the week after a teacher spoke to her about his behaviour as “she was worried it would exacerbate her illness”; again a rather strange comment which might indicate involvement of the children in her delusions and is an indication that Mother’s illness was negatively impacting on Child R’s education. The problem for the school was that they were unaware of Mother’s mental health condition (apart from Father having mentioned that Mother was hearing things) and could not understand this comment in that light.  4.11 One factor that also seemed to have inhibited a fuller assessment of risk to the children was Mother’s diagnosis of acute and transient psychotic disorder. The internal investigation report by the mental health trust comments that the ongoing symptoms and delusions described by Mother should have prompted a review of her diagnosis and the differential diagnosis would have been schizophrenia; a diagnosis that was confirmed after the serious incident. Any possibility of psychosis should have included an assessment of risk to children, particularly as in this case they were involved in Mother’s delusional system.  4.12 The Essex Support and Treatment for Early Psychosis team (ESTEP) is a service designed to offer psychosocial interventions which help people to understand their illness and for the family concerned to understand the impact on their lives. In this case the dominant approach was a focus on the potentially stigmatising impact on the adult of the mental health diagnosis and too little attention was given to the social circumstances and others involved in family life, for example the children’s school. 4.13 Family therapy was offered but the family did not take this offer up and it would have been good practice to reflect on why this was. Reluctance may have stemmed from an earlier experience when Mother first went to the acute hospital with psychotic symptoms. Her sister recalls being very upset as she did not feel that Mother was being honest during the assessment and that the clinician would not listen to her when she said that she believed that mother had paranoid schizophrenia. The notes of the session do record her sisters’ views but also extensive questioning of Mother where she described feeling somewhat better since cutting down on her cannabis use and using natural remedies for her physical problems. Her sister was left feeling that the families views were not important. How best to incorporate the views of families into an assessment that also respects the service users’ position is a   ESCB SCR Child R Report  Page 15 of 32 challenge for all adult services and further consideration needs to be given as to how the families voice can be heard.   4.14 Mother’s expressed wish for the children not to be seen was not considered unusual or unreasonable by the mental health worker but this should not have precluded an approach which actively considered the potential impact of delusional thinking on the children’s lives. Child R’s sibling has told the review that this behaviour impacted on them on a day to day basis for example, by Mother’s refusal to let them drink tap water because it could be contaminated and driving fast because she believed she was being followed. There could also have been a more proactive approach with the mental health service regarding contact with others involved with the family such as schools. 4.15 The school had asked the school nursing service to see both children, but the school nurse would also not have been aware of any mental health problems. The school nursing service in Southend receives mental health notifications through the Paediatric Liaison Services for parents who have been admitted to an acute mental health unit and have a child in a Southend school. This system did not work for this family in either February 2014 or March 2017 when Mother was first diagnosed with psychosis as she had not been admitted to an acute unit.   4.16 There are two issues relating to the school nurse notification process. Firstly, school nurses need to be clear as to expectations on them when they receive such information as they cannot share it without permission unless there are concerns that a child may be at risk of harm. They can however use this information to guide their responses if a school raises concerns about a parent; either by seeing the child, advising and supporting the school, or considering the need for a referral to children’s social care.  Secondly, the review has found that schools may not be aware of this process and would not be prompted to consult the school nurse if they are worried about the mental health of a parent. There are currently plans to provide this information to Southend Schools and its impact will need to be evaluated.  4.17 Adult mental health services are provided by Essex Partnership University NHS Foundation Trust which has an integrated safeguarding adults team. Training is provided to staff aimed at encouraging staff to “Think Family” and consider the impact of adult issues on children. This case illustrates the need to constantly reinforce this message as practitioner discussions indicated that this approach is not consistently embedded into practice.  Where there are indicators of an escalation in the severity of mental health, any indicators of delusional thought patterns towards the children, or where a parent expresses thoughts of self-harm, or of harming her or his children, these should be taken seriously and should prompt an urgent consideration of the safety of the child. Also, where parental mental health problems co-exist with other risk indicators, particularly domestic abuse, but also including drug or alcohol misuse, or social isolation, this should prompt a further assessment of the   ESCB SCR Child R Report  Page 16 of 32 child’s safety13. In this case there were reports of domestic abuse perpetrated by Mother, cannabis use, social isolation and mental health problems. The Trust risk assessment which is a tick box form did not adequately prompt further analysis of these issues using any recognised format; even though policies and procedures set out a clear expectation that this should take place14 .  Physical Health Issues   4.18 In relation to adult social care, there is evidence that when Mother was experiencing acute symptoms associated with fibromyalgia her capacity to care for her children was reduced. The response from adult social care was focused on her physical condition for example an occupational therapy assessment noted that she had two children age six and four but there was no further assessment of the impact of Mother’s medical condition on them. Further assessment by a social worker resulted in a plan for reablement but again no consideration of the family as a whole and the needs of the children. There was a reliance on Father as the main carer for Mother and the children but more could have been done to understand the dynamics of the family as a whole and formal joint planning with Family Action when Mother became “non-compliant” with the reablement and it was noted that Father was planning to move out  4.19 An advocacy service for adults provided support to Mother from 2013 to 2017. Much of the focus of this work was support with conflict with neighbours, housing applications, and a referral to adult social care for an assessment. Mother shared information from time to time that should have prompted contact with children’s social care in order to make sure that the children’s needs were being met. It is important to stress that there were no incidents that would have fallen clearly into the category of child abuse by either parent, but in more general terms there was information that indicated children’s emotional wellbeing could be adversely affected including information from Mother that Child R’s sibling was self-harming once more. The advocate who worked with Mother confirmed that they had not received any children’s safeguarding training.  4.20 There is a code of conduct for all advocacy services which does specify knowledge of adult and child safeguarding. The contract issued by Southend Borough Council for advocacy services required staff to have “safeguarding training” but did not differentiate between adults and children’s safeguarding and in practice this training has tended to focus on adults.     4.21 During the process of Mother applying for housing, the housing officer had received long e-mails from Mother mentioning anxiety and saying that she worried about her  13 Sidebotham et al (2016) Pathways to Harm Pathways to Protection: a triennial analysis of serious case reviews 2011 to 2014. London: Department for Education. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/533826/Triennial_Analysis_of_SCRs_2011-2014_-__Pathways_to_harm_and_protection.pdf 14 EPUT Safeguarding Children Procedure CLPG37, April 2017.   ESCB SCR Child R Report  Page 17 of 32 boys and had them with her in the car until nine pm in the evening.  As far as the housing officer was concerned these e-mails were not out of the ordinary as the housing officers receive many e-mails which often include threats of suicide or killing others. The housing officer thought children’s services were already involved so would not have considered forwarding the e-mails to them.  This episode highlights the challenges of recognising those situations which indicate potential risk and need further action where there is a high volume of similar allegations and staff may become accustomed to worrying information. There is no guidance specifically for housing officers as to when to refer to Children’s Social Care and a housing officer commented on the general need for Children’s Social Care and Housing to understand each other more. Although housing officers are managing a high volume of situations involving adults with a range of vulnerabilities that may affect their children, they currently do not receive any supervision that helps them to reflect on their practice. This is an area for development.  Summary of learning and areas for development across services for adults 4.22 A general issue in relation to all adult services is how far staff have the knowledge skills and confidence to speak to children during the course of their work and judge at what point they should engage the adult in a conversation about the possibility of a referral for help for their child. More confidence is needed in assessing who has prime responsibility for care of the child (in this case this varied over time) and when a reluctance to accept help for their children becomes a formal safeguarding concern.  4.23 Staff working with adults with mental health problems are understandably concerned about the possibility of discrimination against people with a mental health condition and parental mental health problems should not be seen in and of themselves as necessarily harmful to children. The same issue might also apply where an adult has a physical impairment. The challenge is to remain open to the possibility that children may be affected in many different ways and prevent the children themselves being discriminated against because they have a parent with a specific diagnosis. This discrimination may manifest itself in children not receiving help early enough, there being an insufficiently coordinated response across adult and children’s services and risks not being addressed. In this case the children did receive some services mainly via the school and counselling services but there is no evidence of any conversation by adult staff with Mother as to whether she would be willing for them to work with the school or that there was any assessment that analysed the impact of Mother’s physical and/or mental health problems on the children.  4.24 Skills and confidence in asking difficult questions can be developed through training and reinforced through a relationship with a supervisor which promotes critical thinking and reflection on the assumptions and biases that may underpin day to day practice. There is little evidence that either the required training or effective supervision was in place.   ESCB SCR Child R Report  Page 18 of 32     Recommendation Three All mental health providers should communicate the outcome of their assessments including non-engagement back to GPs and mental health trusts must provide assurance that this is now established practice and any barriers to communication are understood and removed.  Recommendation Four The provider of adult mental health services (EPUT) should revise their clinical assessment model and related training so that it is in line with information in current procedure documents which requires thorough risk assessment of the impact on children where a parent has a mental illness. Specifically, the tool should: ➢ Move beyond a description of children as a protective factor for the adult and assess what this means for the lived experience of the child including any risks. ➢ Support an analysis of situations where children may become part of the delusional thinking of the parent or carer.  Recommendation Five All organisations providing services to adults should review the quality of staff supervision in order to ensure that it provides the opportunity for reflection and critical thinking that enables a focus on the needs of all family members particularly children.   Recommendation Six Southend Borough Council should inform schools of the information that may be held by school nurses about the mental health of a parent, clarify expectations on both parties and evaluate the impact of this process on the safety and wellbeing of children.   Finding Two Practitioners providing services to children, need to take a whole family approach in order to understand children’s behaviours within the context of their family circumstances. 4.25 Generally in relation to an understanding of Mothers mental and physical conditions practitioners working with children saw Father and Maternal Grandmother as protective factors. Whilst this was true, there could have been a more structured assessment of the impact on the children’s emotional wellbeing and an acknowledgement that at times Mother would be a sole carer. The School  4.26 The school attended by Child R and his sibling has a very strong pastoral support team of seven staff who work with about 100 children in total at any one time. Each child seen by the team has a named pastoral support worker. Child R was one such child although the school were not unduly concerned about him: generally, their   ESCB SCR Child R Report  Page 19 of 32 perception was that the parents were overly anxious. The school were aware that the children had spoken in the past of seeing “mum hit dad”, and that Mother had physical health difficulties; she had been seen in a wheelchair and Child R’s sibling had reported that he was not allowed into her room. The school did contact Children’s Social Care about an incident where Child R’s sibling was described as having a knife but once they realised the family were not known to them, they decided to refer to Family Action. They were not worried when Family Action closed the case as Father was a supportive figure whom the boys worshipped but the school told the review that the boys would however have been described as young carers if Father had not moved back into the home. This analysis of the situation could have informed thinking when Father was no longer living with the boys after her move back to Essex, although it was assumed that Mother’s family would provide the support needed and in the months before Child R’s death the school had an increase in positive contact with Mother. 4.27 When the older sibling had been seen by child mental health there had been no contact with the relevant school. Current operating procedure within child mental health services15 does provide guidance about issues of consent where there is a need to contact a school or where a school contacts the service. Schools are a vital part of the support system around the child and both guidance and training could be more proactive in positively encouraging a link with schools where a child is being seen by mental health services.  Health Provision – child mental health and the GP services 4.28 Child R and his sibling were referred to child mental health services two years apart.  4.29 GP services, theoretically, are in a good position to consider the whole family and to understand children’s behaviour in this light. In practice, all family records are individual, and links may not be made between children’s behaviour, family patterns and parental circumstances. The episode when Child R’s sibling threatened self-harm for example was not linked with later concerns about Child R’s violent behaviour and Mothers physical and mental health problems.  4.30 The referral to child mental health services in respect of Child R had been made by the GP after Father had expressed concern about Child R’s increasingly violent behaviour and that he had witnessed his Mother being violent towards his Father. The referral also notes Mother’s severe mental ill health. At this stage the GP should have considered whether this cluster of factors indicated potential risk to the child and a safeguarding referral was needed. These factors included a report of Mother’s violence towards Father. Within Southend, there are current proposals to develop a general practice based domestic violence training support and referral programme for primary care staff, this includes signposting for male victims and may have been a helpful prompt to the GP in this case.   15 Now known within Essex as EWMHS (Emotional Well-being and Mental Health Service)   ESCB SCR Child R Report  Page 20 of 32 4.31 This referral was considered (triaged) by the child mental health service and the decision was that Child R did not need a mental health assessment. A letter was sent to the GP and Mother advising self-referral to counselling services. This letter to Mother is an action which did not take account of the whole family circumstances and consider that Child R could potentially be put at risk since Father had described Mother’s violent behaviour. The letter should have been sent to Father as the referrer. 4.32 Child mental health services are now commissioned from a different organisation than the one providing child mental health services at the time Child R’s sibling was seen. This made it impossible to review the records for Child R’s sibling.  The previous Trust kept paper records making it a time-consuming process that has not been commissioned from EWMHS as part of the triage process.   4.33 EWMHS also raised the point that automatically accessing a sibling’s records would raise Information Governance issues. Electronic patient record systems used by health providers in Essex do not automatically link family members together so a sibling link would only be known about if the referrer made specific reference to this and permission was given to review these records.  These factors mean that there is a lost opportunity to understand children’s behaviour within their family context at the triage stage and to use all available information to make a reasoned decision as to the most appropriate course of action, including whether a full assessment is needed.   4.34 The triage process has been discussed in some detail with EWMHS to understand what it involved and what EWMHS has been commissioned to provide. This has been important to understand as part of the overall concern that risks to Child R were not apparent due to a fragmentation of information and response throughout the safeguarding system in adults and children’s services. It seems that EWMHS have been commissioned to provide an accessible service where professionals and families can refer in a wide range of concerns and the triage process is designed to establish whether EWMHS is the right service or the child’s needs could be best met though being signposted elsewhere. There is no detailed information gathering at this stage and the clinician relies on what is written in the referral. For those making referrals, the quality of the information contained in the referral is of crucial importance since this will determine whether a child mental health service is offered. It is not clear how well this is understood amongst the whole professional community, although EWMHS has provided this information to all stakeholders across a range of forums.  4.35 In the case of Child R, EWMHS did not record a clear rationale as to why the referral was not accepted at the point of triage but the rationale given verbally to this review was that there were no clear signs of mental ill health and there was “a low level need of anxiety and anger which could be managed through a community provider”. It was believed that Child R’s anxiety could be best managed via a community counselling service such as Open Door, a decision in line with commissioning requirements that promote less intrusive intervention at the first stage.    ESCB SCR Child R Report  Page 21 of 32 4.36 Whatever the decision about access to child mental health services, it is important that any safeguarding concerns are identified, and the necessary action taken. In this respect the triage process should always involve a risk assessment based on the information received.  In this case the combination of severe parental mental health problems, the report of Mother’s violence and her wish for Child R to be fostered should have triggered a safeguarding alert and action taken to make sure that a referral to children’s social care was made. In this case the GP would have been the most appropriate person and action taken to liaise with the GP to make sure that this had happened.   4.37 If for any reason it was clear that no safeguarding referral was being made, EWMHS could have made this themselves. It should be noted that EWMHS do have a different view about this and argue that the risk factors were based on third party information (what father had reported about Mother) and was historical rather than current. In these circumstances it is the view of EWMHS that they should not make a referral. This is an issue that needs to be resolved and clarified with the Partnership and action taken to make sure all are content with the procedures and the way they are being interpreted.   4.38 The point of referral to the child mental health service was an opportunity to consider whether any help was needed to support the family in meeting the needs of the children. When the decision is that a community-based service is the most suitable, EWMHS commissioning arrangements are such that they do not make a referral but instead ask the parent to self-refer where appropriate. They also do not ask parents for permission to contact the provider and pass on any relevant information. In this case Mother made a self-referral for Child R but the counsellor had no context for the referral and their own assessment at the start of the counselling sessions was based on self-reported information. They could not understand Child R’s presentation or comments during sessions in the light of the family circumstances including Mother’s mental ill health and there was no reason for them to contact other agencies such as EWMHS for further information. Practice would be improved if procedures within child mental health services included asking parents to inform them when a self-referral had been made and for permission to proactively share relevant information with the provider concerned.    4.39 Since under the current system, the receiving service will only have information given by the parent it is common practice to ask parents’ permission to contact other organisations who may have information that will help them to provide the best possible service to the child. The review has been told by Open Door that most parents are happy to give permission, but other agencies often do not respond to requests for information, even where a parent has given written consent. As this case demonstrates, the opportunity to understand the needs of the child within their family context is lost without a holistic approach.   4.40 A recent report by the children’s commissioner into children’s mental health services commented that where a child suffers from “low level” mental health concerns the   ESCB SCR Child R Report  Page 22 of 32 response can be simultaneously everyone’s responsibility, and nobody’s.16 In this case, responsibility for responding to Child R’s needs was picked up by Open Door but this operated in isolation from the rest of the network.  A holistic approach should have sat within the early help framework which is well developed in Essex.17 The cluster of factors described to the GP should have prompted a referral to children’s services and consideration of the need for an early help plan alongside assessment of possible safeguarding concerns. A team around the family approach could have brought together all the services working with the family and been an opportunity to understand the experience of the children in the family and target help accordingly.  Recommendation Seven Southend Clinical Commissioning Group should work with GP practices to ensure that both permanent and locum clinicians have an understanding of the cluster of factors that might indicate the need for a safeguarding referral and that information about how to refer to local Children’s Services is displayed in every GP practice.  Recommendation Eight Child mental health services (EWMHS) should ensure that assumptions are not made about the actions of other professionals in making safeguarding referrals and at the point of triage always consider whether a child may be at risk of harm and a direct referral needs to be made.  Recommendation Nine Child mental health services (EWMHS) should work with those who refer into the service to make sure that the quality of information received is sufficient to make a triage decision about emotional and mental health needs based on referral information.  Recommendation Ten Child mental health services (EWMHS) should be asked to identify the barriers to checking records for any previous involvement with siblings of the referred child and discuss with commissioners of the service as to how these can be overcome and be required practice in future delivery models.    Recommendation Eleven At the close of contact with child mental health services (EWMHS) letters outlining the outcome should be sent to the parents or carers who made the original referral. Information systems should be reviewed in order to facilitate this.  Recommendation Twelve Southend, Essex and Thurrock Safeguarding Children Procedures should clarify the need for effective two-way information sharing (with appropriate permissions) between statutory and non-statutory providers in order to facilitate the most effective help to children and their families.    16 Longfield, A (2020) The State of Children’s Mental Health Services, The Children’s Commissioner. 17 https://www.essexeffectivesupport.org.uk/media/1078/early-help-offer.pdf   ESCB SCR Child R Report  Page 23 of 32 Finding Three The coordination and response of mental health services needs to take account of concerns that a patient with a diagnosed mental health condition is relapsing.  4.41 It is the view of this review that the extent, severity and diagnosis of Mother’s mental health was not sufficiently understood by the Mental Health Liaison Team. 4.42 Although the family have described feeling increasingly worried about mother’s symptoms in the days before the incident. Their care coordinator was away for longer than originally planned due to sickness and although a visit from another team member was offered it is reported that the family preferred to wait. The Early Intervention Team should have been more proactive in undertaking a home visit given the deterioration in Mother’s mental health and missed opportunities to intervene early when there were signs of relapse. This issue is identified in the investigation report from Essex Partnership University NHS Foundation Trust. 4.43 When Mother was taken to the hospital and seen by the Mental Health Liaison Team, it is the view of the internal investigation report that there was an opportunity to recognise the severity of her symptoms and consider admission to a psychiatric unit or request an assessment under the Mental Health Act 1983 to prevent a further deterioration in her illness. Even if this was not deemed necessary there should have been a handover to the Early Intervention Team the next morning rather than relying on Mother to go to the GP and for the GP to prescribe anti-psychotic medication. Procedures do expect that when patients are discharged back to the GP this should be with “a copy of the assessment outcome and personalised advice, information and guidance on re-direction or signposting to other services if required”. There are no timescales within which GPs should be notified, and in this case that notification should have been immediate.     Recommendation Thirteen Essex Partnership University Trust should ensure that where a patient with a mental health condition is seen out of hours and assessed to require medication, a consultation with an on-call psychiatrist is be requested.  Recommendation Fourteen The Rapid Assessment Interface and Discharge Team (RAID) team systems should ensure that when a mental health patient is seen out of hours, contact is made with any treating team and the registered GP at the start of the next working day.  Recommendation Fifteen Essex Partnership University Trust should ensure that Early Support and Treatment in Early Psychosis (ESTEP) protocols and practice in respect of patients who are risk of relapse always includes an urgent face to face consultation with the patient when they have been seen by out of hours services.       ESCB SCR Child R Report  Page 24 of 32 5 SUMMARY OF RECOMMENDATIONS  Recommendation One This report and the findings from the NHS England investigation should be considered by Essex and Southend Safeguarding Adult Boards/Partnerships and the expectation is that there will be joint planning in response to this report and the NHS England independent mental health homicide investigation.   Recommendation Two Southend Safeguarding Children Partnership and Essex Safeguarding Children Board should work with practitioners in all partner agencies to: a) Agree the principles of a Think Family approach and disseminate these to all providers through staff development and training initiatives b) Identify any barriers that prevent the principles being implemented in practice and take steps to mitigate their impact.  Recommendation Three All mental health providers should communicate the outcome of their assessments including non-engagement back to GPs and mental health trusts must provide assurance that this is now established practice and any barriers to communication are understood and removed.  Recommendation Four The provider of adult mental health services (EPUT) should revise their clinical assessment model and related training so that it is in line with information in current procedure documents which requires thorough risk assessment of the impact on children where a parent has a mental illness. Specifically, the tool should: ➢ Move beyond a description of children as a protective factor for the adult and assess what this means for the lived experience of the child including any risks. ➢ Support an analysis of situations where children may become part of the delusional thinking of the parent or carer.  Recommendation Five All organisations providing services to adults should review the quality of staff supervision in order to ensure that it provides the opportunity for reflection and critical thinking that enables a focus on the needs of all family members particularly children.   Recommendation Six Southend Borough Council should inform schools of the information that may be held by school nurses, clarify expectations on both parties and evaluate the impact of this process on the safety and wellbeing of children.     ESCB SCR Child R Report  Page 25 of 32 Recommendation Seven Southend Clinical Commissioning Group should work with GP practices to ensure that both permanent and locum clinicians have an understanding of the cluster of factors that might indicate the need for a safeguarding referral and that information about how to refer to local Children’s Services is displayed in every GP practice.  Recommendation Eight Child mental health services (EWMHS) should ensure that assumptions are not made about the actions of other professionals in making safeguarding referrals and always consider at the point of triage whether a child may be at risk of harm and a direct referral needs to be made . Recommendation Nine Child mental health services (EWMHS) should work with those who refer into the service to make sure that the quality of information received is sufficient to make a triage decision about emotional and mental health needs based on referral information. Recommendation Ten Child mental health services (EWMHS) should be asked to identify the barriers to checking records for any previous involvement with siblings of the referred child and discuss with commissioners of the service as to how these can be overcome and be required practice in future delivery models.   Recommendation Eleven At the close of contact with child mental health services (EWMHS) letters outlining the outcome should be sent to the parents or carers who made the original referral. Information systems should be reviewed in order to facilitate this.  Recommendation Twelve Southend, Essex and Thurrock Safeguarding Children Procedures should clarify the need for effective two-way information sharing (with appropriate permissions) between statutory and non-statutory providers in order to facilitate the most effective help to children and their families.  Recommendation Thirteen Essex Partnership University Trust should ensure that where a patient with a mental health condition is seen out of hours and assessed to require medication, a consultation with an on-call psychiatrist is requested.  Recommendation Fourteen The Rapid Assessment Interface and Discharge Team (RAID) team systems should ensure that when a mental health patient is seen out of hours, contact is made with any treating team and the registered GP at the start of the next working day.      ESCB SCR Child R Report  Page 26 of 32 Recommendation Fifteen Essex Partnership University Trust should ensure that Early Support and Treatment in Early Psychosis (ESTEP) protocols and practice in respect of patients who are risk of relapse always includes an urgent face to face consultation with the patient when they have been seen by out of hours services.       ESCB SCR Child R Report  Page 27 of 32 6 APPENDIX ONE – TERMS OF REFERENCE Serious Case Review Terms of Reference (Child R)   1. Subject of Review   Subject: Child R                                                                           Family Members: Mother          Sibling         Maternal Grandmother       Maternal Grandfather        Father:              2. Reason for the Review  Child R, aged seven, died in July 2018 at his maternal grandparents’ home in Essex. Child R, his nine year old sibling and their mother had been living at the maternal grandparents’ home at the time of his death. It is understood that the cause of death was that Child R was either strangled or drowned in the bath by his mother.  Mother had a lengthy mental health history alongside her physical health issues; she had fibromyalgia and was known to have at times heavily used cannabis to ease the pain. Mother experienced her first psychotic episode in March 2017. There has been an ongoing Police investigation in respect of Child R’s death.  In January 2019, Mother was found not guilty of murder by virtue of insanity. She has been given an indeterminate hospital order.   3. Relevant time period for the review  1st September 2015 (month when Child R started school) to 23rd of July 2018.    ESCB SCR Child R Report  Page 28 of 32 4.    Organisations who should contribute to the review  1) Essex Partnership University Trust  2) Essex Police 3) Rochford Council 4) Southend University Hospital Foundation Trust (SUHFT) 5) Southend GP services 6) Southend Early Help 7) Southend Education  8) Open Door  9) Southend Adult Services   10) Southend Housing  11) POhWER (Advocacy Service) 12) South Essex Advocacy Services 13) North East London NHS Foundation Trust (EWMHS)  5. Review Team Representatives   1) Adult Mental Health (EPUT)  2) Essex Police  3) Southend CCG Designated Nurse  4) Southend CCG Designated Doctor  5) Southend Children Social Care 6) Southend Early Help 7) Southend Education  8) Voluntary Organisation – Open Door Counselling Services 9) Southend Adult Social Care  10) NHS England   6. Questions to be considered 1) How comprehensive were the assessments and plans undertaken by services involved in the care of Mother, particularly mental health services, in considering her parenting capacity? What assumptions were made based on Father’s involvement with the children and the protective nature of the extended family?  2) What do we know about Mother’s level of violence during psychotic episodes? Were these so different from what happened when Child R was killed? What, if anything, did the family know and perhaps did not share with agencies? Was there a fear that the children could be taken away from Mother?    3) The children had mentioned to their school that the family had been involved with Adult Social Care; this needs to be further clarified …was this followed up by the school at any point? Was there a “think family” approach to co-ordinating care for Mother and her children? What levels of support were offered by Adult Services, and was this appropriate?     ESCB SCR Child R Report  Page 29 of 32 4) What was the school’s understanding of both the professional support network and the family support network, especially given Mother’s ongoing mental health issues?  5) Were the assessments of Mother’s mental health thorough and responses appropriate in the days leading up to the incident? Mother alluded to not being in control of her mental health issues; did professionals involved in her care ask Mother what she meant by that. What did the Continuing Care team make of Mother’s presentations and the potential level of risk she posed?   6) What was the quality of the multi-agency safeguarding arrangements in respect of the practitioners working with the family (information-sharing, integrated working, communication between agencies, assessments of risk etc.)?   7) Were attempts made to bridge the gap between Mother’s physical health needs and her mental health needs? Mother did not appear to have a big uptake of GP services; were Mother’s physical needs being met by the acute trusts?   8) The review should gather information about the housing situation for the family, what priority was given / should have been given to this vulnerable family, given mother’s mental health and physical health issues?  9) School referred to the children as young carers; what was meant by this, and how were the children supported as “young carers”?   10) Voice of the children; what was it like to be a child in this family? What was the lived experience of these two children?   11) What significant steps did the family take to manage their situation? The Lead Reviewer is to explore this through family contributions to the review.   12) What was the level of domestic violence in the family? Did professionals ask the relevant questions around domestic abuse; did they get answers; or did they not ask?  13) What was the impact of Mother’s relationship with her new partner and the trip to Jamaica?  14) What was the impact of the stresses Mother experienced around the family’s housing situation and her reported £50,000 debt; were agencies aware of the debt and was this discussed with Mother?  15) How do we work together to provide families with adequate support in circumstances where Children’s Social Care thresholds have not been met?  16) What was the role of MIND with Mother?   ESCB SCR Child R Report  Page 30 of 32  17) Were there any multi-agency meetings to co-ordinate support for the family, and if not why not?  18) What, if anything, could agencies have done differently which may have made a meaningful difference?   7.  NHS England Terms of Reference The investigation is to be conducted in partnership with the Children’s Serious Case Review into the death of Child R Terms of Reference. The investigation will examine the NHS contribution into the care and treatment of Mother from her first contact with specialist mental health services following the birth of Child R up until the date of the incident. • Critically examine and quality assure the NHS contributions to the Children’s Serious Case Review   • Examine the referral arrangements, communication and discharge procedures of the different parts of the NHS that had contact with Mother  • Review and assess compliance with local policies, national guidance and relevant statutory obligation  • Examine the effectiveness of the service user’s care plan and risk assessment, including the involvement of the service user and her family  • Examine the communication with the service user and her family in the lead up to the homicide and the responsiveness of services  • Review the appropriateness of the treatment of the service user considering any identified health needs/treatment pathway  • To work alongside the Children’s Serious Case Review and Chair to complete the review and liaise with affected families  • To provide a written report jointly with the Serious Case Review report to the Safeguarding Board and NHS England that includes measurable and sustainable recommendations that may be published either with the multi-agency review or standalone     ESCB SCR Child R Report  Page 31 of 32 8. Methodology The review process is designed to ensure an open and collaborative approach which includes the perspectives and views of practitioners and family members. that there is a focus on what happened and why practice decisions were made. The review seeks to move beyond a focus on individual practice to an understanding of lessons for the safeguarding system the as a whole.  The process of the review will be: 1. Gathering and analysing written information via chronologies and other relevant reports. 2. Agreeing key practitioners who should be offered an opportunity to contribute. Meeting with family members.  3. Meeting with family members.  4. Meeting with practitioners either individually or in small groups. These meetings will be led by the lead reviewer along with a panel representative with professional expertise in the area bring discussed.  5. Key themes and learning to be agreed with the Review Team. 6. Production of a draft report to be agreed by the Review Team. 7. Sharing of the final draft with all those who have contributed. 8. Production of final report agreed with the Serious Case Review Sub-Committee and presented to LSCB.     ESCB SCR Child R Report  Page 32 of 32 APPENDIX TWO – PRACTITIONER DISCUSSIONS  ➢ Care Co-ordinator, ESTEP (Early Support and Treatment in Early Psychosis) ➢ Psychiatrist - EPUT ➢ Mental Health Practitioner - RAID (Rapid Access Interface and Discharge) ➢ GP - Southend CCG ➢ Adult services social worker - Southend Adult Social Care ➢ Advocacy worker - PoHwer ➢ Headteacher and Pastoral Worker - Primary School  ➢ South Essex Advocacy Service commissioner ➢ Locum GP  ➢ Southend Housing worker ➢ Named nurse for safeguarding EWMHS ➢ Head of Children’s Services EWMHS  1 NHS England independent investigation into the NHS care and treament of Mother in Essex  To be read as an appendix to the Serious Case Review (Child R) First Published: December 2020  2   Contents 1. NHS England independent investigation ........................................ 3 Approach to the investigation ..................................................... 3 Structure of the report ................................................................ 4 2. Arising issues, comment and analysis ........................................... 5 Quality assurance of internal investigation report ....................... 5 Referral, assessment and discharge procedures ....................... 9 Care planning and risk assessment ......................................... 19 Family communication/responsiveness of services .................. 26 3. Overall analysis and recommendations ....................................... 28 Findings and recommendations ............................................... 28 Appendix A – Terms of reference ............................................. 31 Appendix B – Internal report analysis ....................................... 32     3 1. NHS England independent investigation Approach to the investigation 1.1 The independent investigation follows the NHS England Serious Incident Framework (SiF, March 2015)1 and Department of Health guidance on Article 2 of the European Convention on Human Rights and the investigation of serious incidents in mental health services.2 The terms of reference for this investigation are given in full in Appendix A.  1.2 The main purpose of an independent investigation is to ensure that mental health care related homicides are investigated in such a way that lessons can be learned effectively to prevent recurrence. The investigation process may also identify areas where improvements to services might be required which could help prevent similar incidents occurring.  1.3 The overall aim is to identify common risks and opportunities to improve patient safety and make recommendations about organisational and system learning. This investigation was commissioned to support the work of the independent lead reviewer of the Serious Case Review (SCR) which was commissioned by Essex Safeguarding Board, and the terms of reference were agreed jointly. This investigation should be seen as an addendum/appendix to the SCR.  1.4 Following the homicide of Child R by his Mother in July 2018, NHS England Midlands & East commissioned Niche Health and Social Care Consulting (Niche) to carry out an independent investigation into the care and treatment of a mental health service user, called Mother for the purpose of this investigation. Niche is a consultancy company specialising in patient safety investigations and reviews.    1.5 The decision to carry out a SCR took place after new statutory guidance came into force in 20183 and prior to new partnership arrangements for safeguarding children being in place in Essex and Southend. Arrangements for initiating this review and publishing the report have therefore remained with Essex Safeguarding Children Board but it is important that the final recommendations are considered and responded to by both Essex and Southend Safeguarding Children Boards/Partnerships.  1.6 The focus of the SCR is Child R. Due to the circumstances of his death many of the recommendations of this review relate to the way in which risks to children can be recognised by practitioners working with adults with physical and mental health problems.   1.7 This investigation commissioned by NHS England focusses in more detail on the NHS services provided to Mother, however it should be noted that the two reviewers  1 NHS England Serious Incident Framework (March 2015). https://www.england.nhs.uk/patientsafety/serious-incident/ 2 Department of Health Guidance ECHR Article 2: investigations into mental health incidentshttps://www.gov.uk/government/publications/echr-article-2-investigations-into-mental-health-incidents 3 HM Government (2018) Working Together to Safeguard Children.  4 have worked closely together in finalising the findings and recommendations of this review. This report and the findings from the NHS England investigation should be considered by Essex and Southend Safeguarding Adult Boards/Partnerships and the expectation is that there will joint planning in response to this report and the NHS England mental health homicide investigation.   1.8 The independent mental health homicide investigation was carried out by Dr Carol Rooney, Associate Director for Niche, with specialist advice from Dr Lucinda Green, consultant psychiatrist. The investigation team will be referred to in the first person plural in the report. The report was peer reviewed by Kate Jury, Partner, Niche.  1.9 The investigation comprised interviews carried out with the SCR lead author, and a review of clinical records and documents.  1.10 We met with Mother in May 2019. Mother’s family and Child R’s father did not wish to meet us, but the final report was shared with the family.  Structure of the report 1.11 This addendum focusses on an analysis of the care and treatment provided to Mother by NHS services in line with the additional health terms of reference. Mental health services were provided by South Essex Partnership University NHS Foundation Trust (SEPT) until the new Trust was established in April 2017. Mental health services across Essex are now provided by Essex Partnership University NHS Foundation Trust (EPUT). Child mental health services are provided by North East London NHS Foundation Trust (NELFT) and are called the Emotional Wellbeing and Mental Health Service (EWMHS). We have not reviewed the care provided to the children concerned but have included the recommendations made in the SCR as they are recommendations for NHS services. The detailed issues regarding the children’s care are discussed in the full SCR.   1.12 Section 2 provides a review of the EPUT internal investigation report and examines the issues arising from the care and treatment provided to Mother against the health terms of reference (see appendix A).   1.13 Section 3 sets out our overall analysis and recommendations. The SCR has made eight recommendations for health services which we endorse (SCR recommendations 3,4,5,7,8,9 and 10) and we have made three individual recommendations.     1.14 Where we have come to a conclusion we have included these in a ‘summary statements’ box at the end of discussion sections.        5  2. Arising issues, comment and analysis  2.1 The terms of reference for this investigation are to:   • critically examine and quality assure the NHS contributions to the Children’s Serious Case Review;  • examine the referral arrangements, communication and discharge procedures of the different parts of the NHS that had contact with Mother; • review and assess compliance with local policies, national guidance and relevant statutory obligation; • examine the effectiveness of the service user’s care plan and risk assessment, including the involvement of the service user and her family; • examine the communication with the service user and her family in the lead up to the homicide and the responsiveness of services; and • review the appropriateness of the treatment of the service user considering any identified health needs/treatment pathway. Quality assurance of internal investigation report   2.2 The internal investigation was described as a ‘Root Cause analysis investigation report’ but does not reference the definitions in the NHS England SiF.   2.3 The report is written in a root cause analysis format and lists clear terms of reference. A team was established including a Consultant Psychiatrist, a Non-Executive Director, an external investigator, the Head of Safeguarding Children and the Director of Mental Health Services.   2.4 Mother’s previous care in EPUT/SEPT was summarised, and a detailed chronology is provided. Care and service delivery problems were identified against the terms of reference, exploring the care provided in detail.   2.5 The efforts to involve the family are described, and detailed responses to the family’s questions are listed. The process of the investigation is clearly described, including those interviewed and materials accessed.   2.6 Contributory factors were identified, which were patient factors, individual factors, task factors and system factors.    2.7 The patient factors identified were:   • the children were identified by Mother as protective factors, although she had ‘made some reference to them while sharing psychotic beliefs’; • Mother had a long-term diagnosis of fibromyalgia4 and used cannabis to manage pain; • her psychotic symptoms had responded well to antipsychotic medication, although this exacerbated her chronic pain;   4 Fibromyalgia is a long-term condition that causes pain all over the body.  6 • she had a preference for holistic approaches to her health and was reluctant to take antipsychotic medication;  • she went on holiday to Jamaica with her partner and reportedly consumed cannabis, although showed no psychotic symptoms when reviewed after her return, although her mental state deteriorated a week later; • Mother lived in her parent’s house, sharing a room with both children; and • Grandmother was very supportive.   We consider that there was a missed opportunity to clarify who is caring for the children when there are several adults in the house, as highlighted in previous child serious case reviews.5   2.8 The system factors identified were:  • Mother and Grandmother attended A&E on 19 July to obtain antipsychotic medication, but the mental health liaison team do not prescribe out of hours; and • there was a delay in prescribing antipsychotic medication.  In our view a further system factor was that the mental health liaison service did not have a protocol for informing the GP and the early intervention in psychosis service (ESTEP) of the out of hours consultation, and the advice given.   2.9 Task factors identified were:   • some of the staff involved had not completed mandatory refresher training • some staff were not compliant with mandatory supervision    The report does not specify whether the mandatory training included child or adult safeguarding, and whether the supervision was safeguarding supervision.  2.10 In the section entitled ‘root cause’ the report states that ‘the incident was not predictable’, with ‘no past history of aggression towards others or children, and in the absence of overt risk factors for violence’. It does state however that the ‘likelihood of the incident could have been significantly reduced’. The factors contributing to the incident include ‘Mother’s psychotic symptoms, inconsistent engagement with the services, use of cannabis and lack of timely treatment interventions’.   2.11 The omission of previous aggression attributed to Mother is not noted i.e.: there was a history of aggressive behaviour, sibling told a teacher in 2015 that ‘Mum hurts Dad’. Also, in 2016 Mother allegedly grabbed the neighbour and attempted to drag her into the flat. The Trust has clarified that this history was noted in the submission to the SCR, so was not repeated in the internal report.     2.12 The report does not explicitly state whether these was considered to be a root cause or not. In patient safety terms, the root cause of a serious incident is the earliest point at which intervention could have prevented the incident, and in our view this aspect should have been explored further. The terms of reference for the internal  5 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report, Department for Education May 2016.  7 investigation did not in fact require a determination about predictability, so it is unclear why this was included.   2.13 We tested the internal report against our standard ‘credibility, thoroughness and impact’ framework (see appendix A). The score was 21/25, and the areas where the investigation did not meet accepted standards were:   The investigation should have been completed within 60 days.   2.14 The finalised investigation report was supplied to the SCR lead author in September 2019. This is 14 months after the homicide, which is well outside the policy expectations in the SiF. The Trust have commented that the incident was ‘stop-clocked’ in agreement with the CCG for a significant period of time pending conclusion and outcome of Police investigations. Further time was used to source and appoint an independent investigator. Once underway, the investigation was extended, in agreement with the Commissioner. Further witnesses and lines of enquiry were also requested which it was stated was not unusual for a complex investigation of this nature.     Summary statement 1     The internal report was not completed within expected timeliness standards, and the delay was not explained in the internal report.   There was no discussion regarding root cause.  2.15 In the section entitled ‘root cause’ the report states that ‘the incident was not predictable’, with ‘no past history of aggression towards others or children, and in the absence of overt risk factors for violence’. It does state however that the ‘likelihood of the incident could have been significantly reduced’. The factors contributing to the incident include ‘Mother’s psychotic symptoms, inconsistent engagement with the services, use of cannabis and lack of timely treatment interventions’.   2.16 The report does not explicitly state whether there was considered to be a root cause or not. The terms of reference for the internal investigation did not in fact require a determination about predictability, so it is unclear why this was included.    Recommendations do not all relate to the findings and lead to a change in practice, are measurable and outcome focused.  2.17 There were three recommendations made. In order for recommendations to be measurable and outcome focussed there should be a clear statement of what the action is intended to achieve (the outcome) and a statement of what would indicate that it had been achieved. All three of the recommendations use aspirational language and encourage an ‘exploration’ of the issues, rather than actions to address the care and serve delivery problems identified.   2.18 The three actions are for ESTEP to ‘consider the RAG rating for patients’, ‘explore full psychiatric symptomology …in order to fully understand the nature and degree of  8 illness’, and for the psychiatric liaison service to ‘explore developing a process of informing ESTEP if one of their patients is assessed at A&E’. These recommendations are not linked directly to the care and service delivery problems identified.    2.19 The first of these recommendations suggests that a system of rating (red/amber/green: RAG) rating be used to monitor patients who are relapsing. It is not clear whether there is already a system/protocol in place for this, and the liaison team did not use it, or whether this would be a new system.   2.20 The clinical risk assessment and safety management procedure6 already in place does not make any reference to a RAG rating procedure.  Summary statement 2 Recommendations made in the internal serious incident investigation report were not outcome focussed or measurable. Summary statement 3 The clinical risk assessment and safety management procedure does not include a RAG rating protocol to identify heightened need or risk.  2.21 The second recommendation expects that ESTEP should make a thorough mental state examination and take a detailed history. It is then anticipated that the team could ‘better understand the risks and formulate an appropriate risk management plan’.    2.22 The taking of a detailed history is already a clear requirement of the CPA procedure,7 with a list of all the areas that should be explored, including psychiatric and psychological functioning, personal circumstances, social functioning and physical health needs. A thorough assessment should include review of previous health records and requesting previous records from the GP, and the taking of collateral history from a family member.  2.23 Under the heading ‘personal circumstances’, there are prompts related to assessment of family and parenting issues which are ‘family including genogram’, ‘caring responsibilities’, ‘childcare issues’, ‘relationship issues’. The internal report does not comment on the lack of assessment of Mother as a parent, or the potential impact of her mental health issues on the children. If the history taking had identified the extent of her previous lack of functioning in 2014 and the need for Father to move back in as she couldn’t cope in 2015, the assessing clinician might have wanted to find out more about all this in terms of considering parenting capacity and risk to the children.    6 Clinical risk assessment and safety management procedure, CLPG 28, July 2017 7 Care Programme Approach procedure, CLPG30, July 2017   9 2.24 The expectation that CPA assessments include reference to children has been in place since 2008.8  We were informed that the Trust has implemented a ‘Think Family’9 approach which was intended to help services improve their response to parents with mental health problems and their families.  Summary statement 4 The ‘Think Family’ approach did not influence direct clinical practice in ESTEP in this case. There is no ‘child risk screen’ included as part of the assessment process.  2.25 The final recommendation was that the psychiatric liaison service should ‘explore developing a process of informing ESTEP if one of their patients is assessed at A&E’.  2.26 We suggest that this wording should have a clearer outcome focus, for example setting a standard for communication to a team where the patient is already open to an EPUT service. We would also suggest that this standard should include communication back to the patient’s GP.   Summary statement 5 When an existing service user is assessed out of hours, there is no standard for communication back to the relevant clinical team and their GP  Referral, assessment and discharge procedures  2.27 The GP records show that Mother’s first prescription for nerve pain was in 2001.  Mother has told professionals that she suffered from fibromyalgia since the age of 13, which would have been in 1994. GP records from 1994 do not confirm this. There are records showing that amitriptyline10 was prescribed in 2001, which is the first prescription for nerve pain in her records. In these historic records there is reference to her experiencing migraines, but no detailed explanation for this prescription, or referral for specialist input. There is no reference to fibromyalgia until 2007.  2.28 She had a history of asthma which was treated with inhalers. There is also a history of gynaecological problems dating back to 1998.   8 Laming (2003) Recommendation 12 in The Victoria Climbie Inquiry; Summary and Recommendations http://www.victoria-climbie-inquiry.org.uk/finreports/summary-report.pdf  9 SCIE Report 56: Think child, think parent, think family: final evaluation report, March 2012. https://www.scie.org.uk/publications/reports/report56.asp 10 Amitriptyline is an antidepressant medication used in lower doses to treat pain. It is especially good for nerve pain such as back pain and neuralgia. It can also help prevent migraine attacks. https://www.nhs.uk/medicines/amitriptyline-for-pain/   10 2.29 Early GP records note her first pregnancy was in 2008. There are no entries which describe her antenatal care, although her older son was born by caesarean on 9 September 2008. The postnatal GP examination was completed without problems.    2.30 In 2007 the GP records state that she was ‘adamant’ that she had fibromyalgia, and she said she had done a lot of research. Consequently she was referred by her GP to the rheumatology department at Broomfield Hospital. The diagnosis of fibromyalgia was made in 2007, and she was found to have chronic back pain, with limitation of movement in her spine, but with no evidence of rheumatoid arthritis. In 2008 she was treated with depomedrone11 injections but had no pain relief.   2.31 Between 2000 and 2017 she moved GP surgery three times, as she changed addresses. One of the changes in August 2014 was, according to her, because the previous surgery did not provide the services she expected for her pain.   Her GP notes were visible at each new practice and she was referred for physiotherapy, and to rheumatology for back pain and joint pain over many years. She was prescribed pregabalin,12 duloxetine,13 tramadol,14 folic acid and inhalers. She also had a prescription for ‘as required’ diazepam.15  2.32 As well as widespread pain, people with fibromyalgia may also have:  • increased sensitivity to pain • extreme tiredness (fatigue) • anxiety and depression • muscle stiffness • difficulty sleeping • problems with mental processes (known as ‘fibro-fog’), such as problems with memory and concentration • headaches • irritable bowel syndrome (IBS), a digestive condition that causes stomach pain and bloating  2.33 We consider that it is possible that prodromal or negative symptoms of schizophrenia may have been missed because some of the symptoms were attributed to fibromyalgia.  2.34 Although there is currently no cure for fibromyalgia, there are treatments to help relieve some of the symptoms and make the condition easier to live with.  11 Depo-Medrol (methylprednisolone acetate) is an anti-inflammatory glucocorticoid used to treat pain and swelling that occurs with arthritis and other joint disorders. https://bnf.nice.org.uk/drug/methylprednisolone.html  12 Pregabalin is used to treat epilepsy and anxiety, and is also taken to treat nerve pain. https://www.nhs.uk/medicines/pregabalin/  13Duloxetine is an antidepressant medicine. It's used to treat depression and anxiety. It's also used to treat nerve pain, such as fibromyalgia. https://www.nhs.uk/medicines/duloxetine/  14 Tramadol is a strong painkiller. It's used to treat moderate to severe pain, and is also used to treat long-standing pain when weaker painkillers no longer work https://www.nhs.uk/medicines/tramadol/  15 Diazepam belongs to a group of medicines called benzodiazepines. It is used to treat anxiety, muscle spasms and fits (seizures). https://www.nhs.uk/medicines/diazepam/  11  2.35 Treatment tends to be a combination of:  • medicine, such as antidepressants and painkillers. • talking therapies, such as cognitive behavioural therapy (CBT) and counselling. • lifestyle changes, such as exercise programmes and relaxation techniques. • exercise in particular has been found to have a number of important benefits for people with fibromyalgia, including helping to reduce pain.  2.36 On 4 February 2010 the GP records note ‘severe depressive episode with no psychosis’, and that she was referred to ‘improving access to therapies’ programme. According to GP records she was seen by a counsellor in March 2010, but there is no detail provided. Child R was born on 30 September 2010. There are no notes of antenatal or postnatal care, and no further reference to mental health until September 2013. At this time Mother attended the GP surgery with Father, saying she was unable to cope, that she had depression since she was a child, postnatal depression after Child R and was again awaiting pain management help.  2.37 Mother was referred by her GP to the pain management clinic at Southend in 2013. On assessment she reported memory and sleep problems, pain, fatigue and irritable bowel symptoms. Mother also said she had suffered from depression since she was eight years old. She reported having benefited from a pain management programme at Broomfield Hospital. Mother admitted to smoking one ‘joint’ of cannabis every evening and was willing to abstain while undergoing a pain management programme. A referral was then made to the clinical psychologist for chronic pain management. There are no reports back to the GP of what treatment she received.  2.38 She was referred to ‘therapy for you’16 which is an ‘improving access to psychological therapy’ (IAPT) service in Essex. This was an appropriate referral for exploration of Mothers’ mental health issues. The service attempted to contact her by phone on the day she was referred, due to the concerns she expressed. She did not reply, and this was followed up by a letter, as required by the local assessment protocols for IAPT. Mother did not respond to the letter either, and was removed from the waiting list in October 2013. IAPT did not communicate this back to the GP, which would have been in line with expected practice.  2.39 She was allocated to a high intensity IAPT therapist in January 2014, although it is not clear from the records how this referral was followed through.  2.40 Mother was seen in February 2014 ,and as part of the assessment she undertook a Patient Health Questionnaire (PHQ-9).17 Her score was 27, which is the maximum score, and according to the guidance, indicates ‘severe depression, and warrants treatment for depression, using antidepressants, psychotherapy and/or a combination of treatment’. She also completed a General Anxiety Disorder-7  16 https://www.therapyforyou.co.uk/ 17 The Patient Health Questionnaire-9 (PHQ-9) is a nine item questionnaire designed to screen for depression in primary care and other medical settings. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med2001;16:606-13.  12 questionnaire (GAD-7),18 and the total score was 21, which again is the maximum and indicates severe anxiety. According to the guidance, this indicates that ‘active treatment is probably warranted’.    2.41 The IAPT notes on 6 February 2014 record that her scores reflect her ‘frustration that the extent and impact of her physical health condition is not appreciated by professionals’. She was reported to be stressed by money and benefits issues, and the focus was on anxiety/panic symptoms, although she was thought to ‘need further assessment for pain management and depression’. It was noted that she did not feel suicidal at that point, nor had any urge to self-harm. There are undated GAD-7 and PHQ-9 score sheets that show some improvement in scores, but it is not clear when they were completed. She did not attend the second planned session, and she made no further contact at that time, so the plan was to discharge her from ‘therapy for you’.  2.42 Meanwhile Mother had taken an overdose of her prescribed medication and presented at A&E on 12 February 2014. This was a serious overdose: 34 tramadol, 72 pregabalin and 25 duloxetine. When seen by mental health liaison staff in February 2014 she expressed regret at her actions, and said it was impulsive due to stress and frustration, and there had been a family argument that day. There were no psychotic symptoms observed. No child risk assessment was undertaken, there is no evidence of any attempts to clarify her day to day responsibility for the children and whether they were witnessing regular arguments, or whether this was a one-off.  2.43 She was referred to the Rapid Assessment Interface and Discharge team19 (RAID) and seen for an assessment by mental health services on 3 March 2014, and told the assessing team that she had recently started at ‘therapy for you’ and said she felt that would help her. Her GP was written to stating she would not be taken on by secondary mental health services, as she was not actively suicidal and was under the care of IAPT, which seemed the most appropriate service for her. She was also written to advising her of this outcome, and reminding her that it was agreed she would attend her IAPT appointments. It was noted her children were ‘protective factors’ and she cared too much for them to consider a further overdose. There was no record of attempts to explore whether she was actually attending IAPT appointments.  2.44 She was not seen again, and was in process of being discharged by IAPT when the letter from the RAID service arrived, which recommended that she continue with IAPT.    18 Generalised Anxiety Disorder Assessment (GAD-7) is a self-administered patient questionnaire used as a screening tool and severity measure for generalised anxiety disorder. https://patient.info/doctor/generalised-anxiety-disorder-assessment-gad-7  19 Rapid Assessment Interface and Discharge (RAID) team provided an in-reach psychiatric liaison service to prevent avoidable admissions to inpatient wards and mitigate longer lengths of stay associated with mental illness as a co-morbidity to physical conditions.  13 Summary statement 6 Mother was referred by the GP to appropriate primary care mental health services.  Summary statement 7 Mother’s statement about ‘postnatal depression’ is not explored by either the GP or IAPT.  Summary statement 8 After the overdose in February 2014 it is not clear whether this information was conveyed directly back to IAPT, and a joint plan agreed. The outcome of her IAPT contact was not communicated back to the GP. Summary statement 9  After the overdose there was no reassessment offered by IAPT.  2.45 In March 2016 Mother saw a GP and presented as upset and anxious, talking of problems with her neighbours She attended again three days later, and asked to see a GP who knew her, which was facilitated later that day. Mother asked the GP for a letter of support with regard to housing. She reported being attacked by the house manager and people were ‘talking about her’.  Neither GP appears to have explored this in any depth, and the outcome was a prescription for diazepam at her request.  Father saw Mother’s GP in April 2016 to report that she may need counselling for depression and panic attacks. He was given the contact information for ‘therapy for you’.   2.46 Mother changed GP surgery again in April 2016, saying someone had recommended a GP there.   2.47 Mother was referred to the Essex Chronic Fatigue Service in May 2016 after a reported ‘nervous breakdown’ (sic).20 These were Mother’s words, and she was seen with Father and her advocate. She described having depression, anxiety and panic attacks all her life. She was taking diazepam but reported trying to cut this down. She said her neighbours were harassing her and this was now affecting her children. The plan agreed was to support her with a letter to housing, and refer to fibromyalgia clinic, then review.   20 This is the phrase used in the GP records, and does not refer to any recognised mental health disorder.   14   Summary statement 10 The issues in the GP consultation were seen as her reaction to social stressors and chronic pain and fatigue. While this was a reasonable assessment, there could have been an exploration of any thoughts of self-harm or of harming others, or whether the beliefs about the neighbours were delusional beliefs, and if so whether this meant the children were featured in these delusional beliefs, and whether there were any other psychotic symptoms given what she described. It appears there was diagnostic overshadowing in relation to fibromyalgia. The statement about the effects on her children should have been explored.  2.48 In July 2016 the GP noted the feedback from the Chronic Fatigue Service, Mother was now off her pain medication and was gradually increasing her activity, and she was encouraged to access the council’s ‘active women’ programme.   2.49 Mother was seen by the GP in July, September and October 2016 for minor physical health issues with no note of any mental health concerns.   2.50 On 6 March 2017 Mother was brought to A&E at Southend University Hospital by Grandmother. Mother was assessed by the rapid assessment interface and discharge (RAID) mental health team. Grandmother stated that Mother had been paranoid, suspicious and hallucinating for the last three years. Mother thought people were after her, and reported a long history of paranoia and visual hallucinations. The overdose in 2014 was noted, and she denied any thoughts, plans or intent to harm herself. She was not asked about potential harm to others.   2.51 The clinical impression was a 35-year-old lady with a three-year history of paranoia and visual hallucinations, with delusions that were not fixed but constantly returning. It was stated she requires further assessment of psychosis and appropriate intervention. The assessment noted that she had two children (ages six and eight) living with her at Grandmother’s but made no other observation. The GP should have provided ESTEP with information about previous concerns re children and ESTEP should have asked the GP for information about whether children’s services were ever involved and whether there had been any concerns re the children.  2.52 The plan was ‘refer to ESTEP ; appropriate intervention/treatment taking her fibromyalgia into account, and discharge from RAID’.   2.53 Mother was assessed by ESTEP on 18 March 2017 and attended with her sister. The assessment was structured to draw out Mother’s perceptions and understanding as well as any psychotic symptoms. Mother described constant anxiety for many years with some increase since stopping cannabis recently. When she was asked if she was afraid of people her sister interrupted and encourage her to be honest. Mother said she no longer felt that people were following her or plotting against her and said this must be due to the effects of cannabis wearing off. Her sister clearly disagreed and mentioned the neighbours plotting against her. Her sister later became tearful and pleaded with Mother to be honest and open, saying she was  15 worried Mother may have paranoid schizophrenia. Mother insisted she was not holding back and felt better than she did when she came to A&E.    2.54 Regarding her children she mentioned and that she had not been involved in their lives due to being bedridden for so long but was determined to change that. There was no attempt to clarify who was the main carer for the children and to assess the impact of their illness on them.  2.55 The plan was to discuss in the ESTEP team meeting and make a decision about treatment.  2.56 Mother’s parents phoned the RAID team on 5 April to say she was getting worse and asking for a plan. ESTEP tried to call Mother. She was offered an assessment appointment with an ESTEP practitioner and doctor on 21 April 2017. Mother said things were getting worse but did not elaborate, she did say she hoped to be seen sooner. Emergency and crisis numbers were provided.  2.57 Grandmother called NHS 111 on 5 April because Mother was talking of seeing things, saying everything is bugged. Took her to hospital six weeks ago and saw mental health services, and was now waiting for ‘an appointment with a counsellor’. The advice given was to see her GP within 24 hours.     2.58 Grandmother called ESTEP on 7 April 2017 and talked of Mother’s paranoia, how she believed the whole family would be killed by carbon monoxide and she would be dead before the appointment on 21 April. She said Mother would only drink bottled water and goes into Grandmother’s room at night to try to convince her that her beliefs were real. They planned to go to the GP that day to request sleeping tablets for Mother.   2.59 Mother was seen by her GP on 7 April 2017, and was regarded as suffering from a ‘major anxiety disorder’ which also interfered with her sleep. Mother said she had been taking drugs (cannabis) although she does try meditation. She was prescribed zolpidem21 10mg to aid sleep for two weeks.    21 Zolpidem is a nonbenzodiazepine hypnotic prescribed for insomnia. https://bnf.nice.org.uk/drug/zolpidem-tartrate.html   16     Summary statement 11 The assessment letter from RAID is stamped as having been received and scanned in by the GP practice on 15 March 2017. ESTEP later asked for a summary of this GP consultation. This should have been referenced in the consultation on 7 April, and the GP should have considered further information about the children. The history available at this time includes three years of paranoid thoughts, suspiciousness, visual hallucinations and significant delusional beliefs regarding the likelihood that she and her family would be killed and that she was only drinking bottled water due to her fears. She also believes ‘everything is bugged’.  The presentation at this point includes:  • symptoms which strongly suggest a diagnosis of schizophrenia;  • children being involved in delusional beliefs as she believes they will also be killed and poisoned;  • a woman with a psychotic illness who has been bedridden to the extent that she has not been involved in her children’s lives.   2.60 This was discussed in the ESTEP team on 10 April 2017 and it was agreed that Mother needed support sooner than the planned appointment. It was agreed that they would ask the crisis team to become involved. The crisis team stated that she would need to have been seen within 24 hours and referred by a GP. ESTEP staff called grandmother back and asked her to ask the GP to make a crisis team referral, which she is noted to have agreed to. There is no mention of this in the GP consultation.    17     Summary statement 12  Mental health services recognised appropriately that Mother needed help before the planned referral.  Systems were such that the GP needed to make a referral for this to happen, and the expectation was that family would pass this message on.   Both the GP and the Trust missed this opportunity to provide timely mental health assessment and support when the family requested it.  Early intervention in psychosis guidance states that ‘if the service cannot provide urgent intervention for people in a crisis, refer the person to a crisis resolution and home treatment team (with support from early intervention in psychosis services). Referral may be from primary or secondary care (including other community services) or a self-or carer-referral’.22  2.61 ESTEP visited Mother at home however on 12 April 2017 to follow up after Grandmother’s calls. Grandmother was present, and Mother reported that things have been worse recently. She described that her family dogs are acting strangely, and believes they are being poisoned. She believed her children were being ‘spiked’ and bullied at school because of her, she had checked their pupils and thought they were ‘different’. Mother believed that songs playing on the radio were directed at her and tell her what to do, people are coming into the house, since a ‘tin of worms’ had been opened, but she would not elaborate on this.  She also believed that the sleeping tablets the GP gave her recently had caused lumps on her neck, and her sleep is regularly disturbed anyway because her son has nightmares. She was advised that there would be a discussion in the next team meeting and they would be in touch soon regarding a possible assessment by a psychiatrist.   2.62 Mother was seen at home by the associate specialist psychiatrist and a mental health nurse with grandmother on 19 April 2017. Mother confirmed she was still having unusual experiences but they were no worse. Sleep was still a problem and made worse because her son wets the bed and it wakes her up. The notes do not specify which son or when, although grandmother offered to have him to help out for a few nights. They were informed that a care coordinator was allocated and she would visit on 26 April. Aripiprazole23 5 mg was prescribed, to increase to 10 mg after two weeks, and promethazine24 25 to 50mg as needed to aid sleep.  2.63 The GP was written to, and a diagnosis of unspecified non-organic psychosis ICD10 F2925 was made. The risk assessment stated there was a previous history of  22 Psychosis and schizophrenia in adults: prevention and management, Clinical guideline [CG178] NICE 2014. https://www.nice.org.uk/guidance/cg178  23 Aripiprazole is an antipsychotic medication.  https://patient.info/medicine/aripiprazole-abilify  24 Promethazine is an antihistamine medicine that relieves the symptoms of allergies, and can be used as a short term aid to sleep. https://www.nhs.uk/medicines/promethazine/ 25 Unspecified psychosis not due to a substance or known physiological condition. https://www.icd10data.com/ICD10CM/Codes/F01-F99/F20-F29/F29-/F29   18 substance misuse, but no self-harm or suicidal ideation at that time. The risk to others was ‘low’; it was noted she had two young children who were not present, but ‘she receives support to look after them from her mother. There is no clarification of what ‘support’ meant, nor mention of children being ‘spiked’ or their pupils being different.  2.64 In our opinion, at this stage the nature and duration of symptoms would meet the diagnostic criteria for schizophrenia. Had this diagnosis been considered, and if staff had appropriate training in child risk, this should have prompted some serious thinking about a woman with significant psychotic symptoms and negative symptoms having caring responsibilities for her children. Whist the diagnosis in itself cannot be used to determine risk, there is a lot of evidence in terms of the potential harms to children when there is parental schizophrenia. Even without this, the impact of the specific symptoms of a parent with a chronic psychotic illness should be considered and so the combination of symptoms described should have raised serious concerns and warranted a referral to Children’s Social Care.   Summary statement 13 ESTEP responded quickly after family concerns increased, saw her at home and developed a care plan.  Summary statement 14 There is no further exploration of the visual hallucinations that Mother first described.26 The presence of visual hallucinations in psychosis has often been linked to a more severe psychopathological profile and to a less favourable prognosis, and is more usually linked to an organic cause.27 Mother had previously said she had been experiencing these for three years.  The children were clearly involved in delusional beliefs and this is an indicator of high risk28 and should have triggered an immediate reassessment, including the exploration of collateral information about childcare with other family members. There should have been an assessment of whether the children were safe in her care.     Summary statement 15 The NICE quality statement on early intervention in psychosis29 states that treatment should be started within two weeks of referral, which was achieved.  26 Visual Hallucinations in the Psychosis Spectrum and Comparative Information From Neurodegenerative Disorders and Eye Disease. Waters et al 2014. https://academic.oup.com/schizophreniabulletin/article/40/Suppl_4/S233/1875426  27 The effect of delusion and hallucination types on treatment response in schizophrenia and schizoaffective disorder. Kilicaslan E, et al. The Journal of Psychiatry and Neurological Sciences, (3) 2016. 28 Filicide-Suicide: Common Factors in Parents Who Kill Their Children and Themselves, Friedman S et al.  J Am Acad Psychiatry Law 33:496 –504, 2005. 29 Psychosis and schizophrenia in adults. Quality standard [QS80] NICE 2015. https://www.nice.org.uk/guidance/qs80/chapter/Quality-statement-1-Referral-to-early-intervention-in-psychosis-services   19 Care planning and risk assessment   2.65 The allocated care coordinator saw Mother at home a week later with Grandmother. Information about the ESTEP treatment programme and about carer support was shared. Mother stated that the hallucinations she had been experiencing had stopped since taking aripiprazole, and that she had been fearful of people harming her, but they have ‘not done anything’ since she started the medication. She said her pain had increased since taking it, but Grandmother said she had been complaining of increased pain before this. It was noted that Mother was physically sensitive to medication, but was also at risk of stopping it due to her own thoughts about the effects on her fibromyalgia. She said she had stopped using cannabis in March because she could not afford it.    Summary statement 16 The recommended therapeutic dose of aripiprazole for adults is between 10 and 30 mg, increasing gradually from 5 mg.30 Mother had taken a sub therapeutic dose for one week when she said her symptoms had gone. There are findings that indicate some people respond more quickly, and early response is a good predictor.31 There is also some evidence that there are gender differences in response to antipsychotics so that sometimes women respond to lower doses.32 This does seem a quick response however, and we consider that professionals should have had more curiosity about this sudden recovery.  2.66 A risk assessment was completed on 26 April 2017. The format of this is a ‘tick-box’ list of possible risk. The risks ‘ticked’ as ‘yes’ were ‘risk related to health/ mental health conditions’, ‘likelihood of disengagement /nonadherence’, ‘risk to self through the use of alcohol/drugs’. The risk of Mother refusing to take antipsychotic medication because of her concerns about side effects was noted, as was the potential use of cannabis. She was frightened to go out because of fear of harm, feeling someone might make her disappear. She was thought to feel safe at home, but there was no discussion about her care of the children. ‘Risk to children’ was ticked as ‘no’ but without exploration. This is difficult to understand in the context of the extent of her psychotic symptoms and her previous poor functioning.    2.67 The plan was for the care coordinator to see her ‘every one to four weeks’ to monitor risk, mental health and medication.  Medical reviews would be required at least six monthly, to monitor for use of cannabis and offer support with abstinence, to liaise with social worker if required, and support with healthy eating and debt (by signposting as needed).  The contingency plans for her current risk which was listed as ‘my mental health is at risk if I take cannabis. Medication causes me pains and I have stopped taking medication in the past’. Various contingencies were listed,  30 https://bnf.nice.org.uk/drug/aripiprazole.html 31 Agid O, Kapur S, Arenovich T, Zipursky RB. Delayed-onset hypothesis of antipsychotic action: a hypothesis tested and rejected. Arch Gen Psychiatry. 2003;60(12):1228. 32 Seeman MV1. Men and women respond differently to antipsychotic drugs. Neuropharmacology. 2019 May 8:107631.  20 relapse signs were identified as ‘increased pain, hallucinations and paranoia’.  Plans to reduce risks were ‘tell my Mum’, ‘call the ESTEP team’. It was noted that her parents needed to be aware of this risk also. Grandmother was offered carer support.   2.68 A formal care plan was written on 26 April, Mother identified being free of pain, hallucinations and paranoia as goals, and also wanting to be able to sleep and go out alone, and cope without taking medication. She agreed to contact the team if her symptoms increased, or if she wanted to stop medication because it caused her pain. She also agreed to accept help with her use of cannabis is she was unable to abstain.  2.69 In early May Mother was seen by the care coordinator with Grandmother. She reported her physical symptoms had increased and she believed this was due to the aripiprazole. She asked if smoking a small amount of cannabis would be helpful and was strongly advised against this. Both Mother and Grandmother reported that Mother had seemed stressed and irritable about debts, housing and impending divorce.  There were no psychotic symptoms evident.     2.70 She said promethazine did not help her sleeping, and requested zolpidem, which was later prescribed. She talked of not driving at present but would like to, and was advised that she needed to inform the DVLA of the medication she was taking if she did plan to drive. The children were described by her as alright, and various problems with money, housing and physical heath were discussed. She was apparently spending most of the time at home, with visits to her boyfriend in Chelmsford at the weekends. After some cancelled appointments Mother reported she had been away for a few days in Norfolk with her children and boyfriend which they had all enjoyed. She was tired but denied any psychotic symptoms, and had been able to concentrate on sorting out housing applications. There do not appear to have been questions asked by the team about her boyfriend, in terms of risk to children, given the history of domestic violence and that she was clearly a vulnerable woman.   2.71 In July 2017 Mother called ESTEP, angry and upset, saying the DVLA had suspended her licence for six months, because she had indicated she takes aripiprazole and had taken cannabis.  She was angry that she would not be able to drive her children over the holidays, but also said she was being punished. Mother went on to describe her belief that she was being watched inside and outside the house, being followed and being punished, by the “illuminati who run mental hospitals and control everyone’s life”. She said she had stopped taking the aripiprazole the previous week because she was taking antibiotics and felt unwell. She believed the aripiprazole had caused her infection and did not want to restart it. It was agreed she would meet the care coordinator later in July.   2.72 This was discussed with the psychiatrist, it was suggested that Grandmother could be relied upon to call if Mother deteriorated, and a mental health act assessment could be considered. Mother reported starting the aripiprazole again, and when the information from the DVLA was reviewed, it appeared her licence was suspended after she informed them she last used cannabis in March 2017. She was tearful at times but said that restarting the aripiprazole was helping her paranoia. There was  21 no exploration of her statement about being watched, or the ‘illuminati’. There was no consideration of the risk to her children or plan to ensure their wellbeing in the context of a deteriorating mental state.  2.73 In July 2017 there was some discussion about the children; she was sharing a bed with her older (eight year old) son, and her younger son (Child R) slept in a bed above. Mother said it was stressful keeping the children quiet during the day because her father had to get up very early for work, and the house was overcrowded. She said the stress was affecting the children’s behaviour which then affects her physical and mental health. This is not explored further. She spoke of being videoed by strangers while out with her children in Chelmsford, the post man tried to enter the house to steal bikes, and her drink had been spiked. When attempts were made to explore these further, Mother appeared unable to differentiate whether they had happened recently or in the past, becoming vague in her answers.    2.74 The risk assessment and care plans were unchanged. At an MDT review in July 2017 it was noted that her paranoid ideas were ‘very fixed with high conviction’, and it was ‘too soon to commence relapse prevention work’. She had been given information about family work, so it was planned to discuss this again. It was felt that she would benefit from an increase in aripiprazole, but it was uncertain whether she would agree. It was agreed to plan a further MDT review in nine months.   2.75 These symptoms were not evident at the next contact in August, which was by phone. A psychology assessment was arranged for later in August, in line with early intervention standards. In August Mother was agitated about what she said were chemicals in her bedroom, ‘coming through the walls’. She said she has always been sensitive to smells and could now smell that her bedroom smelt ‘dusty’. Mother suggested calling the police and fire brigade as a solution. It appeared there was an increase in family stress, following Child R wetting the bed and her experiencing increased pain. Mother refused to consider an increase in aripiprazole due to side effects.   2.76 This was later discussed with Grandmother by phone; Mother apparently believed the ‘chemicals’ were causing Child R to wet the bed, and they had bought a carbon monoxide monitor. Grandmother clarified that some batteries had been stolen, but there was no concern about bikes or cars. She conveyed that Mother had not said strange things for a while, and it was her belief that Child R wet the bed because he was on a top bunk and couldn’t get to the toilet in time. Grandmother was asked about family therapy but said she was very busy, and was not sure Grandfather would attend.  2.77 In October 2017 Mother spoke of worrying that Child R may have ADHD and being aggressive to his brother. The GP had apparently referred him to Essex Emotional Wellbeing and Mental Health service (EWMHS) ‘and this had helped her’. Her mother and sister were also helping out so that the children did not spend so much time together. There was no communication between the ESTEP team and EWMHS.     22 Summary statement 17 The planned medical review in nine months recognises that she has a chronic psychotic illness but does not consider any risk to the children. A review should also have recognised that the children have been involved in her delusional beliefs. The current Trust risk assessment does not include a framework for assessing risk to children.  There was no attempt to offer an OT assessment to clarify her level of functioning  - it is clear that she had caring responsibilities for her children and that at times she has not been able to function well enough to care for them. There was no communication from EPUT to the GP about a potential mental health referral for Child R.   2.78 A CPA review was planned for 27 October 2017, in line with policy expectations. Mother was seen for a psychological assessment on 24 October 2017. She still maintained that her physical health had worsened on aripiprazole, including causing lumps in her neck. She apparently had no paranoid beliefs at that time, but acknowledged that had previously believed in her thoughts completely.  She believed that her psychotic experiences were caused by cannabis. Mother was able to discuss coping strategies, including diet, exercise and meditation that had been suggested by the Chrysalis Effect33 members. She was encouraged to develop a relapse plan with her care coordinator, and not to decrease medication without discussing with her psychiatrist. Because she appeared to have good coping mechanism it was not felt there was a role for psychology at this time, which Mother agreed with and was noted to feel positive about.   2.79 Mother cancelled the CPA review, and the next contact after that was by phone with the care coordinator in early November. Mother reported being physically unwell due to fibromyalgia, and hyperthyroidism. She said the hyperthyroidism caused her difficulty in swallowing.34 They were awaiting counselling for Child (R) who was said to still ‘take things out’ on his brother but things were ‘alright’.   2.80 The CPA meeting took place on 15 November 2017. She reported an increase in her fibromyalgia symptoms which she attributed to aripiprazole, these symptoms were memory loss, trouble thinking, constipation, cold extremities, weight gain and hair loss. It was noted that she said she suffers from hyperthyroidism which “can cause difficulty swallowing and talking”.  The symptoms described in fact sound similar to hypothyroidism. She said she did not want to discuss her physical health with her GP, preferring natural methods.     33 The Chrysalis Effect is a support organisation for people suffering the symptoms of ME, CFS and Fibromyalgia. https://thechrysaliseffect.co.uk/  34 Mother had not been diagnosed with either hyper or hypothyroidism according to GP notes.  23 Summary statement 18 Thyroid disorders commonly cause significant psychiatric symptoms and it is important to ensure thyroid function is assessed and any thyroid disorder adequately treated. ESTEP should have contacted the GP for further information and to ensure appropriate investigations and treatment had been initiated. There was a lack of curiosity regarding this new physical ailment presented by Mother, and how it might affect her mental health, and ESTEP should have explored this with the GP.  She had not in fact been diagnosed with either hyper or hypothyroidism by the GP.  2.81 At the CPA review Mother mentioned that she was still looking after her sons, Child R was still aggressive towards his brother, and she was also looking after her nephew. There was in our view a lack of professional curiosity re potential link with her mental illness, in terms of both her mental illness contributing to behavioural problems in the children, and also that her having to cope with this behaviour was an additional stress which may contribute to relapse. She was noted to be mentally well, but at risk of deterioration if she stopped her medication. A ‘process of recovery’ user reported measure was completed by Mother, which showed she was feeling much more positive and engaged with her life.    2.82 The care plan was updated: to see her every two to four weeks to monitor mental health and medication, to check physical observations and take a drugs test (for DVLA), start relapse prevention work, reduce and possibly stop aripiprazole. The two children were noted to be a ‘protective factor’. There was no further exploration of her care of her nephew. A medical review was planned at six months.  Summary statement 19 She was noted to be at risk of relapsing if she stopped her medication, yet there was a plan to reduce and possibly stop. The team could have helped her to manage any physical symptoms, and consider the risks and benefits of reducing and stopping medication. Summary statement 20  Outcome measures were used at the CPA meeting, to provide an objective measure of mental health. There was no objective measure of psychosis symptom reduction completed.   2.83 In November 2017 Mother requested to stop taking aripiprazole. The consultant psychiatrist advised against it but suggested she reduce to 5 mg every second day. Contingency plans were agreed, early warning signs were identified as believing people are looking at her, and coming into the house. It was agreed she would start relapse prevention work, and either she or Grandmother would call the team if they  24 have any concerns about her mental health. There was no review of possible effects in the children.  2.84 On 1 Dec 2017 seen at home, was looking after her three-year-old nephew who was asleep. There was no discussion about this. Mother said she had a urinary tract infection, which she maintained had also happened when she stopped medication earlier.35   2.85 Mother’s initial diagnosis in 2017 was ‘non-organic psychotic disorder’, and there was no differential diagnosis developed as the team became more familiar with her. There is no evidence that this was discussed with Mother or her parents in any depth, to help them understand the diagnosis. The reason why this is so relevant and important in this case is that there is evidence in terms of the implications of a diagnosis of schizophrenia for parenting. If this diagnosis had been made, and if staff had appropriate training in child risk and safeguarding, the diagnosis itself should prompt a thorough assessment of potential risk to children. Also we consider that if she had the diagnosis the family may have been able to give more thought to the impact on the children, and professionals could have considered the emotional impact of the children of living with a parent with a diagnosis of schizophrenia.    2.86 The NICE guidance (2014)36 for the management of psychosis and schizophrenia now focusses on each stage of the person’s psychotic illness:  • Preventing psychosis • First episode psychosis • Subsequent acute episodes of psychosis or schizophrenia and referral in crisis • Promoting recovery and possible future care  2.87 The referral to ESTEP provided the opportunity for treatment within national guidance; the NICE guidance for the management of psychosis and schizophrenia recommended these standards for psychological interventions:  2.88 ‘Psychological interventions: CBT should be delivered on a one-to-one basis over at least 16 planned sessions and: follow a treatment manual so that:  • people can establish links between their thoughts, feelings or actions; and their current or past symptoms, and/or functioning; • the re-evaluation of people's perceptions, beliefs or reasoning relates to the target symptoms;  also include at least one of the following components:  • people monitoring their own thoughts, feelings or behaviours with respect to their symptoms or recurrence of symptoms; • promoting alternative ways of coping with the target symptom; • reducing distress; and  35 Mother has a twenty year history of recurrent UTIs. 36 Psychosis and schizophrenia in adults: prevention and management. https://www.nice.org.uk/guidance/cg178  25 • improving functioning.   2.89 Family intervention should:  • include the person with psychosis or schizophrenia if practical • be carried out for between 3 months and 1 year • include at least 10 planned sessions • take account of the whole family's preference for either single-family intervention or multi-family group intervention • take account of the relationship between the main carer and the person with psychosis or schizophrenia • have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work’.  2.90 Mother had regular input from the care coordinator, described as ‘supportive monitoring of her mental health and response to medication’. The interventions documented are of a generally supportive nature, and are not linked to the evidence based interventions as described. Family therapy was offered and refused, and carers assessments were offered and refused.  2.91 The guidance on medication in the 2014 NICE guideline was:   ‘The choice of antipsychotic medication should be made by the service user and healthcare professional together, taking into account the views of the carer if the service user agrees. Provide information and discuss the likely benefits and possible side effects of each drug, including:  • metabolic (including weight gain and diabetes) • extrapyramidal (including akathisia, dyskinesia and dystonia) • cardiovascular (including prolonging the QT interval) • hormonal (including increasing plasma prolactin) • other (including unpleasant subjective experiences)’  2.92 There is clear evidence that medication and its effects and side effects were discussed many times with Mother. The GP was not involved however in these discussions. Her physical observations were recorded in May 2017 and again in December 2017. As discussed earlier, her assertions that aripiprazole caused her to have infections and hyperthyroidism were not challenged.   Summary statement 21 There was a lack of a structured evidence-based approach that would be expected from an EIP service, which should also consider differential diagnoses.   2.93 It was noted at a review in November 2017 that Mother had stopped taking aripiprazole, and had no psychotic symptoms. A medical review in May 2018 noted that she had remained medication free and had no psychotic symptoms. Her risk to  26 other and to herself was regarded as low, and the contingency plans relied on her telling Grandmother that she was unwell, or either herself or Grandmother calling ESTEP.   2.94 This review stated that she had been ‘symptom free’ since June 2017. We question the accuracy of this: she talked of “illuminati who run mental hospitals and control everyone’s life” in July 2017; in August 2017 she believed chemicals were coming through her bedroom walls which caused Child R to wet the bed and were poisoning the family; and in November 2017 she maintained that her physical health had worsened on aripiprazole, including causing lumps in her neck, and that this had caused difficulty in swallowing and hyperthyroidism.    2.95 It was clear that Mother still believed that her psychotic symptoms were caused by her stopping cannabis abruptly. Part of her relapse prevention plan was to ensure she sought help if she was having difficulty abstaining from cannabis use.  Family communication/responsiveness of services   2.96 The family did not agree to meet us as part of this review, therefore our observations are limited to information contained in the clinical records or through interviews with staff and Mother.   2.97 The ESTEP MDT review in May 2018 noted that family therapy was offered and refused, and carers assessments were offered and refused. The care coordinator  had contact with Grandmother when she made contact to express concerns about Mother. The coordinator called Grandmother on at least one occasion to ask for more information about Mother’s presentation when there was a concern.   2.98 It is evident from the records that Mothers sister was very concerned about her at the ESTEP initial assessment in March 2017. There is a record of the staff member offering the sister an opportunity to talk more about this, but there is no further reference to gathering collateral information from family members.  2.99 Grandfather does not appear to have been present at any point when staff met Mother.  It appears that an assumption was made that Grandmother was seen as a protective factor, however Mother clearly had primary responsibility for the children. Grandmother worked full time so was not at home with the children for much  of the time. Grandmother was invited to a carers’ information evening in July 2017, a response was not recorded.    2.100 The coordinator never met either Child R or his brother, apparently at the request of Mother. There does not appear to have been any challenge or curiosity about this.37 Clinicians have documented that there is nothing evident to trigger concern about parenting  There were no comments on when concerns might arise e.g. when her functioning deteriorates or when her psychotic symptoms become more florid.  2.101 A 10 day holiday to Jamaica with her partner was planned in June/July 2018. Mother called ESTEP in early July and was then not contactable when staff called her back,  37 Serious case reviews highlight the importance of professionals being able to see the children.  27 Grandmother called a few days later to say she was concerned that Mother’s paranoid beliefs about conspiracy theories were still there, and now thought she was unwell but putting on a front.  2.102 Attempts were made to contact Mother which were unsuccessful. Grandmother called back and asked for her to be seen. Accounts of the details of the communication over the next few days differ: Grandmother has stated that asked for Mother to be seen, but it was recorded that Grandmother said it could wait until her care coordinator was available.    2.103 On 20 July 2018 Grandmother took Mother to A&E at Southend Hospital as she was experiencing a relapse of psychosis with similar symptoms as previously. She was seen by the Mental Health Liaison Team and following the contact it was advised that they request that the GP restarted the antipsychotic medication.   2.104 It is acknowledged in the internal investigation report that the Mental Health Liaison Team missed an opportunity to treat Mother who was clearly showing signs of a relapse of her psychotic illness. The report also states that the Mental Health Liaison Team should have considered admission to a psychiatric unit or requested an assessment under the Mental Health Act 1983 in order to prevent further deterioration of her mental illness. There is no comment on the assessment of risk to children, considering she was presenting with psychotic symptoms, and was the main carer to her children.  2.105 There was no handover to the GP or ESTEP in the morning. We consider that the team should have asked for a clinical review the next morning rather than relying on GP to prescribe antipsychotic medication. As Mother had relapsed, we believe ESTEP should have made arrangements to assess her the next day. This was another missed opportunity to initiate treatment for the psychotic episode. Grandmother contacted the ESTEP team to make them aware of the presentation and that Mother was back on medication. It was documented that Grandmother agreed for the care coordinator to make an appointment the following week, when the care coordinator returned from holiday. We have been informed that Grandmother has told the SCR lead author that she had a different recollection of this conversation.   2.106 ESTEP missed a further opportunity to reassess Mother after being informed that she had restarted medication. Mother told us that she had been smoking cannabis in Jamaica, and described continuing to use cannabis after her return from holiday a few weeks earlier. Summary statement 22 The views of family and carers should have been sought to ensure there was an opportunity for the family to be listened to, and a more holistic assessment made that incorporated their perspectives. Liaison services should routinely ask about caring responsibilities  for children and ensure there is a safe plan for the care of the children if sending a parent with a psychotic illness home.  28 3. Overall analysis and recommendations Findings and recommendations 3.1 Mother had been under the care of secondary mental health services since March 2017, after an initial short contact in 2014.   3.2 Her diagnosis in 2017 was ‘non-organic psychotic disorder’, and she was treated by the ESTEP team. There was no differential diagnosis developed as the team became more familiar with her, despite symptoms  from 2017 warranting a diagnosis of paranoid schizophrenia. There is no evidence that this was discussed with Mother or her parents in any depth, to help them understand the diagnosis and consider contingency plans if she was in need of urgent support.   3.3 Mother had a diagnosis of fibromyalgia, and was reluctant to take conventional medicines to treat this. This reluctance also applied to taking psychiatric medication, and she continued to use cannabis which she believed helped with pain control. She attributed an increase in physical symptoms to her psychiatric medication, and this was accepted at face value by the ESTEP team, without exploration with either Mother, the family or the GP.  This contributed to some diagnostic overshadowing, and a lack of consideration that an assessment of negative symptoms of schizophrenia was needed as well as the impact of these on her daily functioning and ability to meet the needs of her children.   The assessment of risk did not include any exploration of the makeup of the household, or potential risks to her children. Her children are noted to be ‘protective factors’ without any depth of assessment, and in our view there was a complete lack of consideration of the children’s need and their safety. The extent to which they were involved in her delusional and paranoid ideas was not explored.   3.4 There are many factors in this case which raise significant concerns that the children were at risk and that a referral to Children’s Social Care should have been made including:   (a) The children clearly featured in Mother’s delusional belief system at various times and this alone should have prompted an urgent referral to Children’s Social Care, and a safeguarding alert raised.   (b) Mother’s poor level of functioning should have been more thoroughly assessed given her history of being bedridden. Even with the information available this indicated a potential risk to the children of physical and emotional neglect.  (c) Her history of aggressive behaviour indicates a potential risk of physical harm which warranted further assessment.  (d) The emotional harm caused by living with a parent with significant paranoid and suspicious thoughts needed further assessment.  (e) The combination of serious mental illness, substance misuse and a history of domestic abuse in this family should also have raised concerns. This ‘toxic trio’ is commonly a feature of child serious case reviews.  29 (f) assumptions should not be made about other potential carers being protective factors without an assessment of their availability and suitability to meet the needs of the children.  (g) the importance of being able to see the children has been highlighted in serious case reviews. (h) the new partner was not assessed which is important when there is a history of domestic abuse in previous relationships.  (i) children presenting with aggressive behaviour and bedwetting and reporting concerns to adults suggest the possibility that they are being affected by the situation at home.  3.5 Mother was known to be at risk of relapsing if she stopped her medication, yet there was a plan to reduce and possibly stop this, based on her dislike of taking antipsychotics. The team did not explore her reluctance in any depth, nor try to introduce other medication with a different side effect profile.  3.6 When Mother was reported by family to be showing signs of relapse, there was no structured team approach, such as a traffic light system. In our view the care and risk management plans were not effective in treating her condition or mitigating risk.  3.7 The views of family members were not routinely sought, and actions were not taken on family views where they were provided.   3.8 EPUT has clear policies that include the expectation of a holistic assessment of mental state and risk, a ‘Think Family’ approach, and guidance which encourages staff to consider risk where children are involved in parental delusional systems.   3.9 The internal report into this tragic event was completed in September 2019, 14 months after the death of Child R. The recommendations were not outcome focussed.    3.10 The SCR has made eight recommendations for health services which we endorse (SCR recommendations 3,4,5,7,8,9 and 10) and we have made three individual recommendations.     30  Recommendation 1  EPUT must ensure that Early Intervention Services meet the expectations of best practice guidance and standards.  Recommendation 2 EPUT must ensure the community mental health teams have a structure and systems for responding to relapse or increase in risks, such as a clinical ‘traffic light’ rating tool.   Recommendation 3 EPUT must ensure that internal investigation reports meet the timeliness standards expected by the NHS England Serious Incident Framework, and that recommendations are outcome focused.    31 Appendix A – Terms of reference This investigation was to be conducted in partnership with the Serious Case Review Terms of Reference.  The investigation will examine the NHS contribution into the care and treatment of Mother from her first contact with specialist mental health services following the birth of child up until the date of the incident.  Additional health related Terms of Reference: • Critically examine and quality assure the NHS contributions to the Children’s Serious Case Review  • Examine the referral arrangements, communication and discharge procedures of the different parts of the NHS that had contact with Mother  • Review and assess compliance with local policies, national guidance and relevant statutory obligation • Examine the effectiveness of the service user’s care plan and risk assessment, including the involvement of the service user and her family • Examine the communication with the service user and her family in the lead up to the homicide and the responsiveness of services • Review the appropriateness of the treatment of the service user considering any identified health needs/treatment pathway • To work alongside the Children’s Serious Case Review and Chair to complete the review and liaise with affected families • To provide a written report jointly with the Serious Case Review report to the Safeguarding Board and NHS England that includes measurable and sustainable recommendations to be published either with the multi-agency review or standalone   32 Appendix B – Internal report analysis         Standard  Present  Theme 1: Credibility  1.1 The level of investigation is appropriate to the incident Yes  1.2 The investigation has terms of reference that include what is to be investigated, the scope and type of investigation  Yes 1.3 The person leading the investigation has skills and training in investigations  Yes 1.4 Investigations are completed within 60 working days  No 1.5 The report is a description of the investigation, written in plain English (without any typographical errors) Yes 1.6 Staff have been supported following the incident Yes   Theme 2: Thoroughness  2.1 A summary of the incident is included, that details the outcome and severity of the incident  Yes 2.2 The terms of reference for the investigation should be included  Yes 2.3 The methodology for the investigation is described, that includes use of root cause analysis tools, review of all appropriate documentation and interviews with all relevant people Yes 2.4 Bereaved/affected patients, families and carers are informed about the incident and of the investigation process Yes 2.5 Bereaved/affected patients, families and carers have had input into the investigation by testimony and identify any concerns they have about care Yes 2.6 A summary of the patient’s relevant history and the process of care should be included  Yes 2.7 A chronology or tabular timeline of the event is included  Yes 2.8 The report describes how RCA tools have been used to arrive at the findings  Yes 2.9 Care and Service Delivery problems are identified (including whether what were identified were actually CDPs or SDPs)   Yes 2.10 Contributory factors are identified (including whether they were contributory factors, use of classification frameworks, examination of human factors)  Yes 2.11 Root cause or root causes are described  No 2.12 Lessons learned are described  Yes 2.13 There should be no obvious areas of incongruence Yes 2.14 The way the terms of reference have been met is described, including any areas that have not been explored Yes   Theme 3: Lead to a change in practice - impact Yes 3.1 The terms of reference covered the right issues Yes 3.2 The report examined what happened, why it happened (including human factors) and how to prevent a reoccurrence Yes 3.3 Recommendations relate to the findings and that led to a change in practice are set out  No 3.4 Recommendations are written in full, so they can be read alone  Yes 3.5 Recommendations are measurable and outcome focused No        