Suicide by hanging of a 15-year-old girl at her school in June 2013. Child T and her siblings were the subject of child protection plans in Greenwich and Lewisham. Family had a history of: domestic violence, sexual abuse, parental neglect, regular house moves and changes of mother's partners. Child T moved in with her maternal grandmother in mid 2010, after which point children's social care involvement ceased, until an incident shortly before her death when she was assaulted by an uncle. Child T disclosed self-harm to teachers, including two overdoses, leading to support from the school's pastoral and counselling services. She was referred to child and adolescent mental health services shortly before her death. Uses the SCIE Learning Together method. Poses questions for the Local Safeguarding Children Board to consider including: whether professionals are uniformly well equipped to understand and respond to self-harming behaviour in adolescents; whether there is a tendency for professionals, especially when under pressure, to respond to immediate safeguarding concerns whilst failing to recognise the significance of historical abuse; and whether the referrals process is robust enough to predict and offset likely human error in data recording. Also considers the need for support for professionals after a tragic incident, in this case the impact on school staff.
      
 Title:  Serious case review: Child T: Overview report. LSCB: Greenwich Safeguarding Children Board Author: Sally Trench, Fran Pearson Date of publication: 2016  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1  Greenwich Safeguarding Children Board  Serious Case Review  Child T           Authors:   Sally Trench and Fran Pearson SCIE Learning Together Lead Reviewers    June 2014          2 This Serious Case Review ( SCR)  looked at the final three years of Child T’s life and made a number of recommendations in relation to how professionals working with young people can better understand some of the issues that can lead to self-harm and suicide. There has been a delay in publishing this review as we have been awaiting the inquest into Child T’s death and to ensure that if there were any other issues arising from the inquest that this could be used to inform further lessons to be learnt. This delay does not mean that the recommendations from the review have not been acted upon and changes made.    At the inquest into her death the Coroner concluded that Child T had committed suicide. She found that there had not been any failings by the agencies involved with Child T leading up to her death that had caused or contributed in any way to the suicide. The coroner also found that Child T had been appropriately responded to and well supported by professionals working with her. She further acknowledged that through the Serious Care Review and other individual agencies’ reviews there had been intensive investigation into the situation and therefore did not find it necessary to duplicate this work by making additional recommendations. The SCR and the inquest both concluded that Child T’s death was not preventable.  The Greenwich Safeguarding Children Board (GSCB)  will continue to raise awareness of deliberate self-harm and monitor the response of agencies to this to ensure that young people, like Child T get the best possible support and help.        Nicky Pace  Independent Chair GSCB  18th February 2016                  3 Contents Title Page Introduction  4 Why the case is being reviewed  4 Succinct summary of case 4   Family composition  5 Time frame  6 Organisational learning and improvement  6 Methodology  6 Reviewing expertise and independence  7 Methodological comment and limitations  8 The Findings  11 - 33 Introduction  11 What is it about this case which makes it act as a window on practice more widely?  11 Appraisal of professional practice in this case: a synopsis  12 Finding 1   19 Finding 2   26 Finding 3   29 Learning additional to the Findings  32   Conclusion  33 References  35 Appendix 1: Acronyms and Terminology  36 Appendix 2: The Learning Together model and process  37  4 Introduction  1. Why this case was reviewed 1.1 Child T was a 15-year old girl who committed suicide by hanging at her school in June 2013.  Greenwich Safeguarding Children Board (GSCB) determined to conduct a Serious Case Review (SCR) because the criteria for undertaking a review of this nature had been met:     (a) abuse or neglect of a child is known or suspected; and  (b) (i) the child has died; ... and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  (Working Together to Safeguard Children, 2013:68)  The guidance states further that an LSCB should always undertake a Serious Case Review to examine the actions of professionals or agencies involved and identify any learning that can be shared and implemented.    2.    Summary of the case 2.1      Child T came from a large family, whose life was characterised by continual moves around London and elsewhere in the country.  Her early years were disrupted not only by these moves, but by her mother’s changing partners, and the chronic sexual abuse she suffered from her two older male siblings, beginning at a very young age and continuing for several years.  Child and Adolescent Mental Health Services (CAMHS) were offered and taken up briefly at this point. Social care agencies were involved with the family over two decades, in relation to domestic violence, neglectful care and sexual abuse in the wider family, across and within generational groups.  As a result, T and her siblings were made the subject of Child Protection (CP) Plans in both Greenwich and Lewisham.   2.2  At the age of 11, T ran away from her mother’s care, and chose to live instead with her maternal grandmother and an aunt who was in her early 20s, and thus not many years older than T.  From that point, T had little contact with her mother, although parental responsibility remained with her, or her siblings.  Child T’s safety being assured at this time, she was no longer subject of a CP Plan, nor was there any further involvement from Children’s Social Care (CSC) after mid-2010.  2.3 T’s life in her grandmother’s home was very different, by being both more caring and more structured:  for example, her aunt told T that she was expected to attend school 100% of the time and T was determined to achieve this.  She herself wanted her life to change, and for there ‘to be a new T’.  This was successful, in that her first years of secondary schooling were  5 settled, and T was able to make impressive progress in both her academic studies and to enjoy and excel at creative subjects, especially music.    2.4      The descriptions of T by school staff and by her grandmother and aunt were very similar.  All who knew her felt she was a “‘very, very special girl”, an “amazing”’ young woman, talented and bright.  Her aunt said that, “whatever she put her mind to, she would go above and beyond to achieve it, and would often be amazing at it”.  Aunt described T as ”caring, kind and considerate – the most selfless person she had ever known”.  This was echoed by what school staff told us, that T was universally popular and indeed loved throughout the school community.      2.5 In Year 10 however, T’s progress began to falter, and she became increasingly distressed and unable to cope with her life.  Home had become less happy with the arrival of an uncle, not many years older than T who was described by T’s aunt as controlling and aggressive towards all members of the household.  T was beginning to tell some trusted people at school about her previous experiences of abuse, and about her growing level of self-harm (severe cutting and two instances of self-poisoning), but she remained very guarded about her suicidal intentions.    2.6 During Year 10, T was supported by the school’s pastoral and (latterly) counselling services, and at the time of her death she had just become an out-patient of the local Child and Adolescent Mental Health Service (CAMHS) in Greenwich.  2.7 Shortly before her death, T was attacked and verbally abused at home by her uncle.  He was removed by police, and left the country.  It is the view of her family, in retrospect, that although T was already depressed, this incident was the trigger for her suicide.         3.    Family Composition Family member in T’s household Child T (subject) Maternal Grandmother Maternal aunt Maternal uncle (in the household for the past few months only)  In separate household Mother Stepfather Sibling 3  Sibling 4  Two more siblings live elsewhere   6    4.    Time frame 4.1     This SCR examines professional practice with T and her family over nearly three years, between the point at which Greenwich CSC received notification that MGM and T had moved back into the borough, and her death.    5.    Organisational learning and improvement 5.1 Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including SCRs, states:  ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements that are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.’ (Working Together, 2013:66)   5.2    The GSCB identified that the SCR of this tragic case held the potential to shed light on particular areas of practice:    How well do all services, including schools and CAMHS, respond to the numbers of children and young people with deliberate self-harm and suicidal ideation?  How good are we at assessing and responding to risk for young people where there has been a previous suicide attempt and/or a disclosed history of sexual abuse (CSA)?   Should there be a wider safeguarding network in such cases? Were there services missing for this young person which should have been involved? Had they been asked to be involved?  How well supported was the school in their caring for Child T?  6.    Methodology 6.1 This review was conducted using the Social Care Institute for Excellence’s (SCIE) Learning Together methodology (Fish, Munro & Bairstow 2008). Learning Together reviews seek to understand professional practice in context; the review identifies the factors in the system that influence the nature and quality of work with families.  Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively.  To help all readers, a glossary (of acronyms and terminology) is provided as Appendix 1 of this report.  Details of the model and this process are contained in Appendix 2 of this report.   7    7.   Reviewing expertise and independence Lead Reviewers  7.1  The SCR has been led by two people independent of the case under review and of the organisations whose actions are being reviewed.  Sally Trench and Fran Pearson are both accredited to carry out SCIE reviews, and have extensive experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework in Working Together, 2010.  Neither has any previous involvement with this case.  Neither has any previous or current relationship with Greenwich Council or partner agencies, apart from the fact that Sally Trench was the overview author for a previous Greenwich SCR.     7.2 The lead reviewers have received supervision from SCIE as is standard for Learning Together accredited reviewers. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence.    Review Team  7.3      The Review Team is comprised of senior managers from the agencies involved in the case, who have themselves had no direct part in the conduct of the case.  Led by independent Lead Reviewers, they act as a panel working together throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings.  They are also a source of data in themselves, about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints, changes in structure, etc.     The Review Team members also have responsibility for supporting and enabling members of their agency to take part in the case review.  The Review Team were:    Manager, GSCB  Named Nurse Safeguarding Children, Oxleas NHS Foundation Trust   Senior Child Protection Officer, Academy Schools Trust  Reviewing Officer, Specialist Crime Review Group SC&O 21(2)   Head of Service, Greenwich CAMHS  Safeguarding and Partnerships Leader, Greenwich CSC  Named Nurse, Safeguarding Children Lewisham and Greenwich NHS Trust   Named GP, Lewisham Case Group 7.4 The Case Group is comprised of the professionals who were involved in some way with Child T and her family.  By attending meetings and taking part in  8 individual ‘conversations’ with members of the Review Team, they provide the data about the case: what happened, how, why, what were the contributory factors affecting their work and their view of Child T and her family?  The Case Group contribute to the working out of this material, and to the analysis of what aspects of the case are part of wider patterns, which affect the work of agencies more generally. To elicit their involvement in this case, members of the Review Team held individual conversations with the Case Group professionals. The Case Group also attended two multi-agency meetings to contribute to the analysis and findings from the Review Team and Lead Reviewers.   The people who took part as members of the Case Group were:    Principal, School  Assistant Principal, School  School Counsellor  Two teachers  Pastoral Manager, School  GP  CAMHS Social Worker  CAMHS Psychiatric Registrar  CAMHS Consultant Psychiatrist  Two Team Managers, Children’s Social Care  Consultant Paediatrician  Emergency Department Nurse  8.   Methodological comment and limitations The scope of the SCR 8.1      Child T’s large family were known to universal and targeted services, including CSC, for most of her early life (until her move to live with MGM).  It appears that she and her siblings experienced persistent neglectful care and abuse, exposure to domestic violence, a changing population of fathers/stepfathers, and continual moves – with the consequence that their education was badly affected.  Child T and her two younger siblings were sexually abused over a long period by her two older brothers.  8.2  In the immediate aftermath of Child T’s death, action was taken to safeguard and promote the welfare of the remaining children in the family, and exploration of agency records prompted a number of questions about this history and how risks to the children were handled in the past, not just in Greenwich but in a number of local authorities.  The SCR process thus had to start with a decision about what was the appropriate time frame and focus of the SCR and it was agreed by the SCR Panel that the period to be reviewed was the last three years of Child T’s life, or when she moved back into the Greenwich area.      9  8.3 The unique purpose of a systems review is how it analyses current arrangements and practice, so that changes can be made to improve services now and in the future.  This report has thus focused on the recent period of Child T living with her grandmother in Greenwich, and examines the work of Greenwich agencies during that time.  It acknowledges that the family history is of critical importance in understanding T’s breakdown and suicide.  However, it was decided by the GSCB that it would not be appropriate to try to trawl back further in time, an exercise which would potentially cover two decades and an unknown number of local authorities.  Personnel, policies and procedures, and legal frameworks have all changed during those years, so that there would be limited relevance for those who are currently involved in safeguarding children.   The timing of the SCR 8.4 There is often a balance to be struck at the outset of a Serious Case Review between unnecessary delay in commencing the process and the capacity of staff to participate to the best of their ability following the death of a child.  All staff were affected by T’s death and school staff particularly so because they arguably knew her best.  This did impact upon their ability to reflect more objectively on circumstances at the time and in retrospect, this process would have benefited from a slightly later start.   Family involvement  8.5 Child T’s grandmother and mother were informed about this SCR.     8.6 As in traditional SCRs, family members are normally invited to participate in the SCIE Learning Together process by meeting with the Lead Reviewers.  In this case, this offer had to be postponed, because of other legal processes involving family members.   8.7 After the completion of court proceedings, individual letters were sent to Child T’s mother, grandmother and aunt, inviting them to meet with the Lead Reviewers and giving them an opportunity to provide their perspective on the work that was carried out with them and with Child T during the last three years of her life.   8.8 In the event, only T’s Grandmother and Aunt were able to take up this offer.  We are very grateful for their willingness to meet with the Lead Reviewers.  This was likely to have been especially testing for them, as one of the meetings coincided with the anniversary month of Child T’s death.   We would want to thank them for their valuable contributions and providing the Review with their personal insights of Child T as well as giving us their experiences of the professionals’ involvement with Child T.   8.9 It should be noted that the family’s personal views and information about services received were not available for the work of the Review Team and the  10 Case Group, during their analysis of material for this report.  This final version of the report (November 2015) now has their views woven into relevant sections.  We have also included at various points their descriptions of Child T, for whom they had been the primary carers for several years, and whom they loved dearly.    The absence of the Police from the Case Group  8.10 The Independent Police Complaints Commission carried out an investigation in this case.  This was triggered automatically, in the circumstances of a sudden and unexpected death occurring within a certain number of days of a Police officer having had contact with a victim.  This affected the participation of Police officers in this case review.  There was a Police representative in the Review Team, but not in the Case Group.    The absence of the School Nurse from the Case Group 8.11 The School Nurse was not involved until later in the review process since she was no longer working in the school and, at the outset, believed not to be contactable.  When contact was made, one of the Lead Reviewers was able to meet with and talk to her, so her perspective has been included although she was not part of the group process.      11 The Findings   What light has this case review shed on the reliability of our systems to keep children safe?  9.   Introduction 9.1   A case review plays an important part in efforts to achieve a safer child protection system.  To maximise the likelihood of organisational and individual change it is necessary to understand what happened and why in a particular case and then to go further and reflect on what this reveals about deficits and vulnerabilities in the child protection system more broadly.  The particular case acts as a “window on the system” (Vincent 2004). 9.2 Case Review findings therefore need to say something more about the local area/agencies and their usual patterns of working.  Findings exist in the present and potentially impact in the future.  They can also be expressed indicatively, as questions, if the evidence base for the prevalence of an issue is not clear but the Finding itself is agreed to be valid. 9.3 In order to help identify the nature of a Finding and thereby assist the LSCB to focus remedial action to a particular part of the child protection system, the Learning Together model uses 6 broad systems patterns:  Innate human biases (cognitive & emotional)  Family –professional interaction  Responses to incidents  Longer term work  Tools  Management systems 9.4 It is not an expectation that every pattern will feature in a review and there is overlap between them.  The Findings, however, critically highlight for the GSCB how effective the child protection system was at the time of Child T’s death.  For a more detailed explanation about how Findings are constructed, see Appendix 2.  10.  What is it about this case which makes it act as a ‘window on the system’? 10.1  The most fundamental learning from this case concerns the challenges which face all professionals when working with young people who self-harm, where the degree to which they are vulnerable may not always be obvious.  There is an associated lesson around the need to appreciate the relevance of more historical records or information, where harmful or abusive actions may remain hidden, and there may be no obvious immediate concern.     12 10.2 The numbers of adolescents who deliberately self-harm are growing in many areas, including Greenwich and neighbouring authorities.  Agencies and individual professionals are searching for how to manage these levels of need and how to work together better to help and protect these young people.  The universal settings most affected by this phenomenon are schools. 11.   Appraisal of professional practice in this case: a synopsis  11.1 Those who knew and worked with Child T were committed to doing their best for her and consistently prioritised her wellbeing.  They were thoughtful about her and her family circumstances, even if they did not know all the details of these.  Among those who knew her best (the school staff), however, there were some untested assumptions about T’s care and insufficient understanding about the level of risk to her emotional wellbeing and her safety, especially during the period (mid-Year 10) when her self-harming began to increase in severity.  After her first overdose (April 2013), she commenced twice-weekly sessions with the school Counsellor, but was not referred to specialist mental health provision for a further month, until after her second overdose.  At that point, the appropriate range of agencies became involved in trying to support and safeguard T.   11.2  Sadly, the discovery of T’s farewell letters found after her death, show that she was determined to end her life.  The Review Team is unable to state categorically that this might have been prevented by other actions or decisions; we simply cannot know. 11.3 This case was untypical of many which are the subject of a SCR: until very late in the time frame reviewed, there was no multi-agency network working with Child T and her family.  This was in contrast to Child T’s early childhood, when she had suffered long-term abuse and neglectful care, and when CSC and partners in various local authorities (due to frequent family moves) were involved.  11.4 In the past three years, the professionals who knew Child T and her family remained largely unaware of her history of abuse. She was a child with “invisible, interior wounds”1 similar to many others who suffer from post-traumatic stress disorder (PTSD). The Review Team asked the question: what might one expect for a child with a history of serious and prolonged sexual and emotional abuse who had had limited  therapeutic input to deal with these experiences?  As it emerged in this story, there was an unknown degree of harm to Child T’s emotional well-being and her ability to grow into a healthy young woman.  This lack of awareness of T’s persistent and underlying distress was true for her close family as well.                                                       1 Charlotte Higgins, ‘The Road Home’, The Guardian 30th November 2013  13  The family’s return to Greenwich  11.5 At the beginning point of this case review, Greenwich CSC were informed of T and MGM’s move back into Greenwich by Lewisham CSC.  The letter of notification from Lewisham made a brief reference to T’s troubled history and to previous CP Plans, but went on to state that T was now ‘happy and settled’ with her grandmother.    11.6 The Review Team have been unable to explain why the letter, dated April 2010, was not received by fax in Greenwich until July 2010, despite checking with Lewisham.  11.7 Although T’s current and previous surnames were both supplied in Lewisham’s letter (given as, e.g., ‘Smith/Jones’), an administrative error was made at the point of uploading this information onto CSC’s electronic database, Frameworki, when only her current surname was recorded.  Consequently a search was conducted against one name only, and thus, T’s (and her family’s) extensive history with Greenwich CSC was not discovered and read, as would normally be expected as part of determining what kind of response to make.  The Review Team do not consider that this error had an impact on the outcome of later events but the likelihood that errors such as this will be made is a vulnerability in the system which is explored further in Finding 3.    11.8 The CSC Contact & Referral Team telephoned the family home and spoke to T’s aunt (not to the young person), who reported that they did not need social work help.    11.9  T’s school were aware of her extra needs as a pupil whose primary education had been severely disrupted by the family’s continual moves.  But her needs as a child with severe psychological damage were not fully known at this point. Finding 2 deals with these circumstances: how, in secondary schools, CP records may not be reliably received from primary schools, and may not be proactively used as a tool for supporting pupils in need or at risk of harm.    11.10 When T arrived in Year 7, her academic attainment was very poor, and she was described as ‘semi-literate’.  The school are rightly proud of how they enabled T to learn and achieve very highly in her academic work, and to develop her enjoyment of expressive activities such as music. The school became a haven, where she felt comfortable and safe with other pupils and staff.  On many levels, the school did an outstanding job for T.    11.11  This view of the school’s work with T was echoed by her grandmother and aunt, who praised staff for supporting T to flourish in all aspects of school life, and to achieve excellent exam results – including, poignantly top scores in her science GCSE exams, published after her death.  Grandmother and aunt felt that the response to T in Year 10, when pastoral and counselling staff  14 became involved, was appropriate and more likely to succeed (than a referral to another agency) because of T’s attachment to known figures.   11.12  Things gradually changed for T in Year 10, a time of greater academic pressures and expectations on her (and all pupils).  Staff noted that her good standards of work were slipping, and that she was no longer coping in the way she had hitherto.  She began to rely very heavily on the attention and support of two young teachers, one of whom had taught her and had also been her Learning Mentor.  Their professional boundaries with T – including the amount of their time she regularly absorbed – were increasingly tested.  This resulted in a close relationship between the pupil and the teachers. T was over reliant and too emotionally attached to her teachers, and they did not always maintain a distinct professional distance.     11.13 These are circumstances which, to varying degrees, can and do arise in schools and other settings.  But T’s dependence on and attachment to these two teachers were extreme, as was the amount of time she spent with them.  The teachers did not recognise that the degree to which they were taking personal responsibility for T was concerning; they did not flag this up with senior staff, nor was it noticed by anyone else until late in the school year, when T’s self-harming behaviour escalated.  At that point, the Assistant Principal (the Child Protection Lead in the school) and later the Principal, when he became involved, took decisive action to protect the teachers, and to relieve them of the sense of responsibility they felt towards Child T.  To a degree, this plan succeeded, though it did not prove possible to remove the teachers’ ongoing feelings of distress and anxiety about their pupil, for whom they had developed a strong sense of personal responsibility, as well as affection.   11.14 In the second half of the year, T revealed to these two teachers and to her Pastoral Manager that she had been self-harming by cutting herself, all over her body.   The Assistant Principal then convened a meeting to which T’s grandmother and aunt were invited.  Grandmother recalled being shocked to be told that children who self-harm by cutting are advised about the importance of using sterile materials.  (The Review Team were told that this was included in the staff training on responding to DSH, and indeed it features as advice widely available online, about how to deal with children or young people who are cutting themselves, alongside a suggestion ‘not to express shock or disapproval’.)  Later, Grandmother was advised by the CAMHS team about removing sharp objects entirely from T’s environment, something which seemed more relevant to her.      11.15 From this point, the Pastoral Manager for T’s year group became a more regular link for T, whom she could access when she felt the need for ‘time out’, and as the person who dressed her cuts when they became severe.  This was a clear opportunity to refer for more specialist help, and the fact that the school did not do so is an indicator that they underestimated the seriousness  15 of what they were looking at.  Finding 1 explores professional (mis)understanding of self-harming in greater detail.  11.16  The Pastoral Manager did make a referral to the School Counsellor, because of concerns about both T’s declining school performance, and her self-cutting.  T started seeing the Counsellor in April 2013, but did not disclose the increasing severity of her self-harm.  It is still not completely clear to the Review Team why this information was not shared, nor why there were no regular meetings of those involved in supporting T within the school.  The Pastoral Manager understood from this point onwards that T’s self-harm was being dealt with by the Counsellor, whom she saw as more qualified than she was to assess how to respond to T’s behaviour.   11.17  There is evidence that T valued her twice-weekly school counselling sessions,  but also evidence that she remained guarded about many aspects of her distress, the degree of her self-harm, and her intentions of suicide. A referral to the School Nursing Service, at the very least, should have been made at the point when T’s self-cutting was first discovered; and certainly, an urgent referral to the School Nurse or directly to a specialist mental health service such as CAMHS was needed when T’s degree of self-harming required her to have her wounds dressed by the Pastoral Manager.  There was a clear, presenting need and information was not appropriately shared at this point.        11.18  In this period (between January and May 2013), the regular School Nurse was on planned absence, and although cover was available, this did not involve the regular presence of a well-known individual in the school, as a resource for both pupils and staff colleagues.  In T’s case, there seems to have been no use made of the School Nursing Service at all, either to be involved in meetings about T, or to make an assessment of her emotional state and the possible need for a referral for a mental health assessment.    11.19  As T’s apparent level of distress grew, it became more difficult for teachers, support staff, and senior management in the school to find a consistent way to respond to her, as well as to share information about what was happening for her.    11.20  It is concerning that the school did not make a referral to or seek advice from specialist adolescent mental health services, in what was emerging as a complex mental health condition.  The time frame for such action was relatively short, with the deteriorating situation becoming clearer in early spring.   But, as  already noted above, discussion with a specialist was essential at the point when T’s cutting became severe, and extended to all parts of her body.  This was the responsibility of those with a ‘duty of care’ towards her and something that a School Nurse, had they been consulted, would almost certainly have done, in line with due process.  NICE guidance is helpful and clear about T’s needs at this point:    16 ‘All people who have self-harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.’ (2004:64)  11.21  There is an overlap here with Finding 2, as a clearer understanding of T’s history of abuse and neglect in early childhood might have assisted the school in comprehending the origins of T’s distress and the importance of making a referral for specialist help.    First overdose 11.22  At the end of a school day, T told the two teachers about her overdose of 8 Paracetamol tablets, adding that ‘Pastoral’ had telephoned NHS Direct and had been advised that this amount was ‘within her daily limit’ – the implication being that no specialist medical service was required.   The teachers looked after T, whilst contacting the Assistant Principal, who informed T’s grandmother about what had happened.   11.23  In the course of this case review, it has emerged that the Principal, the Assistant Principal, and all other interested parties believed that NHS Direct had been contacted by someone in the school, and that they had given advice that it was safe for T not to have medical attention on that day.  It has come to light over the course of this Review that this was assumption rather than fact. NHS Direct have no record of any contact and no-one in the school can remember calling them.  11.24 T’s first description of the number of pills she had taken was later revealed to be lower (by at least half) than the real picture.  This was a mental health crisis for T and the fact that she was not assessed at this point by any medical professional was another missed opportunity.  Despite the confusion about advice from NHS Direct, it was the school’s duty of care to have immediately arranged for T to be taken to A&E.  School staff did contact T’s grandmother, and requested that T be taken to her GP, and this was agreed.  11.25 The School Nurse was clear when spoken to as part of this Review that, had she been there and known of this overdose, she would have ensured that this would happen – that any young person in such circumstances would be taken to hospital in order to receive the appropriate attention.  This action is in line with NICE guidance, which states: “Refer to an emergency department urgently unless you are sure this isn’t necessary.” (2012:8)  11.26  T’s second overdose (again disclosed to a teacher) did result in decisive and appropriate action by the school.  T was sent to hospital in an ambulance, and was seen by medical staff and then was assessed by a member of the CAMHS team.  The assessment specifically addressed the issue of whether there was an ‘immediate risk of suicide’, and whether T needed to be  17 detained in hospital under a section of the Mental Health Act 1989.  The decision was that this threshold had not been met, and a ‘safety plan’ was agreed between the CAMHS team, Grandmother and T prior to her discharge home from hospital.  This plan included a number of immediate, follow-up meetings with T by the CAMHS team.  A link was also made by that team with T’s grandmother, to support her to monitor the ongoing risk of self-harm within their home.  This was good practice, and in line with NICE guidance regarding the treatment of young people who self-poison (2004:66-67).    11.27   In conversation with T’s grandmother for this case review, she reflected that she felt that T should have been detained in hospital (‘sectioned’) at this juncture.  She now feels that this would have been “the only thing that could have stopped T from taking her life.”    11.28  The Review Team has been unable to establish whether T was physically examined in hospital in a way that would have revealed how she was cutting herself all over her body, increasingly severely.  This was not documented in the notes of the Emergency Doctor who initially saw Child T, and he is no longer available to be asked about this.  Although she was admitted because of an overdose, the Review Team are of the view that this more holistic kind of physical examination would have better informed an assessment of risk.   11.29   A final point about the actions following T’s admission to hospital: a discharge notice of this episode was sent from the hospital Paediatric Liaison Officer to the School Nurse via her individual work email.  In the absence of the SN, who was still on leave, this meant that an urgent notice was not picked up in a timely way.   It is not known whether an ‘out of office’ message was triggered or whether this contained any re-routing instructions due to annual leave and even if it had, such messaging would not continue to recur over a longer period. This is an example of the kind of routine practice to which everyone is prone, particularly where professional relationships are well established. It is deserving of some thought in terms of guidance to staff around notifications and the different priorities that may need to be attached to these.   11.30   The CAMHS Team were involved for the last 3 weeks of T’s life, and appropriately met with T herself, and liaised frequently with family members and other professionals, especially the School Counsellor.  Their discussions continued to address the level of ‘chronic risk’ of self-harm which CAMHS believed to be present for T.  Both T’s Counsellor and family members were given information about how to remain alert and keep T as safe as possible, while therapeutic input could be put in place.  It is clear from the records that these discussions were held on a regular basis.        11.31   Despite this, it has emerged that some members of the school community and family members now feel critical of mental health services for either “not finding out how bad T was” and/or not “telling them that T was suicidal”.   18 This may reflect a real difficulty in how aspects of high risk are communicated by mental health professionals, and how they are understood, not just by lay persons/family members, but also by professionals such as school staff.    11.32   As part of trying to understand more about why T had overdosed, the SW in the CAMHS team tried to retrieve background information from Lewisham CSC, understanding that T’s history was a critical factor in her degree of disturbance.  In contributing to this case review, the psychiatrists  referred to very young victims of sexual abuse as being likely to “retain a deep and negative sense of their worth”, and this sadly seems to have been true for T, despite all the progress she had made and the warm and close relationships she had developed as a young teenager.     11.33   In her return-to-work week, the School Nurse was alerted to T’s second overdose (by the hospital Paediatric Liaison Officer, not by school managers), and therefore arranged to see her in school.  T met with the School Nurse, but did not want any further help from her, as she was already involved with the School Counsellor and, now, with the CAMHS team.  11.34  In a significant turn of events, it was an ‘incident’ which prompted a referral back into CSC.  This was the physical and verbally abusive attack on T by her young uncle who had been staying in the household for several months.  In response, Borough Police arrested the uncle and held him in custody.  A CAIT officer contacted CSC about this by telephone on the following morning (12/06/12). A Section 47 (formal child protection) investigation could have commenced immediately, but it was agreed between the police officer and the receiving duty worker to await the written referral before the next steps of the investigation.   11.35   The next day (a Thursday), CSC received the Police Merlin report and a faxed school referral about the same incident, but there was no verbal communication to/from the referrers. The administrator as required uploaded the police report and the referral from the school onto the electronic case management system.  When the team manager noted the referrals, later on the following day, she made a risk assessment and judged appropriately, in the context of the incident, that T was not at immediate risk of harm.  She saw that a Section 47 investigation was required, but in the circumstances (T being protected by family members), she decided that this would be followed up on the next working day (after the week-end).  This was a decision made in relation to the presenting information CSC held at the time.   11.36   Despite the continued error on the electronic system about T’s full name and a failure to link her with her previous family records, there was a mention of previous CP concerns in the school’s referral.  The Team Manager appropriately determined to research the history further with Lewisham, as there was clearly an unexplained gap in information about T’s past.     19  11.37   The CP referral was passed on to the Assessment Team on the 3rd working day (Monday) after the initial telephone call from the Police, and there was a further delay for two reasons: 1) CSC attempted to speak to the allocated police officer, who was not available until the following morning; and 2) the most appropriate and skilled worker for the case was not available until the next day to meet with T and her family.   To wait one day for the right person to be allocated and to visit was an appropriate decision to make at the time, as there was no current risk from the uncle, and no known immediate risk from further self-harm.  Sadly, T died before a meeting took place.   11.38   It would be an inappropriate use of hindsight to conclude that different decisions or other courses of action would have stopped T from taking her life, notwithstanding the fact that opportunities to bring in skilled professional support were not taken in a timely way. There was strong evidence that T wished to keep her final intention secret, and that her suicide was planned, and tragically, was something that she wished for.       Findings in detail  Each of the review Findings are laid out applying the Learning Together ‘anatomy’ (see Appendix 2), which names the fundamental issue and why it matters, seeking also to understand the degree to which the issue might be replicated throughout the multi-agency child protection system.   Where evidence for replication requires further exploration and corroboration by the LSCB the Findings are expressed indicatively, as questions.  12.   Finding 1:  Professionals are not uniformly well enough equipped to understand self-harming behaviour, meaning that the response they offer is unlikely to be either confident or consistent.   12.1  This review has explored what may get in the way of more effective collaboration across agencies about responding to DSH, whether via consultation, referrals for individual children, or advisory input to staff.  It particularly questions the baseline understanding in schools, where staff have more contact with young people than any other setting, yet perhaps do not have the professional skills and experience to know how to respond to a young person who is self-harming, beyond what might be basic guidelines (e.g., not to react in a shocked manner).  The emotional impact on teachers and other staff can be powerful and distressing. However, the issue is not likely to be exclusive to schools: typically, much self-harming behaviour is kept secret, but there are many more young people in recent years who do disclose DSH to staff at school, in other youth settings, to GPs, and elsewhere.  One of the messages from the participants in this case review is  20 also that numbers of young people with DSH are rising locally. There is also a noticeable trend being reflected on a national basis.    12.2  The need for improvement in recognition and effective response is becoming more urgent in the face of a significant increase in recent years of numbers of young people who self-harm.  It is possible too that this may, perversely, inhibit referrals to specialist services such as CAMHS.  The argument is that the numbers are too great to be able to refer them all – perhaps with the assumption that many referrals would fail.   12.3  Elsewhere, in all settings, there is pressure on resources and service provision which will inevitably affect how well episodes of DSH are managed, when they come to light.  Added to this is the awareness that a significant proportion of self-cutting remains hidden from professionals in all settings.   How did the issue feature in this particular case? 12.4  The issue highlighted by this Finding is manifested most clearly in the way that the school in this case for a long time managed T’s behaviour itself, in full knowledge that she was self-harming, rather than seek the support of other agencies or make a referral for specialist help.  They did not appear to equate her behaviour with suicidal ideation nor did they see it as a safeguarding issue which warranted specialist intervention.  This led the Review Team to question whether there was sufficient awareness generally of thresholds for upward referral, but a more fundamental issue may be the lack of understanding that safeguarding thresholds apply to self-harming behaviour.  12.5  Child T gradually disclosed to school staff her self-cutting, which became more severe over time.  Near the end of her life, she took two overdoses.  School staff were clear that concerns and information about T were to be shared with the Designated CP Lead (the Assistant Principal), who together with the Pastoral Manager and the Counsellor was planning and monitoring how the school dealt with T.  The School Nursing Service was not consulted about T’s self-cutting even when the Pastoral Manager was dressing her wounds for her.  An earlier assessment for a mental health referral, which would be part of this service’s area of expertise and responsibility, was not apparently considered or sought, nor was any advice sought from a social worker.  It was only when T took a second overdose that she was sent to hospital and then received a mental health assessment, including her level of risk of further self-harm.  From this point, there was helpful communication between school and T’s CAMHS social worker.  12.6  An important and associated issue in the school was the degree to which two young teachers were drawn into befriending and supporting T, as well as worrying about her and going several ‘extra miles’ to try to help her.  This was not well picked up by the school, although measures were put in place latterly to try to restore appropriate working boundaries.  Research evidence  21 suggests that complex circumstances, such as a young person self-harming, can be overwhelming and anxiety-provoking for teaching staff, of any age and experience.  They may, for example, struggle to go against the wishes of a young person – in this case, one who was afraid of being ‘locked up’ in a mental hospital.    12.7  Responsibility for T was therefore ‘held’ by the school beyond an appropriate threshold for too long.  There were no timely discussions with any child mental health specialists about how T’s difficulties were being approached and managed, nor did the school, as Lead Professional, attempt to co-ordinate a multi-agency assessment to address T’s wider support needs.  The level of T’s self-harming behaviour became sufficiently concerning to warrant consideration of a referral to Children’s Social Care as well as to CAMHS, but this was not done, even on a level of advice seeking. (NOTE: This review found that the relevant staff in T’s academy did not know about the CSC Consultation Line which is available for informal discussion and this has now been remedied.)  Family members (Grandmother and Aunt) were involved in a school meeting, but there is evidence from our interviews with them that they, like school staff, remained uncertain in their  understanding of T’s self-harming behaviour (cutting and overdoses).  This is an area where mental health specialists can and should be helpful, by addressing the need to explain simply and communicate clearly and effectively with the young person, non-specialist professionals, and family members.       12.8  T’s school does have a policy for responding to DSH, which is not widely known to all members of staff, including the Counsellor and Pastoral Manager, and is therefore not being well used.  However, school staff did understand that any incident of harm which came to their notice should be reported directly to the CP Lead, and this guidance was followed.  But the need for a referral of T onwards to specialist services was not understood or acted upon in a timely manner and the case was not appropriately referred until the most senior member of the school became involved (and then, as the result of T’s second overdose).      How do we know it is not peculiar to this case? 12.9  The Review Team came to the view that the responses to T were not unique in this school, and unlikely to be unique in other schools and other settings.  There are a number of reasons for this.  Emotional impact of DSH 12.10 Given the typical age of onset of DSH, teachers in secondary schools are often the first professional to become aware of a child or young person’s self-harming.  This is likely to create not only uncertainty about what to do, but other very difficult emotions.  Best (2005), in looking at pastoral care in education, noted the following in relation to responses to deliberate self-harm:   22 “There is also evidence that many teachers are in fact ill-prepared to manage such emotionally distressing situations, expressing feelings of ‘sorrow, alarm, panic, anxiety, and shock…” (2005:7)  These reactions may be additionally complicated by pleas from a young person to keep the behaviour secret – either from other professionals or from his/her family.  The complexity of confidentiality guidelines is another area which affects professionals in schools and in health settings.   Knowledge and confidence about what to do 12.11  The Review Team were told that there is a DSH policy in the school, but two important members of staff were not aware of this: the Pastoral Manager and the school Counsellor.  Their decision-making about what information to share and when to make referrals (including among themselves) was not always clear, so that, for example, the increasing severity of T’s self-cutting was not known to all members of the small group who were involved with her care.    12.12  For many other children and young people, their self-cutting is more superficial than in T’s case, and this spectrum may add to uncertainty about what to do and when for this growing group.    12.13 This review has suggested that there is also a need for clear and consistent guidance for professionals in various settings – though, perhaps most relevantly in secondary schools – regarding what to do for the victim in cases of self-poisoning.  This should include, for example, that the young person should automatically be taken to a hospital A&E department, where the relevant forensic tests could be carried out, alongside a psychiatric assessment.  Guidance such as this would relieve staff of the difficult responsibility of assessing and then deciding what to do with the young person (as after Child T’s first overdose), in a highly-charged emotional situation.   Uncertainty about when to refer to specialist services? 12.14 This case has demonstrated that appropriate and timely referrals to specialist services are not always made.  The Principal of the academy and the Review Team member representing education (from another secondary academy) suggested another factor: the amount of DSH in the school – ’30 to 50 per year’ in T’s school.  It would not be possible, they suggested, to refer all of these pupils to CAMHS.  But, how do they decide which children are at greater risk and do need referrals?  12.15 Research briefings on this subject (SCIE, 2005, NSPCC, 2009, and NICE, 2011) suggest that the School Nurse has a key role in determining what is appropriate for a young person: counselling within the school, or a complex mental health assessment by CAMHS.  The SN has the advantage of close links with other parts of the Health service, and of professional supervision to  23 guide her in such assessments.  In addition, he/she can bring an overview and a sense of balance, from working in other schools and other pupil populations.    12.16 A school or academy with a lower level of SN time (the minimum provision is 1 or 1.5 days per week, depending on the size of the school) will find it harder to get this essential input.  Might this, along with no regular CAMHS support, contribute to a culture within schools which is slower to seek advice from, or make referrals to, outside agencies?    What numbers of cases are affected, and how widespread is the pattern: local, regional, national? 12.17 Rising numbers of children and adolescents who self-harm are creating ‘pressure on services and affecting the assessment and treatment of self-harm episodes’ (SCIE:8).  This is a pattern which affects all areas of the country.     Locally 12.18  Referrals for all CAMHS ‘self-harm emergencies’ in Greenwich and neighbouring boroughs Bexley and Bromley are predicted to have risen by an average of 32% in the year 2012/13.  Other London LSCBs are noting similar increases, and are focusing on training and guidance for staff (e.g., Ealing, Harrow, Hillingdon).  The SCIE briefing paper suggests why this is essential:    12.19  Given that a history of DSH, especially repeated episodes, is a significant risk factor for suicide,   “It is…important to be able to recognise self-harm amongst children and adolescents and the risk factors associated with these actions. Social care, health and education professionals may all be involved in identifying and managing self-harm among children and adolescents.” (SCIE:5) The London Safeguarding Children Board are responding to this growing area of concern across London, with the establishment of a working group to develop a multi-agency protocol about how to respond to deliberate self-harm in children and young people.  Greenwich’s Safeguarding and Partnerships Officer is a member of this group, and has also been a member of the Review Team for this SCR. Nationally                                                                                                  12.20  Suicide is the main cause of death in adolescents in this country, but different parts of the UK show significant variations in the trends for suicide among young people.2  Similarly, the prevalence of DSH among adolescents is high,                                                  2 Over the last 30 years the number of suicides among 15 to 19 year olds has decreased in England and Wales whereas it has increased significantly (by 315 per cent) in Northern Ireland. In Scotland, the five-year average rate in 2011 was 77 per cent higher than 1984, but the rate has been on a downward trend since 2003. For 10 to 14 year olds the rate has remained relatively stable in England and Wales, has increased in Scotland (though has  24 and there are indications that it is rising steeply.  In the past year, DSH as a reason for contacting ChildLine jumped by 41% (= 13,500 more young people).  This was the largest year-on-year increase among the top 5 reasons for young people to contact ChildLine.  These referrals have risen steadily since the mid-90s.    12.21 The NSPCC research briefing gives figures for the incidence of DSH from different studies, ranging between 1/15 to 1/10. It also includes some startling figures for responses to anonymised surveys, with rates far higher than this (up to 70% - CASE Study, 2005).  Much of self-harming remains hidden, so anonymised surveys are an important source of evidence about prevalence.    What are the implications for the reliability of the multi-agency Child Protection system? 12.22  There is a large amount of research evidence available to help professionals in all agencies respond more effectively to children with DSH.  It is important, in particular, for key staff to access and understand the evidence which reflects higher levels of risk – e.g., the link between overdoses and suicide, and persistent DSH and suicide (SCIE, 2005).   12.23  In the context of an apparent rise in the incidence of DSH, professionals need to work together more effectively so that in all settings there is an appropriate, consistent and well-informed response to situations of risk.  Otherwise, harmful behaviour in children and young people will continue to occur without adequate protective interventions, including early multi-agency collaboration, and timely referrals to specialist services in circumstances of greater risk.   12.24 Greenwich CSC have done a great deal of work on improving multi-agency communication and collaboration, so that an increasing number of children receive early help.  There is a local Prevention Strategy, with key themes around building resilience, prevention and protection, which is well understood by most agencies and professionals.  A Consultation Line for professionals to talk to social workers about cases without having to make a referral has been in place for some time.  CAMHS have provided a ‘pathway’ document to guide and support appropriate consultations and referrals.  All these developments demonstrate a commitment to improve the flow of multi-agency collaboration.  In addition, there has been highly positive feedback to a recent GSCB survey, asking agencies whether they are confident about when and how to make referrals to partner agencies.  Whether this groundwork is sufficiently strong to support an improved                                                                                                                                             decreased in the last three years) and has increased significantly (by 221 per cent) in Northern Ireland. In 2011, the five-year average rate for 15 to 19 year olds was 157.2 per million in Northern Ireland, 108.9 per million in Scotland and 36.8 per million in England and Wales. For 10 to 14 year olds, the five-year average rate in 2011 was 18 per million in Northern Ireland, 6.7 per million in Scotland and 1.7 per million in England and Wales. (NSPCC, How Safe Are Our Children?, 2013)  25 recognition and response specific to DSH is a question for the GSCB to determine.      Finding 1: Professionals are not uniformly well enough equipped to understand self-harming behaviour, meaning that the response they offer is unlikely to be either confident or consistent. This is compounded by the significant and rising numbers of children who self-harm.   Numbers of children who self-harm are increasing.  Those who do it to a level requiring admission to hospital are recorded in public health statistics relating to ‘non-accidental injury’.  There are many more who might not require hospitalisation but for whom self-harm has become a routine way of coping with anxiety.  Harm is more often than not hidden.  It is not easy to distinguish between self-harm as an extreme coping mechanism and self-harm as an indication that someone is failing to cope.  The trajectory between self-harm and suicide does not come with an easy-to-follow or inevitable roadmap.  Given that it is not likely to be possible to provide every child who thinks about and/or acts out self-harming behaviour with immediate or consistent access to specialist support, it is vital that professionals who are not specialists are helped to understand and work with it. If not, the more routine support that is provided to vulnerable children will not necessarily be timely or helpful and in more extreme cases may unknowingly make matters worse.   Questions and issues for the Board and member agencies to consider  Does the Board agree that this Finding is important?  How much is known about the growth of DSH and the different ways in which it may manifest itself, both locally and in the London region?   How might the Board assure itself that there is a good level of awareness in universal services of thresholds and pathways for specialist support, specifically in relation to DSH?  What kind of interventions and longer term support might be most effective in working with young people who self-harm?  Which agencies could usefully be involved in discussions in relation to this?  Has the direct experience and feedback from young people who self-harm ever been sought?  How might the Board support staff, particularly in secondary schools where this issue is likely to arise most often?  Is there evidence to support the suggestion that the growing number of young people who self-harm is deterring school staff from referring to CAMHS?    How can the Board make best use of the knowledge of specialist services to raise the awareness of self-harming among other professional groups?   Is there a way to assess, and if necessary challenge, how well local schools are using appropriate specialist resources for pupils with DSH?  Can the Board establish (and promote) what is ‘working well’ where there are regular links between CAMHS and schools?   26  How can the Board promote better awareness of the CSC Consultation Line, as a means of supporting appropriate referrals?  How will the Board assure itself that understanding of the nature of self-harm has improved and there is a greater consistency of response to children and young people?  13.   Finding 2:  Is there a tendency for professionals, especially when under pressure, to react only to immediate safeguarding concerns, risking the invisibility to the system of vulnerabilities due to historical abuse?  13.1  The review has found that, despite there being extensive records about this young person and her history of prolonged abuse within her family, this critical information remained unaccessed by the agencies who were involved with her.  The information existed, but it was not explored. This meant that the level of her vulnerability was invisible, and when she began to break down, there was no fully-informed response to her behaviour.   13.2 We have expressed the Finding as indicative because the degree to which it is widespread is unclear.  It was manifested in this case within the school but the tendency illustrated by this Finding is a systems vulnerability for any organisation, particularly at the point when an initial assessment of risk is made.  The need to know and understand the child’s personal history is critical in every case, but especially those where the harm to the child was severe and prolonged, and has remained unresolved.  These are circumstances associated with higher risks of serious self-harm and suicide (NSPCC, 2009)    How did the issue feature in this particular case?  13.3 In her first year at secondary school, T was still on a CP Plan in Lewisham, though this ended shortly when she began living with her grandmother.  This meant that there was a CP file in the school, and at that time, a school representative would have been invited to CP Conferences for T.  Thus, it seems likely that her CP file was ‘live’ at that time, and known to at least the CP Lead in the school, if not others.  Once T was no longer subject of a CP Plan, the file ceased to be active.    13.4  The school changed its status (twice) in the next two years and the new senior management team were not aware of the contents of the CP file.  The file was not proactively sought out until after T’s death.  These records contained extensive descriptions of the abuse and neglect which T experienced throughout her early childhood, and therefore would have shed light on T’s needs and her level of vulnerability, both at home and at school, further strengthening the argument to seek specialist support.    13.5  When information about Child T came to Greenwich CSC in July 2010, this did not indicate current CP concerns although it flagged T’s history of traumatic  27 and severe sexual abuse within her family. These were followed up in a ‘checking’ telephone call with a member of the household and reasonably not considered to constitute a current or pressing need at the time, but, unlike the system within the school, the existence of prior history was flagged in the notification and its importance thereby acknowledged.    How do we know it is not peculiar to this case? 13.6  The Review Team recognised the tendency to react to the immediate rather than give full consideration to previous history to be a vulnerability, especially at times when volumes of cases are high and/or when people are more busy than usual, making it less likely that the links between current presentation of clients or patients, and their previous history, will be properly considered by professionals.  There are a number of factors that compound this:  a)        ‘History fades’ very easily.  Personnel change in all agencies, and there may be no one around anymore with direct knowledge of the family members or the case history.  This being so, systems need some kind of alert to remind a service of ‘invisible’ difficulties, and links among large extended families – for example, a flag on a system to show that a child is vulnerable or a visible note on a pupil’s school record to show the existence and whereabouts of a child protection file.       b)         Chronologies are a key tool for social workers in accessing complex histories and recognising patterns of behaviour.  However chronologies are not consistently created and used which makes it more difficult to understand how the past is affecting the children and to inform what needs to happen to safeguard and promote the child’s welfare.   c)        The ‘here and now’ picture of cases has greater impact on the response of agencies, and reassurance about current events can be persuasive. In addition, presenting incidents tend to elicit a positive response in more cases than ongoing concerns, even when these are possibly linked to past abuse.  13.7     In addition, the Review Team noted a ‘lack of curiosity’ which can result in not trying to find out whether a child was previously known when they come to notice and investigating that to inform an assessment of need in the present.  The same issue applies to the fact that a CP record for a child in a school may not be known to senior school managers, especially if they were not in post when the child, and his/her CP file, arrived in the school.  Rather than proactively identifying and reading all CP files as a preventative measure, this case suggests that the records may not be consulted unless an issue precipitates this.  Pressure of workload and/or assumptions as to the reasons for particular behaviours are likely to have an inhibiting effect on this professional curiosity.   28  What numbers of cases are affected, and how widespread is the pattern: local, regional, national? 13.8  The Review Team saw the factors listed above as generalisable across the country.  They are not peculiar to local agencies, and they apply to the significant number of families whose complex vulnerabilities and problems persist, or re-emerge, over time.  The issue has been highlighted before in research pulling together issues that surface in Serious Case Reviews, particularly in relation to the recognition and response to chronic neglect.  If practice is appropriately child-focussed, a natural question to ask is whether there is any more information available that would help to determine whether  a child is safe.  13.9  Secondary schools receive high volumes of pupils transferring in each year – sometimes not in a timely way.  However, not all pupils have a CP record, in addition to their academic ‘school’ record, so it should be feasible for this smaller number of records to at least be known to the CP Lead in a school.    13.10  The issue is also a potential vulnerability within CSC and or MASH systems for processing referrals through the front door, in the context of a service which receives roughly 8,000 contacts/referrals per year.  At times of high incoming work, there will inevitably have to be some prioritisation in terms of which referrals are subjected to the most complete background research.  The process of selection, again inevitably, is likely to focus on those with the higher immediate presenting need.   A high volume of referrals is a continuous reality in Greenwich and this, in combination with the movement of families across and between authority areas, makes for complex on the spot decision-making.    What are the implications for the reliability of the multi-agency Child Protection system? 13.11  There are a number of inherent challenges for agencies in retaining an awareness of longstanding and complex family histories.  It may prove even harder in families where sexual abuse of children is endemic, but remains largely secret.  Achieving a better long-term awareness is not easy, but nor is it impossible, if the importance of the history is understood, and the records are accessible.    13.12  This case has shown how a known past history of abuse can go unnoticed over time, and how the ongoing vulnerability of a child can remain hidden. The implications are that the risks of various kinds of behaviour – including self-harm or abuse towards others – are poorly understood and left unaddressed.        29 Finding 2:  Is there a tendency for professionals, especially when under pressure, to react only to immediate safeguarding concerns, risking the invisibility to the system of vulnerabilities due to historical abuse?  An initial assessment of risk is key to determining what happens next in terms of levels of professional support and/or statutory intervention.  In pressurised conditions, this assessment can become a binary decision: is this child at immediate risk of harm, or not? Clearly, there are shades of vulnerability in between these – for example, the presence of ongoing emotional support needs resulting from prior experiences of abuse. These needs not only impact on a young person’s current wellbeing, but also make them vulnerable to more serious harm in the future.    An effective assessment and ‘triage’ system should be able to identify and respond to these intermediate levels of need, for example by advising referral to higher or lower tier services as appropriate. Where this does not occur, young people with longstanding vulnerability, but not immediately high levels of risk, may not receive the support they need to prevent worsening need and protect them from more serious harm.    Questions and considerations for the Board - Does the Board recognise this finding to have been an issue at the time?  Is still an issue? - Have there been any previous efforts to tackle it and how assured is the Board that these have been effective? - How might the CP element of records held by schools be made more accessible and their transfer more timely? - How might schools assure themselves that pupils’ CP records have been reviewed/, the implications of their content understood and that the necessary communication has taken place with other professionals? - How can schools develop systems for achieving this, especially when senior managers change?  - Are current arrangements for triage of incoming CSC referrals fit for purpose in the context of this finding?    14.  Finding 3:   Is the process for oversight of CSC referral and response robust enough to predict and offset the likelihood and impact of human error in data recording?  14.1 It is inevitable and therefore predictable that people will make the odd error when inputting data into a database, particularly when the task is so routine that concentration lapses and/or when otherwise distracted or under pressure.  This human susceptibility is not such a problem if organisations have mechanisms in place to be able to detect errors in a timely way.  30  How did the issue feature in this particular case?   14.2  The letter from Lewisham informing Greenwich that T was moving back into the borough contained two surnames for T, clearly designated as such.   The administrator logging the details onto the CSC electronic record noted one surname only.  Led by this, the manager did not identify that there was a duplicate record, although the Lewisham letter made it clear that the family were previously known to Greenwich.  This meant that the existing extensive personal and family records for T were not linked to the new referral. The agreed process is that all names should be checked.   14.3 When the CP referrals were received from the police and the school in June 2013, following an attack on T by her young uncle, T’s family history was again not flagged up on the system.  This time, the Duty Manager did query this gap, since the referrals mentioned a history of abuse.  She determined to follow this up with Lewisham.  The relevant records were found, in Greenwich, after T’s death.    How do we know it is not peculiar to this case? 14.4  This Finding is expressed as indicative because we do not have the firm evidence to point to other examples of errors being made, both in the specific context of the CSC front door or in equivalent triage settings within health, education, police or other organisations.  It is named because it can be evidenced in this case and because of the likelihood of its occurrence elsewhere.  14.5 It is also possible that the management oversight of work at the point of entry can be affected by the manner in which a referral is made.  There are different processes for responding to referrals depending on whether they are made by telephone or in writing.  Had a telephone referral been made (in addition to the written referral) by the school, it would have been responded to by a social worker on the same day. There are more social workers to pick up telephone referrals or people calling into the office than there are managers to handle the volume of written notifications and written referrals. There is potential for a busy manager receiving a high volume of incoming notifications and written referrals not to notice if the detail in the referral does not quite match what has been recorded on the electronic system.  14.6  The Review Team were told about why a written referral may be preferred to a telephone conversation, although it is important to stress that this factor was not an issue in this case.  Multi-agency colleagues in the Case Group spoke about their common difficulty when trying to make a referral to Greenwich CSC via the front-door contact centre.  Frequently, their attempts failed.  The telephone line is significantly over-busy, and, in their experience, it is not unusual for a call to be cut off after waiting for some time to be connected to the relevant team.  This creates a potential barrier for multi- 31 agency working at the critical point of referral and makes it more rather than less likely that a referral will end up being made in writing. The Council collect data about the efficiency of their front-door telephone system, and these are generally positive; however, this conflicts with the ‘lived experience’ of those who took part in this case review (including the results of recent ‘mystery shopping’).   14.7  The CSC Consultation Line, in contrast, provides straightforward access to this service, and is very well used by multi-agency partners.  The fact that it was not known to key staff in the school in this case (Pastoral Manager and Counsellor) suggests that more work is needed to promote and maintain awareness of the service.   14.8 Informally and outside agreed procedures, an administrator will sometimes immediately alert a busy Team leader to a written referral that they feel needs immediate attention, but this cannot be relied upon.  It is more likely that ‘informal’ processes will be resorted to at times of high pressure/high demand and more necessary therefore that there is sufficient management oversight to pick up any errors of judgement and/or recording resulting from this approach.  What numbers of cases are affected, and how widespread is the pattern: local, regional, national?  14.9  It is widely known that databases are only as good as the data you put in them.  This is true for electronic systems in use across agencies and services around the country.    14.10  The majority if not all contacts and referrals are uploaded onto electronic systems now in every public-facing organisation.  The likelihood that an uploading error will at times be made, combined with the probability of distraction under different types of pressure – time, volume, task, personal – is a challenge for the system.  What are the implications for the reliability of the multi-agency Child Protection system?  14.11  A combination of a predictable human error in uploading data, and a lack of rigour in interrogating databases, means that important information about children is not always retrieved.  The consequence of errors in these early steps is that critical information about a child or family remains unavailable for making appropriate responses to their needs and risks. Errors are more likely to be made when people are working under high pressure.  The capacity of management to monitor contacts/referrals, especially when these are written rather than verbal, is a critical factor in ensuring accuracy and timeliness in picking up urgent child protection concerns.   32  Finding 3: Is the process for oversight of CSC referral and response robust enough to predict and offset the likely impact of high volumes of incoming work and to be able to consistently pick up predictable human error?  Human error is entirely predictable in the context of data-inputting, and electronic systems are designed in ways to make them more or less proficient in helping to reduce its likelihood.  Error is also more likely at times when volume of work is particularly high.  Both these factors are intrinsic to ‘front door processes’ for receiving referrals and as such, the management oversight of the process should be able to a) predict how errors may happen; b) expect that they are more likely when the system is under pressure; and c) contingency-plan different means by which incoming work can be overseen so that the consequence of an error made at this early stage does not then impact unnecessarily on professional assessment and decision-making.  Questions and issues for the Board and member agencies to consider  - Does the Board recognise this as a real or potential issue, in relation to CSC first response processes and more widely? - What kind of oversight is routinely provided in relation to administrative functions at the front door? - Is the Board assured that these work well enough when the ‘system’ is under pressure? - What might be getting in the way of effectively addressing the issue? - How might the Board be assured that the issue has been addressed?    15.  Learning additional to the Findings  15.1   Support for staff after a tragic incident The brave participation of staff in this case review, so soon after the death of Child T, made the Review Team acutely aware of the impact it had had on many individuals, in various settings.   15.2 School staff inevitably had the most difficult experience, especially since T’s suicide happened on the school site, and her farewell letters were addressed to the people she knew there.  We learned that the school had arranged for the offer of immediate and ongoing counselling support from an independent source, which was undoubtedly a compassionate and appropriate action.  This was made available to pupils and staff in all areas of the school, and several types of counselling were offered, bespoke to the needs of staff.  For example, a religious counsellor was offered to a member of staff with strong religious beliefs.  What we found surprising was that, of the six members of the Case Group who took part in conversations and the Workshop Day, none  33 had used this service.  And yet, there was evidence of the ways in which T’s death continued to trouble and affect them.  15.3 This led us to thinking about a different approach, which ensured that agency leaders and staff would ‘model’ the use of a counselling service, so that it became an expected way to respond.  Through a member of the Review Team, we heard about how an emergency fire service has a regular structure in place for debriefing fire officers after an incident, both in a group and as individuals.  It is expected that the group will participate in this.   15.4 The Review Team also learned that, in other non-school settings, even where there had been little or no personal contact with Child T, some professionals experienced considerable shock and upset about what had happened, and anxiety about how well they had carried out their professional task and whether they would be blamed in any way.  We found that the needs of these less involved staff had not been recognised and some had been left without support or advice.  16.5 Can the GSCB assist in any way – by helping agencies to:  avoid assumptions about who will need support/help;  think about the needs of ‘leaders’ and senior managers, who may feel they have to be ‘strong’ for others, and who may not get enough help themselves for their own recovery; and   ensure there is pro-active support for the agencies most clearly and directly affected, with the expectation that staff will access help?  16.  Conclusion   16.1  All Serious Case Reviews are required to report and learn from what happened in a particular child or family’s story.  This systems review has also tried to move beyond what happened to Child T, in order to analyse how well Greenwich safeguarding systems are working more generally, and how they might be improved.     16.2 The principal learning from this review has focused on the issues of working with children and adolescents who deliberately self-harm.  This work poses complex challenges for the wide range of professionals involved with these young people, most of whom are not specialists in this field and who need considerable support and clear guidance in order to respond effectively.    16.3  The incidence of DSH continues to grow locally and elsewhere, and the circumstances like those of Child T will inevitably be repeated – in a number of settings, but principally in secondary schools.  It is hoped that the GSCB will find this review useful in considering ways to support multi-agency collaboration in this complex and distressing area of work, especially for school colleagues.     34 16.4 The story of Child T remains at the heart of this Serious Case Review.  It became clear after her death, from the messages that she left, that she was no longer able to carry on living, and that she was determined to keep the intention of suicide secret from her family and from the school staff who knew her best.  She was effective in this, in that professionals and family members alike have spoken of ‘a huge shock when T died’.     16.5 It has not been possible to conclude that T’s death was preventable.  There were missed opportunities which could have led to a more coordinated effort to evaluate further risk of self-harm.  This in turn may have enabled a more informed and joint effort to manage Child T’s growing distress which could have helped to keep her safer.  However, this too is only a hypothesis, born of the wishes of hindsight.  We can point to what other appropriate help might have been offered to T, but we cannot with any certainty say that the outcome would have been different.      35 References   Best, R. (2005) Self-harm: A Challenge for Pastoral Care. Pastoral Care in Education, 23 (3), 3-11  Child and Adolescent Self-harm in Europe (CASE) study, 2005  Childline helpline statistics, 15/11/13   Community Care, “Community Care survey exposes how rising thresholds are leaving children in danger”, 20th November 2013  Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009  Higgins, C., ‘The Road Home’, The Guardian, 30th November 2013  London Child Protection Procedures, London Safeguarding Children      Board, 2010  NICE, CG16, Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care, 2004  NICE, CG16 (as above), Quick Reference Guide, 2012  NSPCC, How Safe Are Our Children?, 2013  NSPCC, Young people who self-harm: Implications for public health practitioners, March 2009  SCIE Research briefing 16: Deliberate self-harm (DSH) among children and adolescents: who is at risk and how is it recognised?, 2005   Working Together to Safeguard Children, Department for Education, 2013   36 Appendix 1  Acronyms and Terminology  ACAN Adolescents with Complex and Additional Needs Team (within Greenwich CAMHS)   CG Case Group CAIT Child Abuse Investigation Team (Metropolitan Police) CAMHS Child and Adolescent Mental Health Services CASE study Child and Adolescent Self-harm in Europe study, completed in 2005.  A 7-year international research project funded by the European Commission Daphne Programme and coordinated by the National Children’s Bureau. CP Child Protection ED Emergency Department (hospital) EIT Early Intervention Team (from CAMHS) GP General Practitioner/family doctor GSCB Greenwich Safeguarding Children Board  HV Health Visitor LSCB Local Safeguarding Children’s Board  LT Learning Together (model for case review) NSPCC National Society for the Prevention of Cruelty to Children PTSD Post-traumatic stress disorder SCIE Social Care Institute for Excellence SCR Serious Case Review  SN School Nurse SW Social Worker RT Review Team TAMHS Targeted Mental Health Services for schools WT Working Together to Safeguard Children, 2013 National statutory guidance for multi-agency safeguarding children    37 Appendix 2   The Learning Together model and process of this SCR  1.  This SCR has used the SCIE Learning Together (LT) model for case reviews. This is a ‘systems’ approach which provides a theory and method for understanding why good and poor practice occur, in order to identify effective supports and solutions that go beyond a single case.  Initially used as a method for conducting accident investigations in other high risk areas of work, such as aviation, it was taken up in Health agencies, and from 2006, was developed for use in case reviews of multi-agency safeguarding and CP work (Munro, 2005; Fish et al, 2009).  National guidance in the 2013 revision of Working Together to Safeguard Children (2013) now requires LSCBs to use systems principles in carrying out SCRs.      2. The LT model is distinctive in its approach to understanding professional practice in context; it does this by identifying the factors in the system that influence the nature and quality of work with families.  Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively.   3.  LT is a multi-agency model, which enables the safeguarding work of all agencies to be reviewed and analysed in a partnership context. Thus, many of the findings relate to multi-agency working.  However, some systems findings can and do emerge which relate to an individual agency.  Where this is the case, the finding makes that explicit.    4.  The basic principles – the ‘methodological heart’ – of the LT model – are described in summary form below:   a.  Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time (the ‘view from the tunnel’).  What was influencing and guiding their work? b. Provide adequate explanations – appraise and explain decisions, actions, in-actions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it c.  Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what bolsters and what hinders the reliability of the multi-agency CP system.  d. Produce findings and questions for the Board to consider. Pre-set recommendations may be suitable for problems for which the solutions are known, but are less helpful for puzzles that present more difficult conundrums.   38 e.  Bonus principle: use of qualitative research techniques to underpin rigour and  reliability.  5.  Typology of underlying patterns  5.1 To identify the findings, the Review Team has used the SCIE typology of underlying patterns of interaction in the way that local CP systems are functioning.  Do they support good quality work or make it less likely that individual professionals and their agencies can work together effectively?   They are presented in six broad categories of underlying issues:  1. Multi-agency working in response to incidents and crises 2. Multi-agency working in longer term work 3. Human reasoning: cognitive and emotional biases 4. Family – Professional interaction 5. Tools 6. Management systems Each finding is listed under the appropriate category, although some could potentially fit under more than one category.   5.2   Anatomy of a finding For each finding, the report is structured to present a clear account of:  How the issue features in the particular case?  In what way it is an underlying issue – not a quirk of the particular individuals involved and in the particular constellation of the case?  What information is there about how widespread a problem this is perceived to be locally, or data about its prevalence nationally?  How the issue is usefully framed for the LSCB to consider relative to their aims and responsibilities, the risk and reliability of multi-agency systems. This is illustrated below in the Anatomy of a LT finding.   