Death of an adolescent boy by apparent suicide in May 2017. Laurie and siblings had been looked after by the local authority since 2011. Laurie refused to return to foster care placement and moved to mother and stepfather's home. Children's social care undertook a placement with parent ("P") review, recommending that return home should be supported but closely monitored. Laurie was arrested three times between 2015 and 2016 following threats to mother and stepfather. Assessed by Child and Adolescent Mental Health Services (CAMHS) but declined further involvement. Case was transferred to the leaving care service as Laurie approached sixteenth birthday. Several instances of self harm but no referrals to CAMHS or GP. Inquest into Laurie's death pending. Ethnicity and nationality not specified. Findings include: family support for Laurie's mother and stepfather was overlooked; the leaving care service's assumption of primary responsibility was premature; there is no evidence that any agencies looked into why Laurie did not engage with services; and responses to self harm and suicidal ideation were inconsistent. Recommendations include: obtain assurance that the looked after child review process is robust; request that children's social care share the outcome of their placement with "P" procedures review; disseminate the learning from this case review to stress the importance of recording and appropriately responding to incidents of self harm; develop a multi-agency policy for services experiencing difficulty in engaging children and families; and learning from this case review should inform any review or process for developing the local suicide prevention strategy.
      
 Title:  Executive summary of a serious case review in respect of a young person ‘Laurie’. LSCB: Wakefield District Safeguarding Children Board Author: David Mellor Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                             1       Executive Summary of a  Serious Case Review  in respect of a young person  ‘LAURIE’          David Mellor Review Facilitator & Author   August 2018    2 1. Introduction  1.1 On 1st May 2017 a young person who will be referred to in this report as Laurie died after apparently taking his own life. At the time he had been in the care of Wakefield Council since 2011 although placed in the care of his mother and step father since 2015. An inquest into Laurie’s death will take place in due course.  1.2 Following Laurie’s death, Wakefield and District Safeguarding Children Board decided to conduct a serious case review (SCR). The Safeguarding Children Board commissioned David Mellor to be the lead reviewer for this SCR. He has several years experience of conducting SCRs and has no connection to Wakefield or any of the agencies involved in this case.   1.3 Laurie’s mother and step father, his girlfriend and Laurie’s previous foster carers contributed to this review.  2. Brief summary of the case  2.1 In 2011 Laurie and his siblings became looked after by the local authority. Laurie spent almost five years in a successful foster care placement. During the early months of 2015 Laurie began to express the wish to have more contact with his birth family and talked of returning to them permanently.  2.2 In July 2015 Laurie refused to return to his foster care placement and moved to his mother and step father’s home. This led to the urgent completion of a Placement with Parent (“P”) assessment under the Care Planning, Placement and Case Review (England) Regulations 2010. Given Laurie’s age and understanding together with improvements within the life of mother and step father, it was recommended that Laurie’s wishes should be supported but that his return home closely monitored.   2.3 Laurie continued to be supported by the Looked After Children (LAC) team and statutory visits and reviews took place as previously. It was recommended within the Placement with P report that six weekly multi disciplinary meetings should be held to closely monitor Laurie’s placement, identify any support needs and provide additional support if required.   2.4 The view of Laurie’s independent reviewing officer (IRO) had been obtained which was that she would have preferred that Laurie remained in foster care and moved back to his birth family in a planned way.   2.5 During August 2015 a LAC review chaired by a new IRO took place at Laurie’s home. Laurie was said to be happy in the placement although ‘pushing boundaries’.  2.6 On 1st September 2015 Laurie was arrested by the police after threatening to stab mother and step father. Laurie was released from custody but re-arrested after making further threats to mother and step father. Whilst in custody Laurie was assessed by the child and adolescent mental health services (CAMHS) crisis team after threatening self-harm.   3 Laurie subsequently declined further involvement with CAMHS.  Laurie was referred to the youth offending team (YOT) for a youth conditional caution for an offence of affray arising from this incident.  2.7 During a LAC review in November 2015, Laurie was said to have settled back into the family home, was doing well in education and engaging with YOT. Support for mother and step father to manage Laurie’s behaviour was to be explored by the social worker.  2.8 The leaving care service became involved with Laurie as his sixteenth birthday approached. An assessment of Laurie’s needs took place in order to determine the advice, assistance and support to be provided after he left local authority care. A pathway plan was prepared and personal advisor appointed. Laurie’s case was transferred to the leaving care service in February 2016.  2.9 Also in February 2016 Laurie’s educational placement noticed marks on his arms and legs which were said to have been self-inflicted following a split with his then girlfriend. Although support was offered, no referral to CAMHS, the LAC nurse or Laurie’s GP appeared to be considered.   2.10 In April 2016 an IRO chaired LAC review took place at which Laurie was said to remain happy to be living at home and mother said that their relationship had improved. However, a referral to the intensive support team (IST) to provide family support to mother and step father remained outstanding but was not followed up.  2.11 In early May 2016 Laurie posted images of self-harm marks on his arm on Facebook accompanied by comments which suggested he was making progress in overcoming difficulties. His post generated largely positive responses but also attracted criticism. Laurie’s leaving care worker became aware and advised him to remove the images which were said to be ‘from three weeks ago’. No referral was made to CAMHS or Laurie’s GP.   2.12 The following day Laurie attended the local NHS Hospital Emergency Department with cutting wounds to his arm and chest following the end of a relationship with his then girlfriend. The wounds were diagnosed as superficial and he was discharged. Laurie’s GP received a notification in which the injuries were described as “trivial self-harm”. Laurie was referred to the emotional wellbeing team (EWBT) by his leaving care worker, although Laurie’s engagement with the EWBT was short lived.  2.13 In May and June 2016 mother sought support from NHS 111 and her GP to address Laurie’s behaviour which included self-harm. Laurie again declined a referral to CAMHS.   2.14 Also in June 2016 Laurie’s previous foster carer contacted children’s social care to express concern about Laurie’s relationship with mother. A period of respite was arranged for Laurie during which he stayed with the foster carer’s son in Chichester.    4 2.15 In September 2016 an IRO chaired LAC took place at which it was said that Laurie was happy to remain in the family home and that arguments had decreased.   2.16 In December 2016 Laurie was arrested after threatening mother and step father with a knife. He later appeared at court and a pre-sentencing report was requested. It was also agreed that Forensic CAMHS would complete a structural assessment of violence in youth (SAVRY) assessment followed by a review of Laurie’s mental health. (This assessment was completed just prior to Laurie’s death). Laurie was also referred to the young person’s drug and alcohol service and the YOT supporting families lead practitioner.   2.17 In January 2017 Laurie was sentenced to a referral order for 12 months and his case was allocated to the same YOT worker who had previously worked with him. YOT work with Laurie was to focus on controlling temper, knife awareness and family relationships.  2.18 Later the same month Laurie asked his college for a referral to a counsellor but there is no record of whether he saw a counsellor or not.   2.19 In early February 2017 Laurie declined his annual LAC health assessment for the third consecutive year. Around the same time a drugs worker conducted initial screening with Laurie during which he disclosed regular drug misuse.  2.20 The YOT supporting families lead practitioner visited Laurie, mother and step-father during February 2017 but mother and step father were said to be unwilling to engage at that stage. Around this time Laurie’s YOT worker and his leaving care worker began to feel that Laurie’s home circumstances were contributing to his risk of further offending and it was suggested that independent living should be considered.  2.21 A March 2017 LAC review was attended only by the IRO, mother and the leaving care worker. Significant conflict between Laurie and his mother was noted. Whilst it was concluded that Laurie should remain in his current placement, checks would be carried out into the suitability of Laurie staying at his girlfriend’s address. Laurie had been in a relationship with his girlfriend since before Christmas 2016 and had begun to stay at her house for several nights each week. There was no discussion of independent living for Laurie.  2.22 Later that month Laurie was assessed by the drugs worker who identified that Laurie may have been experiencing symptoms consistent with panic disorder (panic disorder is an anxiety disorder characterised by recurrent unexpected panic attacks).   2.23 During April 2017 Laurie was present during an incident of domestic abuse involving a sibling and her partner which Laurie reported to the police. Later that month Laurie’s girlfriend called an ambulance when Laurie was struggling to breathe after a panic attack.     5 2.24 During the late evening of 1st May 2017 step father contacted the ambulance service to say that Laurie had hanged himself from a tree not far from their address. Laurie was taken to hospital but was found to be dead on arrival.   3. Analysis  3.1 Placement with “P” Assessment Against very tight time pressures the placement with “P” assessment carried out by children’s social care was thorough and comprehensive in many respects. However, the potential impact of mother’s emotional difficulties on her parenting of Laurie should have been more fully explored. This may have led to more detailed consideration of the support mother needed to parent Laurie effectively.   3.2 The decision to place Laurie with his mother and step father Whilst children’s social care had several misgivings about the placement with mother and step father and the haste with which it became necessary to implement it, this placement was considered to be the lowest risk option available. Legal disruption of Laurie’s unauthorised presence in mother and step father’s home (e.g. harbouring notices) was rejected on the grounds that this course of action might prove counterproductive and could be harmful to Laurie.   3.3 Laurie’s foster carers were critical of the decision to place Laurie with mother and step father as Laurie’s contact with them had always been supervised and he had not had weekend leave with them either. In their view, going from this position to returning to live permanently with mother and step father seemed ‘too big a jump’.   3.4 Review of contact arrangements The need for an assessment of contact arrangements between Laurie and mother was identified in 2014 following concerns that mother was putting her needs ahead of Laurie. This assessment did not take place. Had it taken place, the assessment may have helped to improve the relationship between Laurie, mother and children’s social care and may have reduced the extent to which children’s social care found themselves reacting to events when Laurie’s foster care placement broke down.  3.5 The extent to which Laurie’s ‘voice’ was heard. Laurie’s return to the care of mother and step father accorded with the preference he expressed. Children’s social care arranged for the children’s advocacy and participation service to advocate for Laurie, although they were not asked to provide advocacy to Laurie during the placement with “P” assessment.  3.6 Monitoring of Laurie’s placement with mother and step father The placement with “P” regulations make it clear that where the child’s welfare is not adequately safeguarded and promoted by the placement, the local authority must review the case. (Regulation 30) There were several occasions when it was apparent that Laurie’s welfare was not being adequately safeguarded and promoted by the placement but there is   6 no evidence that the placement was reviewed as a result or that implementation of the placement breakdown contingency plan was considered.  3.7 Support for Laurie’s mother and step father The placement with “P” assessment recognised the possible future need for relationship work between Laurie and mother. Relationship work became necessary when the placement came under strain. The November 2015 LAC review proposed a referral to the intensive support team (IST) to provide family support to mother and step father with parenting strategies to manage Laurie’s behaviour but this was said to be ‘still outstanding’ during the April 2016 LAC review and not followed up thereafter.   3.8 Relationship work did not begin until the referral to the YOT supporting families lead practitioner following Laurie’s arrest in December 2016. This work was unsuccessful primarily because mother and step father were of the view that the work should be directed towards Laurie solely.   3.9 Children’s social care did not initially appreciate that Laurie’s return home fundamentally changed mother’s role from a parent who had only supervised contact with their Looked After Child to full time carer for that Looked After Child. The placement with “P” regulations state that the local authority must provide such services and support to the parent(s) as appear to them to be necessary to safeguard and promote the welfare of the child (Regulation 20).  3.10 The Looked After Child review process The IRO chaired LAC review process was the crucial point of collaboration between practitioners, Laurie and mother and step father. The process began constructively but meetings were not always fully informed of all relevant issues. When concerns were more fully shared, the actions proposed did not match the level of those concerns. Over time, attendance dwindled to mother and Laurie’s leaving care worker. Health practitioners including LAC nurses were not represented at any of the LAC reviews, nor was the YOT.  3.11 Laurie’s transfer to the Leaving Care service The point at which the leaving care worker became the primary worker for Laurie was premature. Laurie’s subsequent pathway plan lacked insight into Laurie’s background and the context of mother’s care. Despite moving to independent or semi-independent accommodation being identified in Laurie’s pathway plan in November 2016, no meaningful searches or services had been identified at the time of Laurie’s death in May 2017.   3.12 Engagement with Laurie and his family Children’s social care experienced difficulty in engaging consistently with Laurie. The placement with “P” regulations state that on each statutory visit the social worker must speak to the child in private. It is unclear whether this always happened. Children’s social care were unable to prevent some visits being taken up with discussing Laurie’s mother’s concerns.    7 3.13 The YOT worker’s approach involved taking Laurie away from the home environment which appeared to be successful. Consistency of worker also appeared to be an important factor in Laurie’s positive engagement with the YOT. Children’s social care have reflected on how their service could have considered engaging with Laurie differently and outside more traditional routes.  3.14 Laurie appeared to be resistant to engaging with therapy offered by CAMHS.  It is unclear whether any practitioner explored why Laurie was unwilling to engage with therapy. CAMHS respected Laurie’s wishes and discharged him from the service and provided information on how to refer back. The question of whether this is sufficient arises. Should ‘duty of care’ considerations indicate a need to go further? ‘Hard to engage’ procedures adopted by some local safeguarding children boards (LSCB) require cross agency communication at the point that an agency ceases to offer a service as a result of disengagement. (1)   3.15 The involvement of the LAC Nurse Service When Laurie began to decline annual LAC health assessments from 2015 onwards, the ‘LAC refusal pathway’ should have been followed. This pathway requires the exploration of all possible options to complete the assessment and the gathering of information about the child’s health from the information systems of agencies in contact with the child. Unfortunately, the pathway was not followed and the LAC nurse service took a narrow view of Laurie’s health needs, placing less emphasis on his mental wellbeing.    3.16 General Practitioner involvement Laurie registered with mother’s GP shortly after he returned to the family home. The GP practice was not informed about Laurie’s placement with “P”. The GP practice was also unaware of the Laurie’s lack of engagement with the LAC nurse. Had the GP been aware of this, they could have undertaken a more detailed assessment of his health needs to support the LAC health care plan.    3.17 Agency responses to self harm and suicidal ideation. The response of agencies to incidents of self-harm and suicidal ideation by Laurie was inconsistent. Some incidents were not fully documented or appropriately shared, one incident was trivialised and some incidents were referred to CAMHS whilst several were not. The risks that Laurie presented to others appeared to mask his risk of self-harm on occasions. Additionally, there is no evidence that Laurie’s accumulating history of self-harm and suicidal ideation was reviewed by any agency. This might have assisted practitioners to clarify triggers for self-harm such as relationship breakdowns which could have informed subsequent work to support Laurie.   3.18 A 2017 University of Manchester study Suicide by children and young people found that over half of young people who die by suicide have a history of self-harm (2) and although there are many antecedents of suicide in young people, the study considered self-harm to be a crucial indicator of risk which should always be taken seriously, even when the physical harm is minor. (3)   8  3.19 Good Practice Examples of good practice include Laurie’s successful long term foster placement and the support the foster carers provided to Laurie after the placement ended; children’s social care prompt and largely comprehensive placement with “P” assessment; efforts to support Laurie to remain engaged with education and training; the high degree of persistence and tenacity several practitioners demonstrated in engaging with Laurie and his family; the continuity of worker achieved by the advocacy service and the YOT; the voluntary engagement offered to Laurie by YOT when their formal engagement with him ended.  4. Findings and Recommendations  4.1 Support to, and monitoring of, Laurie’s placement with parents Laurie’s placement with parents was not successful. Children’s social care had misgivings from the outset but placing Laurie with mother and step father accorded with Laurie’s stated wishes and was considered to be the only viable alternative in the circumstances.  4.2 The placement got into difficulties from an early stage but family support was overlooked and was only finally put in place as a result of the referral order imposed nearly eighteen months after the placement began. This was far too late. Any optimism there may have been at the outset of the placement had long since dissipated and the YOT supporting families lead practitioner was unable to make progress. Overall, the perception that children’s social care held of mother as a parent who had problematic contact with Laurie, did not shift quickly enough to an appreciation that she was now parenting Laurie full time.      4.3 The leaving care service rightly became involved when Laurie reached 16 but that service’s assumption of primary responsibility for Laurie’s case was premature. This seemed to be a largely ‘automatic’ decision making process which would have benefitted from more careful consideration. Once the leaving care service began to manage Laurie’s case exclusively, the focus shifted to planning for independence when much work remained to be done to enable Laurie to thrive in his placement with mother and step father.   4.4 The IRO chaired LAC review process was not an effective vehicle for monitoring Laurie’s care plan. Multi-agency engagement fell away alarmingly and one of the consequences of this was that the LAC review meetings were not always fully informed of Laurie’s needs. However, the final LAC review was largely aware of the escalating concerns in Laurie’s life but the actions proposed were limited.  4.5 Practitioners who contributed to this SCR expressed the strong view that the IRO should be better supported to ensure the LAC review process effective and inclusive. They did not perceive the weaknesses in the LAC review process disclosed by this review to be limited to this case only. Additional administrative support may be required as well as an attitude shift amongst partner agencies to see LAC reviews as ‘must attend’ events.    9 Recommendation 1: That Wakefield and District Safeguarding Children Board obtains assurance that the LAC review process is robust and involves all relevant parties.  4.6 Children’s social care is to conduct a review of placement with “P” procedures with a particular focus on placement breakdown and family support. The LSCB may wish to be made aware of the outcome of this review.  Recommendation 2: That Wakefield and District Safeguarding Children Board requests children’s social care to share the outcome of their placement with “P” procedures review with them so that the Board can obtain assurance that placement with “P” procedures are applied effectively to ensure that placement, care and pathway plans fully meet identified needs.   4.7 Engagement with Laurie Engaging with Laurie and his family proved extremely challenging at times. Some agencies were more successful than others. Continuity of worker and the presence of statutory orders appeared to be important factors. When Laurie did not engage, agencies only infrequently considered working with those agencies with which Laurie was engaging successfully. One agency – the LAC health team - did not follow their non-engagement policy. Those agencies which found difficulty in engaging with Laurie could have considered alternative approaches.  4.8 There no evidence that any agency explored with Laurie the reasons why he did not want to engage with services. When Laurie decided not to engage, his wishes were respected and he was discharged from the relevant service. This resulted in Laurie’s needs being unmet. Some LSCB’s have multi-agency policies which provide guidance on approaches to be adopted in order to address difficulties in engaging. Such policies are not limited to Looked After Children. The LSCB may wish to consider developing a multi-agency policy along similar lines.   Recommendation 3: That Wakefield and District Safeguarding Children Board should consider developing a multi-agency policy to provide guidance on action to take when services experience difficulty in engaging with children and families.  4.9 Self harm and suicidal ideation Agency responses to self harm and suicidal ideation were inconsistent. No agency in contact with Laurie appeared to have a complete understanding of his self harm history, and the triggers for his self harm, including Laurie’s difficulty in coping with intimate relationships coming to an end.   4.10 Although the University of Manchester study considered self-harm to be a crucial indicator of risk which should always be taken seriously, the following additional thirteen antecedents of suicide in people under the age of 20 were also identified (4); contact with social care/local authority services; contact with CAMHS (at any time); self-harm by cutting; psychiatric diagnosis; Looked after Child; bereaved; experienced abuse; bullied; self harm   10 by self poisoning; contact with youth justice/police (at any time); excessive alcohol use; illicit drug use and no service contact.  4.11 In Laurie’s case, several of these antecedents were present, specifically contact with children’s social care; Looked after Child; CAMHS contact; youth justice/police contact; self harm by cutting; bereaved (step father advised the review that a paternal uncle of Laurie’s had committed suicide); experienced abuse (exposed to domestic abuse between birth father and mother and had been present during domestic abuse incident involving elder sibling and partner shortly before death) and illicit drug use. It is unclear to what extent professional practice is informed by these antecedents of suicide.  4.12 It is proposed that the LSCB widely disseminate the learning from this case and make use of it as a vehicle for stressing the importance of recording and appropriately responding to all incidents of self harm (no matter how apparently superficial) and suicidal ideation and raising awareness of the antecedents of suicide in children and young people.  Recommendation 4: That Wakefield and District Safeguarding Children Board widely disseminate the learning from this SCR in order to stress the importance of recording and appropriately responding to all incidents of self harm and raising awareness of the antecedents of suicide in children and young people.  4.13 The provision of support to parents of children and young people should also be informed by awareness of the antecedents of suicide in children and young people.  4.14 This case has confirmed the extent to which social media is a factor in cases involving the suicide of children and young people. Laurie posted images of his self harm on Facebook which exposed Laurie to unkind comments indicating that it may have been unwise to compromise his own privacy in that manner.   4.15 Ensuring appropriate support for parents of children and young people at risk of suicide or serious self harm and raising practitioner awareness of the role that social media can play in suicide and serious self harm are just two of the issues arising from this review which should inform the local suicide prevention strategy. It is therefore recommended that the learning from this case is made use of to review the local suicide prevention strategy.  Recommendation 5: That Wakefield and District Safeguarding Children Board ensure that the learning arising from this serious case review informs any review or process for developing the local suicide prevention strategy.         11 References: (1) Retrieved from http://pandorsetscb.proceduresonline.com/files/working_harder_engage_families.pdf (2) Retrieved from http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/cyp_2017_report.pdf (3) ibid (4) ibid  Glossary   Independent Reviewing Officers (IRO) have a duty is to ensure the care plans for children in care are legally compliant and in the child’s best interest. All local authorities have a duty to appoint an IRO to every child in care.  IROs are required to oversee the child’s care plan and ensure everyone contributing to the care plan fulfils their legal obligations to the child.  A Looked after child (LAC) is a child who is being looked after by their local authority. They might be living with foster parents; at home with their parents under the supervision of social services; in residential children's homes or other residential settings like schools or secure units. They might have been placed in care voluntarily by parents struggling to cope or children's services may have intervened because a child was at significant risk of harm.  A Person Education Plan (PEP) is a statutory tool to ensure that everyone involved is actively prioritising the education of the Looked After Child.  Placement with “P” Regulations When parents have their own children returned to them after being in local authority or social services arranged care, it’s known as ‘placement with parents’. This process is governed by the The Care Planning, Placement and Case Review (England) Regulations 2010.  Youth Community Resolution is the resolution of a less serious offence through informal agreement between the parties involved as opposed to progression through the traditional criminal justice process. Children aged 10 – 17 years old can be given a Youth Conditional Caution if they admit a criminal offence. Youth conditional cautions are a caution with one or more conditions attached.  All children who receive youth conditional cautions are referred to the YOT.   Referral Order Where a young person is before a court charged with a criminal offence for the first time and pleads guilty, the Court must pass (in most cases) a referral order.  Under the order the young offender agrees a contract with the youth offender panel which can include reparation or restitution to their victim, as well as undertaking a programme to address their offending behaviour.   