Death of a 17-year-old boy, as a result of hanging. Ryan was found with a ligature around his neck in a cell in a Young Offender Institute (YOI); Coroner's inquest concluded accidental death. Ryan had been in the care of Leeds City Council since he was 16-months-old; when he was 13-years-old his long-term foster placement broke down and he did not have another stable placement. History of: extensive record of offending; chaotic lifestyle and risk-taking; aggressive behaviour; and frequent movement between accommodation. Issues identified include: focus of interventions on symptoms rather than causes of Ryan's difficulties; failure to agree a multi-agency response that included contingency planning for repeated crises; and failure to address frequent requests for contact with family members. Makes recommendations covering: corporate parenting responsibilities for promoting education, training and employment; and provision of suitable, specialised accommodation for young people with high support needs. Report was originally completed in February 2012 and reviewed in 2013. Report includes response to Coroner's Inquest, which was completed in January 2014.
      
 Title:  Serious case review in respect of Ryan Clark (Child V): overview report. LSCB: Leeds Safeguarding Children Board Author: Pamela Shelton Date of publication: 2015  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     Leeds Safeguarding Children Board   Serious Case Review In Respect Of Ryan Clark (Child V)   Overview Report   Published 19th March 2015        2 CONTENTS                                          Page        Introduction         3  Conclusions, Recommendations &  Response to Coroner’s Inquest          3  Reasons for a Serious Case Review     10  Terms of Reference of the Review     11  Methodology         12  Sources of Information       13  Summary of Key Events       13  Analysis         26  Views of Family Members       44  Conclusions and Key Learning      44  Recommendations         45  Learning Lessons from Serious Case Reviews    46  Appendix1 Terms of Reference      48  Appendix2 Methodology       49  3  1. INTRODUCTION   1. This Serious Case Review (SCR) was commissioned by Leeds Safeguarding Children Board following the death of Ryan Clark, a 17 year old male, who died whilst remanded in custody to a Young Offenders’ Institution (YOI).  Ryan had been in the care of Leeds City Council since he was 16 months old.  2. CONCLUSIONS & RECOMMENDATIONS (repeated in sections 8 & 9 and written in February 2012, prior to the inquest of January 2014)  2. Having carried out this SCR, the SCR Panel and overview report author have reached the following conclusions.   3. The Inquest completed in January 2014 concluded that the death was accidental. From evidence produced for the Panel, there is no indication that Ryan expressed any intention to harm himself. In fact, when asked directly, he expressed satisfaction with his life, although the manner in which he lived his life suggested otherwise. Staff involved with Ryan, including those in the YOI, could not reasonably have predicted Ryan’s death. However, they were insufficiently alert to the emotional turmoil that underlay his overt behaviour.  4. There are clear indications that Ryan was vulnerable from early childhood, and stark evidence that, in the 12-month period leading to his death, there was an acceleration in his personal difficulties and social exclusion. Staff focused their attention on the individual crises with which Ryan regularly presented them and did not stand back and consider the underlying causes of his behaviour.   5. There was an absence of regular and thorough assessments and re-assessments of Ryan’s situation that gave due recognition to his vulnerabilities based on the level of risk factors and lack of protective factors in his life.   6. When Ryan was in the YOI there was insufficient assessment of his vulnerability and the care he received was not always child centred.  7. Whilst it is evident that Ryan had a close attachment to his first, long-term foster carers, this placement broke down when he was 13 years old and he never had a stable placement thereafter. This is likely to have had an impact on his sense of security.  8. Agencies invested considerable time and money in providing a range of interventions aimed at supporting Ryan, much of it positive and well planned at an individual agency and worker-level. However, the interventions were insufficiently coordinated and focused upon the symptoms rather than the 4 cause of Ryan’s difficulties. The review system established to monitor the efficacy of care planning for looked after children failed in its purpose.   9. The serious case review did not identify a causal link between Ryan’s death and the nature of the services provided to him in the community. However, the efficiency and effectiveness of interventions were considerably undermined by the failure to agree a multi-agency response that included contingency planning for the repeated crises in Ryan’s life. This conclusion links to the City Council’s responsibilities as a corporate parent for its population of looked after children. The guidance makes clear that councils can expect the full cooperation of partner agencies in fulfilling these responsibilities. Evidence presented to the Panel suggested that those groups that had responsibility for ensuring the wellbeing of looked after children were not fully functioning.  10. There is some evidence of sensitivity to Ryan’s racial, cultural, linguistic and religious identity. There is also evidence of individuals ascertaining and taking account of his wishes and feelings. However, his frequent requests to have contact with family members and to know more about his father’s family were overlooked over a lengthy period.  11. At a personal level, the collective corporate system let Ryan down despite the best efforts and good intentions of individual members of staff. There was no one person who assumed responsibility for Ryan as a looked after child, ensuring that his overall wellbeing was promoted and safeguarded. The organisation legally charged with parental responsibility did not adequately discharge it.   12. All agencies involved in this SCR produced good quality IMRs that facilitated learning and contributed to the overall SCR.  None of the IMR authors had any operational involvement with Ryan and each was at an appropriate level of seniority for undertaking the review and challenging agency practice. In all instances, a more senior manager countersigned the report. The individual agencies made recommendations that were appropriate to them and progressed and completed actions in response.  The following, additional, recommendations are few in number and have wider application than this individual case. They also reflect the Panel’s understanding that changes and developments in practice pre-date this review.  1. The LSCB should satisfy itself that multi-agency arrangements for care planning and reviewing looked after children have improved and are efficient and effective.   2. The LSCB should satisfy itself that the programme of work being undertaken to improve corporate parenting responsibilities in Leeds includes promoting access to education, training and employment opportunities and enhancing emotional wellbeing.   3. The LSCB should review the sufficiency of provision of suitable, specialised accommodation for young people with high support needs, with a particular focus upon looked after young people. 5   4. The LSCB should promote more effective approaches to risk management and assessment of children and young people with complex needs.  5.  The LSCB should endorse the IMR recommendations and require their implementation and should satisfy itself that actions are completed and embedded.  13. At the end of October 2012, Ofsted published a report – Ages of concern: learning lessons from serious case reviews. It is a thematic report based on an analysis of 482 serious case reviews that Ofsted evaluated between 01 April 2007 and 31 March 2011. The main focus of the report is upon babies less than one year and young people aged 14 or above. It came to the attention of the overview report author after completion of the final draft of the overview report. However, the report conclusions in respect of young people aged 14 or over clearly resonate with the findings of this review and are reproduced below for reference:    Agencies had focused on the young person’s challenging behaviour, seeing them as hard to reach or rebellious, rather than trying to understand the causes of the behaviour and the need for sustained support;   Young people were treated as adults rather than being considered as children, because of confusion about the young person’s age and legal status or a lack of age-appropriate facilities;   There was no coordinated approach to the young people’s needs and practitioners had not always recognised the important contribution of their agency in achieving this.  The overview report author recommends dissemination of this useful and relatively brief report.  The Response of the Serious Case Review Panel to the Findings of the Coroners’ Inquest  concluded on the 28th January 2014.   1. The Serious Case Review (SCR), in respect of Ryan was completed in February 2012 and revised in April 2013. Both the original report and the revision predated the Inquest touching the death of Ryan which ended on the 28th January 2014. Following the Inquest  the SCR Panel was reconvened under the Chairmanship of Sheila Sutherland and met on the 27.02.14 and the 13.03.14 to consider the issues raised by the Coroner and also the Youth Justice Board Report, “Deaths of Children in Custody: Action Taken, Lessons Learnt”, 2014.    2. The conclusion of the Inquest was accidental death, the medical cause of death being attributable to hanging.  Additional to the verdict the Assistant 6 Coroner, in her Regulation 28 report, identified several concerns which required action to be taken by Leeds Children’s Social Work Service, Leeds Children’s Services (Targeted Services) and the National Offender Management Service (NOMS). These concerns and responses are as follows:    (a)To Leeds Children’s Social Work Service and Leeds Children’s Services (Targeted Services/Youth Offending Service);  ‘That all relevant information, concerns and issues about a young person who goes into custody are imparted to, and discussed with Young Offender Institution staff by the said young person’s social worker and Youth Offending Team Case Manager as soon as the young person arrives in custody and within 24 hours thereof ‘.  3. Response from Leeds Children’s Social Work Services ( Targeted   Services/Youth Offending Services)   Response to concerns:  “The following procedure has been agreed between Leeds Children’s Social Work Service (“CSWS”) and Leeds Youth Offending Service (“YOS”) in response to the above concerns set out by  Miss Melanie J Williamson, Assistant Coroner, in her regulation 28 report, dated 3 February 2014:  When a child appears in court with the potential to be remanded or sentenced to custody, the YOS Court Officer will collate all relevant information, concerns, vulnerabilities and issues known about that young person from existing YOS engagement.  The YOS Court Officer will also check if the child has a social worker. If the child does have a social worker the YOS officer will contact the social worker to request all relevant information, concerns, vulnerabilities and issues about the young person.  If the social worker is unavailable, enquiries will be escalated to the relevant team manager.  If the team manager is not available, enquiries will be escalated to the relevant Service Delivery Manager.   This information will form part of a joint report to be delivered to the relevant institution within 24 hours of the young person arriving in custody. Where there is no allocated social worker, the YOS Court Officer will provide an individual report within 24 hours of the young person arriving in custody.  Where the child has a social worker but the YOS Court Officer has been unable to collate information from the social worker, the YOS Court Officer will inform the social worker at the receiving institution of this, will provide an individual report and will inform the relevant CSWS Head of Service who will expedite the sharing of any additional relevant information within 24 hours of the young person arriving in custody.”    Agreed and signed by Saleem Tariq Chief Officer, Children’s Social Work Service and Jim Hopkinson, Head of Targeted Services    (b)To the National Offender Management Service (NOMS); 7   ‘ At HMYOI Wetherby (i) The Personal Officer Scheme was not properly implemented and did not operate effectively vis a vis trainees; (ii) ACCT checks of a trainee were not made and/or were not made in accordance with the times prescribed by the trainee’s ACCT document; (iii) The correct procedure when conducting a roll count of trainees was not adopted by Prison Officers; (iv) Prison Officers were not fully conversant in the administration of first aid and CPR and had not received regular refresher training in relation thereto.’   4. Response from NOMS   “The four concerns raised are addressed in turn.  Personal Officer Scheme  Prison Service Instruction (PSI) 08/2012 Care and Management of Young People requires that young people are assigned a Personal Officer/ Caseworker during the induction stage of their imprisonment. This arrangement aims to achieve the following: • Each young person understands to whom they can turn to, to discuss all issues of concern, including resettlement. • The personal officer or caseworker attends each training plan review during the custodial period • There is appropriate contact with, and involvement of, each young person’s family and supervising officer and that links between all parties are strengthened     In addition to this, PSI 75/2011 Residential Services sets out the need for all staff to engage positively with prisoners (and young people, as at Wetherby) and describes the key part that residential staff have to play as positive role models.  In October 2013 HMP and YOI Wetherby implemented a revised personal officer scheme that aims to ensure greater continuity in the allocation of staff to young people and includes a ‘relief’ arrangement whereby a paired officer is available to cover during the periods of absence that are inevitable with staff working shifts. The new scheme emphasises the supportive element of the role, and staff have been briefed on this. A copy of the new policy document is attached for your” (the Coroners) “information. More generally, the Governor is aware that even the best personal officer scheme has limitations, and encourages all staff to establish and maintain positive relationships with all young people in the establishment.  ACCT Checks  The governor is confident that the failure of one officer to conduct an ACCT check on one occasion is not representative of practice amongst staff at HMP and YOI Wetherby, and the incident in question was the subject of a 8 disciplinary investigation. Staff are now briefed on the timings of ACCT checks and the need for good quality interactions and observations at the start of each shift. In addition, full ACCT guidance has been reissued, and priority is being given to providing ACCT refresher training for all staff. In order to provide further reassurance, the Governor has introduced an additional layer of management checks of all ACCT documents.  Roll Checks  The two failures to follow the procedure for roll checks identified in this case have been the subject of investigations, and disciplinary action has been taken against the staff involved. All staff have been briefed on the importance of roll checks, and these are now subject to covert checks by managers. If, following a covert check, there is any doubt as to whether or not a proper roll check was carried out, CCTV evidence is examined, and a disciplinary investigation is instigated where necessary.     First Aid and CPR  PSI 01/2014 First Aid describes the process for ensuring effective provision of first aid that enables NOMS to discharge its duty of care to its employees, to prisoners and to visitors to our premises. Governors are required to ensure that at all times such numbers of suitably trained first aiders as is sufficient and appropriate for the circumstances are available. A First Aid risk/needs assessment is undertaken by the local Health and Safety Advisor to determine the appropriate numbers. Governors must ensure that first aiders are trained to levels which are appropriate for the circumstances and hold a valid certificate of competence in either First Aid at Work (FAW) or Emergency First Aid at Work (EFAW).  This policy is being implemented at HMP and YOI Wetherby. In accordance with it, all 16 custodial managers will be trained in FAW by the end of June 2014 and all of the 27 operational support grades who carry out night patrols in residential areas will be trained in EFAW during 2014. This arrangement will supplement the 24 hour healthcare cover at the establishment, which includes the availability of two trained nursing staff at all times, including overnight”.      Signed by Jacqueline Townley,       National Offender Management Service   5. The progress in the implementation of these responses and actions will be monitored and followed up by the Leeds Safeguarding Children Board Serious Case Review sub- committee through six monthly reports to it by the agencies concerned.       9    6. The SCR Panel also considered the following issues from the Youth Justice Board Report “Deaths of Children in Custody: Action Taken, Lessons Learnt” 2014, some of which had particular relevance to the circumstances of Child Ryan.:   “Improving the quality of information shared with the YJB Placement Service and the secure estate from Youth Offending Service” The Youth Offending Service (YOS) Deputy Service Manager and the Governor of Wetherby Young Offenders Institution both confirmed to the SCR Panel that information sharing is mentioned in both the YJB Report and the Regulation 28 recommendations.  Current practice in Leeds is that Placement Information Forms and Post Court Reports usually are sent to the YJB via Connectivity and followed up by secure email to the YJB placements team to ensure receipt. Asset assessments are sent by secure email due to Connectivity validation issues in the Leeds YOS case management system. The correct information being sent to the relevant secure establishment is the responsibility of the YJB not the individual YOS.   A national notification system has been established by the YJB to ensure any omission in information regarding a young person’s placement is flagged up to the YOT Head of Service. The YOS manager reported that the number of young people in Leeds receiving custodial sentences is greatly reduced when compared to the situation at the time of Ryan’s sentence to custody. There is confidence that young people receiving custodial sentences are the subject of detailed planning and information sharing. Regarding the YJB Report p15. Re Placement Information Form (PIF) – this is a standard pro forma that has been in established use for a long time. “All children remanded now become ‘looked-after children’ and are therefore entitled to additional support from their home local authority when remanded.”  Children and young people who are on remand in custody are given ‘Looked After Child status’. This change has been implemented since the introduction of the Legal Aid, Sentencing and Punishment of Offenders Act of 2012. The SCR Panel were asked whether agencies were aware of this and the implications it brings. It was confirmed that across the secure establishments, YOS and CSWS, all relevant people are aware and the relevant flowcharts have gone into guidance which has been distributed to social workers. All young people on remand in custody are now allocated a Social Worker as 10 well as a Youth Justice Officer. There are now dedicated Social Workers within Wetherby HMYOI; this has been implemented approximately from the time that the SCR V was commenced. The Panel Health representative confirmed that Looked-After Children Health Reviews are overseen by Nurses within the HMYOI establishment. The reconvened SCR heard that since the time of Ryan’s death, services to young people who both were vulnerable and challenging to work with, had greatly improved. There was now a reduction in the numbers of children receiving custodial sentences, which was felt, to be due to the much improved multi agency work with those children at risk of becoming involved in, or responsible for criminal activity. The Governor HMP & YOI Wetherby amongst other detail was able to inform the Panel that all children in custody were regarded as Looked After and a Social Worker working within the YOI responded to them as such. Panel members described the present multi agency response, to children in similar circumstances to those Ryan had experienced, as well coordinated and responsive. Leeds Children’s Social Work representative gave an account of an improved response to corporate parent responsibilities for Looked After Children with further developments in hand.    3. REASONS FOR A SERIOUS CASE REVIEW  14. Ryan’s long-term foster placement disrupted when he was 13 years old following difficulties that included offending behaviour. He first became involved with the Leeds Youth Offending Service (YOS) around the same time and they supervised him under a range of orders over the next four years.   15. At 17 years of age, Ryan appeared in court again; he was remanded to custody and was admitted the same day to a YOI. 20 days later an officer found Ryan in his cell with a ligature round his neck. Staff attempted resuscitation until paramedics arrived and took over. Ryan was transferred to hospital by ambulance where he was pronounced dead.   16. The decision to undertake a Serious Case Review (SCR) was made by the Leeds Safeguarding Children Board (LSCB) Executive Committee acting in the capacity of the Serious Case Review Standing Sub-committee. The LSCB Chair, who has ultimate responsibility for deciding to undertake a SCR, was in attendance. The decision was, in this instance, straightforward in that the guidance (Working Together to Safeguard Children [WTSC], March 2010) states in paragraph 8.9 that: “a SCR should always be carried out when a child dies in custody”.   11 17. A Prison and Probation Ombudsman investigation has been undertaken within a similar timescale to the SCR. The Panel Chair and LSCB Assistant Manager have liaised with the Ombudsman service in order to ensure that information about the circumstances of Ryan’s death is shared as appropriate.  18. An inquest will in due course be held in order to establish how Ryan died and record a verdict. The Coroner is aware that a Serious Case Review is being undertaken.   4. TERMS OF REFERENCE   19. The purposes for any SCR carried out under the WTSC guidance are to:  • Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and  • Improve intra- and inter-agency working and better safeguard and promote the welfare of children.   20. WTSC guidance states that SCRs are not inquiries into how a child died or who is culpable. “These are matters for coroners and criminal courts to determine as appropriate. Rather, they are intended to enhance learning within the agencies involved with the child or young person who was the subject of the review in order to inform future operations, planning and developments.”  21. The LSCB agreed the time period of the review as the last 12 months of Ryan’s life. Ryan was a looked after child and had been in the care of Leeds City Council since he was 16 months old. The LSCB decided that the case review should not encompass Ryan’s entire time as a looked after child but focus on events leading up to his remand into custody.   22. However, in order to provide a context to the review, agencies were asked to look at their records from when Ryan’s long-term foster placement broke down when he was 13 years old and provide a summary of their involvement during this period. A chronology was not required for that part of the review.  23. The LSCB agreed six terms of reference specific to this case and agencies contributing to the review were asked to address each of these in their Individual Management Reviews.  These are listed in appendix 1 of this Overview Report.     12   5. METHODOLOGY  Agencies and individuals involved in the review  24. A SCR panel was convened with an Independent Chair and representatives of relevant agencies. In addition an Independent Overview Report Author was commissioned who was not a member of the SCR Panel but who attended Panel meetings in connection with writing this Overview Report.  25. The Independent Chair was Sheila Sutherland who has over 30 years’ experience in children's social care, both as a social work practitioner and operational manager, including fourteen years as Head of Service/Assistant Director. Since October 2009, she has worked as an independent consultant carrying out case reviews and investigations into staff conduct issues. In addition, she acted as social care consultant to the Centre of Education Leadership at Manchester University on the design and delivery of Social Care Leadership Programmes.  26. The Independent Overview Report Author was Pamela Shelton who has over 35 years’ experience in children’s social care, including as a frontline social worker and senior operational manager. She has worked independently since 2000 undertaking a wide range of assignments that include: inspections and reviews of children’s services; safeguarding audits; complaint investigations; serious case reviews; improvement programmes in local authorities, and the development of programmes to support newly qualified social workers and advanced practitioners.   27. Sheila Sutherland and Pamela Shelton have never worked for Leeds City Council and have no interests in any of its dealings.  28. A full list of the membership of the SCR Panel is included as appendix 2 of this report.  29. The recommendations made were acted on during the process of the review in order to ensure delay was not incurred in using the learning as it emerged.  30. The Overview Report has been reviewed and revised by Peter Ward in preparation for publication.  In carrying out the revision Mr Ward has considered the report of the investigation into the circumstances of the death of Ryan carried out by the Prisons and Probation Ombudsman which was not available when the overview report was completed.   31. Mr Ward has a background in social care and has worked in management and front line social work.  He is qualified to degree level in social work and has a post-graduate diploma in management studies.  He is now the Director of Arrow Social Care Consultancy Limited and as such undertakes investigations and other consultancy work on an independent basis.  This has 13 included involvement in numerous Serious Case Reviews. He has no involvement or interest in any of the dealings of Leeds City Council.  Sources of Information   32. The SCR Panel and overview report author received an individual management review (IMR) from each of the public and voluntary sector agencies that had had involvement with Ryan and his family. Each IMR included a detailed chronology of the agency’s involvement during the last 12 months of Ryan’s life. These chronologies were combined into one integrated chronology for the benefit of the Panel members and the overview report author.  33. Other agencies provided information about involvement that fell outside the timescale of the review and brief involvement that did not warrant an IMR.  (Agencies contributing to the review are listed in appendix 2).  34. The Panel chair, Assistant LSCB Manager and overview report author had a pre-meeting to plan for the review.  Subsequently, the Panel met on four occasions and all but two of the IMR authors joined the Panel for its first two meetings in order to introduce their reports and participate in the subsequent discussion.  35. For the purpose of this review, the overview report author referred to relevant City Council documents and national research reports, legislation and guidance. These are listed in appendix 2.  Family Information  36. A genogram was constructed to provide Panel members and the overview report author with information about Ryan’s family.  Interviews were carried out with Ryan’s mother, a sibling of Ryan’s who Ryan had indicated he felt close to and the long term foster carers who Ryan had been living with up to 13 years of age.    37. Ryan’s father died shortly before Ryan’s 16th birthday and The Panel was interested to establish, in particular, his cause of death and any potential relevance to Ryan. It proved very difficult to find any information about him but very late in the review, information was received which indicated the cause of death and provided an insight into Ryan’s father’s background.   14 6. SUMMARY OF KEY EVENTS   Initial period  38. Agencies were asked to review their records from when Ryan’s long-term foster placement broke down when he was 13 years old up to 12 months before he died, a period of three years and four months.  They were asked to provide a summary of their involvement during this period. A chronology was not required for that part of the review. However, the chronology that formed part of the CYPSC IMR incorporated key events that occurred during this period and they have been included in the integrated chronology.   39. Supervision notes from six months before the placement broke down, in the records of CYPSC, state that Ryan’s long-term foster placement was stable with no significant problems. However, two months later, the foster carers reported that they were finding it increasingly difficult to manage Ryan’s behaviour. There is evidence of efforts by the social worker to support the placement.  40. Ryan was attending a high school and Education staff attended the six-monthly reviews required for a looked after child. There is evidence in school records of a Personal Education Plan having been partially completed and sent to the social worker at this time but no prior or subsequent plan.   41. Around this same time, Ryan was excluded from school on three occasions for poor behaviour. At a review meeting in this period, an action was to produce a Behaviour Support Plan as required but there is no evidence that this occurred despite continuing problems. Subsequently Ryan was without a school place for three months up to the end of the school year.   42. During this same period, Ryan committed an offence and entered the final warning programme organised by the Youth Offending Service (YOS): a pre-court voluntary intervention that is brief and restorative in nature, usually offered when a young person has been arrested on no more than one or two occasions.   43. YOS staff and the social worker communicated frequently and also liaised with Ryan’s school. The YOS worker completed a full ASSET assessment. According to guidance from the Youth Justice Board: “Asset is a structured assessment tool to be used by Youth Offending Teams in England and Wales on all young offenders who come into contact with the criminal justice system. It aims to look at the young person's offence or offences and identify a multitude of factors or circumstances - ranging from lack of educational attainment to mental health problems - which may have contributed to such behaviour.”  44. Ryan’s score was medium/high, which is unusual at a final warning stage and reflected a number of indicators that Ryan was likely to re-offend.   15 45. A statutory Looked after Child (LAC) review was held and the case record notes that Ryan’s needs were met and the plan was appropriate. However, the IMR author was not able to locate the review form or report of the meeting. The supervision record shortly after states that the placement had irretrievably broken down and that Ryan was missing. The agreed plan was to locate Ryan and place him in an emergency placement to allow an assessment to be made to inform future placements. It also states that every effort should be made to return Ryan to his long-term placement, though this view was revised within the month to acknowledge that there was little likelihood of Ryan returning to the previous carers. The placement disruption was not reported to the Fostering Panel and no disruption meeting was held. Within two weeks, Ryan had been arrested and placed in an emergency foster placement.   46. Four months later Ryan moved to another short-term foster placement after expressing unhappiness with the first placement. According to the LAC review, the plan remained to identify a long-term placement for him. However, by 12 months later, there was agreement that the social worker should apply for a change of status of the current placement to long-term. Ryan was present at these LAC reviews.   47. Ryan commenced at a new school when he moved foster placements but was excluded two months later at which point the school gave notice that they were returning him to the first school. He remained out of school for the next 11 weeks on an authorised basis. Ryan then entered a phase of persistent absences from school and, from five months later, attended alternative education provision with four different providers. One provider requested a Personal Education Plan but the school did not have one available.   48. The nurse from the LAC nursing team completed Ryan’s Health Needs Assessment (the annual statutory health review for looked after children) shortly before his 15th birthday at his foster home (after considerable effort on her part).   49. At 14¾ years of age, Ryan was sentenced to a 10-month supervision order. He responded very positively to this order and, during the first six months, experienced a stable period, including being well settled with his foster carer. The YOS case manager also carried out eight sessions of anger management work with Ryan. The assessment completed towards the end of the order indicated that the risk of Ryan re-offending remained medium/high but his attitude towards offending had improved, particularly his recognition of the consequences for self and victims. However, Ryan committed another offence seven months later, for which he received a further supervision order that superseded the earlier one. Over the next few months, Ryan’s school attendance decreased and he spent time away from his foster home.    50. Shortly after his 15th birthday, Ryan started to attend the City Council’s teaching and learning provision but his attendance was terminated four months later following an incident. He moved back to alternative provision 16 and, in the time until he left school that summer, received some positive comments about his progress and abilities.  51. At the LAC review held when Ryan was 15½ , the record indicates that the plan to transfer the status of the current foster care placement to long-term was hampered by Ryan’s increasing absences from the placement. It was agreed to make a referral to the Pathway Planning team (the team within CYPSC that caters for young people aged 16 and over who are or have been looked after) to ask for the appointment of a personal advisor.   52. Ryan appeared before the court again the following month on new charges and for breaching his supervision order. He entered the bail support scheme: an intensive form of support for young people awaiting sentence who are otherwise at risk of a remand to custody, and responded well during the three-week period. However, the ASSET assessment indicated a significant increase in risk factors, as well as concerns about his behaviour and wellbeing.  53. The following month, the court imposed a new 12-month supervision and curfew order. Ryan returned to live with his foster carer and, four months later, the social worker reported that the placement had stabilised. Ryan cooperated well with the new order and was seen 54 times – virtually an appointment every week during the year. The YOS substance misuse worker met regularly with Ryan who was cooperative, although the involvement had little impact on his substance misuse.  54. Around the same time, Ryan’s case transferred to a new social worker because the current worker could not provide Ryan with the level of input he required as a result of other demands. Two days before Ryan’s 16th birthday, the social worker was informed of the death that day of Ryan’s father. The social worker offered Ryan bereavement counselling, which he declined. The YOS worker noted that Ryan had expressed a wish to have got to know his father better. Staff encouraged him to discuss his feelings but Ryan claimed to be unaffected, although his foster carer reported that he became emotionally distant.   55. Over a four month period, when Ryan was 16 years of age, he missed many appointments with YOS and his order was breached and a 12-hour reparation order substituted. He spent increasing amounts of time away from his foster carer’s home, effectively moving to live with his relatives.   56. When Ryan was 16½ years of age, a social work student completed a risk assessment that identified four concerns. The resulting action plan was non-specific.  57. Immediately following this assessment, the social worker requested an alternative foster placement for Ryan. No reason was evident. Later that same month, the social worker recorded that Ryan was refusing to consider any alternative placement and stated that the plan was to pursue an independent living arrangement for Ryan.  17  58. Ryan refused a foster placement and continued to live with his relatives. The social work student had discussed his case with the Pathway Planning team and arranged for the involvement of a support worker from the Supported Independent Living Service, a voluntary sector organisation, commissioned by the Supporting People service, that provides ‘floating’ housing support and tenancies for young people aged 16-25. One of its projects relates specifically to care leavers and involves both housing support and support in relation to education, employment and training.  Summary of events during the last 12 months of Ryan’s life  59. The following summary focuses on key events and details deemed relevant. It does not, therefore, fully reflect the high level of activity undertaken by the staff involved with Ryan, including both the direct contact with him and the liaison between agencies.  Month 1   60. During this month, the social worker completed a Pathway Plan, which was agreed by Ryan although not signed off by the manager.  This recorded that Ryan was to be assisted in registering with a local GP practice, which was done the following month, and supported regarding his substance misuse.  It was noted that he was ‘open’ to counselling following the death of his father but no action was recorded to address this.   61. Concern was expressed to the social worker that Ryan was not looking after himself and a request was made for him to be placed in secure accommodation. The social worker’s response was that he did not meet the criteria although the IMR notes that there is no record of the social worker discussing this request with her team manager or supervisor.  Month 2  62. The social worker acknowledged during supervision that Ryan’s placement was not meeting his needs. There was agreement that the social worker would look for long-term accommodation for Ryan. At the LAC review later that same day, Ryan agreed to a referral to an independent sector organisation commissioned by Leeds City Council that provides supported accommodation and flexible and intensive packages of support. The application was necessary because the Supported Independent Living Scheme had no accommodation in an area suitable for Ryan: that is, one where Ryan identified he would not be at risk from other adults. However, it was clear that the Supported Independent Living Scheme would continue to provide the support in view of its staffs’ established relationship with Ryan.  63. In the middle of the month, Ryan was arrested and charged by West Yorkshire Police (WYP).   Month 3 18  64. Early in month 3, Ryan agreed with the social worker, that he needed more support.   65. At a court appearance, Ryan was bailed for three months and complied well with the bail support requirements: he had 28 appointments with staff in the three-month period, missing just one appointment.   66. Ryan’s placement with his relatives ended a few weeks before his 17th birthday following an alleged incident. Leeds Housing Options (part of the Environment and Neighbourhood Directorate) assisted in securing Ryan accommodation at Hostel1, a hostel for single homeless males over 16 years with 24-hour staffing, commissioned by the Supporting People Programme (also part of the Environment and Neighbourhood Directorate). The social work student made enquiries about Ryan’s application to Ryan Housing for a tenancy and the latter expressed concerns about Ryan’s behaviour in previous accommodation.   Month 4   67. Early in the month, the social work student noted that Ryan reported being ‘hassled’ by other residents in Hostel1.   68. Ryan did not attend the registration appointment with the practice nurse at the new GP practice; he said he would not attend for his Health Needs Assessment and was advised that he should be seeking medical advice. He was continuing his substance misuse.   69. The independent reviewing officer’s note of a LAC review states that the social worker requested a personal advisor for Ryan because of his high level of need; also, that Ryan would like more information about his father’s family and this was an action for the social worker. The IMR author could find no record to indicate any action taken. The IMR author also notes that there was no entry in the section on Emotional and Behavioural Development.  70. During the month, Ryan was evicted from Hostel1. The hostel advised Leeds Housing Options of the position and they, in turn, informed the social work student. The latter asked for help about alternative accommodation options and was told that Housing Options had discharged its duties to Ryan under the legislation and suggested that Ryan looked at private rental accommodation. The personal advisor at the Pathway Planning team confirmed that the housing position was as set out by Housing Options and recommended Hostel3, although it was not accommodation registered by the Council as part of its Supporting People Programme. The social work student arranged a bed and breakfast placement at Hostel3, provided Ryan with money and requested that the Supported Independent Living Scheme support worker explore housing options with two providers.    19 Month 5  71. At the beginning of the month, the CYPSC team manager decided that Ryan’s needs would be better met by a social worker from the Pathway Planning team; further, that Ryan’s relationship with his current social worker was not of significance so a change would not have a negative impact. The Pathway Planning team had capacity to take on the case and the social worker was asked to prepare a transfer summary within a week.  The social work student maintained contact with Ryan.  72. The updated Pathway Plan included reference to Ryan having been allocated a housing support worker from the Supported Independent Living Scheme; that Ryan was still not in any form of employment, education or training (bail support and Supported Independent Living Scheme workers to assist); that he would benefit from advice about healthy eating from the nurse or GP; and that he wanted contact with specific relatives.  73. Hostel3 closed down in the second half of the month for refurbishment and Housing Options again advised that the duty to accommodate Ryan lay with CYPSC. Ryan moved from Hostel3 to Hostel4 due to factors outside anyone’s control. This was a similar establishment to Hostel3, and he remained until his court appearance the following month. During this period he received a high level of support from the bail support worker. The ASSET assessment completed during this time triggered a vulnerability management plan with actions intended to minimise the identified risks in relation to substance misuse, attitude to offending and emotional wellbeing.   Month 6  74. Leeds Housing Options received a housing application from Ryan for housing with Leeds Homes who manage the lettings process and ALMOs (arms-length management organisations) on behalf of Leeds Council.  75. Following his period of bail support, Ryan was sentenced for the offences committed four months earlier by way of a Youth Rehabilitation Order (a further period of supervision) with a requirement to complete 80 hours of unpaid work. Ryan did not comply well with the order and his overall situation remained very unsettled. He was asked to move out of Hostel4 and went back to Hostel3. The YOS requested longer-term planning to provide him with more appropriate accommodation.   76. At the end of the month, the LAC nurse visited Ryan in his bed and breakfast accommodation to undertake his Health Needs Assessment. The nurse noted that: he appeared to be generally well and had no worries about his health despite his lifestyle. Ryan indicated that he was not worried about his health, felt happy with his life and intended to continue with his current lifestyle. He chose not to be immunised. He identified who he would approach if he were sad or worried.    20 Month 7  77. The nurse passed on the written information to CYPSC the same day and had a discussion with the social worker the next day: the nurse recommended that Ryan needed a supported living placement. The social worker reported that Ryan’s issues were all being dealt with by YOS or CYPSC.   78. Three days later, Ryan contacted the social work student to say he was concerned about staying at the current accommodation because ‘people were after him’ On advice from the Supporting People manager, the student arranged for Ryan to move to Hostel2, provided by a voluntary sector organisation that catered for an adult male population. The hostel support worker contacted the social work student three days later to say that Ryan was not cooperating and they wanted a meeting that would include YOS staff.   79. In supervision the social worker noted that apart from awaiting his move to the Pathway Planning team, there were no other matters relating to Ryan that required discussion. In the middle of the month, Ryan received a final warning from the YOS in relation to him missing his unpaid work. The social work student completed a case summary that stated that Ryan needed to register with another, more local GP; he was not in education; and there were concerns about his behaviour.   80. Near the end of the month, the social worker undertook the statutory LAC visit to Ryan who agreed to meet the hostel support and Pathway Planning workers. At a meeting at the hostel next day, Ryan reluctantly agreed to attend sessions with the support staff – a requirement for maintaining the placement. The Pathway Planning team worker contacted Leeds Housing Options to set up the arrangement that would allow Ryan to bid for council properties.  Month 8  81. Having been charged with an offence Ryan was bailed for two weeks early in the month and made subject to an Intensive Surveillance and Support order. He cooperated well. When he returned to court for sentencing 16 days later, he was made the subject of another Youth Rehabilitation Order with an Intensive Surveillance and Support Order. The latter requires young people to be seen on a daily basis for the first three months and to be subject to a curfew, in Ryan’s case between 9.00pm and 7.00am with an electronic tag. It is a demanding programme and Ryan struggled to comply. He returned to court on three occasions for breach proceedings and each time the court agreed to allow the order to continue. Although Ryan did not fulfil the expectations of the order fully, he did derive considerable benefit from the contact with staff.  82. YOS staff reviewed the vulnerability management plan and identified an emerging issue of concern as Ryan’s reports of intimidation from other adult offenders. He was never specific about the threats made to him but indicated that they were connected to the supply of drugs. Staff were sensitive when 21 making arrangements to meet Ryan to avoid areas of the City where he felt unsafe. This information was shared with the Police and they were active in seeking to assist but Ryan did not provide further information. The lack of detail about the individuals concerned meant they could not investigate the matter further.  83. The case transferred within CYPSC to the Pathway Planning team. During a visit to Ryan near the end of the month, the social worker advised him that he was not currently in a position to make housing bids because the continual breaching of his court order meant that he would lose any tenancy. The following day, the hostel worker advised Ryan that the amount of damage caused by him and another resident was unacceptable.   84. The next day, the social worker received notice from Hostel2 of Ryan’s immediate eviction as a result of an incident the previous night. The social worker spent considerable time, including liaising with the Supporting People team, in order to arrange alternative accommodation. The manager in the Supporting People team requested that a case conference should be convened in view of the complexity of Ryan’s needs. Ryan spent at least one night in a voluntary sector resettlement hostel where residents can stay for up to six months whilst seeking permanent accommodation. It caters for adult males who are mostly offenders. By the end of the month, he had returned to Hostel1. The social worker noted in supervision that day that Ryan was not happy in his accommodation. It was agreed that the social worker would contact previous bed and breakfast accommodation to enquire whether he could return there.    Month 9  85. During a visit from his social worker early in the month, Ryan said that at times he felt he wanted to be violent to people. He agreed to the social worker arranging therapy for him but said that it had not worked in the past. Six days later, Ryan expressed concern to his social worker that a young person moving into Hostel1 wanted “to beat him up”. The social worker moved Ryan back to Hostel3.   86. In the middle of the month, YOS staff requested a meeting to discuss the risk Ryan presented to others, which the social worker duly arranged for later in the month. The following day, Ryan was arrested. He was held in custody overnight but no further action was taken. The social worker explained in an email to the YOS and Supporting People workers that it was not possible to pursue a council tenancy for Ryan because of the risk of him going into custody. He was due to be breached for non-compliance with the ISSP order.  87. YOS staff and the social worker met a week later to discuss a recent incident when Ryan had been physically aggressive. This was the first evidence of such behaviour. It was acknowledged that Ryan was at risk of a custodial sentence. Further action to support Ryan in relation to his offending behaviour was agreed.  22  88. Just before the end of the month, the social worker noted in supervision that Ryan had been breached for not complying with the conditions of the ISSP; his risk status had risen to medium; the application for council housing had been made.  Month 10  89. Early in the month, YOS sent Ryan a formal and final warning about his missed appointments. Ryan attended his LAC review at which the IRO noted the repeated request from Ryan to have contact with specific relatives, and a further request for information about his father’s family. (The IMR author notes that this same action was included in two previous LAC reviews and there is no record that any action was taken.)  90. In addition, where Ryan had previously refused offers of counselling, he was now willing to consider the same. The action from the review was for the social worker to make a referral to the therapeutic social worker as soon as possible.   91. Ryan appeared in court accompanied by his social worker, for non-compliance with the ISS programme. He was given four weeks (again) to comply or would face a custodial sentence. Ryan told his social worker that the YOS worker was trying to get him sent down. The social worker took him to the ISSP that day but Ryan failed to attend the following day. He did, however, keep an appointment about his housing with the Supported Independent Living Scheme worker.   92. In the middle of the month, Ryan visited his social worker and said he had been thrown out of Hostel3. The social worker confirmed that Ryan still had a place there despite an incident that had occurred. Ryan indicated his determination to be thrown out on the basis of his belief that he could not be breached if homeless. Ryan failed to attend the ISS programme on three out of the next four days. He was then arrested. He attended various sessions at YOS.   93. Also at this time, the Supported Independent Living Scheme worker met Ryan to look at his housing papers and to make bids for flats.   94. The following day, Ryan was the subject of discussion at the Drug and Offender Management Unit (DOMU), a team responsible for managing the Deter Young Offender (DYO) cohort. This is a group of offenders identified by the YOS as presenting the highest risk of re-offending. Officers from DOMU work closely with staff from the YOS to manage the DYO cohort. Following the meeting, there was an increased level of activity from DOMU officers reflecting the concerns about Ryan’s poor compliance with the YOS and the associated heightened risk of re-offending.  23 95. One day later, the Housing Support Service received a care leaver referral for Ryan. The application attracted an additional needs classification and was backdated to Ryan’s 16th birthday.   96. Over the next 18 days, Ryan’s compliance with the ISS programme was spasmodic. A police officer from DOMU was due to meet with Ryan about his fears of attending YOS because ‘people were after him’. Ryan failed to turn up. He appeared in court for breach of the ISSP order: the outcome was that the order should continue with a three-month curfew requirement and electronic tagging in addition to the original sentence. However, Ryan continued his pattern of part-compliance.   Month 11  97. In the middle of the month the social worker was contacted about a letter inviting Ryan to view the new-build council accommodation for which he had made a bid.   98. Four days later, Ryan received a final warning about his non-compliance with the curfew. That night, Ryan was arrested and held in custody so could not attend the housing open day the following day. Subsequently, Hostel3 indicated that they did not want Ryan back. In a case discussion, the social worker stated that Ryan had exhausted all the accommodation options.   99. The Supported Independent Living Scheme and Pathway Planning workers found Ryan overnight accommodation in another hotel. The social worker later negotiated for him to stay longer. Leeds Homes received a bid for a council property. The Supported Independent Living Scheme agreed to offer a trainer flat to Ryan and the social worker applied for his leaving care grant.   100. Later in the month, Ryan made a trip to an adult prison as part of an initiative within his ISS order aimed at deterring young offenders: ‘Prison Me No Way’.   101. Two days later, Ryan received the offer of a tenancy from one of the arms-length management organisations within Leeds City Council.  He subsequently viewed and accepted the property. Four days afterwards he was arrested and charged with possessing a controlled drug. He was also not complying with his ISS order by failing to attend sessions.   Month 12   102. At the beginning of month 12, Ryan attended an interview with a police officer to discuss his lifestyle and welfare, and identify what additional help and support he needed. The record indicates that Ryan was not amenable to help and support at this time.   103. Ryan failed to appear at court and a warrant was issued for his arrest. Two days later, he was arrested and appeared in court, the outcome being that the ISS order was to continue with an additional three-month curfew. He did not attend ISS sessions the next day and a week later received a final warning for 24 his failure to comply with the ISS programme. Meanwhile, the Supported Independent Living Scheme advised the YOS that Ryan’s flat would be ready in two weeks.  104. In supervision, the social worker from the generic childcare team (who remained involved until the case transfer was fully completed) noted that Ryan was getting on well with the Pathway Planning social worker. Agreed actions were that the social worker would discuss Ryan’s education with Connexions and ask the LAC nurse to see him about his dental health, Ryan having agreed the latter.   105. The following day, Ryan received a final warning from YOS for curfew violations.   106. Five days after receiving the final warning, Ryan signed up for his tenancy with his social worker acting as trustee and an agreement that the Pathway Planning team would pay his rent until he was 18. He began buying items for the flat.   107. Later that day, Ryan was arrested and detained in custody to appear at the next available court. He was subject of a risk assessment as part of the custody booking-in process, and answered in the negative to all the questions relating to any concerns about his physical and mental health. Subsequently, Ryan did not have an appropriate adult present when questioned because he was over 17 years and was not assessed as a vulnerable person who required such support.  108. Having received legal advice, Ryan was placed in a cell and began to bang his head and fists on the cell door. He was abusive to staff and refused to see the SERCO nurse. His risk was re-assessed by the custody sergeant and nurse and they formulated a care plan that stipulated that Ryan should be visited every 30 minutes and roused should he fall asleep, in view of the bangs to his head.  109. Ryan appeared in court the next day. He was remanded into custody and transferred from court to the Young Offender Institution. The escort form from court stated “Previous self-harm by banging head on cell wall” but gave no further information as to when or why the incident occurred. Ryan later told the nurse that he had received the injuries (grazes to his knuckles and forehead) during a fight two days previously. Any indication of self-harm should be notified to the receiving establishment on a specific form. The YOI did not receive any such notification.  110. On admission, in line with normal practice, Ryan underwent a comprehensive risk assessment process by staff, including a registered nurse. The interviews covered an assessment of: o immediate and longer-term welfare needs; o any vulnerability concerns; o any risks posed to individuals with whom he might share a cell; and o a full health assessment including mental health.   25  111. This assessment was considered alongside information received from West Yorkshire Police and the Youth Offending Service, including the lengthy ASSET document, which together provided a comprehensive profile of Ryan throughout his formative years up to the present time. There was no indication in any of these documents or from the interview with Ryan that he posed a risk of self-harm. All such documents are held electronically in the YOI so as to be available to any member of staff as necessary.  112. Ryan underwent a ‘first night in custody’ interview with a member of staff trained to complete such a task. There was no indication of any risk of harm to self.   113. On reception, Ryan was allocated a key worker whose role was to support him throughout his time in custody. The latter had regular contact with Ryan on the unit and held two formal meetings during the 20 days he spent in the YOI: his five-day remand review and another review. The key worker drew up a remand plan that was maintained throughout his period on remand.   114. A doctor saw Ryan on day two and noted that he was calm and relaxed, and was assessed as having no suicidal thoughts. The nurse saw him again and advised him of the need to complete his immunisations, which he refused.  He also had a routine sexual health screening.  115. The Chaplaincy team conducted an initial interview with Ryan after which he attended Chapel services on two occasions. Staff described him as quiet and unassuming. Ryan later indicated a wish to be baptised and participated in baptismal preparations the same day.   116. Ryan spent the first six days on the ‘first night in custody’ suite and underwent a full induction programme. During his five-day remand review, attended by both his YOS worker and social worker. He declined any assistance with substance misuse (although it was part of his remand care plan); said he felt settled and had no concerns regarding self-harm; and only required help with writing and finding accommodation on his release.   117. Later that same day, there was an incident of note during which Ryan verbally abused and threatened a member of staff and caused damage to his room. He moved the following day to another residential unit, the aim being to de-escalate the situation and provide him with a fresh start. It is, in any event, common practice to move to another unit within this time frame. Ryan appeared before a Governor and received a punishment based on a tariff system that takes into account any mitigating circumstances.    118. Ten days after being detained in the YOI Ryan appeared at court in Leeds. Staff, including a nurse, interviewed him on his return and raised no concerns about him.   26 119. A worker from the Young People’s Substance Misuse Service within the YOI saw Ryan on two occasions but he declined involvement with the service, stating that he had no current drug dependencies.   120. Five days after he appeared in court, the Connexions personal advisor in the YOI visited Ryan to complete his Individual Learning Plan that set out what he wanted to achieve whilst in custody. The worker discussed the courses available within The YOI but Ryan expressed no clear idea about what he wanted to do.   121. 20 days after being detained in the YOI, Ryan was found dead in his cell room. The details are set out in the first section ‘Summary of events leading to a Serious Case Review’.   7. ANALYSIS  Analysis based on the Terms of Reference   122. The terms of reference agreed by the LSCB are considered in turn below, whilst also taking into account the purpose of Serious Case Reviews as set out in WTSC guidance.   Was adequate support provided to the subject to ensure his safety and wellbeing whilst he was living independently in the period leading up to his remand?  123. In the 12-month period up to his remand to custody, there were seven agencies that had substantial and/or significant involvement with Ryan. These were: • The Youth Offending Service (YOS) who supervised him almost continuously as a result of his offending behaviour; • NHS Leeds Primary Care Trust whose LAC nursing team assessed Ryan and provided or offered him access to health services; • Housing Services who provided advice about accommodation and ultimately offered him a tenancy; • The Supported Independent Living Scheme, which provided advice and ongoing support in relation to accommodation, training and employment; • West Yorkshire Police who arrested and held him in custody on 36 occasions during the period covered by this review;  • The Young Offender Institution in whose custody he was held for the last 20 days of his life; and • Children and Young People’s Social Care in whose care Ryan remained under a care order.  124. In some of these agencies, more than one worker was involved with Ryan. He experienced four social workers, including two social work students, in the generic child care team before being transferred to the Pathway Planning team.  The latter is the specialist team responsible for care leavers and young 27 people, such as Ryan, who remain subject to a statutory order but who are moving to greater independence. The YOS has different workers for the different programmes they administer, such as the bail support programme and the intensive supervision and surveillance programme.   125. Both CYPSC and YOS have recognised the difficulties for a young person of having a range of workers involved at any one time, a situation that hardly supports the development of a sustained and meaningful relationship. It also runs the risk of inconsistency in the response to the young person. For a young person like Ryan this situation is highly significant as, so far as the Panel is aware, he lacked any consistently positive and meaningful relationship with any other young person or adult.   126. The YOS Panel representatives reported that the service has been restructured to ensure, wherever possible, that one case manager holds a case involving a number of different staff throughout all the court orders. Other staff will necessarily have to be involved as well but the case manager provides continuity.   127. The CYPSC is reviewing its looked after children service and is planning a restructure to four locally-based 13-plus teams in order to reduce the unnecessary change of social worker. In each instance the motivation to make some change pre-dated Ryan’s death. It is a welcome development that both services are considering the implications of discontinuous relationships when young people are likely to have suffered poor or damaging attachments previously.   128. The overview report author now considers the input of the various services in turn.  Youth Offending Service  129. The YOS had almost continuous involvement with Ryan during the last 12 months of his life, as well as substantial involvement in the previous three years. Staff worked very hard to help Ryan to change his behaviour, by providing support and confronting him with the consequences of his activities. Their immediate focus was his offending behaviour but they also took account of, and sought to assist with improvements to, other aspects of his life (such as substance misuse) that had an impact upon his offending. Ryan was not easy to help as he fluctuated between positive compliance with the programmes resulting from the court orders and hostile rejection of both court requirements and the support proffered. The IMR author considers that staff persevered beyond normal expectations despite the occasions when Ryan failed to cooperate. As an individual service, YOS made tremendous and positive efforts to help Ryan, including liaising with the other services involved. However, the service operated too much on its own and did not secure the full involvement of other agencies, and CYPSC in particular, in agreeing actions on a multi-agency basis to ensure Ryan’s safety and wellbeing.  28 Health service  130. The LAC nurse made considerable effort to contact Ryan and assess his health needs as a looked after child shortly before his 15th birthday and again soon after he was 17; and to offer health services to him. Following the second of these assessments, she advised the social worker, both verbally and in writing, of her concerns about Ryan’s lifestyle and disregard for his health; she received assurances that action was in hand to deal with the concerns. However, the LAC nursing team was not being invited to attend or contribute to the LAC reviews and so had no way of knowing whether matters relating to Ryan’s health were receiving attention. Ryan never completed his registration at a GP practice nearer to where he lived, which might or might not have encouraged him to seek medical attention. His evident self-neglect was a clear sign that Ryan was not in control of his life and should have triggered a better response involving a discussion between key agencies to decide what realistically could be achieved. The LAC nursing team could have played its part in ensuring this happened.  Accommodation and housing support services  131. After his 16th birthday, Ryan began spending increasing amounts of time away from his second foster home. By the time he was 16½, the foster placement had ended (though the precise reason and timing of this are not recorded). The options for a young person like Ryan thereafter became limited: there was no formal remand-fostering scheme in Leeds at that time. Ryan said that he would not consider another foster placement but may have accepted a scheme specifically geared to his needs. There is no evidence that staff considered a residential placement within CYPSC, and a supported tenancy or training flat was either not available or not acceptable to Ryan because of its location, the latter linked to his fear of other unknown persons. Thus, despite the recognition that Ryan was unlikely to succeed in a tenancy on his own, the plan became, by default, to pursue an independent living arrangement for him: he was now aged 16½ years.   132. From this time onwards, accommodation became a problematic and time-consuming matter. Over the 12 months prior to his death, Ryan lived with relatives, in a bail hostel, in three hostels for homeless males aged 16 upwards (one of them on two occasions), and three bed and breakfast hotels, two of them on two and three separate occasions. Each arrangement ended as a result of incidents of aggression on Ryan’s part (sometimes involving offending behaviour), save once when the social worker moved Ryan because he was in fear of another resident. On one occasion, Ryan pretended that he had been evicted from a placement in the belief that he could not be breached by YOS if he were homeless and then remanded into custody – an indication of his sense of desperation.  133. Panel members agreed that there was an insufficient range of accommodation options in Leeds that was suitable for young people like Ryan who are challenging but also have high support needs.  At the same time there was an absence of sufficient forward or contingency planning for Ryan 29 that attempted to insert some coherence and consistency into his situation. The placements were all responses to crises, which is not an efficient or effective basis on which to make plans.   134. Housing Options provided assistance to the social worker in arranging a hostel placement on the first occasion but declined assistance thereafter, quoting the legislation that places on CYPSC the duty to arrange accommodation for a looked after young person. The IMR author for housing services acknowledges that, although legally correct, this was an unhelpful stance and not conducive to fulfilling the City Council’s corporate responsibility towards its population of looked after children. However, he rightly asserts that having to respond to crisis situations inevitably limited the options available and did not help the formulation of longer-term plans. In addition, it no doubt did little to enhance positive relationships between the two departments.   135. The Housing Service IMR makes clear that the two hostels in which Ryan was placed are commissioned by the Supporting People service and hence subject to monitoring. In addition, staff undertake a risk assessment to be sure that young people are not put at undue risk from being placed alongside adults, some of whom will be offenders, including sex offenders. In Ryan’s case, there is evidence that his behaviour, in fact, put other residents at some risk and he was, as a consequence, evicted on more than one occasion. This is evidence of a young person whose life was getting out of control where his risk to others became a focal point and the underlying vulnerability was overlooked.  136. The Children and Young Persons Act 2008 introduced a general duty on the local authority to secure sufficient accommodation within its area to meet the needs of its looked after children. The Panel did not have evidence that Leeds City Council has reviewed its provision for looked after children population in the light of this legislation.  137. The Supported Independent Living Scheme began their involvement with Ryan five months before his 17th birthday and 13 months before his death. Workers drew up plans to guide their involvement though it proved difficult to maintain contact with Ryan and hence fulfil their objectives. There is evidence of regular liaison by the Supported Independent Living Scheme staff with both the CYPSC service and YOS and of attendance at LAC reviews.   West Yorkshire Police  138. West Yorkshire Police had substantial involvement with Ryan from the start of the period covered by this review until his remand to custody shortly before his death. Two months before Ryan was remanded to custody, his case was discussed at DOMU following nomination by YOS.   139. DOMU is the umbrella department for several crime reduction programmes and initiatives within West Yorkshire, with five district hubs across the area. Each hub accommodates a multi-agency partnership team, including 30 personnel from the Police, Probation, Youth Offending Teams and Prisons plus substance misuse experts, housing advisers and staff to assist with education and training. The Deter Young Offenders programme focuses on young people aged between 10 and 17 years who have already been sentenced to a community order or detention and present the highest risk of re-offending. There is clear evidence of the programme’s efficiency and effectiveness in reducing the level of re-offending.  140. YOS referred Ryan because of his poor level of cooperation during supervision, linked to a negative attitude towards staff. He was accepted on to the programme and a police officer nominated to work with him. It was agreed to review the situation in 12 weeks or sooner should circumstances indicate the need. However, Ryan rejected the officer’s approaches, either failing to attend arranged interviews or to cooperate despite positive efforts from the Police.  At this juncture in his life, Ryan was entrenched in his opposition to offers to help him.   141. On a number of occasions during the last 12 months of Ryan’s life, he informed his social worker and YOS staff about people “being after him”. When the concerns were raised with the Police, Ryan refused to provide any detail so making it impossible to proceed. However, this type of information should have featured as part of multi-agency discussions in relation to Ryan so that agencies could assure themselves that all the relevant information had been shared and necessary steps taken to protect him.  The Young Offender Institution  142. The role of the YOI is considered in a later section.  Children and Young People’s Social Care  143. There is evidence of the social workers involved with Ryan responding to his concerns and demands promptly; they discussed his case in supervision, and dealt with the regular crises in his life, in particular his homelessness and offending. However, the response was reactive rather than a proactive approach to assessing and planning for Ryan on the basis of the information available from the various agencies involved. During a supervision session two months after Ryan’s 17th birthday, the social worker noted that apart from awaiting his move to the Pathway Planning team, there were no other matters relating to Ryan that required discussion. This came at a time when, a few days previously, the LAC nurse had raised concerns about Ryan’s self-neglect; Ryan had reported that he was at risk from other people; he was not in settled accommodation and his level of offending was considerable. This assessment amounted to a failure from a social care team to fulfil its responsibility for young people looked after.   144. At three LAC reviews, there are references to Ryan asking to have contact with family members and to know more about his father’s family. There is no evidence that the social worker followed up these requests, despite them being agreed as actions from the review. This lack of response can only have 31 served to increase Ryan’s sense of his worthlessness in that his reasonable requests merited little attention. It may not have been appropriate for him to have contact with the family members but for the request to be ignored on more than one occasion demonstrates a lack of care and sensitivity.   Conclusion  145. There is evidence of positive interventions and much energy and activity devoted to Ryan. There is also no doubt that he was difficult to help and that he rejected proffers of support or did not cooperate with agreed interventions. However, the plethora of interventions did not add up to a sufficient plan designed to ensure his overall safety and wellbeing. Too many of the interventions were responses to a crisis and, as such, were not an efficient or effective use of resources. Ryan may not have responded positively whatever the arrangements made for him but was entitled to expect a coordinated plan for providing support that included contingency planning to manage crisis situations. This was particularly important in the absence of any other responsible or actively caring adults. As such, the nature of the support provided to him was not adequate to ensure his safety and wellbeing in the period leading up to his remand.  Were mental health services appropriately involved?  146. According to Better Mental Health Outcomes for Children and Young People, emotional wellbeing has been defined as: “a positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment.”  147. When Ryan was aged 13½, the foster carers and school were clearly struggling with his behaviour, which exhibited the symptoms of a conduct disorder: defiance, physical and verbal aggression, offending behaviour that in turn led to truancy and exclusions from school, and the breakdown of the foster placement.  148. The significance of a conduct disorder is not to be underestimated.  Better Mental Health Outcomes for Children and Young People states, “conduct disorder is the most common mental disorder in childhood. By the time they are 28 years old, individuals with persistent antisocial behaviour at age ten have cost society ten times as much as those without the condition.” According to the Office for National Statistics, in a study carried out in 2004, conduct disorder is the most common disorder amongst the one-in-ten 5-16 year-olds defined as having a clinically significant mental health problem.  149. From the time of their initial involvement, the YOS assessments of Ryan identified strong indicators consistent with conduct disorder as above, as well as a dismissive attitude towards offending and a view that crime was a way of life. Subsequent assessments, including a risk assessment by the social work student when Ryan was 16½ , identified a series of further, serious concerns about Ryan and his lifestyle.  32 150. Ryan’s father died two days before Ryan’s sixteenth birthday. Ryan refused the offer of counselling subsequently made by his social worker.  The Panel became aware latterly that Ryan had been in contact with his father in recent years and was, in fact, present when his father died. There is no indication from any of the other information presented to the Panel that those involved with Ryan were aware of these events.   151. According to the CYPSC IMR, it was reported that Ryan became emotionally distant after his father’s death, and the YOS worker recorded that Ryan had previously expressed a wish to get to know his father better.  152. In month 1 of the last 12 months of Ryan’s life, concern was expressed to the social worker that he was not looking after himself and a request made that he be placed in secure accommodation. The social worker noted in month 2 that Ryan had made a reference to other people being ‘after him’ – subsequently a recurring theme. In month 8, the YOS reviewed Ryan’s vulnerability management plan and identified an emerging concern about intimidation from adult offenders. At the Health Needs Assessment undertaken by the LAC nurse two months Ryan affirmed that he was not worried about his health and felt happy with his life yet, in month 9, he admitted to his social worker that at times he felt he wanted to be violent to people. Ryan agreed at this point to a referral for therapy although he said it had not worked in the past.   153. Throughout the 12-month period leading up to his death, Ryan engaged in risky behaviour and neglected himself. At no time, however, did he give any indication that he would directly harm himself. The incident in Police custody when he banged his head and fists on the cell door occurred at the point he was remanded to custody and the Panel was not made aware of any earlier incident, although Ryan’s mother has said that there had been a previous incident of self harm when Ryan was in a police cell. This incident would not, on its own, have led staff to consider that Ryan presented a danger to himself. But his overall behaviour conveyed a sense that he did not value himself.  In turn, he behaved in a manner that alienated those around him or, at least, made it very difficult for them to help him. Despite the level of concern about his lifestyle and emotional wellbeing, none of the agencies considered a referral to mental health services. The social worker offered counselling or therapy but did not take action when Ryan finally indicated his willingness to a referral.  154. Panel members heard from the General Manager for Safeguarding, Child and Adolescent Mental Health Service (CAMHS), that those cases of children and young people diagnosed as having a conduct disorder amount to almost one third of the service’s caseload. In addition, the service has successfully piloted multi-systemic treatment for hard to reach 11-18 year olds and their families, and has increased the availability of this intervention as a result of funding secured from the Department for Education, with strong support from CYPSC.  155. The General Manager indicated that, in the case of a 16 year old who is causing workers a lot of concern, the first step is a referral to the monthly Therapeutic Services Prioritisation Panel, which can refer on to CAMHS or the 33 therapeutic social work team: a (long-standing) dedicated service for looked after children and young people that offers direct work with the child or young person or consultation and advice for staff. In addition, he noted that there are three and a half full time equivalent CAMHS workers in the Youth Offending Service. The overview report author has looked at the CAMHS information leaflet for professionals, which is concise and informative about the process and criteria for referrals to the service.  156. Improving the emotional and behavioural health of looked after children and young people includes a review of the evidence about which interventions work for young people. On the basis of current knowledge, they conclude that enhanced foster care and multi-systemic therapy have the best chances of success, including a positive effect on offending behaviour. The Panel heard that Leeds has a specialist-fostering scheme and information about its multi-systemic treatment service is referred to above. What prevented staff from appreciating Ryan’s need and referring him for therapeutic input?  157. The lack of adequate multi-agency planning for Ryan is considered in a later section and better planning may have identified the need for therapeutic input. The IMRs indicate that staff said in interview that Ryan would not have cooperated with a referral to mental health services, and his level of cooperation with services offered to him was indeed variable. However, there were occasions when he worked well with YOS interventions, and there is evidence of positive involvement with the alternative education provision during a six month period prior to his 16th birthday.  In addition, in month 2 of the 12 month period prior to his death, he agreed with his social worker that he needed more support and the following month a referral went to the Supported Independent Living Scheme who subsequently became involved in supporting Ryan. In month 9, Ryan agreed to the social worker arranging therapy for him (on an occasion when he expressed feelings of violence towards other people), despite asserting that it had not worked in the past; at his LAC review in month 10, it was noted that Ryan was now willing to consider counselling and an action was for the social worker to refer him to the Therapeutic Social Work Service. However, there is no evidence that the referral for therapeutic input was made on either occasion. It was as though the social worker did not appreciate the extent of Ryan’s malaise and the urgency of his situation and was responding to a specific event in his life – though this in no way justifies the inaction.  158. It is not possible to second-guess whether Ryan would have responded positively to an intervention from CAMHS or the Therapeutic Social Work Service. The overview report author concludes that Ryan’s lack of cooperation could be linked to a sense that there was little point in making the effort to change things: adults let him down (such as, not following up the action from no less than three LAC reviews to explore contact with family members and to find out more about his father’s family).   159. However, irrespective of how Ryan responded, a referral should have been made to the Therapeutic Services Prioritisation Panel to allow discussion of his current needs whilst taking account of his historical circumstances. If Ryan 34 would not accept a therapeutic service, staff would have benefited from advice about how to intervene more effectively. By failing to recognise his needs (or in the case of the social worker, not taking action to make a referral), staff were responding to Ryan’s presenting behaviour rather than understanding and assessing the underlying causes of that behaviour.  160. Apart from the need for therapeutic input, it is clear that Ryan lacked a pivotal and stable carer who would provide boundaries to give him some sense of security but, who he also knew, would ‘look out for him’ and ‘fight his corner’: in other words be a surrogate parent to him. At this stage, all the evidence indicates that he had little reason to care about himself or the effects of his behaviour on others. Staff from the various agencies involved with Ryan, and the YOS staff in particular, made considerable efforts to assist him but their input is necessarily professional and impartial. Ryan had no one person with whom his relationship was special for him alone.  Conclusion   161. Ryan may have suffered from a conduct disorder but this cannot be confirmed. Nevertheless, his behaviour was both socially unacceptable and deeply concerning. The evidence indicates that the focus of attention by professional staff was upon the manifestations of his behaviour rather than the underlying emotional turmoil. The nature of his highly problematic behaviour inevitably forced attention upon it. However, there was insufficient regard to the reasons for that behaviour. Mental health, including therapeutic, services were not appropriately involved to assist staff in understanding Ryan’s behaviour and planning appropriate interventions.    What support was in place to ensure that the subject was either in education or employment?  162. Ryan’s time in secondary school falls outside the 12-month timescale set for the serious case review. However, the Education Service has provided detailed information in its IMR, which is highly relevant to understanding Ryan’s experiences. From when he was 13 years old until he left school at 16, Ryan had serious difficulties in school as evidenced by the number of exclusions, some of which were for serious incidents of aggression.   163. The first school arranged a ‘managed move’ to another school but the IMR author notes that the process was “unstructured, not conducive to effective transition, not child centred” and hence “unlikely to meet Ryan’s needs”. The move proved ineffective in that it lasted only two months before another serious incident precipitated Ryan’s exclusion and return to the first school. Following an unsuccessful reintegration, Ryan began to attend alternative provision with four different providers. Some reports from them indicate that Ryan was receptive to learning if given the right opportunity.  164. The school made efforts to avoid a permanent exclusion of Ryan, albeit with two lengthy periods of authorised absences and an unsuccessful move to another school. However, records on Ryan were not adequate and there was 35 a less than thorough adherence to policies relating to looked after children.  The school did not fully complete or maintain a Personal Education Plan, or develop a Behaviour Support Plan, despite it being an action from a LAC review meeting.  School staff attended the LAC reviews but there is no evidence of internal meetings to discuss the management of Ryan in school.  All this is indicative of insufficient action to support a young person who was without doubt challenging yet highly vulnerable.   165. At the point that Ryan completed his full-time education, there is no indication of discussions with him about his future. In fact, there are very few references in the management reviews to discussions regarding his further education, training or employment opportunities. Agencies were reacting to the immediate challenges that Ryan presented rather than taking a longer-term approach based on a full assessment, in the context of his personal history, or his current and future needs.   166. Leeds City Council has produced a leaflet, entitled ‘Our promises to you’, that summarises its promises to its population of looked after children. This reflects the City Council’s understanding of its role as corporate parent, a concept - introduced by central government in 1998 as part of the Quality Protects initiative - that places collective responsibility on councils to achieve good parenting for all their looked after children. The Minister said that councils should judge the quality of their provision to looked after children by asking: “would it be good enough for my child?” The concept reflects evidence demonstrating that looked-after children experience poorer outcomes than other children across a range of measures, including health and education, as a result of their circumstances and experiences. Information about educational attainment from the Department for Education in December 2010 demonstrates that a third of children previously looked after are not in education, employment or training at age 19 (Statistical data on educational attainment of looked after children).   167. The revised Children Act 1989 Guidance and Regulations relating to care planning (March 2010) states (paragraphs 1.14 & 1.15): “The role of the corporate parent is to act as the best possible parent for each child they look after and to advocate on his/her behalf to secure the best possible outcomes. However, they cannot fulfil this responsibility without the full cooperation and support of a range of other agencies which provide services to children and their families”.  168. In Leeds City Council, there is a Corporate Carers’ Elected Members’ Group and also a Multi-agency LAC Partnership of agencies with responsibilities towards looked after children in the city.  The Panel has not received information about the terms of reference of the Corporate Carers’ Group or what action it has taken in the interests of children and young people looked after in Leeds. The Multi-agency Partnership has recently been re-launched with revised terms of reference. The work plan has yet to be agreed but the priority for the first six months is to “coordinate work on a full review of the Looked after Children’s Strategy”. Some councils take positive action to offer looked after young people shadowing or mentoring opportunities within the 36 council, or trainee posts as an acknowledgement of their parenting responsibility.  Conclusion  169. In the leaflet Our promises to you, under the section Support you to achieve your goals in life, the City Council states its promise to: “provide you with support, guidance and the resources to help you achieve your goals in life” and “support you to find a job when you leave school”. Overall, there is limited evidence that this promise was fulfilled in respect of Ryan or that his future training or employment was made a priority.  Were links adequately made between services to address his offending behaviour and services to address his health and social care needs?  170. The agencies that had involvement with Ryan in the last 12 months of his life are listed in the section relating to the first of the terms of reference. In addition, the Education Service was involved until Ryan completed his compulsory education. There was evidence of much activity by the various workers involved and of regular communication and exchange of information between the various agencies. The question is whether the individual interventions of individual agencies and the totality of the interventions were sufficiently linked up to deal with Ryan’s needs effectively.  171. YOS operated in a structured manner in its approach to Ryan, as dictated by the court. There is clear evidence of liaison between YOS and CYPSC, although the YOS IMR makes the point that the quality of communication improved once Ryan’s case was transferred to the Pathway Planning team with their more specialist experience of young people.   172. YOS staff had more involvement with Ryan than any other agency, particularly in the 12-month period leading up to his remand in custody, and were, therefore, in the best position to build up a relationship with him. It is easy to see how the CYPSC social worker might, therefore, leave management of the case to YOS in these circumstances and only respond when a crisis occurred.   There is a telling comment from the team manager in month 5, when arranging for the transfer of Ryan to another social worker, to the effect that there was no meaningful relationship with the current worker. This may realistically have been so in view of the level of involvement from YOS. However, this was not a valid stance, undermining as it does the statutory role of the social worker in ensuring that a plan was in place that encompassed all Ryan’s needs and was based on agreement from the various agencies involved about their actions, as well as the views of the young person.   173. The LAC nursing team was not invited to attend LAC reviews on a regular basis and, although the responsibility rested with CYPSC to organise invites, the team had no system to alert them to this oversight. The exclusion of other professionals from LAC reviews can be deliberate and appropriate in recognition of the young person’s views. However, were that to be the case 37 (and there is no evidence one way or the other in relation to Ryan), there is an onus on the relevant personnel to obtain or provide information pertaining to the young person in order to inform the review.   174. The nurse in the YOS was not involved directly with Ryan. This is appropriate in circumstances where a young person is looked after and, therefore, is dealt with by the looked after children nursing service. However, in Ryan’s case, there was no liaison between the LAC nursing team and the nurses in YOS that would ensure a full exchange of information relating to Ryan’s health to inform planning for him.  175. The Housing Service, operating as part of the Environment and Neighbourhood Directorate, reacted to requests for assistance with accommodation but played no part in assessment of Ryan. This was appropriate in view of Ryan’s status as a looked after young person and hence the expectation that assessments would have been completed by CYPSC. However, whereas it is not expected that the Housing Service would take a lead role in responding to the difficulties that Ryan faced, their actions were limited in scope.   176. The Housing Service IMR author duly notes his department’s shared responsibility as corporate parent to looked after young people and the “inconsistencies in the service” provided to Ryan. He also refers to the protocol (Joint Working Protocol Between Environment & Neighbourhoods Directorate and Children’s Services Directorate – Provision of Accommodation for 16 and 17 year olds who are Homeless or Threatened With Homelessness) and recommends a revision to incorporate early intervention procedures when a threat of homelessness is apparent; and to clarify arrangements for placing 16/17 year olds in accommodation. This is welcome. However, the protocol does not specifically clarify responsibilities to young people who are or have been looked after and this requires attention.  177. CYPSC commissioned the Supported Independent Living Scheme to provide support to Ryan. It was not the responsibility of a voluntary sector organisation to initiate multi-agency care planning in respect of Ryan, though senior staff should reflect upon their responsibility to raise any concerns they might have had about the direction and overall management of the case with other agencies. It was incumbent upon CYPSC as the service commissioners to be clear about their expectations for the Supported Independent Living Scheme’s involvement and how it fitted with the work of other agencies.  178. Ryan was discussed at the Drugs and Offender Management Unit (DOMU) in month 10, having been nominated by YOS. A police officer from that unit sought thereafter to assist Ryan but to no avail. Ryan would have benefitted from a multi-agency approach at a much earlier stage of his life (see below), and it is incumbent upon both the Police and YOS to consider how they might raise their concerns about Ryan’s level of offending in a multi-agency forum. These two agencies were in a prime position to recognise that a young person was out of control, a situation that is more likely to lead to offending behaviour.  38  179. CYPSC had overall responsibility to undertake the planning for Ryan in view of his status as a looked after child. As such it was the social work team’s responsibility to: [i] coordinate the number of professionals involved with Ryan and [ii] agree a strategic approach to interventions when Ryan’s life was chaotic and at times out of control.  180. The revised Children Act 1989 Guidance and Regulations state: “The child’s care plan provides the overarching vehicle for bringing together information from the assessment across the seven dimensions of the child’s developmental needs [regulation 5] and from any other assessments of the child and his/her family. The health and education dimensions of the care plan are populated by the health plan [regulation 7] and the personal education plan (PEP) [regulation 5(b)(ii)].”  181. As such, the care plan builds upon the assessment that brings together information about the child’s developmental needs, parenting capacity and family and environmental factors. Assessment “is thus an iterative process which for some children will continue throughout work with the child and the family and caregivers. In order to achieve the best outcomes, the framework should be used also at important decision making times when reviewing the child’s process and future plans” (Framework for the Assessment of Children in Need and their Families [April 2000]).  182. There is no evidence in the social work records that Ryan’s needs were re-assessed during this difficult and highly problematic period of his life – or indeed in the previous three years. In addition, planning was undertaken within the forum of the arrangements for reviewing looked after children and did not include input from Health or the Youth Offending Service. The care plans drawn up for the purposes of the LAC review were not completed in full and give an impression that they were prepared in a formulaic manner to fulfil the requirements of statute, rather than being the vehicle whereby actions to support and sustain a young person - who was highly vulnerable and in considerable need - could be formulated and agreed. Ryan presented considerable challenges but that made it all the more important to formulate a plan that included the other relevant agencies.   183. Children and Young People’s Social Care had the lead responsibility for ensuring that effective planning took place. There is, in addition, a function enshrined within the Children Act 1989 (and amended and strengthened by the Children and Young People Act of 2008) that places a responsibility upon local authorities to oversee the provision of care to looked after children by independent reviewing officers (IROs).  “The independent reviewing officer must— (a) monitor the performance by the local authority of their functions in relation to the child's case; (b) participate, in accordance with regulations made by the appropriate national authority, in any review of the child's case; 39 (c) ensure that any ascertained wishes and feelings of the child concerning the case are given due consideration by the local authority.”  184. The CYPSC IMR confirms that the Leeds policy and procedure that were in place in 2010 specify “the responsibility of the IRO to accurately record actions and time scales and to follow up any actions not completed”. However, the IMR author notes that some actions were not specific as to what was required; they all lacked a completion date; and there was no record of the reasons why actions from one review had not been carried out by the time of the next review. This included Ryan’s request made in three reviews to have contact with family members and information about his father’s family. In addition, the IRO did not refer to the review team manager or operational managers the significant lapses in carrying out agreed actions from the review.  185. In Ryan’s case, the LAC reviews represented the only evident forum for reviewing the planning of his care and for involving, either in person or through written reports, other relevant agencies. Again, the process had all the hall-marks of an arrangement intended to comply with legislative requirements rather than ensuring that the needs of looked after children and young people were appropriately assessed; that meaningful plans were drawn up; and that action was taken for which individual workers (and their managers) were held to account. The Panel heard an acknowledgement from CYPSC that the reviewing unit was not functioning well during the period leading up to Ryan’s death.   186. However, the Panel was advised that substantial changes have now been made to address the problem, including robust arrangements for quality assurance, such that Leeds has now received national recognition of its sound practice. In addition, the overview report author has seen a recent document that sets out the role of the independent reviewing service and its key aims and objectives; this is in the context of an enhanced status for the service as reflected in an increased number and regrading of its staff. If the aims and objectives are translated into robust processes, this will substantially improve the arrangements for safeguarding looked after children and young people in Leeds.   187. In any event, the last year of Ryan’s life indicated the need for multi-agency planning via a professionals’ meeting. In this regard, other agencies had a responsibility as well as CYPSC. The YOS had considerable involvement with Ryan. It could have done more to insist on a coordinated approach to Ryan that sought to tackle the many other problems facing him that inevitably had an impact upon his offending behaviour. The staff in the looked after nursing team were rightly concerned about Ryan’s lifestyle and his risk-taking behaviour in respect of his health and overall wellbeing. The LAC nurse conveyed concerns to the social worker and received reassurances that the situation was in hand; but there was no follow-up, including ensuring progress at the point of the next review. The manager in the Supporting People team appropriately expressed the view that CYPSC should convene a case conference in order to discuss Ryan’s situation because it was so serious. 40 The social worker apparently did nothing about this proposal; equally, there is no indication that the Supporting People manager followed the matter up. When professionals in one service are not satisfied with the response from another agency, the facility to involve more senior managers should be clearly understood. The Panel understood that there is an escalation policy to allow for just such a situation.  Conclusion   188. Ryan’s record of offending was extensive and his life beyond his offending was chaotic and involved very risky behaviour. There is a clear link between offending and a lack of stability and emotional wellbeing in a young person’s life. Overall, the effectiveness of the interventions by the individual agencies involved with Ryan was considerably undermined by the failure to agree a multi-agency response that responded to his offending and his health and social care needs; and included contingency planning for the repeated crises in his life. In addition, the system of reviews for ensuring that appropriate care planning took place was ineffective and did not fulfil its function. All agencies bear some responsibility to ensure that appropriate planning takes place but CYPSC bears the major responsibility in view of its statutory duties in respect of looked after children.   Was sufficient consideration given to the young person’s vulnerability in a custodial setting (with reference to family contacts, peer relationships and bullying)?  189. The overview report author and SCR Panel considered this issue based on the information in the YOI IMR, Panel discussion and the exchange of letters in July 2011 between the Acting Assistant Ombudsman and the Governor of the YOI. However greater detail emerges from the investigation carried out by the Prisons and Probation Ombudsman and the key points have been incorporated within this analysis.  190. There is an admission process in place within the YOI whereby prison officers and health staff undertake a comprehensive risk assessment that includes reference to the mental health of trainees. The assessment takes account of information from the Police and YOS, including the ASSET document, thus providing an extensive picture of the young person’s current situation and history. Note is taken of whether this is a young person’s first time in custody. In Ryan’s case, the assessment revealed no concerns regarding his mental wellbeing and no indication of a risk of harm to self – in line with the assessments of other agencies. However, the Prisons and Probation Ombudsman comments that the mental health assessment relied on self reporting by Ryan as to his mental health needs and did not consider existing records.   191. Ryan’s mother referred in interview to the forms that accompanied Ryan from court to the YOI that included reference to the incident in the police cell where Ryan was held after arrest before appearing at court the next day: he banged his head and fists on the cell door but refused to see the nurse; the custody 41 sergeant and nurse then formulated a care plan to ensure his safety. She considered that this incident indicated Ryan’s vulnerability to self-harm and should have led to him being monitored accordingly. The escort form did not specify when the incident occurred and Ryan told the nurse during his health assessment on arrival at the YOI that he had sustained the grazes to his knuckles and head during a fight two days previously. Ryan was, therefore, managed within the YOI in the normal manner: that is, no exceptions were deemed necessary to take account of assessed vulnerability or risk of harm to self. The Prisons and Probation Ombudsman concludes that the note from the police about this incident of self-harm was “insufficiently followed up by staff at court and (the YOI’s) reception and also that “the first night vulnerability assessment was confused and there was scope for a fuller mental health assessment.”  192. Elsewhere, the overview report author concludes that, prior to Ryan’s remand to custody, staff from the range of agencies involved had not fully appreciated Ryan’s level of vulnerability. However, although Ryan lived a life that was harmful to himself, as far as can be ascertained, he had not deliberately inflicted physical injuries upon himself prior to this incident. Therefore, the overview report author considers that even if the form had correctly specified how the injuries occurred, they would not on their own have reasonably led YOI staff to consider that Ryan posed a risk of self-harming when set against the other evidence. Furthermore, day-to-day records reveal that Ryan portrayed himself at times as viewing his detention as a comfortable setting and, further, that he would be prepared to use violence against others.  193. Following the incident when Ryan was threatening and abusive to staff, he appeared before a governor who applied sanctions involving a number of deprivations. The IMR author judges that the adjudication award was “below the medium range punishment for this offence”. The YOI has instigated a Rewards and Sanctions scheme that, according to the IMR, Her Majesty’s Inspectorate of Prisons judged, at its visit to the YOI to provide motivation to trainees to behave positively. It concluded that the scheme was applied consistently across units.  Notwithstanding the above, the Ombudsman concluded that, in this case, the incident was not adequately investigated or documented, insufficient consideration was given to mitigating factors, the response was not child centred and the punishment was severe  194. The YOI allocates a key worker to each trainee on admission. In Ryan’s case, the officer had an initial remand review meeting with him shortly after admission and a further review took place after five days with his YOS worker and social worker in attendance. The purpose of these meetings is to set sentence plan targets in relation to behaviour; education, training and employment; family and personal relationships; and substance misuse. Additionally, residential personal officers provide the day-to-day support to trainees. However, although the YOI tries to maintain some continuity of care, the pattern of deployment of staff is subject to the overall demands of the establishment and the shift working arrangements. Advice from the Governor, reported to the Panel, is that the “personal officer scheme is in need of an overhaul and clarification”. In a similar vein the Ombudsman expressed 42 concern that, due to weaknesses in the personal officer scheme, there was limited scope for Ryan to have a member of staff whom he could trust and with whom he could share some of his concerns. Consequently the overview report author welcomes the recommendation arising from the YOI IMR to review how the establishment meets the specific needs of looked after children.  195. Prior to the night of Ryan’s death, there was no evidence that he was subject to bullying. He indicated on admission that he had problems with some young people outside the YOI but this did not translate into concerns raised about potential difficulties with any other trainees within the establishment. After Ryan died, other trainees from the YOI made allegations of verbal abuse and threats being shouted at and by Ryan on the night of his death, although relevant staff on duty that night did not make any record of such threats being made and have stated that they did not hear them.  These specific allegations remain unsubstantiated but during the Ombudsman investigation the investigators found that the “shouting out policy” was not implemented as it should have been. They concluded that whilst the YOI had good policies to tackle bullying, staff had not been adequately trained to implement them.  196. Trainees in the YOI have access to telephones by which to contact their family. Ryan used the phone twelve times during a nine day period shortly before his death to speak to family members but only spoke to people on two occasions for a very brief time.  197. The Panel was advised that another young person in the YOI attempted to hang himself 10 days prior to Ryan’s death. He was subsequently assessed as vulnerable and moved to a specialist Unit. There is some suggestion from other trainees interviewed after Ryan’s death that Ryan wanted to follow the same pattern. The Panel has discussed whether the YOI should have considered this Unit as an option for Ryan and the overview report author has looked at the relevant documentation about the unit.   198. The Unit is a national facility whose purpose is “to provide a specialist service to 15 to 17-year-old young men who for a variety of reasons are not engaging – or are unlikely to engage - with the normal regime in a young offender institution” (Placement Protocol). Placements in the Unit are co-ordinated by the Youth Justice Board. Having reviewed the referral criteria and considered how Ryan presented within the YOI, the Panel concluded that Ryan did not fulfil the criteria for admission and it was rightly not considered as an option. The Ombudsman reached a similar conclusion.  199. The Prisons and Probation Ombudsman concludes that it would have been extremely difficult for YOI staff to have identified the extent of Ryan’s vulnerability.  Nevertheless the report includes several criticisms of the way in which his vulnerability was assessed and the care he received.  The report from the Ombudsman contains 15 recommendations.     43 Conclusion   200. Whilst it would have been extremely difficult for YOI staff to identify the extent of Ryan’s vulnerability, there were specific occasions when assessments and/or communication should have been more thorough.  As a result of this insufficient consideration was given to his vulnerability.     Was the young person’s level of risk and vulnerability appropriately assessed and monitored (with defensible decisions to support assessments)? Was risk/vulnerability management and monitoring consistent with the level of assessed risk?  201. Ryan grew up in a variety of settings and faced a range of risk factors.  This review has found a lack of protective factors to help mitigate these risks.  202. Assessments by YOS, including assessments of Ryan’s risk and vulnerability, were appropriately completed according to nationally prescribed formats, and captured the current concerns about Ryan’s functioning. These assessments were translated into plans that were subject to regular review. YOS staff worked extremely hard with Ryan to try to maintain him successfully on the various programmes imposed by orders of the court, and to have an impact on issues that contributed to his offending, such as substance misuse. Staff liaised regularly with CYPSC to exchange information.   203. Staff within Health who had some responsibility for Ryan’s health and wellbeing included the GP, the LAC nursing team and the nursing team in the YOI. The GP did not see Ryan within the time span for this review but did receive copies of the LAC reviews. As the GP had no direct experience of Ryan, it is reasonable that he or she took no action in relation to any concerns that the LAC reviews might raise. Ryan never got round to completing his re-registration with another GP practice nearer to where he was based, despite the efforts of his social worker. It is not possible to conclude whether a transfer would have made any difference to his contact with health services but at least those services would have been more accessible to him.  204. The LAC nurse made considerable effort to track Ryan down and complete a Health Needs Assessment shortly after his 17th birthday and, subsequently, discussed concerns arising from that assessment with the social worker. The latter gave assurances that all matters were in hand and the nurse did not press the issue. Taken with the lack of involvement with the LAC reviews, the LAC nursing team had no assurance that Ryan’s health needs, which encompass his mental health and emotional wellbeing, were being properly looked after. In view of the level of concern on the part of the LAC nursing staff, they should have pursued the matter in order to satisfy themselves about the situation.   205. The Supported Independent Living Scheme completed an assessment, including an assessment of risk, and drew up plans for their involvement, to which Ryan signed up. Like other workers, they struggled to maintain regular contact in line with the agreed plans because Ryan did not live an orderly life 44 and keep to planned arrangements. The support worker assessed, rightly, that Ryan would need support if he were to maintain a tenancy successfully. Ryan had not previously had responsibility for managing a household and the experience up till then of him handling his finances was not promising. The decision, therefore, by agencies to support Ryan in having a council tenancy comes across as a desperate response. It was not a decision based on sound judgement and subject to robust planning that would have provided some assurance of success.  206. Within CYPSC there was no systematic approach to assessment let alone the assessment of risk; in fact, there is evidence of just one risk assessment undertaken by a social work student. There was no evidence of a core assessment following the foster placement breakdown when Ryan was 13 years old or a placement disruption meeting, which would have provided an analysis of what went wrong and an assessment of Ryan’s needs. It is as though having completed the care proceedings, the focus became solely about responding to Ryan’s current behaviour. The history and context, which explained who he was, were lost and, as a consequence, some understanding of why events turned out as they did.  Conclusion   207. Assessments during the period under review were not overall adequate. The YOS assessments took some account of family circumstances but for the purpose of their interventions focused upon current behaviour. CYPSC did not re-assess Ryan on a regular basis and there is no evidence of a recent assessment that reviewed his current functioning in the context of his problematic history. Again, their interventions focussed upon responding to Ryan’s behaviour rather than having an agreed plan that sought to respond to all his identified needs. As such, the author concludes that the significance of what had happened to Ryan in his early life was not understood and, therefore, his high level of risk and vulnerability was not taken sufficiently into account when formulating interventions.   The views of family members  208. Regarding the interview with Ryan’s mother, her concerns about the manner in which she learned of Ryan’s death, the time taken by the YOI to formally inform her of his death and her concerns about staff action in trying to resuscitate Ryan are outside the scope of this SCR and are rightly addressed in the report from the Prisons and Probation Ombudsman.    209. The overview report author has dealt with the issue of Ryan’s vulnerability to self-harm in an earlier section.   210. Ryan’s mother was critical of the service provided by the Pathway Planning team. The Panel was advised that a review of the service has been underway since February 2011 aimed at identifying gaps in the service and ensuring continuity of staff. The review should have regard to the conclusions of this serious case review before finalising its conclusions.  45 8. CONCLUSIONS & KEY LEARNING  211. The Inquest completed in January 2014 concluded that the death was accidental. From evidence produced for the Panel, there is no indication that Ryan expressed any intention to harm himself. In fact, when asked directly, he expressed satisfaction with his life, although the manner in which he lived his life suggested otherwise. Staff involved with Ryan, including those in the YOI, could not reasonably have predicted Ryan’s death. However, they were insufficiently alert to the emotional turmoil that underlay his overt behaviour.  212. There are clear indications that Ryan was vulnerable from early childhood, and stark evidence that, in the 12-month period leading to his death, there was acceleration in his personal difficulties and social exclusion. Staff focused their attention on the crises with which Ryan regularly presented them and did not stand back and consider the underlying causes of his behaviour. There was an absence of regular and thorough assessments and re-assessments of Ryan’s situation that gave due recognition to his vulnerabilities based on the level of risk factors and lack of protective factors in his life.  When Ryan was in the YOI there was insufficient assessment of his vulnerability and the care he received was not always child centred.  213. Whilst it is evident that Ryan had a close attachment to his first, long-term foster carers, this placement broke down when he was 13 years old and he never had a stable placement thereafter.  This is likely to have had an impact on his sense of security.   214. Agencies invested considerable time and money providing a range of interventions aimed at supporting Ryan, much of it positive and well planned at an individual agency and worker-level. However, the interventions were insufficiently coordinated and focused upon the symptoms rather than the cause of Ryan’s difficulties. The review system established to monitor the efficacy of care planning for looked after children failed in its purpose.  215. The review did not identify a causal link between Ryan’s death and services in the community. However, the efficiency and effectiveness of interventions were considerably undermined by the failure to agree a multi-agency response that included contingency planning for the repeated crises in Ryan’s life. This conclusion links to the City Council’s responsibilities as a corporate parent for its population of looked after children. The guidance makes clear that councils can expect the full cooperation of partner agencies in fulfilling these responsibilities. Evidence presented to the Panel suggested that those groups that had responsibility for ensuring the wellbeing of looked after children were not fully functioning.  216. There is some evidence of sensitivity to Ryan’s racial, cultural, linguistic and religious identity. There is also evidence of individuals ascertaining and taking account of his wishes and feelings. However, his frequent requests to have contact with family members and to know more about his father’s family were overlooked over a lengthy period.  46 217. At a personal level, the collective corporate system let Ryan down despite the best efforts and good intentions of individual members of staff. There was no one person who assumed responsibility for Ryan as a looked after child, ensuring that his overall wellbeing was promoted and safeguarded. The organisation legally charged with parental responsibility did not adequately discharge it.  9. RECOMMENDATIONS  218. A study of recommendations arising from serious case reviews 2009 – 2010 reports an impression that recommendations are becoming more clearly focused and specific though rarely few in number, despite repeated recommendations to the contrary: see in particular paragraph 8.52 of WTSC. The above study also notes:   “Putting the child at the forefront of our thinking and understanding is crucial. However there is always a tension in trying to learn from serious case reviews about whether we focus on the powerful learning from unique features of interactions in the individual case or whether we concentrate on the wider transferability of lessons and learning.”  219. All agencies involved in this SCR produced good quality IMRs that facilitated learning and contributed to the overall SCR.  None of the IMR authors had any operational involvement with Ryan and each was at an appropriate level of seniority for undertaking the review and challenging agency practice. In all instances, a more senior manager countersigned the report. The individual agencies made recommendations that were appropriate to them and progressed and completed actions in response.  The following recommendations are few in number and have wider application than this individual case. They also reflect the Panel’s understanding that changes and developments in practice pre-date this review.  1. The LSCB should satisfy itself that multi-agency arrangements for care planning and reviewing looked after children have improved and are efficient and effective.   2. The LSCB should satisfy itself that the programme of work being undertaken to improve corporate parenting responsibilities in Leeds includes promoting access to education, training and employment opportunities and enhancing emotional wellbeing.   3. The LSCB should review the sufficiency of provision of suitable, specialised accommodation for young people with high support needs, with a particular focus upon looked after young people.   4. The LSCB should promote more effective approaches to risk management and assessment of children and young people with complex needs.  47 5.  The LSCB should endorse IMR recommendations and require their implementation and should satisfy itself that actions are completed and embedded.   Learning lessons from serious case reviews  220. At the end of October, Ofsted published a report – Ages of concern: learning lessons from serious case reviews. It is a thematic report based on an analysis of 482 serious case reviews that Ofsted evaluated between 01 April 2007 and 31 March 2011. The main focus of the report is upon babies less than one year and young people aged 14 or above. It came to the attention of the overview report author after completion of the final draft of the overview report. However, the report conclusions in respect of young people aged 14 or over clearly resonate with the findings of this review and are reproduced below for reference:    Agencies had focused on the young person’s challenging behaviour, seeing them as hard to reach or rebellious, rather than trying to understand the causes of the behaviour and the need for sustained support;   Young people were treated as adults rather than being considered as children, because of confusion about the young person’s age and legal status or a lack of age-appropriate facilities;   There was no coordinated approach to the young people’s needs and practitioners had not always recognised the important contribution of their agency in achieving this.  The overview report author recommends dissemination of this useful and relatively brief report.  48  APPENDICES  Appendix 1 – Terms of Reference  221. The LSCB agreed the following additional terms of reference that are specific to this case:  1. Was adequate support provided to the subject to ensure his safety and wellbeing whilst he was living independently in the period leading up to his remand?  2. Were mental health services appropriately involved?  3. What support was in place to ensure that the subject was either in education or employment?  4. Were links adequately made between services to address his offending behaviour and services to address his health and social care needs?  5. Was sufficient consideration given to the young person’s vulnerability in a custodial setting (with reference to family contacts, peer relationships and bullying)?  6. Was the young person’s level of risk and vulnerability appropriately assessed and monitored (with defensible decisions to support assessments)? Were risk/vulnerability management and monitoring consistent with the level of assessed risk?                   49 Appendix 2 – Methodology  222. The following people were members of the Serious Case Review Panel.  Position Agency Panel Chair Independent  Assistant Manager Leeds Safeguarding Children Board Head of Service, Safeguarding Children and Young People’s Social Care, Children’s Services Directorate, Leeds City Council Head of Region (Yorkshire, Humber and the North East) Youth Justice Board  Deputy Service Manager Youth Offending Service, Children’s Services Directorate, Leeds City Council  Operational Manager Youth Offending Service, Children’s Services Directorate, Leeds City Council Strategic Manager Education Services, Children’s Services Directorate, Leeds City Council Operations Manager Housing Support, Environment and Neighbourhoods Directorate, Leeds City Council - one meeting Performance Management Officer Environment and Neighbourhoods Directorate, Leeds City Council - two meetings Designated Nurse, Safeguarding Children NHS Leeds Governor, Head of Residence The Young Offender Institution Detective Chief Inspector, Safeguarding Unit West Yorkshire Police Senior Services Manager Supported Independent Living Scheme   223. In addition, the LSCB Administrator attended Panel meetings in order to take minutes and Pamela Shelton attended in her capacity as the overview report author.  224. In retrospect, the overview report author considers that it would have been helpful to have someone with expertise in mental health as a Panel member. However, the General Manager for Safeguarding, Child and Adolescent Mental Health Service, acted in an advisory capacity and attended one meeting. The Head of Service for Looked after Children in Children and Young People’s Social Care attended one meeting to advise the Panel on recent developments within the department.  The following agencies undertook Individual Management Reviews as part of the SCR:  Children and Young People’s Social Care, Leeds City Council  Education – Schools and Services, Leeds City Council Environment and Neighbourhoods, Leeds City Council NHS Leeds Primary Care 50 Leeds Community Healthcare NHS Trust NHS Leeds (Health Overview report) Youth Offending Service, Leeds City Council West Yorkshire Police The Young Offender Institution A Supported Independent Living scheme  225. After attending Panel meetings IMR authors made amendments (some minor and others more substantial) to their agency reports in order to clarify the text or include additional material that the Panel considered important to provide the evidence to support their conclusions. The discussion between Panel members and authors was very constructive and helpful. Authors responded positively to the critique of their report and made amendments that have greatly improved the quality of the IMRs and hence enhanced the overall quality of and learning from the review. There has clearly also been learning for the individual report writers, to the benefit of those agencies, some of whom had no previous experience of participating in a serious case review and completing an IMR.   226. In addition, the Child and Family Court Advisory and Support Service provided a summary of the agency’s involvement with Ryan’s family which falls outside the timescale for the review.  227. The Connexions service, known in Leeds as the Integrated Youth Support Service (IYSS), provided a one-page statement of its limited involvement with Ryan. Staff had one interview with him when he was 16/17 years old and offered other appointments, which he failed to keep. There was one interview with Ryan in the YOI during which the personal advisor suggested courses that might be of interest. Panel members agreed that this level of involvement did not merit an IMR.   228. The NSPCC provided brief information about involvement when Ryan was a toddler. This clearly falls outside the timescale for this review.  229. The Panel has had sight of a letter from the Acting Assistant Ombudsman of the Prisons and Probation Ombudsman Service. It sets out a summary of her preliminary findings following her investigation into the circumstances of Ryan’s death. The Panel has also seen the letter from the Governor of the YOI in response.  230. The Panel has seen the letters sent to family members inviting them to participate in the review.  The Overview Report Author considered the following documents:  Title of document Author and date Leeds City Council documents  Joint Working Protocol: Provision of Accommodation for 16 and 17 year olds who are homeless or threatened with Environment and Neighbourhoods Directorate and Children’s Services Directorate, undated 51 homelessness  Leeds Child and Adolescent Mental Health Service – Information for Professionals NHS Leeds Community Healthcare (Leeds PCT), October 2010 Multi-agency Looked after Child Partnership draft terms of reference Leeds City Council, undated Memorandum of Understanding Leeds Youth Offending Service, Leeds Children and Young People’s Social care, Leeds Housing Service, undated Our promises to you Leeds City Council, 2009 Service Level Agreement Leeds Youth Offending Service and Housing Services, Environment & Neighbourhoods Directorate, May 2010 National documents  Ages of concern: learning lessons from serious case reviews – a thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 Ofsted, October 2011 Asset – Young Offender Assessment Profile Youth Justice Board guidance, May 2011  Better Mental Health Outcomes for Children and Young People National CAMHS Support Service, Child and Maternal Health Observatory The Children Act 1989 Guidance and Regulations Ryanolume 2: Care Planning, Placement and Review HM Government, March 2010 The Children and Young Persons Act 2008 HM Government, 2008  Framework for the Assessment of Children in Need and their Families Department of Health, April 2000 HMYOI: Placement Protocol relating to specialist unit Youth Justice Board, October 2010 How do you know you are a good corporate parent? Local Government Improvement and Development Agency, Website, December 2010 Improving the Emotional and Behavioural Health of Looked After Children and Young People Centre for Excellence and Outcomes in Children and Young People’s Services, 2010 Statistical data on educational attainment of looked after children Department for Education website, December 2010 A study of recommendations arising from serious case reviews 2009 - 2010 Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson: University of East Anglia, University of Warwick. Published for Department for Education, 2011 Working Together to Safeguard Children HM Government: department for children, schools and families, March 2010  Child V Composite Action Plan – March 2015         1   Serious Case Review Action Plan Regarding Ryan Clark (Child V) March 2015.   Ref No Recommendation Action Responsible Agency/Lead Person Outcome and Date  1 The LSCB should satisfy itself that multi-agency arrangements for care planning and reviewing looked after children have improved and are efficient and effective.   1)  C&YPSC Safeguarding & Reviewing Section (ISU) to provide a report which sets out statutory requirements for LAC and identifies what has changed in Leeds   2) The LSCB performance management sub group (via multi agency audit programme) to audit the effectiveness of those arrangements.  3)  Enhance care planning and communication re 13+ LAC by regular link meetings between Team Managers. YOS & Children Head of Service      LSCB Assistant Manager    Chair of Joint Agency Decision Review Panel    Completed February 2012     Completed  LSCB  Audit Nov 2013    Completed March 2012  2 The LSCB should satisfy itself that the programme of work being undertaken to improve corporate parenting responsibilities in Leeds includes promoting access to education, training LSCB and Corporate Parent Links to be strengthened by:   1. LSCB  to provide overview of Annual    LSCB Manager    Completed Child V Composite Action Plan – March 2015         2 Ref No Recommendation Action Responsible Agency/Lead Person Outcome and Date  and employment opportunities and enhancing emotional wellbeing.  Report and Business Plan  annually to Corporate Parenting  Board   2. Corporate Parenting Board to identify priorities from LSCB report for further Board scrutiny and action in response to Report and Plan  3. Children’s Services to provide summary of LLRs and SCRs to be reported to Corporate Parenting at publication.  4. Children’s Services to work with Corporate Parenting Board to provide annual report of Corporate Parenting Board activity to LSCB    Corporate Parenting Board to strengthen oversight of issues relating to employment and training and emotional health by:  1. Children’s Social Work Services  to provide update report on MALAP work and action to be submitted to the CC Board   2. Corporate Carers Board to identify issues for further CC Board scrutiny and action        HoS LAC     CS Improvement Hub   CS Improvement Hub         HoS LAC     HoS LAC     Feb 2015   Completed Feb 2015    Completed Jan 2015   Completed Feb 2015         In hand Agreed for 2015/16   Completed New thematic format developed for CCB Child V Composite Action Plan – March 2015         3 Ref No Recommendation Action Responsible Agency/Lead Person Outcome and Date   3.   Children’s Social Work Services to extend performance reporting to CC Board to include regular data and performance analysis on related issues of employment and health.   LSCB to receive updates on progress to promote access to education, training and employment opportunities and enhancing wellbeing  HoS LAC       HoS LAC   Completed Data set routinely provided to CCB meetings   Completed Reports to LSCB: • 22.05.14. • 15.01.15  3 The LSCB should review the sufficiency of provision of suitable, specialised accommodation for young people with high support needs, with a particular focus upon looked after young people.   1) LSCB to receive updates from the two current work strands addressing accommodation issues for young people:  o Leaving care Accommodation Strategy    o Environments & Neighbourhoods Youth Accommodation review   2)  To reflect concerns re accommodation in LSCB Annual Report and to share with the Children’s Trust Board.  LSCB Assistant Manager            LSCB Manager & LSCB Chair        Completed  May 2014    Completed August 2013   Completed Sep 2013  Child V Composite Action Plan – March 2015         4 Ref No Recommendation Action Responsible Agency/Lead Person Outcome and Date      4 The LSCB should promote more effective approaches to risk management and assessment of children and young people with complex needs.    LSCB to promote a programme of work and events including:  1) Review of referral pathways, assessment & appreciation of thresholds for intervention.  2) Conferences to promote intervention and management of risk within the community.      LSCB Assistant Manager    Completed Nov 2012   Completed  LSCB Conference 2013  5 The LSCB should endorse IMR recommendations and require their implementation and should satisfy itself that actions are completed and embedded.   1) Partner agencies to provide evidence of action plan completion  2) Sample audit of partner agencies recommendations to check extent actions have been embedded  Partner agencies   Performance Management Sub Group Completed  Dec 2013  Completed Sample Audit Jan 2014.  