Death by suicide of a 17-year-old young person in 2016. There were over 30 multi-agency contacts or events involving the young person and/or their close family in the ten month period prior to the young person's death. Professionals saw no self-harming behaviours or ideation in the young person. Key lessons: the need to further develop the knowledge and skills in understanding and responding appropriately to adolescents and young people at risk of self-harm; to review how agencies fulfil their statutory obligations by recognising a 17-year-old as a child and ensure the child's voice and views are key elements in the decision-making process; training to enable practitioners to be confident in recognising the impact of religious, ethnic and cultural influences; the need to actively promote support and advocacy services for young carers; to understand communication needs particularly in families whose first language is not English. There are no recommendations in this learning summary.
      
    Serious Case Review No:  2018/C7417  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.                 1  Learning Summary  Context In 2016 a 17 year old Young Person ended their life. The resulting independent review considered how professionals responded to in excess of 30 multi-agency contacts/events involving the young person and/or their close family in a 10 month period prior to the young person’s death. In this particular case professionals saw no indication of self-harming behaviours or ideation exhibited by the young person.   Key learning points from the serious case review:  1. The need to further develop the knowledge and skills of staff in understanding and responding appropriately to children who are at risk of self–harm, particularly adolescent children and young people.   2. Agencies need to review how they fulfil their statutory obligations by recognising a 17 year old as a child and ensuring that the child’s voice and views are key elements in decision making processes.  3. Staff training should enable practitioners to feel confident in their ability to recognise and understand the impact of religious, ethnic and cultural influences and how these elements might add additional factors to consider within already complex family relationships. Examples include understanding the dynamics of sibling and interfamilial emotional and domestic abuse and adult mental health.  4. The need to actively promote support and advocacy services to raise awareness of their availability to young carers and improve children’s ability to readily access these services.   5. The need to understand the communication needs of all within our community and to conduct regular reviews of communication services to identify any gaps in provision. Scoping should include the appropriate use of interpretation services using a variety of approaches (such as face to face and telephone interpreting services, visual aids/translated documents, sign language and websites).  Practitioners should be able to readily access these aids to help them to work effectively with families whose first language is not English, including BME communities where individual family members may have particular communication needs. 6. It is essential that agencies are able to communicate with each other securely in the knowledge and confidence that action is going to be promptly taken. Agreed secure systems and effective inter-agency communication is essential to ensuring that delays in responding to incidents are kept to a minimum.   