Death of a 14-year-old boy in August 2015 by having climbed a tree and got his neck caught in a rope that was hanging in the tree. He had been accompanied by a care worker from the children's home who was at ground level when Callum died. Callum and younger sibling were taken into foster care in March 2013, but because of violence and aggression between them, Callum was placed in a children's home in June 2013 where he stayed until his death. He was big for his age but his emotional and behavioural development was that of a much younger child. There were several risk assessments in place including one which specified he should not climb trees, fences or other obstacles because he had no regard for his personal safety. Ethnicity or nationality is not stated. Learning includes: to identify improvements in the assessment of risk and how this can be implemented through effective risk management plans; to identify whether there are improvements to supervision and management that would ensure better management of risky behaviours; to consider whether all aspects of Callum's care and behaviour were brought together to comprehensively appreciate his needs and how to manage them. Recommendations: for Local Authority children's homes to design and implement processes in which risk assessments can be developed with relevant partners and family members where appropriate; for Emergency Services to establish a best practice approach to working at suicide incidents; for school nurses to document any knowledge of a child attending A&E and share that knowledge with other relevant health professionals.
      
 Title:  Serious case review concerning Callum Garland: overview report. LSCB: Leeds Safeguarding Children Board Author: Peter Ward Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Overview Report – Child B April 2018      Page 1 of 45                                 Leeds Safeguarding Children Board  Serious Case Review concerning Callum Garland  Overview Report   April 2018        Author: Peter Ward     Overview Report – Child B April 2018      Page 2 of 45  Independent Chair’s Overview of the Serious Case Review Commissioned by the LSCB following the death of Callum Garland.  This Serious Case Review relating to the tragic death of Callum Garland was the very first ‘serious incident’ to come across my desk on taking up my role as Independent Chair of the Leeds Safeguarding Children Board. From the outset the circumstances of Callum’s death stood out as especially heart-breaking, and I am aware that whilst this has been incomprehensibly difficult for all concerned, this must be especially so for Callum’s family and all those who loved him, and my sincere personal condolences go out  to all those affected by the death of this young man. Serious Case Reviews give an opportunity for careful consideration to be given to circumstances where things have gone wrong, so that we can all better understand what happened, why it happened and use what we learn from tragedies such as this to make sure that we do better in future. If at all possible I would like to think that what we learn from Callum’s death will help to ensure that something like this is now less likely to happen again, which perhaps will be of some limited succour for his family.  What we learn from the review very clearly is that whilst the risk assessment for Callum fully addressed his propensity for climbing, and that this was known to everyone who worked with him, that this element of the risk assessment was not followed by Callum’s key worker on the day of his tragic death.   The Review succinctly draws together a number of recommendations for risk assessments and for the process of reviewing looked after young people like Callum. Reflecting on the fact that whilst Callum’s needs were known, and there was agreement about how best to meet them, the actions taken by his key worker on the day he died fell short of what should have been reasonably expected.  What is similarly made clear in the review is that whilst the risk assessment for Callum was detailed and extended to a wide variety of potential situations and circumstance, it cannot be argued  that the risk Callum faced through climbing was somehow ‘lost in the detail’. But rather his attraction to climbing and high places was well known and, as such, should have been taken into account in all circumstances.  I accept without reservation the findings and recommendations of this Serious Case Review, and will ensure that the LSCB requires of the relevant agencies, that they take  steps to ensure that in future,  risk assessments for looked after young people are kept up to date. Moreover that all those working with vulnerable young people like Callum, adhere to the direction of the risk assessment irrespective of their own personal feelings as to whether this is appropriate or not. I Overview Report – Child B April 2018      Page 3 of 45  will remind managers within all agencies providing services to looked-after young people that a regular aspect of staff supervision, should be discussion of individual current risk assessments, the degree to which these reflect evolving individual need and a commitment by all involved to accept and follow the guidance therein without reservation. Furthermore that the process of regular review for looked after children should be purposive, facilitating what is termed in this review   “...a comprehensive appreciation of (young people’s) needs and how to manage them.”  In taking the matters raised by this Serious Case Review forward, I will endeavour to ensure that Callum is not forgotten. This as a mark of respect to both Callum himself and to his family.   Mark Peel Independent Chair LSCP   Overview Report – Child B April 2018      Page 4 of 45  Table of Contents    Page 1. Introduction  5 2. Aims and Objectives  6 3. The Statutory Basis for Conducting a Serious Case Review   7 4. The Review Process  7 5. Summary of Agencies Involved 9  6. Findings and Analysis using the Key Lines of Enquiry   11 7. Identification of Learning using the Aims and Objectives  32    8. Areas Requiring Action  36     Appendices Appendix 1 – Key Lines of Enquiry Appendix 2 – Abbreviations  Appendix 3 – Actions taken by agencies since the death of Callum as reported in agency reports Appendix 4 – Recommendations included within agency reports   Overview Report – Child B April 2018      Page 5 of 45  1. Introduction  1.1 This Serious Case Review concerns Callum Garland who tragically died from hanging in August 2015 whilst on an outing away from the children’s home where he was living.  He was 14 years of age at the time and had been living in the children’s home for a little over two years.  Callum died having climbed a tree and got his neck caught in a rope that was hanging in the tree.  He had been accompanied on the outing by CO5, a care officer from the children’s home, who was at ground level near to the tree when Callum died.    1.2 Callum was born in 2001 and had several older half siblings and a younger sibling.  Leeds Children’s Social Work Service (CSWS) involvement with his mother and her children dates back a number of years.  Callum remained with his mother and younger sibling when his parents’ relationship came to an end.   1.3 Following social care involvement, in March 2013, Callum and his sibling were accommodated on a voluntary basis by the Local Authority and placed with foster carers.  At the first Looked After Children Review a decision was taken that Callum and his sibling should be separated.  This was primarily because of violence and aggression and because of Callum putting himself into risky situations.  Attempts were made to find an alternative foster placement for Callum but despite a national search a suitable place could not be found.  Consequently Callum was placed in a Leeds City Council children’s home in June 2013.  He was made subject to a full Care Order in October 2013 and he remained in the same children’s home until his death in August 2015.  1.4 During the period of 26 months that Callum lived at the children’s home his behaviour fluctuated with periods when he appeared quite settled and others when he exhibited behaviour that challenged those around him.  This included leaving the home without permission, aggression, self-harm and other challenging behaviour.  In addition, he was considered to put himself at risk by climbing.  He was also a victim of bullying and physical assault from other young people living in the home.    1.5 At the time of his death Callum was over six feet tall and weighed in excess of 14 stone.  Therefore he was big for his age.  By contrast, he functioned below the expected level for a young person of his age.  He sometimes acted spontaneously and put himself into risky situations with little thought to his own safety or the potential consequences of his actions.  The children’s home had several risk assessments in place for Callum  one of which specified that he should not climb trees, fences or other obstacles because he had little or no regard for his personal safety.  1.6 Callum enjoyed regular face to face contact with his mother, one of his older siblings and his younger sibling and spoke to his father on the phone.   He wanted to live with his mother and to see his father regularly.  He also had a girlfriend whom he frequently saw with the support of staff from the children’s home and the girl’s mother.  Callum was the youngest resident in the home at the time of his death.  He had close relationships with all the care staff and his relationships with the other young people varied.  He took pride in keeping his bedroom tidy and enjoyed gardening at the home; he also enjoyed singing.  At school, Callum Overview Report – Child B April 2018      Page 6 of 45  appeared to enjoy supporting other children and he had recently received an end of year award from his school.    1.7 On the day of his death, CO5 had accompanied Callum to a play park so he could meet with his girlfriend. On their way back to the children’s home, and despite the aforementioned risk assessment, Callum had climbed up and down a nearby tree a few times.  Later that day, the same member of care staff accompanied Callum to a take away to buy Callum’s tea.  They returned to the tree that Callum had climbed earlier in the day and, after eating his tea, Callum climbed the tree again.  It was whilst he was in the tree on this occasion that Callum tragically died.  1.8 The exact circumstances of Callum’s death will never be known but this review has not seen any information that suggests there were ever indications that he would seriously harm himself or take his own life.  Staff from the children’s home and Callum ’s mother, who spoke to him on the phone shortly before he went to get his tea on the day that he died, were of the view that he had enjoyed seeing his girlfriend that day and was feeling happy.  2. Aims and Objectives  2.1 The aim of this review is to provide a rigorous, objective analysis of what happened in this case and why so that: a. important lessons can be learnt and services improved to reduce the risk of future harm to children; b. Good practice can be shared so that there is a growing understanding of what works well.   2.2 The time frame under examination is from March 2013 (the point when Callum became looked after to Leeds City Council) to the end of August 2015.  2.3 The objectives are: 1. To identify improvements in the assessment of risk, and how this can be implemented through effective risk management plans;  2. To identify whether there are improvements to supervision and management arrangements that would ensure better management of risky behaviours;  3. To identify whether there are training and staff development needs arising from the circumstances of this case;  4. To consider the emergency response and incident management arrangements for all agencies involved with this case and whether these can be improved;  5. To identify whether there are improvements to be made to information sharing processes which could improve care arrangements and the management of risky behaviour; Overview Report – Child B April 2018      Page 7 of 45   6. To consider whether all aspects of Callum’s care and behaviour where brought together and contributed to a comprehensive appreciation of his needs and how to manage them;  7. To consider how learning from this review can inform wider systems learning and improvement of local services and interagency cooperation.   3. The Statutory Basis for Conducting a Serious Case Review  3.1 This review was commissioned by Leeds Safeguarding Children Board on 18 August 2016 in compliance with Regulation 5 of the Local Safeguarding Children Boards (LSCBs) Regulations 2006 which came into effect on 1 April 2006.  Regulation 5 sets out the functions of LSCBs including the requirement for them to undertake reviews of serious cases in specified circumstances.  Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely:   5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.    (2) For the purposes of paragraph (1) (e) a serious case is one where:    (a) abuse or neglect of a child is known or suspected; and    (b) Either — (i) the child has died; or (ii) the child has been seriously harmed 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.  3.2 The relevant guidance for conducting Serious Case Reviews is contained within Chapter 4 of Working Together to Safeguard Children (HM Government 2015).  Leeds Safeguarding Children Board and the Lead Reviewer have followed that guidance in conducting this Serious Case Review.   4. The Review Process  4.1 Chapter 4 of Working Together to Safeguard Children 2015, states that Serious Case Reviews and other case reviews should be conducted in a way which:  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.  Overview Report – Child B April 2018      Page 8 of 45   Makes use of relevant research and case evidence to inform the findings.  4.2 A Serious Case Review Panel with the following membership was established to oversee the review:  Independent Chair;  Independent Lead Reviewer;  Assistant Manager, Leeds Safeguarding Children Board;  Head of Service, Learning for Life, Children’s Services, Leeds City Council;  Head of Integrated Safeguarding Unit, Children’s Services, Leeds City Council;  Deputy Designated Nurse, NHS Leeds Clinical Commissioning Groups Partnership;  Head of Service Safeguarding/Designated Nurse Children Looked After & Care Leavers, Leeds Community Healthcare NHS Trust;  Service Manager, NSPCC;  Chief Inspector, Safer Leeds, West Yorkshire Police.  4.3 Organisations which had been involved with the family between 28 March 2013 when Callum was first accommodated by the local authority and 6 August 2015 when he died were asked to provide chronologies and brief reports of their involvement including relevant background information which pre-dated this time period.  In analysing their involvement the organisations were asked to consider 15 key lines of enquiry agreed by the Serious Case Review Panel (appendix 1).  4.4 Reports were provided by the following organisations:  Barnardo’s;  Leeds City Council Children and Families (Children’s Social Work Service);  Leeds City Council Children and Families (Education);  Leeds Community Healthcare NHS Trust;  Leeds Teaching Hospitals Trust;  NHS Leeds Partnership Clinical Commissioning Group (in respect of GP services);  The National Society for the Prevention of Cruelty to Children (NSPCC);  West Yorkshire Fire and Rescue Service (The Fire Service);  West Yorkshire Police (The Police);  Yorkshire Ambulance Service (The Ambulance Service);   4.5 In addition to the individual agency reports, the Lead Reviewer has had access to documents provided by West Yorkshire Police to the inquest touching the death of Callum, Looked After Children Reviews concerning Callum and Regulation 33 and 44 Reports concerning the children’s home in which Callum lived.  4.6 Chapter 4, paragraph 10 of Working Together to Safeguard Children 2015 lists seven “principles for learning and improvement” that should be applied to all reviews.  One of these is that “professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith”.  In writing their individual reports agencies involved first line managers and practitioners who had been directly involved in providing services to Callum and his family. Towards the end of the review process a ‘learning event’ was held at which relevant practitioners and their managers were able to contribute to the learning from the review and to help develop draft action plans which addressed the reviews findings.   Overview Report – Child B April 2018      Page 9 of 45  4.7 Another principle is that “families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively”.  The Lead Reviewer and the Assistant Manager of Leeds Safeguarding Children Board invited Callum’s mother, father and the older sibling with whom he had regular contact to meet with them.  A meeting took place with Callum’s mother and her comments about her son and the services received are incorporated within this report.  Neither Callum’s father nor sibling responded to the invitation.  4.8 Section 4 of this report addresses the 15 Key Lines of Enquiry (KLoE’s) presenting both facts and analysis relating to the KLoE’s.  KLoE’s 4, 5 and 6 are addressed together due to the extent to which they are interlinked.  Section 5 uses the seven objectives (see Section 2 above) identified by the Serious Case Review Panel to identify the learning from this review.  Section 6 sets out recommendations for action.  5. Summary of agencies involved with Callum    Barnardo’s; 5.1.1 Barnardo’s provided two distinct and specific services to Callum. A therapeutic health worker (THW1) undertook some work with Callum in 2015 and a children’s rights worker from the Children’s Rights Service for Looked After Children visited Callum in June 2015 at Callum’s request in connection with his desire to have contact with his father.    Leeds City Council Children and Families (Children’s Social Work Service); 5.1.2 Callum’s day to day care was provided by staff in the children’s home where he lived.  Of particular note are the Registered Home Manager, referred to as RHM1 throughout this report, Care Officer 1 who was Callum’s keyworker for the majority of the time he lived there and Care Officer 5 who became his keyworker in April 2015.  Care Officers 1 and 5, and other care officers who worker in the home are referred to throughout as CO1, 2, 3 etc.  5.1.3 As a child looked after, Callum had regular Looked After Children Reviews which were chaired by an Independent Reviewing Officer (IRO).  He had three different social workers (SW1, 2 and 3) during the time covered by this review and two team managers (TM1 and 2) managed these social workers.  In addition the Therapeutic Social Work Team and the Co-ordinator for Challenging Behaviour were involved for short periods of time.  Leeds City Council Children and Families (Education); 5.1.4 Callum attended one specialist school until September 2013 and then moved to a different one.  In addition to school staff he had brief contact with an educational psychologist.  Overview Report – Child B April 2018      Page 10 of 45  Leeds Community Healthcare NHS Trust; 5.1.5 One Child Looked After (CLA) Nurse was involved with Callum throughout the time he was a child looked after.  The CLA nurse had contact with Callum from time to time throughout this period in connection with a variety of health issues.  A school nurse also had contact with him.  Callum was also seen by a practitioner from the Child and Adolescent Mental Health Service (CAMHS) in December 2014 after an incident of self-harm.   Leeds Teaching Hospitals Trust; 5.1.6 Callum attended the Emergency Department of Leeds Teaching Hospitals Trust on one occasion in December 2014 after an incident of self-harm.  Callum was taken to the hospital after he died.  NHS Leeds Clinical Commissioning Groups Partnership (in respect of GP services); 5.1.7 Callum was registered with a GP practice whilst living in the children’s home and had occasional appointments with the GP in relation to health issues that are not directly relevant to this review.  The National Society for the Prevention of Cruelty to Children (NSPCC); 5.1.8 Callum made contact with the NSPCC Childline on four occasions in December 2014 and once the following month.     West Yorkshire Fire and Rescue Service (The Fire Service); 5.1.9 The only contact that West Yorkshire Fire and Rescue Service had with Callum was during the incident that led to this review.  West Yorkshire Police (The Police); 5.1.10 West Yorkshire Police had sporadic contact with Callum during his time living at the care home.  They were called to the home in respect of incidents of aggression from Callum, occasions when Callum was a victim of aggression and occasions when Callum had gone missing.  Several different officers were involved in responding to these incidents.  Officers from West Yorkshire Police were also involved during the incident that led to this review.   Yorkshire Ambulance Service (The Ambulance Service); 5.1.11 The only contact that Yorkshire Ambulance Service had with Callum was during the incident that led to this review.    Overview Report – Child B April 2018      Page 11 of 45  6. Findings and Analysis using the Key Lines of Enquiry   1. Critically comment on the efficacy and robustness of the risk assessment arrangements for (a) Callum and (b) vulnerable young people looked after whose behaviour places them at risk of harm.  Risk Assessments at the Children’s Home  6.1 During the time that Callum lived at the children’s home there was a clear system in place within the home for creating, reviewing and sharing risk assessments for all the young people who lived there.  Risk assessments were written on a specific form that was used in all of Leeds City Council’s children’s homes.  All members of the care team at the children’s home Callum lived in were familiar with the risk assessment system and the forms.  6.2 At the time of Callum’s death the children’s home had 18 separate risk assessments in place for him relating to specific, identified risks. In addition there was a risk management plan for when Callum was out in the community and one for when he was in the home.  CSWS advise that 18 is not an unusual number of individual risk assessments for a young person and is not considered to be excessively high.  It is understood that all members of the care team at the children’s home were aware of the risk assessments that related to Callum including the one that related to him climbing.    6.3 Children’s home records for Callum do not detail when risk assessments were reviewed.  When risk assessments were amended the previous version was overwritten and therefore there is no historic record of all risk assessments for an individual resident.  This makes it difficult to track changes in a person’s behaviour or to gauge the efficacy of risk assessments. However, it is recorded in CO5’s supervision of 3 July 2015 that he had reviewed the risk assessments for Callum and these had been signed off by RHM1.  Following Callum’s death, a copy of the risk assessment relating to climbing was given to the Police showing that this had last been modified on 30 July 2015, although the information within it was the same as a version dated 28 April 2015.    6.4 Evidence suggests that the risk assessments were very much an in-house arrangement for the children’s home.  There is no indication that they were considered or referenced during Looked After Children reviews or that other services which were working with Callum were aware of them.  Therefore, there is no sense of a shared view of the risks that Callum faced or of how these should be addressed.  Social Worker (SW) 3 told the Police that she had been made aware that there was a risk assessment in relation to Callum climbing trees but that such assessments are carried out by the children’s home and would not necessitate social work involvement. The School and Child Looked After (CLA) nurse have stated that they were not aware of the risk assessment relating to climbing.  Whilst some of the identified risks may well be quite specific to a young person’s care within the children’s homes it would be appropriate to share others with a wider network of agencies and practitioners or to seek specialist skills of others in Overview Report – Child B April 2018      Page 12 of 45  creating the risk assessments.  Doing so would improve the robustness of the risk assessment arrangements.      6.5 It is the view of the CSWS report author that each risk assessment and the risk management plan relating to Callum  comprehensively addressed potential risks with due consideration to his emotional and social developmental needs.  This Serious Case Review has only considered the risk assessment relating to climbing and therefore can only comment on this one.  It is written in the risk assessment that Callum should be given clear boundaries before commencing an activity and that if he starts to climb trees or obstacles when out in the community then he should be advised to come down immediately.  The risk assessment does not detail what action staff should take if Callum does not follow their instruction to come down immediately.  However, following Callum’s death CO3 told the Police that if Callum climbed on anything the staff member was expected to monitor the situation, encourage him to come down and to inform colleagues of their location to obtain support and assistance.  The risk assessment also makes reference to Callum climbing on the roof of the home.  It is written that when he does this, he should be told to come down, the care staff should monitor him whilst he is on the roof and all instances of him climbing on the roof should be logged on his file and the social worker should be informed.    6.6 The Lead Reviewer considers it to be a weakness in the risk assessment that directions were not given as to the action care staff should have taken if Callum climbed when out in the community and did not obey the instructions to come down immediately.  In that regard this specific risk assessment could have been more robust.  However, even without such instructions the Lead Reviewer considers that it would be unacceptable for a care worker not to seek help or to report the incident at the time.   6.7 In the version of the risk assessment that has been made available to this review, it is written under the heading ‘What further action is necessary?’ that Callum ’s keyworker had identified two climbing walls where Callum  had been able to climb with qualified teachers in a safe way.  There is no record as to what it was anticipated this would have on Callum’s tendency to climb elsewhere or how this was to be monitored.  This review has been informed that Callum attended one of these on 27 April 2014 and 28 June 2014, when CO1 was his keyworker, but then lost interest and became engaged in other activities.  Therefore he had not attended a climbing wall for more than a year before his death.  Nevertheless, this action remained on the risk assessment.  This suggests that the reviews of the risk assessment had been insufficiently thorough and the risk assessment had not been amended and kept up to date as circumstances changed.    6.8 This review has been told that, because there had been no reports of Callum climbing during the six months prior to his death, CO1, RHM1 and SW3 believed that he had stopped climbing.  This belief is not reflected in the risk assessment which is further evidence that the risk assessment was not kept up to date despite being reviewed.    6.9 Notwithstanding the above comments, there is no evidence to suggest that Callum climbed a tree because of a problem with the efficacy or robustness of the risk assessment arrangements or the specific risk assessment.  Instead, he climbed the tree because he was given an opportunity to do so despite the risk assessment.  This is addressed in greater detail in the analysis of KLoE 2. Overview Report – Child B April 2018      Page 13 of 45  Other Risk Assessments  6.10 During the period covered by this review Callum was reported to the Police as missing on eight occasions.  Three of these were in May 2013 whilst Callum lived in a foster placement, one was in July 2013 and four were between August 2014 and November 2014.  6.11 Between the first and last four occasions when Callum was reported as missing West Yorkshire Police’s approach to missing persons changed and a substantially amended policy was introduced in May 2014.  Notwithstanding the change in policy West Yorkshire Police had ongoing problems with inconsistency amongst supervisory staff in risk assessing missing children.  As a result of this inconsistency in risk assessment, a further revised policy was introduced on 1 July 2016.  Her Majesty’s Inspectorate of Constabulary PEEL: Police effectiveness 2016 inspection report published in March 2017 reported: “The force has recently updated its missing person’s policy, with a good understanding of this being evident among staff within the force and partner organisations.”  6.12 This review has found that there was inconsistency in the risk assessments relating to Callum when he was reported to the Police as missing.  In view of the change of policy that has already taken place no recommendations are made about this.  6.13 There were two occasions in 2014 when Callum  disclosed to school staff that he had harmed himself and a third occasion, in 2015, when he disclosed to children’s home staff that he had done so (see KLoE’s 4, 5 and 6).  The school could have instigated a pupil risk assessment which would have encouraged a multi-agency response for all professionals working with Callum to formally identify strategies to support him to address his self-harming behaviour.  The resulting pupil risk assessment plan could have considered how to minimise any opportunity for him to cause harm to himself both at school and in the wider community.  It could also be expected that the children’s home would have written a risk assessment aimed at addressing self-harm but there is no evidence that this was done.  6.14 Each of the calls made to NSPCC Childline, were identified as low risk against the Childline risk assessment criteria as there had been no indicators of suicidal ideation or abuse and Callum was appropriately utilising Childline support. He had also talked positively about a career in the home, who he said was helping and supporting him. As such, there was no further action taken and he was encouraged on each occasion to call Childline again if needed.  2. Evaluate the effectiveness, or otherwise, of how the risk assessment was managed and implemented in practice for this case.    6.15 As is noted in KLoE 1, all members of the care team staff at the children’s home were aware of the risk assessments relating to Callum climbing and therefore that aspect of its management was effective.  6.16 It is less easy to judge how effectively the risk assessment was implemented as inconsistent statements have been made regarding whether or not Callum had climbed this tree in the presence of CO5 prior to 6 August 2015 and also whether Overview Report – Child B April 2018      Page 14 of 45  any other staff from the children’s home knew that he had climbed the tree previously.    6.17 Considering all the information seen, the Lead Reviewer considers it highly likely that Callum had climbed the tree in the presence of CO5 prior to the afternoon of 6 August 2015.  CO5 told the Police that Callum climbed the tree several times in the afternoon of 6 August 2015 after he met his girlfriend and before they returned to the children’s home.  If he had not climbed the tree previously then it is to be expected that CO5 would have mentioned this to his colleagues on his return to the children’s home.  Furthermore, if Callum had climbed the tree against CO5’s instruction then it would not have been appropriate for CO5 to have gone near the tree with him again that day.  In addition, it was recorded by an Emergency Duty Team (EDT) social worker, on the day Callum died, that another care worker said that Callum had climbed this tree many times before. However, this review has not been provided with evidence of any specific occasions when Callum climbed the tree apart from the aforementioned occasions on the day of his death.    6.18 GP records from an appointment that Callum had 14 months before his death refer to him having recently had a fall from a tree.  CSWS have no records relating to this incident so it is not possible to determine how Callum came to be climbing the tree or how it was handled afterwards.  This incident occurred 14 months before Callum died and when it was known that he liked to climb.  Callum was not seriously hurt in this fall and the GP appointment was in relation to a different matter.  Nevertheless, it is a matter of concern that CSWS do not have a record of this incident, particularly as there was a risk assessment in place in respect of climbing.   3. How effective was the management and supervision of the care worker tasked with implementing the risk plan?  6.19 CO1 was the keyworker for Callum until April 2015 when CO5, who was new to the care home took over this role.  This followed CO1 being promoted to a more senior role in the home.  CO5 had moved from a different care home within Leeds which had closed.  He was an experienced care officer who was used to the keyworker role and had experience of working with children with complex emotional and behavioural needs.  He was also familiar with the risk assessment forms as these were used across the Leeds City Council children’s homes. 6.20 There is an expectation within CSWS that supervision is held every month with care officers from children’s homes and that they are supervised by the senior care officer and deputy manager.  Records show that CO5 received formal supervision on three occasions over a 13 day period in the middle of April 2015 and again on 3 July 2015 but did not receive any formal supervision in May or June 2015.  The first two supervision sessions took place with RHM1, the third was with CO3, a senior care worker and the final one with CO1 as CO3 was away from work having sustained a fractured leg.  It was because of CO3’s fractured leg that CO5 did not receive supervision in May or June 2015.  6.21 The second supervision session between CO5 and RHM1 appears to be of particular significance.  This took place on 13 April 2015, just four days after their first meeting and it is recorded that it took place because RHM1 had received an email from another member of staff expressing concern about aspects of CO5’s attitude to the safety of young people living in the home, including an allegation that Overview Report – Child B April 2018      Page 15 of 45  he had allowed one of the residents to climb trees in the park (this resident was not Callum).  It is recorded that RHM1 made it clear to CO5 that there were risk assessments for each young person in the home and that these must be adhered to.  It is further recorded that CO5’s response was that he did not see tree climbing as an issue, stated “boys will be boys” and shared a view that he thought they were too strict in the care home.  6.22 Of the supervision with CO3, which took place nine days later on 22 April 2015, it is written that CO5 was more settled in his role and that “he needed to develop his relationships with the young people in the home and ensure he reads all the paperwork including care plans and risk assessments.”  Of the supervision with CO1 in July 2015 it is written that CO5 was now the keyworker for Callum and had reviewed the risk assessments which had been signed off by RHM1.  6.23 It is reported that informal discussions were held between RHM1 and CO5 during May and June 2015 but no evidence has been provided of these.  There are no records to suggest that the concerns about CO5’s approach to safety, or his response when this was raised with him in April 2015 was ever revisited by RHM1 or anyone else.   6.24 There is no indication that RHM1 or CO5’s supervisor were provided with any information to suggest that CO5 or anyone else was not complying with the risk assessments for Callum.  Nevertheless, in light of the concerns raised in April 2015 about CO5’s behaviour and his stated attitude to risk during the subsequent supervision session, it would have been appropriate for this matter to have been revisited with him and, if appropriate for further measures to be put in place to ensure compliance.   4. Consider to what extent Callum’s behaviour and needs were unusual or extreme, or required specialist support and whether this was available and used?   5. Examine whether there were any previous concerns, incidents or indications which might have signalled any risks of self- harm or given rise to other concerns. and 6. Investigate how any previous incidents of risky behaviour were managed and whether there was learning from these to inform Callum’s care plan.  6.25 According to CSWS records, Callum was assessed for Autism in 2009 but did not meet the diagnostic criteria for further assessment.  Subsequently, the Therapeutic Social Work Team screened him for organic disorders such as Attention Deficit Hyperactivity Disorder (ADHD) and Autism but no diagnosis was made.  Throughout the CSWS records Callum  is referred to as having global development delay although in 2015, having considered inconclusive results from several tests, an educational psychologist stated that he should not be described in this way.  Notwithstanding the absence of any formal diagnosis, it was believed that Callum required more significant levels of support than would be needed by other children of a similar chronological age and his emotional and behavioural development was that of a much younger child.    Overview Report – Child B April 2018      Page 16 of 45  6.26 By contrast to Callum’s emotional and behavioural development being that of a much younger child, his large size would have made him more of a threat when he became aggressive and it would have been difficult for carers to restrain him if he was putting himself at risk.  Sub consciously or otherwise, people may also have treated him as older than he was.    6.27 Paragraph 1.4 refers to various challenging behaviours exhibited by Callum whilst he lived at the children’s home. The following paragraphs describe these behaviours in greater detail and consider how they were addressed including what specialist support was available and used.  Callum’s climbing behaviour is not considered in this section as it has been addressed in respect of KLoEs 1, 2 and 3.  Going Missing/Leaving the Children’s Home without Permission  6.28 The Children’s home contacted the Police on five occasions and reported that Callum had gone missing.  Four of these occurred in the second half of 2014 when things were particularly unsettled within the resident group at the children’s home.  6.29 CSWS report four other occasions when Callum left the children’s home without permission, twice within the first month that he was living there and once each in May and June 2015 after a decision had been taken that he could not go out without supervision (see paragraph 6.42).  In addition, information seen by the Lead Reviewer suggests there was at least one other occasion when he left without permission.  In all these instances Callum was only missing for a short time before returning to the home.  The Police were not informed on these occasions.  6.30 West Yorkshire Police policy describes a persistent missing person as one who is missing or absent on four or more occasions within a month or six or more occasions within three months.  Callum briefly met this criterion at the end of August/beginning of September 2014 but otherwise it appears that this was not a particular problem.  Even at the time he met the criterion his absences were relatively short and he returned to the home of his own volition with no evidence that he was exposed to significant risk whilst he was missing.  Consequently his behaviour, in this regard, is not considered to have been particularly unusual or extreme and it was managed in an appropriate way.  Aggression  6.31 Children’s home staff contacted the Police on eight occasions when Callum had either assaulted a member of staff or had been involved in some other disturbance.  Only one of these incidents was dealt with by formal Police action. In addition CSWS report three occasions during the first month that Callum was at the children’s home when he was verbally abusive or aggressive towards staff but the Police were not called.    6.32 As with the incidents of Callum going missing from the home, these incidents of aggression took place over three time periods.  These were in the first few weeks following his admission, the unsettled period at the children’s home in late 2014 and late spring/early summer 2015 following the incident that had resulted in a decision that Callum  could not go out alone.   Overview Report – Child B April 2018      Page 17 of 45   6.33 Children’s home staff contacted the Police for support when it was considered necessary and restorative practice1 was used to help build relationships and repair harm.  Self-harm   6.34 On 13 October 2014, 4 December 2014 and 26 June 2015 Callum was observed to have harmed himself by scratching his arm.  On 4 December 2014 he also stated that he had been chewing a piece of glass during the morning but there is no evidence that he swallowed any glass.    6.35 The first of these incidents was identified by Teaching Assistant (TA) 1 at school who informed a member of staff at the children’s home.  Callum informed TA1 that he had scratched himself with glass and he had done so because he was upset, due to not being allowed to sleep at his older sibling’s home on the Sunday evening.   The recorded view of staff at the children’s home was that Callum had copied another child at the home although it is not clear what evidence there was to support this view.  CO1 informed SW3 that staff would monitor the situation.    6.36 Callum himself brought the second incident to the attention of TA1, who then took him to the Emergency Department at hospital.  Callum was admitted to hospital and seen by a worker from CAMHS in line with the local procedures before being discharged back to the children’s home that same day.  A member of the care team from the children’s home also attended the hospital and was present when the CAMHS practitioner spoke to Callum who disclosed bullying and taunting at the children’s home.  He said that the girls living there often picked on him but then wanted to be friends, which confused him.  CAMHS records indicate that plans were arranged to address conflict and monitor risk at the children’s home and a follow up visit from CAMHS was arranged but then cancelled.  The circumstances of the cancellation have not been clearly documented but it appears that a telephone call took place between the two services and CAMHS were told that Callum’s behaviour around wanting to harm himself was a direct cause of incidents of bullying which had occurred at the home but that this had been addressed and Callum was doing much better.  The children’s home have no records relating to a planned follow up visit from CAMHS and staff have reported that they believe that Callum said that he did not want a further visit from CAMHS whilst he was still at the hospital.  6.37 The third incident occurred six months later, on 26 June 2015, and was identified by care staff.  Callum told staff that he scratched himself because he was upset and angry that he had hurt a member of the care staff.  It was suggested to him that if he was feeling low he should tell staff or find a place to calm down in order to prevent further episodes of self-harm.    6.38 The physical injuries that Callum inflicted upon himself with each of these incidents were superficial.  However, any issue of self-harm should raise concern and be                                                   1 “Restorative practice is a term used to describe a way of behaving which helps to build and maintain healthy relationships, resolve difficulties and repair harm where there has been conflict.” (We are child friendly Leeds; One minute guide, No27, May 2015) Overview Report – Child B April 2018      Page 18 of 45  addressed.  It is positive that on each occasion discussion took place with Callum which acknowledged his behaviour and sought to understand the reasons behind it.  He was also reassured by staff at the children’s home that he could talk to them if he needed to, which was good practice.  It is unclear what led children’s home staff to conclude that the episode of self-harm in October 2014 was copycat behaviour on the part of Callum  and this is a potentially unhelpful and dismissive explanation for the behaviour that is inconsistent with the explanation Callum  gave to TA1 and which does not acknowledge whatever was upsetting Callum  at the time.  6.39 Leeds Safeguarding Children Board, Leeds City Council and the NHS have produced guidance for staff working with children and young people in Leeds who self-harm or feel suicidal.  The staff in the Emergency Department followed this guidance in their response to Callum but this review has not been provided with any evidence as to whether or not the other practitioners who worked with Callum considered the guidance when he self-harmed and whether it guided their responses.  Better understanding of this guidance should have resulted in a more appropriate response from the children’s home.  Challenging Behaviour/Identity  6.40 Callum experienced difficulties in terms of his understanding and behaviour regarding puberty, sex and relationships.  Staff at the children’s home contacted the CLA Nurse for specialist support at the end of 2013.  Initial support from the CLA Nurse was provided in early 2014 and included conducting one to one work and liaison with nursing staff at the school in order to maintain a consistent approach to supporting Callum ’s needs.    6.41 In early 2015 there was further concern about Callum’s understanding and behaviour regarding puberty, sex and relationships and the CLA nurse referred him to the Futures Service within Barnardo’s on 11 March 2015.  It was agreed that a therapeutic health worker from Barnardo’s (THW1) would undertake work with Callum looking at a number of relevant issues.    6.42 There was a positive and appropriate response to Callum’s needs with regard to puberty, sex and relationships.  Children’s home staff, the CLA nurse, the school nurse and Barnardo’s worked together to support Callum  at his pace and in a way in which he felt comfortable although Barnardo’s have identified that it would have been good practice for THW1 to have had more direct contact with children’s home staff whilst this work was being delivered.  As his behaviour became more of a concern action was taken to protect him and others and specialist help and support was sought.    Bullying and assaults against Callum   6.43 There were times at the children’s home when Callum was a victim of bullying.  Of the five Looked After Children reviews that were held whilst Callum was a resident of the home reference was made at the second, third and fourth to him being the victim of bullying from other residents.  At the last review, held on 4 March 2015 it was recorded that the bullying of Callum had been addressed.   Overview Report – Child B April 2018      Page 19 of 45   6.44 In addition there was one occasion when children’s home staff contacted the Police after Callum was assaulted by a resident and an occasion a few weeks later when they again contacted the Police after he was threatened by the same resident, whose behaviour was causing frequent difficulties in the home.  There were also two occasions when Callum told staff at school that he had been physically hurt by other residents.  The school contacted the children’s home on both occasions.  This second incident was just a day before it was stated at review that the bullying had been addressed.  6.45 As with the aggression displayed by Callum, children’s home staff dealt with these incidents of bullying and aggression using restorative practice.  There were also occasions when individual residents were moved into different placements as it was determined that the home could not contain them.  Managing Risky Behaviour   6.46 The preceding paragraphs describe how some specific incidents of risky behaviour were managed.  Also, as stated in KLoE 1, the children’s home produced a series of risk assessments for Callum which were reviewed every three months to assist with managing his risky behaviour.  In more general terms, CSWS have explained that Callum was a young person who had a tendency to forget things and therefore he required regular reminders to reinforce the behaviour that was expected.  This was done through regular key work sessions and was addressed in the risk assessment relating to climbing.  In addition, the care team provided consistent, clear messages and focused on positive activities.  Accessing Specialist Support   6.47 The preceding paragraphs describe some of the specialist support that was accessed to assist Callum, such as CAMHS, the CLA nurse and the Futures Service.    6.48 When Callum was first accommodated he was subject to a statement of Special Educational Needs and attended a specialist school.  In September 2013, having moved to the children’s home he transferred to a different specialist school which provides education to children with a range of complex learning difficulties.  Callum continued to attend this school until the time of his death.      6.49 Callum was referred to the Therapeutic Social Work Team on 13 January 2014 following a recommendation to that effect being made at the Looked After Children review held in November 2013.  The purpose of the work was to help Callum understand the trauma he had experienced over a long period of time and the reasons he was a Child Looked After.  After four months the work ceased because it was judged that Callum was not ready to engage.  6.50 At the Looked After Children review held on 3 March 2015 it was agreed that SW3 would refer Callum to the educational psychologist who, it was thought, might be able to provide some advice about how to help Callum to process information and to get the most from work done with him.  This led to a meeting between CO1 and Overview Report – Child B April 2018      Page 20 of 45  the educational psychologist on 10 June 2015 and a plan for a follow up meeting with the psychologist, CO1 and Callum’s teacher in the autumn term.  This did not take place due to Callum’s death.     6.51 At a Looked After Children review in March 2015 there was discussion of a possible referral to CAMHS as this was recommended by a health needs assessment.  However, due to the other work that was planned it was decided not to refer Callum at that time but to reconsider at the next review, which would have taken place before 4 September 2015.   Placement at the Children’s Home  6.52 When considering the specialist support that was accessed for Callum it is necessary to consider whether it was appropriate for him to live in the children’s home.  When a decision was taken to move Callum from the foster placement with his bother the intention was to place him in a foster placement where he would be the only child present.  However, despite a national search it was not possible to find a suitable foster placement and he was instead placed in the children’s home.  6.53 Callum lived at the children’s home for over two years without the placement ever being at threat which suggests a degree of stability.  Nevertheless, CSWS acknowledge that there was a significant difference in both chronological and developmental age between Callum and other residents with Callum being the youngest resident and having a developmental age that was younger still.  CSWS state that the decision to place him at the children’s home and to keep him there was finely balanced and under constant review with relationships continually considered and analysed to ensure that risks were addressed and managed.  6.54 Records show that the possibility of a fostering placement was discussed at the last three Looked After Children reviews that were held but that at the first of these the chair was of the view that therapeutic work needed to be undertaken first whilst at the second it was said that a placement would not be without risk as Callum’s family ties made it difficult for him to commit to living in a family.  At the next review, held on 4 March 2015 it was again stated that a placement would not be without risk because of Callum’s ties to his family but also because of his recent negative behaviours.  Notwithstanding these concerns, it was agreed that enquiries would be made with the fostering team regarding possible matches.  The IRO met with Callum in advance of the review and Callum expressed a preference to live with his family but also said that he would rather live in a foster placement than in the children’s home.  6.55 The regulation 332 visitor has recorded that in a phone conversation on 18 March 2015, just two weeks after the Looked After Children review, SW3 said that further                                                   2 Regulation 33 of the Children’s Home Regulations 2001 required the registered provider of a children’s home, in this case Leeds City Council, to have quality assurance arrangements in place.  At a minimum these involved someone visiting the home at least once a month to observe the care provided, the practice of the staff, inspect compliance with regulations, systems and processes and the quality of the environment.  The person who undertook the visit was also required to provide a report of the visit.  Overview Report – Child B April 2018      Page 21 of 45  work was required before Callum would be ready for a foster placement and whilst ideally he would not be in residential care it was considered that greater stability needed to be achieved in terms of his behaviour.  There is no indication that anything significant had changed during these two weeks.  6.56 The CSWS records for Callum include a record of a supervision session between SW3 and TM2 on 10 June 2015 where a discussion took place regarding the possible impact of a move on Callum.  Subsequently, in a report for a Looked After Children review that was due to take place on 15 July 2015 SW3 referred to Callum having remained unsettled at the children’s home. SW3 wrote that the long term plan was for Callum to be moved to a foster placement but this would not be progressed until the ongoing work regarding puberty and identity was completed.  It is not known whether Callum was aware of this change of plan and, if so, whether it had an impact on his behaviour.  This planned review was postponed and due to be rearranged to take place before 4 September 2015.    6.57 The work did not take place until two months after the Looked After Children review of March 2015.  It is not known why the decision of the Looked After Child Review that enquiries would be made with the fostering team regarding possible matches had not been acted upon during this two month period.  6.58 As a further complication, Regulation 443 reports show that from April 2015 the age range of the home was being changed from 12 – 17 years to 15 – 17 years but that Callum was going to remain at the home despite being only 14 years of age.  It is written in the report of the Regulation 44 visit undertaken on 8 April 2015 that the staff team were very committed to Callum  and confident that they were managing the different needs of the young people.  It is also written that the plan was for Callum to remain in residential care until independence.  This statement is not consistent with the outcome of the previous Looked After Children review or the statement in the report written by SW3 for the following review.   Conclusions for KLoE’s 4, 5 & 6  6.59 Taken as a whole it can be seen that throughout the period covered by this review Callum exhibited a range of risky and harmful behaviours.  The severity of these varied from time to time but generally they were not regarded as particularly unusual or extreme, especially considering his history.  6.60 The challenging behaviour displayed by Callum in late 2014 appears to have been linked to the behaviour of residents and the overall difficult environment at the home.  Children’s home staff have also expressed the view that his behaviour deteriorated when he was told that he was not going home.  As 2015 progressed, his challenging behaviour became increasingly risky and difficult to manage and there continued to be instances of aggression towards staff.  6.61 Appropriate action was taken to address the challenging behaviour exhibited by Callum, using a restorative approach and engaging with specialist services as                                                   3 Revised Children’s Home Regulations published in 2015 amended Regulation 33 of Children’s Home Regulations 2001to require that visits to Children’s Homes are carried out at least once a month by an Independent Person.  The revised amendment is Regulation 44. Overview Report – Child B April 2018      Page 22 of 45  required.  There is evidence of this being done in a co-ordinated way, using the Looked After Children reviews to agree interventions in an attempt not to overwhelm Callum.   Notwithstanding this careful approach Callum would not always engage with services so it was difficult for professionals to make progress in their work with him.  6.62 Although Callum lived at the children’s home for over two years without any risk to his placement it is acknowledged that it was not an ideal placement for him and it appears that much of the challenging behaviour he exhibited, particularly in late 2014, was linked to the behaviour of other residents.  It is a concern that CSWS did not make enquiries about a possible foster placement for Callum after it was agreed in the review on 4 March 2015 that they would do so.  It is also a concern that contradictory statements were made about whether the long term plan for Callum was to remain in residential care or to seek a foster placement.    7. Consider whether there were any significant changes in behaviour and relationships that might have indicated increased risk of violence or harm.  6.63 During the 10 weeks that Callum lived in a foster placement with his sibling he engaged in aggressive and risky behaviour, including climbing and going missing.  This pattern of behaviour continued when Callum moved to the children’s home but after the first two to three months things settled down.    6.64 From around mid-August 2013 until mid-July 2014 Callum had a much more settled period at both school and the children’s home although there were some examples of him being bullied by other residents and he continued to put himself at risk by climbing.  6.65 From mid July 2014 until the end of December 2014, Callum was much more unsettled again.  He went missing from the children’s home seven times, albeit for short periods of time, assaulted staff and on two occasions superficially harmed himself by scratching his left arm.  He continued to be a victim of bullying and was also assaulted by other residents at the home.  This very unsettled period for Callum coincided with a difficult period at the home generally, including a period of 2½ months when the Police were contacted by the staff at an average of almost once each day.  Regulation 33 reports seen by the Lead Reviewer suggest that there were particular problems relating to two young people which unsettled the dynamics in the home.     6.66 From January 2015, following one resident moving from the home things appear to have been more settled again for Callum although there was an increase in his challenging behaviour, which culminated in May 2015.  During this period, children’s home staff continued to describe his behaviour as challenging.  In June and July 2015 there were further incidents of Callum being aggressive towards members of staff at the children’s home, he scratched his arm again and, on at least one occasion, he left the children’s home alone and without permission.    6.67 Callum’s mother told the Lead Reviewer that she frequently spoke to her son on the telephone and on 31 July 2015, one week before he died, he was quite upset and told her that staff at the children’s home had been picking on him.  The following day Callum went out for the afternoon with his mother; he did not mention Overview Report – Child B April 2018      Page 23 of 45  the issues that he had raised the previous day and he seemed very happy.  According to Callum’s mother it was not unusual for him to talk to her in this way but he was inconsistent in what he said.  On 6 August 2015, Callum spent the afternoon at the park with his girlfriend and seemed happy to all who saw him, although he was disappointed when he had to say goodbye to her and return to the children’s home.  After returning to the children’s home he phoned his mother and told her about his day and that he was going to get a takeaway.  Her opinion is that he had enjoyed his day and was happy.   6.68 Considering all the available information, it is evident that Callum’s mood and behaviour fluctuated during the 26 months that he lived at the children’s home.  It is also evident that there was an increase in challenging behaviours in the few months immediately preceding his death.  The challenging behaviour displayed by Callum indicated an increased risk of harm to Callum and to vulnerable young people with whom he associated and appropriate action had been taken to try to address this.  6.69 However, this review has not seen any information that suggests there were ever any indications that Callum would seriously harm himself or take his own life.    8. Examine the inter and intra agency communication regarding Callum and whether there were gaps in information sharing that impacted on the risks he faced.  6.70 The school and home worked well together to establish behaviour management plans for Callum when he started to attend the school but school staff were of the opinion that, as time passed, the children’s home did not communicate sufficiently with them about things that were taking place in the home.  This included occasions when Callum harmed himself and experienced bullying.  School staff did contact the children’s home when they became aware of such incidents but did not make children’s home staff aware of their concerns about the level of communication at the time.  CSWS made the school aware of the incident regarding aspects of his continuing challenging behaviour.  However, although a home and community safety plan was compiled, it appears that it was not shared with the school.  6.71 Of the four Looked After Children reviews that were held at the children’s home after Callum started to attend the school, school staff only attended the first one.  School staff state that they were not informed of the dates of the reviews although CSWS state that invitations were sent to the school.  School staff should have been aware that reviews would take place every six months and there is one record of staff asking the Independent Reviewing Officer (IRO) for the date of the next review.  The school in question usually attend Looked After Children reviews for their pupils and it is not clear why this did not routinely happen in respect of Callum.  Ideally the IRO should have sent the review invitations to a nominated senior person at the school.  6.72 Children’s home staff did attend parent’s evenings at the school.  6.73 At the Looked After Children review held on 21 November 2013, SW1 said she had been trying to arrange a Personal Education Plan (PEP) meeting but had not heard Overview Report – Child B April 2018      Page 24 of 45  back from the school.  In 2015 SW3 also experienced difficulty arranging a meeting with the school to review the PEP.  6.74 One CLA nurse worked with Callum throughout the period that he was a child looked after.  The nurse did not attend the Looked After Children reviews held in November 2013 or April 2014 but did attend the following two reviews.  CLA nurses initiate an annual health needs assessment for children looked after but do not have the capacity to attend all Looked After Children reviews and therefore prioritise which they attend.  The CLA Nurse should review the records and if there are any changes to the Health Needs Assessment they will contact the Social Worker or IRO before the meeting.  The CLA nurse knew these reviews were taking place; she sent apologies and submitted reports to the reviews she did not attend.  There is no suggestion that her absence from the reviews caused communication difficulties.  6.75 The CLA nurse, care staff from the children’s home and Barnardo’s staff communicated with one another and worked together to support Callum  with his issues relating to sexual health and puberty and there was also some engagement with the school.  There was a delay before the CLA nurse was made aware of the first two episodes of self-harm from Callum.  6.76 It would have been appropriate for the CLA nurse to have been informed of Callum ’s self-harming behaviour in both October 2014 and December 2014 and it could reasonably have been expected that both the school nurse and the children’s home would have done so.  However, this was not done at the time. Hospital staff informed the GP and SW3 of Callum’s attendance in December 2014, but did not inform the CLA nurse and would not usually expect to do so, considering that informing the GP and social worker was sufficient.  The CLA nurse was informed of the June 2015 self-harming incident in a timely manner by CSWS staff and she visited Callum to discuss the self-harm.  Callum said that he was unhappy at the care home and requested a visit from the Children’s Rights Service, who became involved over the next few weeks.  6.77 There was appropriate communication within the children’s home to ensure that care staff were aware of the risk assessments relating to Callum but it appears likely that information was not shared about Callum continuing to climb trees.  There was also a lack of communication about the risk assessments with other agencies.    6.78 West Yorkshire Police involvement was limited to responding to specific incidents of aggression and of Callum going missing and communication between the children’s home and the Police was appropriate in respect of these incidents.  West Yorkshire Police conduct return interviews with young people who have been missing.  Copies of the actual interview form are not given to CSWS as they may contain confidential information about other people.  However, representatives from CSWS and West Yorkshire Police attend a daily meeting where all missing children and the content of interview forms are discussed.  During the latter part of 2014 the Police were concerned about the frequency with which this particular children’s home was making contact and initiated communication with the home to address their concern.    Overview Report – Child B April 2018      Page 25 of 45  9. Review whether Callum’s relationships with adults and peers was analysed to inform care planning and risk management.  6.79 The descriptions of Callum that have been provided to this review suggest that he was a young person for whom relationships were important.  He wanted to be liked and this impacted both positively and negatively on his behaviour.  The following paragraphs consider Callum’s relationships with a variety of individuals and groups with whom he had regular contact and whether these relationships were analysed to inform care planning and risk management.  Relationships with staff at the children’s home  6.80 It is written in the report that CSWS provided to this review that:           “Callum experienced close and supportive relationships with members of the care team at (the children’s home) which represented a protective factor in his life and (these) relationships were considered as part of the care planning process.”  6.81 Throughout most of the time that Callum lived at the children’s home CO1 was his keyworker, although it appears that he was well known to all the care staff and had developed close relationships with them all.  In April 2015 CO5, who was new to the home, became his keyworker due to CO1 being promoted to a more senior position.  There is no evidence of any analysis of the likely or actual impact of this change on Callum.  Relationship with residents at the children’s home  6.82 CSWS report that when making friendships Callum was drawn to children who were younger than him.  This is not unexpected given the delay in his own emotional and social development but it did present some difficulties as physically he presented more like a young adult. According to the CSWS contribution to this review, this incongruity in respect of Callum’s development and his presentation was considered and analysed to inform care planning and risk management.  6.83 Although Callum was drawn to children who were younger than him, the majority of residents who came and went from the children’s home during the time that he lived there were older than him.  At the Looked After Children review that was held on 25 April 2014, it was reported that the other three residents were older and more mature than Callum and relationships varied with bullying a concern.  6.84 At the Looked After Children review that was held on 30 September 2014, CO1 reported that Callum had built strong relationships with the care team but he was being targeted by other residents because he was trying to conform.  This was having an effect on his emotional wellbeing and had led to him being assaulted by another resident.    6.85 At the next Looked After Children review, held on 4 March 2015, it was reported that the negative behaviours of other residents were impacting negatively on Callum and he was then responding in the same way towards members of the staff Overview Report – Child B April 2018      Page 26 of 45  team.  As a result of the concerns about the placement it was agreed that enquiries would be made with the fostering team about a possible match for Callum although it was considered that there would be some risks associated with fostering (see paragraph 6.55).  6.86 Therefore it is evident that there was analysis of Callum’s relationship with other residents.  Other Friendships  6.87 This review has been made aware of friendships that Callum had with children who did not live in the children’s home.  He had a girlfriend whom he frequently saw with support of staff from the children’s home and the girl’s mother.  This was considered, at the time, to be a positive relationship and is still believed to have been so.     6.88 There were evident risks associated with some friendships due to the vulnerability of Callum and other parties.  These risks would have increased and there should have been analysis of them and clear plans in place for managing the friendships.  This review has not been made aware of any such plans although there is a record of a discussion taking place on 1 May 2015 between SW3 and CO1 around Callum visiting a friend’s house and it not always being possible for staff to support him in doing this.  It is not specified which friend this refers to.    Relationships with family members   6.89 Family was very important to Callum; throughout his time as a child looked after, he wanted to be back living with his mother and he greatly valued family contact.  This was discussed at each and every Looked After Children review and it was recognised that this was important within his life and needed to be a significant factor in his care plan but that there were a number of risks and needs that had to be balanced.  6.90 Callum had direct face to face contact with his mother, one older sibling and his younger sibling and frequently spoke to his father on the phone.  Whilst he was living at the children’s home contact with his father resumed, initially by letter and then over the phone.  Callum wanted this to progress to face to face contact and was unhappy with CSWS’s approach to this. He was assisted by the Children’s Rights Service provided by Barnardo’s to make a complaint about this and this was resolved.  6.91 There is some evidence that Callum’s understanding was that he was in care because he had misbehaved and that if he behaved well he would be able to return to his mother’s care.  At a safeguarding risk management meeting held in February 2015 it was agreed that some life story work would be undertaken to try to help Callum to gain a better understanding of why he was in care.  This work did commence but due to the need not to overwhelm Callum with interventions (see paragraph 6.62) structured life story sessions did not continue after an initial session.  Overview Report – Child B April 2018      Page 27 of 45  Relationships at school  6.92 The Looked After Children review held on 21 November 2013 took place less than three months after Callum changed school.  The school representative reported that Callum was “very popular with other children”; was “very helpful, affectionate and caring towards less able children” and had “strong relationships with staff”.  No-one from the school attended the subsequent reviews although staff from the children’s home were able to provide some information about Callum’s progress at school as they had attended parents’ evenings.  At the review on 4 March 2015, RHM1 said that Callum  was described as being “caring of others at times” and also that “he has a role of looking after the other young children in school when preparing to leave for the end of school and he feels a sense of responsibility in doing this.”    Changes of social worker  6.93 Callum received statutory visits from his social worker at a minimum of every six weeks.  In June 2014 responsibility for Callum moved from a locality social work team to the looked after service in accordance with the usual procedure in Leeds.  SW1 was the allocated social worker until the change of team.  SW2, from another team attended the review held in September 2014 and all social worker contacts after then were with SW3, from the same team as SW2.  The information provided by CSWS to this review provides no information as to the relationship between Callum and the social workers.  CSWS state that there is no evidence that these changes were detrimental to the work undertaken with Callum.  10. Consider whether appropriate professional curiosity was exercised by those professionals and agencies working with Callum.    6.94 On 8 December 2014, the GP practice was notified by Leeds Teaching Hospitals Trust that Callum had attended the Emergency Department having swallowed glass and cut his left wrist.  Callum attended the GP surgery 23 days later on 31 December 2014 and twice more during 2015.  These appointments were not related to his attendance at the Emergency Department or to self-harm; nevertheless the author of the CCG report for this review suggests that this was a missed opportunity for the GP to ascertain if there had been any further episodes or thoughts of self-harm and to ensure that Callum had been followed-up by CAMHS.  6.95 Similarly the GPs never explored a recommendation in the Young Persons Care Plan dated 10 April 2014 concerning issues relating to sexuality and emotions or his ongoing needs with relationships and puberty that were noted in his Review Health Assessment on March 2015.  These are regarded as further missed opportunities to exercise professional curiosity.  6.96 School staff contacted the children’s home when Callum drew their attention to scratches that he had made on his arm and when he said he had been eating glass.  Contact was also made with the children’s home when Callum said he had been injured or bullied by other residents.  In retrospect school staff have expressed the view that they were not satisfied with the response from the Overview Report – Child B April 2018      Page 28 of 45  children’s home.  However, they did not pursue this at the time which suggests that they did not exercise appropriate professional curiosity.  6.97 West Yorkshire Police involvement was limited to dealing with specific incidents and professional curiosity appropriate to this level of involvement was exercised.  The Police never had reason to believe that a greater level of involvement was required.   11.  Identify whether those working with Callum had a shared understanding of his needs and the risks he faced.  6.98 Evidence suggests that the majority of care staff in the children’s home knew Callum well and had a shared understanding of his needs and the risks he faced.  There was also regular communication between the care staff and the social workers to whom Callum was allocated at different times whilst he lived at the care home.  6.99 Looked After Children reviews took place at the required frequency and considered Callum’s needs and some of the risks he faced.  The absence of school representation at some of these reviews (see paragraph 6.72) is likely to have negatively impacted on the development of a shared understanding regarding Callum.  6.100 The school developed their understanding of Callum’s education and behavioural needs through formal assessments such as the statement of need/Education Health Care plan, annual review meetings, and his individual behaviour support plan. Callum’s social worker and children’s home staff were consulted in the development of these assessments and plans so there was some shared understanding.  6.101 As stated in KLoE 1, the risk assessments in place at the children’s home were created and monitored in house with little or no communication with practitioners from other services.  Reports of Looked After Children reviews suggest that they were not discussed at the reviews.    6.102 Staff from the school and CSWS appear to have had different perspectives regarding the episodes of self-harm whilst the CLA nurse was unaware of the self-harm until the summer of 2015.  6.103 West Yorkshire Police involvement with Callum was restricted to them responding to specific incidents without any wider input into his needs or the risks he faced.  Given the relatively low level of Police involvement with Callum this can be considered appropriate.    12. Review how care planning and case oversight by Callum’s social worker and IRO was linked to the day-today management of his care by the residential home.  6.104 CSWS state that throughout the time that Callum was living at the children’s home the allocated social workers undertook statutory visits with the required frequency Overview Report – Child B April 2018      Page 29 of 45  of at least once every six weeks.  In addition the author of the CSWS report refers to consistent and regular communication via email, telephone and meetings between the care team at the children’s home and the allocated social workers.  It is considered that day to day management of Callum at the children’s home was very much informed by discussions that were held between the care team and the allocated social workers.  6.105 Despite these assertions, the information provided to this review includes few references to contact between children’s home staff and the social worker during the four month period at the end of 2014 when there was a marked deterioration in Callum’s behaviour.  However, there are examples whereby contact between the children’s home and the social worker was good and communication led to appropriate responses regarding concerns around Callum’s behaviour.  6.106 Looked After Children reviews were held within the required timescale of at least once every six months with the same IRO chairing every review except for the final one.  Every review was attended by a social worker and a member of the care team from the children’s home but there was a lack of consistency as to which individuals attended.  SW1 attended the reviews in November 2013 and April 2014, SW2 attended the September 2014 review and SW3 attended the review in March 2015.  From the children’s home four reviews were attended by CO2, CO3, CO1 and RHM1 in that order.  CSWS state that the IRO was notified of significant events although the information provided by CSWS to this review includes very few references to any contact with the IRO between the reviews.      13. Consider Callum’s experience of School and how his behaviour and engagement differed from that in his residential setting or elsewhere.  6.107 Callum showed low level difficulties at the specialist school that he attended from September 2013 but did not exhibit behaviour that warranted any formal risk management plans.  Overall there was an improvement in his behaviour at school with 34 incidents of low level, disruptive, challenging and defiant behaviour during his first academic year and six the following year.  Reference was made to Callum experiencing some bullying at school at the first Looked After Children review after he commenced but this was not mentioned at subsequent reviews.  Notwithstanding the overall improvement in his behaviour at school it was reported to the Looked After Children review in March 2015 that he had recently become more challenging of boundaries and there had been some outbursts at after school clubs.    6.108 Callum was given opportunities to help and support other children at school and it appears that he enjoyed and thrived upon this responsibility.  Such opportunities were not available at the children’s home where Callum was the youngest and least mature resident.    6.109 The last school report for Callum was excellent in terms of his educational progress and his social interaction and engagement and he received an end of year award.    6.110 Overall his behaviour at school appears to have been less disruptive than it was in the children’s home.    Overview Report – Child B April 2018      Page 30 of 45  14. Consider the sequence of events surrounding the incident and whether all reasonable actions were taken at the time by agency personnel.   6.111 CO5 told the Police that after finishing his tea on 6 August 2015 Callum climbed the tree whilst CO5 himself moved about five metres away into the sunshine.  He could not see Callum in the tree.  After about five minutes, CO5 shouted to Callum that it was time to go and Callum responded along the lines of “one minute”.  After a further four or five minutes CO5 shouted to Callum again but on this occasion he did not receive a reply.  CO5 walked to the bottom of the tree and looked up; he could see Callum and thought he was standing on branches quite high up.  When Callum still did not respond to his shouts CO5 climbed up the tree to a point where he was face to face with Callum.  At this point he could see that there was a rope around Callum’s neck and what looked like foam coming out of his mouth.  CO5 tried to lift Callum but was unable to support his weight and hold onto the tree.  He felt for a pulse but could not find one.  CO5 then descended from the tree and phoned CO4 at the children’s home.  CO7 was also in the children’s home and set off to drive to the area where she understood the tree to be.  On her way there she saw CO5 walking hurriedly back to the children’s home.  CO7 and CO5 returned to the tree and after CO7 saw Callum in the tree she was very concerned and told CO5 to ring 999, which he did.  Later that evening CO4 told a social worker at EDT that this phone call was made at 17:50 although the Police referred to it as having been made at 18:24 when they interviewed CO5 in May 2016.    6.112 Whatever time CO5 phoned the children’s home there was a major failure on his part to initiate an emergency response when he first became aware that Callum was in difficulty.  According to the information that CO5 provided to the Police and the inquest, he had seen the desperate situation that Callum was in.  By any reasonable interpretation this was a situation that required emergency medical assistance and it is hard to comprehend his decision to phone the children’s home and then to start walking back towards the home, rather than phoning 999 and asking for emergency assistance from the Police, Ambulance Service and Fire Service.  The explanation given by CO5 for his behaviour was that he went into shock and was not thinking clearly.    6.113 Emergency services’ records show that the first call received about Callum was made at 18:37 and was from CO5 to the Police.  CO5 told the emergency call handler that a 14 year-old had climbed a tree, appeared to be stuck and CO5 was getting no response.   The call handler understood this to be a call about a young person who was stuck in a tree, rather than a young person who had died or was injured, and determined that the information should be passed on to the Fire Service.    6.114 This information did not come close to conveying the seriousness of the situation and, as a direct result, the initial response of the emergency services was appropriate for a person who was stuck in a tree but insufficient for a person in a tree who had died or was injured.  This review has considered whether the call handler who spoke to CO5 missed any clues to the seriousness of the situation or if they should have asked other questions.  Within this, consideration has been given to whether the fact that English was not CO5’s first language was a factor.  The view of this review is that the information provided by CO5 and his tone of voice did not suggest that this was a serious situation that required an emergency response and therefore the initial response by the emergency services was sufficient in light of the information that was available to them. Overview Report – Child B April 2018      Page 31 of 45   6.115 Having determined that the information should be passed to the Fire Service the call handler mistakenly contacted the Ambulance Service but this mistake quickly became apparent, the call was ended and the call handler contacted the Fire Service instead.  This call was made at 18:40.  Based on the information provided by the Police, the Fire Service mobilised one appliance with the intention of supporting the self-rescue of a young person stuck up a tree.  This was in line with current policy and the intended action of the crew on arrival would be to provide a ladder to access the young person.  If the Fire Service had received the call stating the young person was unresponsive and not conscious then the incident would have warranted and received a full attendance suitable for a Rescue from Height.    6.116 When Fire Service personnel arrived at the scene the officer in charge was able to ascertain that Callum was actually hanging.  A fire fighter trained to Emergency Life Support standard climbed up to Callum and was unable to detect any signs of life.  The officer in charge requested a Line Rescue Appliance to attend to remove Callum’s body from the tree and also requested that the Police and the Ambulance Service attend due to the nature of the incident.  Based on the information provided by the caller, the Ambulance Service coded the call as Green 2 which is the second highest coding and has a target response time of 30 minutes.  An ambulance was dispatched at 19:01 and arrived on the scene at 19:10, 12 minutes after the request was made and therefore, well within the target response time.  6.117 A key factor in the decision to code this call as Green 2 was that when the call handler was asked whether the casualty was conscious and breathing the answer given was ‘don’t know’.  If the call handler had said that the casualty was not conscious and not breathing the incident would have been given the highest coding which has a target response time of eight minutes.  The Ambulance Service have identified that when the Fire Service phoned to request an ambulance the call handler should have utilised the Secondary Emergency Notification of Dispatch which is used for calls made between emergency services.  This would have given more structure to the call and the question about conscious level and breathing status would have been asked earlier within the call. However, as the Fire Service did not know if the patient was conscious and breathing it is unlikely this would have resulted in a different response from the one that was arranged.  6.118 Once the ambulance crew arrived on the scene policy and protocol was followed correctly by the Ambulance Service.  All reasonable steps were taken to establish whether Callum was conscious and breathing.  Subsequently, when he was removed from the tree, a more thorough clinical assessment took place which confirmed that there was no breathing and no pulse.  The ambulance crew used the Recognition of Life Extinct protocol in line with Yorkshire Ambulance Service and national resuscitation procedures.  They then followed the Yorkshire Ambulance Service policy for the conveyance of patients by taking Callum to the Emergency Department at Leeds General Infirmary.  6.119 Best practice from CSWS would have been for a member of the care team to have accompanied Callum to the hospital but that did not happen in this case.  CSWS describe it as regrettable that this did not happen and they are unable to explain the reason.  Overview Report – Child B April 2018      Page 32 of 45  15. Review how information was gathered and recorded about the incident and Callum’s death and how this was used to inform learning and investigations.   6.120 The Sudden Unexpected Death in Infants and Children (SUDIC) process was followed and agencies provided information to this as appropriate.    6.121 West Yorkshire Police investigated the death over the period of nearly a year and the investigation was reviewed by a Detective Superintendent who had had no previous involvement in it.  Evidence was submitted to a senior Crown Prosecution Service (CPS) lawyer and a charging decision obtained which indicated that there was insufficient evidence to proceed with a prosecution.  A full file was supplied to the Coroner to inform his deliberations and the identification of any lessons.  6.122 CSWS took immediate action to secure all information that related to Callum and the incident.  Agency policy and procedure was subsequently followed in respect of staff involved in the incident.  6.123 The response by the emergency services was reviewed by the Ambulance Service Deputy Medical Director and Risk Manager and was discussed at Incident Review Group in August 2015.  It was determined that it would not have been possible to categorise the 999 call from the Fire Service any higher given that information about the conscious level and breathing status of Callum  was not available.  There has been individual learning for Emergency Medical Dispatcher B about using the correct protocol when taking calls from other emergency services.  7. Identification of Learning using the Aims and Objectives   1. To identify improvements in the assessment of risk, and how this can be implemented through effective risk management plans.  7.1 Children’s home staff had identified that Callum put himself at risk by climbing and there is no dispute that the care staff at the home knew he should be discouraged from climbing trees.  Nevertheless, some improvements could have been made to how the risk assessment was written; in particular it should have stated the action to be taken by staff if Callum  refused to follow an instruction to come down from a tree immediately (see paragraph 8.1c).  7.2 When risk assessments were reviewed the previous risk assessment was overwritten with the new one so it was not easy to identify changes over time.  This has been addressed by CSWS and risk assessments are now saved at each review as a standalone document.   7.3 It would be beneficial for children’s home staff to involve the young people themselves in developing and monitoring the risk assessments that apply to them.  Such an approach would be consistent with the principles of restorative practice which recognises that outcomes are improved when practitioners work alongside people, rather than make decisions for them (see paragraph 8.1a). Overview Report – Child B April 2018      Page 33 of 45   7.4 It is essential that risk assessments are kept relevant and up to date.  Although the risk assessment relating to climbing was reviewed as recently as July 2015 it contained out of date information and did not reflect that there had been no reports of Callum climbing during the previous six months (see paragraph 8.1b).   7.5 The risk assessments were kept very much in-house by the children’s home and appear not to have been discussed at Callum’s Looked After Children Reviews.  There is no indication that children’s home staff consulted with other agencies when writing risk assessment or made other agencies aware of the risk assessments that were in place.  Some risk assessments may well be very specific to keeping a child safe in the children’s home but others should be shared more widely(see paragraph 8.1e).  7.6 The risk assessment included action to be taken to enable Callum to climb in a safe environment.  The impact of this action was not monitored and it remained as an action on the risk assessment months after Callum had stopped going to the climbing wall (see paragraph 8.1d).    7.7 There was a missed opportunity for the school to instigate a pupil risk assessment when Callum self-harmed.  Action has been taken by Education Services to address this.  2. To identify whether there are improvements to supervision and management arrangements that would ensure better management of risky behaviours.  7.8 Callum’s tragic death was not a result of the risks associated with climbing not being recognised, or of the care team not knowing about these risks.  Instead his death occurred because the risk assessment was not followed on the day of Callum’s death.    7.9 It appears highly likely that senior staff at the home, were incorrect in their belief that Callum  had ceased climbing six months previously and the supervision and management arrangements did not identify that at least one member of staff was aware of this.  7.10 In view of CO5’s opinion expressed about the home’s approach to risk management, it would have been prudent to have explicitly revisited this matter with him and, if doubts remained about his attitude, to have ensured that he was not in a position where he had sole responsibility for enforcing risk assessments that he did not agree with (see paragraph 8.2).    3. To identify whether there are training and staff development needs arising from the circumstances of this case.  7.11 With hindsight school staff have expressed concern about a lack of day to day communication from the children’s home and have also expressed dissatisfaction with the response from the children’s home to incidents of self-harm by Callum and occasions when he suffered harm from other residents.  These issues were not Overview Report – Child B April 2018      Page 34 of 45  raised at the time which suggests that staff at the school need some guidance on escalating concerns (see paragraph 8.5).  7.12 The GPs at the surgery require guidance around speaking to children and young people, specifically CLA and young people who have harmed themselves.  The CCG has taken action to address this.   7.13 Other training and staff development needs arising from this case are identified elsewhere in the learning.  4. To consider the emergency response and incident management arrangements for all agencies involved with this case and whether these can be improved.  7.14 CO5’s actions when he became aware that Callum was in difficulty in the tree were inadequate.  Thankfully few people will ever find themselves in a situation such as this and no-one knows quite how they would react in such a situation.  Nevertheless, CSWS needs to consider how children’s home staff can be trained to deal with emergency situations (see paragraph 8.3).  7.15 The initial response from the emergency services was appropriate for a young person who was stuck in a tree, as was believed to be the case based on the information that had been provided by the care worker.  Subsequently, when the seriousness of the situation became apparent the emergency services responded in line with policy.  Three potential policy and practice changes to the response of the emergency services have been identified for further consideration by those services: a. The Ambulance Service currently use the highest category of response in cases where it is reported that the casualty is not conscious and not breathing and the second highest category when it is not known whether or not they are conscious and breathing.  The SCR Panel query whether this policy should be amended to require that the highest category of response be used for this latter group.  Using the higher category response would not have made a difference in this case but may do in another situation (see paragraph 8.9). b. Based on information provided, the Fire Service followed policy by sending one appliance to Callum.  The Fire Service are to consider whether it would be appropriate to change this policy to require the full attendance of a Rescue at Height for any call stating people are involved where height is a safety consideration (Recommendation made by the Fire Service).  c. Calls into emergency services cannot be transferred between the different services.  Therefore information has to be passed from one service to another without direct input from the caller.  This has the potential for relevant information to be missed at the collection stage or inaccurately passed between services.  The Police, Ambulance and Fire Services should work together to identify how this can be addressed (Recommendation made by the Fire Service).   5. To identify whether there are improvements to be made to information sharing processes which could improve care arrangements and the management of risky behaviour.  7.16 Inconsistent and incomplete attendance at Looked After Children Reviews inhibited good quality information sharing.  CSWS need to ensure that robust arrangements Overview Report – Child B April 2018      Page 35 of 45  are in place so that all appropriate agencies and individuals receive invitations.  Equally, agencies which would expect to be invited to a Looked After Children Review need to put in place arrangements to ensure that when an invitation is received it is passed to the most appropriate person.  Agencies and individuals should also take some responsibility for ensuring that they know when the next review is due and for making contact with CSWS if an invitation is not received (see paragraph 8.7).  7.17 The children’s home staff should have been more pro-active in keeping school staff appraised of significant incidents relating to Callum such as bullying, aggression and self-harm.  If school staff considered that this was not happening they should have made children’s home staff aware of this (see paragraph 8.8).    7.18 There should have been prompt communication from children’s home staff, the GP and the school nurse to inform the CLA nurse of episodes of self-harm.  LCH have identified that the CLA nurse should ensure that the children’s home staff are familiar with the role and responsibilities of the CLA nurse and know when it is appropriate to contact her (see paragraph 8.8).    7.19 Better communication is required between agencies to share information about risk (see paragraph 8.8).    6. To consider whether all aspects of Callum’s care and behaviour where brought together and contributed to a comprehensive appreciation of his needs and how to manage them.  7.20 This report has identified that Callum’s behaviour fluctuated whilst he was living at the children’s home.  There were times when he was quite settled and other times when he exhibited a range of challenging behaviour.  There is some evidence to suggest that the more challenging behaviour occurred when the children’s home was generally unsettled due to the behaviour of other residents and when Callum was stopped from going out alone.     7.21 Various aspects of Callum’s care and behaviour were brought together at Looked After Children reviews to inform the care plan.  There is evidence that specialist support was accessed to try to address Callum’s needs but he would not always engage with the services that were provided.  There was a thoughtful approach to how and when support was offered in an attempt to work at Callum’s pace and not to overwhelm him.  There is also evidence that Callum was supported to maintain contact with family members and to see his girlfriend.  7.22 Not all appropriate agencies attended Looked After Children Reviews on a consistent basis and although other meetings such as Safeguarding Meetings and PEP meetings took place but there was never an occasion when all the agencies providing support to Callum met together.       7.23 A more co-ordinated response would have been appropriate when Callum inflicted injuries upon himself.  In particular the CLA nurse should have been made aware of the first two incidents and it could reasonably have been expected that the GP, school nurse and children’s home staff would have done so.  Children’s home staff Overview Report – Child B April 2018      Page 36 of 45  should also have listened to Callum’s explanation of why he had scratched himself rather than deciding that he had copied another resident.  This response suggests that practitioners should be reminded of the self-harm and suicide protocol previously issued by Leeds Safeguarding Children Board, Leeds City Council and the NHS (see paragraph 8.4).     7.24 Although it was decided at Callum’s Looked After Children Review in March 2015 that enquiries would be made regarding a possible foster placement this was not done and inconsistent and contradictory statements were made about whether the long-term plan for Callum was to remain in residential care or to move to a foster placement. It is unclear whether or not this degree of uncertainty was known to Callum and whether it affected him.  7. To consider how learning from this review can inform wider systems learning and improvement of local services and interagency cooperation.  7.25 The learning identified within the preceding paragraphs is relevant to the wider safeguarding community within Leeds and should be disseminated to all relevant practitioners.  8. Areas Requiring Action   Within their reports agencies have identified actions that they have taken since the death of Callum and other actions they will take.  These are included in appendices 3 and 4 respectively.    This review has identified the following areas where the LSCB should consider requiring action to be taken:  1. To strengthen children’s home risk assessments by requiring the following changes to the development and review of risk assessments: a. Young people should be involved in developing and monitoring their risk assessments (see paragraph 7.3).  b. Risk assessments must be reviewed at an agreed frequency and kept up to date (see paragraph 7.4).  c. Risk assessments should detail the action to be taken if a young person is in a risky situation and the carer(s) present cannot resolve the situation safely (see paragraph 7.1).  d. Where actions are taken with the aim of reducing a young person’s risk-taking behaviour the impact of that actions needs to be measured and recorded whenever the risk assessment is reviewed (see paragraph 7.6).  e. For every risk assessment, consideration should be given as to what specialist advice is required to complete the risk assessment and who should be made aware of the risk assessment (see paragraph 7.5).  Overview Report – Child B April 2018      Page 37 of 45  2. Care arrangements at children’s home should be structured to minimise the possibility of a member of the care team not complying with a young person’s risk assessments and care plan (see paragraph 7.10).   3. Staff who provide care to children and young people should be equipped to deal with emergencies (see paragraph 7.14).  4. Agencies should ensure that staff are aware of the suicide and self-harm guidance and that its use is embedded in practice (see paragraph 7.23).    5. Agencies should ensure that staff are aware of the ‘resolving professional disagreements and escalation’ procedure and that its use is embedded in practice (see paragraph 7.11).    6. Robust arrangements are required so that all appropriate agencies and individuals receive invitations to Looked After Children Reviews (see paragraph 7.16).  7. Agencies which would expect to be invited to a Looked After Children Review need to put in place arrangements to ensure that when an invitation is received it is passed to the most appropriate person.  Agencies and individuals should also take some responsibility for ensuring that they know when the next review is due (see paragraph 7.16).  8. Better communication is required between agencies caring for children and young people, including the children’s home, school, CLA nurse and GP (see paragraphs 7.17 – 7.19).  9. Yorkshire Ambulance Service should consider whether to amend their response categories to require that the highest category of response be used when it is not known whether or not an individual is conscious and breathing (see paragraph 7.15a).          Overview Report – Child B April 2018      Page 38 of 45  Appendix 1 – Key Lines of Enquiry  1. Critically comment on the efficacy and robustness of the risk assessment arrangements for (a) Callum and (b) vulnerable young people looked after whose behaviour places them at risk of harm. 2. Evaluate the effectiveness, or otherwise, of how the risk assessment was managed and implemented in practice for this case.  3. How effective was the management and supervision of the care worker tasked with implementing the risk plan? 4. Consider to what extent Callum’s behaviour and needs were unusual or extreme, or required specialist support and whether this was available and used?  5. Examine whether there were any previous concerns, incidents or indications which might have signalled any risks of self- harm or given rise to other concerns 6. Investigate how any previous incidents of risky behaviour were managed and whether there was learning from these to inform Callum’s care plan. 7. Consider whether there were any significant changes in behaviour and relationships that might have indicated increased risk of violence or harm 8. Examine the inter and intra agency communication regarding Callum and whether there were gaps in information sharing that impacted on the risks he faced. 9. Review whether Callum ’s relationships with adults and peers was analysed to inform care planning and risk management 10. Consider whether appropriate professional curiosity was exercised by those professionals and agencies working with Callum   11. Identify whether those working with Callum had a shared understanding of his needs and the risks he faced. 12. Review how care planning and case oversight by Callum’s social worker and IRO was linked to the day-today management of his care by the residential home. 13. Consider Callum’s experience of School and how his behaviour and engagement differed from that in his residential setting or elsewhere. 14. Consider the sequence of events surrounding the incident and whether all reasonable actions were taken at the time by agency personnel.  15. Review how information was gathered and recorded about the incident and Callum’s death and how this was used to inform learning and investigations.     Overview Report – Child B April 2018      Page 39 of 45  Appendix 2 – Abbreviations   ADHD - Attention Deficit Hyperactivity Disorder  CAMHS – Child & Adolescent Mental Health Services CCG – Clinical Commissioning Group CLA – Child Looked After  CO – Care Officer CSWS – Children’s Social Work Service EDT – Emergency Duty Team EHC – Education Healthcare  IRO – Independent Reviewing Officer KLoE’s – Key Lines of Enquiry NSPCC - The National Society for the Prevention of Cruelty to Children  PEP – Personal Education Plan THW1 – Boys and Young People’s Health Worker  RHM – Registered Homed Manager SEND – Special Educational Needs and Disability SILC – Specialist Inclusive Learning Centre SUDIC - Sudden Unexpected Death in Infants and Children  SW – Social Worker TA – Teaching Assistant TM – Team Manager   Overview Report – Child B April 2018      Page 40 of 45  Appendix 3 – Actions taken by agencies since the death of Callum as reported in agency reports   Barnardo’s Barnardo’s has a Health and Safety Annual Quality Assurance process where individual risk assessments are sampled.  In 2016/2017 it was identified that files have individual risk assessments where applicable.    Health and Safety and Safeguarding are standing items on staff supervisions.  Clinical Commissioning Group All GP Practices in Leeds have been written to, to remind them of the need to regularly review the Health Care Plans of Looked After Children and Young People to identify any unmet health needs, or requirements for further assessment and/or referral to another health agency.  All GP Practices in Leeds have been sent the electronic link to The RCGP/NSPCC Safeguarding Children Toolkit for General Practice.  All GP Practices in Leeds have been written to remind them to take the opportunity where possible to speak to children and young people who attend surgery for whatever reason following an episode of self-harm to ensure they are receiving appropriate care and support.  Leeds City Council Children and Families (Children’s Social Work Service) There are already significant developments taking place at a strategic and operational level with regard to the development of an integrated EHC process for children and young people with SEND.   CSWS have stated that since Callum died the children’s home has introduced the following changes to the risk assessment process:  The completion of risk assessments are now the responsibility of the two managers in the home. These are completed in consultation with each child’s key worker and are an outcome focused document;   Risk assessments are shared with the care team and there is a requirement that each member of the care team signs to evidence that they have read and understood the content;   There is a single, overarching risk assessment for each young person; Assessments are saved at each review as a standalone document which ensures changes to presenting risks can be evidenced and analysed over time.  Leeds City Council Children and Families (Education) The report author will ask the Chair of the LSCB Education Reference Group to send a reminder to all schools to instigate a formal pupil risk assessment plan for all pupils known to be self-harming.  Overview Report – Child B April 2018      Page 41 of 45  West Yorkshire Police Action has been taken to improve consistency in respect of risk assessments for missing children and a process of internal audit is continuing to provide oversight of Force performance in this area.   Overview Report – Child B April 2018      Page 42 of 45  Appendix 4 - Recommendations included within Agency Reports  Barnardo’s - Leeds Children’s Rights; Looked After Children  1. On receipt of a referral or a self-referral from a young person then it needs to be explicit within the referral protocol that existing risk assessments should be requested as soon as practicably possible.  2. To build into an initial referral/assessment meeting a check list that ensures that workers are aware of existing risk assessments for working with the young person and to undertake their own risk assessment.  3. To ensure that when working with the same young people across Barnardo’s services that risks and relevant information is shared.  Leeds City Council Children and Families (Children’s Social Work Service)  1. Regulation 44 and external inspection findings that relate to staff supervision in Children’s Homes in Leeds to be collated in a quarterly report and submitted to the Children’s Services Practice Improvement Meeting.  2. For Local Authority residential homes to design and implement processes in which risk assessments for children and young people can be developed, alongside and in partnership with, relevant partners including professionals and family members where appropriate.   West Yorkshire Fire & Rescue Service  1. Attendance at Incidents a. To consider if appropriate any call received into Fire Control stating people are involved where height is a safety consideration to mobilise the full attendance of a Rescue at Height (Pre-determined attendance -  PDA).  b. For the data to be collated on number of incidents we attend where height is a factor in the mobilisation.   c. To identify where height has been highlighted and the request for makeup of resources has occurred.  d. To consider how many times this request would be made and if adopted would it adversely affect Fire Cover.  Overview Report – Child B April 2018      Page 43 of 45  e. To be sent for consideration to Area Manager, Operations and the Technical Operational Knowledge Officer (TOKO) to consider if a multi-agency response to the request is appropriate.  2. Sharing Learning between Emergency Services. a. To consider where Emergency Services work together at an incident where death or serious injury has occurred following Suicide, a multi-agency debrief is routinely organised to establish any learning.  b. Emergency Services frequently work together at suicide incidents; we should establish a best practice approach to these events.  c. There are already established groups who meet to discuss incidents and share learning but they currently do not incorporate suicide.  d. To be sent for consideration to Area Manager, Operations and the Technical Operational Knowledge Officer (TOKO) to consider if a multi-agency response to the request is appropriate.  3. Call Transfers between Emergency Services a. Calls into Police and vice versa to Fire are unable to be transferred maintaining caller on the line to any other Emergency Services. This has the potential for information to be missed or not gathered in the specific way for the responding service.  b. To share learning across the call received where the need to mobilise a different service to the incident than the one initially requested occurs to identify the communication strategy used.  c. Explore any system that can be adopted to allow this function to happen.  d. Engage Police and Ambulance to establish if this would be practical and assess potential impact on service delivery and budgets.  e. For this to be discussed there needs to be some collaborative working between Control Rooms to come together and share learning. Currently this has previously been tried but due to constraints and service priorities this has not come to fruition.   f. To be sent for consideration to Area Manager, Operations, Technical Operational Knowledge Officer (TOKO) and Station Manager Control to consider if a multi-agency response to the request is appropriate.  4. Direction on Casualty Care in relation to Suicide a. Policy / Guidance are not currently in place to direct WYFRS crews on actions when attending incidents involving suicide.  Overview Report – Child B April 2018      Page 44 of 45  b. To liaise with the Clinical Medical Director to ascertain our actions when attending suicide incidents. To discuss if our protocols are in line with YAS and adopt a position in line with our service delivery aims.  c. Any change in policy or guidance can be circulated as an Operational Policy Information Document to all operational personnel.  d. Guidance to support crews attending such incidents would assist both the OIC and Firefighters to develop a tactical plan to manage the incident and support other Emergency Services at scene.  e. To be sent for consideration to Area Manager, Operations, Technical Operational Knowledge Officer (TOKO) and Clinical Medical Director to consider if a multi-agency response to the request is appropriate.  Leeds Community Healthcare  The author has identified three learning points to take from this review: 1. The school nurses to document any knowledge of a child attending A&E even if they have not been involved in the event leading to that presentation.  For school nurses to share that information with the other relevant health professionals having contact with that child to ensure all health practitioner awareness.   Action Named Nurse for Safeguarding Children to approach school Nurses regarding documentation of A&E attendance and information sharing.  Action taken The named nurse for safeguarding children for Leeds Community Healthcare has met with a senior school nurse and the school nurse clinical lead regarding the need to accurately document any attendances at Emergency Departments.  Information has been circulated to all SILC school nurses highlighting the importance of accurate record keeping and sharing information with other colleagues on a need to know basis.  2. There appears to be an area of improvement in terms of communication between children’s home staff and the CLA nurse. I have suggested that the CLA nurse approach children’s home staff to update them regarding her role and responsibilities to assist improved working practices.  Action  CLA nurse to approach children’s home staff and update them regarding her role.  Action taken The CLA nurse who works with the children’s home where Callum lived has had a discussion with managers in the home regarding her roles and responsibilities and the need for relevant information to be shared with her.  Overview Report – Child B April 2018      Page 45 of 45  3. Senior CAMHS Psychologist acknowledged that information could have been documented more clearly.  This has been highlighted to other senior CAMHS practitioners for them to cascade to all CAMHS practitioners via an email.    Action taken CAMHS have disseminated an email to remind practitioners of the importance of clear accurate documentation.  Leeds Teaching Hospitals Trust  The agency report author will ensure that the standard for the Trust’s record keeping audit does measure the issue of how practitioners record their name, signature and status. 