Death of a 16-year-old girl on 16 November 2013 at a hostel where she was living. Coroner recorded the cause of death as hanging but returned a 'narrative' verdict as it was unclear whether Child W intended to take her own life. A significant number of professionals were supporting her at the time including social workers, hostel staff and substance misuse and mental health services. W was removed from her birth family at 7-years-old because of physical abuse and neglect. She was adopted at 10-years-old with her younger brother. Adoptive parents struggled to cope with her and her sibling's behaviour and requested support from professionals. Prior to her death, W had left her adoptive home following a breakdown in relations. Other concerns included an unsuccessful contact meeting with birth father; self-harm; and substance misuse. W was also the victim of an alleged rape. Findings include: Child W was assessed as needing "intensive therapeutic support" following her early childhood experiences and attachment issues but this support was not provided. Recommendations include adoption support plans need to clearly detail how and by whom therapeutic needs will be met; attachment needs of adopted children should form part of specialist therapeutic services in local commissioning arrangements; and local authorities should ensure that staff are clear about local guidance and support for homeless 16 and 17-year-olds.
      
 Title:  Serious case review: Child W: overview report. LSCB: Hull Safeguarding Children Board Author:  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.                                           SERIOUS CASE REVIEW  Prepared under Chapter 4 of  ‘Working Together to Safeguard Children (2013)’   Child W    Report of the Hull Safeguarding Children Board following consideration of a review independently led by:  Reconstruct Ltd                     December 2015   2 Contents  1. Introduction  2. The Approach to the Review   3. Time Period 1: September 2004 – July 2013  4. Time Period 2: July 2013 – November 2013  5. Findings, Developments and Recommendations   Appendix 1: SCR Review Panel Membership  Appendix 2: Brief Description of Services  Appendix 3: List of Abbreviations                                   3 1.       Introduction  1.1     The circumstances which led to a Serious Case Review  1.1.1 Child W was 16 years old when she died. On 16th November 2013, she was found, by a worker at the hostel in which she was living, on her knees in the bathroom, with her head facing forward and a ligature around her neck. ‘999’ was called and an ambulance transferred her to Hull Royal Infirmary. All attempts at resuscitation were unsuccessful and Child W was declared dead shortly after.  1.1.2 An inquest into Child W’s death was held in March 2014. The coroner accepted the pathologist’s conclusion as to the cause of death as ‘hanging’ and accepted that the toxicology reports were negative. On the balance of probability the coroner returned a ‘narrative’ verdict. This verdict reflects the conflicting views of those who gave evidence at the inquest. It means that it is unclear as to whether or not Child W intended to take her own life.  1.1.3 Child W was born in Barnsley in 1997. She experienced a very difficult and troubled early childhood, which led to her removal from her birth family when she was 7 years old. After a period in foster care, Child W and her younger brother were placed for adoption with carers in Hull. Child W was formally adopted when she was 10 years old.   1.1.4 In the months leading up to her death, Child W had left her adoptive home and was living in hostel accommodation in Hull. She had been the victim of an alleged rape. A significant number of professionals and services in Hull were involved during this period in helping and supporting her.  1.1.5 Given all of these circumstances, the Independent Chair of Hull Safeguarding Children Board decided that a Serious Case Review into Child W’s death would be undertaken.  1.2     Family Background  1.2.1 Child W was the second daughter of her birth parents. She also had a younger brother. All three children were made subject to Interim Care Orders in October 2004 and a decision was taken by Barnsley Metropolitan District Council (MDC) that it was no longer safe for them to live with their birth parents.  1.2.2 Child W and her younger brother were initially placed with local Barnsley foster carers before moving to live with carers in Hull in July 2006. These carers had been approved as adoptive parents by Hull City Council in February 2006. They initially fostered Child W and her brother with a plan for adoption. Child W and her brother were legally adopted by the Hull carers in August 2007.    4 1.3     Child W  1.3.1 During the course of this review, people who knew Child W have been keen to share their memories of her. The words used to describe Child W, her character and personality, are strikingly similar, from those who knew her best and those whose contact with her was more fleeting: she was popular, caring, keen to help others and always defending the ‘underdog’. Child W was well liked by her peers and by the adults who knew her.  1.3.2 Child W’s parents describe her as being able to ‘fit in’ and make friends from across a very broad range of social backgrounds: she delighted in describing her family context as “posh” in contrast to her early childhood in Barnsley but she was always charming and polite and “fitted in everywhere”.  1.3.3 From an early age, Child W wanted to pursue a career in a caring profession because she wanted to help others. Primarily she wanted to become a medic in the army.  1.3.4 Teachers at Child W’s secondary school describe her as having a “cheeky but playful” attitude towards school life and that she liked nothing better than to have a “good debate”. Her caring outlook was further shown in her need to “ensure justice for anyone wrongly accused”.  1.3.5 Child W’s school report for the academic year 2011/12 (her year 10) described a confident member of the tutor group keen to volunteer for tasks. She volunteered as a ‘Reader Leader’ and her tutor described her as being “very supportive of her peers and always willing to help”. She was described in this report as being “an outstanding ambassador for the school”  1.3.6 During her childhood and early teenage years in Hull, Child W engaged with a wide range of voluntary and community sector services and activities, including the Guides, the Army Cadets and, from October 2013, the Warren.  1.3.7 The Army Cadets describe her as a popular cadet who enjoyed band, camps, swimming and keeping herself fit by running. She is described as a talented musician, playing the drums and flute, and taking charge of the flute section. When she stopped attending the cadets in May 2013 without explanation, her place was kept open for her in the hope that she would return.  1.3.8 Child W took part in various activities at the Warren, including craft work and music, and was described as being a popular member of the Warren community. After her death young people at the Warren organised a ceremony to celebrate her life.    5 1.3.9 Child W also formed strong and positive relationships with the adults who were helping her during the last few months of her life, including her social worker and project workers at Hostel 2. Workers at the hostel fondly recall the many hours they spent with Child W helping her with her homework, applying make-up, buying her beauty products comforting her when she needed it. They describe her as always wanting to be cuddled by staff.  1.3.10 They describe her as having an infectious smile and laugh; as being bright and bubbly, and, when in good spirits, vibrant and full of life. Child W lived at the hostel during a particularly troubled period in her life. Not surprisingly staff also found her to be quite emotional and that her behaviour could be erratic at times.   1.3.11 Their overriding memories of her however are of a young person who put other people before herself; who was fiercely loyal to those she cared about, often putting their needs before her own and; as someone who would do her utmost to cheer up anyone who was sad. Child W had lots of friends and was instantly liked by people who she met.   1.3.12 Her parents too describe her capacity to make people feel valued: this capacity was illustrated after her death amidst the plethora of tributes and messages posted on Facebook by the significant number of young people who genuinely considered themselves to be Child W’s “best friend”.  1.3.13 It is apparent that Child W’s character and personality were such that she had a powerful positive impact on those who knew her: her family, friends and the adults who tried hard to help her. This also explains why all those who knew her were so profoundly affected by her tragic death.                   6 2.  The Approach to the Review  2.1 Statutory guidance requires Serious Case Reviews (SCRs) to be conducted in a way that:   Recognises the complex circumstances in which professionals work together to safeguard children;  Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  Is transparent about the way data is collected and analysed; and  Makes use of relevant research and case evidence to inform the findings.  2.2 Under the guidance, Local Safeguarding Children Boards (LSCB) may use any learning model which is consistent with the principles.   2.3 The Hull Safeguarding Children Board (HSCB) commissioned Reconstruct Ltd to provide Independent Lead Reviewers for this review. Agencies provided individual chronologies of events, which were combined into an integrated chronology. This was used to help inform an initial scope and focus for the review.  2.4 A ‘review panel’ of senior professionals representing the agencies that were or had been involved with Child W and her family, and other members of the HSCB Serious Case Review sub-committee, was established (see Appendix 1).   2.5 The panel agreed that the main focus of the review should be on establishing any learning from the way in which local services and professionals had worked together to help and support Child W from March 2012 until her death in November 2013.   2.6 It was also agreed, however, that it would be important to consider the impact, and practice issues, of Child W’s early childhood experiences, placement and subsequent adoption in Hull (2006-07), since this provided an important context to understanding her needs and vulnerabilities.   2.7 The panel agreed that the review should tell the story of Child W’s life and journey through the helping services, from the perspective of those who knew her, and to draw out any learning for the LSCB about the way in which agencies need to work for the future. Specifically, the initial focus would be on:  The impact of her adoption and the level of support offered to her and to her family to make this placement a success given her family history;  The impact if any of her adoption status on the help she received and the perception of her needs and risks held by professionals;   7  The response from professionals to her family when things began to escalate from March 2012 up until the point of her death, including the sharing of information and how this informed practice;  The joint police investigation into her rape allegation and the level of support offered to her, plus the way in which risk to her was assessed from this point, including whether CSE protocols were considered;  The role of the voluntary sector and the thresholds and protocols for their support to and safeguarding of vulnerable young people.  2.8 The review panel agreed that the Independent Reviewers would carry out an “independent investigative review” using the principles of appreciative enquiry. The process involves asking open ended questions in order to gather facts and opinions and to understand the context in which people were working and made decisions at the time.   2.9 The independent reviewers:   Met with the key professionals and had direct access to agency records  Met on three occasions with Child W’s adoptive parents at the start of the review  Produced draft reports and carried out further investigations as the review progressed  Facilitated a ‘learning event’ on 16th July 2014 which was attended by most of the practitioners and managers involved in the review  Attended several additional meetings with the HSCB Independent Chair and senior Board members, to discuss the development and final shape of the report.  Produced a further draft report for consultation at the end of October 2014.  2.10 This report was initially considered by the HSCB Serious Case Review sub-committee on 3rd November 2014. It had been received by the Board shortly before this meeting. It was agreed that members of the review panel should be asked to provide comment on the draft.   2.11 The draft report and the feedback from panel members were considered in more depth by the SCR sub-committee on 14th January 2015. Members agreed that the independent reviewers had helpfully identified the key learning from Child W’s death.  2.12 As the review progressed and the key learning was identified it became clear that the original main areas of focus (paragraph 2.7 above) needed to be adjusted somewhat, and, in particular, to draw out some of the wider local ‘systemic’ learning about how the partnership as a whole responds to the needs of vulnerable young people in a coordinated way.  2.13 The HSCB SCR sub-committee agreed that it would be helpful to re-structure the report in order to better draw out the learning, by focusing on ‘Areas of Significant Practice’ and also in order that the final report:   8   Would not harm the welfare of any children, young people or vulnerable adults involved in the case;  Presented a more rounded picture of Child W, as she was known to her family and to the people who tried hard to help her;  Adequately reflected the complexities of living and working with vulnerable young people, in a way which enabled a critical analysis of practice.  2.14 The report still relies extensively on the work of the independent reviewers and includes the lessons learned and conclusions which they helpfully drew out in their analysis. It has been restructured to address the concerns and issues outlined above.  2.15 The death of this young person has been the subject of considerable local publicity in which she has been identified. Her parents have been clear that they do not wish her identity to be disguised in any way in this review. In earlier drafts she was referred to by her given name.   2.16 After careful consideration of the potential immediate and longer term impact  however, HSCB took the decision to uphold standard best practice by not using ‘given names’ because of its duty of care to protect information about individuals who could be identified and who have not given permission for that information to be shared.   2.17 HSCB recognises that, for a range of complex reasons, it has taken longer than it ought to finalise a report for publication. There is learning for the Board as a whole about process and methodology.  Chapter 5 of the report identifies systems and practices which have improved over the period of time covered by the review, specific improvement actions linked directly to learning from Child W’s death and plans for ‘system-wide’ improvements explicitly informed by this learning.                     9 3. Time Period 1: September 2004 – July 2013  3.1 ASP 1:  Child W’s Adoption and Post-Adoption Support (August 2007 – August 2010)  3.1.1 Child W and her siblings were placed on the Child Protection Register by Barnsley Local Authority in September 2004. The registration category was neglect. Child protection agencies in Barnsley were concerned that Child W was experiencing physical abuse and neglect and that she had attachment dysfunction and delayed social and emotional development.  3.1.2 In October 2004 an Interim Care Order was made and Child W and her younger brother were placed with local short term foster carers. A full Care Order was made in June 2005, when Child W was 8 years old. She did not return to the care of her parents.  3.1.3  In November 2005, Hull Children’s Social Care commenced a home study assessment on a female couple who wanted to become adoptive parents. During the assessment process, the couple attended a regional inter-agency adoption event held in Wakefield and expressed an interest in being considered as adoptive parents for Child W having read her profile at the event. The couple were approved as adopters by the Hull Adoption Panel in February 2006.  3.1.4 In the meantime, Barnsley Children’s Social Care had commissioned an assessment by an NSPCC psychologist of Child W and her younger brother’s attachment and therapeutic needs. The assessment identified the need for intensive therapeutic input to their placement in recognition of the children’s previous experiences and their attachment difficulties. The assessment also identified a positive attachment between Child W and her brother, supporting a plan for them to be placed together. As a first step, the Hull carers agreed to care for both children, with a view to adoption.  3.1.5 Barnsley Children’s Social Care was pursuing permanency for Child W and her brother and assessed the Hull couple as specific foster carers, with a plan for adoption. The assessed need for specialist attachment and therapeutic work was clearly considered and discussed between Barnsley and Hull during this period. However, there is a record of an email from a Hull social worker to Barnsley, in April 2006, stating  that the specialist support assessed as likely to be required would not be available in Hull.   3.1.6 In June 2006, the Hull couple were approved as foster carers for Child W and her brother by the Barnsley Fostering Panel. The children were placed in Hull in July 2006, four weeks after they were first introduced. It appears from records, and from the accounts of the Hull couple, that the planned timescale for the placement was accelerated as the   10 children’s existing foster carers were going on holiday and were unable to take both children with them.  3.1.7 A Looked After Children (LAC) Review was held on 20th July 2006. The NSPCC in Barnsley had ceased direct work with the children but provided a report detailing their observations and recommendations for the review. They subsequently (27th July 2006) wrote to the Hull couple, confirming an offer of ‘one-off consultation’ in relation to attachment theory and confirming their understanding, from the Barnsley social worker, that support would be provided by a Hull based agency. Given the email of April 2006 (paragraph 3.6 above) the basis of this understanding is unclear.   3.1.8  Child W and her brother were matched by the Barnsley Adoption Panel in October 2006. The minutes of the Barnsley Adoption Panel at which the match was made state that the Hull couple were aware that “therapeutic services are available in Hull but do not feel that these are needed at the moment”. The couple sought a commitment that these [therapeutic] services would be available if needed. According to the minutes, this was incorporated in the Adoption Support Plan.  3.1.9 The Adoption Support Plan (prepared for the Adoption Panel in October 2006) states that the “NSPCC will identify any future therapeutic needs as part of their work with Child W”. However, as above, the NSPCC had concluded its detailed assessment and finished its work with the children by July 2006 (at the latest). The need for “intensive therapeutic input” had already been assessed.   3.1.10 The support plan did clearly state Barnsley’s commitment to working with the carers to “identify the most appropriate resources” once therapeutic needs [have] been identified and also stated that enquiries had been made with both statutory and non-statutory resources depending on Child W’s changing therapeutic needs. The plan confirmed Barnsley’s financial responsibility for three years post placement to meet any additional costs as a result of therapeutic need.  3.1.11 A Placement Order was made in April 2007 and an Adoption Order in August 2007. Until the Adoption Order was made, the children remained looked after children to Barnsley MDC. In May 2007, a social worker in Hull recorded some concerns about how the Hull carers were coping with the children. This worker was then not able to attend the subsequent statutory review, which concluded that the placement was progressing well, albeit, that some behavioural difficulties were noted.   3.1.12 The ‘Annex A’ report prepared as part of the Hull carer’s application for an Adoption Order recommended that the order be made. The report was jointly compiled by social workers from Barnsley and Hull. The closure summary on the Barnsley Children’s Social Care records, which was completed following the making of the Adoption Order in August 2007, states that “at present, the adoptive parents do not feel   11 the need for any additional support either for themselves or the children”.   3.1.13 Child W’s adoptive parents were reminded that the responsibility for post-adoption support in the first three years following the making of the Adoption Order (i.e. up to August 2010) rested with Barnsley MDC, the placing authority.  3.1.14 In practice, this meant that the agreed contact arrangements with Child W’s birth family (two indirect contacts per year, or exchange of cards and letters, and one direct contact per year with birth parents) were managed and supervised by the Barnsley Adoption Team.   3.1.15 The fostering allowances which had been paid to the family ended upon the making of the Placement Order in April 2007. The family report that this placed additional stress on them as a result of the time and cost involved in travelling to Barnsley for support. There is evidence that there was some local Hull provision of services to the family (beyond universal support) during this period in response to specific incidents and identified need (see 3.2)  3.1.16 This included some Child and Adolescent Mental Health Service (CAMHS) support for Child W’s younger brother which commenced in July 2008 and had concluded by May 2009, when, according to a letter sent by the service to the Barnsley Adoption Team, the adoptive parents had “not identified any further need for CAMHS involvement”.  3.1.17 There are no records during this period of any additional requests for help and support made by the family to Barnsley MDC. There is no requirement under adoption regulations for local authorities to provide formalised, ongoing post-adoption support or to periodically review progress, and so the responsibility for seeking additional support was vested in the adoptive parents.   3.1.18 At the end of Barnsley’s period of statutory responsibility for the provision of post-adoption support, there was no active, ongoing support provided by them to the family and, therefore, nothing to be ‘handed over’ to Hull. Barnsley continued to manage the contact between Child W, her brother and their birth family beyond this period.   Analysis  3.1.19 Recent Government sponsored research1 into adoption disruption found very low overall rates of disruption. The factors identified as being the most significant in increasing the risk of disruption were: the child’s age at the time of disruption; older age at placement; a longer than average waiting time between placement and securing the                                             1 ‘Beyond the Adoption Order: challenges, interventions and adoption disruption’. Research Brief April 2014. Julie Selwyn, Dinithi Wijedasa and Sarah Meakings – University of Bristol School for Policy Studies, Hadley Centre for Adoption and Foster Care Studies.   12 Adoption Order. Teenagers were found to be ten times more at risk of experiencing disruption compared with children under the age of four. The majority of young people whose placements disrupted had been abused and neglected by their birth families. Most adoptions disrupted during the teenage years.  3.1.20 Child W was eight years old when she became looked after, nine when she was placed as a looked after child with the Hull carers who became her adoptive parents, and ten years old when the Adoption Order was made in August 2007. The childhood experiences of abuse and neglect which led to her becoming looked after and which created assessed difficulties for her in making positive attachments, coupled with her age at placement, created the conditions for a higher than normal likelihood of adoption disruption in later years.  3.1.21 Child W’s placement with the Hull carers, as foster carers with a view to adoption, was clearly planned. Barnsley Children’s Social Care assessed and approved the couple as specific foster carers for Child W and her younger brother. However, the eventual speed of their placement appears to have been a response to events, which may well have limited the opportunity for proper preparation and for the children’s wishes and feelings about the placement to be fully taken into account. In the circumstances however, the decision to expedite their placement in Hull, rather than to seek an alternative short-term placement with other carers, appears reasonable.  3.1.22 Given her childhood experiences and attachment difficulties, Child W was assessed as likely to need “intensive therapeutic input” to support the development of positive attachments and a successful adoptive placement. The most experienced of carers were likely to be presented with challenges in managing behaviour and responding to emerging needs.  3.1.23 The Hull couple were clearly committed to providing a loving and caring home, on a permanent basis, for Child W and her younger brother. They were also aware of the outcome of the psychological assessment and the issues which might arise in caring for the children. Neither had previous parenting experience, nor access to an extended support network which might have given more resilience to the placement.  3.1.24 The eventual disruption of Child W’s adoption (May/June 2013) was not inevitable. However, the apparent optimism about the placement was misplaced without firm and robust arrangements in place for the provision of skilled and specialist therapeutic work on attachment.   3.1.25 Neither of the adoptive parents was identifying a need for additional support up to and beyond the making of the Adoption Order in August 2007. Like many parents, there is some evidence to suggest an understandable desire on their part to show that they were ‘coping’ and   13 that seeking additional external support might be interpreted by professionals as a failure on their part.  3.1.26 Nevertheless the onus was on the professionals to ensure that Child W and her brother received the specialist support and intervention they required. Whilst the Adoption Support Plan confirmed the commitment of Barnsley MDC to provide financial support (for 3 years post-adoption) to meet the therapeutic needs of the children, the plan is insufficiently clear and specific about how such support would be obtained. The Plan (prepared for the Adoption Panel in October 2006) states that the “NSPCC will identify any future therapeutic needs as part of their work with Child W”. In fact, by that time, the NSPCC had concluded their work with her and clearly articulated their assessment of what would be needed in the future to meet her needs.  3.1.27  Given the detailed assessment provided by the NSPCC, the “intensive therapeutic input” assessed as being needed, should have been specified, identified and made available with a clearer description of what Child W and her brother needed and how her adoptive parents could support this, rather than being somewhat vaguely described as being available as and when the need arose (i.e. in response to subsequent behavioural issues which might arise). The conclusion of the review is that the lack of therapeutic work, pre and post-adoption, significantly limited the capacity of the adoptive parents, and subsequently of agencies, to meet Child W’s emerging and long-term needs.  3.1.28 It should also be recognised that the adoption practice being assessed here took place in 2006 and 2007. The passage of time has meant that few of the individual practitioners, or their managers, have been available to contribute directly to the review. Adoption legislation and practice also changed in 2006, so the framework within which decisions were taken and plans developed for Child W was relatively new.   3.1.29 Given the more recent national focus on adoption, and further additional practice guidance and legislation, adoption practice has undergone significant change in the intervening years. In particular, the understanding of the post-adoption support needs of adoptive families, including the provision of appropriate therapeutic services to help children recover from damaging early experiences, has been a focus of recent government initiatives.  Nevertheless, this review recommends that the two LSCBs (Barnsley and Hull) take steps to ensure that the lessons learned are understood in the context of current practice.  Finding 1: Adoption Support Plans need to clearly and explicitly detail how, and by whom, any assessed therapeutic needs in respect of children placed for adoption will be met.    14 Finding 2: The attachment needs of children placed for adoption should form part of the specialist therapeutic services in local commissioning arrangements.   3.2 ASP 2: Support for Child W from Hull agencies as problems emerged in the family (up until May 2013)  3.2.1 A diary note in Child W’s Children’s Social Care (CSC) file (November 2008) indicates that she was visited at school by a social worker and police officer, following some concerns having been raised about how her adoptive parents were managing her younger brother’s behaviour.    3.2.2 During the joint police and social worker visit to see her at school Child W is recorded as saying that she was sad because she didn’t like having two mums and that she and her brother would like to have a mum and dad.   3.2.3 There is no referral, strategy discussion or manager decision record on CSC files in relation to this visit, and therefore nothing to indicate that it was conducted as part of a section 47 enquiry (Children Act 1989) and the source of the referral is unclear.   3.2.4 Child W was, however, seen in school so it would appear that she may have shared her concerns at school and that the school may subsequently have made the referral. Humberside Police has no record of this visit, or of any strategy discussion, on their systems. The CSC record indicates that Child W was advised to raise any further concerns with her teacher. There is no record of this on her brother’s file, nor any record of these concerns having been discussed with her adoptive parents.  3.2.5 Between January 2011 and November 2012, there was a more significant level of involvement with the family by local professionals. The primary focus of this involvement was on providing the family with help and support in meeting Child W’s younger brother’s needs. A series of multi-agency meetings was held and there were recorded concerns that his adoptive placement was breaking down.    3.2.6  There is evidence that the situation at home was having a significant impact on Child W. In January 2011, for example, Children’s Social Care records report her as “struggling to cope”. In February 2011, she disclosed at school that the situation at home was upsetting her. She also sprayed deodorant on a wound and her mother confirmed to the school that she had done this before. The school had a consultation with a Common Assessment Framework Coordinator and also made a referral to the Barnardos’ Sibling Support Group. Child W started to attend sibling support groups in May 2011.    15 3.2.7 At this time, both children are recorded as requesting to go into care. There was professional discussion about a potential adoption breakdown. A core assessment of Child W’s younger brother was initiated. Support was managed by the Hull Adoption Team together with a Locality (Social Work) Team. Respite provision was requested by the family for the younger brother and the Marlborough Family Support Team provided outreach support and activities to the family.  3.2.8 Child W is only occasionally referenced in the notes of the multi-agency meetings held during this period. For example, there is a note on the records (23rd June 2011) that she had been told on Facebook that her father had died (he hadn’t) and, on 15th September 2011, the social worker recorded a list of issues she was facing, related to the wider issues within the family.   3.2.9 There is very little reference in the records to work being carried out directly with Child W, despite the evidence that she was being adversely affected by the home situation.   3.2.10 In November 2011, Child W’s parents requested help and support specifically for her via the Community Support Team worker who was already working with her brother. Child W had complained that she was being bullied by a pupil from another school. Her parents are recorded as feeling that they were “failing as parents” and were also concerned that Child W had begun stealing from home and damaging things. There had also been a request from Child W’s older sister for contact with her. On 13th January 2012, the social worker recorded a concern that the adoptive placement was “breaking down”.   3.2.11 A range of services and support were considered and offered to Child W and her family over the next few months. In addition to ongoing support provided by the Community Support Team Worker, Child W received support from the Rights and Participation Project (RAPP), a service providing advocacy and support to children and young people in need, or at risk, in Hull. At the project, she was involved in activities such as drama and music. Her parents describe this as being an enjoyable experience for her.  3.2.12 In March 2012, the police attended the family home because Child W had climbed out on to the roof and threatened to jump. Her parents had confiscated her mobile phone and ‘grounded’ her for a month. The police officers who attended persuaded Child W to climb down and concluded that her behaviour was “attention seeking” and that she had no real intention to harm herself. Her adoptive parents emailed the Community Support Worker about the incident and Humberside Police notified Children’s Social Care. The police referral to Children’s Social Care indicated that the officers who attended had a discussion with Child W and her parents together, once she had come down from the roof. It is recorded that Child W had stated that she wanted either to go into care or to live with her birth father.   16  3.2.13 The response to the email from Child W’s adoptive parents was not immediate as the worker was on leave when it was sent. He responded to the email on his return and offered to meet with Child W so that she had someone to speak to about her feelings. Child W’s mum responded by saying that Child W had subsequently apologised for the incident and confirmed that she did not want to live with her birth father.  3.2.14 Child W’s case was closed to the Community Support Team on 11 May 2012. The closure records indicate that this was because her parents had informed the worker that she was no longer interested in speaking to him, but that she knew that there were people and agencies she could speak to if she chose to. The supervision record states that while the case would be closed, the fact that the Community Support Team continued to support her brother meant that Child W’s needs could continue to be overseen.  3.2.15 On 16th March 2013, the school’s Child Protection Coordinator observed that Child W was upset due to unpleasant texts being sent by a former boyfriend. She also showed a teacher a cut which she had made to her arm. The school contacted Children’s Social Care for advice and they advised Child W’s parents to contact the Police if the texts continued and to discuss her self-harming with the family GP. The school also advised that they would make the school nurse aware of her self-harming. There is no record of any further support provided or sought in relation to this incident.  3.2.16 This incident on 16th March 2013 is the single incident of concern noted in relation to Child W between March 2012 when she climbed onto the roof at home (paragraph 3.2.12) and the end of May 2013. Neither were there any additional requests or referrals for support made during this period.  3.2.17 The evidence is somewhat contradictory about what Child W’s life was like during this period. On the one hand, her parents describe deteriorating relationships between themselves and Child W, and state that she was spending more and more time away from the family home, although she was never reported to the Police as missing from home during this period.  3.2.18 On the other hand, Child W’s school attendance record was excellent, and well above average, in Years 9, 10 and 11 (she had 100% attendance in Year 11 between September 2012 and May/June 2013 and is recorded as being late on only 5 occasions). With the exception of the one incident in March 2013, the school observed no cause for concern about Child W or her health and development and this was supported by her excellent attendance record during this period. She also attended to sit all of her (GCSE) examinations in May/June 2013. She did not reach her predicted grades as, in the view of the school   17 she sometimes failed to fully apply herself, but she did achieve pass grades in both BTEC Health and Social Care and Applied Science.  3.2.19 During this period Child W regularly attended the Cadets, having joined in 2009. She continued to do so until May 2013 at which point her attendance stopped without explanation. Her place at the Cadets was kept open for her in the hope that she would return. Leaders at the Cadets observed no indications that Child W was emotionally troubled. At the same time (May 2013) Child W received a letter from the Army notifying her that her application to train as a medic had been rejected. This was a significant blow to her hopes and ambitions.  Analysis  3.2.20 Records indicate that professionals were aware that the situation at home at the time was having a significant negative impact on Child W. It would have been helpful, and good practice, for her needs to have been separately and specifically assessed as a child in need under section 17 of the Children Act 1989 at this time, so that she could have been provided with support to address her individual and thoroughly assessed needs, including work to strengthen her attachment to her parents.  3.2.21 As early as November 2008 (the joint visit by a police officer and social worker to see Child W at school) she was recorded as being sad and saying that she and her brother wanted a mum and a dad. This recorded sadness may have given an indication of the impact of her early childhood experiences on her capacity to make secure attachments and that this had been insufficiently explored at the point of placement or subsequently. This was an opportunity to explore Child W’s ‘sadness’ with her more thoroughly which was missed.  3.2.22  Professionals appear to have accepted the view that the incident in March 2012, when Child W threatened to jump from the roof at home was “attention seeking behaviour”, linked directly to sanctions imposed by her parents in response to her behaviour.  On the basis of the information available to them and the situation which they found, this was a reasonable judgement for the attending police officers to reach. Neither the attending police officers, nor indeed her parents, viewed this incident as one which required immediate follow-up by Children’s Social Care.  3.2.23 In their email to the Community Support Worker, Child W’s parents said that they were not sure “how serious” she was about living somewhere else, but felt that they should make the worker aware. By the time the worker responded, on his return from leave, Child W had apologised and changed her mind. The offer to meet with her alone and discuss her feelings with her was an appropriate and proportionate response.     18 3.2.24 Nevertheless, the review has found that, whilst support was provided to Child W for some of this period, there was an insufficient focus on assessing her individual needs, alongside the understandable primary professional and family focus on her brother.   Finding 3:  There should be an holistic approach to assessment which captures and reflects the needs of the whole family in the process.  3.3 ASP 3: The response of agencies as Child W’s needs escalated and her Adoptive Placement broke down (9th July 2013)  3.3.1 On 30th May 2013, Child W was taken to Hull Royal Infirmary Accident and Emergency Department by ambulance having been involved as a pedestrian in a road traffic accident. She told a member of the ambulance crew that she had been smoking cannabis.  Subsequently she gave nursing staff at the hospital differing accounts of how the accident had happened. Child W was with her boyfriend at the time of the incident. Yorkshire Ambulance Service staff contacted the Children’s Social Care Emergency Duty Team about the incident. Children’s Social Care subsequently made contact with Child W’s parents who are recorded as being concerned that she was “associating with the wrong crowd”  3.3.2 On 2nd June 2013, Child W was allegedly raped by an older man who was a friend of her boyfriend. She did not report this rape at this time, either to her parents or to professionals. She subsequently made a disclosure about the rape to a social worker on 9th July 2013 (see  separate section relating to rape allegation, 4.4 )  3.3.3 Child W was arrested by the Police on 3rd June along with a group of other young people on suspicion of being involved in arson and burglary of a house next door to where her alleged rape had occurred. Whilst in custody, during a private consultation with her solicitor, Child W threatened to kill herself. She was put in a ‘camera cell’ pending her interview and release from custody. The Hull Youth Justice Service provided an Appropriate Adult. The worker noted old self-harm cuts to Child W’s arms and made a referral to the Children’s Social Care Emergency Duty Team (EDT). Child W also reported a numb right arm and pain in her right leg from the road traffic accident. She was released from custody on police bail to return on 27th June 2013.  3.3.4 Child W’s parents told the EDT that the situation at home had become “untenable” due to her mixing with young people who were involved in criminal activity. She was spending time away from the family home and repeatedly telling her parents that she did not want to live at home.   3.3.5 They made direct contact with Children’s Social Care Central Duty Team (CDT) on 4th June 2013 and the CDT alerted the Adoption Team of this contact.  An Adoption Team Social Worker visited the family on   19 18th June. This visit was originally arranged for 11th June but was rearranged due to the sickness absence of the worker.  3.3.6 Child W’s parents described their concerns about her lifestyle and the impact of her behaviour on their health and on her brother. They stated that Child W did not want to live at home and that she only returned home to collect clothes. They wanted some “distance” between themselves and Child W. It was agreed that a request for support would be made to the Integrated Looked After Children (ILAC) Team. Child W was not at home at the time of this visit.   3.3.7 As agreed, on 20th June 2013 the Adoption Team Social Worker discussed Child W with a Team Manager in the ILAC Team who agreed to consider her at an allocation meeting early the following week. On 26th June 2013 the Adoption Team social worker was advised to seek help and support for Child W from the Community Support Team. As she was neither looked after nor a care leaver, she did not fall within the remit of the ILAC Team.   3.3.8 In the meantime Child W had presented herself at a police station on 22nd June 2013 saying that she was “blacking out and fainting”. An ambulance was called and she was checked over before being collected and taken home by her mother.   3.3.9 On 23rd June 2013, Child W’s parents made contact with the Emergency Duty Team. Child W had left home on crutches to stay at a friend’s house. Her parents were concerned that she was at risk of further injury. They were advised to report her as missing and EDT undertook to alert the Adoption Team in the morning.   3.3.10 On 27th June 2013 a Community Support Team worker went to the police station in an attempt to meet Child W, having noted that she was due to answer her bail on that day. The CST worker was unaware that her requirement to attend the police station to answer her bail had been cancelled as a ‘no further action’ decision had been taken in respect of her initial arrest.   3.3.11 Having not managed to meet Child W, the CST Worker decided to make an ‘impromptu’ visit to the family home, in the hope of meeting her and her parents there. There was no-one at home. The worker left some housing leaflets and forms for Child W with a neighbour and close family friend and a message for her parents on their answer phone.  Analysis  3.3.12 The initial response of the Hull Adoption Team to the request for help made by Child W’s parents was timely. An initial appointment was offered within 5 working days, although this was delayed for a further 5 working days due to sickness absence.   20  3.3.13 Having met with her parents (18th June 2013) it is apparent that the Adoption Team social worker felt that colleagues in other teams/services within Children’s Social Care would be better placed to provide the help and support which Child W might need, and, in particular, the potential need to find alternative accommodation for her.  3.3.14 Within a further 7 working days the Community Support Team had agreed to offer help and support and a CST worker attempted to make direct contact with Child W. This attempted contact with her at the police station shows an enterprising and swift response from the worker concerned.  3.3.15 Unhelpfully, the internal conversations between the Adoption and ILAC Teams and the Adoption Team and Community Support Team are reflected in case records as “referrals”, whereas they more accurately reflected professional conversations focused on identifying the most appropriate source of help and support for Child W. These conversations, albeit concentrated within little more than one working week, reflect a degree of professional uncertainty at the time as to the specific role and remit of various different teams.   3.3.16 Given Child W’s status as an adopted child, the Adoption Team was the first point of contact in seeking help and support. It could be argued that this status led to a delay, albeit a short one, in accessing the help and support which her circumstances and needs warranted, with the Adoption Team effectively acting as ‘brokers’ for the family.   3.3.17 The records indicate a real sense of professional uncertainty about how best to respond to Child W’s needs: the post-adoption social worker felt that the issues were not adoption related, whilst other teams saw adoption as a ‘complicating factor’. A joint approach across services at this point might have been the most helpful response.  Finding 4:  The needs of children and young people must be at the centre of decision making about the provision of support, and service or organisational boundaries should not act as a barrier to children, young people and families accessing the most appropriate help and support according to those assessed needs.               21   4 Time Period 2: Child W’s admission to Hostel accommodation (9th July 2013) to her death on 16th November 2013  4.1     Narrative  4.1.1 Child W first visited the Targeted Youth Service (TYS) offices in Hull City Centre on 2nd July 2013. She stated that she was homeless. Staff discussed options with her and she agreed to return home as her parents had not said that she couldn’t return there. On 8th July 2013, she presented at a local police station saying that she was homeless. Child W had returned earlier than planned from a week long holiday with her boyfriend and her parents were away for the weekend. After liaising with the Children’s Social Care Emergency Duty Team and with her parents, the police took Child W to stay overnight with a friend.  4.1.2 On 9th July 2013, Child W visited the Targeted Youth Support (TYS) Team offices in Hull City Centre. She stated that she did not want to return back home to live with her parents. Her parents were contacted and confirmed that she could return home. However, they felt that she needed to be found alternative accommodation as their relationship with her had deteriorated. A place was obtained for her at Hostel 1, a local young people’s hostel.   Child W was allocated a social worker who worked in the TYS team.   4.1.3 From 9th July 2013 until her death on 16th November 2013 Child W lived in young people’s hostel accommodation in Hull. In addition to the staff at both of the hostels in which she lived during the period, her TYS social worker and other TYS colleagues, a wide range of other professionals and agencies were involved in providing help and support to her.   4.1.4 There were also a number of personal relationships which Child W was trying to make sense of and sustain during this period: an important relationship with her boyfriend, a young care leaver from a neighbouring authority; her relationships with her parents and brother, which had become strained but remained significant to Child W; and her relationship with her birth family.  4.1.5 Child W’s relationship with her boyfriend has been described by professionals as a mutually loving one. It was also a highly intense one. Professionals were concerned at times that Child W was too easily influenced by her boyfriend and there are frequent examples of her giving him money to cover debts he had accrued.   4.1.6 His eviction from Hostel 2, at which they were both living in October 2013, clearly angered and upset Child W and led to a particularly unsettled period, during which she rarely stayed overnight at the hostel.     22 4.1.7 The breakdown in this relationship, and the consequent events of 2nd and 3rd November 2013, led directly to the decision that Child W could no longer live at Hostel 2. On 15th November 2013, in a meeting with her social worker, Child W was clearly upset because she had heard via Facebook that her boyfriend had started a relationship with someone else.   4.1.8 It is also clear during this period that Child W wanted to rebuild a more positive relationship with her adoptive parents and with her brother, although she consistently stated that she did not feel ready to return home to live. Her parents felt that some ‘distance’ between them was needed, although they continued to agree that she could return home if she wanted to.  4.1.9 The records indicate that Child W’s relationships with her adoptive parents were “up and down” during the period, but she was also comforted at difficult times by being able to talk to them and receive reassurance that they still loved her.  4.1.10 According to hostel records, Child W spoke with her brother on 7th October 2013, and was upset about how that conversation had gone. This same day she harmed herself with a razor at the hostel, and she later told hostel staff that “everything with her brother”, in addition to recent contact with her birth father, her childhood experiences, problems with her adoptive parents and the court case, had caused her to do it.  4.1.11 Notes of a meeting on 29th October 2013 between Child W, a senior hostel worker and social worker, confirm that she wanted to restore a good relationship with her brother describing this as essential for them both. Child W met her brother, in the company of other young people, earlier on the day she died. Her parents report that this was a positive meeting.  4.1.12 On 26th September 2013, Child W’s birth father made contact with her. This was in response to her making contact with him to see if the information in her “letter for later life”, prepared for her as part of the adoption process, was true. Child W was said by hostel staff to be “overwhelmed with excitement” at the prospect of meeting her birth father, as she had questions for him and wanted to know if the “rumours” about why she was taken into care were true. Hostel staff advised her against this meeting and sought advice from her social worker.  4.1.13 Despite the concerns of the professionals and of her parents, she was determined to meet her birth father and did so on 1st October 2013. The records show that this visit did not go well and that Child W was upset about it. She told hostel staff that her birth father was drunk and kept calling her by her older sister’s name. She told staff that she didn’t think she would be seeing him again.   23  4.1.14 There are extensive records detailing Child W’s daily life and her various contacts with agencies during this period. For the purposes of this review, and the learning which can be derived from it, it is helpful to consider key themes and issues, as areas of significant practice, which facilitate an overall analysis and understanding of service provision and practice. The main learning and findings relate to the wider ‘systems’ of support to vulnerable young people, and these are captured as part of the ‘over all analysis and learning’ (section 4.10). Where there are more specific findings these are included after the analysis for the relevant ‘area of significant practice’.  4.1.15  However, there are a number of key events which help to provide an overall context to Child W’s life during this period:  9th July 2013: Child W went to live at Hostel 1. She also disclosed to her TYS social worker that she had been the victim of rape.  12th July 2013: A telephone strategy discussion took place between Children’s Social Care and Humberside Police and a section 47 enquiry was initiated.  17th July 2013: The social worker facilitated a ‘mediation meeting’ with Child W and her parents.  6th August 2013: Child W met with a police officer and her social worker to complete the pre-interview assessment in respect of the rape allegation.  7th August 2013: Child W was formally given a place at Hostel 2, having ‘moved herself in’ over the previous weekend. Her boyfriend was living at the same hostel.  20th August 2013: Child W was interviewed by the Police, with her social worker present, on DVD about the rape.  23rd August 2013: The alleged perpetrator of the rape was arrested by the Police, charged and remanded in custody.  26th Sept 2013: Child W’s birth father made contact with her.  1st October 2013: Child W had an ‘unsuccessful’ face-to-face contact with her birth father.  7th October 2013: Child W received treatment at Hull Royal Infirmary Accident and Emergency Department having self-harmed with a razor.  7th October 2013: Child W visited her social worker and agreed to a referral for a full health assessment, CAMHS assessment and to see the Housing Options Worker to explore alternative accommodation options.   24  18th October 2013: Child W’s boyfriend was evicted from Hostel 2. A primary mental health screening telephone assessment took place between the social worker and a CAMHS health liaison worker.  22nd October 2013: Child W’s boyfriend was given accommodation at another hostel run by the same organisation as Hostel 2.  25th October 2013: An application for supported lodgings for Child W was approved and potential carers identified.  28th October 2013: Child W met the supported lodgings carers but decided against taking up this placement.  29th October 2013: A meeting took place between Child W’s social worker and a senior member of hostel staff of Hostel 2 in the context of concerns that the hostel could no longer meet Child W’s escalating needs. A behavioural contract was agreed.  30th October 2013: Child W saw a Refresh substance misuse service worker, who commenced a comprehensive assessment of her substance, sexual and emotional health needs.  2nd November 2013: Child W’s relationship with her boyfriend ended.  4th November 2013: Child W was evicted from Hostel 2. A place was found for her back at Hostel 1.  11th November 2013: Child W saw her Refresh worker. The risk assessment was updated. She then attended an appointment with a CAMHS worker for assessment.  13th November 2013: Child W was informed that the Plea and Case Management Hearing scheduled to take place that day for the alleged perpetrator of the rape had been adjourned.  15th November 2013: Child W contacted the manager of Hostel 2. He confirmed that he would hear her appeal against her eviction from the hostel on 19th November 2013.  16th November 2013: Child W was found by a worker at Hostel 1 on her knees in the bathroom, with her head facing forward and a ligature around her neck.     4.2 ASP 4: Social Work Help and Support for Child W.  4.2.1 As soon as Child W made direct contact with TYS on 9th July 2013 she was allocated an experienced and qualified social worker. This same worker remained her social worker for the remainder of her life.    25  4.2.2 There is substantial evidence from the various records and from the conversations with practitioners that Child W had a positive relationship with her social worker, regularly seeking her help, advice and support and asking for the social worker to support her at various key times (for example, the pre-interview assessment and DVD interview in relation to the rape allegation and Child W’s CAMHS assessment).  4.2.3 The social worker made consistent and persistent efforts to help and support Child W and there is evidence of close liaison with other agencies, in particular with Hostel 2, and of referrals to CAMHS, supported lodgings, health services, the post- adoption team (for a sessional worker ) seeking support for the presenting issues. At points, the social worker was also in daily contact with Child W, one of many young people on her caseload.   4.2.4 It is also noteworthy that Child W and her boyfriend were frequent visitors to the TYS team and not always to seek support with current ‘crises’. This indicates that she felt comfortable and ‘connected’ to the service. There is also evidence that she received responsive ‘ad-hoc’ support from the wider team when she made unplanned visits to the service and her social worker was not present to see her.  4.2.5  In consultation with her line manager, the social worker initiated the conversations with Children’s Social Care Central Duty Team and Humberside Police which led to a telephone strategy discussion on 12th July 2013 and a decision to initiate a section 47 enquiry into the allegation of rape. As part of this decision-making process, the social worker confirmed that she would undertake a Core Assessment of Child W’s needs in accordance with procedures. The core assessment was not completed within the 35 day timescale pertaining at the time, and indeed, had not been completed by the time of Child W’s death in November 2013.  Analysis  4.2.6 The assessment process represented an important opportunity to fully and comprehensively assess Child W’s needs, and indeed risks, by bringing together information from a range of sources and to inform a clear plan for her, which might have identified the range of agencies and services providing help to her and the respective roles and responsibilities of those involved.  4.2.7 It is a feature of this period in Child W’s life that there were many different services involved in responding to her needs and providing help, but that , at no time was there a multi-agency meeting convened to coordinate support and agree one coherent plan. This meant that the risks associated with her lifestyle were not explicitly discussed in a multi-agency context and nor, therefore, was the collective involvement of different practitioners reflected upon in a way which might have   26 promoted better joint working, to provide greater continuity of support and to mitigate risk.  4.2.8 A clearer structure for management oversight of the case would have meant that a coordinated plan, alongside reflective discussion about the progress of the core assessment, was more likely to happen, and where relationships or communication between agencies were not working well this would more likely have been exposed and addressed. Supervision records between the TYS Manager and the social worker from 14th November 2013 indicate a discussion about the need to revisit the section 20 (Children Act 1989) accommodation issue, the fact that Child W’s needs showed that she would require long-term support and an agreement that it would be helpful to convene a professionals meeting to share information and coordinate support.   4.2.9 The meeting was convened to take place the following week, by which time Child W had died. Such a meeting could, and might helpfully, have been triggered by key incidents and processes (e.g. the strategy discussion, the core assessment, her eviction from Hostel 2) or at any point in time as her needs escalated and the number of agencies involved in her life multiplied.   4.3 ASP 5: Consideration of Child W’s Legal Status  4.3.1  When Child W first presented as homeless, Children’s Social Care sought advice from their legal department as to whether she should be accommodated under section 20 of the Children Act 1989. This advice was sought in the context of the ‘Southwark Judgement’ (Law Lords, May 2009), case law which obliges a local authority to provide accommodation and support to homeless 16 and 17 year olds, and to treat such young people as ‘looked after’, unless, based on an initial assessment, the child is not “in need” in the local authority’s judgement.   4.3.2 There is no doubt that Child W would have been assessed as “in need” as intended by the judgement and legislation and in accordance with the local HSCB thresholds of need guidance.  Analysis  4.3.3 The legal advice provided appears to be that, since her parents were not saying that she could no longer live at home, Child W was not in fact homeless. Nevertheless she was found hostel accommodation having effectively made herself homeless by refusing to return home to live. In this context, the issue of accommodation under section 20 should have been explored with her parents and with Child W herself.  4.3.4 As Child W was aged 16 at the time, her agreement to be accommodated under S 20 CA 1989, and to become a ‘looked after   27 child’, would have been needed. Since there is no evidence that this option was explored with her, it is not helpful to speculate as to whether or not she would have wanted to become a ‘looked after child’.   4.3.5 It is also difficult to envisage how such a step might materially have affected the arrangements made for Child W’s accommodation. Becoming ‘looked after’ would have opened up the possibility of a placement for her either in foster or local residential care. Subsequent attempts to persuade Child W to take up a supported lodgings placement made it clear that she did not want to live with another family and it seems likely that she would have had similar reservations about any proposed foster placement. It is also unlikely that placement in a local children’s home would have better met Child W’s needs at the time, indeed, given her lifestyle and her overriding desire to be with her boyfriend, such a placement might have exacerbated risk. It was clear, from the outset that Child W wanted to live in hostel accommodation and, specifically, Hostel 2, at which her boyfriend was living.  4.3.6 However, had the issue been fully explored with Child W, as it ought to have been under the legislation, and had she asked to be looked after, this would have afforded her the additional formality of the looked after process through the structure in planning and independent reviewing which this entails.  4.3.7  It is important to reflect too, that whilst LAC status for Child W might, in itself have provided a clear regulatory framework within which multi-agency planning would have occurred, it was by no means a necessary pre-condition for such joint planning to happen.   Finding 5: The Local Authority should ensure that it agrees and produces for staff clear local guidance on the interpretation and application of the ‘Southwark Judgement’.  4.4 ASP 6: The response of agencies to the allegation that Child W had been raped  4.4.1 Child W’s TYS social worker first contacted the Police and Children’s Social Care Central Duty Team about her allegation that she had been raped on 10th July 2013. The telephone strategy discussion which led to the decision to initiate a section 47 enquiry, led by the Police, took place on 12th July 2013. A Vulnerable Witness Officer (VWO) in the police was identified to lead on this on 15th July. The officer spoke to Child W on the same day and arranged to visit her on 18th July 2013.  4.4.2 Several appointments to see Child W were missed by her and attempts to contact her on mobile numbers she had left proved unsuccessful. On 30th July 2013 the VWO did make contact with Child W on a mobile phone number and arranged to meet her on 6th August 2013. Child W   28 subsequently asked her social worker to attend the meeting with the police and this was agreed.  4.4.3 The pre-interview assessment was completed at this meeting on 6th August 2013. Child W decided that she did not want to proceed immediately to DVD interview, although the interview suite had been booked in case, and this took place, again with her social worker accompanying her, as arranged on 20th August 2013.  4.4.4 On 23rd August 2013 the alleged perpetrator was arrested by the police, interviewed, charged with the rape of Child W and remanded in custody. Child W was informed of the outcome.  4.4.5 The Officer in the Case subsequently visited Child W on 23rd September 2013 to provide her with a personal update on the investigation and progress of the case and then provided her with a further progress report later in October 2013. In the meantime, her parents received a letter from the Humberside Young Witness Service on 6th September 2013, offering support for Child W should the rape allegation proceed to trial, informing them of the plea hearing date (Plea and Case Management Hearing) and confirming that the defendant had been remanded in custody.  4.4.6 Child W received a letter on 8th November from the Witness Care Unit informing her that the plea hearing would take place on 13th November 2013. On 13th November 2013, her social worker was advised that the plea hearing had been adjourned until 27th November 2013. Child W was angered and upset about the delay when she was told of it by her social worker.  Analysis  4.4.7 The investigation into the rape allegation was conducted sensitively and at Child W’s pace. Appropriate measures were taken to ensure that she was as comfortable as possible, including a positive response to her request to be accompanied by her social worker. The completion of a pre-interview assessment prior to the DVD interview follows the best practice expected under Achieving Best Evidence.   4.4.8 Understandably, Child W was extremely anxious about the criminal proceedings and became more anxious and frustrated as scheduled hearing dates approached and there were successive adjournments with no progress being made. Her anxiety about the case was explicitly linked, by those caring for her at the time, to her subsequent self-harming behaviour (7th October 2013).  4.4.9 Child W’s social worker discussed accessing counselling for her when she first commenced working with her. At this stage Child W was adamant that she did not wish to speak with anyone. There is no evidence in the records that her potential therapeutic needs in relation   29 to the rape were further explicitly explored so that appropriate counselling might have been arranged had she wanted it.   4.4.10 Had the initial strategy discussions included health colleagues, it is possible to imagine that a full assessment of Child W’s health needs, including the need for any pre-trial therapy, might have been agreed as part of the assessment and enquiry process.  4.4.11 Consideration has been given during the course of this review as to whether or not Child W was a victim of Child Sexual Exploitation and, if so, whether there were missed opportunities before the alleged rape to identify potential vulnerability. No information was known to professionals immediately prior to the alleged incident (2nd June 2013) which ought to have led to an assessment of her vulnerability to CSE. Neither has any evidence emerged to indicate that she had been groomed by her alleged assailant.   Finding 6: Health professionals should be routinely involved in section 47, Children Act 1989 strategy discussions, as set out in ‘Working Together 2015 and in local Hull Safeguarding Children Board procedures.   4.5 ASP 7: Child W’s accommodation needs and the role of the hostels  Hostel 1 (9th July – 7th August 2013 & 4th – 16th November 2013)  4.5.1 During her initial stay at Hostel 1, Child W was absent for 14 of 28 days and nights. Most often when she was absent from the hostel she was staying with her boyfriend’s mother in Bridlington.  4.5.2 On 10th July 2013, the day after she moved in, she was issued with a ‘reviewable notice’ (a warning) by hostel staff for smoking cannabis on the premises. A week later hostel staff made a referral to the Refresh substance misuse service on Child W’s behalf.  4.5.3 Child W returned to live at Hostel 1 following her eviction from Hostel 2 on 4th November 2013. The admission process was carried out by the Housing Options Worker (a member of the TYS team), with Child W’s social worker also present.   4.5.4 Child W was allocated a female link worker and an external male advocate to assist her with her planned appeal against her eviction from Hostel 2. Child W’s parents report her phoning them on an almost daily basis at this time, expressing her distress about the eviction, and at overhearing comments which she interpreted as meaning that she was “beyond help”.  4.5.5 Hostel daily records, recorded in a communications log and email handovers, confirm that Child W spent most of her time away from the hostel and also indicate a complicated relationship with her boyfriend.    30  4.5.6 Child W was returned to the hostel by the police in the early hours of 16th November, having called at a Police Station saying that she and a friend were being followed by a man. According to hostel records she slept until about midday then left the hostel and went into town to meet up with the boyfriend of another hostel resident and with her brother. The hostel worker made a routine room check and observed nothing unusual in her room.   4.5.7 According to the worker, Child W returned to the hostel in the early evening, asking the worker if she could use the hostel phone, saying “it’ll be the last time, I promise.”  The worker now thinks the comment may be significant. After the call Child W told the worker that she was going to meet her boyfriend the following day. She looked upset. She then went upstairs.   4.5.8 The hostel worker later went to ask Child W if she had taken the cigarettes of another resident. Child W was having a bath. She answered the worker and sounded quite cheerful. The worker went back downstairs to prepare for handover with his colleague.  4.5.9 A female resident then came downstairs to say that she had been on Facebook and read that Child W was in town talking to a woman. The hostel worker thought this strange and so went to check on Child W. Child W was still in the bathroom. She had been in there for about forty minutes, which was not unusual. The worker knocked repeatedly on the bathroom door but got no answer. He spoke to his colleague who also got no response from Child W. This worker unlocked the bathroom door and found Child W on her knees, having hanged herself with a dress tie. The Police and Ambulance Service were called. Child W was taken to hospital where she was pronounced dead.  4.5.10 The workers at Hostel 1 who were interviewed as part of this process were totally shocked and deeply affected by Child W’s death. They had not observed anything in particular that would help explain her actions on that evening.  Hostel 2 (7th August – 4th November 2013)  4.5.11 From the day of her admission to Hostel 1, Child W was determined to obtain a place at Hostel 2. She was a frequent visitor and had got to know some of the staff because her boyfriend was living in this hostel. Whilst visiting Hostel 2 on 16th July 2013, Child W completed a self-referral and gave hostel staff the name of her social worker to approach for a reference.  4.5.12 Staff at Hostel 2 contacted Child W’s social worker for a character reference on 16th and 17th July 2013. The social worker said that: she had only recently met Child W and did not yet know her well; Child W was highly vulnerable due to her emotional wellbeing and risk of sexual   31 exploitation; and, she doubted that, given these concerns about Child W’s vulnerability, a mainstream hostel would be suitable for her.   4.5.13 The referral was rejected at this point: there was professional consensus that Child W’s support needs were too high for the hostel, coupled with concerns about the impact on her should her relationship with her boyfriend break down whilst they were living under the same roof.  4.5.14 On Saturday 3rd August 2013, Child W was staying as a guest at Hostel 2. She persuaded staff that her permanent admission had been agreed with her social worker and was allowed to move herself in.   4.5.15 It is not entirely clear from the respective records on precisely which date her place at the hostel was confirmed. It is apparent that Child W’s vulnerability and her suitability for the hostel were discussed. The outcome of the discussions was an agreement, which had been reached by 7th August 2013, that Child W would be allowed to stay, but that she would need to comply with the hostel terms of tenancy, that she would be closely monitored and that, if her relationship with her boyfriend within the hostel became an issue, she would need to move elsewhere.   4.5.16 This decision reflects the hostel’s general willingness to do their best to help and support vulnerable young people and a level of realism and pragmatism: Child W had seldom stayed at Hostel 1 and it was likely that she would be more settled at Hostel 2, which was her preferred placement.  4.5.17 During August 2013, there is evidence of good communication between hostel staff and Child W’s social worker and the Housing Options Worker. The main focus of concern in relation to Child W at this time centred on her relationship with her boyfriend, which staff observed could be controlling at times, and on managing her money. The social worker also agreed to liaise with Child W’s boyfriend’s pathway worker and to undertake some protective behaviour work with Child W.   4.5.18 Child W had the same link worker for the duration of her stay at Hostel 2 and took part in regular ‘Star Links’ updates on 23rd August, 22nd September and 29th October 2013. ‘Star Links’ sessions contributed to Child W’s support plan which was reviewed every three months. The ‘Star Links’ records provide a helpful insight into what Child W’s life was like at any one time and it is clear that she enjoyed the sessions and contributed fully to them.  4.5.19 The session conducted with her on 23rd August 2013, recorded ‘no issues’ in relation to Child W’s emotional well-being and confirmed her long-term goals as: to find a suitable college course; to find suitable accommodation; and to work on her relationship with her parents. In   32 relation to accommodation, Child W is recorded as considering a joint tenancy with her boyfriend in the future, but not feeling ready yet for that big commitment.  4.5.20 Hostel records indicate that an ‘inter-agency support planning meeting’ took place on 28th August 2013 between a senior member of hostel staff and the Housing Options Worker. According to these records, the senior member of hostel staff expressed concern about the lack of progress in finding Child W accommodation more suited to her support needs and discussed the need to develop an “easing out plan”.  4.5.21  There are no available notes of this meeting and no record of it on social care files. This is one of a number of examples of discrepancies in the records of the two agencies (Hostel 2 and Children’s Social Care). There is no record, either, of this discussion in the summary of Child W’s ‘Daily Diary and Risk Management Plan’ emailed by the hostel to the Housing Support Worker in October 2013.  4.5.22 The hostel records indicate that a further ‘inter-agency support planning meeting’ took place on 7th September 2013. These were regular meetings which took place between the senior member of hostel staff and Housing Options Worker to review the progress of all (Hull) young people living at the hostel. There are no notes of the meeting, but the hostel daily diary records continue to note visits from the police regarding the court case, problems with her benefits, Child W giving her boyfriend money and low attendance at college.   4.5.23 Child W’s next ‘star links’ session took place on 22nd September 2013. She is recorded as saying that she liked doing the ‘star links’ as it “shows you how well you are doing.” This session confirmed that she was happy at the hostel and not feeling ready for a move on at present. Child W also said that she was feeling under pressure at the moment due to the pending court case and said she would speak to her social worker about getting some counselling. She said that she was feeling more positive and attending college. Child W reported smoking cannabis on a regular basis but didn’t feel this was a problem. She also said that she had good friends who she could talk to but that things were “a bit up and down” with her Mum.   4.5.24 On 6th/7th October 2013, Child W self-harmed at the hostel by scraping her left arm with a razor (see section 4.6).  4.5.25 In response to this incident of self-harm, the hostel re-assessed Child W’s support needs from “low” to “high”. Further discussions took place between the hostel and Child W’s social worker. The social worker agreed to pursue a supported lodgings placement for Child W and to seek sessional work support for her. The outcome of the conversation, at this time, was that Child W did not need to move out of the hostel immediately, but that a ‘move on’ to more suitable accommodation needed to be arranged.   33  4.5.26 Child W’s boyfriend was evicted from the hostel on 17th October 2013 for persistent breaches of hostel policy. Her boyfriend told a TYS worker that Child W had attempted to self-harm as a result of this. Child W visited the TYS offices on 18th October 2013. She was clearly upset and angry about her boyfriend’s eviction from the hostel and threatened to self-harm. A discussion took place with her about supported lodgings, alongside efforts to rebuild her relationship with her parents.  4.5.27 Records indicate that Child W was agitated and unsettled over the weekend (19th and 20th October 2013), repeatedly asking hostel staff if her boyfriend could be re-admitted to the hostel, packing her belongings ready for moving out on the Monday (21st October) and staying out overnight on 20th October at the house of a friend of her boyfriend.  4.5.28 On 21st October 2013 Child W visited the TYS offices and told a worker that she had packed her belongings and that she wanted to leave the hostel and move to a flat with her boyfriend. Records indicate that she turned down supported lodgings saying that she did not want to live in another family situation. She threatened several times that she would harm herself if she didn’t get her own way. Child W calmed down and her parents were contacted and said that she could return home. Eventually she agreed to return to the hostel and to consider supported lodgings. Hostel records show that the TYS worker spoke on the phone with a senior member of hostel staff who confirmed that Child W’s place at the hostel was still available for her.  4.5.29 On 22nd October 2013, hostel management agreed to offer Child W’s boyfriend a place at another hostel. It is clear from the records that this decision was taken primarily as a means of supporting Child W and settling her down.   4.5.30 On 23rd October 2013, her mum contacted the hostel to express concern about Child W’s emotional well-being. Child W is reported as telling her mum that “she has had enough and wants to end it all”. Child W spent the night away from the hostel with a longstanding friend from school.  4.5.31 She did not sleep at the hostel on 25th, 26th or 27th October 2013. When she returned to the hostel on 28th October, the hostel worker who had last seen her on 25th noted that she appeared to have lost weight, and looked pale, tired and dishevelled.   4.5.32 On 29th October 2013, a meeting took place between Child W, a senior member of hostel staff and the social worker. Child W was due to start a new course with Inspiring Youth on 4th November. All agreed that she continued to have difficulty in budgeting. Child W confirmed that she would like her social worker to identify a sessional worker for her. She   34 also said that she would like to restore a good relationship with her brother which she felt was essential for both of them. Concern about her weight loss was discussed. Child W said that she wanted to go to the gym and that she liked to do the Saturday morning run in East Park. She reported that she had not self-harmed for some time (since 7th October) but “understood why she does it.”  4.5.33  The social worker drew up a written agreement (described in the hostel records as a ‘behaviour contract’) which outlined the expectations of the social worker, the hostel and Child W and which all parties signed. It was agreed that this would be reviewed in four weeks’ time.   4.5.34 Child W and her link worker had a further ‘star links’ session later on 29th October. The records refer to the meeting (4.5.32) and that the Housing Options Worker would complete a ‘move on’ form for Child W in January (2014) if her behaviour “continues to improve”. The record confirms that Child W was receiving physiotherapy to build the muscle in her leg. Child W reported feeling under less pressure at the moment and said that she was looking forward to starting her new college course the following week. She also said that she was now engaging with a Refresh substance misuse worker and reported that things were going a little better between her and her Mum.   4.5.35 Over the weekend (2nd & 3rd November 2013) Child W fell out with her boyfriend over money and the relationship came to an end. It is clear from the hostel records that she and her boyfriend repeatedly rang each other and that Child W was in and out of the hostel over the weekend, arguing and shouting with her boyfriend. At one point, the hostel’s resident’s phone was unplugged by a hostel worker because Child W’s boyfriend was frequently ringing it. Child W needed, and received, comfort and support from workers over the weekend, which was given, including in the form of cuddles.  4.5.36 On 4th November 2013, having been informed by hostel staff of the events of the weekend, the senior member of Hostel 2 asked for an urgent meeting with the Housing Options Worker prior to meeting jointly with Child W. Child W’s social worker was not available to meet. Both decided that Child W’s support needs were too high for Hostel 2. A ‘notice period’ of two weeks was agreed, to enable time for Child W to be found more suitable accommodation.   4.5.37 Child W joined the meeting in a state of high agitation. According to the hostel records she made repeated threats to harm herself, was shouting, pacing the room and flailing her arms about. She is recorded as saying that no one in her life cared about her. She was asked to leave the room.  4.5.38 It was decided that she could not return to Hostel 2. Child W was upset with the decision and refused to consider returning to her adoptive   35 home. She did agree to go back to Hostel 1 and was taken to Hostel 2 to collect her belongings and on to Hostel 1. Her up to date Risk Management Plan was emailed to the Housing Options Worker by Hostel 2’s Deputy Manager.  Analysis  4.5.39 Hostel accommodation was never seen as being the most appropriate option, best suited to meeting Child W’s needs. The preferred option was for her relationships with her adoptive parents to be sufficiently restored to enable her to return home to live in the longer term.   4.5.40 Given that she was unwilling to return home to live, and her parents felt that some “distance” was needed, her social worker discussed supported lodgings with her at her first meeting with Child W and her parents on 17th July 2013. Child W did not want to consider this option and it is clear that she was determined that she wanted to live at Hostel 2.   4.5.41 It was not until 21st October 2013 that Child W agreed to consider a supported lodgings placement. An application was swiftly made and approved on 25th October 2013. A potential carer was identified for her and she was taken by her social worker to meet the carer on 28th October 2013. Child W turned down the placement.   4.5.42 Initially she said that this was because the placement was too far away from where her boyfriend was living. Later, she told her social worker that she did not want to live in a family environment, due to previously being in care and the breakdown of her relationship with her adoptive family. Child W said that if things didn’t work out for her in a hostel then it wouldn’t hurt as much as it would in a family home.  4.5.43 It is clear that Child W formed important and supportive relationships with staff at Hostel 2 who nurtured her at a time in her life when she needed it most. Case records inevitably fail to capture a full picture of these relationships, although there is evidence in the ‘star links’ work that Child W was happy at the hostel. For example, staff helped her with her coursework, applied make up, bought her beauty products and comforted her when she needed it.   4.5.44 The hostel had shown, despite reservations from the outset that Child W’s needs were too high for it to meet given the staffing ratio, that it was willing to work with her, and continue to do so, with a ‘move on’ plan, even as her needs escalated during October 2013. The decision on 22nd October 2013 to offer Child W’s boyfriend a place at another hostel owned by the same company is an example of the hostel continuing to focus on how best they could continue to support Child W despite her increasing support needs.    36 4.5.45 The events of the weekend (2nd & 3rd November 2013) and Child W’s responses during the meeting on 4th November 2013 were judged to demonstrate that Hostel 2 could no longer meet her escalating needs. This decision, in the context of Child W’s high and escalating support needs, is understandable.   4.5.46 Nevertheless, the decision clearly upset her and she immediately started to ask about an appeal against it. Her eviction came at a time when her court case as a victim of an alleged rape was approaching and she had just ended an important relationship with her boyfriend. Her distress will have been compounded by comments which she is said to have overheard and which she is reported by her Mum as interpreting as meaning that she was “beyond help”.  4.5.47 Child W’s re-admission to Hostel 1 recorded that an assessment of her vulnerability had been completed, but this was not on file or received by the hostel. Child W’s risk management plan, completed by Hostel 2, and emailed to the Housing Options Worker, was not passed on to Hostel 1. The document contained considerable information which might have assisted Hostel 1 in supporting Child W.  4.5.48 The information on the hostel file focused on Child W’s substance use, personal circumstances and likely support she would receive from CAMHS, via the mental health assessment which was due to be undertaken on 11th November 2013, and from her social worker.   4.5.49 There was no needs assessment of Child W created by Hostel 1, other than a support plan focusing on ‘my way forward’ aims. The staff team report having had no training in self-harm or in recognising suicidal ideation, assessing risk or child sexual exploitation in the previous 12 months. There was no evidence of daily link worker sessions and there had been no formal supervision of staff for the previous 12 months.  4.5.50 There are important lessons to be learned about the range and type of accommodation available in Hull to vulnerable young people, the extent to which such accommodation is supported to meet the needs of vulnerable young people and the need for protocols, as part of local commissioning arrangements, setting out clear expectations for sharing information with, and between, hostel providers which is needed to help meet the needs of young people.   4.5.51 This learning is explored further in the ‘overall learning and analysis’ (section 4.10) and reflected in ‘Finding 8’.  4.6   ASP 8:  Child W’s emotional health and the response of professionals  4.6.1 There are a number of instances known to professionals when Child W either harmed herself or made threats to do so: in February 2011 (spraying deodorant on an old wound); March 2012, the incident on the roof at home; March 2013, a cut to her arm and 3rd June 2013 when in   37 police custody. None of the known incidents of self-harming behaviour resulted in more than ‘superficial’ injury.  4.6.2 At her first meeting with her social worker in July 2013, Child W told her social worker that she had previously self-harmed when she had split up with a boyfriend.  4.6.3 There are no further records of self-harming behaviour or of Child W making threats that she would harm herself until 7th October 2013 when she self-harmed by scraping her upper arm with a razor.   4.6.4 The incident took place at Hostel 2. Child W took herself to the local Hull Royal Infirmary Accident and Emergency Department for treatment. According to hostel records her injury was superficial. Child W is recorded as saying that she had harmed herself because of “everything: her brother and meeting with her Dad (birth father) and all the bad things that happened when she was younger and the problems she has got with her parents and the court case coming up”.   4.6.5 Hostel staff immediately informed Child W’s social worker of the incident. Child W had an appointment with the social worker later that day. This incident prompted the hostel to reassess Child W’s support needs from ‘low’ to ‘high’.  4.6.6 The hospital sent a discharge summary to Child W’s GP surgery on 8th October 2013. The description of ‘upper arm injury’ did not state that the injury was self-inflicted and did not, therefore, alert the GP of any need to follow it up.  4.6.7 Child W and her social worker talked about the self-harming later on 7th October 2013. Child W told her social worker that she had no intention to end her life, but that she wanted to feel pain. She agreed to a referral to the Child and Adolescent Mental Health Service (CAMHS) for assessment. This was an appropriate response to this incident. The CAMHS referral was made on 11th October 2013.  4.6.8  On 18th October 2013, a telephone mental health screening assessment took place between Child W’s social worker and a CAMHS health liaison worker. The assessment concluded that there was no immediate risk, but that an appointment within 10 days was required. There was no available appointment within this timescale. An appointment was made for 11th November 2013, after 16 working days.  4.6.9 On 11th November 2013, Child W, accompanied by her social worker and sexual health worker, attended for her CAMHS assessment. The CAMHS worker carried out a screening assessment using the ‘Strengths and Difficulties’ Questionnaire. The conclusion of the assessment was that there was no immediate suicide risk but that Child W would be referred into the CAMHS self-harm pathway. It was   38 agreed that contact would be made with the TYS social worker to progress this further by the end of the week (16th November 2013).  4.6.10 The assessment took place outside of the expected timescales (16 working days instead of the target of 10). CAMHS waiting times are a feature of the service nationally, and have been a feature locally too for many years. However, Child W did not experience an extensive delay in being assessed.  4.6.11 The CAMHS worker was not aware that Child W had asked to see a female worker and had said that she would be uncomfortable talking to a man.   4.6.12 On 15th November Child W met her social worker. The recording for this date refers extensively to her boyfriend and Child W saying that she was “fed up” and that she couldn’t be “bothered with anything anymore”. The social worker spent time with her, encouraged her to contact her mum and helped her to arrange her appeal against her eviction, and feels that Child W left the meeting in a much more positive frame of mind.  4.6.13 The following day on 16th November 2013, Child W died. Staff at the hostel had not noticed anything in relation to her behaviour or mood prior to this, which might have given rise to concern.   Analysis  4.6.14 During this period (9th July – 16th November 2013) there is one recorded incidence of Child W self-harming (7th October 2013). This incident appropriately triggered a referral to CAMHS for more specialist assessment. There were a number of occasions on which she threatened to hurt herself, when stressed or as a means of trying to persuade adults to accede to her requests. Her parents also expressed concern about her emotional well-being to professionals on several occasions.  On each such occasion, however, Child W subsequently saw professionals and provided reassurance that she did not intend to self-harm and did not have any suicidal thoughts.  4.6.15 Child W made threats to self-harm to a number of different workers and it would have been very difficult for any worker to assess how serious these threats were, or how much risk there may have been of suicide, particularly as her actual recent self-harm had involved relatively minor cuts and scratches (March 2013 and October 2013). This difficulty will have been compounded by the fact that none of the staff in contact with her, other than the CAMHS worker, had received any specific training in recognising the risk factors or in ‘Youth Mental Health ‘First Aid’.  4.6.16 In the consultation for the development of Hull’s ‘Emotional Health and Wellbeing Strategy’, professionals fed back that it was “hard to spot the   39 difference between ‘normal’ teenage behaviour and a teenager with emotional health needs”.   4.6.17 Adolescence is known to be a time of extreme emotional turmoil, and of physiological changes2 which make it difficult for teenagers to make sense of their world. For teenage girls this is compounded by hormonal changes which produce mood swings, impulsive behaviour, and physical symptoms. They often rebel against and withdraw from the care and influence of the adults who would protect them and develop intense relationships which produce equally intense emotions when these go wrong. They are struggling to make sense of who they are at a point when they are physiologically not well equipped to do so.   4.6.18 The presence of strong familial bonds and flexibility in parental care and control is crucial in enabling this process to happen in a positive way, and these factors were not present for Child W. Her emotional turmoil would have been magnified by her attempts to make sense of her abusive childhood and her relationships with her birth and adoptive families. Her “letter for later life” from her adoption social worker explaining the circumstances of her coming into care was found in her possessions at the hostel.     4.6.19 Child W had been in a highly intense relationship with her boyfriend which had recently ended. Her behaviour in response to this (attention-seeking, distressed, demanding of staff time and energy) contributed directly to the decision to evict her from Hostel 2 as her support needs could no longer be met there. Whilst this was an understandable decision, nevertheless it had the effect of adding to Child W’s emotional turmoil at the time.   4.6.20 At the time of writing this report, six teenagers (including Child W) have taken their own lives, whether deliberately or not, across Hull and the East Riding of Yorkshire in the last 2-3 years. In Hull, there has been a noticeable increase in the numbers of children and young people attending accident and emergency having self-harmed. Local schools, both primary and secondary, also report a significant increase in self-harming behaviour and general concerns about teenage emotional well-being.  4.6.21 The links between self-harm and suicide are not straightforward. Self-harm is defined as “intentional self-injury or self-poisoning, irrespective of type of motivation or degree of suicidal intent”3. This reflects the often mixed nature of intentions associated with self-harm and also the fact that suicidal intent is a dimensional rather than unitary                                             2 Raising Girls S Biddulph Harper Publications, 2013 3 Hawton K, Harriss L, Hall S, Simkin, S., Bale E, Bond A. Deliberate self-harm in Oxford, 1990-2000: a time of change in patient characteristics. Psychol. Med 2003; 33: 987-96 and National Institute for Health and Clinical Excellence (2011). Self-harm: longer-term management CG133. National Institute for Health and Clinical Excellence: Manchester     40 phenomenon - many young people who self-harm do not go on to kill themselves, and have no intention of doing so.  4.6.22 This can lead some professionals to underestimate the impact of other risk factors, and of the impulsivity which is a feature of many young people, particularly those who have had challenging and abusive backgrounds, and who are struggling with poor self-esteem. 4.6.23 Given this complexity, and given Child W’s previous pattern of behaviour, it would not have been possible for any of the professionals involved in supporting her to have predicted the outcome and neither will it ever be known whether or not Child W intended to take her own life. Finding 7: Practitioners working with young people need to have a good understanding of adolescent development. Access to training, advice and consultation for professionals and families regarding children and young people’s emotional health and wellbeing needs to be clarified as the current strategy has not yet been fully delivered or achieved.  4.7 ASP 9: The response to Child W’s health needs and issues (excluding emotional health) 4.7.1 Child W was taken to Hull Royal Infirmary on 30th May 2013 having been struck by a vehicle. She had injured her leg. She attended the accident and emergency department on 30th August 2013 for advice about her knee, but did not wait to be seen. A letter was sent to her GP which highlighted missed appointments. Child W missed many of her appointments for physiotherapy on her knee, including on 9th and 23rd October and 6th November 2013. 4.7.2 She attended Hull Royal Infirmary, accident and emergency department on 7th October 2013, having cut her upper arm with a razor and received treatment for the wound. The hospital discharge letter to her GP did not describe the injury as having been self-inflicted. 4.7.3 Between 30th September and 12th November 2013, there are five recorded instances of Child W accessing ‘walk in’ medical help for a variety of health complaints and tests.  Analysis 4.7.4 The lack of a fully coordinated, joined up multi-agency approach, such as might have been achieved via a professionals meeting, meant that the health services with whom Child W had been in episodic contact over the last few months of her life, had no opportunity to share information about that contact, or to put her visits and health needs into any broader context. These health records were not, therefore, pulled together at any point.    41 4.8    ASP 10: Help provided to Child W in relation to her substance use 4.8.1 Child W was first referred to the Refresh young people’s substance misuse service by staff at Hostel 1 on 17th July 2013, following being given a warning at the hostel the previous week for rolling a cannabis joint on the premises. She was interviewed and an initial referral/risk assessment completed, but she declined support at this time. 4.8.2 It is clear from Hostel 2’s records that Child W continued to use cannabis on a regular, and sometimes daily, basis but that she didn’t consider this to be problematic. On 19th September 2013, the hostel daily diary records Child W as being sick and under the influence, having taken a legal high. This is the first recorded instance of her using other substances, most probably Mephedrone (M-CAT). She was advised about the dangers. 4.8.3 On 17th October 2013, Child W self-referred to the Refresh substance misuse service. On 30th October 2013, her allocated Refresh substance misuse worker started a comprehensive assessment of her substance, sexual and emotional health needs, focusing on Mephedrone (M-CAT) reduction, sexual and physical health. 4.8.4 Child W had an unplanned meeting at Refresh on 8th November. She told her worker that she was having difficulty relaxing and said that this made her feel vulnerable. She agreed with her worker that they would practice relaxation techniques at the end of their sessions. On 11th November, Child W saw her Refresh worker and the assessment was updated. She scored high on substance misuse, neglect, vulnerability and mental health. 4.8.5 When Child W saw her worker on 13th November 2013 she told her that she had not used M-CAT since 8th November 2013.  Analysis 4.8.6 There is evidence in the respective records of communication between Child W’s Refresh worker and her social worker, and that they saw Child W together on at least one occasion. Concern about her continued drug use was one of the issues which influenced the decision to arrange a professionals meeting. This decision was taken shortly before Child W died (para. 4.2.8).   4.9  ASP 11: Support for Child W in meeting her training and further education needs 4.9.1 In May 2013, as she was taking her GCSE examinations, Child W received a letter informing her that her application to train as a nurse in the army had been rejected. On 23rd April 2013, she had previously accepted the offer of a place on a child care course at Hull College. 4.9.2 On 22nd August 2013, Child W’s social worker helped her to obtain her GCSE results from school. She had obtained D’s and E’s in her   42 GCSEs and had passed her BTEC Health and Social Care and Applied Science.  The school offered her support in the future in discussing her next options. 4.9.3 On 28th August 2013, Child W did not attend an appointment at college, as she had decided that the course she was due to start was not what she wanted to do. The hostel records state that her social worker would help find her a more suitable course. 4.9.4 Arrangements were made for Child W to switch to a Business Administration course at Hull College. On 6th September 2013 she was given a grant to buy stationary and clothing for the course. The hostel records indicate that her attendance at college was inconsistent, with many daily entries showing that she did not attend. 4.9.5 On 29th October 2013, she is recorded as looking forward to starting a new course (with ‘Inspiring Youth’) on 4th November, as she had not been enjoying her previous course. In the event, Child W never did start this course.  4.9.6 Child W met twice with the duty worker at the Connexions Service on 14th November 2013. She said that she had no money and was advised that she needed to enrol at college in order to receive her benefits. Child W explained that the antibiotics she had been prescribed were ‘wiping her out’ and that this was why she had not attended. Arrangements were made for her to go into college on Monday (19th November 2013). She was given a ‘mega-rider’ for the bus. Analysis 4.9.7 Arrangements were made for Child W’s future learning via the Risk of NEET (Not in Education, Training or Employment) indicator process (RONI) managed through the Connexions Service. She received personalised outreach support from a Connexions worker and the service tried to support her to attend college and to communicate with other services as required.  4.9.8 In the context of what was going on in her life at the time, however, particularly from October onwards, it is not surprising that Child W found it difficult to attend college on a regular basis or give attendance the priority she may have wished. 4.9.9 Greater overall coordination of the help and support being provided to Child W would have also assisted both the college and Connexions service to tailor their particular provision and responses to her individual and changing needs and circumstances as part of one agreed support plan. 4.10    Overall Analysis and Learning  4.10.1 All of the practitioners who were interviewed and took part in this review were deeply affected and saddened by Child W’s death.    43  4.10.2 There is clear evidence that many who worked most closely with her cared about her as a young person, and worked hard to build positive relationships and trust with her - and were also very concerned about the risks associated with her lifestyle and created by her experiences. They wanted her to be safe and did what they could to encourage her to stay safe. At some points contact with key staff was on a daily basis. This was good practice.  4.10.3 There is also ample evidence that Child W built positive and supportive relationships with key adults in her life: this included staff at Hostel 2 and her TYS social worker. There is evidence too that she found many of the services which she used, and the staff working in them, accessible, welcoming and ‘young person friendly.’ When she called at services ‘on spec’ and her allocated worker was not available to see her, there is also good evidence that other staff were willing to provide help, support and advice. The approach of workers and the ‘feel’ of services, as experienced by Child W and others, form part of an approach and value-base which must continue to form the basis of any local redesign of support services for vulnerable young people.  4.10.4 Practitioners also wanted much more for Child W: to help her to get her life onto a more secure and stable footing and realise her full potential; to obtain permanent, suitable accommodation; to resume training or education or employment and; to improve her physical and emotional health. To this end many professionals showed persistence and determination and did not stop trying to help, despite the challenges. These qualities and skills too need to be recognised as central to the learning from Child W’s death and informing what improvement might look like.  4.10.5 Work with vulnerable young people is an area of specialism in its own right. This review has highlighted the difficulties some young people face in accessing services. It has highlighted the need not just to improve the quality and range of accommodation options, but more fundamentally, the need to ensure that accommodation and support are provided in a much more seamless way, and in the context of a clear framework for practitioners and an explicit, value-based approach for working with young people.   4.10.6 There are arguably resource and capacity issues which can leave young people more vulnerable than in the past. Practitioners taking part in this review highlighted from their perspective the impact of ‘cuts’ in funding of services for this group of children.   4.10.7 There is a strong history of good multi-agency working with young people in Hull; however, as services have been reduced the different elements of an integrated model of working with young people have fragmented, and the relationship between different parts of the system and respective roles and responsibilities has not been made sufficiently   44 clear. The effect of this has arguably been that staff are more likely than before to be working in isolation.  4.10.8 It may well be the case that, in the context of budget cuts across the public sector, there has been an insufficient focus locally on how to remodel services for young people across the partnership to ensure that needs can be met. It is, therefore, essential that the local partnership comes together to understand what life is like for this group, listens to them and makes a joined up response accordingly.   4.10.9 It is widely recognised that ‘mainstream’ systems of help and support, including child protection systems, can sometimes inhibit the kind of person-centred engagement work that is needed to build the confidence of young people and draw them back into mainstream services. Vulnerable young people may often have had negative experiences of professionals and/or harmful relationships with adults. They will also often be coming into contact with a range of different agencies - voluntary, community and statutory. Their networks of support can be fragmentary and transient.   4.10.10 This kind of work needs to be recognised in the workforce development of the partnership as a valued and important part of the range of provision that can help keep young people safe, requiring a particular set of skills and values.   4.10.11 In addition, training, awareness-raising and guidance on self-harming behaviours in young people are needed for practitioners across the partnership. With the sole exception of the CAMHS worker, none of the staff in contact with Child W had any training in recognising the risk factors associated with self-harm. It is, by its very nature, extremely difficult to understand the factors which contribute to death as the result of deliberate self-harm. Knowledge of the broad risk factors provides a context for assessment but the same risk factors can be applied to large numbers of troubled young people who do not die as a result of deliberate self-harm. The literature also suggests that deliberate self-harm is frequently characterised by impulsivity, which provides a further challenge in terms of keeping young people safe.   4.10.12 Despite the best efforts of many staff across the partnership, communication between individuals and agencies was not always as good as it needed to be. Whilst professionals from different agencies did communicate, and did meet, there was no multi-agency meeting convened for the purpose of coordinating information, including understanding risks and strengths, and drawing up an agreed plan. This meant that the risks associated with Child W’s lifestyle were not explicitly discussed in a multi-agency context; nor therefore was the collective involvement of different practitioners reflected upon in a way that might have promoted better joint working between agencies and practitioners. This might have reduced the number of interfaces Child W had to negotiate at times and rationalised roles between   45 practitioners which, importantly, may have simplified things for her. It might also have helped Child W to feel that all the adults working with her were giving consistent messages about how they could help.   4.10.13 A clearer structure for management oversight of the case would have meant that a coordinated plan was more likely to happen, and, where relationships or communication between agencies was not working well, this would more likely have been exposed and addressed. Work with vulnerable young people must operate within a clear framework and must be continuous with the wider system of help and safeguarding. Child W’s needs were at no point considered within a risks framework. This is also an area for development and learning.   4.10.14 There is a balance to be struck between the capacity for self-determination of a young person, and the advice, support and accommodation options presented to them based on their needs as assessed by the adults who have a duty to safeguard and promote their welfare. A future framework for working with young people should include how the assessment of housing needs is carried out, together with the responsibilities of respective agencies in addressing the needs of this group.   4.10.15 Many of the professionals involved in the review considered that many young people remain at an unacceptable level of risk in the city through homelessness and that there are seldom sufficient adequate places for them to stay.   4.10.16 The review has highlighted a skills gap and also a need for clarity about some key procedures and protocols to ensure that admission and exit processes are fair and consistent and that risk management is robust. Above all, there need to be realistic expectations of the capacity of hostel staff in managing high levels of need for some young people. This issue, the provision of supported accommodation for young people, needs to be addressed in the context of a wider review of services for this age group.  4.10.17 Child W’s determination got her to the hostel that she wanted to be at. It is clear that other options were discussed with her and it is difficult to see how this might have been different. The status of ‘s.20’ would have afforded the added formal structure of the looked after children reviewing process, but it would only have been a protective factor had Child W chosen to cooperate with it. It would, however, have provided a framework within which practitioners came together to review Child W’s care and placement.    4.10.18 Child W’s experience also highlights the need for clear post-adoption support arrangements, particularly when arrangements cut across different local authority areas. There is a need for post adoption support to be better understood in its own right and in relation to   46 safeguarding services and other engagement services for young people. Older young people may find youth support and engagement services more relevant to them depending on their age and circumstances - each young person needs to be assessed in their own right and services need to talk to each other, and with the young person, about the best way of working with them. Agencies can spend too much time talking to each other and deciding whether a young person is eligible or has an entitlement to a particular service, rather than meeting to decide who is best placed to work with each individual. This might usefully form part of the overall framework and approach.  4.10.19 Child W’s experience informs us that the design and commissioning of services, whether accommodation or support services, must be more closely integrated with the overall framework of support for young people and reflect the needs and views of young people in the city.   Finding 8: There is a need for a fundamental, ‘whole system’ review of support arrangements for vulnerable young people in Hull, which captures the learning identified in this review.                 47 5.   Findings, Developments and Recommendations  5.1 Adoption Practices and Post-Adoption Support Finding 1: Adoption Support Plans need to clearly and explicitly detail how, and by whom, any assessed therapeutic needs in respect of children placed for adoption, will be met.  5.1.1 The adoption and post-adoption support issues addressed in this review (Chapter 3, section 3.1) date back to a period between 2006 and 2010. The review has made reference to the heightened national focus on adoption since that time and to the changes in statutory guidance which have had an impact on adoption practices.  5.1.2 The adoption practice issues and learning from this review relate specifically to Barnsley local authority, since it was they who placed Child W for adoption and carried the responsibility for providing post-adoption support for three years after the making of the Adoption Order.  5.1.3 There is evidence that Barnsley Adoption Services have undertaken significant improvements since the time when Child W and her brother were first placed. The most recent Ofsted report notes that social workers work well with people wanting to become carers (both foster carers and adoptive parents) and provide them with good support after they are approved to care for children.  5.1.4 Ofsted also found that there has been a good focus on developing adoption support in Barnsley through the appointment of a dedicated worker. Detailed adoption support plans are routinely developed to enhance adoptive placements. These include emotional support packages through CAMHS for parenting support for adopters and access to specialist counselling services for children  5.1.5 Whilst it was Barnsley which placed Child W for adoption, this review has been commissioned by the Hull Safeguarding Children Board (HSCB) and so it is appropriate and necessary for the HSCB to seek assurances from Hull City Council about the current quality of adoption practices and provision of post-adoption support.  5.1.6 The Board is assisted in this regard by the findings of the recent Ofsted ‘Inspection of services for children in need of help and protection, children looked after and care leavers’. The inspection took place in November and December 2014 and the report was published in February 2015.  5.1.7 Adoption performance overall was judged to ‘require improvement’. This judgement related primarily to the timescales within which children are placed for adoption after entering care and to the arrangements for monitoring the progress of children with a plan for adoption.   48  5.1.8 The performance in Hull on numbers of children placed for adoption was judged by inspectors to be ‘good’. The adoption panel was assessed as being chaired well, and the panel minutes and recommendations found to be clear and appropriate. However, inspectors found that the quality of child permanence reports received by the panel was too variable, citing examples which had not included all risk issues, or recorded history well.   5.1.9 The quality of prospective adopter reports and matching reports seen by inspectors were judged to be good, containing clear analysis and detail. Adoption disruption rates in Hull were found to be low and all of the adopters spoken to reported that a suitable match was made. The inspectors also found post adoption support to be a strength of the local authority. Adopters spoke positively about adoption support and were aware how to access this now and in the future.  Recommendation 1: Hull and Barnsley Safeguarding Children Boards should assure themselves that adoption processes, and arrangements for post-adoption support, are now good, including the need for handover arrangements, should there be ongoing involvement of the placing authority at the end of the three year statutory period. In relation to older children in particular, the way in which post-adoption support services are accessed and provided in collaboration with other relevant services should also be set out.   By: 31st March 2016  5.2     Access to specialist therapeutic services to address attachment needs  Finding 2: The attachment needs of children placed for adoption should form part of the specialist therapeutic services in local commissioning arrangements.  5.2.1 The recent Ofsted inspection (para. 6.1.4 above) acknowledged that Hull local authority had recognised the need for consistent and readily available psychological support for looked after children, and that, “in the absence of targeted health commissioned service” had employed two psychologists. This had enabled a focus on attachment issues for young people, a greater understanding of behavioural issues and is helping to support the needs of looked after children. In addition, the inspectors saw examples of the local authority buying packages of support for young people with specific complex needs, and that this was helping to improve outcomes.  5.2.2 However, both the Ofsted, and the simultaneous Care Quality Commission (CQC) inspection found that looked after children were insufficiently prioritised for mental health services, with relatively few receiving direct support from the Child and Adolescent Mental Health   49 Services (CAMHS). Ofsted found that CAMHS was not delivering the agreed ‘targeted and dedicated specialist service’ for children in care. Some young people were waiting too long to access the service and their needs were going unmet.   5.2.3 These findings translated into a CQC recommendation for access to CAMHS for looked after children to be improved. This review has identified that Child W did not receive the specialist therapeutic help that had been identified as being needed for her, either whilst she was still looked after by Barnsley local authority, or subsequently, post-adoption. Whilst this was never specifically sought for her, nevertheless doubts were expressed at the time as to whether it would have been available if requested.   5.2.4 Local partnership work to improve access to specialist CAMHS services for looked after children, including in relation to attachment, should extend to include children who have been adopted and, in respect of whom, therapeutic need extends beyond the adoption itself. The HSCB has established clear mechanisms to oversee progress in improving access to CAMHS for looked after children.   Recommendation 2: The emotional and mental health needs, including those relating to attachment, of children placed for adoption, and those who have been adopted, should be prioritised by commissioners of therapeutic services   By: 31st March 2016   5.3       Assessing the needs of whole families  Finding 3: There should be an holistic approach to assessment which captures and reflects the needs of the whole family in the process.  5.3.1 The review identified that, during the period from November 2008 – May 2013, when there was significant professional involvement with the family, there was an insufficient focus on Child W’s needs as an individual.  5.3.2 In January 2014, Children’s Social Care implemented a new model for the delivery of social work services in Hull, based on a systemic approach to social work practice. Under the new model, small teams of social workers, known as ‘pods’ were established, led by a Consultant Social Worker. The model is based on each Pod operating as a ‘learning system’ with shared workload, regular reflective group discussion about ongoing assessments and work, and access to clinicians to support the work.  5.3.3 The new model was still in its relative infancy at the time of the inspection, but inspectors still identified, as one of the local authority’s   50 strengths, that recent assessments were of increasing good quality with a strong focus on the voice of the child. They also found many examples of good direct work with children and well developed social work relationships with children and families, “characterised by social workers and their managers who know the needs of children well.”  5.3.4 The systemic approach to practice is increasingly embedded. A significant investment has been made in training and development of social work staff. The approach places emphasis on the quality of the work with children and families, looking at whole family dynamics and explicit consideration of risk and the specificity of risk in relation to individuals.   5.3.5 The use of genograms and other tools to help understand the experience of all children and adults in the immediate and extended familial network is emphasised. Weekly reflective meetings are designed to provide visibility to cases to the wider pod and oversight by the CSW, as well as provide support and challenge to the hypotheses upon which the interventions are based.   5.3.6 The reflective meetings also include clinicians who work to help understand and challenge the dynamic between the practitioner/agency and family and explore how this has a bearing on effecting change. Work is also increasingly focused on specific goals designed to effect and monitor change. Change to reduce risk and sustain families is the premise for involvement, with constant reflection and review. Since the Ofsted inspection greater emphasis is placed on the ‘risk’ elements of assessments and plans and the oversight of CSW’s and managers  5.3.7 Notwithstanding these developments, Children’s Social Care will need to ensure that this particular element of learning is clearly communicated to the ‘frontline’ and features as part of routine reflective discussion and supervision.  Recommendation 3: Managers in Children’s Social Care should ensure that this specific learning is clearly communicated to frontline practitioners and reflected in work with children and families.   By: 31st January 2016   5.4      Service Provision  Finding 4: The needs of children and young people must be at the centre of decision making about the provision of support, and service or organisational boundaries should not act as a barrier to children, young people and families accessing the most appropriate help and support according to those assessed needs.     51 5.4.1 Since the commencement of the Serious Case Review considerable work has been undertaken to re-shape services. Some of this work and the evidence of improved practice are described above. Others are described in relation to ‘Finding 8’ below.   5.4.2 It is nevertheless acknowledged that a more fundamental ‘whole system’ review of partnership arrangements for the provision of help and support to vulnerable young people is needed. One of the key principles underpinning service re-design must be that children and young people can access the right service, at the right time and in the right place, and that their legal status or history does not act as an unnecessary barrier for them.  Recommendation 4: Hull Safeguarding Children Board should ensure that this key principle is reflected in the development of a new local multi-agency framework for the integrated support of vulnerable young people.   By 30th June 2016   5.5     Assessing the need to accommodate homeless 16 & 17 year olds under section 20, Children Act 1989.  Finding 5:  The assessment of ‘homeless’ 16 & 17 year olds should always include consideration, with them and their families, of the potential for accommodation under section 20, Children Act 1989.  5.5.1 The local authority has produced a draft protocol clearly describing its legal responsibilities under the Children Act 1989 and Housing Act 1996. More importantly the protocol describes the way in which different services should work together to assess the needs of young people who are at risk of homelessness or who are in housing need.  5.5.2 The protocol now needs to be refined, agreed and implemented in order to achieve greater clarity and consistency, and better outcomes for 16 and 17 year olds in need of accommodation.  Recommendation 5: The Local Authority should ensure that it agrees and implements for staff clear local guidance on the interpretation and application of the ‘Southwark Judgement’.   By 31st January 2016   5.6     Strategy Discussions under section 47, Children Act 1989  Finding 6: Health professionals should be routinely involved in s 47 strategy discussions as set out in ‘Working Together 2015’ and local HSCB child protection procedures.   52  5.6.1 The involvement of health professionals is assisted by the co-location of the health safeguarding team with the Police and Social Care decision-makers. This means that there is increasing involvement of health professionals in s47 discussions. This needs to become more embedded and forms part of the post inspection improvement work to establish a multi-agency early help and safeguarding hub.  Recommendation 6: Hull Safeguarding Children Board should receive regular reports in relation to the involvement of health professionals in section 47 strategy discussions and the impact of this on the quality of decision-making and planning.   From: January 2016 onwards   5.7      Adolescent emotional and mental health and wellbeing  Finding 7: Practitioners working with young people need to have a good understanding of adolescent development. Access to training, advice and consultation for professionals and families regarding children and young people’s emotional health and wellbeing needs to be clarified as the current strategy has not yet been delivered or achieved. 5.7.1 Since Child W’s death considerable work has been undertaken to improve the range of services and increase early intervention in relation to the emotional and mental health and wellbeing of children and young people. The development of the Children and Young People’s Mental Health and Wellbeing joint commissioning strategy and associated delivery plan, overseen by the Children, Young People and Families Board has identified gaps in provision particularly at a universal and targeted/early help level.   5.7.2 These gaps have been addressed by:  Extensive consultation with children, young people and parents, as well as stakeholders and partners, and learning from examples of good practice in other areas.  Mapping existing good practice locally and identifying areas of development and improvement at a universal and targeted/early help level (traditionally known as tier one and two).   The development and implementation of a multi agency workforce development and training plan, which will: o Provide staff with information on evidence based approaches which promote protective factors and support children and young people’s emotional health in Universal & Targeted/Early Help settings. o Enable skills development and capacity building in Universal and Targeted/Early Help services that support children, young people and their families/carers.   53 o Increase the numbers of brief interventions undertaken in Universal and Targeted/Early Help services to initiate and support behaviour change or improvement. o Improve partnership working though shared and consistent training, knowledge and practice.  5.7.3 In its first year, 67 practitioners were trained in Youth Mental Health First Aid .They were from a range of agencies: 43 from Hull City Council, including social workers, youth workers and early help practitioners; 13 were from the voluntary and community sector;  and 11were from other agencies such as health, schools  and police.   5.7.4 This year this training is being delivered to all children’s homes staff in addition to being offered to a range of agencies as previously. Additional thematic training is being developed including self-harm training and bereavement training. In addition CAMHS are piloting training with youth justice and Refresh workers which will equip them to undertake emotional health assessments, enabling them to refer appropriately and improve early access to specialist CAMHS where needed.  5.7.5 Other developments have included:  Piloting of a range of universal and targeted provision across schools, community and family for young people aged 10-14 (HeadStart).  The development of digital tools for young people including an app which provides information and support and enables young people to access appropriate online support (designed with young people) (2014).  Improved publicity of existing local and national services for teenagers via a Z card (designed with young people).  The development and implementation of a counselling framework in 2014. The framework has 4 providers who deliver counselling for children and young people aged 5-19 who are LAC, have social care involvement, are accessing substance misuse services or who are a young offender. Counselling can be accessed within 28 days of referral although this is usually quicker.   The commissioning of a community based counselling service for 10-19 year olds who do not fit into any of the cohorts described above. This service launched in September 2015. Counselling will be accessed within 28 days of referral.   The development of a 0-19 delivery model for universal and targeted/early help services which is being finalised and will include provision to address gaps identified in consultation with children, young people and other stakeholders, including: o One to one support for young people e.g. mentoring and support to build confidence and reduce social isolation as well as improve engagement in services e.g. youth services;    54 o Targeted group work on key issues e.g. bullying, anxiety and stress or with key groups e.g. NEETS or boys and young men, BME communities; o Increased capacity needed to provide effective parenting support (e.g. one to one and group work). This includes support for parents in identifying and supporting their young people on emotional health issues but also work to improve parenting skills and support parents with mental health issues which impact on the family.  5.7.8 All of these issues/needs relate to those children and young people who do not currently meet the CAMHS threshold but who, without interventions at the universal/early help stage, could end up needing that service.  Recommendation 7: Hull Safeguarding Children Board should support, monitor and challenge the development and implementation of the emotional and mental health and wellbeing action plan and accompanying workforce development plan.  Effective from May 2015 and on a half yearly basis   5.8    Helping and supporting vulnerable young people in Hull  Finding 8: There is a need for a comprehensive, ‘whole system’ review of support arrangements for vulnerable young people in Hull, which captures the learning identified in this review.  5.8.1 Since the SCR commenced much work has been undertaken to improve services. This has taken place against a backdrop of various needs to reshape services. Some of this work, and, in particular the development of new models of working within Children’s Social Care and the work on emotional and mental health and wellbeing has been described above.  5.8.2 The systemic approach is being extended into work in targeted youth including the youth justice service and work with young people at risk of CSE.  5.8.3 Change has taken place in respect of the safeguarding oversight of vulnerable young people. There is now a stronger alignment between Targeted Youth Support and Children’s Social Care and this has now been in place for some time.   5.8.4 This has strengthened the management oversight of the safeguarding of vulnerable young people to ensure informed decision making about risk management, based on assessment. Where appropriate, CSC lead fully on the assessment and will assume case responsibility in some cases; in others cases although the lead is CSC, targeted youth   55 remain involved to ensure specialist input in areas such as benefits and supported accommodation is given, yet the safeguarding element continues from CSC providing input into the assessment and the continuing work.      5.8.5 Work is underway to consider options for extending the provision of post-16 accommodation in the city to meet a range of needs. This work includes undertaking an analysis of gaps and consideration of how a broader range of options can be provided locally. This important work needs to be taken forward in the context of the more fundamental ‘whole system’ review of partnership arrangements for supporting vulnerable young people.  5.8.6 Ofsted found that recent commissioning work has already resulted in the provision of new accommodation, including a one to one 24-hour facility for young people with the most complex needs and that the work to increase the range and choice of suitable accommodation has led to improvements, enabling needs to be met in the majority of cases.   5.8.7 Other examples include:  o Targeted youth work that sees considerable work to prevent young people’s homelessness and proactive approaches to resolve and reconcile issues with young people and families or carers.  o The preventing family breakdown pod- DfE funded Innovation project to support families who are in crisis.  o The learning from this review being considered and reflected in the current re-commissioning of Public Health 0-19 nursing services.  5.8.8 Whilst the service developments described represent welcome progress, nevertheless they do not yet fully capture learning from this review, and Child W’s experiences of service provision. There remains a need for the local partnership to come together to more fundamentally review arrangements, to ensure that the benefits of a fully integrated approach are maximised.  5.8.9 As the SCR process developed, it became clear that the learning implied a need to review the whole system of help and support to vulnerable young people. This learning, which is captured in section 4.10 of the report, was formulated into a recommendation made in March 2015 to the HSCB in advance of the completion of the review. The review of the system of support of vulnerable young people has been initiated by the Hull Children, Young People and Families Board which will oversee the development of a framework for services.    56 5.8.10 The review will take a ‘whole system’ approach, reflecting changes that have already been made in working with younger children and families locally in re-designing the system of social care and early help and promoting a systemic practice model in working with vulnerable young people.  5.8.11 It will provide a comprehensive overview of services which will take into account current and ongoing work to transform, remodel and improve services for vulnerable young people and their families. Critically, the review will engage closely with vulnerable young people ensuring that their views and experiences will help to shape service provision, so that the value-base, ‘feel’ and accessibility which Child W often experienced is reflected in future design.  5.8.12 All of the key learning from this review will be reflected in the new framework. The HSCB will monitor the progress of the review, to assure itself that it is being undertaken and that the final outcome captures relevant learning. It is anticipated that the review will be concluded by 30th June 2016. . Recommendation 8: That Hull’s Children, Young People and Families Board (HCYPFB) undertakes a comprehensive review of provision for vulnerable young people in Hull, and develops a framework for working with them    By: 30th June 2016   Recommendation 9: That Hull Safeguarding Children Board seeks assurances that the learning highlighted by this review is embedded within the new framework.   Recommendation 10: That Hull Safeguarding Children Board reviews its threshold of needs guidance as it relates specifically to teenagers, as part of the development of a new framework for this work locally.  By: 30th September 2016              57  Appendix 1:   Members of the Serious Case Review Panel:  The Serious Case Review panel for this case, comprised members of the HSCB Serious Case Review Sub-Committee, as follows:   Paul Dyson, HSCB Independent Chair (Chair of Panel)  Neil Colthup, HSCB Manager  Manager, Hull Safeguarding Adults Board  City Safe and Early Intervention Manager, Children, Young People & Families Service, Hull City Council  Designated Nurse for Safeguarding Children, NHS Hull Clinical Commissioning Group  Head of National Probation Service, Humberside (Hull and East Riding Local Delivery Unit)  City Safeguarding Children Manager, Children, Young People & Families Service, Hull City Council  Project Coordinator, East Riding Voluntary Action Services  Designated Doctor for Safeguarding Children, NHS Hull Clinical Commissioning Group  Chief Superintendent, Humberside Police  Cathy Eccersley, Child Death Review Coordinator, HSCB  HSCB Professional Practice Officers                     58  Appendix 2:   Brief Description of Services  Hostel 1  (between July-November 2013)  Hostel 1 comprised of 3 shared flats, each with two bedrooms, a shared living area, kitchen, toilet and bathroom. Child W had her own room with a lockable door. All other services were shared. The service provided bedding and towels, an iron, vacuum cleaner, tumble drier, television, DVD player and a communal lounge. Residents prepared and purchased their own food. The conditions of occupancy were via a licence agreement. At the time, the length of stay in the hostel was aimed at being approximately ten days.  The service was managed by a Client Services Manager. The staff team comprised three support staff and three night staff. The manager was supervised by a Business Contract Manager. The hostel was staffed 24 hours a day, supported by an on call system which could arrange additional back-up cover. There is no legislative framework governing staffing levels in hostels.  The hostel operated a link worker system and had the capacity to provide one to one support for clients. Staff provided housing related support, but relied on referral to external agencies to access more specialist support, such as counselling or in relation to substance misuse issues.   Hostel 2 (August-November 2013)   Hostel 2 is one of three in Hull managed by a local project. The manager of this hostel has responsibility for two of the three hostels. . The staff team comprises of 13 full-time and three part-time staff working across the three sites.  The hostel mission statement describes a facility which provides “temporary board and lodgings in homely surroundings and provides support and assistance to residents in enabling them to find or regain their place in mainstream society”. Its vision is to “identify residents’ needs, build self-esteem, listen, consult, advise, encourage, counsel and support. The project will provide a warm, secure, comfortable and homely environment”.  The criteria for admission (in July 2013) were ‘medium to low dependency’. The hostel has 12 single bedded units. Child W had her own bedroom with a lockable door. All other facilities were shared. Residents were provided with cooked food. The conditions of occupancy were via a Licence Agreement and Resettlement Contract. At the time, the length of stay in the hostel could be up to 18 months.   59  All residents were allocated a link worker and had a ‘risk management plan’. Link worker sessions took place every three weeks and formed a support plan known as ‘Star Links’. The support plan was reviewed every three months.   The staffing complement within the project allowed for only one member of staff to be on duty at any one time, giving a 1:12 ratio of staff to young people.   Children and Young People’s Services (Hull City Council)  A number of different teams and services are referred to at various times. For the period from 2011-2013, these included:  The Central Duty Team (CDT)   This was the single point of contact/referral for children at risk of significant harm. The team undertook initial assessments in respect of referrals, before transferring children and families to Locality Social Work Teams, where longer term social work support was assessed as being needed.  Emergency Duty Team (EDT)   The EDT was the point of contact with Children’s Social Care outside of normal office hours.  Locality Social Work Teams   There were three locality Social Work Teams. These teams provided social work help and support to children subject to Child Protection Plans, Children in Need and to children who were looked after where no permanency decision had yet been reached.  Integrated Looked After Children (ILAC) Team   This team provided social work help and support to children who were looked after in the long term. The team was also responsible for recruiting and supporting local foster carers and for managing local children’s homes.  The Adoption Team   This team provided a range of adoption services: assessment of adoptive parents; matching children with adoptive parents; providing post-adoption support.  Community Support Teams (CST)   There was a CST linked to each locality social work team. The role of the CST’s was to provide help and support to children and families where there was need but the need did not meet the threshold for social work support.  Marlborough Family Support Team   This is a team which works flexibly, including out of hours, to provide support to families to prevent breakdown which   60 would necessitate children becoming looked after. The team is able to access/provide short break and respite looked after placements as part of packages of family support.  Targeted Youth Support (TYS)  Targeted Youth Support (TYS) provides early interventions and crisis support to young people (aged 16 -18) and families. The Access and Support Team provides a universally accessible duty service. The Housing Options Team provides housing advice and support                                            61  Appendix 3:  List of Main Abbreviations  Barnsley MDC  Barnsley Metropolitan District Council  CAMHS  Child and Adolescent Mental Health Services  CDT   Central Duty Team  CSC   Children’s Social Care  CSE   Child Sexual Exploitation  CST   Community Support Team  EDT   Emergency Duty Team  HSCB   Hull Safeguarding Children Board  ILAC   Integrated Looked After Children Team  LAC   Looked After Child  LSCB   Local Safeguarding Children Board  NSPCC  National Society for the Prevention of Cruelty to Children  SCR   Serious Case Review  TYS   Targeted Youth Support (Service)  VWO   Vulnerable Witness Officer    