Attempted suicide of an adolescent boy in September 2013. The young person's attempt on his life has been linked to a drug influenced psychotic episode. Family were well known to agencies and there had been professional concerns around neglect of the young person and his siblings since 2005. Between 2009 and 2011 the young person was the subject of a child in need plan, a child protection plan, care proceedings and a supervision order. Issues identified include: poor school attendance; offending; substance misuse; mother and young person's lack of engagement with professionals; mother's non-compliance with parenting orders and school attendance; and challenges associated with the significant number of professionals and agencies involved with the family. Identifies learning points including: need for professional awareness about the link between substance misuse and mental health problems and the link between long term neglect and suicide ideation; and need to maintain focus on older children when there are younger children in the family. Recommendations include the development and implementation of a toolkit to help professionals engage with 'hard to engage' young people.
      
 Title:  Serious case review: subject: A Young Person: the overview report. LSCB: Kirklees Safeguarding Children Board Author: Paul Sharkey 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        Kirklees  Safeguarding Children Board   Serious Case Review   Subject: A Young Person  The Overview Report  December 2014  Lead Reviewer and Independent Overview Author: Mr Paul Sharkey (MPA)    2  CONTENTS 1.  INTRODUCTION         4 1.1  a) Purpose of the Serious Case Review      4 b) Reasons for the Serious Case Review     4 c) Timescale for the Review       5  2.   METHODOLOGY         5 2.1 Terms of Reference         5 2.2  SCR Overview Panel        5 2.3 Review Process        6 2.4 Sources of Information       6 2.5 Parallel Inquiries        6 2.6 Family Involvement        6 2.7 Style and Format of Report      6  3.   CASE SUMMARY        7   4.   OVERVIEW OF KEY EVENTS        8  5.  ANALYSIS OF KEY ISSUES AND LEARNING    16  5.1 Self-harm and Mental Health issues     16  ToR1 a) Self- Harm and Suicidal Ideation     17 Learning points re self-harm and suicidal ideation    18  ToR1 b) Substance Misuse        18 Learning points: substance misuse:      21  ToR1 c) Warning signs of mental health issues     23 Learning points: Mental Health and Emotional Well-being   25  5.2 ToR 2: Multi-agency working with neglectful families    25 Learning points: multi agency working with neglect     27  5.3 ToR 3: Child focus          27 Learning points: the focus on the child      29  5.4 ToR 4: Assessment, planning, implementation and review     29  ToR 4 a) Assessment        30  ToR 4 b) Planning and Implementation      31  3   ToR 4 c) Reviewing         35  Learning points: assessment, planning & review processes   35  6. FAMILY VIEWS        37  7. CONCLUSIONS        39  8.  RECOMMENDATIONS       40    Appendix 1: Terms of Reference and Key Practice Episodes   42 Appendix 2: Membership of the SCR Overview Panel and Sources  of Information     44 Appendix 4: Learning points from the SCR    45  Appendix 3: Glossary of Terms      49  Appendix 5: References        50      4  1.  INTRODUCTION 1.1  a) Purpose of the Serious Case Review This Serious Case Review Overview Report (henceforth referred to as the Report) on the Young Person was commissioned by the Kirklees Safeguarding Children Board in accordance with the HM Government statutory guidance  ‘Working Together to Safeguard Children, 2013’. Its purpose is to:  ‘Look at what happened in the case, and why, and what action will be taken to learn from the review findings, so that action results in lasting improvements to services which safeguard and promote the welfare of children and help protect them from harm; and  there is transparency about the issues arising from individual cases and the actions which organisations are taking in response to them, including sharing the final report of the SCR with the public.’(Working Together, 2013, page 65) b) Reasons for the Serious Case Review This SCR was commissioned by the Kirklees Safeguarding Children Board (KSCB) on 9th January 2014, because the case circumstances met the criteria set out in Working Together 2013:  That abuse / neglect was known or suspected: This was evidenced from the on-going service provision to the young person's family in relation to neglect, the fact that the young person had recently been the subject of a Child Protection Plan, and was the subject of care proceedings, at the time of a life threatening incident (hereafter referred to as, the incident.   That the child suffered serious injury: This was evidenced by serious injury sustained by the young person in the incident.   That there is cause for concern as to the way in which the authority, Board partners or other relevant persons have worked together to safeguard the child: Although the young person's serious injury was self-inflicted, he had experienced the intervention of many services over a period of years. Due to lack of sustained and focused engagement with the young person, opportunities to provide appropriate, timely and effective interventions were missed.   5  c) Timescale for the Review The Review focused on the period from March 2011, when the young person was subject to a Child in Need Plan, to September 2013 when the incident occurred.   2.   METHODOLOGY 2.1 Terms of Reference-see Appendix 1 2.2 SCR Overview Panel  The SCR Panel (henceforth known as the Panel) comprised senior agency representatives who considered the information obtained from agency chronologies, Individual Management Reviews, the Learning Event and Court documents. The Panel (see appendix 2 for membership) was chaired by Mrs Bron Sanders, who is the Independent Chair of the KSCB.  2.2.1  The Lead Reviewer was Mr Paul Sharkey (MPA)1 who has wide experience of both writing and chairing Serious Case Reviews since 2002. He is presently an independent safeguarding consultant with over thirty years background in both statutory and third sector child protection agencies. He completed the Department of Education/ NSPCC/ Action for Children/ ‘Improving Serious Case Reviews’ course in July 2013 and is on the Association of Independent Chairs of LSCBs register for independent SCR Chairs and Lead Reviewers. He has had no previous involvement with the KSCB or any of its partner agencies prior to this SCR.   2.2.2 The Overview Panel met on the following dates,   10 March 2014, which included Lead Reviewer briefing of IMR authors  1 May 2014 with IMR authors  5 June 2014 with IMR authors  30 June 2014  2 July 2014, Learning Event  31 July 2014  7 August 2014  15 September 2014  5 November 2014  20 November 2014                                                             1 Master’s in Public Administration ( 2007) from Warwick University Business School 6  2.3 Review Process 2.3.1 Individual Management Review [IMR] authors spoke to their reports with the Panel on the 1st May and the 2nd June 2014. Key Practice Episodes2 (see appendix 1) were identified by the Panel and the Lead Reviewer. These informed the basis of analysis of the four Terms of Reference conducted at the Learning Event of 2/07/2014, which all Panel members, IMR authors and relevant front line practitioners attended.  2.3.2  The Learning Event was facilitated by the Lead Reviewer using the analytical techniques in an attempt to understand from a systems view why and how decisions and actions were made within the context of prevailing organisational and agency practices and expectations. The Panel and Lead Reviewer were mindful of hindsight and outcome bias in conducting the analysis. The Panel critiqued early drafts of the Overview Report on 07/08/2014, 15/09/2014, 05/11/2014 and 20/11/204 The Overview Report was submitted to the KSCB on 18/12/2014.  2.4   Sources of Information – see appendix 2  2.5 Parallel Inquiries There were no criminal or care proceedings or other parallel enquiries ongoing at the time of this Review 2.6 Family Involvement The young person was not able to be interviewed and offer his views due to his current circumstances. The young person’s mother, father and extended family members were interviewed and their views are included in the Report.   2.7     Style and Format of Report This report has been written, in a way that is mindful of recent (July 2014) publications3 about the need for SCR Reports to be succinct, shorter and focussed on learning points and lessons. It has also sought to comply with current statutory guidance (Working Together, 2013) regarding reports being written in a way that publication will not be likely to harm the welfare of any children or vulnerable adults and is compliant with the Data Protection Act, 1998. Therefore, identifying information and personal details have been                                                            2 These are episodes from the case that require further analysis and are thought to be significant to understanding the way the case developed and was handled. They are not restricted to specific actions or inactions but can extend over longer periods. See SCIE ‘Learning together to safeguard children, developing a multi-agency systems approach for case reviews (2008).  3 See ‘First Annual Report’ of the National panel of independent experts on serious case reviews ( July 2014) and the DfE Research Report into Barriers to Learning from Serious Case Reviews (July 2014, Anne Rawlings et al) 7  omitted whilst attempting to achieve a balance with the need for public accountability and transparency. 2.8  For the purposes of identity protection and confidentiality a family structure and genogram is not provided in this report. However, a full genogram was compiled as part of the overall review process.  3.   CASE SUMMARY  3.1 The young person is an adolescent who comes from a large family and lived with his mother and siblings prior to the incident. He is of White British background, his language is English and he is of no documented religious background.  The young person's father left Kirklees before the birth of his son but has maintained contact with him.  3.2  The young person has had considerable involvement with his nearby extended family throughout the timeframe of this review. 3.3 There had  been professional concerns around neglect of the young person since 2005 resulting in various attempts at providing family support through Child in Need (CiN) and Common Assessment Framework plans up to late 2011. In addition, the young person had significant school attendance issues by around 2008 which disadvantaged his educational development. He was subject to an Educational Statement for Emotional and Behavioural Difficulties from 2007.  3.4 Multi-agency attempts at encouraging the young person back to school and supporting the family proved unsuccessful and led to him and his siblings becoming the subject of child protection plans under the Neglect category in late 2011. However, sustained improvement was not achieved. The young person became involved with the criminal justice system in the summer of 2012, and continued not to attend school. There were also concerns that he was misusing alcohol, cannabis and MCAT (Mephedrone)4.  3.5 Continuing professional concerns resulted in the local authority deciding to start care proceedings in May 2013 with the intention of removing the young person from his mother’s care. An interim care hearing in the summer of 2013 ordered that he should remain at home with his mother under an Interim Supervision Order pending the final hearing which occurred in late 2013 when he was made the subject of Supervision Order.                                                             4 Also known as 4-methylmethcathinone (aka Miaow or Meow), a legal substance until April 2010. It is a synthetic opiate/stimulant and has been a Class B controlled drug since April 2010. See KFx factsheet, ‘Learning of Substance’ on Mephedrone, website, www. Ixion.demon.co.uk  8  3.6 Throughout the statutory interventions with the family, which included the Youth Offending Team (YOT) supervised Referral Order, the young person refused to engage with the professionals and consequently, very little was known by them about him. 3.7 Whilst subject to the interim supervision order, the young person’s mental health and behaviour suddenly deteriorated in September 2013. This was observed with some alarm by extended family members and his then girlfriend. It was brought to the attention of a YOT health professional (not allocated to the young person and not previously known by that professional) who encountered him a few days before the incident. She made positive suggestions about sources of help and also agreed to meet with him some two days before the incident. The young person did not turn up for the meeting.  3.8 It is likely that the young person had experienced a drug influenced psychotic episode shortly before the incident. He was found by his mother in a life threatening state at home and taken by ambulance to a nearby hospital.  4.   OVERVIEW OF KEY EVENTS                                        March-December 2011 4.1 The young person and his siblings had been subject to a Child in Need (CiN) plan since late 2009. Professional opinion in early 2011 viewed the mother’s engagement as sufficient with signs of improvement in her children’s situation. A CiN meeting in March 2011 decided that Children’s Social Care (CSC) should withdraw from the case and step down work with the family to a Common Assessment Framework (CAF). The young person’s mother had disengaged with the Common Assessment plan by the end of March, previous support from a relative had stopped and home conditions were getting worse. A CiN referral was made by the health visitor to CSC in May. A new CiN plan started in mid-July.   4.2 The young person's school attendance remained very poor. He agreed in September to attend a work experience placement at a local college but did not start. Due to continuing concerns for him and his siblings, CSC started a Section 47 child protection enquiry. This concluded that the children's physical, emotional and social needs were not being adequately met and were adversely impacting on their development. In addition, the young person was reported to be using cannabis and other substances. His mother appeared to have minimal understanding of the importance of meeting her children’s needs, and had not co-operated with professionals, or with the various plans. 9  She was arrested in December 2011 for failure to attend a court hearing regarding the young person’s [and other siblings] school attendance. 4.3 The young person and his siblings were made the subjects of Child Protection Plans under the category of neglect in December 2011. There was no record of his views being obtained for the initial Child Protection Conference. The Child Protection Plan included an assessment of his substance misuse, which was to be undertaken by the social worker.   2012 4.4 A parenting assessment was completed by the Family Support and Assessment Worker (FSAW1) in February 2012. It concluded that the mother had some basic knowledge regarding the needs of her children and how to address those needs. However, when it came to putting the knowledge into action or maintaining provisions for them she fell victim to her own inadequacies or wishes. Moreover, she required a large amount of support, to be able to parent and be able to adapt her parenting to keep up with her children’s ever changing needs and development.   4.5 The young person and his family were referred in February 2012 with a view to becoming part of the HUB, a new initiative from Kirklees Children’s Social Care aimed at working with families with entrenched neglect and parenting issues. Based upon the ‘Hackney model’, a team of three workers (a senior practitioner, a social worker and a child care officer, managed by a team manager) was to be assigned to try and improve parenting and achieve better outcomes for the young person and his siblings. 4.6 Following a referral to the YISP (Youth Inclusion and Support Panel)5 in January by the educational access team, the young person was offered a service by the PAYP (Positive Activities for Young People) team. By mid-June, he had only attended one session with PAYP, and was discharged from the service due to lack of engagement. The young person was also allocated a student social worker (SSW1) to try to get him to attend his new educational placement. Several unsuccessful attempts were made over February and March by SSW1, but the young person refused to engage. His mother attended a meeting in early February at a local school about poor attendance and a parenting contract was drawn up. 4.7  The first Child Protection Review Conference met in February and kept the young person on his Child Protection Plan                                                            5The YISP was a programme aimed at reducing youth crime through providing support to young people at risk of committing crime and their families.  10  4.8  The young person was referred to the community dental team at the end of February but did not attend for treatment. His school health records were not passed on to his educational placement resulting in no health information being shared. No mention was made of him at the third core group meeting6  in March and no minutes were received by the health visitor and the school nurse. Overall, the Health Visitor received only six out of thirteen core group meeting minutes. The fourth core group met in mid-April when it was noted that the mother was allowing the young person to come and go as he pleased and was not informing the educational placement of his absence.   4.9 The young person was arrested in late April for behaving in a drunk and disorderly manner and assaulting a Police Community Support Officer (PCSO). He was taken to the Emergency Department of the local hospital and treated for a lacerated eye brow and head injury. He spent the night in Police cells and was released the next day. The hospital and the Police were not aware that he was on a Child Protection Plan. The young person was given a nine month Referral Order in July for his drunken and disorderly behaviour and allocated to a Youth Offending Officer (YOT1). 4.10 The Police visited the young person’s home the day after the drunk and disorderly incident and noted evidence of neglect and a lack of appropriate supervision of the children. A joint Police/CSC home visit was made in early May to undertake a welfare check. The Police served a neglect warning on the mother; however, there was not agreement between the Police and CSC for further action at this stage. A further Police visit in mid-May noted increased concerns regarding home conditions. Given the recent neglect warning the Police considered removing the young person and his siblings under Section 46 (Children Act; 1989) Police Protection powers. A joint welfare visit was suggested to the Emergency Duty Service who declined emergency intervention as ‘work was in progress to improve conditions’ and because it was likely that the children would be returned home unless a planned approach was taken to legal intervention. The Police noted in late May a conversation with the social worker (SW3) that the mother had been given a clear message that childcare matters had to improve otherwise CSC would instigate care proceedings. 4.11 The second Child Protection Review held in May noted that the young person was not attending school and that there had been limited progress made by the mother on routines and boundaries. The mother was not present. The conference decided to continue with the Child Protection Plans and recorded that ‘legal proceedings needed to be urgently considered’, which was the first mention of legal action in this case. The health professionals noted that their                                                            6 A Core Group comprises multi-agency representatives and identified family members, and meets regularly to review the progress of a Child Protection Plan 11  roles and responsibilities were very confusing given the considerable number of professionals involved in working with this large family. 4.12 The Social worker (SW3) took over from SW2 in late May and attended the core group. She stated that a robust support package was required to intensify the help for the family. In addition to SW3, a family support worker and community care officer were to be allocated from the HUB team.  4.13 The core group in mid-June noted that the case was to be discussed with the Kirklees legal team. Concerns remained about home conditions, the young person's poor engagement with Positive Activities for Young People (PAYP) and school attendance. SW3 spoke to the mother about these issues.  4.14 A legal planning meeting was held on 12/07/2012 which resulted in an advice memo being sent by Kirklees legal section to the social worker (SW3) to start the Public Law Outline (PLO) process. The significant harm threshold had been met and psychological and paediatric reports were needed as part of the overall assessment for possible legal proceedings. It was agreed that a detailed ‘letter before proceedings’ was to be prepared setting out all the support that had been offered to date. In addition, a PLO meeting was to be convened to discuss the concerns with the mother who was to be asked to sign a contract of expectations. The social work assessment was to be completed and updated, pulling together the needs of the young person and his siblings, and indicating whether their mother had the capacity to change. Viability assessments were to be undertaken of any family members who may be able to care for any of the children.    4.15 The young person was taken by ambulance to Hospital 2 in mid-July following a reported overdose of MCAT, apparently taken two days previously, and reported regular taking of alcohol. A safeguarding referral was made. The hospital was not aware that he was subject to a child protection plan and CSC was not contacted by them prior to his discharge.  4.16 The July core group meeting was informed that the young person had apparently taken ‘bath salts’ and not MCAT. SW3 said that legal advice was being sought and that there was an intention to start the PLO process. The young person had not attended his YOT appointments in late July and was discharged from the PAYP service because of lack of attendance. 4.17 Professional concerns of neglect, poor home conditions and deterioration of the young person and his siblings’ care continued during August 2012. The Police Safeguarding Unit requested a strategy discussion with CSC and a joint visit to assess the home situation with the possibility of a Police Protection powers being used to remove the children if the situation warranted it. The social work manager was of the view that the Magistrates would not be convinced in granting an Emergency Protection Order on the children in the 12  event that they were taken into Police Protection. It was suggested that a joint visit should take place if the mother did not improve her parenting and care of the children. A joint Police/CSC home visit was made in late September when home conditions were found to be acceptable. However, the mother was served with a second neglect warning stating that she needed to maintain home conditions.  4.18 The young person did not attend his YOT appointments in July and September, and was allocated a new YOT social worker (YOT2).There should have been a YOT  assessment (ASSET) completed within twenty eight days of the start of the Referral Order ( two months previously) for the Referral Panel to consider in order to agree a suitable intervention plan. This had not been done. In October, the young person’s lack of engagement with the Referral Order resulted in a YOT Special Panel meeting, which decided to return the case to the Court for breach of conditions. The young person did not attend court in December for breach of his Referral Order. He was arrested and appeared before the Youth Court on 10/12/2012. The court allowed the Referral Order to continue. 4.19 A letter of instruction for a paediatric assessment in relation to care proceedings on the young person was sent in mid-September for filing by the end of November. The core group held on 18/09/2012 noted some evidence that the situation was improving for the young person's siblings.  4.20 A third Review Child Protection Conference was held in October when it was decided to keep all of the children on their child protection plans under the neglect category. Little progress was noted and it was recorded that CSC was continuing to collate evidence with a view to completing the assessments for care proceedings. The mother did not attend. 4.21 The family was referred to the Family Intervention Support Service (FISS) at the end of October. Its purpose was to prevent family breakdown and young people becoming accommodated.  4.22 The mother was arrested in mid-November for non-compliance with parenting orders and school attendance failure for which she received a twelve month community order. The ninth core group met in late November without her in attendance. The young person had not engaged with any of the services offered or mandated. Assessments were on-going with the psychological assessment due in at the end of the month. 4.23 The family were allocated a Family Support Worker on 14/12/2012. The tenth core group met in mid-December with no attendance from the mother or the young person. Concerns were expressed from core group professionals to the CSC about the young person and his siblings’ wellbeing. The response was that assessments needed to be completed before starting care proceedings. 13  Following the receipt of the psychological assessment in mid-December, Legal Services received instructions from CSC to start legal proceedings with a view to removing the young person and his siblings.   2013 4.24 The YOT ASSET was completed in January 2013 and concluded that the young person was at medium vulnerability and thus in need of a vulnerability/ risk management plan. The resulting plan was not dated or countersigned by the manager as required. Nor was there any evidence that it had been subsequently discussed in supervision or been reviewed, despite it stating that there would be monthly reviews. Important elements of the plan included a referral to a YOT specialist substance misuse worker and fortnightly visits and contacts from YOT2, which do not appear to have happened. There was no evidence that the young person had been seen by YOT2 as an obvious requirement of the assessment.  4.25 The YOT report was presented to the YOT Review Panel. The young person and his mother attended the Panel with the former signing a contract. During February 2013 the young person did not engage with his YOT worker and failed to attend meetings. A final warning letter was sent to him on 19/02/2013.  4.26 The social work assessment for care proceedings was completed on 18/01/2013 and concluded that that there were clear and evident concerns about the mother’s abilities to parent her children over the long term, underpinned by her lack of acceptance of these concerns. On 23/01/2013 the mother was informed that she had four to six weeks to show improvement; otherwise the local authority would begin care proceedings with a view to removing the children from her care. The mother signed the PLO agreement with the local authority on 28/01/2013.  4.27 The planned fourth Review Child Protection Conference due for the 29/01/2013 was postponed because the Conference Chair was on sick leave.  4.28 The eleventh core group held on 26/02/2013 expressed significant concerns about the lack of progress regarding the child protection plans for the children. The young person was not in education and was in breach of his Referral Order with the YOT. The Chair of the Review Child Protection Conference was updated by the Legal section on 11/03/2013 regarding care planning.  4.29 The core groups held in February and March voiced continuing concerns to CSC about case drift and lack of progress regarding plans for the children. A letter was sent to the Care Management team leader from the Head Teacher noting concerns about case drift. The Conference Chair was also written to 14  with the concerns. It was noted by YOT2 that in the event that the young person was removed from his mother’s care he would be unlikely to accept a placement and would return home or go missing.  4.30 A social work visit was made on 03/04/2013 to the mother to share the PLO letter. She was reported to have acknowledged the concerns. The young person attended a session with the YOT on 05/04/2013, the first he had attended on his own. However, he failed to attend further sessions in April and was once again in breach of his Referral Order.  4.31 On the 16/04/2013 the local authority legal team received instructions from CSC that care proceedings were to be lodged regarding the young person and his siblings with a plan to remove them from the care of their mother. An e-mail was sent to the paediatrician (PD1) asking for the outstanding report. A legal planning meeting was held on 22/04/2013 and a legal memo was sent to CSC on the same day confirming the plan to lodge care proceedings. Consideration was to be given to the young person either remaining with his family or being offered a foster placement. 4.32 The thirteenth core group was held on 10/05/2013 when the mother was in attendance. It was noted that ‘things appeared to be improving again’. A further e-mail was sent by legal to PD1 in mid-May requesting the paediatric report. 4.33 Regarding contact with YOT2, there appeared to have been none with the young person or his mother since the review panel of 20/03/2013. A Special YOT Panel was held on 20/05/2013 but neither the young person nor his mother responded to the invitation to attend. The decision was made on welfare grounds to allow the order to continue and not return it to court.  4.34 On 24/05/2013 legal proceedings were issued by the local authority in respect of the young person and his siblings. A letter was sent to the young person’s father on 28/05/2013. An allocations hearing took place on the 29/05/2013 when it was recorded that the local authority had planned for permanence for the children away from their mother’s care. The plan for the young person was for him to be placed with a relative on a Supervision Order. 4.35 A five day contested hearing took place in late June with the final hearing set for October 2013. The Children’s Guardian’s analysis suggested that there was little benefit in the young person in moving away and that he could be better safeguarded at home. She recommended an interim supervision order. The Court ordered that the young person remained at home with his mother on an Interim Supervision Order (ISO). The judge suggested that the local authority would not be in a position to persuade the court that the test for interim removal was satisfied at that time. A referral for family support and a family group conference was made by the Court.  15  4.36 The fourth and final Child Protection Review Conference was held on 07/07/2013 when the young person and his siblings were taken off child protection plans. This was because they were now involved in Care Proceedings and were subject to Supervision Orders. This conference was some three months out of time due to the illness of the Conference Chair. 4.37 The young person was seen by the social worker on 11/07/2013. It was reported that he made good eye contact with her and said that he would engage with activities. A YOT review panel was convened on 13/08/2013.  Neither the young person nor his mother attended. The Panel had the powers to return the young person to Court but decided not to breach him, but rather to get him through the order as best it could. There was subsequently an unscheduled and unsuccessful home visit made by YOT2 with no reply. 4.38 The family did not attend a Family Group Conference meeting on 19/08/2013 with the convenor as suggested by the Court. By 03/09/2013 the local authority had decided to seek a Supervision Order for the young person, who was to remain with his mother.   Events during the week leading up to the incident in early September 4.39 It was only a few days before the incident that the young person showed any signs of self-harming behaviour and suicidal ideation.  He had spent time with his extended family and they had become very concerned about the rapid deterioration in his behaviour and mental health, in particular his hearing voices, morbid thoughts and anxieties about his family. The young person’s father was contacted but states he did not receive the sent text. No involved professionals were alerted.  4.40 An extended family member was so worried about the young person’s mental health that he took the young person to the GP surgery on the day before the incident, saying that the young person was hearing voices and had self-harmed. He requested that a GP see the young person but there were no GPs at the surgery at that time. The family member was asked if he wanted to make an appointment. However, the young person refused to go in to the surgery, stating that he was ‘ok’ and no appointment was made. The extended family described being sufficiently concerned to remove the knives from the kitchen. 4.41 On the day of the incident, the young person returned home in the early evening and seemed ‘fine’ according to his mother. She had not heard of any concerns about her son’s well-being from anyone that day or previously. It seemed that the extended family did not have her telephone number to inform her of their worries. She went upstairs a short time later to find her son in a 16  very serious state consequent to the incident. He was taken by ambulance to the local hospital.  4.42 In addition to the concerns identified by his wider family in the few days leading up to the incident, the young person was seen by the YOT health worker (YOTHW1) for his girlfriend. YOTHW1 reported that the young person admitted he smoked cannabis and described prodromal7 psychosis due to cannabis use. The young person was said to be hearing occasional voices. The young person refused to give his surname. His girlfriend said he needed to know where to go to get advice. YOTHW1 gave the young person the details for single point access and said he could also see his GP. The young person told (YOTHW1) he was definitely not suicidal and did not have any thoughts of harming himself.  4.43 YOTHW1 thought that the young person did not indicate or appear suicidal and offered him an appointment for two days later when she was due to see the girlfriend at her YOT appointment. In the event, neither turned up for the appointment but YOTHW1 did manage to speak to the girlfriend that evening who said that she was worried for the young person and could not contact him on the phone but had spoken to an extended family member about her concerns. The girlfriend said that the young person was saying that he was not suicidal, that he had been ‘ok’ when YOTHW1 saw him, but was ’bad’ the next day. The YOT health advisor repeated earlier advice about available support services, Accident and Emergency and the Police, if events reached crisis point, but the young person would not accept help.  4.44 Medical tests conducted on the young person after the incident showed recent cannabis and MCAT (Mephedrone) use, with evidence of self- harming.  5.  ANALYSIS OF KEY ISSUES AND LEARNING The following analysis seeks to address and answer the four Terms of Reference (ToR) and relevant key practice episodes (KPE).   5.1  ToR 1: the young person’s self-harming and suicidal ideation: Were there any warning signs of self-harm, suicidal ideation, mental health issues or substance misuse prior to the incident ? If so, how well were they recognised and responded to by professionals? To what extent was the incident  predictable and preventable?                                                              7 The term "prodrome" refers to a period of pre-psychotic disturbance, representing a deviation from a person's previous experience and behaviour. As in clinical medicine, prodrome is a retrospective concept, diagnosed only after the development of definitive symptoms and signs. See www.mentalhealth.com/mag1/scz/sb-prod.html  17  The relevant KPE sought to examine agency responses to the young person in relation to his mental health, self-harm and substance misuse. (See appendix 1)  5.1.1   ToR1 a) Self- Harm and Suicidal Ideation   There was no evidence to suggest that the young person showed any self-harming behaviour or suicidal ideation until a few days before the incident. There was no evidence to indicate that any of the professionals directly involved with the young person were alerted by the wider family to their concerns around his self-harm and suicidal ideation. The YOT health worker (for the girlfriend) did not think that the young person was suicidal when he was seen a few days prior to the incident. She acted appropriately by offering him an appointment two days later and giving advice about sources of professional support, despite not knowing him.  5.1.2 When the young person was taken to his GP surgery by a family member, the surgery offered an appointment for him when a GP became available but the young person refused the offer of a GP appointment.  5.1.3 Given the late onset of warning signs of the young person’s self-harm and suicidal ideation and that none of the assigned professionals were aware of these, it is concluded that the incident was neither predictable nor preventable.  5.1.4 The evidence suggests that the young person’s self-harming and suicidal ideation were probably elements of a psychotic episode; most likely brought on by his use of alcohol, cannabis and MCAT. The effect of these substances can include psychosis, paranoia and anxieties.  5.1.5 The SCR Panel meeting of 30/06/2014 heard evidence from ‘The Base’ Young People’s Substance Misuse Project about the trend in recent years for young people to use synthetic cannabis, which has been developed to be more potent than the cannabis in use in previous years, but which can have negative effects on mental health which can last up to 9 months and longer. The use of MCAT can lead to dis-inhibited and sometimes criminal behaviour and can result in low mood, anxiety and paranoia. It is believed that young people with psychological vulnerabilities may be more at risk of mental health problems associated with cannabis and MCAT. It is apparent that many professionals are not aware of the impact of the new range of synthetic and often legal drugs which are available in local communities, and the associated risks for the mental health of young people. 5.1.6 Although the young person's self-harm and suicidal ideation are believed to be elements of a psychotic episode triggered by substance misuse, they 18  occurred against a backdrop of long term neglect, possibly compounded by the uncertainty of his family situation.  5.1.7 Research, (see Brandon et al, 2013, NSPCC/University of East Anglia), highlights self- harm and/or suicide as being a possible consequence for adolescents who have experienced long term neglect. 5.1.8 Learning points in relation to self-harm and suicidal ideation:   Professionals should be aware of the possibility of mental health problems associated with newly evolved strains of cannabis, and other drugs such as MCAT.  Professionals should consider the possibility of self-harm and/or suicide when working with vulnerable adolescents who have experienced long term neglect.  5.1.9 ToR1 b) Substance Misuse   There were four missed opportunities for professionals to respond                  to the young person’s substance misuse, namely;  As part of the Child Protection Plan following the Initial Child Protection Conference  The two Accident and Emergency admissions  As part of the YOT Asset assessment   Child Protection Plan: 5.1.10 The young person’s substance misuse was first identified as a concern at the Initial Child Protection Case Conference of December 2011. It was also referenced in the social work report to the Conference which stated that, ‘There is evidence that the young person may be smoking cannabis’. The ensuing outline child protection plan stated that an assessment should be arranged by the allocated social worker of the young person’s substance misuse in order for him to receive support in addressing ‘any assessed needs in this regard’. 5.1.11 In the referral made by SW2 on 15/12/2011 to the Family Support Co-ordination Group for a parenting assessment and support for the mother, the young person’s substance misuse (drug and alcohol) was listed as a risk. However, there was no mention of a request for support on this issue or for consideration of how the risk was going to be addressed. Reference is made in the core group minutes of 18/01/2012 that no one had engaged with the young person so therefore the plan for him to see someone regarding his alleged substance misuse had not been achieved. The substance misuse 19  action should have been considered and followed up at the subsequent Child Protection Reviews but was not.  5.1.12 There should have been a referral made to the Base young people’s substance misuse project. The core group minutes of the 19/07/2012 noted that the young person had apparently taken Radox bath salts rather than MCAT, not realising that the former term was another name for the latter.8 The school nurse did contact The Base (the substance misuse agency for young people aged under 25 years) for information and erroneously learned that young people often thought that ingredients in bath salts produced similar effects to MCAT. She also became aware that a referral to The Base could not be made without the consent of the young person. There was no evidence that a referral to the Base was discussed with the young person by any professional, and he was not offered a service to address his substance misuse.  5.1.13 It is not clear why the young person’s substance misuse was not followed up. It has been suggested by CSC that specific issues relating to the young person were seen to focus on his school attendance and personal hygiene. His needs had been overshadowed by those of the younger siblings. At fourteen years old he was showing clear signs of being a troubled young person. Yet no serious questions - a seeming lack of professional curiosity – were being asked by professionals as to why he had misused  alcohol, cannabis and MCAT, what the underlying reasons might be for such behaviour, what the impact of long term neglect was on him and what was the state of his mental and emotional health.  Accident and Emergency admissions: 5.1.14 There were two recorded episodes of substance misuse by the young person, namely, being arrested for being drunk and disorderly in April 2012 and an attendance (taken by ambulance)  at Accident and Emergency in July 2012 for a reported MCAT overdose and alcohol ingestion. Following the agreed Pathway9 a referral (with consent) should have been made to The Base substance misuse service by Accident and Emergency staff as a result of the July attendance.  5.1.15 The Panel was informed by the Acute Trust that the Nurse Consultant for Accident and Emergency has since developed a pathway for young people attending with substance and alcohol misuse issues and is reportedly working closely with specialist services to ensure that the pathway is embedded into practice.                                                             8 The SCR Panel learnt this at the meeting with the two experts on substance abuse held on the 30.06.14.  9 See the Calderdale and Huddersfield NHS  ‘ Protocol for Young People aged less than 16 years presenting to Accident and Emergency due to alcohol/drug excess or with an injury sustained as a result of drugs/alcohol use’ ( June 2012).  20  5.1.16 Because Accident and Emergency staff were not aware that the young person was subject to a child protection plan – due apparently to a problem in transferring the information between the Acute Trust’s external and internal alert register systems – CSC was not alerted to his admission prior to him being discharged. The Panel was informed that the EDIS system (which identifies if a child is on a child protection plan) was audited and problems were identified in information transfer to the internal alert system (i.e. Accident and Emergency). The Acute Trust reported to the Panel that this problem has now been rectified although there have been no recent audits to verify this.  5.1.17 A further issue with the July 2012 Accident and Emergency episode was that the paediatric liaison form alerting the paediatric nurse to the young person’s second admission for substance misuse was not completed. The school nurse was therefore not informed of the issue until her attendance at a core group on 19/07/2012. The Acute Trust has stated to the Panel that proper use of the paediatric liaison form has recently been audited, reviewed and disseminated to Accident and Emergency staff.  YOT Assessment: 5.1.18 The YOT Asset assessment completed by YOT2 in January 2013 determined that the young person was at medium risk of harm to himself, based on parental neglect and his substance abuse. This should have resulted in the implementation of a vulnerability management plan that included action to address his substance misuse with a specialist worker. A meeting to set this up did not happen, nor was the draft vulnerability plan signed off by the YOT operations manager, resulting in no effective or timely work being done to tackle the young person’s substance misuse. This omission constituted a breach of YOT policy and practice and marked a missed opportunity to try and respond to his substance misuse and wider welfare needs. There was one substance abuse/alcohol session held on the 21/06/2013 attended by the young person who said that he no longer took drugs as his partner did not want him to. 5.1.19 In seeking to understand why there was no vulnerability meeting and no early referral made to the substance misuse specialist, the Panel was informed that there was a mind-set of getting the young person through the (Referral) Order without risking him becoming more involved in the criminal justice system for what was a relatively minor first offence. This objective influenced the conduct of the case, including failing to make a referral to the substance misuse specialist. 5.1.20 A second factor accounting for the lack of a referral to the substance misuse worker was that the young person had said he would not co-operate and was perceived as hard to engage and non- compliant with professionals. He was 21  only seen once by a YOT worker in the first five months of a nine month order, due to his non-compliance and the change of worker in September 2012. He was returned to Court under breach proceedings in December 2012, and the outcome of that hearing was that his order be allowed to continue. The Asset was not completed until January 2013, the lateness of which would not have facilitated effective engagement with a young person such as this, who would have had issues around trusting adults and little understanding of consequences.  5.1.21 A third factor was that the young person’s case was seen by the agency as low risk of re-offending given that he had offended only once. In pursuing the imperative of getting him through his Referral Order, the YOT neglected consideration of some significant welfare issues, including his substance misuse. This dynamic was reinforced by the absence of any critical management oversight and challenge to the mind-set.  5.1.22 There should have been a vulnerability plan meeting leading to a plan that would have addressed the young person's specific vulnerabilities, involved appropriate specialists; included contingencies and been regularly monitored. Given that YOT2 was a member of the core group the plan could have been incorporated into the young person’s child protection plan.  5.1.23 In addition to the need for an effective vulnerability plan there should also have been a more vigorous effort at trying to engage the young person at an early stage in the Referral Order and rapid follow up action when he failed to comply with conditions. 5.1.24 In conclusion, there were clear and obvious warning signs of the young person’s substance misuse which were recognised by agencies within the core group but were not addressed. There were four known missed opportunities to try and respond to and address the young person’s substance misusing behaviour. The reasons for agencies not responding in a timely and effective manner have been set out in the above paragraphs. 5.1.25 Learning points in relation to substance misuse:  Where there is a Child Protection Plan   Consideration should be given to the use of an assertive outreach approach in working with ‘hard to reach’ and non-engaging adolescents  Focus should be maintained on the young person where there are younger children in the family  A referral should be made to the Young People’s Substance Misuse service as part of a child protection plan where substance misuse has been identified as a risk factor.  22   Consideration should be given to understanding the underlying reasons for a young person’s substance misuse. They should be seen as a ‘troubled’ child as opposed to a ‘troubling’ teenager.  Effective audit and scrutiny should be provided by Child Protection Review Conferences to ensure that actions have been completed and if not, why not, with recourse to contingencies. Where the Acute Trust is involved  There should be adherence to the Pathway for referral to the Base substance misuse service by Accident and Emergency staff where young people have known substance misuse issues.  There should be arrangements to test the effectiveness of the Pathway periodically.   There should be an effective notification system to Accident and Emergency of children subject to a child protection plan.  Accident and Emergency staff should notify Children’s Social Care of admissions when a child is subject to a child protection plan.   There should be an effective notification process from Accident and Emergency to the paediatric nurse service of any safeguarding issues concerning children admitted to the department.  Where the YOT is involved  YOT should have a focus on a young person’s safeguarding and welfare needs as well as offending behaviour. All young people assessed as being of medium risk of harm to themselves should have an effective vulnerability management plan that includes consideration of all relevant safeguarding issues and where appropriate, addressing substance misuse needs.   There should be early and assertive efforts at engaging young people on their orders.  There should be timely completion of Asset assessments.  There should be rapid follow up action to ensure compliance with consequences when young people do not co-operate with orders and their conditions.   The YOT should provide effective management oversight, challenge and audit of vulnerability management plans and their implementation. Where appropriate, vulnerability management plans should be incorporated into a young person’s child protection plan.      23  5.1.26 ToR1 c) Were there warning signs of mental health issues?    Although the young person showed no signs of having any mental health issues until the days immediately prior to the incident, the evidence indicates that he suffered long term neglect. 5.1.27 ‘Working Together’ (2013) defines neglect as,  “The persistent failure to meet a child’s basic and/or psychological needs, likely to result in the serious impairment of the child’s health or development’. Neglect may involve a parent or carer failing to (…..amongst other things….) ensure adequate supervision ….it may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.” 5.1.28 In addition to neglect, evidence from the psychological profile of the young person and his mother undertaken for the care proceedings of 2013 indicated that he became increasingly peripheral within his family and emotionally distant from his mother. However, there is evidence that he spent time within his extended family which may have met some of his emotional and social needs. He also had some contact with his biological father who he stopped seeing at the age of ten, albeit contact was maintained through the sending of birthday and Christmas cards. 5.1.29 The psychological evidence for the care proceedings noted the mother’s parenting style as one of minimal involvement, few boundaries and little emotional warmth”, resulting in the absence of a “secure, stable, boundaried and nurturing environment that is most likely to result in a secure attachment between parent and child.  5.1.30 Research indicates that some of the consequences of neglect (Hicks and Stein:2010:14) for adolescents include poor mental health and are typically shown by anxiety, depression, low self-esteem, proneness to suicide and recourse to risky health behaviours such as drug and alcohol abuse. Depression in adolescents 10 can manifest itself in a sense of hopelessness, social isolation and dropping out of usual activities, substance abuse, self-harm and recurrent thoughts of death and suicide. A recent University of East Anglia/ NSPCC/ report into Neglect and Serious Case Reviews (Brandon et al: 2013) found that neglect can be life threatening with serious outcomes occurring across all ages, including adolescence. Relevant learning points include:  Young people with long experiences of chronic neglect and rejection find it very difficult to trust and may present as hard to help                                                            10 See,  Adolescent Depression Awareness  Program:www.hopkinsmedicine.org/psychiatry/speciality_areas/moods/ADAP/) 24   The root causes of young people’s behaviour needs to be understood so that the responses of carers and professionals do not confirm young people’s sense of themselves as unworthy and unlovable  At the age of 16 young people lose the protection of school and have no equivalent protected route to adulthood and few routes out of a neglectful situation at home. 5.1.31 Given the young person's experience of neglect, he fitted the profile of an adolescent who had the potential of becoming vulnerable to mental health problems. A possible opportunity to assess his emotional well-being was through the school nursing service. The school nurse (SN1) was unable to arrange a health assessment for the young person because he was not in school and because of difficulties in contacting his mother. She was also under the mistaken impression that because CSC had made a referral for psychological and paediatric assessments on the young person, this was to include an assessment of his mental health and emotional wellbeing. In the event, this was not the case. 5.1.32 However, she states that she did (in September 2012) make referrals to the health advisors at the Pupil Referral Unit (PRU) and the Youth Offending Team. An attempt was made by the PRU health advisor to see the young person but was unsuccessful because he was not attending the PRU. YOT health records confirm an exchange of information between SN1 and Youth Offending Team Health Worker (YOTHW), but no referral, nor was there anything in the exchange between the health professionals that suggested a referral was needed. 5.1.33 No Further attempts were made to assess his emotional wellbeing. The school nurse and health visitor described a lack of clarity about their roles and responsibilities within the core group and the child protection plan. There should be clarity around the roles and responsibilities of each member of the core group in relation to specific actions for a child on a child protection plan aimed at achieving SMART11 outcomes.  5.1.34 The young person’s emotional wellbeing was not raised as an issue in the original core assessment of December 2011, or in the later social work assessments done for the care proceedings in June 2013. The issue was not considered at the Initial Child Protection Case Conference (ICPC) in December 2011 and a health assessment was not included as an action in the young person’s child protection plan.   5.1.35 Overall therefore, it can be concluded that the young person’s emotional wellbeing was not effectively recognised or responded to throughout the period in question. His experiences of long term neglect were not recognised                                                            11 SMART refers to Specific, Measurable, Achievable, Relevant and Time bound 25  by professionals as having potential consequences for his mental health and emotional wellbeing.  5.1.36 Learning points: Mental Health and Emotional Well-being:    Professionals should understand and assess the impact of long term neglect on an adolescent’s emotional wellbeing and mental health.   A holistic health assessment that considers emotional wellbeing should be included in the child protection plans of adolescents. There should be clarity as to which professional has responsibility, within a SMART child protection plan for ensuring that a holistic health assessment is completed.   There should be a holistic health assessment for all young people subject to YOT vulnerability plans that includes emotional wellbeing.  5.2 ToR 2: Consider the issues around multi agency working with neglectful families, including professional curiosity and the use of case history. How far was the case history used to inform actions and decisions? 5.2.1 The Section 47/core assessment completed by the duty social worker (SW1) for the Initial Child Protection Conference (ICPC) contained a comprehensive chronology that set out the case history of agencies’ involvement with the young person and his family going back to January 2005.  5.2.2 The ICPC minutes make reference to the previous case history and the fact that the mother had not engaged with CiN and CAF and that the home conditions had not improved. These are cited as key factors in the necessity for child protection plans. The evidence indicates that the use of the case history did inform the decision to make the young person and his siblings the subjects of child protection plans.  5.2.3 Thereafter, there are only two instances of use being made of the case history, namely, the legal memorandum of July 2012 to the Care Management Service and the care proceedings of June - November 2013. References to the chronology or case history are not evident in the three Child Protection Review Conferences or the core group conference minutes.  5.2.4 The parenting assessment of March 2012 did not feel confident that the mother would be able to parent without a large amount of support, and be able to adapt her parenting to keep up with her children’s ever changing needs and development. These findings reinforced and augmented what was already known about the mother’s parenting skills from the previous case history. The assessment’s findings should have been considered by the core group and CSC at the subsequent Child Protection Review Conference 26  (CPRC) of the 09/05/2012. This was at a time when the Police had issued a neglect warning to the mother who was also in breach of her parenting order. The parenting assessment was an informative piece of work which should have been included in the (updated) core assessment and planning process for the young person and his siblings. 5.2.5 When the case was transferred to the HUB team in May 2012, with the aim of intensive work on neglect issues, there was little evidence to show that the updated Core Assessment took into account the previous case history in its work with the family. Indeed, the approach taken was consistent with the ‘Start again syndrome’ and the ‘rule of optimism’ (Brandon et al, 2008) sometimes adopted by professionals. 5.2.6 The ‘Start again Syndrome’ tends to occur in families with complex, confusing and overwhelming case histories. One way for professionals to deal with such complexities is to put aside knowledge of the past and focus on the present, ‘here and now’ (hence ‘Start Again’), supporting the parents and not fully analysing their capacity – including a consideration of the previous case history – to care for their children. Starting with a clean slate, can (according to Brandon et al) be prompted by a transfer to a new worker or team, as was the case with the allocation to the HUB in 2012. Referral on to short term, intensive programmes like the HUB can be a coping mechanisms for practitioners and managers who feel overwhelmed by families ( Brandon et al, 2008) but are unlikely to produce the long term changes required to protect children from the harmful impact of serious neglect, as was the case in this instance. 5.2.7 Brandon et al conclude that, ‘The ‘Start Again Syndrome’ prevents practitioners and managers having a clear and systematic understanding of a (long standing neglect) case informed by the knowledge gleaned from past history’. (2008, page 73) 5.2.8 The new workers seem to have focused on the mother and her needs and abilities, in the belief that this would improve conditions for the children, without the balance of ‘respectful uncertainty’ (Laming, 2003) and professional scepticism. However, if the professionals had assessed her ability to change using established tools such as DiClemente and Prochaska’s ‘Stages of Change’ model (see Wikipedia entry for more details), it is likely that her motivation, ability to change and tendency to minimise/deny professional concerns would have been apparent.  5.2.9 An important instance of the family’s case history informing actions and decisions was the legal memorandum of the 20/07/2012 to Children’s Social Care following the legal planning meeting of the 12/07/2012. This evidences consideration of the social work chronology and the history of social work 27  involvement from 2005/06 onwards and notes that, ‘there was a consistent pattern of poor home conditions, chaotic household and poor school attendance………despite the family being offered a lot of support over time there has been consistent non-engagement with regard to the children’s developmental needs’.  5.2.10 One of the challenges of working with neglectful families is the successful coordination of the various professionals, a clear understanding of roles and a shared overview of what progress, if any, is being made. Work with this large family was additionally complicated by the number of professionals involved. In hindsight, the Review concluded that, in an effort to input considerable resources to make a difference, there were times when the numbers of professionals engaged in visiting and setting expectations of the mother became counterproductive. Successful engagement of the mother and coordination of professional became problematic at times because of this.   5.2.11 Learning points in relation to issues around multi agency working with neglect:   Professionals should recognise the importance of considering in a timely way a family’s case history as a possible predictor of future capacity to parent   Professional should understand the features of the Start Again Syndrome and ensure that this is focussed on in supervision.  Consideration should be given to the impact of the number and range of professionals working with neglectful families to ensure that this does not become counterproductive.   5.3 ToR 3: Child focus: How far did the focus remain on the young person, his emotional wellbeing, attachments and sibling relationships? How well did professionals engage the young person and balance the issues of self-determination and his vulnerability as a teenager  5.3.1 The relevant key practice episode examined issues in relation to engaging the young person including consideration of him as a young person who had experienced neglect and its impact on him. 5.3.2 The evidence suggests that professionals were not  able to engage the young person to the point where he felt able to participate meaningfully in activities aimed at integrating him back into education provision, helping him access health services, assessing his needs, undertaking a psychological assessment, ascertaining his wishes and feelings or effectively facilitating his Referral Order. Professionals frequently commented that they did not know 28  him and did not have a good enough understanding of him to be able to identify his wishes and feelings. 5.3.3 One of the key negative outcomes for the young person, common to many adolescents who have experienced long term neglect (Stein et al, 2010, Brandon  / NSPCC / University of East Anglia, 2013), was a lack of trust in adults including the many professionals who had attempted to intervene in his life. The lack of trust led to a pattern of withdrawal and marginalisation within his immediate family. Although there is evidence that he had developed significant relationships with parts of his extended family, the professional perception was of a ‘hard to reach’ adolescent who did not engage with services. The model of his mother’s inconsistent engagement with professionals may also have reinforced his non-engagement attitude.  5.3.4 The use of non-engagement as a coping strategy is a common feature in adolescents who have experienced long term neglect (Brandon / NSPCC / University of East Anglia, 2013). Professionals trying to help sometimes interpret such behaviour as sabotaging attempts to support a young person and may rationalise non engagement as adolescent ‘resilience’, within an exaggerated ‘self-determining and young person’s rights’ perspective, because they are older and have survived their teens. This can lead to a negative cycle of mutual rejection and resulting lack of effective help for the young person, leading to them becoming even more vulnerable. 5.3.5 There were other factors apart from the absence of basic trust that resulted in the mutual lack of engagement between the young person and the helping network. These included the large number of individual professionals entering the family home and the lack of any tangible consequences in not engaging in his Referral Order or in attempts to get him back into education provision. 5.3.6 Overall, there was little consideration given to understanding the impact of long term neglect on the young person, what life was like for him in his family and which relationships were important to him. There were attempts to get alongside the young person, for example the allocation of the student social worker, but these were not successful, and arguably required more tenacity. In hindsight it may have been beneficial to have had an allocated worker who had consistently focused on him.  5.3.7 Some key findings from recent research into developing routes to effective help and support  for children and young people at risk of harm  (Children’s Commissioner, October 2013) identified;  The importance for professionals to notice signs and symptoms of children’s and young people’s distress and not to rely unduly on the young person to talk about their abuse or neglect. 29   When trusted professionals respond sensitively and show concern for the young person they may begin to talk about underlying problems.  Young people valued professionals they could trust, who were effective, knowledgeable and available. Teachers and youth workers were particularly important as people to tell and social workers were valued as being able to provide holistic support.  Of central importance was the young person’s past experiences of professionals, as well as their experiences in the family and community, influencing how comfortable they felt about talking and their willingness to trust and talk to practitioners.  The crucial importance of an offer of early help. 5.3.8 It is acknowledged that there are significant challenges for professionals in trying to engage adolescents who have experienced neglect. Therefore, creative and flexible methods using techniques of ‘assertive outreach’, that understand the effects of long term neglect and trust issues for adolescents, need to be developed. Professionals need to be more persistent, committed and prepared to invest time in establishing trusting relationships with vulnerable teenagers working alongside them in achieving a balance between autonomy and welfare.  5.3.9  Although outside the timeframe of this Review, a determined and robust offer of early help at the stage when the young person was starting to miss school, may well have prevented, or reduced the subsequent level of his disengagement and reduced the likelihood of further neglect. 5.3.10 It is concluded that the lack of active engagement between the professional system and the young person was a key factor in not being able to get effective help to address his vulnerability and emotional wellbeing during the time frame of this review.  5.3.11 Learning points regarding the focus on the child:  Professionals should identify creative and flexible ways of engaging with vulnerable young people which aim to develop trust and show perseverance in the face of dis-engagement   In child protection cases where there is difficulty in engaging a young person, consideration should be given to allocating a separate worker for that young person.  Professionals should make early, robust and concerted efforts to re-engage young people with school attendance problems.   5.4 ToR 4: Consider assessment, planning, implementation, review, contingency arrangements and decision making. How effective were 30  these in responding to the young person’s needs, particularly in relation to multi-agency child protection and intervention whilst subject to his child protection plan?  5.4.1 The APIR (assessment, planning, implementation, review) framework is a well-established model of case management. This section will examine and analyse each of the elements. ToR 4 a) Assessment 5.4.2 Assessment of a child’s needs, including safeguarding needs provides the foundation of the APIR framework. A sound assessment of a child’s needs, that fully considers the three holistic domains12 of the Assessment Framework as set out in ‘Working Together’ 2013, that includes the wishes and feelings of the child, should result in a robust plan that effectively promotes their wellbeing and safety.  A high quality assessment is vital in cases of long standing neglect which are often very complex in nature and background history.  5.4.3 The section 47/core assessment completed by the Duty and Assessment social worker (SW1) for the Initial Child Protection Conference (ICPC) of December 2011 did not include an analysis of the young person’s holistic needs. It focused on educational issues and mentioned concerns around cannabis use. It should have included emotional and behavioural development and an analysis of the nature of the relationship between the young person and his mother. The young person’s views were not obtained as the social worker did not have the opportunity to speak to him.   5.4.4 The assessment report was appropriate for the purpose of the ICPC and concluded correctly, that the young person (and siblings) should be made the subject of child protection plans under the category of Neglect. However, a full core assessment should have been completed soon after the case conference, in accordance with the recommendation of the ICPC and the outline child protection plan. This should have included a holistic assessment of the young person’s needs so as to inform the more detailed child protection plan to be later ‘fleshed out’ by the core group. There was no record that this happened and the assessment remained uncompleted. It was not updated until the care proceedings in January 2013.  5.4.5 In conclusion, the assessment element of the APIR framework was flawed and fell short of the existing agency and West Yorkshire Safeguarding Procedures practice standards.                                                             12 Namely the child’s developmental needs, parenting capacity and family and environmental factors 31   ToR 4 b) Planning and Implementation   5.4.6 The ICPC produced an outline child protection plan which was considered at the first core group meeting on 10/12/2011. There was one action specific to the young person, namely addressing his substance abuse. There was no provision for him to have a comprehensive health assessment.  5.4.7 The child protection plan did not have SMART outcomes.  Therefore, it was not clear to the core group what the goals were, who was responsible for achieving them and in what time.  5.4.8 The minuted contingency in the event of non-compliance was that if actions recommended are not followed through the local authority will seek legal advice. If the children are left alone and unsupervised legal advice will be sought regarding immediate protection. 5.4.9 Despite meeting regularly in accordance with safeguarding guidance, the core group did not develop the outline plan into a more detailed Child Protection Plan, nor did the parent of or the young person received a working copy 5.4.10 The first Child Protection Review Conference (CPRC) was held on 10/02/2012. A CSC meeting chaired by the Team Manager (TM2) on the 24/02/2012 agreed on working to a nine point plan that included completion of a social work assessment, a parenting assessment, assessment of family members, including the children’s fathers, and a referral to the EI and TS Family Support Team. There was no mention of the young person’s substance abuse assessment.  5.4.11 There were two recorded supervision sessions held between SW2 and TM2, these being on the 18/01/2012 and the 12/04/2012. The requirement was for monthly supervision sessions to have taken place in February, March and May 2012, in accordance with agency policy. Regular supervision, preferably involving an element of the ‘reflective approach’ between social worker and manager, should have been a key ingredient in effective case planning and intervention, especially in such a complex case as this one. 5.4.12 It had become apparent by the second CPRC held on 09/05/2012 that no real progress had been made with the child protection plan. The mother was not in attendance. FSA1’s parenting assessment completed in March 2012 was negative in regard to her parenting abilities and the outcomes for her children, including the young person. The Early Intervention Family Support Team had not been successful in engaging either the young person or his mother and the Police neglect warning of early May had been issued to the mother. There had also been the ‘Drunk and Disorderly’ incident of late April involving the young person.  32  5.4.13 The Conference Chair (IRO1) had expressed her concerns and suggested that a Public Law Outline should be urgently considered. 5.4.14 A decision had been made in February 2012 for the young person and his family to become part of the trial ‘Reclaiming Social Work (RSW)’ initiative that Kirklees Children’s Services was developing13. The intention was to allocate a small number of cases, including the young person and his family, to a dedicated, small team of workers (referred to as the ‘HUB’) who would work very intensively with particular ‘Child in Need’ and ‘Child Protection Plan’ families to prevent escalation into care proceedings.  5.4.15 SW2 told the Child Protection Review Conference that a decision was due to be made the next day about progressing the HUB approach. SW2 was of the view that the children should remain on child protection and that the HUB could run concurrently. SW2 told the conference that a formal letter would be sent to the mother inviting her and her solicitor to a PLO meeting. It would be explained what was expected of her with the option of going to court if the agreement was broken. 5.4.16 SW2 left the Department on 21/05/2012 and a new social worker (SW3) was allocated to the family the next day (22/05/2012) with CCO2 (a new community care officer) also allocated to the case at this time. The advent of a new social worker and community care officer should have been the occasion for TM2 to have reviewed the case, in the light of the pessimistic findings of the recent child protection review conference (CPRC) and to have developed a revised plan. The (core) assessment had not been completed by the previous social worker (SW2) prior to her departure. There should have been a timely social work assessment completed to inform case planning.  5.4.17 However, a decision seemed to have been taken to continue with ‘more of the same’ (an example of the ‘Start again Syndrome’), by the referral on 30/05/2012 to the Early Intervention and Family Support Team requesting a parent support service. A parenting worker was allocated in August 2012 to assist the mother with identified aspects of parenting but there seemed to be a degree of overlap and duplication with the work of CCO2, the community care officer in the HUB team. The mother was offered a ‘Family Links course’ in August and October 2012, both of which she failed to attend. None of these actions seemed to have been co-ordinated with the existing child protection plan. These family support services were in addition to the parenting work being attempted by the health visitor and the nursery nurse.  5.4.18 There was no record of case supervision between TM2, the social worker and community care officer between May to September 2012.                                                             13 This way of working was commonly referred to as the ‘Hackney Model’, see Community Care 24/10/2013, 06/11/2013 33  5.4.19 The legal planning meeting on 12/07/2012 and subsequent memorandum of July 2012 agreed to convene a PLO meeting, send out a detailed ‘letter before proceedings’ and ask the mother to sign a Contract of Expectations. These actions were standard operating procedures of the PLO process, prior to the local authority starting care proceedings. The core group was told by SW3 on 20/07/2012 that there was an intention to start the PLO process.  5.4.20 However, the three actions were not implemented or completed within two or three months of the meeting as would be expected. There was no record of the rationale not to implement the PLO decision of the legal planning meeting of 12/07/2012. CSC seemed to have come to a view sometime around late July/mid-August 2012 to start to prepare the ground for possible care proceedings on the young person and his siblings. This was reflected in the requests made for psychological and paediatric assessments (21/08/2012 and 14/09/2012 respectively) in order to gather evidence for care proceedings. 5.4.21 At the same time a decision was made to continue the intensive work with the mother in an effort change parenting behaviours and competence.  5.4.22 In relation to the core group and the existing child protection plan, from September 2012, CSC started to play an increasingly more dominant role in the case. Reasons for this included the move towards care proceedings and the process of evidence collation. This development tended to marginalise the non CSC members of the core group and render the existing child protection plan secondary to the emerging PLO process and eventual care proceedings. Non CSC core group members lacked clarity about the role and remit of the HUB and its practitioners, what their roles were within the existing child protection plan and where the PLO process was operationally. 5.4.23 The problematic dynamics operating within the core group were, to a degree, iterated within and mirrored by the HUB team. It’s operation was characterised by a lack of clear leadership, confusion between TM2 and the Consultant Social Worker (CSW1) regarding management oversight and accountability for the case, no evidence of any formal line management supervision, poor recording, lack of a child focused analysis regarding risk to the children, and minimal line management presence in any of the weekly HUB meetings. As a result of concerns about the operation of the HUB, the initiative was closed in January 2014. 5.4.24 Although there were weekly HUB meetings, these tended to focus on practical matters around cleaning up the home and getting the children to school, rather than an evaluative analysis of risk and the impact of parenting on the children. In regard to the social worker (SW3) and the community care officer (CCO2), it is understood that they were both line managed by the consultant social worker (CSW1). She had oversight of two HUBs involving twenty-five 34  cases and because of the volume of work, had limited time to give to this case. 5.4.25 The structural and systemic impediments to decision making and other factors outlined above did not, therefore, make for effective and timely planning by CSC and the HUB between May 2012 to January 2013, with associated implications for effective multi-agency core group working. Thus, for example, it was unclear to the lead reviewer why a family support worker was introduced to the family on 14/12/2012. This intervention served to duplicate the work of the HUB team, and unnecessarily added yet another professional into the many personnel involved with the family. 5.4.26 In December 2012 CSC received the psychological assessment commissioned by the local authority. The local authority’s legal section was instructed on 19/12/2012 to issue care proceedings with a view to removing the young person and his siblings from their mother’s care. The social work assessment was completed on 18/01/2013. However, at this point, and seemingly contrary to the instruction, the social worker was instructed by line management to start the PLO process with the mother. She was informed on the 23/01/2013 that she had between four to six weeks to show improvement. This was retracing work which should have been taken forward in the latter half of 2012.  When the core group of 26/01/2013 was told that the PLO process had been initiated, it was confused and concerned about case drift, and wrote to the CSC team leader. 5.4.27 A (PLO) letter was shared with the mother on 03/04/2013, and finally on receipt of the paediatric report, care proceedings were issued on the young person and his siblings by the local authority on the 24/05/2013.  5.4.28 In conclusion, despite regular core group meetings planning and Implementation were rendered less effective by the lack of a SMART child protection plan, the introduction of the HUB team, the resulting marginalisation of the core group and the impact this had on multi agency working. This added to the already existing complexity of working with a large family. Because of structural and systemic factors in the HUB effective planning and implementation were compromised. Case management was marked by case drift and delays in taking decisions, especially around the way the PLO process was managed. The core group was left unclear about the actions and intentions of the HUB team. This episode also highlighted the complexity of managing several processes running in parallel (the Child Protection Plan, the PLO, CSC case management and legal advice) and the need for careful coordination and good communication by the CSC team manager and social worker.  35   ToR 4 c) Reviewing 5.4.29 The absence of SMART outcomes for the young person made it difficult to review his progress around wellbeing and risk reduction. Furthermore, although agency reports were provided to CPRCs, the Child Protection Plan was not systematically reviewed and elements of the plan (such as the young person’s substance abuse) did not get actioned. The Conference Chair should have insisted and ensured that all child protection plans were SMART and that they were reviewed against agreed actions and outcomes. This now happens under the new ‘Strengthening Families’ approach adopted by the Kirklees Independent Reviewing Service. Additionally, the Conference Chairs should have sight of all core group minutes, significant case developments and the single assessment before reviewing a case. This is now possible under the current electronic case recording system.   5.4.30 The Conference Chair (IRO) did attempt to challenge CSC at the May 2012 CPRC regarding lack of progress with implementing the child protection plan and the need to consider the PLO process but without any remedy. It is important that the Child Protection Reviewing Service (CPRS) is respected and supported when it challenges agencies, including CSC and other local authority services. Agencies should respond to advice and concerns from the CPRS in a timely and positive manner with outcomes reported back in writing to the Conference Chair and the core group. There should be recourse to KSCB dispute resolution procedures when necessary. 5.4.31 The final CPRC held on 07/07/2013 was three months out of time and should have been held by mid- April 2013. The CPRS should have ensured that this happened and not have left it to the CSC team manager to decide on the date. Given the written concerns of late March 2013 from the core group to the CSC management about the way the case was being managed a timely CPRC was essential. Arrangements need to be in place to ensure that the CPRS decides on dates of ICPCs and CPRCs and not individual agencies.  5.4.32 In conclusion, the reviewing element of the APIR framework was less effective because the child protection plan was not systematically reviewed to ensure that agreed actions had been completed. 5.4.33 Learning points regarding assessment planning and review processes: Assessment   A full, holistic and timely core assessment should be completed within the agreed timeframe after an ICPC ( as set out in the outline child protection plan) 36   The participation of the family and the subject child/young person should be facilitated.  The assessment should be quality assured and signed off by the team manager. Planning and Implementation  Child protection plans for each child should be child focused and subject to appropriate updating.   Parents/carers and children  should be fully involved in the production of plans and  receive signed copies of the plans   Core group members should be clear about roles and responsibilities within the child protection plan.   There should be clarity for the core group and parents about contingency actions to be taken to protect children in the event of non-compliance  Lack of progress with the plan should be robustly challenged, underpinned by a professional approach of ‘respectful uncertainty’ and professional curiosity.  There should be  proactive and skilled management oversight with easy access to managers who are familiar with cases and regular high quality ‘reflective’ supervision  Decisions should be recorded in a transparent way and communicated clearly to workers, parents, children and core group members  PLO arrangements should be fully enacted in a timely and robust manner and incorporated into the child protection plan.    Action should be escalated to care proceedings in the event of PLO agreements being breached so as not to delay decisions to protect children's welfare.  Review  Conference Chairs should review SMART child protection plans.  Conference Chairs should have access to assessments, core group minutes and significant developments in the case.   Agencies should respond to concerns and recommendations from Conference Chairs in a timely manner with outcomes reported back in writing to the Chair and core group.  There should be recourse to the KSCB dispute resolution process in the event of disagreement between the Conference Chair and any agency.  Arrangements should be in place to ensure that the Child Protection Reviewing Service decides on dates of conferences and not agencies.   37  6. FAMILY VIEWS 6.1 The young person’s mother was seen as part of this process. She acknowledged that a lot of agencies were involved with the young person and her family. She stated that the young person was not willing to engage with the majority of these professionals. Both the young person and the older two of his siblings found the intrusion into their family life difficult and felt that several people would be in and out of the family home within one day, all saying the same thing. This resulted in the young people not listening or responding to what was said. The young person’s mother also pointed out that it was not helpful that her daughters were told they would end up down the same road as the young person; this was said in front of him. 6.2 She did identify that the young person’s difficulties with school began as soon as he was in reception class. She felt this was because of his August birthday and he was significantly younger than many in his class and therefore struggled and school were not prepared to hold him back a year, consequently he always felt at a disadvantage and quickly became disengaged with the learning process. 6.3 The young person’s mother was very clear that she did not feel anyone could have done any more to get alongside him and that professionals had all tried.  The young person did speak to the student social worker, but once the worker qualified he moved on. The young person would not work with the youth offending team as he saw them as an obstacle to him joining the army at 16 because of the order that was in place; he was offered support from the youth services but the activities were not of interest to him. He enjoyed going to the gym and had been committed to that for about one year prior to the incident. The mother indicated that however much support was on offer the young person would only speak to people he wanted to and nothing would alter that. She acknowledged that no one could have anticipated that he would do what he did and that there were no warning signs to suggest any risk.   6.4 The young person’s father was seen as part of the process. He maintained regular indirect contact with the young person up to the incident.  He provided relevant information of a personal nature which for confidentiality reasons is not appropriate to include in this report  6.5 The father confirmed that he had been granted Parental Responsibility by the Court but that he was not party to the Care Proceedings. He felt strongly that he should have been, and believes that his contact details were known to the young person’s family.  6.6 The father believes that the signs were there which made the incident predictable or preventable although he does however acknowledge that this is 38  with hindsight and that resource issues were a factor. He said it felt as though the case kept being closed without things being sorted out. 6.7 The father acknowledged the difficulties agencies had engaging the young person, and  that they would say they had tried very hard. He considered that everyone is under pressure, but he said they should have continued to try to engage the young person. 6.8 The father said that the young person should have been removed from the environment and that consideration could have been given to placing him within the extended family. The father was clear that he would have offered to help if he had known what was going on. He said he doubts anyone will know why the young person did what he did. The father views the situation as “misadventure” rather than attempted suicide. He thought that the young person’s environment must have been a factor. 6.9 Members of the young person’s extended maternal family were seen as part of the review. One part of the family felt that agencies should have been persistent in trying to engage him. They acknowledged that he would only speak to those he wished to and that he did refuse to work with agencies but felt that this should not have deterred professionals from continuing to try.  They felt that he just needed someone to talk to who was there just for him and would listen because they wanted to, not just because it was their job.  They did point out that the young person was too old by this point and effective engagement should have happened earlier.  They did suggest that moving him from the home environment into foster care or with extended family may have helped to get him back into school.  However, they did acknowledge that they would not have been able to make him do what he did not want to. 6.10 The young person had very positive relationships with another part of the wider family and they described him as being very much part of their family. They provided him with a place to be, they talked to him and fed him and he had a very good relationship with a family member of similar age to himself and they spent a lot of time together.  They described the young person as a young man who had confidence and who spent time at the gym and getting fit.  They felt that the change in the young person’s behaviour was very sudden and recent. They knew in the past he had misused substances but had made an effort to stop, even rejecting cigarettes and it was only the recent change in behaviour that raised their concerns. They had tried to help the young person and contacted other family to alert them to their concern.  This wider family did get alongside the young person but were not aware of all the professional agency involvement. Also as it was a sudden and rapid deterioration there was no time to take any other action. The family do not appear to blame 39  anyone for the young person’s situation. They are clear that his paranoid behaviour was unusual and most probably due to recent drug misuse. 6.11 The lead reviewer and the Panel agreed that more effort should have been made by CSC and the Children’s Guardian in 2012/13 to have contacted the father, both for the social work assessment and the care proceedings. The father’s potential significance to the young person and any possible role he might have been able to play in his future care should have been considered. All possible and reasonable efforts should be made to contact fathers (or the absent biological parent) where they are living away from their children, to establish whether it is in the child’s best interests for there to be an appropriate level of involvement.  6.12 Overall, it is considered that more effort could have been made in assessing the significance of the young person’s extended family and the potential for their support in re-engaging him back into education and mainstream social activity.  7. CONCLUSIONS 7.1 The young person showed no self-harming behaviour or suicidal ideation until a few days before the incident. These behaviours were elements of a probable, psychotic episode; most likely brought on by his use of alcohol, cannabis and MCAT.  7.2 Given the late onset of warning signs of the young person’s self-harm and suicidal ideation and that none of the assigned professionals (or, indeed his mother) were aware of these, it is concluded that the incident was neither predictable nor preventable.  7.3 The incident was preceded by a long period of neglect for the young person that could have made him vulnerable to substance misuse and mental health difficulties. His emotional wellbeing needs were not effectively recognised or responded to throughout the period in question. His experiences of long term neglect, low control/low warmth parenting, non-school attendance and substance misuse were not given sufficient consideration by professionals as having potential consequences for his mental health and emotional wellbeing.  7.4 There were missed opportunities to try and respond to the young person’s known substance misusing behaviour and to assess his overall health needs. These were, as part of the child protection plan following the Initial Child Protection Conference of December 2011, the two Accident and Emergency admissions of the 2012 and as part of the YOT Asset assessment. Given the young person’s tendency to withdraw from professional contact there was no 40  certainty that he would have consented to assessment but attempts should have been made nonetheless.  7.5 The inability of professionals to engage the young person was a key factor in not being able to effectively address his problems and needs. Once the young person became disengaged from school, professionals were not able to gain his trust and engage him to the point where he felt able to participate meaningfully in activities aimed at integrating him back into education provision, promoting his safety and wellbeing and effectively facilitating his Referral Order. This dis-engagement resulted in there being insufficient focus on him by agencies, who focused on his siblings and mother.  The absence of any real consequences in not engaging in, for example, his Referral Order or attempts to get him back into education provision, were additional factors in the young person’s hard to reach, non-engaging attitude and behaviour.  7.6 Whilst there was a consistent pattern of multi-agency meetings over the period of the review, the assessment and planning processes which underpinned multi-agency working did not adequately focus on the young person's specific needs and did not sufficiently take into account the case history. In addition the large number of professionals involved in work with this large family was an added complexity, and was at times counter- productive. Once the HUB took on intensive work with the family, the core group became marginalised and there was added confusion about the direction of planning when the PLO process was started alongside this work. Bringing in a new team also resulted in the 'Start again syndrome’ and added to the delays in progressing the PLO process.  7.7 The local authority did attempt to safeguard and promote the young person’s welfare by obtaining an interim supervision order in June 2013 which was the only viable legal option open to it. Both the Court and the Children’s Guardian took the view that the young person should remain in the care of his mother whilst on the supervision order. The incident happened during the care proceedings and prior to the final hearing in November 2013.  7.8 The analysis of the pertinent issues in this case has produced a number of learning points and recommendations. The expectation of this Report is for the Kirklees Safeguarding Children Board and its partners to consider how best to take action to improve safeguarding services which promote the welfare of children and protect them from harm.            8.  RECOMMENDATIONS 1. The KSCB should ensure that relevant professionals are made aware of the mental health risks associated with new synthetic drugs, and that the Board 41  works with the Children's Trust to ensure that there are strategies in place to raise awareness with young people and communities about these issues 2. The KSCB should ensure that all relevant professionals within the safeguarding partnership access learning on adolescent suicide and self-harm that includes the impact of long term neglect on young people’s emotional and mental health.  3. The KSCB should obtain assurance that the referral pathway to Young People’s Substance Misuse Services is effective and in wide use by professionals. 4. The KSCB should ensure that all adolescents who are subject to a child protection plan for neglect are offered a holistic health assessment which includes their emotional health and wellbeing.  5. The KSCB should arrange for professionals to be aware of the pitfalls associated with the ‘Start again syndrome’ and remind practitioners of the importance of including previous family histories in assessments, especially in long term neglect cases. 6. The KSCB should arrange through the Board to develop and implement a toolkit enabling professionals to engage effectively with ‘hard to engage’ young people  7. The KSCB should seek assurance that there are robust arrangements in place for the timely management of children with school attendance problems 8. The KSCB should endorse the recommendations and action plans of the agencies’ IMRs and obtain assurance:   That agency learning is shared with and disseminated widely with staff forthwith;  That the KSCB, as part of its learning and improvement agenda, receives regular six monthly reports from agencies on the progress of action plans, dissemination of learning and evidence of the learning having made a difference to the safety and wellbeing of children.  8.1 The KSCB should ensure that the recommendations and learning points are incorporated into an Action Plan which will be monitored and regularly reviewed by the KSCB Serious Case Review Workstream, with referral on to other workstreams as appropriate.    42  Appendix 1: Terms of Reference and Key Practice Episodes  Terms of Reference  1. The young person’s self-harming behaviour and suicidal ideation: Were there any warning signs of self- harm, suicidal ideation, mental health issues or substance misuse prior to the incident with the young person and if so, how well were they recognised and responded to by professionals?  To what extent was the incident predictable and preventable?   2. Consider issues around Multi-agency working with neglectful families including professional curiosity and the use of case history: How far was the case history used to inform actions and decisions? 3. Child focus: How far did the focus remain on the young person, his emotional wellbeing, attachments and sibling relationships? How well did professionals engage the young person and balance the issues of self-determination and his vulnerability as a teenager?  4. Assessment, planning, implementation, review, contingency arrangements and decision making: How effective were these in responding to the young person’s needs, particularly in relation to multi-agency child protection and intervention between December 2011 and July 20  Key Practice Episodes The five Key Practice Episodes (KPEs) considered at the Learning Event in regard to the Terms of Reference were;  1. Examine issues in relation to engaging the young person. Include consideration of him as a young person who had experienced neglect, and the impact of this on him.   Why were there difficulties in engaging the young person?  2. Examine multi-agency planning and intervention within the period of May 2012   – June 2013.  3. What were the opportunities for assessing the young person’s health and wellbeing throughout the period of the SCR?  4. Consider issues around multi agency working with neglectful families.  5. Examine agency responses to the young person in relation to his mental health, self-harm and substance misuse. Regarding vulnerable adolescents and mental health, self-harm and substance;   43   What arrangements are there for early recognition?  What access is there to advice and what are the pathways to services for young people, family and friends?  What are the levels of practitioner awareness and capacity?  What are the learning points?    44  Appendix 2: Membership of the SCR Overview Panel and Sources of Information Membership of the SCR Overview Panel  Independent Chair (Ms Bron Sanders, also the Independent Chair of the KSCB)  Kirklees Children and Young People Service-Head of Early Intervention and Targeted Support  Head of Service, Family Support and Child Protection, Kirklees Council  (first Panel meeting only)  Kirklees Learning Service  Greater Huddersfield and North Kirklees Clinical Commissioning Group; Designated Nurse   Locala Community Partnerships; Director of Clinical and Operational Services  West Yorkshire Police; Superintendent  Head of Integrated Youth Support, Kirklees Council  KSCB Manager  KSCB Safeguarding Co-ordinator  Administrative support was provided by the Business Support Manager of the KSCB.  Sources of Information  Individual Management Reviews from Kirklees Children’s Social Care/ Family Support and Child Protection, West Yorkshire Police, Locala Community Partnerships, Kirklees Learning Services, Kirklees Early Intervention and Targeted Support Services/ Integrated Youth Support.  Composite chronology  The Court ‘Bundle’ of relevant documents relating to legal proceedings  Minutes of the Initial and Review Child Protection Conferences   45  Appendix 3: Learning points from the Serious Case Review Learning points in relation to self-harm and suicidal ideation:   Professionals should be aware of the possibility of mental health problems associated with newly evolved strains of cannabis, and other drugs such as MCAT.  Professionals should consider the possibility of self-harm and/or suicide when working with vulnerable adolescents who have experienced long term neglect.  Learning points in relation to substance misuse:  Where there is a Child Protection Plan   Consideration should be given to the use of an assertive outreach approach in working with ‘hard to reach’ and non-engaging adolescents  Focus should be maintained on the young person where there are younger children in the family  A referral should be made to the Young People’s Substance Misuse service as part of a child protection plan where substance misuse has been identified as a risk factor.   Consideration should be given to understanding the underlying reasons for a young person’s substance misuse. They should be seen as a ‘troubled’ child as opposed to a ‘troubling’ teenager.  Effective audit and scrutiny should be provided by Child Protection Review Conferences to ensure that actions have been completed and if not, why not, with recourse to contingencies. Where the Acute Trust is involved  There should be adherence to the Pathway for referral to the Base substance misuse service by Accident and Emergency staff where young people have known substance misuse issues.  There should be arrangements to test the effectiveness of the Pathway periodically.   There should be an effective notification system to Accident and Emergency of children subject to a child protection plan.  Accident and Emergency staff should notify Children’s Social Care of admissions when a child is subject to a child protection plan.   There should be an effective notification process from Accident and Emergency to the paediatric nurse service of any safeguarding issues concerning children admitted to the department.  46  Where the YOT is involved  YOT should have a focus on a young person’s safeguarding and welfare needs as well as offending behaviour. All young people assessed as being of medium risk of harm to themselves should have an effective vulnerability management plan that includes consideration of all relevant safeguarding issues and where appropriate, addressing substance misuse needs.   There should be early and assertive efforts at engaging young people on their orders.  There should be timely completion of Asset assessments.  There should be rapid follow up action to ensure compliance with consequences when young people do not co-operate with orders and their conditions.   The YOT should provide effective management oversight, challenge and audit of vulnerability management plans and their implementation. Where appropriate, vulnerability management plans should be incorporated into a young person’s child protection plan.  Learning points: Mental Health and Emotional Well-being:    Professionals should understand and assess the impact of long term neglect on an adolescent’s emotional wellbeing and mental health.   A holistic health assessment that considers emotional wellbeing should be included in the child protection plans of adolescents. There should be clarity as to which professional has responsibility, within a SMART child protection plan for ensuring that a holistic health assessment is completed.   There should be a holistic health assessment for all young people subject to YOT vulnerability plans that includes emotional wellbeing.  Learning points in relation to issues around multi agency working with neglect:   Professionals should recognise the importance of considering in a timely way a family’s case history as a possible predictor of future capacity to parent   Professional should understand the features of the Start Again Syndrome and ensure that this is focussed on in supervision.  Consideration should be given to the impact of the number and range of professionals working with neglectful families to ensure that this does not become counterproductive. 47  Learning points regarding the focus on the child:  Professionals should identify creative and flexible ways of engaging with vulnerable young people which aim to develop trust and show perseverance in the face of dis-engagement   In child protection cases where there is difficulty in engaging a young person, consideration should be given to allocating a separate worker for that young person.  Professionals should make early, robust and concerted efforts to re-engage young people with school attendance problems.   Learning points regarding assessment planning and review processes: Assessment   A full, holistic and timely core assessment should be completed within the agreed timeframe after an ICPC ( as set out in the outline child protection plan)  The participation of the family and the subject child/young person should be facilitated.  The assessment should be quality assured and signed off by the team manager. Planning and Implementation  Child protection plans for each child should be child focused and subject to appropriate updating.   Parents/carers and children  should be fully involved in the production of plans and  receive signed copies of the plans   Core group members should be clear about roles and responsibilities within the child protection plan.   There should be clarity for the core group and parents about contingency actions to be taken to protect children in the event of non-compliance  Lack of progress with the plan should be robustly challenged, underpinned by a professional approach of ‘respectful uncertainty’ and professional curiosity.  There should be  proactive and skilled management oversight with easy access to managers who are familiar with cases and regular high quality ‘reflective’ supervision  Decisions should be recorded in a transparent way and communicated clearly to workers, parents, children and core group members  PLO arrangements should be fully enacted in a timely and robust manner and incorporated into the child protection plan.  48    Action should be escalated to care proceedings in the event of PLO agreements being breached so as not to delay decisions to protect children's welfare Review  Conference Chairs should review SMART child protection plans.  Conference Chairs should have access to assessments, core group minutes and significant developments in the case.   Agencies should respond to concerns and recommendations from Conference Chairs in a timely manner with outcomes reported back in writing to the Chair and core group.  There should be recourse to the KSCB dispute resolution process in the event of disagreement between the Conference Chair and any agency.  Arrangements should be in place to ensure that the Child Protection Reviewing Service decides on dates of conferences and not agencies.    49  Appendix 4: Glossary of Terms  APIR:   Assessment, Planning, Intervention, Review CAF:   Common Assessment Framework CiN:  Child in Need CP Plan:  Child Protection Plan CPRC: Child Protection Review Conference CPRS:  Child Protection Reviewing Services  CSC:  Children’s Social Care CSW:   Consultant Social Worker FISS:   Family Intervention Support Service HV:   Health Visitor ICPC:   Initial Child Protection Plan IMR:   Internal Management Reviews IRO:   Independent Reviewing Officer ISO:   Interim Supervision Order KPE:   Key Practice Episode KSCB:  Kirklees Safeguarding Children Board LSCB:  Local Safeguarding Children Board MCAT:  Mephedrone PAYP:  Positive Activities for Young People PCSO:  Police Community Support Officer PLO:   Public Law Outline PRU:   Pupil Referral Unit SCR:   Serious Case Review SMART:  Specific, Measurable, Achievable, Relevant, Timely SW:   Social Worker TM:   Team Manager ToR:   Term of Reference YOT:   Youth Offending Team    50  Appendix 5: References Brandon M. et al (2008): ‘Analysing Child Deaths and Serious Injury through Abuse and Neglect: What can we learn?  Brandon M. et al (2013): ‘Neglect and Serious Case Reviews’ NPSCC/ University of East Anglia  The Children’s Commissioner (October 2013): ‘It takes a lot to build trust: Recognition and telling: Developing earlier routes to help for children and young people’  Community Care: 24.10.13 and 06.11.13   Diclemente and Prochaska:   ‘The Change Cycle’ Wikipedia  Hicks L. and Stein M. (2010): ‘Neglect Matters: A multi-agency guide for professionals working together on behalf of teenagers’  Laming H. (2003): The Victoria Climbie Enquiry  Department of Education (2013): ‘Working Together to Safeguard Children’      Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date  1  SCR 026 Case summary: Young person – aged 16 years: sustained life-changing injury following attempted suicide – 09/2013. Family had a long history of agency interventions.  SCR 026 / 001 Kirklees Safeguarding Children Board [KSCB]  All relevant agencies  Findings 1a & 1b: Understanding of adolescent mental health / suicide / self-harm issues and their relation to long term neglect and/or substance misuse  Section 5.1 in Overview Report [OR]  Key Practice Episode [KPE] 5  Recommendation 1.  The KSCB should ensure that relevant professionals are made aware of the mental health risks associated with new synthetic drugs, and that the Board works with the Children’s Trust to ensure that there are strategies in place to raise awareness with young people and communities about these issues.  Multi-agency briefing to be provided for front line professionals; raising awareness of emerging synthetic drugs as part of Learning from SCR.   CRI/The Base approached for information re strategic event in Jan-15 and other training carried out and who for  CRI/The Base to provide briefing paper for inclusion on the KSCB website and in a SCR Lessons briefing paper  New synthetic drugs on the agenda for discussion at the June meeting of the Children’s Trust  CRI/The Base update:  To provide further content including local prevalence, trends, supply, effects, screening, harm reduction, referral & signposting.  Other methods by which awareness is raised of NPS includes drop-in’s and group-work within schools, colleges and universities, targeted group-work within children’s homes and hostels, outreach within local communities and the night time economy.   Children’s Trust agenda     Briefing on Novel Psychoactive Substances provided on 15/10/14.  Attendance register provided to KSCB as evidence.  NPS training delivered from Feb 2014 to Jan 2015 to 1089 professionals from a range of services.   Briefings and training to be arranged for 2015. In January 2015, CRI instigated the development of a NPS strategy and steering group.   Awareness raising Mar-15 G R E E N May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date  2   campaigns delivered to all local stakeholders, including young people and parents via social media and the CRI website.   SCR 026 / 002 KSCB  All relevant agencies  Finding 2: Multi-agency work with Neglect issues  Section 5.2 in OR  KPE 4   Recommendation 2.  The KSCB should ensure that all relevant professionals within the safeguarding partnership access learning on adolescent suicide and self-harm that includes the impact of long term neglect on young people’s emotional and mental health.   KSCB to incorporate into multi-agency neglect training  KSCB Training courses content has been updated to reflect learning Courses contents Jan-15 G R E E N May-15 Single agency training to incorporate learning into neglect training   Learning & Development work stream to discuss at meeting in April 2015. Agenda to include: KSCB Learning & Improvement briefing paper for dissemination to individual agencies  Learning & Development work stream agenda – 20 April 2015 Apr-15 A M B E R May-15 KSCB to provide workshop on impact of neglect as part of a Learning from SCR Conference  KSCB Lessons from SCRs conference to take place Oct-15. Workshop to focus on impact of long-term neglect.    Oct-15 A M B E R May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date  3  SCR 026 / 003 KSCB  Young People’s Substance Misuse Services Finding 1b. Young people’s substance misuse – referral pathways  Section 5.1 in OR  KPE 5 Recommendation 3.  The KSCB should obtain assurance that the referral pathway to Young People’s Substance Misuse Services is effective and in wide use by professionals.  CRI/The Base to provide briefing paper for inclusion on the KSCB website and in a SCR Lessons briefing paper   CRI/The Base update: Referral details available on CRI website and other local and national web pages including local authority pages, Voluntary Action Kirklees, Alcohol Concern, Talk to Frank, Facebook and Twitter.  All aforementioned training programmes include specific information on referral pathways. Generic referral pathway is to contact The base via phone or drop-in. This sits alongside specific referral pathways in existence between The Base and; CAMHS, CHEWS, YOT, TYS, Connect housing, A and E departments, Kirklees college, LAC private and council residential homes plus foster care, CSE Ongoing work to develop a joint pathway between universal education, TYS and The Base.  Ongoing work to develop the existing pathway between Huddersfield University and The Base.  Ongoing work in an attempt to increase referrals from A&E departments into young person’s drug and alcohol services.   Referral source information and numbers from Sept 2013 to Sept 2014 provided to KSCB as evidence. Further information expected to be available by March 2015.  Mar-15 A M B E R May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date  4  hub and PRU’s.  KSCB to put the CRI briefing papers and  information regarding referral pathway for professionals onto the website  CRI/The Base to provide briefing paper for inclusion in the second SCR Lessons briefing paper   Apr-15 A M B E R  The Base to provide assurance that there is a clear referral pathway, and also information on numbers referral and agency source CRI/The Base approached for information re referral pathways and referral numbers / agency sources. Information to be included in E&E data collection for ongoing monitoring. Information also to be included in KSCB newsletter and on website.     Mar-15 A M B E R   SCR 026 / 004 Child Protection Review Unit (CPRU)  Finding 2: Mental health and emotional well-being: Holistic health assessment to be available for young people subject to a CP Plan  Section 5.1 in OR Recommendation 4.  The KSCB should ensure that all adolescents who are subject to a child protection plan for neglect are offered a holistic health assessment which includes their emotional health and A holistic health assessment is to be included within the Child Protection Plan where relevant.  IRO’s to monitor at review conference  Apr-15 A M B E R    May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date  5   KPE 3 wellbeing.  SCR 026 / 005 KSCB  All relevant agencies  Finding 4. Assessment, planning, intervention, review, contingency arrangements and decision making all need to be more robust.  Section 5.4 in OR  KPE 2  Recommendation 5.  The KSCB should arrange for professionals to be aware of the pitfalls associated with the ‘Start again syndrome’ and remind practitioners of the importance of including previous family histories in assessments, especially in long term neglect cases. KSCB Learning & Development to incorporate in courses content into multi-agency training.   To be considered at L&D workstream meeting – April 2015   L&D workstream meeting agenda  – April 2015  Courses contents updated: Neglect Safeguarding Skills for Managers  Mar-15 G R E E N  May-15 KSCB Learning & Development to incorporate in courses content into single agency training  To be considered at L&D workstream meeting – April 2015  L&D workstream meeting agenda  – April 2015  Courses contents Apr-15 A M B E R   Social Care to include in Single Assessment themed briefings week  Briefings taken place; Social Care to provide dates and evidence of inclusion of issues.  Mar-15 A M B E R   To be included in the second learning lessons briefing / newsletter  Family histories / start again syndrome / long term neglect to be included in the second learning lessons briefing / newsletter   Apr-15 A M B E R  May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date  6  Lessons to be used in KSCB Learning from Reviews Conference planning Conference planned for October 2015 Conference Plan Oct-15 G R E E N  SCR 026 / 006 KSCB  All relevant agencies  Finding 3: Maintaining focus on and engaging with, ‘harder to reach’ young people   Section 5.3 in OR  KPE 1 Recommendation 6.  The KSCB should arrange through the Board to develop and implement a toolkit enabling professionals to engage effectively with ‘harder to engage’ young people.   KSCB to coordinate a working party to consider current strategies for working with hard to reach young people and develop an overarching strategy  KSCB to contact agencies to form a working group to include TYS / IYSS / ‘Missing in Education’ / The Base/CRI / Social Care / Stronger Families / FIP to identify models for evidence based, best practice to develop a toolkit for use with harder to engage young people     Jun-15 A M B E R   May-15 SCR 026 / 007 KSCB  Education  Finding 3: Child focus - School attendance   Section 5.3 in OR  KPEs 1 & 3 Recommendation 7.  The KSCB should seek assurance that there are robust arrangements in place for the timely management of children with school attendance problems.   KSCB to request a report from the ‘Missing in Education’ team re numbers involved, actions taken and impact. Report requested Sept 2014.   Education provided:  CME Policy and Procedures Jan 2014   CME guidance for schools  Request e-mail trail   Apr-15 A M B E R May-15 Evaluation & Effectiveness (E&E) work-stream to Core Data set ready for data.  Mar-15 A M B May-15 Kirklees Serious Case Review – A Young Person – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date  7  incorporate data into the Core Data set for monitoring  E R SCR 026 / 008 KSCB  All relevant agencies   Learning & Improvement   Section 7.8 in OR Recommendation 8: The KSCB should endorse  the recommendations and action plans of the agencies’ IMRs and obtain assurance:   That agency learning is shared with and disseminated widely with staff forthwith.  That the KSCB, as part of its learning and improvement agenda, receives regular six monthly reports from agencies on the progress of action plans, dissemination of learning and evidence of the learning having made a difference to the safety and wellbeing of children.  Lessons to be incorporated into regular KSCB newsletters and briefings papers.   Briefing paper widely circulated to agencies in January 2015; next issue due out in April 2015. Briefing papers incorporate a feedback sheet to provided evidence of how learning has improved practice.   Apr-15 A M B E R  May-15 Learning and Development workstream to incorporate into multi and single agency training L&D workstream to consider at meeting in April 2015.  Learning & Development work stream agenda – 20 April 2015 Apr-15 A M B E R May-15 SCR work-stream to monitor progress of identified actions from recommendations via six monthly Action Plan Review meetings.  Action Plans Reviews meetings established in 2014. To take place six monthly and to include SCR w/s members and chairs of other work-streams.  Review of this Action Plan will be incorporated into the established process. It will be subject to updates from agencies and review in May-15 and Nov-15  May-15 G R E E N May-15  