Review of three cases involving adolescent self-harm, including a young person who attempted suicide in 2021. Themes include: professional fears around challenging conversations with young people on self-harm being rooted in a fear of making situations worse; if foster carers are equipped and supported when taking on a young person who self-harms; issues around risk management plans and working collaboratively to find the best support for a young person; issues of working across boundaries, including young people being registered for services in a different borough and in relation to child and adolescent mental health service (CAMHS) provision; if therapeutic interventions are focused enough on the impact of adverse childhood experiences; lack of knowledge or experience in discussing gender identity with young people. Recommendations include: review working practices to improve the confidence and ability of practitioners to have difficult conversations that focus on mental health; adolescents are able to have agency over their own risk management plans; training on gender identity and what this means for young people; support parents struggling with self-harming behaviour; support the training of foster carers in understanding self-harm and risk management; the young person and their parent/carer have continued access to a CAMHS clinician regardless of where they are living; agree a mechanism for managing risk across agencies; ensure gender identity is a key strand of equality action planning across all agencies.
      
 Title:  Thematic child safeguarding practice review – child and adolescent mental health (Young Person H and others). LSCB: Ealing Safeguarding Children Partnership Author: Ealing Safeguarding Children Partnership Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1     Thematic Child Safeguarding Practice Review – Child and Adolescent Mental Health  (Young Person H and others)  Introduction   This review was conducted to consider three cases involving adolescent self-harm, occurring in close time proximity to each other; alongside young people involved in the Partnership reporting the daily struggles of young people with their mental health. This led us to the view that reviewing the cases would promote further improvement and learning. Only one of the cases met the criteria for a Rapid Review as defined in the Guidance, however, a Rapid Review was convened in a second case that, while not meeting the criteria, provoked a high level of professional anxiety regarding the ability to manage risk.    This Review was conducted in accordance with the requirements set out in Working Together 2018 and is written with the intention of publication.   Process   In completing this Review, a number of key elements were employed to understand the experience of the three young people with services and to reflect on the challenges relating to adolescent mental health for practitioners and for young people. This included the following:   1. Individual agency reports to inform of services’ involvement  2. An event with practitioners to explore the issues raised and to consider issues around risk and professional anxiety that such cases bring  3. A number of events with young people to discuss mental health services and to determine their perspective on the services provided. These events were coordinated by the Youth Service and supported by the Young Ealing Safeguarding group.   The reason for the Child Safeguarding Practice Review (CSPR) Learning Event:   In 2021, information was received by children’s social care that a young person was found in their room by a fellow resident choking / having breathing difficulties having consumed unknown substances. They had several cuts and scratches to their body, both new and older; their body was covered in black paint or ink, as was their room. They left a ‘suicide’ note  A panel of senior multi agency professionals was convened to consider the criteria for a CSPR in Working Together to Safeguard Children 2018. It was at this panel that two other  2  young people were discussed as each had common features. In addition, all presented professionals with high levels of anxiety around managing risk. It was decided to conduct a single local Child Safeguarding Practice Review and learning event regarding all three young people to identify learning and to improve arrangements to safeguard and promote the welfare of children. One of those young people was also subject of a separate Rapid Review.   The three young people:   • Young person A was born in the UK in 2004, their mother and father being from different middle Eastern countries. Young person A was born female but in November 2020 stated that they identified as non-binary and wanted to be referred to as ‘they’ or ‘their’. They also changed the name they wished to be known by.  They has been looked after by the local authority since August 2016.  • Young person B was born abroad in 2004. They were a few days old when they came to be cared for by their adoptive parents, the adoptive parents knowing a friend of the birth mother. The adoption was later formalised. The family moved to the UK in 2016. In September 2019 the young person first came to the attention of Children’s Social Care when they became looked after by the local authority, subsequently returning briefly to the care of their adoptive parents, before returning to the care of the local authority.   • Young person C was born in the UK in 2005, their ethnicity is white. Young person C was born female but over the summer of 2021 they stated that they now identify as non-binary and wish to be known by another name. They have four siblings; their mother has a disability resulting in communication challenges.  They have an Education, Health and Care Plan and are on roll at a school for young people who require social and emotional support.   Legal framework and methodology for the review The ESCP’s statutory and relevant agency partners agreed to conduct a local CSPR with a thematic element to include three young people with common features. • It was agreed for a collective Child Safeguarding Practice Review (CSPR) learning event with all the professionals involved to be led by John Churchill, Acting Assistant Director from Children’s Social Care, Thomas Webster, Named Nurse Safeguarding Children and Young People from Health and Sheila Lock, Independent Chair and scrutineer of the Local Safeguarding Children Partnership.   • A large quantity of multi-agency information was gathered in the initial stages of the review to support the practitioners’ learning event. The learning event was to identify learning to improve arrangements to safeguard and promote the welfare of children.   • The practitioners learning event took place virtually in December 2021, attended by 42 professionals from 15 organisations.  3  • Young people undertook sessions under the leadership of the YES group  Common features of cases for consideration These notes are a summary of the information drawn from the submissions of partner reports and from the commentary and the direct contributions of those attending the learning exchange events. It is clear that in all three cases there are  common features of the cases that merit discission  • They all involved adolescents  • They were all born female  • There were challenges around identity, particularly sexual identity  • Sexual abuse had been reported in the past and had gone largely unaddressed  • All displayed significant episodes of self-harm which was escalating  • All were - or had been - in the care of the LA  • All cases presented considerable concern to professionals regarding the ability to effectively plan and contain risk    Key themes of the review practitioners learning event It is clear in the analysis of the learning reports supplied by agencies that all three young people presented issues in relation to their home circumstances that necessitated them coming in the care of the Local Authority. Self-harm and challenging behaviour were central to increased parental concern regarding their ability to keep their child safe from the risk of serious injury or death. Managing such risk and working to reduce it, are significant challenges for professionals also, and in each of the three cases professionals reported feeling anxiety that they could not mitigate out the risk for these young people.   Underpinning this fear was a sense of an expectation that children being cared for by the state would be ‘safer’ and that, as professionals, in serious self-harm cases, this could not be a given. The review recognised that even the most detailed plan with strategies to ensure supervision could not prevent instances occurring. The young people went to considerable and determined lengths to cause injury to themselves. At the root of professional concern was a real sense that ultimately in the event of injury or death, they would be held responsible, despite best efforts.   There were a number of key areas that emerged in the discussion and the chat around these cases. These issues triangulate with the discussions held amongst young people around self-harm and adolescent mental health These are set out with a short narrative below:  a. The understanding of adolescent behaviour and risk taking The discussions with professionals and young people focused on the need to understand the development of adolescent brains, and the appetite for increased risk taking, alongside the development of behaviour to self-regulate that risk. There  4  was a view that the challenging behaviour of adolescents creates challenges for professionals, and, as a consequence, adolescents feel unheard and not seen. Risk means often the behaviours aren’t explored or discussed. For professionals the fear around the challenging conversation about self-harm is rooted in a deep fear of making the situation worse. For young people, not talking about such issues deepens a sense of not being cared about or listened to. The reality is – if someone is self-harming and is risking life changing injury or death, what worse can happen?   b. Holding case risk  This is an area of considerable exploration and discussion. There was a recognition of anxiety for professionals in relation to escalating self-harm and the unspoken fear that a child /young person might die from escalating activity. The culture of ‘blame’ was explored and recognised as a factor. The inability to mitigate or fix risk was discussed and acknowledged, alongside the challenge of how we accurately record such risk. In such cases professionals are left with a position of recognising that it is impossible to mitigate 100% of risk in such cases, and that this is something that alongside our professional responsibilities we must live with.   c. Planning and managing risk  In the discussions and using the written submissions, the issues around holding case risk, planning and assessment were explored and acknowledged. A number of issues and areas of challenge and potential improvements were noted, including:  • Any significant change /incident should trigger more effective multi-agency planning and collaboration to share understanding of the presenting issue  • Before changing a plan significantly, i.e., a placement, are we asking: what has changed to make this a viable proposition? Or are we being driven by available resources rather that the needs of the young person?   • Are we effectively managing risk through strategy discussions when the risk is an allegation of a new kind of abuse on an open long-standing case?  It was concluded that reflecting on these issues in our planning framework was important, reminding professionals of the need to collaborate and share decision making in high-risk cases.   d. What does care look like for this group  There was considerable discussion to consider the ‘ask’ we are making of foster carers in these situations: do we prepare, equip, and support them sufficiently with the reality of the risk they are taking on with a young person who self-harms? The responsiveness of our local approach to a crisis and potential breakdown in foster care was considered, alongside a discussion about who is the client in these cases. Is it the young person? Or is it those trying to support the young person? Or is it both?      5  e. Collaboration in risk management was discussed  There was a view that in not planning effectively around risk management plans we don’t communicate and distribute risk across the system; this in turn means we are not working collaboratively to find the best support for the young person. It also means the risk sits disproportionately with one agency.   f. Cross boundary working  The complexities of regional arrangements, particularly in health were explored. The issue of working across boundaries was discussed, in particular, the challenges of being registered for services in a different borough to the residing borough, or in relation to the provision of CAMHS. The Integrated Care System and ensuing changes prompted a conversation regarding the protocols that should operate to ensure no one falls under the radar.   g. Appropriate therapeutic intervention  There was a discussion around therapeutic intervention and the assessment of the model to be deployed and its focus. Is it focused enough on the impact for young people with adverse childhood experience(s) was a critical and live question. The suggestion was that, too often, the impact of history on current mental state goes largely unexplored and that we could do more to ensure that this is recognised as being an underlying factor in current behaviours.  h. Understanding health and health passports  The discussion focused on whether health professionals did enough to ensure that mental health was given parity with physical health in the health passport. It was felt young people could be given more accessible tools, including the app to help ensure they were the drivers of information held about them. In addition, using technology to encourage young people to check in on feelings and moods was considered as an opportunity to open up greater dialogue.  i. The complex nature of young people who self-harm and risk  The multitude of professionals involved, illustrated by attendance at the learning events, was a feature that impacts on communication and planning, and that was recognised, particularly as some services are not borough-based. Ensuring one point of contact for young people was considered something that professionals should explore more effectively, recognising that this should be determined by young people and based on trust. The use of advocacy and the concept of care navigators were explored in trying to ensure the voice of young people was at the forefront.   j. The challenge of parenting a child with mental health difficulties  In many ways this is linked to the earlier points about responsiveness and supporting the right people to offer care. It was recognised, though, that managing anxiety and risk and its challenges, as articulated by professionals, is the same challenge parents face. They often have little by way of skills and experience, and feel significant anxiety when a child  6  starts to self-harm. Supporting those parents through training, information, advice, buddying and peer support, alongside engaging them fully and acknowledging their concern was felt to be important. The issue of respite was also a feature of the discussion - short break schemes akin to services for children with a disability.   k. Gender identity  There was an acknowledgement of the lack of knowledge, skill or experience in discussing this with young people and of the key part it plays in adding to young people’s sense of belonging and identity. Professionals highlighted the complexity of gender identity and the ability of professionals to keep abreast of this as part of the agency approach to equality and diversity. While recognising this is part of the piece around challenging conversations, it is also a key strand of equality training. Professionals considered that they want to operate in a climate of respect and inclusivity and that without exploring the issues for themselves safely they harbour a fear of getting it wrong. Young people were of the view that they have something to bring to the table in raising awareness and training professionals on these issues, based on their experience.   l. The ability of the system to be responsive and to share and manage risk at an operational /strategic level  The professionals group considered the concept of a dynamic risk register / risk panel to keep a multi-agency response to these young people high on the agenda. Professionals felt that such an approach would promote greater ownership and awareness, create more proactive responses and improve risk oversight.   Key themes to consider in next steps  A comprehensive action plan in response to this learning will be attached, but in the spirit of co-production, this will be produced following further collaboration with those commissioning services as well as with practitioners and will include collaboration with young people.  a. Upskilling our workforce  • Confidence to have difficult conversations, knowing sometimes that will reduce risk and does not increase it  • Making sure IROs bring challenge to allegations that haven’t been pursued, particularly around CSA • Focused learning on gender identity – using lived experience of young people where possible • Making sure equality planning considers learning regarding gender identity  • Developing professional curiosity and asking the right things  • Understanding collective role as corporate parents      7  b. Recording of unmitigated risks  • Reminding professionals not all risk can be managed away and those areas that cause ongoing concern should be captured    c. Developing our collective responsibilities • Planning  • Assessment  • Listening to each other with respect  • Validation of all contributions being important   d. Reinforcing the voice of young people • Ensuring young people know their plan • Giving young people agency over their own plan • Providing a rationale to young people when it is not possible to safely act on their wishes   Conclusions from the review practitioners learning event There were a number of conclusions and reflections from consideration of these three cases. Attendance at the events and including young people’s views suggest that this was experienced as a useful and worthwhile approach.   a) The common features of the self-harm cases • All three were born female • All three highlighted issues around gender identity  • All three have alleged being sexually abused • All three became looked after by the local authority  b) We should not focus on introducing new things, but instead strengthen the process and policies we have, but perhaps remind people of the points above     c) If we do have new things, we should limit them to be effective to include  • A focus on upskilling people to have difficult conversations /talk about difficult issues  • A focus on professional curiosity  • Building skills and knowledge around gender and identity  • Supporting professionals to recognise that you cannot mitigate against 100% of risk    8  Recommendations  A number of key recommendations emerge from this work and should be considered further by the Ealing Safeguarding Children Partnership:    Recommendation 1 - Understanding and managing the risk • Reviewing working practices to improve the confidence and ability of practitioners to have difficult conversations that focus on mental health  • Dynamic risk management as Corporate Parent, including social work team and foster carers  Recommendation 2 - Improving our engagement and plans for young people  • Having the young person at the centre of the plan – adolescents are able to have agency over their own plans.  • IROs to challenge practice to ensure young people are owning their own plans  • Shared ownership of the plan to ensure all involved know and support this plan • Specific training to be provided on gender identity and what this means for our young people  Recommendation 3 – Improving Engagement and plans with parents and carers  • Supporting parents struggling with self-harming behaviour so that care is not always seen as the solution to managing risk  • Supporting the training of foster carers in understanding self-harm and risk management   Recommendation 4 - Strategic • Young person and their parent or carer to have continued access to a CAMHS clinician regardless of where they are living as part of the corporate parent offer • Agree working practices to ensure the location of young person’s GP is not a hindrance to continuity of CAMHS access  • Agree a mechanism for managing risk across agencies, through exploration of a Dynamic Risk register • The partnership must ensure that gender identity is a key strand of equality action planning across all agencies and that it is a feature of workforce training     9  Post-script – case study During the course of this Review, professionals have continued to work with the three young people involved.  In respect of one young person, they moved home over three months ago and there has been no hospital admittance during that time; and there has been no self-harming. There is support provided in the home, although this has reduced. The young person has been able to return to mainstream school and receive support from CAMHS.  There are challenges, but there are some very good days too. The young person has been able to develop friendships at school and enjoy the normality of school life as well as being able to go shopping with friends. The young person’s relationship with the parent they live with is also improving helped by time they spend together walking. (25.3.22)    