Death by suicide of a 16-year-3-month-old girl in January 2017. Rachel lived with her mother and younger sister; she had frequent support from her father and his partner. Her family, school and local Child and Adolescent Mental Health Services had been concerned about her wellbeing for some time including a risk of self-harm, suicidal ideation and acts. She became known to her GP, the local Emergency Department, ambulance services, police and children's social care. The family is White British. Findings: the reliability of a young person taking prescribed medications and the possibility of secreting medication to use later to overdose; the LSCB should seek to learn from the wider picture and research into adolescent self-harm and suicide to consider prevention and treatment options in the commissioning and provision of local services; teachers may not have had training in young people's mental health especially acute mental ill-health and its management; the need to increase understanding of the impact of social media on young people's decision-making and actions. Recommendations: expedite publication of a Local Strategy for Prevention of Suicide by Young People and whether this should be a Strategy to prevent harm and suicide by young people; to raise awareness and learning between schools about children's mental health and risk; to seek reassurance from partners that there is a robust and coordinated response to suicide by a young person, to identify and mitigate the impact on other children and young people.
      
 Title:  Multi-agency case review: Rachel. LSCB: City and Hackney Safeguarding Children Board Author: Malcolm Ward Date of publication: 2019  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.                                   Multi-Agency Case Review   Rachel                          March 2019                    Malcolm Ward Independent Reviewer  1    Contents page Background Summary 2 Synopsis of Events from December 2015 to January 2017 4 Family views about services received, what may have helped Rachel, lessons learned and possible actions  24 Practitioners’ Views  36 Findings 41 Recommendations 60 Appendixes:   The City & Hackney Safeguarding Children Board Response (CHSCB) and Partner Agencies’ Responses to Rachel’s death   63  Relevant findings from research into suicide by children and young people   64  Reading 68 Useful Organisations / Resources 69                2   This multi-agency review seeks to learn from the tragic death of Rachel who took her life in January 2017. It also makes recommendations to the City and Hackney Safeguarding Children Board and its partners to seek to improve responses to children and young people’s mental health, self-harm and suicide.   Rachel was 16 years and 3 months when she died. Her family, school and local Child and Adolescent Mental Health Services (CAMHS) had been concerned about her well-being for some time; including a risk of self-harm, suicidal ideation and acts. She had also become known to her GP, the local Emergency Department, the London Ambulance Service, the Police and Children’s Social Care.   Rachel lived with her mother and younger sister. She had frequent contact with and support from her father and his partner. The wider maternal family, including Rachel’s uncle, aunt and grandparents, also provided regular direct care and support.  The family is White British, of professional background. Rachel attended a local secondary school where she progressed well and was seen to be bright and academically able; she was predicted to do well. She was also involved in local youth activities, in sports, in politics, and she played music. She had a close group of friends at school.   1. Background Summary  1.1. Concerns about Rachel’s emotional wellbeing were first raised at primary school in 2005 by her Mother who questioned whether Rachel had some form of autism. Rachel was referred to the Child and Family Consultation Service (a forerunner to CAMHS) for soiling and concerns about her reaction to her parents separating. She was seen by a Nurse Practitioner.   1.2. In autumn 2009 Rachel, age 9, was referred to First Steps, a tier-two Psychology Service, which was part of the local Primary Care Trust Services. There was concern about her behaviour, including fighting with her younger sister and challenging parental control by threatening to jump off a balcony. Her mother questioned whether she may have Asperger’s Syndrome, however, it was noted that she was able to show empathy for friends. She was assessed to have secure attachments and a good family support network. There were meetings with Rachel, Rachel and her mother and finally Rachel, her mother and sister. These were to help Rachel’s parents develop strategies to manage Rachel’s behaviour, for Rachel to learn to manage her emotions, such as anger, and to improve the relationship with her sister. Rachel’s mother was offered the opportunity to return for further assessment  3   after four months if these approaches had not worked. Rachel did not wish to follow up with a different practitioner; the original person she had seen was on family leave.   1.3. It is noted in later health records that in 2011 there were several incidents of Rachel ‘running away’.  1.4. Rachel’s mother informed this review that in 2013 she had spoken with the school as Rachel was unhappy and wished to move school. Rachel’s mother had asked the school for help. Rachel’s mother gave a background of Rachel having called the police when she was upset with her mother. The school was also advised of Rachel having run away and of concerns when Rachel was at primary school and that she had been referred to First Steps while at primary school.   1.5. In July 2015, Rachel’s mother raised with the secondary school whether some of Rachel’s behaviour may have a link to autism. Rachel was seen by the school counsellor from October 2015 to discuss this and other matters; she attended three sessions but did not attend two others. Rachel said that she did not wish to continue the meetings. She was not referred by the school for further testing as she was not judged to be showing autistic behaviour. This was not what the family had understood from their feedback from the school, at the time. Later tests show that Rachel did not score highly on the autistic spectrum scale.   1.6. In early December, Rachel attended her GP, alone, reporting low mood / depression and self-harm over the previous six months.  Rachel also disclosed an overdose of aspirin, two days previously. Rachel had concealed the ongoing self-harm from her mother. She had been encouraged to attend the GP by a friend.    1.7. From this point Rachel became a patient of CAMHS, she was provided with community adolescent mental health services, was for periods a day patient or an in-patient of an adolescent psychiatric service and continued to go to school. At critical points when she self-harmed or attempted to take her own life she became known to the ambulance service, the local emergency department and the police.   4    2.  Synopsis of Events from December 2015 to January 2017   December 2015 – end of January 2016 (Rachel 15 yrs 3 months - 15 yrs 4 months)    Recognition and increasing concern about Rachel’s emotional state, self-harm and suicide risk and its management in the community  2.1.  The GP appropriately referred Rachel to CAMHS and discussed with Rachel the need to inform her mother of the symptoms; to which Rachel agreed.  CAMHS saw Rachel two days later for an urgent assessment; her mother was present. A Safety Plan was agreed, pending the start of treatment in CAMHS in three weeks.    2.2.  Two weeks later, just before Christmas, CAMHS responded to Rachel’s father’s request for information about the treatment plans and agreed to keep him informed.   2.3.  At the end of December 2015, Rachel was seen with her mother.  The initial assessment was that this was a depressive episode of moderate severity with underlying perfectionistic traits.   There was also a question about possible autistic spectrum disorder. A Safety Plan was agreed with Rachel and her mother about emergencies and safety at home. Treatment options to be considered were medication (Rachel’s mother was not sure about medication at that point but agreed to consider it in the future if necessary) and cognitive behavioural therapy, minimum weekly. Rachel was to be assessed for social communication as part of an autism assessment.  The Multi-Disciplinary Team was to be consulted about options.   2.4.  In the first week of January 2016, Rachel and her mother attended CAMHS. Rachel described finding everyday self-care as difficult and was anxious about how she would cope with the rest of the academic year and education over the next few years. She had found the return to school difficult. She had not been sleeping well, had continued to self-harm most days and had had suicidal thoughts. The Safety Plan had deterred her from acting on those thoughts. The Safety Plan was revised after separate discussions with Rachel and her mother and then agreed with by both.  Rachel was to speak with her mother if she felt anxious. The overall view was that Rachel had insight and was slightly improved from her assessment in December 2015. She was thought to have experienced a moderate depressive episode with possible autistic spectrum traits. Options for treatment were discussed and Rachel’s mother expressed a preference for psychotherapy rather than  5   medication (fluoxetine1), which CAMHS had suggested; although Rachel’s mother agreed to look further into this. Rachel agreed to a psychotherapeutic approach. Options for day or in-patient care were also discussed if the risks were to increase further. An autistic spectrum assessment was completed by Rachel’s mother on behalf of Rachel.  Rachel’s father attended the assessment, unexpectedly. It was agreed with him that he would not join but would be updated after it. In that later conversation he stated that he thought that Rachel had autistic traits. It was agreed how CAMHS would keep him informed about future appointments.    2.5.  During the weekend, Rachel was very anxious about returning to school on the Monday, she was not sleeping well. During the night she had barricaded herself in her room and cut herself; she refused to go to her father as planned. Her mother contacted CAMHS by phone on the Monday morning to report this. She also wanted more information about the proposed medication. She was uncertain about keeping Rachel safe.  An urgent appointment was made for that afternoon with mother and father; Rachel did not attend.   2.6.  In that appointment the parents’ concerns about the possible side-effects of medication (including suicidality) were discussed, and written information was given about possible side-effects. It was agreed to start fluoxetine at 20 mg, alongside psychological therapy. Hospital admission was also discussed, and it was agreed that Rachel’s parents would talk with her about this because of the seriousness of the situation and suggest that she visit the Adolescent Unit.  The Safety Plan was revised; Rachel was not to be left alone, she should either be at school or under adult supervision and hospital admission should be considered if there was further risky behaviour. The family established 24 hour a day supervision.   2.7.  CAMHS monitored the situation the following day by phone, there was some improvement.  Rachel went to school. On the next day Rachel was seen at CAMHS, with her mother. She had started the fluoxetine and reported feeling ‘no worse’. She was anxious about not missing lessons at school and about the potential impact on her exams. Rachel was still self-harming and had suicidal thoughts three to four times per week but did not think she would try to take her life, unless things became worse. She disliked the increased adult supervision and did not want hospital in-patient treatment but accepted that it would be considered if things were worse.  Rachel agreed to try and talk more with her mother and was happy to be referred to the CAMHS Adolescent Team. It was agreed that Rachel                                                  1 Fluoxetine is a type of antidepressant known as an SSRI (selective serotonin reuptake inhibitor). It can be used for children over 8.  https://beta.nhs.uk/medicines/fluoxetine/      https://www.nhs.uk/conditions/antidepressants/  6   would have weekly CAMHS appointments and that a Care Coordinator would be appointed to meet her twice per week. The Safety Plan was updated, a family member would stay over the weekend to support Rachel and her mother. It was noted that the self-harm and risky behaviours were escalating, and that hospital admission may need to be considered.   2.8.  The same day Rachel’s mother confirmed by phone to CAMHS that she had updated the school. The school had requested information direct from CAMHS about Rachel. Rachel and her mother agreed that they would provide copies of the CAMHS update reports to the GP to the school.     2.9.  The following Monday, Rachel’s mother contacted CAMHS requesting an urgent appointment as Rachel had suffered from nosebleeds, was having difficulty waking in the morning and mother thought that Rachel may prefer to discuss her dark thoughts with someone other than her. She wondered if these factors may be side-effects of the fluoxetine. An appointment was arranged for that afternoon.   2.10.  Rachel was initially seen alone by the Care Coordinator; they were later joined by mother. There was evidence that new cuts to Rachel’s arms were more serious than previously seen.  Rachel saw the self-harm by cutting as a relief and ‘one of the things that kept her alive’. The Safety Plan was revised.   2.11.  Rachel was seen mid-morning by a CAMHS Medical Doctor (Speciality Trainee in Psychiatry), with her mother, and was assessed to be in an agitated state. Rachel thought the violent thoughts of self-harm she was having were increasing – but on further exploration it was assessed that they were similar to those before she commenced fluoxetine. She had also shown some suicidal behaviour.  It was agreed to continue the fluoxetine but to monitor closely and for mother to inform CAMHS of any further incidents. The risk was seen to be increasing and admission to an in-patient unit was to be considered if the situation became worse.     2.12.  Mother contacted CAMHS after the weekend asking for an urgent appointment. There were questions as to whether Rachel was having a negative reaction to the fluoxetine, with a physical reaction and increased suicidal thinking.   2.13.  Rachel and her mother were seen later that day by the Care Coordinator. Rachel was keen to continue the medication. She had cut her arms more seriously. The Safety Plan was reviewed.  The family was continuing to monitor Rachel during the night.   2.14.  In the early hours of the following morning, Rachel’s mother contacted the Mental Health Trust Crisis Line as Rachel had attempted to use a ligature round her neck. Rachel’s aunt  7   had found and cut Rachel down from a shower fixing.  Mother agreed that the situation could be managed at home, monitoring Rachel at all times with another adult rather than taking Rachel to the Emergency Department.   2.15.  Rachel and her mother were seen by CAMHS that afternoon. The risk was seen to have increased, with Rachel having planned to kill herself over some days. Although the parents had hoped to keep Rachel out of hospital it was agreed to admit her as a day patient to the Adolescent Unit, as soon as possible.  On further clinical advice it was agreed to stop the fluoxetine. Rachel’s father was also consulted, he also agreed to the admission.  That evening it was agreed with Rachel and her mother to prescribe Promethazine2 to help Rachel sleep.  Sertraline3 was also considered as a replacement for fluoxetine (but not prescribed). Admission to the Day Unit was being planned.   2.16.  Two days later Rachel and her mother were seen by the Care Coordinator. The situation was described as worse with Rachel having strong suicidal thoughts and agitation. The previous night Rachel was found to have hidden a lanyard under her pillow.  Rachel’s mother hoped that the day unit would be preferable to in-patient admission, in the first instance.   2.17.  Rachel’s father contacted CAMHS to discuss his worries and question whether Rachel should be admitted to hospital, especially if new medication (sertraline) was to be tried. He was advised that Rachel and her mother did not want Rachel to be admitted to a unit outside London.   2.18.  The next day a meeting was held at the Adolescent Unit with Rachel and both her parents to plan her admission to the Day Unit three days later (with the possibility of the family ringing the Acute Unit over the weekend, if necessary) over the weekend.    February 2016 – mid-April 2016 (Rachel 15 years 4 months to 15 years 7 months)   Rachel as a day patient in the Adolescent Day Unit  2.19.  Rachel first attended the Adolescent Day Unit at the beginning of February 2016, five days per week, with 24/7 back-up cover. Rachel initially said she felt “down all the time”, she wished to reduce her fluctuating thoughts of self-harm but was pessimistic that she could. Her thoughts were heightened at school and in the evenings. She was prescribed                                                  2 Promethazine can be sued for insomnia and has sedative and non-psychotic inducing properties  https://bnf.nice.org.uk/drug/promethazine-hydrochloride.html  3 Sertraline is a type of antidepressant known as an SSRI (selective serotonin reuptake inhibitor). https://beta.nhs.uk/medicines/sertraline/   8   mirtazapine4 for low mood, anxiety, and prolonged sleep onset latency; and a week of Zopiclone5 to aid sleep – with the aim that this would enable her to take part better in psychological therapies.  She was to have regular 1:1 Cognitive Behavioural Therapy (CBT), and Rachel, her parents and sister were to take part in Family Therapy.   2.20.  During her time in the Day Unit there were several episodes when Rachel cut herself superficially, but these reduced in frequency towards her discharge.   2.21.  On the first Sunday of March 2016, Rachel cut her arms many times and took an overdose of six fluoxetine, which she had stored from before it was stopped. She told her mother about the overdose after four hours. Rachel’s mother took her to the local Children’s Emergency Department. In assessment Rachel reported no particular trigger to this episode but said that she had wanted to end her life. She also said, despite adults in the family being protective, that if she had the chance she would do it again. She had experienced general low mood “for a year” but some days felt better. She found trying to “keep up” and “being best” at school difficult.   2.22.  After this overdose attempt Rachel improved and following adjustments to her school programme she was able to commence re-integration into school a few days a week and continue at the Day Unit the other days. A Care Programme Approach (CPA) Meeting was held mid-April 2016 and Rachel was discharged back home under the care of the CAMHS Adolescent Team. She was diagnosed with mixed anxiety and depressive disorder and continued on mirtazapine.    Mid-April 2016 – end of August 2016 (Rachel 15 years 7 months to 15 years 11 months)  Regular treatment, return to school, exams, holiday – symptoms continue but appear to be less acute  2.23.  Five days after discharge, Rachel’s mother emailed CAMHS to seek advice about particular behaviours observed in Rachel over the past ten days, including: not eating or eating then purging. Rachel’s mother queried the impact of vomiting on medication which may not be fully ingested. Other concerns included an episode of Rachel hyperventilating, occasional self-harm, worrying about school, and possibly not taking her medication (which had been observed but denied by Rachel). Mother said that Rachel had good days with friends and family but was also at times moody and argumentative. She did not want to take her                                                  4 Mirtazapine is an anti-depressant    https://www.nhs.uk/conditions/antidepressants/  5 Zopliclone is used to treat insomnia. https://beta.nhs.uk/medicines/zopiclone/   9   medicine as she thought it made her gain weight and meant she could not drink at parties.     2.24.  Rachel met with the Care Coordinator the next day. They discussed eating and purging, Rachel saw it as an alternative to self-harm and was also worried about her body image. They agreed to do further work on this area of distress and on emotional dysregulation6.   2.25.  Later that week Rachel was reviewed by the psychiatrist, both parents were present. Rachel had low mood, was binge-eating and vomiting, and self-harming when stressed. She was worried that the medication was making her gain weight. It was agreed to cease the mirtazapine and commence sertraline; information was given about sertraline. However, sertraline was not started – melatonin was increased, instead. Rachel’s parents were advised how to deal with crises. Rachel was to be reviewed a week later.   2.26.  Two days later, Rachel was admitted to the local hospital following an overdose of 25 mirtazapine; she had been secretly storing her medication for some time. The overdose was on ‘impulse’ rather than planned; Rachel was upset that she had not qualified for a youth run and also felt that she was not being allowed to assist the event as a helper. At the time of the overdose Rachel had hoped to end her life. Rachel also said that she was stressed at school, particularly about exams. She had friends that she could talk with. It was noted that this was the third suicide attempt and that Rachel was regretful of her action. Rachel’s mother was surprised at the incident as Rachel had seemed happier and more positive recently. She was treated medically for the overdose and then later reviewed by psychiatry. Rachel’s mood became stable with no evidence of psychotic symptoms or active self-harm or suicidal intent. Rachel did not wish to return to the Adolescent Unit as she wished to be at school to complete her exams.  She had insight into her situation and was willing to continue to engage in treatment. Rachel was assessed at mid-risk for self-harm and the increase in suicide attempts was noted. It was agreed that she could be discharged home and a Safety Plan was agreed with her parents (medication and sharps to be locked away and Rachel to be monitored overnight). Rachel was due to meet with her Care Coordinator the following day.   2.27.  Children’s Social Care (CSC) was informed by the hospital and contacted Rachel’s mother.  CSC agreed that there was no role for them as CAMHS was fully involved. Permission was given for CSC to liaise with the school.   2.28.  Rachel was reviewed by CAMHS the next day. Rachel had stored medication for three weeks. She was worried about gaining weight, even though she had not, and was unhappy                                                  6 Emotional dysregulation refers to difficulty in managing emotions, which may interfere with daily life.   10   about not being permitted to take part in a marathon. There was disagreement about the proposed change of medication. Rachel was willing to try but her mother wished to try non-pharmacological approaches. Rachel denied having a razor.   2.29.  At the end of the session Rachel’s father asked privately for support for himself.  He was advised about this.   2.30.  The Adolescent Multi-Disciplinary Team (MDT) reviewed Rachel’s case. It was noted that Rachel was only taking her sleeping medication not her anti-depressants. Medication was to be discussed at the next psychiatric review.    2.31.  The next day Rachel met with her Care Coordinator – they worked on positive body image. They met again the following day and started a programme of Cognitive Behavioural Therapy (CBT).     2.32.  Rachel’s mother emailed that day and again a week later, seeking advice on how to manage low points at home following an argument when Rachel had binged and vomited.  The Care Coordinator advised Rachel’s mother that she would follow this up with Rachel and also referred Rachel to the dietician.   2.33.  In the first week of May 2016, Rachel was again discussed at the Adolescent MDT. The working diagnosis was ongoing anorexic conditions, vomiting and diet restriction, emotional dysregulation with ongoing suicidal thoughts and a query of emerging personality disorder.   2.34.  Rachel was seen by the Care Coordinator and eating was discussed. Rachel was irritable and tired. Rachel’s mother emailed to say that she was at a loss and from what she had been reading she felt that quick action was needed. Rachel’s father’s partner raised concerns about the impact on family dynamics and whether she should be included in family meetings. She was not included.    2.35.  The following week Rachel was seen for psychiatric review. Emotional dysregulation was identified with self-harming urges, poor sleep, restriction of diet and excessive exercise. She was assessed as low risk to herself and others. The melatonin dose was increased. Weekly sessions for Rachel with the Care Coordinator and Family Therapy were agreed. The Care Programme Approach assessment and plan was updated. In the same week Rachel and her mother met with the dietician.   2.36.  The following week Rachel met with the Care Coordinator. She had self-harmed and was to be seen by the GP for a superficial laceration to her arm. Rachel discussed family issues.    11   2.37.  The following day the Care Coordinator discussed Rachel in clinical supervision. The supervisor was to seek further advice about treatment options. Rachel was seen as very unstable.    2.38.  By the end of May 2016, there was improvement in Rachel’s eating. At the beginning of June 2016, there was a review with the psychiatrist. Rachel’s mother was worried as she had found rope in Rachel’s room. Rachel had had fleeting suicidal thoughts but said that she had none at the time of this review.   The melatonin was increased, and the Safety Plan was revised. Rachel was seen over the next two days by CAMHS practitioners to discuss her progress and the ‘noose’ that was found.   2.39.  The following week Rachel and the Care Coordinator met for CBT about stress intolerance. Rachel worked well and showed some insight into her behaviours. The next day Rachel’s parents met the Family Therapist and before Rachel joined them, they discussed Rachel’s experimenting with cannabis use and whether it impacted on her. They had different views about this.  (Rachel’s mother later told this review that she did not think that Rachel used cannabis a lot.)  2.40.  In the session a week later with her Care Coordinator, Rachel discussed stress intolerance and was able to demonstrate that she could think about what upset her and why.   2.41.  The next day Rachel’s mother emailed to say that she had found two suicide notes in Rachel’s room. Rachel had said that she would kill herself after her GCSE exam. The Care Coordinator spoke with both mother and father to consider the implications and options. An urgent CAMHS appointment was offered for that afternoon but later declined after Rachel’s parents had met her at school and satisfied themselves that she was alright. Mother had informed school of the risk. One of the school counsellors ensured that Rachel stayed in school all day.   2.42.  The following week Rachel was again discussed at the Adolescent Multi-Disciplinary Meeting. It was agreed to refer her to the Eating Disorders Team for September.   2.43.  The next day in a Family Therapy session the parents talked about the stress of Rachel’s recent suicide notes and these were then discussed with Rachel when she joined the session.   2.44.  Two weeks later in the first week of July 2016, Rachel met with her Care Coordinator. She was stressed by the mock exams and because a friend was unwell. Rachel engaged well, and the possibility of dialectical therapy was discussed with her. She was willing to try it. In the Family Therapy session, the next day, Rachel, her mother, father and sister discussed  12   family dynamics.    2.45.  Throughout the rest of July 2016, Rachel continued to meet her Care Coordinator to work on distress intolerance and discuss her worries about her body image and eating. She was planning to go to Europe with a friend’s family.  In the Family Therapy session at the end of the month, Rachel’s mother questioned if Rachel was eating less in preparation for her holiday.    2.46.  There were no problems reported while Rachel was away on holiday with another family.    2.47.  In the middle of August 2016, Rachel did not attend the planned session with her Care Coordinator. Rachel was described as being truculent since her return from her holiday. Her mother wondered if she was worried about the upcoming exam results. Rachel was seen by the Coordinator in the afternoon. Rachel had been worried about her body while on holiday, and since her return she had been self-harming and making herself vomit. Her mood was low, and she was anxious. Rachel wanted to find a medication that was different to fluoxetine and mirtazapine.    2.48.  In the last week of August 2016, Rachel was seen by her Care Coordinator for a review. Rachel’s exam results were due the next day. Rachel said she would kill herself if she did not get an A*. The Care Coordinator alerted Rachel’s parents to Rachel’s threat by email as she could not reach them by phone and she recommended a Safety Plan.  Rachel was offered an extra session for the following day.   2.49.  In the following day’s session Rachel was lighter in mood as she had achieved two As in her GCSEs. The family had devised a surveillance plan to keep an eye on her and noted that Rachel was really unhappy with her result.    End of August 2016 – mid-October 2016 (Rachel 15 years 11 months to 16 years 1 month)  Serious overdose, self-harm, admission to Adolescent Mental Health Unit as an inpatient and later day patient   2.50.  Over the Bank Holiday Rachel overdosed on 64 paracetamol tablets. (This is a very large dose) Her mother called for an ambulance, but Rachel was taken by family to the local Emergency Department, where she was also found to have new superficial cuts to her arms.  The overdose was initially described as an anxious response to disappointment with exam results. She had intended to kill herself. Rachel actively planned the overdose by buying tablets from different shops. After taking the tablets Rachel told her mother as she felt guilty about how her mother would react to her death. Rachel then regretted telling her mother. Rachel later gave a different account of the overdose saying that she had actively  13   planned it after an argument over drinking alone and taking laxatives, however, she had been having suicidal thoughts since her exam results.   2.51.  Rachel was treated medically under the national guideline7 for a significant paracetamol overdose, and the possible impact on her liver was monitored. The hospital noted Rachel’s recent psychiatric history in its assessment and treatment. It was noted that Rachel reported drinking alcohol occasionally with friends and that she had smoked cannabis ‘a week ago’. The hospital checked with CSC and was informed that Rachel was not a current case.    2.52.  The psychiatric assessment noted the impulsivity of the act. Rachel was alert, orientated and not agitated. She described mild insomnia, and fluctuating appetite with bingeing and vomiting. She was disappointed with the exam results but unconcerned about the suicidal act. There was no evidence of thought disorder or hallucination. She did not have current intent or a plan to attempt suicide. She was assessed as a high risk to herself. Rachel’s mother was concerned about how she could set appropriate boundaries for Rachel, such as challenging her drinking.    2.53.  Rachel’s parents were worried about Rachel’s impulsivity and what seemed to be an escalation when Rachel had seemed to be ‘getting better’. Rachel and her parents agreed to Rachel being admitted as a voluntary in-patient to the Adolescent Mental Health Unit. Rachel’s father agreed with medication. They were keen to get a diagnosis for Rachel. Rachel transferred to the Unit the following day.    2.54.  The Emergency Department referred Rachel to CSC which agreed to undertake a Child and Family Assessment.  Rachel and her sister were both seen as part of this assessment and Rachel’s mother was consulted. It was agreed that there was no role for CSC as CAMHS was working intensively with the family, there were no safeguarding concerns in terms of family relationships, home environment or parenting and that the family was able to provide appropriate supervision (it was noted at the time of the assessment that Rachel was an in-patient).    2.55.  Rachel settled well in the Adolescent Unit and formed good relationships with staff and peers. She participated well in therapies and other activities and with the psychology team. Rachel and her family continued with the Family Therapy.  In mid-September 2016, Rachel had her first overnight home visit. Despite suicidal thoughts she did not act on these as she                                                  7 Treating paracetamol overdose with intravenous acetylcysteine: new guidance; Dec 2014 https://www.gov.uk/drug-safety-update/treating-paracetamol-overdose-with-intravenous-acetylcysteine-new-guidance  14   was worried that it would cause an extension of her stay as an in-patient. Rachel also demonstrated that she was aware of techniques to use to prevent her harming herself. There were no subsequent reports of her having had suicidal thoughts during home leave. At the end of September 2016, it was noted that Rachel was unkempt and that she had not been showering; she also reported self-harm and fluctuation in eating and vomiting.    2.56.  Rachel transferred to the Adolescent Day Service at the end of September after the CPA was updated. She started a gradual re-introduction to school and was back at school full-time within two weeks. Rachel and her parents started Group Dialectical Behavioural Therapy (DBT)8. Rachel was discharged from the Adolescent Unit back to the CAMHS community-based service in the second week of October 2016; the Family Therapy was to continue under the community service, as before. Her medication had been reviewed and she continued on melatonin only.   2.57.  The school and GP were kept informed of Rachel’s overdose and subsequent care and treatment. The Adolescent Unit Education Department liaised with the School about Rachel’s school work and exam preparation. There was good contact between the two agencies.  A member of staff from school visited the Unit.    Mid-October 2016 – mid-December 2016 (Rachel 16 years 1 month to 16 years 3 months)  A further serious overdose, self-harm, discharge back to community, further self-harm, change of key CAMHS workers, anxiety about exams, consideration of medication   2.58.  Rachel and her family continued with DBT sessions and Rachel had individual sessions with her Care Coordinator.  In the week after her discharge from the Adolescent Unit no concerns about self-harm or suicide were noted.   2.59.  However, 10 days later, at the end of October 2016 in the late evening, Rachel attended the local Emergency Department with her mother having again overdosed on 64 paracetamols.  There was also evidence of recent cutting to her arms. Rachel had argued with her sister and later gone to a party where she had got drunk, before buying the paracetamol and taking the overdose. (Rachel’s mother believes that Rachel planned the overdose before the party.) Rachel called an ambulance and was assisted by a passer-by who called her mother. At hospital, she was treated medically for the overdose and seen for a psychiatric review. Rachel described feeling “low” lately. Her affect was flat but there were                                                  8 Dialectical behaviour therapy - a talking treatment based on cognitive behavioural therapy (CBT), but adapted to help people who experience emotions very intensely. https://www.mind.org.uk/information-support/drugs-and-treatments/dialectical-behaviour-therapy-dbt/#.WxvSEPZFzIU   15   no concerns about her orientation or her mental state and she had insight into what had happened. This was again seen as a serious overdose. There was a question about whether Rachel had been taking her melatonin – she reported that she was not good at taking it when on school holidays, as there was no regular routine. The concern about eating and vomiting was reduced.  Rachel was assessed to be at high risk of self-harm but there was no evidence that Rachel intended to kill herself with this overdose. Her low mood and alcohol were factors in the overdose, but she had sought help quickly.   2.60.  It was agreed with Rachel and her mother that Rachel would return home; she did not wish to return to the Adolescent Unit. Rachel and her mother were to agree ‘crisis plans’ and Rachel was to be seen by CAMHS again the next day. Rachel and her mother met the next day with the Care Coordinator and a psychiatrist who was newer to Rachel, as the previous Consultant had left the Trust. The weekend admission was reviewed again. Rachel had been affected by the recent suicide of a young person from her school. She had no current plans to end her own life and wished to continue working with the CAMHS Community Team rather than go back to the Adolescent Unit. The possibility of re-starting medication was discussed; Rachel was only prescribed melatonin at this time. The Care Coordinator agreed to work with Rachel and her mother to support re-integration to school.    2.61.  Four days later, at the beginning of November 2016, Rachel and her mother attended the DBT group and met afterwards with the Care Coordinator. The impact of the other young person’s death was discussed by Rachel in the DBT group. Rachel’s mother talked with the Care Coordinator about the impact on her of Rachel’s health. The Care Coordinator advised Rachel and her mother that she would be leaving the Trust and there would be a careful handover and parallel working with a new Care Coordinator for several weeks. Rachel and her mother were upset by this; the psychiatrist had recently changed, too.   2.62.  Rachel met Care Coordinator 2 the following day with Care Coordinator 1. They discussed Rachel’s ‘perfectionism’ and that she was worried about being behind with her school work. Approaches to this were discussed. (Rachel’s mother believes that Rachel was not necessarily a perfectionist but was responding to academic pressure.) Three days later in a further session, Rachel and Care Coordinator 1 looked together at some school homework, which was overdue, to plan how it could be managed. The following day both Coordinators met with the Family Therapist, Rachel, her mother and her sister; they discussed tensions in relationships and how much Rachel could be prompted or challenged at home without upsetting her.        16   2.63.  Two days later Rachel attended her sixth DBT session – a ‘resource tool box’ 9 was discussed to help her self-manage the heightened anxiety and feelings.    2.64.  The next day, a Friday, the school contacted CAMHS to say that Rachel wished to speak with Care Coordinator 1 urgently. Rachel was crying and had had a sudden dip in mood. She was seen that afternoon, she was unkempt, and her hair was not washed. Rachel was worried about the approaching mock exams and was worried that the new US President had been elected.  A plan was agreed for how Rachel would manage over the weekend and it was agreed that they would meet again on the Monday for a review with the psychiatrist. (Rachel’s mother has noted, in retrospect, that it was from November when she was probably not really coping – with regard to this issue she remembers feeling numb and not knowing how to respond.)   2.65.  On the Monday Rachel attended CAMHS alone, she was unkempt; there were signs of superficial cuts to her arms. Options for continued treatment were discussed – continue in 1:1 therapy with the new Care Coordinator alongside Family Therapy, restart mirtazapine as it had no dangerous side-effects or to try a different medication. Rachel was reluctant to resume mirtazapine as it made her gain weight. It was agreed to discuss medication at the next CPA Meeting when her parents would be present.   2.66.  After the psychiatric review Rachel and Care Coordinator 1 continued discussion. The cutting was discussed. Rachel explained that it served multiple purposes – ‘to de-intensify feelings, to change her mood and as an escape’.   2.67.  In the early hours of the next morning Rachel was brought to the Emergency Department by her father, at mother’s request (Rachel’s mother has said to this review that she was struggling by this time, which is why she had asked Rachel’s father). Rachel had cut her forearm with a pencil sharpener blade, deeper than usual – saying “but I’ve done worse”. This was noted as part of an increasing pattern of self-harm; however, the pattern of self-induced vomiting had lessened. Rachel had poor sleep when she ‘forgets to take her melatonin’. She said that she had had a bad two weeks with the death of a school friend (whose funeral was that day), news about the change of her Care Coordinator and the death of her cat. Rachel was also worried about her upcoming mock exams. Medication was to be considered ‘after Christmas’.  There was no current suicidal ideation.  Rachel was assessed as having emotional dysregulation with a chronic risk of self-harm and                                                  9 The tool box in DBT: the young person is encouraged to develop a tool box for self-soothing i.e. identify all sensory activities that can assist with self-soothing during times of crisis, utilising all senses. The concept is to do activities that assist in reducing distress and help with the passing of time without resorting to maladaptive coping strategies. Examples include looking serene pictures, touching a fluffy object, listening to music, smelling a nice scent or tasting chocolate.    17   suicide rather than acute risk. It was noted that the frequency of incidents was increasing, possibly as a reaction to recent stressors – but that the risk was not worse than previously. It was assessed, with father, as safe for Rachel to return home to her mother that night. CAMHS was informed.   2.68.  In the CAMHS DBT session two days later Rachel’s mother shared that she was finding the situation with Rachel challenging and would welcome an opportunity to speak with other parents.10   2.69.  The following Monday, Rachel met with Care Coordinator 1 and described a very volatile mood that day. They explored her friendships, what Rachel enjoys and possible triggers to low mood – of which chocolate was identified.  The Consultant Psychiatrist spoke with Rachel’s mother on the phone to propose starting Rachel on medication following her mock exams after Christmas, so that she could be monitored closely.  Mother enquired if there was a diagnosis for Rachel and it was agreed that this would be discussed at the next CPA Meeting.   2.70.  That week Rachel’s mother contacted the GP to ask for a prescription of melatonin. She described Rachel as improving since her most recent overdose, going to school most days and wanting to get better.   2.71.  There was a Family Therapy session the next day – mother could not attend as she was away with work. In the 1:1 DBT session later that day Rachel talked about going to hospital as she had cut herself. The next day Rachel met with the two Care Coordinators as part of the handover between them. Future sessions with Care Coordinator 2 were agreed.    2.72.  The following Tuesday Care Coordinator 1 returned a call to Rachel’s grandmother who had care of Rachel while Rachel’s mother was out of the UK. Rachel had had a bad day and refused to go to school on the Monday. She had gone to school with the support of the school support officer on Tuesday. The grandmother was worried about how little Rachel was eating. Care Coordinator 1 agreed to raise this with Rachel at their next meeting. They met the following day, Rachel maintained that there was nothing to worry about regarding her eating. They talked about pressures at school and how Rachel might use future sessions at CAMHS. Rachel wanted to be less anxious and low in mood and she wanted                                                  10 The parent DBT group ran in parallel to the young persons’ group on a fortnightly basis. It covered developing the awareness of the impact of stressful environments on children and the level of sensitivity their children have to stressful emotional experiences. It provided group support amongst the parents which aimed to reduce feelings of isolation and shame in their experience of having a child with such a high level of mental health difficulty. Parents were also given an overview of the skills that their child was being taught so that they could reinforce them at home i.e. skills in mindfulness, interpersonal effectiveness, emotional regulation, tolerating distress and "walking the middle path" (instead of getting caught in polarised family dilemmas).  18   the medication to work.   2.73.  The next day mother and Rachel attended a group DBT session, which they both said they found helpful. Rachel’s mother shared the challenges of how to care for Rachel when Rachel was anxious and how far she could push Rachel – for example when Rachel did not shower.   2.74.  The following week, the second week of December 2016, Rachel and her mother met with both Care Coordinators. Rachel was low in mood, she had opened a school report that had been sent to the house without warning, her grades had dropped significantly. Mother was due to meet with the school to discuss an education plan for Rachel. It was clear that Rachel had recently self-harmed as blood could be seen on her shirt, but she refused to discuss this.   2.75.  The same day Care Coordinator 1 and the Psychiatrist met to consider Rachel’s medication plan. It was proposed to prescribe sertraline daily. The family was said to be concerned about use of medication because of the previous adverse reaction to fluoxetine.  Possible side-effects and support were discussed.   2.76.  Two days later Rachel met with Care Coordinator 2 and the School Counsellor. It was agreed that Rachel would not sit any mock exams and a Safety Plan was agreed; a copy was sent to Rachel’s mother. Rachel was to use some work sheets to help her resist self-harming. Rachel also attended a DBT session.   2.77.  In the third week of December 2016, Rachel had her final meeting with Care Coordinator 1. Rachel later met with Care Coordinator 2.  They agreed a Safety Plan of who to contact as Care Coordinator 2 was going to be on leave and Rachel’s mother was also going to be away.   They reviewed strategies that Rachel had learned previously to cope if she felt overwhelmed.  Rachel stated that she had some suicidal thoughts but that she was not planning to act on the thoughts. The Safety Plan was emailed to Rachel’s mother and it was noted that Rachel would be in the care of her grandparents while Rachel’s mother was away for work.    Mid-December 2016 – early January 2017 (Rachel 16 years 3 months to 16 years 4 months)  A further serious overdose, monitoring, Safety Plans for the holidays, a serious overdose, self-harm and anxiety about returning to school; finally, Rachel took her life    2.78.  The next day Rachel was brought to the Emergency Department by her aunt and the police under Mental Health Act 1983, section 136, in the evening.  She had gone missing and her family had found a suicide note. Rachel’s computer showed that she had researched how  19   to kill herself. They reported her missing to the police. Rachel called the CAMHS Crisis Line mid-evening to say that she had taken Sudafed (which contains ibuprofen) and was feeling unwell, she did not wish to go home and she had intended to kill herself. The Crisis Line called an ambulance. A member of the public also called the police when they saw Rachel in a dangerous situation. When Police found Rachel, she told them that she had taken 36 Sudafed tablets with the intention of killing herself.   2.79.  Rachel tried to abscond from hospital several times overnight; police remained and prevented her. She was admitted and treated medically for the overdose. She reported several stressors including the departure of Care Coordinator 1, her mother being away, worries about a peer who was unwell and exam stress. She had been ambivalent about ending her life the previous day and prevaricated between taking tablets and calling the CAMHS Crisis Line or ChildLine. Mother has said that Rachel used the ChildLine online service on several occasions but would never give her full identity; this did not become clear until Rachel’s computer was accessed by family after her death. At the time of this assessment, Rachel was accepting treatment and did not wish to end her life. The initial plan was to transfer Rachel to the Adolescent Unit as an in-patient under the mental health section.   2.80.  The next day, while still in hospital, Rachel was assessed by the CAMHS team. She was discharged from the section 136 and continued to be monitored on the ward under the supervision of a mental health nurse while she was being medically treated for the overdose.   She was re-assessed by a psychiatrist the next day with her father present. Her father had requested an in-patient bed at the Adolescent Unit as a voluntary patient or under section. This was not agreed as it was thought Rachel would be better treated in the community with continuing DBT. Rachel was discharged to her grandparents’ care, with additional adult supervision in place.   2.81.  CSC was notified by the police of the incident. CSC spoke with CAMHS and with Rachel’s mother and it was agreed that CAMHS was the appropriate lead agency and that there was not a role for CSC.  Young Hackney11 resources were suggested for Rachel’s younger sister, to support her. Rachel’s Mother said that she was receiving support from her GP.  2.82.  Rachel was reviewed psychiatrically at CAMHS, with her mother present, in the week before Christmas. There had been no more suicidal ideation, but Rachel had self-harmed. There was no serious adverse reaction to the sertraline, although Rachel had had a                                                  11 Young Hackney provides a range of resources for children and young people; including activities, advice and community involvement.   https://www.hackney.gov.uk/young-hackney   20   nosebleed. A plan was agreed about how mother should respond if Rachel was feeling suicidal. The Safety Plan agreed was: In a situation where Rachel felt suicidal: The first step would be using a DB strategy; the second step would be planning - with the hope that the feelings would pass; the third step would be using a crisis line. Finally, Rachel could seek help from an adult, using a yellow card to say that she needed some support, e.g. supervision for up to an hour, joining the adult in what they were doing or a red card to say that Rachel wanted or needed to go to A&E.  If the situation did not improve then the Emergency Department could be used.   2.83.  Rachel was reviewed again two days later. She felt more stable, was less suicidal and was self-harming less (Rachel’s mother has queried whether this is an example of Rachel telling staff what she thinks they want to hear). Rachel was anxious about the Christmas break. The medication was discussed, and a question was raised as to whether Rachel’s recent overdose related to worry about the new medication, but this was not conclusive. It was agreed to increase the dose after Christmas. She was also worried that her DBT sessions were coming to an end. The Safety Plan was re-confirmed.   2.84.  The next day Rachel attended her last DBT session. The following day, the Friday before Christmas, the psychiatrist and mother spoke on the phone to discuss the plans for Christmas and a Safety Plan was agreed.    2.85.  Rachel’s Mother has told this review that Rachel used the yellow card on Boxing Day night. In the early morning, the day after Boxing Day, Rachel was taken to the Emergency Department by her mother, after self-harming. She had multiple lacerations to her arms. She had tried to use the DBT techniques which had been helpful over Christmas, which she had found stressful, but that day she had not been able to follow the techniques.  However, she had told her mother about the self-harm after the event. The cutting made her feel better. She did not feel suicidal but was having frequent thoughts of self-harming. It was agreed that it was safe for her to go home under supervision and the Safety Plan. It was noted that Rachel had frequent self-harm, poor coping mechanisms, fluctuating moods and emotional unstable personality disorder.   2.86.  The next day Rachel and her mother met with Care Coordinator 2 at CAMHS. The sertraline dose was increased. Mother was worried that Rachel’s self-harming was increasing in both intensity and the areas of her body that she was cutting.  Rachel was seen to be more energetic. She said that cutting made her feel better.  She denied any suicidal thoughts. The Plan included the Care Coordinator monitoring Rachel by phone over the next few days because of the increase in medication.     21   2.87.  In the Family Therapy session, the next day with Rachel, her mother and sister, the stress on family members ‘needing to walk on egg-shells’ was discussed.   2.88.  The day after the New Year 2017, Rachel was seen by Care Coordinator 2. Rachel had a good new year in with friends. Therapeutic work was done in the session and Rachel was given some therapy tasks to work on at home.   2.89.  The next day Rachel met first with Care Coordinator 2 and later they both met with the Psychiatrist and Rachel’s mother. Work was undertaken on positive approaches and how to respond to texts from friends (Rachel’s mother has said that she understood the texts between a group of friends to have been about exam worries).   It was agreed that Rachel would return to school the following day (Thursday) – a Safety Plan was agreed around this. There were no current suicidal thoughts. She was using coping strategies effectively to manage her thoughts about self-harm. There were no major side-effects to the increase in sertraline, but Rachel did report headaches. She was concerned about returning to school the next day and had planned to contact the school counsellor in advance.   2.90.  The next day Rachel went missing instead of going to her father’s house which had been arranged as she felt that she could not go back to school, as planned.  She rang her mother and told her that she had taken 30 paracetamol and codeine tablets. She did not want the police involved and did not want to go to hospital. She was found and taken by police, with mother, to hospital on section 136.  It was also suggested that she had taken 40 tablets and that 35 tablets were unaccounted for. Rachel was seen alone initially but later with her mother and father. Rachel had taken the pills in the local park. She had been anxious about returning to school, rather than low in mood.  At the time Rachel was thought to have acted on impulse. Rachel’s mother has said that a suicide note, which had been written the night before, was later found on Rachel’s computer. At the time of the overdose she had intended to die but, in the Emergency Department assessment Rachel said that she was glad that she had not died.  She was also anxious about the change of Care Coordinator. The view formed was that the sertraline was seen to be helpful as it had increased her responsiveness, but this was to be closely monitored because of a possible parallel increase in self-harming thoughts. Rachel maintained that she was no longer actively suicidal, although she had previously told a nurse that she was still suicidal and had a plan. When later asked about this statement to the nurse, Rachel denied that she was suicidal. Rachel had mental capacity and insight. She was assessed as not being sectionable. Rachel did not want to be admitted as a voluntary patient, although Rachel had previously told the nurse that she wanted to be admitted as an in-patient. This was discussed with the psychiatrist and parents, but Rachel did not confirm it. It was assessed that it was safe for her to return home under the supervision of her parents. She was to be  22   followed up by CAMHS and the sertraline was to be reviewed as there is a risk of it increasing suicidal thoughts and behaviour. It was also recommended that the Adolescent Team followed up Serotonin Syndrome 12 regarding possible increase in anxiety.  The psychiatrist noted that Rachel was to remain at home under the supervision of her mother, or other family adults.  Rachel’s mother says that she was not advised by the psychiatrist whether Rachel should go to school or not, but that this changed later when CAMHS staff decided that Rachel would continue to attend school and called the school pastoral counsellor about this, from the hospital, before Rachel was discharged home. An appointment was made for Rachel to meet with the school pastoral counsellor the following day, Friday.   2.91.  No new safety plan was agreed. The plan in place was thus a continuation of the plan previously agreed in December (see paragraph 2.80 above). The Care Coordinator was to follow up by phone the next day with Rachel and her mother. An appointment with Rachel was agreed for the following Tuesday.    2.92.  CSC was informed of Rachel’s attendance at hospital and the circumstances.   2.93.  The next day (Friday) the Care Coordinator 2 checked Rachel’s well-being by phone. Rachel had been to school to meet with the School Counsellor to plan her return. She felt better. She was planning a quiet weekend with her mother and did not feel anxious about returning to school on the Monday. A safety plan was agreed with Rachel to speak to her Care Coordinator on her work mobile if she felt anxious, or the crisis line if her Care Coordinator was not available. Rachel was to go to school if she felt able and see the School Counsellor; and was to text her mother on arrival and departure from school. Her Care Coordinator would check in with her at the end of the day. Mother was informed of the plan. It was confirmed that Rachel and the Care Coordinator would meet the following Tuesday.  2.94.  On the Saturday evening Rachel was taken to the Emergency Department by her mother as she had self-harmed and a metal staple was lodged in her wrist. She had low mood but was not suicidal. The staple was removed, and Rachel was seen by a psychiatrist. Rachel had previously secreted the staple as a ‘back-up’ as she was denied access to other sharps. She had told her mother about the staple as she could not remove it herself and was anxious about it. Rachel was assessed as not being suicidal; coping strategies and a Safety Plan were agreed with her for either thoughts about self-harm or suicidal thoughts.                                                  12 Serotonin Syndrome  https://www.nhs.uk/conditions/antidepressants/side-effects   23   She planned to meet with Care Coordinator 2 on the Tuesday to continue their therapeutic work. Rachel was discharged home in the early hours of Sunday. (Rachel’s mother has told this review that Rachel made a point of seeing friends and family that weekend.)   2.95.  On the Monday Rachel said that she felt able to go to school. She met initially with the School Counsellor. The Counsellor was off-site for the rest of the day. Rachel became too anxious to join lessons and used the agreed Safety Plan to go to a quiet area where she could sit reading in a room where there was an administrator. At lunchtime she went out of the school. She did not return. Rachel called her Care Coordinator 2 but the call cut out.  The Care Coordinator rang back several times but was not answered.  The school contacted Rachel’s mother and informed her that Rachel had not returned to school after lunch. Rachel’s mother tried to contact Rachel unsuccessfully. Police were informed. Rachel was later found in a building in a local park where she had hidden and hanged herself. The police and paramedics attempted resuscitation, but it was unsuccessful.     2.96.  The Inquest into Rachel’s death, completed in July 2017, determined that Rachel died as a result of suicide, by hanging and that at the time of that act she intended to die.  The Coroner did not give an Article 2, narrative judgement, to seek to learn lessons from Rachel’s death.      24    3.  Family views about services received, what may have helped Rachel, lessons learned and possible actions  3.1.  Rachel’s parents and family were invited to contribute to this review. The Independent Reviewer met separately with Rachel’s mother; with Rachel’s younger sister, maternal uncle and aunt – together; and with Rachel’s maternal grandparents. Rachel’s mother has provided several documents for the review and a written statement. She also signposted the reviewer to a BBC programme13 in which she had taken part about research into prescribing anti-depressants to adolescents; to other media items relating to the research; and to her own submission to the Consultation on the Green Paper about adolescent mental health14.   3.2.  It is clear from the meetings with family members that they all greatly loved Rachel, wanted her to be well and wanted ‘treatment’ to work for her. There was frustration that after a year of treatment Rachel was not better. Rachel’s mother took the major role in her care, supported by Rachel’s father and local uncle and aunt, and at times grandparents (who were not local) who would stay when mother had to be absent or work. They found looking after her over this period, especially 24-hour supervision, and living with her stressful and challenging.  Rachel’s grandparents said that initially they were not aware of how serious things were and that they were probably being protected, at first.  Family members have commented on how stressful holding the lead responsibility was for Rachel’s mother. They also felt that they had to rely on Rachel’s mother for information about assessments, treatment and Safety Plans instead of being part of a whole family care team sharing her care. It was only in crisis that they had direct contact with services in Rachel’s mother’s absence. They did not feel that they had a complete picture.   3.3.  The adult family members attended the 5 half-days of the Inquest and had been frustrated about its outcome, not feeling that it had answered their questions or addressed the lessons which they felt should be learned for other young people like Rachel.   3.4.  Rachel’s mother, in a written statement to this review, has said that it is the family’s view that Rachel’s death was ‘both predictable and preventable’. In summary the family views                                                  13 BBC The Doctor who Gave up Drugs Series 2    https://www.bbc.co.uk/programmes/b0b578bd  14 Transforming Children and Young People’s Mental Health Provision: a Green Paper, Dec 2017 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf   25   are that at the time of her death it was known that Rachel was at high risk. She had been brought to hospital five days prior on a police mental health section after she had tried to kill herself. Rachel had not followed the Safety Plan on that occasion (and did not know why she had not) and so there could be no guarantee that she would follow a revised Safety Plan on her return to school a few days later.   3.5.  School was known to be a stressor for Rachel and she was anxious about her school work.  The pressure of upcoming exams, after missing several weeks of school, in the family’s view added to her stress.    3.6.  There had been a change of Care Coordinator. Rachel had strong trust in the first Care Coordinator who had left the Trust mid-December 2016.   3.7.  Rachel was started on a different SSRI medication (sertraline) at the beginning of December 2016. Such medication was known to have possible side-effects in adolescents. The re-starting of SSRI medication and building up to a full dose had been planned gradually to seek to prevent an adverse reaction. It was thought that in February 2016 Fluoxetine (the first SSRI medication tried with Rachel) had been the cause of a negative reaction and suicide attempt; and as a result, that medication had been stopped.  Following the prescribing of sertraline in early December 2016, the family noted the following incidents: a suicide attempt mid-December and self-harming at Christmas. The dose was increased at the end of December 2016 followed by a further serious suicide attempt in early January 2017 where the assessing psychiatrist (not Rachel’s own psychiatrist) noted that consideration would have to be given to a risk of ‘serotonin syndrome’15.   3.8.  The family’s view is that Rachel’s death could have been prevented by hospital admission. Rachel was not ‘sectionable’ but was compliant and could have been told that she needed to be in hospital. A conversation with one of Rachel’s friends after her death revealed that Rachel did not understand why she had not been admitted to hospital on this occasion and thought that she should have been admitted, but Rachel had managed to avoid it saying that she ‘had got away with it’.   3.9.  The family’s view was that the Safety Plan on Rachel’s discharge home after the suicide attempt in early January 2017 should have included the family watching Rachel all the time and that Rachel should always have been monitored in school and accompanied to and from school by family and not allowed out on her own.                                                    15 Serotonin syndrome https://www.nhs.uk/conditions/antidepressants/side-effects/     26    3.10.  The family has also suggested that, on her last day, if Rachel had been spoken with at school by a trained person (a medical practitioner or someone trained in ‘zero-suicide’ conversations16) her death may have been prevented. Rachel’s mother has also raised the question of whether someone at school could have had a conversation with Rachel that day about how she was feeling and whether that would have made a difference.  Information has become available, retrospectively, that Rachel had posted an ambivalent message on a social media group about whether she wished to live or die.   3.11.  There is a further question for the family as to whether the Safety Plan was updated adequately after Rachel’s suicide attempt in early January 2017. The psychiatrist who discharged Rachel from the section 136 that day did not know that Rachel would return to school within a few days. The need for Rachel to be fully monitored at school was not noted and so was not communicated to the school. The Care Coordinator was on a course on the fatal day and so was unreachable by phone when Rachel tried to ring her.   3.12.  Rachel’s mother’s view is that she had become a conduit for communication between CAMHS and the school rather than them speaking direct to ensure that the school was fully aware of the Safety Plan.     3.13.  There is also a question for the family about whether the risks of returning to school for Rachel, and how they should be managed, were fully thought through by the CAMHS team. Rachel’s mother thought, at the time, that the pros and cons of Rachel’s return to school had been assessed but in retrospect believes this not to be the case. The school was unaware of the risks. On communicating with the school that final morning Rachel’s mother thought that there was a team of people keeping a close eye on Rachel.    3.14.  Considering the longer-term factors in reflecting on the lessons from Rachel’s death, Rachel’s mother has noted that Rachel had shown mental health concerns previously – particularly in the year preceding the year when she became a patient of CAMHS.  Rachel’s mother believes that as Rachel was a good and well-behaved student these concerns did not get picked up. There was a question about whether Rachel had autistic traits, but this was not followed up.                                                      16 https://www.zerosuicidealliance.com/faqs/  27   3.15.  Rachel was also greatly troubled by external and environmental factors, for example, reports of mass killings, the deaths of celebrities who she admired and as a politically sensitive young person, she was worried by Brexit and Trump’s election. Rachel was not thought to be a big user of social media; however, she was influenced strongly and emotionally by the news which she monitored regularly – including during the night. Rachel’s mother has queried whether she should have been given more advice about Rachel’s access to news media or You Tube and how as a parent you can decide what content may be a harmful to a young person like Rachel. This raises the question of how a parent could enforce or monitor viewing.   3.16.  Some of her close friends and acquaintances also had emotional health issues which impacted on her.  Rachel’s mother believes Rachel was susceptible to peer pressure.   3.17.  A particular issue noted by several family members, including Rachel’s sister, was the stress of exams and the new GCSEs, and the continual pressure brought by schools and the system to push children to achieve. Rachel’s mother saw stretch targets and predicted grades as factors which can push students to work harder. Being expected to achieve A*s was stressful to Rachel; her peers are also said to have commented on how stressful it was.  Rachel had high predicted grades, and these contributed to her being emotionally overwhelmed easily.   3.18.  Rachel’s mother questions whether alternative forms of education could have been considered for Rachel – such as home tuition – as Rachel found school particularly stressful.   3.19.  A further question for the family is how well-equipped the school was for understanding Rachel’s needs. The school did not realise how serious her situation was. There seemed to be no way to take her mental health into consideration in the marking of her GCSEs; the view was that she could re-sit them the following year if she did not do well.  It was not clear to the family that there was enough understanding in the school about mental ill-health, or the possible side-effects of SSRI medication. Given the increasing numbers of young people with mental health problems in schools, the family’s view is that it is important that schools have access to sufficient knowledge or expertise in this area.   3.20.  The family believes that they needed more assistance and direct contact with CAMHS without Rachel being present. At times Rachel’s mother and father met staff with Rachel but felt inhibited from talking about issues or asking questions in front of her as this would often trigger a negative reaction. They would have welcomed the chance to meet  28   professionals without her present. Wider family members felt that they did not have access to CAMHS staff but that it would have been helpful for them to do so, especially as they were part of the care team.  The family’s view is that this would have helped provide CAMHS with a reality check on what Rachel was saying to staff in her private sessions with them, including at times of acute risk assessment, as she did not always convey how she was actually behaving and the risks that she was taking. There was a family view that Rachel would say things that staff wanted to hear. Rachel did not respond well to the CPA process and CPA meetings which further inhibited the parents’ ability to share their observations and concerns and seek help and detailed guidance that they might need, in front of her.   3.21.  Rachel’s mother said to the Independent Reviewer that she may have given an impression of coping and being able to manage but that this was not the case. The wider family was also concerned about the impact on Rachel’s mother and her ability to cope, when she also had stresses at work and another child to care for. Independent Reviewer comment: A Carer’s Assessment would have been an avenue to explore this.   3.22.  Rachel’s mother said, “Living with a suicidal teenager is dreadful”. Having to discuss the pros and cons of managing the risk safely at home and whether you can/will take the young person home after a suicide attempt (in front of the young person who does not wish to be in hospital) was very hard. The family did not feel that they could say ‘no’; but they did not feel equipped to manage Rachel’s risk and behaviours. The family was ‘treading on eggshells’ for a year. If Rachel was upset she would make an attempt on her life and so the family tried not to upset her; she also ran away, banged her head on hard surfaces, self-harmed and shouted. “To manage such behaviour and risk at home requires training and support from the health team.”    3.23.  The family’s view is that CAMHS did not get to the bottom of Rachel’s illness. They ask if the case should have been escalated for a second opinion. They believe that the change of lead doctors over the year and the change in Care Coordinator meant that there was no long-term view. This is supported by the Joint Trust Serious Untoward Incident Review see section 5.2 onward of this report.  They have questioned the depth of experience of some of the lead practitioners. There seems, in their view, to have been no clear diagnosis or treatment plan. The relationship with the first Care Coordinator and the pilot DBT Group seemed to be helpful but both came to an end in December 2016 and Rachel seems to have deteriorated after that.   3.24.  The family has questions about the use of medication, including from some family members  29   strong views against the use of medication at all. They believe that medication raised Rachel’s hopes for being better but then dashed them when it did not work. Rachel’s mother has raised the question about research into the possible negative side-effects of SSRIs on Rachel and other young people and whether the medication and its possible impact was monitored sufficiently.  Also, she questions whether Rachel’s disappointment that the medication was not having a better impact was considered.   3.25.  The Independent Reviewer spoke with family members about how Rachel was supervised in taking her medication, as it had become known that she secreted tablets and several family members noted that they had caught Rachel pretending to take the tablets and conceal them.  There is no clear picture of how big an issue this was. (Reviewer comment: This raises questions about whether the supervision of medication should be addressed in Treatment Plans.)     3.26.  Rachel’s mother’s view was that the CPA Process and Reports were inadequate, especially from early December 2016. There was a systems issue with this, accepted by the Trust, as a new computerised system was being piloted. No CPA report was provided for the family or school updating the diagnosis or treatment plan, including re-commencing SSRI medication from the early December 2016 meeting.  Rachel was said to have been looking for this report just before her death. A system print-out provided posthumously was thought by mother to be inadequate.     3.27.  In addition to the statement provided by Rachel’s mother which has been summarised above, the family members raised the following issues.  After the police returned Rachel’s phone and computer (taken for examination after her death), the family was able to access Rachel’s use of the internet and media, which had not been possible before. This raised the question of how much Rachel may have used social media that was not previously known about. It was also subsequently discovered, after the Inquest, that she had been part of a social media group of young patients from the Adolescent Unit where she had been a day and an in-patient. Rachel had also accessed websites in favour of euthanasia.   3.28.  The family wondered if Rachel had been planning the suicide from her discharge after the overdose and section 136 in early January 2017. Over the weekend she had made a point of meeting with or talking to family members and friends and had seemed affectionate, including getting into bed with her mother for a conversation, which was unusual.   Rachel had said that one of the things that had stopped her taking her life on the Thursday was that she had not said goodbye to people.    30   3.29.  The family’s view, in hindsight, was that it was wrong for Rachel not to have been admitted to hospital in early January 2017. The decision should have been taken out of Rachel’s hands. They have questioned if she could not be ‘sectioned’ could she have gone as a day patient or a voluntary in-patient. They believe staff should have been more directive with Rachel saying that they recommended that she should be in hospital. Her family saw her as compliant and said that if strongly advised to go she would have gone to hospital. They also questioned whether Rachel should have been allowed to go back to school at that point.   3.30.  The notes of the last CPA Meeting, in early December 2016, were not distributed to parents or the school. There was a question about whether there should be a different CPA Process for children and young people. Rachel found it difficult to take part in the CPA meetings.   3.31.  The family have asked whether more could have been done to look into whether Rachel had autistic traits as she had unusual reactions to stimuli.   3.32.  The family thought that the DBT treatment was helpful to Rachel and that she responded well. But they question how much of her behaviour had become engrained.   3.33.  The second SSRI medication was a planned risk. Rachel had reacted negatively to the fluoxetine – a nosebleed which was rare for her, shaking and violent thoughts.  However, Rachel was keen to take the medication as she hoped it would make her better. Her mother thought that she took the tablets and she was usually supervised – but it was accepted that she also pretended and hid medicines, at times. Rachel stopped taking her mirtazapine as she was worried it was making her gain weight.   3.34.  Mother has questioned whether she should have been entitled to a Carer’s Assessment in her own right. There was no professional support for the wider family who played key roles in caring for Rachel and who relied on mother to share the thinking from the CAMHS Team. They said that there was a lot of weight and stress on mother’s shoulders. Being responsible for Rachel 24-hours a day was stressful, especially in terms of sleeping, family assisted with ten-minute watches.   3.35.  The family was too scared to argue with Rachel over normal issues. She dominated the house. It was not easy for the family to talk to each other when Rachel was in the room. Parents and families need guidance on how to communicate with young people with mental health issues and also with each other about and around the young people.   31    3.36.  Other family members have questioned whether enough attention was paid to the possibility that Rachel may not have been truthful in her responses to professionals, especially during risk assessments. They thought that she could be manipulative. They also saw Rachel as compulsive and reactive to things rather than able to take control. In their view she was unable to control her emotions.  She could be obsessive about some issues.   3.37.  Rachel would search on-line about mental health and about medication and what it does – including the medication that she took in overdoses. She worried about world issues and read books on mental health – including one on ‘Reasons to stay alive’. They believe that she lived her life for the future. Rachel had said to her grandparents, “I just want to be normal.”.   3.38.  The wider family did not think that medical staff had taken a longitudinal view in making assessments of risk in the final crises and questioned whether some of them were aware that Rachel had attempted hanging previously.   3.39.  They questioned whether there was a view that self-harm by cutting was ‘allowed’. When seeking advice about this during periods of monitoring Rachel they believed they had been advised that Rachel having a screwdriver was probably not as serious as her having something sharper.  They would have expected more detailed guidance about day to day management of Rachel in times of crisis or heightened risk. They thought they were working ‘blind’. The grandparents did meet with the first Care Coordinator after one suicide attempt and received advice on distraction therapies but overall the wider family did not feel that they knew what was happening between Rachel and her therapists and how to support her around this. They would have welcomed a wider family meeting to get guidance and advice over the whole period.   3.40.  The wider family believed that communication between CAMHS and schools should be improved. Rachel’s sister thought that schools should be automatically informed when young people had been admitted to Emergency Departments.   3.41.  They questioned that Rachel had been described by some professionals as a ‘perfectionist’ as one of her traits. In their view, this was not the case as in some areas she let standards fall, personal hygiene being one of them. The stress of her studies and exam pressures were not, in their view, perfectionism but worry. They questioned, especially Rachel’s sibling, whether too much emphasis is placed on young people about exams and the need to study hard and the impact that this has, with no enjoyment.   32    3.42.  Rachel’s mother and separately other family members questioned whether the family should have had more support from Children’s Services. Mother asked, “what could they have done to help me?”  She had agreed that as the family were caring for Rachel and receiving services from CAMHS there was not a role for CSC. She noted that she had not seen a copy of the CSC Child and Family Assessment.    3.43.  When questioned Mother said that religious faith had not been a significant issue for Rachel.    3.44.  It was not thought that Rachel had been a serious user of cannabis by the family but that she may have experimented.    In response to seeing a draft of this report Rachel’s family made the following additional points:   3.45.  ‘Zero Suicide Approach’ Rachel’s family feels, in hindsight, that Rachel’s suicide was predictable. Service planning and service provision should take into consideration risk of critical incidents, such as suicide and learn from other professions (such as the aircraft industry) about risk avoidance.  The family advocates the introduction of a zero suicide approach.  A high number of UK Health Trusts and CCGs have adopted this approach, first developed in the USA.  The approach does not accept that some suicide is inevitable but strives to provide those who come in to contact with service users with the skills to deal with and prevent it, so that no-one, especially a child, dies as a result of suicide.17   3.46.  Supervising patients who have a high risk of self-harm or who attempt suicide  The family’s view is that the safety plans in place from December 2016 did not meet the increasing levels of risk. In particular, they believe that greater guidance should have been placed on close supervision of Rachel, including escorting her to and from school, and monitoring and observing her in school.    3.47.  Leadership  There is a need in cases like Rachel to ensure a ‘bigger picture’ view of the risks and any patterns over time. There was a discontinuity of care (as professionals changed or responses were provided by different services, e.g. in crisis). The family believes greater oversight was needed. The family is not clear what oversight there is above the consultant in longer term cases (e.g. over nine months). A recommendation                                                  17 Zero Suicide Alliance UK https://www.zerosuicidealliance.com/faqs/ and https://www.england.nhs.uk/mental-health/case-studies/zero-suicide/   33   about this is made by the family below.   3.48.  Medicine and Healthcare Products Regulatory Agency (MRHA) 18  and SSRI Medication use in children  The family has questioned whether enough is being done nationally to monitor and collect data about the side-effects of SSRI medication in children. They believe that professionals and service users are not fully aware of the ‘yellow card’ scheme19 which can be used to notify the MHRA of side-effects of medication; and that this should be promoted more widely.   3.49.  Rachel’s mother’s family statement also presented a separate paper on the use of medication in Rachel’s treatment and its side-effects and findings of recent research about the possible impacts of SSRI medication in adolescents.   3.50.  In a final meeting with the Independent Reviewer in response to the draft of this report Rachel’s mother made the following points:   3.51.  At the time of Rachel’s assessment, on section 136 of the Mental Health Act, in early January 2017 Rachel’s mother did not understand why the advice for Rachel to stay at home under supervision was later changed to allow Rachel to go to school if she felt able to do so. However, she did not question it at the time, assuming that professionals were saying that Rachel was well enough to go to school, if Rachel felt well-enough to do so. On reflection Rachel’s mother has thought that it would be helpful for there to be clarity about when advice is being given or when a parent is being given an instruction, she would have found it helpful to have been told clearly whether or not Rachel should have returned to school, rather than it being left to her or to Rachel to decide. The question of attendance at school or not, and under what conditions, was not spelled out in the Safety Plan.    3.52.  Looking back, Rachel’s mother believes that she needed more direct guidance on how to manage Rachel’s (challenging) behaviour, including daily management skills of a young person with such mental health issues, including how and when to supervise Rachel closely.   3.53.  Rachel’s mother has also raised the following questions:    3.54.  Could there be alternatives to Emergency Departments that could be used for young people in crisis, such as ‘havens’ as promoted by Young Minds? 20                                                   18 MHRA https://www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency  19 MHRA Yellow card scheme   https://yellowcard.mhra.gov.uk/  20 “Young Minds is calling for more safe places where children and young people can go in a crisis, such as   34    3.55.  If a young person does not require a mental health section and does not wish to be a voluntary in-patient could there be a ‘middle way’, such as a ‘wrap around’ community-based service, possibly including home tuition; where school is a possible stressor?  3.56.  Is there a point at which the mental health team should discuss with a parent when a child needs more care at home than a working parent can easily give and whether help may be needed to think about taking time off or ceasing work, if practicable? We acknowledged that this would be an issue for consideration as part of a Carer’s Assessment – not usually a task of the mental health team; also, that professionals formed a view of Rachel’s mother as knowledgeable, coping and being able to manage. However, towards the end this was not how she felt, she would have preferred more guidance and direction.  (See paragraph 5.21)  3.57.  Rachel’s mother’s written statements on behalf of the family make a number of suggestions about actions which should be taken by local services to seek to support other young people like Rachel. These are:   a.  A review of Safety Plan principles and standards by CAMHS.   b.  The Hackney Suicide Strategy should be reviewed to include a ‘Zero Suicide’ approach.   c.  Hackney should sponsor or undertake a study into the incidence, nature and reported causes of self-harm episodes, suicide attempts and suicides of young people in the borough over the last 5/10 years by gender in order to build up a greater picture of factors and causality; inviting other boroughs to do similarly.   d.  Given the incidence of adolescent mental ill health appoint psychologists to larger schools or clusters of smaller schools to ensure that schools have access to a mental health specialist.   e.  CAMHS should arrange mandatory regular meetings with parents as part of the CPA Process, in which the young person is not present.                                                                                                                                                                       safe havens in the community, so that they are no longer forced to rely on A&E. For those that do arrive in A&E, the charity is calling for dedicated mental health liaison and referral support, so that young people don’t end up in a cycle of returning to A&E in a crisis.” See https://youngminds.org.uk/about-us/media-centre/press-releases/ae-attendances-by-young-people-with-psychiatric-conditions-almost-doubled-in-five-years-new-figures/   35   f.  Provide training for the parents of young people who are suicidal so that parents can be more able and confident in talking with them.   g.  When SSRI medication is prescribed ensure that there is increased vigilance to monitor not only the possible negative side-effects but also the possible negative impact on the morale of the young person if they believe the medication is not working.   h.  Review and calibrate the Care Programme Approach processes to ensure that diagnosis and treatment plans are shared properly.   i.  CAMHS services to ensure that longer term cases (e.g. nine months or more) where there are continuing high risks to be reviewed by a different or more senior consultant (a second opinion) to monitor longer-term view of risk, treatment, progress and (dis)continuity of care. Such a review to include the family and young person.    j.  Hackney should ask the MHRA for current data on SSRI use in children. Information should be promoted to staff in Hackney services across health, social care schools/education and the police, and also to the public about the MHRA yellow card scheme.  36    4. Practitioners’ Views   4.1. As part of the review methodology, a Practitioners’ Focus Learning Group was arranged for as many of the Practitioners who had worked with Rachel and her family as possible, to consider the services offered and lessons learned. The Independent Reviewer and Designated Nurse (a Member of the Review Panel) met with the Practitioners. Practitioners and Managers from CAMHS, the Adolescent Treatment Unit, the School and Children’s Social Care were in attendance; the Acute Hospital and GP Service was not represented. Some of the Practitioners who had worked with Rachel and her family had left the services and were not available. In addition, the Independent Reviewer also met separately with the School Counsellor, Head Teacher and Deputy Head Teacher.   4.2. The following information, questions and thoughts about lessons came from the Practitioners’ Focus Group.   Health Services  4.3. CAMHS has introduced a daily crisis briefing of ‘Red Ragged Cases’ to help the crisis team and duty team have continuity for young people over time and have early recognition of increasing frequency and presentations of risk.  (This was introduced after Rachel’s death)   4.4. The Trust generally had lower use of SSRI medication for adolescents than some other Trusts. Their prescription is guidance based. In Rachel’s case it would have been questionable not to use them.   4.5. When assessing young people, practitioners take into account the reliability of what they are saying based not just on content but by observing the young person’s affect, their mental state, their behaviour, congruence with what is known, seeking corroboration and reviewing the history.   4.6. A psychologist who worked directly with Rachel and who assessed her did not believe her to be on the Autistic Spectrum. This was based on the face to face work with Rachel and information about her neuro-developmental history. Rachel did have rigid thinking but this was seen as part of her emotional dysregulation – rigid thinking can be associated with this.   4.7. The impact of Rachel’s behaviour on the family and how to manage this was discussed in the DBT Groups. The Trust would take the lead from the parents on deciding who to involve  37   from the wider family in assessments and treatment. If it was assessed that a parent was not having difficulty coping with the young person’s behaviour this issue would not be pursued – this may be a systems issue that needs to be looked into, to enquire how parents or carers are coping.  It was acknowledged that Rachel’s mother was seen as a key communicator. Rachel’s mother has stated that she was unaware that the Trust was ‘taking the lead’ from her and feels that there should have been a greater exploration of the family dynamics, which in her view were not fully explored. She also believes that this impacted on the value of the family therapy.    4.8. Rachel’s use of social media and the influence of her peers were also discussed in the DBT Group sessions. Ground rules about social media and its risks were agreed, including the risks of sharing information between peers and the skills needed to understand social media. The group also discussed the impact of the suicide of another young person and how to manage this.   4.9. In responding to possible systems issues about how to support non-mental health staff in this area, a school practitioner noted the benefits of the ‘WAHMS Project’ 21  as a Transformation Plan for working more closely with schools. This had been put in place after Rachel’s death (and the suicide of another young person in the same school).     The Schools’ response to Rachel and Adolescent Mental Health   4.10. The school has said that they did not become aware of the concerns about Rachel in early 2016 until she was admitted as a day patient to the Adolescent Unit in February and the Unit’s Education Department requested information about Rachel and school work for her in relation to her exams. Rachel’s mother has advised this review that she and Rachel’s father attended the school prior to Rachel’s admission and shared information about Rachel’s previous behaviour. The school had been unaware that Rachel was found with a ligature around her neck in January 2016. They had not been aware that she had been assessed as high risk but they were aware that she was very vulnerable.                                                    21 The WAMHS (Wellbeing and Mental Health in Schools) Pilot had two key strands.  A Wellbeing Audit tool to be completed by all 40 schools in the pilot, supported by Wellbeing Framework Partners (Leadership and Management Advisers from Hackney Learning Trust).  Areas for development would be agreed from this and an Action Plan devised.  This was supported by a CAMHS worker allocated to work strategically in the school for between one day per month and one day per week, depending on school size.  The CAMHS worker’s role and activity will be defined by the Action Plan; they will not hold a caseload or do ongoing, direct clinical work with children.  The aim of the pilot was to promote Academic Resilience and grow capacity within the school, as well as establishing excellent working relationships and communication across schools and CAMHS.   38   4.11. The School was familiar with CPA Meetings but has learned the importance of MDT Meetings (multi-disciplinary team meetings) when a young person at risk is being reviewed at CAMHS. The School Counsellor attended CPA Meetings.   4.12. When Rachel returned to school from the Adolescent Unit she agreed her attendance with the School Counsellor and came in at different times if she was feeling too anxious or overwhelmed. A team of staff was in place to support Rachel including the Counsellor, the Head of Year and the School Office.  If she was too anxious to attend lessons Rachel would sit in a quiet space and read.   4.13. The school sought to work closely with CAMHS to understand what was causing Rachel’s anxiety and how to help her manage it; breathing techniques, walking techniques learned by Rachel at DBT, etc. The Head Teacher’s view is that there was a good working relationship between the School Counsellor and Care Coordinator 1. The school supported Rachel by using the same techniques used in sessions at CAMHS.  Rachel was herself very much part of the approach of how the school planned her support.   4.14. The school had a good relationship with family members and felt able to talk with them about Rachel without difficulty.  They monitored Rachel’s daily presentation and noted if she was tired or anxious. They trusted the family’s judgement about whether Rachel was well enough to be in school. Rachel did not attend school for the last two weeks of the 2016 Autumn Term.   4.15. The School Counsellor attended the CPA Meeting at the beginning of December 2016.   4.16. On the fatal day, the school was not sufficiently aware of the intensity of the level of risk and would have wanted to be fully involved in discussions about how this should have been managed.  The school had been informed on the Friday of the most recent incidents by mother who brought Rachel to school for the meeting with the school counsellor. They assumed that CAMHS was saying that Rachel was well-enough to be in school.   4.17. The school saw Rachel’s mother as very competent and assumed that she would communicate the assessments and plans from CAMHS, if necessary. There was also direct communication between the school and CAMHS.  A lesson for the school is: What would help a parent be able to say to a school or other service ‘I need help, I am finding it hard to manage this?’   4.18. The School commented on the need for increased capacity in schools and training about  39   mental health and how this is negotiated with all agencies.   4.19. Schools do not have an understanding of ‘impulsivity’ as an issue in adolescent mental health and behaviour.   4.20. A key question for the school was ‘Who makes the decision about a student’s mental and emotional capacity to attend school when they have mental ill-health?’  There is a need for shared risk assessments with sign-off by suitably senior staff from all relevant agencies. Schools need to be able to assess how they can manage high risks and whether additional resources would be needed for a student with mental ill-health; and when the school can say that the risk is too great for the student to attend.   4.21. A question that has arisen for the school is:  Is there a wider systemic issue that schools may be under-diagnosing students with autism when those students are seen as intelligent and articulate?   4.22. The practitioners were aware that children and young people conceal issues and cover things up and queried whether this is disguised compliance? (Reviewer comment: Or is it normal adolescent behaviour? Children and young people often tell adults and professionals what they think the professionals want to hear.)   4.23. The School noted the following lessons and questions for itself and possibly other schools:    The importance of good contact with parents where young people have mental health difficulties.    The need for clarity about how a young person with such levels of risk can be managed at school and if they can be managed in school; including an understanding of the significance and possibility of impulsive actions. Being clear about what can and cannot be done with differing levels of risk. This may include awareness of when the mental ill-health meets the level of a disability under the Disability Discrimination Act, 2010.     The need for greater clarity about confidentiality and what can be shared between different agencies to ensure good exchange of information about risk. Could the school be automatically notified about young people who have attended an Emergency Department? Could schools be routinely advised about young people who are receiving services from CAMHS?   40      How much a young person with mental ill-health should be allowed to self-determine decisions?    The need to seek advice from health experts.  A good relationship with CAMHS including CAMHS being aware of the school’s knowledge. Skills and capacity in this area.     Given the high incidence of young people in schools with mental health difficulties the need to have in place a Disaster Recovery Plan to help the other students, staff and school to deal with the impact of a serious incident, like a suicide.   4.24.  Overall, the practitioners who attended the Focus Group were in agreement with the emerging lessons that the Review Panel had suggested. These are discussed in the next section.      41    5.  Findings   5.1.  Rachel’s death is tragic. The purpose of this review is to learn lessons to influence future practice with adolescents who are experiencing anxiety which is leading them to self-harm or consider taking their own lives. It is not to undertake a forensic examination of all the actions taken; nor is it to make a judgment of whether her death was predictable or preventable.  The Review Panel has noted the following findings which will be of assistance to practitioners, agencies and families working to support young people like Rachel.    Key Line of Enquiry 1    Diagnosis, risk assessments and treatment of adolescents who self-harm and who have chronic anxiety and impulsivity with acute suicidal ideation or behaviour, including self-harm – including use of SSRI medication for low mood    Serious Untoward Incident Review22   5.2.  Following Rachel’s death and prior to the Inquest, The Mental Health Trust which had treated her throughout 2016 and up to her death undertook an independent internal Serious Untoward Incident Review, which is standard NHS practice. This was done jointly with the Acute Hospital Trust where Rachel had been treated in the Emergency Department following her suicide attempts or for self-harm. The school also contributed to the SUI review. The SUI Review’s main findings are:   Two examples of notable practice      ‘The level of support provided to Rachel and her family by the staff in the Adolescent Mental Health Team is particularly impressive in terms of their responsiveness, flexibility and accessibility. The care package included pharmacotherapy, family therapy, DBT and other individual therapies.  … The team sought always to take into account the wishes and concerns of Rachel and her family in treatment and decision-making.’    In January 2017 when Rachel had taken an overdose, ‘a Staff Nurse from the Emergency Department was very concerned about the possibility of Rachel being returned home and queried the decision of the Consultant Psychiatrist, given that Rachel had told her that she                                                  22 NHS Guidance: Serious Incident Framework 2015  https://improvement.nhs.uk/documents/920/serious-incidnt-framwrk.pdf  42   wished to be admitted to a mental health unit. Both the Consultant Psychiatrist and the Staff Nurse discussed these comments with Rachel and her mother in a further assessment of Rachel.’    Other examples of good practice were:    Meticulous record keeping in both NHS Trusts for this case.     ‘There were no concerns about any aspects of care provided by the Acute Hospital Emergency Department during any of Rachel’s presentations. Engagement with Rachel and her family by the staff concerned was of a uniformly high standard.’   The Acting Adolescent Mental Health Team Consultant sought advice about medication from another Consultant in the trust with special expertise in psychopharmacology. He also consulted a Senior Pharmacist who specialises in CAMHS. In November 2016, Rachel’s case was discussed anonymously at a trust wide CAMHS consultants’ meeting and the consensus was that a low dose of SSRI with careful monitoring was the correct management strategy.     Rachel and her parents participated in a 12-week pilot Dialectical Behaviour Therapy (DBT) Group. Rachel and her family experienced this as a very23 helpful treatment for her.    In early January 2017, following Rachel’s suicide attempt and five days prior to her death, the Consultant Psychiatrist undertook a very careful assessment; including Rachel’s mental capacity.  The Consultant consulted fully with the Approved Mental Health Practitioner and took into consideration the view of the Emergency Department Nurse who was concerned about Rachel being allowed to return home. Admission was considered but not possible under the Mental Health Act, 1983 because of Rachel’s presentation. Rachel was seen by the Consultant Psychiatrist on three separate occasions before it was agreed that she could be discharged from the Emergency Department.  24   The assessment undertaken by the (Psychiatric) Core Trainee supported by the CAMHS Higher Trainee/Registrar on call was thorough (and documented in detail).                                                   23 Rachel’s mother has commented to this review that they found the techniques helpful but not ‘very’ helpful.  24 Rachel’s mother has stated that the possibility of voluntary admission was not fully explored, in her view.   43    5.3.  The SUI Review noted the pattern of increasing frequency and seriousness of episodes of self-harm in the final months of Rachel’s life as denoting increasing risk to her life and wellbeing. The (SUI) Panel have addressed the concern that the risk assessments may have underestimated risk in this case’.   5.4.  ‘The overarching conclusion of the (SUI) Panel is that, for different reasons, Rachel’s depressive episodes were undertreated (especially in terms of psychopharmacology) over this time period. The Panel are struck by the dissonance of Rachel’s reassurances to staff and family about her health, well-being and lack of suicidality being frequently followed within a very short time by serious and potentially fatal overdoses and of her latterly being placed twice by the police on section 136’.   5.5.  Particular issues that were considered by the SUI Panel but not thought to constitute care delivery problems include:   Prescription of Fluoxetine at a starting dose of 20mg    5.6.  The SUI Panel’s view was that “Recognised guidelines do not unambiguously support the contention that commencing fluoxetine at 20mg was inappropriate. The NICE guidelines do provide the possibility of starting fluoxetine at doses of more than 10 mg for children of higher body weight or when an early clinical response is prioritised although the Maudsley Guidelines are more circumspect. Furthermore, Rachel did not develop serotonergic syndrome and it cannot be concluded that her adverse reaction to fluoxetine was dose dependent”.     Should admission have been considered for Rachel after the overdose in mid-December 2016 or after the overdose in early January 2017?   5.7.  The SUI Panel note ‘that on both occasions Rachel was brought to hospital under Section 136 and assessed by a Consultant Child and Adolescent Psychiatrist and an Approved Mental Health Practitioner, among others. On both occasions Rachel was noted to have capacity. Admission was considered and not thought to be helpful by Rachel, staff or family members with the exception of Rachel’s father, who did ask for admission to be considered after the December overdose. Rachel was not considered to be detainable under the Mental Health Act 1983 and was agreeing to her ongoing treatment plan. Under the circumstances the (SUI) Panel thought that it was reasonable not to push for admission at these times. Risk assessments were noted to be thorough at each assessment’.   44     Should Rachel have returned to school for the Spring Term 2017?   5.8.  The school reported to the SUI Review that they were insufficiently aware of the level of risk presented by Rachel, particularly following the mid-December overdose. The school questioned whether Rachel should have been allowed to return for the Spring Term. The school says it was not informed that Rachel should not have been allowed to leave the school premises at lunchtime.    5.9.  The (SUI) Panel’s view was: ‘This was a very finely balanced decision. Rachel had wanted to go to school and different risks would have pertained if she had remained at home, unsupervised 25 , rather than attending school. Given the previous discussion about admission, this would have been the only option. Furthermore, the school had been in possession of the agreed Safety Plan. Given the available information at the time, it is the view of the SUI Panel that the risk to Rachel was not greater from being at school than from being at home’. The Christmas holiday would have impacted communication with the school staff over the holiday period.    Problems with Care Delivery   5.10. ‘Anti-depressant medication should have been more strongly pursued following discharge from the Adolescent Unit in April 2016 (as recommended by the then Acting Adolescent Mental Health Team Consultant Psychiatrist)’.   5.11. At discharge from the Adolescent Unit in October 2016 there seem to have been conflicting views regarding Rachel’s diagnosis – Unit staff focussing on emotional dysregulation with no need for pharmacological treatment as opposed to clear evidence for moderate to severe depressive episodes in the past. The (SUI) Panel also note the presence in the discharge summary of an incorrect diagnosis “F12.1 Mental and behavioural disorders due to use of cannabinoids; Harmful use”. The SUI Panel agree with the family that the lack of clarity and explanation about a diagnosis which could include the possibility of a picture of emerging personality disorder with depressive illness and anxiety symptoms was unhelpful and confusing for the family and especially for Rachel.                                                   25 Review Author comment: It is not clear why it was thought that Rachel would have been unsupervised had she remained at home that day. The family had regularly made arrangements to supervise her when she was unwell and unable to attend school.   Rachel’s mother has confirmed to this review that if Rachel had not gone to school the family would not have left her at home unsupervised.   45     Problem with Service Delivery   5.12.  During her contact with the Adolescent Mental Health Team where her case was transferred in January 2016, Rachel was under the care of several different Consultant Psychiatrists. The substantive Consultant left the team in April 2016 to work elsewhere in the Trust. Since then there have been three different Consultant Psychiatrists for the Adolescent Mental Health Team in either acting or locum positions, the most recent taking up post in October 2016. It is acknowledged that the service have done everything possible to recruit a permanent member of staff.    Overall conclusion of the SUI Review   5.13.  The root cause of this incident relates to the mental state of Rachel at the time of the death. The available evidence at this time is that Rachel intended to make a serious suicide attempt and that she concealed her plans and used a more instantly lethal method (suspension) than as previously (mostly) overdoses.  The (SUI) Panel note that her death occurred at a time when she was increasing her dose of sertraline to therapeutic levels and was being closely monitored. Her family believe that this was a relevant factor in her choice of a more lethal and faster method of suicide. In the past it has been suggested that anti-depressants can potentiate and activate suicidal thoughts and behaviour through increasing energy and motivation. However, recent studies provide differing risk/benefit conclusions in relation to the use of fluoxetine and sertraline in adolescence. Gibson et al (2012) did not find significant effects of treatment on increasing suicidality, Bridge et al (2007) concluded that a small increase in suicidality was mediated by the efficacy of treatment in major depressive illness.   5.14.  ‘The (SUI) Panel have been asked to consider whether this incident was predictable and preventable. It is the view of the Panel that it was predictable that Rachel would make further suicide attempts. She had a history of self-harm; increasing in frequency and severity. The role of medication in her choice of method in her final attempt remains unknown’.   5.15.  ‘It is possible that the incident could have been prevented (at least in the short term) by hospital admission but that would have depended on the agreement of Rachel, her family and the Adolescent Unit staff for informal admission and for the Mental Health Act, 1983 to have been applicable should she have refused admission’. In the longer term, the best hope of prevention of further suicide attempts would have been effective treatment of her  46   recurrent depressive episodes with remission of her symptoms and the ongoing use of DBT strategies and other support to help Rachel manage her emotional dysregulation. This was in fact the treatment plan in place at the time of her death.’   5.16.  ‘Lessons learned in this (SUI) review relate to identified care and service delivery problems and highlight the need for stability of staff in taking a longitudinal view of illness and risk and in being able to challenge patient’s wishes and need to normalise with a clear understanding of previous contrasting behaviour’.    City and Hackney Safeguarding Children Board (CHSCB) Multi-Agency Learning Review learning in relation to the diagnosis and treatment of Rachel, in addition to the Trusts’ SUI Report   5.17.  This CHSCB Multi-Agency Review notes the SUI findings summarised above. In addition, it proposes the following additional lessons:   5.18.  A holistic family view  The CAMHS Adolescent Mental Health Team, Adolescent Unit and Acute Hospital Trust could have taken a wider view of ‘family’ than either mother or father, being those who had parental responsibility for Rachel. Other key family members played an important role in supporting Rachel and her mother and sister. It is not clear how the views of the wider family members and their roles were taken into account when assessments of Rachel’s care at home in the community was being considered, given that Rachel’s mother was a single working parent whose work occasionally took her abroad. Was there over reliance on Rachel’s mother communicating risk, supervision and treatment needs to other family members who were at times acting in loco parentis?   5.19.  Supporting Parents/Carers Rachel’s mother is of a professional background and was in a responsible job which showed personal competence. It is not clear that there was a sufficient assessment of how and whether she was coping and whether she was able to continue to cope with the stress and the increasing difficulties that Rachel was presenting after a year. The Parents’ DBT group worked in parallel to the young persons’ pilot group to support parents in understanding young people’s behaviour and the treatments being offered to them. It is not clear if it also sought to assess parents’ ability to cope with and manage the behaviour and risks. Rachel’s mother’s view is that this was not explored in the DBT group; she understood that the group was to advise parents about supporting their children.   5.20.  Parents’ worries and observations Rachel’s mother has raised the difficulty of seeking advice for herself and expressing her worries in sessions where Rachel was also present.  47   She and Rachel’s father were able to find ways of communicating privately to staff by email or orally to express their concerns about Rachel without stimulating a reaction in Rachel but Rachel’s mother felt inhibited in this as there was no clear structural way to do this.  The Trust’s view was that the DBT Parents’ Group was a place where parents could raise their concerns and seek advice and support, including from other parents. It is important to note that Rachel’s mother did not see it in that way. While respecting a young person’s right to privacy and confidentiality it is important that their parents or carers are clear about how they can express their concerns to the practitioners and how this will be managed in relation to the young person’s right to know what is being said and their welfare and safety.   5.21.  Rachel’s mother was entitled to be considered for a Carer’s Assessment26 under the Care Act, 2014. This did not happen. The reasons for this are not clear. The Trust has said that this should be usual practice. The SUI did not address this matter.  An issue in this case is perhaps that Rachel’s mother (and father) were both seen as competent and well-able to manage Rachel’s care. However, the stress that they were under and its impact on them required a parallel and separate assessment. This could have included clarity about how they could communicate their observations and concerns about Rachel’s behaviour without triggering outbursts or set-backs. A Carer’s Assessment is the responsibility of the local authority not the health trust.  A systems issue which needs to be considered is that within children’s services carer’s assessments are usually undertaken by specialists in children with disability services. There may not be a clear pathway for considering the need for an assessment where CSC are not involved with the child or family.   5.22.  Impulsivity  Some of Rachel’s worrying behaviour was impulsive although it has also become clear in hindsight that she did search websites to inform her about medication and other areas of mental health. This raises a question about how impulsivity as a dynamic is understood and assessed in young people who are at risk of self-harm or suicide; especially by parents and non-health staff. After each event Rachel was able to help analyse it and show some rationality; her treatment through DBT was to help her overcome overwhelming thoughts and feelings so that she would seek alternative strategies to self-harm. Rachel had shown insight and rationality in assessments after self-harm or suicidal behaviour but had then later acted impulsively again. The possibility of impulsive thoughts and actions needs to be held in mind in risk assessments; especially based on a longer-term view of a young person’s previous behaviour pattern. Rachel’s family’s view is that some of Rachel’s self-harm or suicidal behaviour was planned rather than impulsive – but when questioned                                                  26 Carer’s Assessment https://www.nhs.uk/conditions/social-care-and-support-guide/support-and-benefits-for-carers/carer-assessments/  48   Rachel said they were impulsive.   5.23.  Related to this is the possibility of disguised compliance and that young people in mental health (or other) treatments learn from each other or from professionals how to make the system work.  There is a question about whether Rachel said what she thought the professionals assessing the levels of risk wanted to hear, especially after self-harm or overdoses. (Rachel’s family believes this to be the case.) The reports to this review and the practitioners’ comments at the Focus Group were clear that practitioners are aware of this dynamic and use different ways to assess genuine responses and intentionality.  But such compliance can be persuasive. Rachel’s family members were of the view that Rachel sought to hide her true thoughts at times. It is a useful reminder, however, for practitioners to bear in mind that there needs to be respectful scepticism and evidence seeking (including from the family) to corroborate what a service user is saying. As part of that it is important to test against known history and behaviour in previous similar circumstances. A systems challenge is that it is sometimes practitioners who are new to the service user who are undertaking risk assessments in crises.  Attention to known history, previous patterns and the observations of family/carers is therefore an important part of testing reliability and plausibility.   5.24.  Peer influence, social media, internet use and media  As a young person Rachel could be influenced by peers. She had a number of friends and acquaintances who had their own emotional problems. It is not clear how much these and social media impacted on her. There are suggestions that she was affected negatively by comments on social media, on at least one occasion, but it is not clear how much these were explored with her to help her develop strategies to deal with them. Given that social media and internet use are integral to usual teenage life it will be important to consider with a young person who has emotional dysregulation how to manage their use, including the possible negative impact of specialist websites, which young people may access for advice.   5.25.  SSRI Medication for Adolescents Rachel’s mother and family have raised the issue about the use of SSRI medication and whether this increases the risk of suicidality in young people. This is addressed in the Trusts’ SUI Report. Recent media and articles27 and the TV programme that Rachel’s mother took part in refer to recent meta-research (2016) questioning the efficacy and possible risks of SSRI medication suggesting that only one –                                                  27 See for example https://www.bbc.com/news/health-44821886 or The Independent 21 July 2018 https://www.independent.co.uk/news/uk/home-news/children-antidepressants-prosac-school-age-drugs-pills-brain-doctors-a8458236.html   49   fluoxetine is effective28.  The Royal College of Psychiatrists’ leaflet for parents, carers and those who work with young people about depression in adolescents, updated in March 2017, says that some SSRI medication can be helpful.29   The National Institute for Health and Care Excellence (NICE) guidance30 on the treatment of depression in children and young people, published in 2005 and updated in 2015 and again in 2017 (after Rachel’s death) confirms that view. It also states that where moderate to severe depression in adolescents is unresponsive to combined therapies (including medication and psychological treatment) or where it is recurrent, sertraline (or other medication) may be used. In Rachel’s case serious consideration was given to the possible risks of sertraline as they were known at the time and the Consultant Psychiatrist consulted other specialists and guidelines on its use before commencing the treatment. While it is important that practitioners and particularly prescribers keep abreast of research in relation to prescribing it is expected that they will follow the NICE guidance. Rachel was being monitored for any sign of adverse side-effects after the prescription of sertraline.  A systems question is: how parents and carers are taught to know what to look for with regard to any changes and risks on a day to day basis between contacts with CAMHS and how to respond to these and when to seek earlier contact with the treatment team.   5.26.  Hiding medication Another learning point from Rachel’s case which may be common with other adolescents is the reliability of a young person taking prescribed medications. Rachel wanted to be better and was reported to be keen to try medication, while other members of her family were more sceptical about it or worried about the risk of negative side-effects.  However, it is known that Rachel, at times, secreted her medication which she later used to overdose.  5.27.  Several family members told the Independent Reviewer that they either discovered Rachel seeking to fake taking her medication or that they found a stash of medication which she had hidden. It is also known that Rachel stopped taking her mirtazapine as she thought that it made her gain weight. She also described that she was not good at taking her melatonin in the school holidays as she did not have a routine. Rachel’s mother could not remember this issue being specifically addressed in discussions with CAMHS staff nor as part of the Treatment or Safety Plans; although she did seek advice about Rachel vomiting medication                                                  28 Dr Andrea Cipriani et al; 2016:  Comparative efficacy and tolerability of anti-depressants for major disorder in children and adolescents: a network meta-analysis; The Lancet Vol 388 August 2016  https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30385-3/abstract 29 Royal College of Psychiatrists: Depression in young people - helping children to cope: information for parents, carers and anyone who works with young people;  March 2017 https://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/depression.aspx 30 Depression in children and young people: identification and management; NICE; Clinical guideline (CG28); 2005, 2015 and 2017   https://www.nice.org.uk/guidance/cg28   50   while purging, shortly after Rachel was discharged from the Adolescent Unit in Spring 2016, questioning whether this would reduce its efficacy.   5.28.  Family ‘usually’ supervised Rachel taking medication, but this did not include seeking to check that she had swallowed rather than secreted it. Rachel’s mother has stated that she did seek advice about this from the Treatment Team. Similarly, the effect of bingeing and vomiting could have had an impact on the efficacy of doses. It does raise a question about how much medication she was actually taking and whether she had had enough medication for any positive effects or any negative side effects to take place. Practitioners at the Focus Group reported that such behaviour is not uncommon in teenagers in treatment. While parents and practitioners will want to trust young people and normalise them as young adults to take responsibility for their own treatment and managing their own oral medication – where such medication is a key component of the treatment plan it is important that the plan considers whether medication taking should be supervised; especially when there have been examples of secreting medicines and overdoses.    5.29.  Should Rachel have been recommended to go into the adolescent psychiatric residential unit after the early January overdose?  The issue of whether Rachel should have been admitted after the January 2017 overdose has been addressed in the SUI Report, summarised above. This review has been asked whether more could have been done to recommend to Rachel to accept voluntary admission as she trusted staff and would have agreed if they had strongly advised her to agree to admission. The SUI Review confirmed that the decision not to convert the section 136 into a section 2 or 3 of the Mental Health Act, 1983 was correct. Voluntary admission was discussed on at least two occasions with Rachel as she had told a nurse that she wanted to be admitted – although that is not what she told the assessing psychiatrist. The family’s view is that the possibility of voluntary admission to hospital as an option was not fully explored, as a decision had been made that it was not appropriate. Family care was the only option fully considered when it was decided that Rachel did not need to go to hospital. Rachel’s family has subsequently asked whether other fords of ‘wrap-around’ care or community support, including over weekends is available; but this was not considered at the time. This raises a more strategic question, as well as a practice question, about what other non-hospital resources may be available when it is decided that hospital is not appropriate and how families are assessed for their understanding of risks and what any increased care and supervision needs may be. (See also paragraph 5.37 below)  5.30.  Care Programme Approach, Treatment Plans and Safety Plans  Issues about diagnosis and treatment are covered in the Trusts’ SUI Report. Additional learning points here relate  51   to how these are recorded and shared with key stakeholders; e.g. family and other key agencies, such as the school. It is to be noted that the School Counsellor attended CPA Meetings which is good practice; both in terms of coordinating a school’s response to a student with mental ill-health and also increasing understanding about school or study/exams as possible stressors – not just for Rachel but for young people in general it is recognised that examinations can be a major factor in mental ill-health.   5.31.  It seems that the record of the December 2016 CPA Meeting (the last CPA Meeting) was not shared with mother or the school. It is understood that the Trust was piloting a new recording system for the CPA. It is not known why the CPA record was not shared at this time; a time when the Care Coordinators were handing over. It can be argued that the key persons were present and so knew what was agreed and what the Treatment Plan was, but it is important that these agreed actions are noted and shared in a timely way, especially if more agencies are involved or are absent. In Rachel’s case this was only the school and GP (in the background) but in other cases, especially where CSC, YOS or other services are involved this could be a key issue.   5.32.  Rachel’s mother has shared with this review a print out that she was later given by CAMHS of the CPA Meeting in December 2016. This is an unhelpful ‘screengrab’ document of an inputting screen rather than a finished document as a record of a meeting. It is not clear to the Independent Reviewer that all the text in the text inputting boxes is shown or whether some additional text may be hidden in the paper version. A criticism in another Case Review31 of an adolescent suicide has been that the proforma used in the CPA Process are often adult focused not child or young person focussed. The questions on this form are such and have no specific space for risk assessments or for parents’ or carers’ issues as providing a safe and caring environment for the young person. Clearly the CPA process should not be a ‘tickbox’ exercise and there is no evidence that it was or that the form was used to direct the meeting; but as working tool to progress the assessment and plan after the meeting it is questionable, at best. The Mental Health Trust has stated that it is continuing to review the CPA and recording process, including trialling the written plans which are provided to parents, to improve them.    5.33.  Safety Plans Rachel was assessed as being a high risk to herself on several occasions. The Safety Plans seen as part of this review are simple typed or hand-written bullet point documents. At different crises, Rachel was assessed, and it was agreed that Rachel should return home. The revised Safety Plans had to be produced quickly, there is a question,                                                  31 SCR Child J; Lambeth Safeguarding Children Board, 2016   52   however, as to whether they have enough detail to be meaningful to anyone who was not present in the discussion.  It is not clear if they supersede previous Plans or complement them or how they relate to the identified risks which are not spelled out. Some are signed, and others are not signed or dated and do not have contact numbers for emergencies. It is clear from evidence to the Inquest that the school was confused about the status of some of the Safety Plans that they had been sent, which they had not been party to discussing. Clearly, they are for use in emergencies, but the evidence seen suggests that CAMHS practice differs across practitioners.  The Trust introduced a new template for Safety Plans with effect from early 2018; service users were involved in its introduction.   5.34.  Changes in the Treatment Team  Organisational systems issue can have an impact on the way services are delivered to service users. It has been noted that for Rachel changes in key practitioners may have impacted on her responses, or on decisions made. In the early stages Rachel commented to one psychiatrist that she had already met several people and would prefer not to have more changes. An additional issue to be considered for Rachel and other young people who move between services such as Community CAMHS, In-Patient CAMHS or need psychological medicine or psychiatric assessments services through an Emergency Department because of crises is that they will be seen by different practitioners or change whole Treatment Teams as their levels of need or risk change. Continuity and transfer should be carefully managed as it was in the longer parallel handover between Care Coordinators – which was good practice. The summary SUI Report draws attention to the differences in diagnosis and in treatment options between the Day/In-Patient Unit and Community CAMHS and the impact that this had on Rachel’s management in the longer term, but it is not clear if this is a cultural difference between the two services.     Learning from the wider context of research about adolescent self-harm and suicide  5.35.  A review into one young person’s death can give a picture of how local services may be operating and whether any improvements may be required. Lessons from Rachel’s death will be considered locally alongside the reviews into the deaths of two other young people. However, the CHSCB and its partners must also seek to learn from the wider picture and research into adolescent self-harm and suicide to consider prevention and treatment options in the commissioning and provision of local services; as well as ensuring up-to-date knowledge and skills for practitioners at the front line.  Section 9 of this report summarises some key research and data on Suicide by Children and Young People published in July 201732 and the NCISH Annual Report for 201833 which provides additional data.                                                   32 Suicide by children and young people. National Confidential Inquiry into Suicide and Homicide by People with Mental   53    5.36.  The 2017 report sets out a number of key factors which can influence suicide in young people, alone or in combination. The report refers to ten common themes previously found in the previous study of suicide by children and young people up to 20 years of age. These are family factors, e.g. mental illness; abuse and neglect; bereavement and previous experience of suicide; bullying; suicide-related internet use; academic pressures especially related to exams; social isolation or withdrawal; physical health conditions that may have a social impact; alcohol and illicit drugs and mental ill health; self-harm and suicidal ideas. Of the suicides studied 51% of the young people were in education (school or college) and of those 43% were experiencing academic pressures (32% exam pressures). Another important factor in suicide was prior self-harm, 52% had a history of self-harm; cutting or overdose were the most common. 58% had previously expressed suicidal thoughts or hopelessness. 7% had had an episode of self-harm in the week prior to the suicide. 41% had a diagnosis of a mental disorder – most commonly an affective disorder such as bipolar or depression. 16% of the young people were receiving anti-depressants – usually SSRI or SNRI34 drugs. The presence of one of these factors is not an indication that a young person will take their life but that they may be in need of support and intervention. It will be seen that some of the indicators assessed in Rachel over the twelve months of her care are not uncommon. The national data serves to signpost indicators for risk assessment, treatment and commissioning options which should be considered in service planning and delivery.     5.37.  In October 2018, Young Minds commented on the incidence of young people’s attendance at A&E Departments, where the young person has a psychiatric condition, noting an increase in numbers over five years35. From 2010-11 to 2017-18 the increase was from 9,372 to 27,487 for Diagnosis of Psychiatric Conditions and for Intentional Self-Harm a smaller increase from 18,291 to 21,904. The questions raised are whether A&E is the right environment for responding to young people’s mental health crises. Young Minds says that there is a need for community based alternative venues (‘havens’) for young people experiencing mental health crises and the need for dedicated mental health liaison and referral support to prevent young people being caught up in a cycle of returning to A&E.                                                                                                                                                                        Illness (NCISH) Manchester: University of Manchester 2017   See section 9 of this report  33 The National Confidential Inquiry into Suicide and Safety in Mental Health. Annual Report. October 2018 University of Manchester     See section 9 of this learning review for a summary of key issues  34 SSRI - selective serotonin reuptake inhibitors; and SNRI - Serotonin–norepinephrine reuptake inhibitors  35 Young Minds is a charity which promotes awareness and provides advice mental health for young people, parents and professionals:   Press Release, 25 October 2018:  https://youngminds.org.uk/about-us/media-centre/press-releases/ae-attendances-by-young-people-with-psychiatric-conditions-almost-doubled-in-five-years-new-figures/   54    Key Line of Enquiry 2   Supporting young people with mental health problems in a community school setting – the challenge for schools   5.38.  There is no doubt that Rachel’s school was caring and supportive of Rachel. Her suicide has raised some questions for the school about her care and its multi-agency management which were discussed above in the context of the Joint SUI report to which the school contributed. Key lessons that may be applicable to other schools where there are young people with serious mental health issues, including self-harm and suicidal thinking or behaviour are noted here.   5.39.  It is important to see adolescent mental health in schools, the major universal service for this age group, in a wider public health and social context rather than a single school.  Recent reports have noted the increase in young people having mental health problems and requiring services. The Children’s Society’s recent report on children’s mental well-being raises concern about the number of young people needing services and the prevalence of self-harm .36 37  The Government’s Green Paper: Transforming Children and Young People’s Mental Health Provision, 2017 38, a proposal and consultation document; and the Government’s response in 201839 show increasing numbers of young people with adverse mental health, ‘one in ten children and young people has some form of clinically diagnosable mental health disorder’, and the need to develop a strategic response nationally and locally, not just child by child.   5.40.  There are wider systems issues than a single school. Although each school has a part to play in how it supports the well-being of its adolescent students who are going through a physical and psychological developmental life-stage into adulthood; while also learning and preparing for further education or employment. Schools are primarily education not welfare institutions. Schools can be a stressor as well as a safe place if a young person is worried and becomes unwell because of general academic stress or overwhelming anxiety about exams. This raises questions about how young people as groups are advised, encouraged and supported about exams, and where a single young person who has anxiety fits into                                                  36 https://www.childrenssociety.org.uk/news-and-blogs/press-releases/one-in-four-14-year-old-girls-self-harm 37 The Children’s Society: The Good Childhood Report 2018 https://www.childrenssociety.org.uk/sites/default/files/good_childhood_summary_2018.pdf  38 Transforming Children and Young People’s Mental Health Provision: a Green Paper; December 2017. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf    39 Government Response to the Consultation on Transforming Children and Young People’s Mental Health Provision: a Green Paper and Next Steps; July 2018  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/728892/government-response-to-consultation-on-transforming-children-and-young-peoples-mental-health.pdf   55   this. Media responses to GCSE and A Level success, toughness and league tables can feed into this anxiety.   5.41.  Teachers may not have had training in young people’s mental health, especially acute mental ill-health and its management. The Government Green Paper commented on the value of Mental Health First Aid Training for schools40 and the need to increase mental health awareness of school staff.   5.42.  In Rachel’s school, there was good liaison and communication with CAMHS, including attendance at the CPA Meetings by the School Counsellor. However, a school may not have the in-house expertise to deal with high risk cases.  Rachel’s school did not fully understand the level of risk for Rachel and trusted CAMHS to make the decision about whether Rachel was well enough to return to school after an absence because of exam stress – when Rachel had fallen further behind and had exhibited worrying suicidal behaviour. For schools to be able to manage high risk behaviour in a potentially self-harming or suicidal student they must be a full partner to the risk assessment and Safety Plan to understand the risky behaviours and what actions the school can take to mitigate them or prevent harm. This means that schools must be proactive in seeking to be in key meetings (including remotely) with the assessing and treating health professionals and parents, or able to ask questions about and challenge the likely or probable risks and to consider how and if the student can be managed safely in the school.   5.43.  School based Safety Plans should consider who will step in when key named persons are likely to be absent so that the student, family and others are aware of contingencies; including who to contact. If a student is to have time-out from class because of stress there needs to be a process for checking with that student how they are, over time, and whether it is right for them to continue to be in the school or whether they need more support and when a parent should be called.   5.44.  After the deaths of Rachel and another student (two months previously) in Rachel’s school the Clinical Commissioning Group arranged that CAMHS would support local secondary schools with specialist mental health workers, part-time to provide advice, but not clinical work, as part of a pilot programme to develop approaches in schools.  The WAMHS Project was seen by Rachel’s school as very helpful.41  A similarity can be seen in the proposals in                                                  40 See also the Institute of Education’s evaluation of the Mental Health First Aid training in schools. An Evaluation of Phase One of the Youth Mental Health First Aid (MHFA) in Schools programme: “The training has given us a vocabulary to use.” Report October 2018  41 The WAMHS (Wellbeing and Mental Health in Schools) Pilot had two key strands.  A Wellbeing Audit tool to be   56   the Green Paper for Mental Health Support Teams to work with clusters of schools to provide expertise and up to date knowledge to the school staff. This review notes that Hackney Local Authority and Clinical Commissioning Group have made a bid to be one of the ‘trailblazer’ authorities to test the proposals in the Government’s Green Paper for improving mental health responses in schools. As well as the mental health support teams these will also include encouragement for every school to have a Designated Senior Lead for Mental Health; and shorter waiting times for children who need to be assessed by NHS mental health services.   5.45.  Rachel’s schools own lessons since the two tragic deaths have included introducing quiet rooms and spaces for students (a quiet garden space has been provided by a charity set up by the parents of Rachel and the other young person, with the support of fundraising by students and others), work with parents, and work with students about how to get help if they feel anxious. The school’s communication protocols in relation to students with a known mental health problem have been strengthened, with weekly meetings for identified students about whom there is concern; and a protocol has been established for students who are returning to school after a period of absence for mental health problems. A help group for parents of students with mental health problems has been established. Staff and students have had mental health first aid training. Peer listeners have been trained. Mental health has been included in assembly topics and the counselling capacity within the school has been increased. An important question for this review is:  How are these lessons being learned in other schools which have not had the tragedy of a death such as Rachel’s?   5.46.  A further learning point from the school is the need for schools to consider the possibility of suicide and its impact on students, staff and a school in critical incident plans or Bereavement Plans to ensure that something is in place in case if it is needed. That includes where to access counselling for peers and staff in schools after a tragedy.  This review was informed that borough-wide guidance for schools on critical incidents was available but such guidance could not be found – raising the question about how easily schools would find it, when needed.                                                                                                                                                                         completed by all 40 schools in the pilot, supported by Wellbeing Framework Partners (Leadership and Management Advisers from Hackney Learning Trust).  Areas for development would be agreed from this and an Action Plan devised.  This was supported by a CAMHS worker allocated to work strategically in the school for between one day per month and one day per week, depending on school size.  The CAMHS worker’s role and activity will be defined by the Action Plan; they will not hold a caseload or do ongoing, direct clinical work with children.  The aim of the pilot was to promote Academic Resilience and grow capacity within the school, as well as establishing excellent working relationships and communication across schools and CAMHS.  57   5.47.  Preliminary evaluation research by the Institute of Education into the Mental Health First Aid Training Programme for Schools notes increased confidence for school-based champions who have had the training with greater understanding of mental health issues and how to respond and support whole school approaches42. It is not clear how much the free Mental Health First Aid Training for Schools43 has been taken up by other schools in City and Hackney. The CHSCB may wish to explore this further.    5.48. The DfE Research Report: Mental health and wellbeing provision in schools; Review of published policies and information; October 201844 was commissioned, as a limited, desk-based study, to see the extent and availability of schools’ published policies; how these were set within a whole school approach; how they differed by type or region of school; and in particular how such policies describe a school’s approach to promoting and supporting pupils’ mental health and wellbeing.  It is noted that there is no legal duty for schools to publish online policies on children’s mental health, per se. Of the sample schools (90) 4% of primary and 1% of secondary schools had published a mental health policy online. The research explores the existence of other published policies which impact on pupils’ mental health and how these have been embedded. 56% of primary schools and 44% of secondary schools were providing some form of mental health support, including targetted support to pupils with emotional and behavioural difficulties or universal support to promote self-esteem and resilience. Targetted support included counselling, anger management classes, and interventions to raise self-esteem. These were provided mostly through the Pupil Premium strategies, where pupils had been identified as needing additional support. A small number of primary schools were using mental health screening tools to identify pupils with additional support needs. Some primary and secondary schools were providing universal or preventative activities to promote mental health and wellbeing; including wellbeing centres, school nurture approaches, school pastoral teams and home liaison workers and embedding mental health education and resilience building within the curriculum. Although there were limitations with the methodology the research review proposes that schools would benefit from further awareness, advice and resources to enable interventions to support mental health to be further embedded within whole school strategies and not just within behaviour policies aimed at managing difficult behaviour.  Assistance may be needed to help schools see the close links between mental health and behaviour more holistically; including assisting schools to be more aware of risk factors relating to mental illness where pupils are not overtly disruptive but are showing symptoms                                                  42 https://mhfaengland.org/mhfa-centre/news/ucl-report-schools-programme/  43 Mental Health First Aid Training in Schools   https://www.gov.uk/government/news/pm-mental-health-training-for-teachers-will-make-a-real-difference-to-childrens-lives  44 Department for Education: Mental health provision and wellbeing provision in schools; Review of published policies and information; Research Report; Rebecca Brown; October 2018   58   such as anxiety, depression, self-harm or suicidal thoughts.   5.49.  Additional findings  The main purpose of this review has been to seek to learn preventive lessons applicable in the wider field of child and adolescent mental health in cases where young people have self-harming and/or suicidal behaviour.  Three findings arise from the period after Rachel’s death relating to investigation and support.   5.50.  Investigation and safeguarding – use of digital media    When a child or young person takes their life and the police have ascertained that a crime has not been committed, the investigation may not have the same resources as if the death had been as the result of harm or incitement by someone else. This can mean that the investigation does not fully consider the young person’s use of the internet or social media. However, it is an intelligence source to identify wider safeguarding risks to other, possibly identifiable, young people that might arise, for example, as a consequence of suicide or self-harm contagion. Attempting to investigate someone’s digital footprint as soon as possible after their suicide should be an immediate task, led by police, as this may help identify other young people who could be affected.  Rachel was in an online group with other vulnerable young people and was also friends with young people known through mental health services. Accessing her computer and phone quickly would have alerted professionals to any specific actions which might have been required to safeguard or support them.   5.51.  The Government Guidance, issued by Public Health England in 2015, Identifying and responding to suicide clusters and contagion; A practice resource 45  notes that identifying suicide clusters can be difficult and sets out indicators to be considered at the early planning stages. It suggests responses including identification of individuals and groups who may be particularly vulnerable and practical interventions to reduce the risk of a spread of suicidal (or self-harming) behaviour. There is a stronger potential for spread in mental health services and schools. With social media it should be noted that a cluster could be geographically dispersed.   5.52.  Increasing understanding of the impact of social media on young people’s decision-making and actions    It has become known that Rachel used and was impacted in different ways by social media, and the media, generally. She was reported to have used the internet to seek information about the amount of medication required to cause harm or death. She was also thought to have been affected by messages in a social media group of                                                  45 Public Health England, 2015, Identifying and responding to suicide clusters and contagion; A practice resource https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/459303/Identifying_and_responding_to_suicide_clusters_and_contagion.pdf   59   which she was a member – which was not fully known at the time. Internet use and social media use can be a useful indicator of a young person’s state of mind in the period up to self-harm or suicide. As well as giving a view of the state of mind of a young person after the event to assist an understanding what led up to a critical incident or death it is important to consider how young people can be assisted to evaluate the information that they are accessing or that is being pushed to them. Rachel’s family have become aware that Rachel posted a message saying that she did not know whether she wanted to live or die. This raises a further question about how peers of young people experiencing emotional or mental health problems are advised on ways to respond to worrying messages, including seeking further help.   5.53.  From a public health perspective, it is important to seek to measure how such use impacts young people’s decision-making and impulsivity when they are vulnerable from mental ill-health. To build up a picture over time and across a population of such young people it is important to consider whether a more forensic approach could be taken with regard to the use of the internet and social media by young people who self-harm or take their life. Over time this would allow preventative measures, including education, to be taken and could influence public health awareness and practitioner awareness. This may also inform risk assessments of particular young people to consider more fully how they are using social media and of its likely impact on them.   5.54.  Peer support after suicide     No school, or other institution, wishes to consider that a young person in their care may take their life and of the impact it may have for other young people, staff and the overall service. A young person’s death by suicide will require a different approach to other forms of Emergency or Generic Critical Incident Plans. Guidance which can be activated at immediate notice – given that in parallel social media information can travel faster than a school can seek to manage messages to students and families. Rachel’s school had to adapt a generic approach to respond to the emotional impact on the whole school system following the prior death of another student, in the term before Rachel’s death. The school has also learned subsequently that this is the case in other schools. At a time of great shock when actions need to be put in place quickly to inform and support the school population it would be important to have a well-designed template which sets out the steps and signposts resources.   60    6. Recommendations    6.1. The City and Hackney Safeguarding Children Board should consider the recommendations made to this review by Rachel’s Family at 3.57 above.    In addition:   6.2. The Health and Wellbeing Board should expedite the completion and publication of a Local Strategy for Prevention of Suicide by Young People and consider whether this should be a Strategy to prevent self-harm and suicide by young people. The Board should set a timescale for completion and set out how the strategy will be implemented, monitored and reviewed; what key indicators should be collected regularly about young people’s mental health, self-harm, attempted suicide and suicide; and what the local resources are. A Head Teacher representative should be co-opted to the Steering Group.    6.3. The Clinical Commissioning Group, Local Authority (including the Director of Public Health and Director of Education) and the East London Foundation Trust Child and Adolescent Mental Health Service with local Head Teachers and Chairs of Governing Bodies (or their equivalents) should build on the positive links between schools and CAMHS started in the WAHMS project. A strategy and action plan should be devised to set out steps for this and be presented to the CHSCB and the Health and Wellbeing Board.  (See Paragraphs 5.39 - 5.44 and also the summary of research and guidance from 5.47.)     It is noted that the Hackney CCG has made a bid to be a pilot trailblazing Local Authority in the trialling of the national actions to be taken as part of implementing the Green Paper: ‘Transforming children and young people’s mental health provision: a green paper’46.   6.4. The CHSCB should consider convening a conference for Head Teachers and Chairs of Governors (and their equivalents) or working with their local representative bodies to promote the lessons from this review and the parallel reviews of young people’s deaths by suicide. The purpose of such a conference / liaison would be to raise awareness and                                                  46 https://www.gov.uk/government/consultations/transforming-children-and-young-peoples-mental-health-provision-a-green-paper   61   learning between schools about children’s mental health and risk.  This should include the national picture with regard to increasing understanding about children’s mental health in schools and the local lessons from this and other reviews; including study and exam stress, bullying, impact of social media and peer pressure. Such an event would build strong links to the WAHMS project. It could promote a review of whole school mental health approaches or policies, including a specimen approach. It could also provide guidance and develop mentors on Immediate School Recovery and Support Programmes in relation to child deaths, by suicide. The CHSCB should consider inviting the charity created by Rachel’s mother and the mother of another young person to assist with such a conference or wider liaison in order to promote the lessons from one school more widely.  (See Paragraph 5.48, and the revised guidance Mental health and behaviour in schools, November 2018 published by the Department for Education47.)      6.5. The CHSCB should ask the Director of Education to review the take up of Mental Health First Aid Training in schools and promote this actively across Hackney, possibly including commissioning local delivery from the Mental Health First Aid charity across a cohort of local schools to build a network of informed and skilled staff from schools who can support each other. (See Paragraph 5.47)  6.6. The ELF Trust CAMHS should review its guidance for and management of the Care Programme Approach (CPA), agreement of Treatment Plans and guidance about creation and write up of Safety Plans for children and adolescents; including how patients, parents (carers) and key partner agencies can contribute to risk assessments, monitoring, and safety in an informed, holistic, realistic and achievable way. The Trust should reassure the CHSCB of the outcome of the review, actions taken and how the process will be quality assured, going forward.        6.7. The ELF Trust CAMHS should review how assessments consider the impact of stress on carers and wider family as part of ongoing assessment of a family’s ability to protect and care for a young person who has self-harming or suicidal behaviour. This should include providing information about Carers Assessments and when to refer to Children's Social Care for a Carers Assessment. The Trust may wish to review a number of current cases to consider if referring for a Carers Assessment would be appropriate and to understand what may be the barriers to this process.  (See Paragraphs 5.18 – 5.20)                                                    47 https://www.gov.uk/government/publications/mental-health-and-behaviour-in-schools--2   62    6.8. The CHSCB should seek reassurance from partners that there is in place, a robust and coordinated response to suicide by a young person, in the context of identifying and mitigating the impact on other children and young people.   This is likely to be as part of the revised Rapid Review process following a critical incident, as set out in Working Together to Safeguard Children 2018, chapter 4.  This should include if and how a young person’s digital footprint will be assessed to see if there are indications that others may be at risk of harm.   (See Paragraphs 5.50 – 5.51)  6.9. The CHSCB should ask the Director of Education to review the generic guidance to schools on responding to critical incidents and its accessibility to ensure that it covers child deaths and support to peers and schools, including where a student takes their life. (See paragraphs 5.46 and 5.54)   6.10. The CHSCB or successor Child Death Review Partners48 (when they come into place) with the Child Death Overview Panel should consult with the Metropolitan Police and the Local Coroner about the investigation of child deaths by suicide in relation to access to electronic equipment used by the young person which may give a greater understanding of influences on the young person and their state of mind, over time. This will enable the Child Death Review Process to build up a clearer public health picture of the possible use of specialist websites, online advice services, social media and other important influencers on young people’s decision-making and impulsivity. (See Paragraph 5.53)  6.11. The CHSCB should provide an anonymised summary report of the key lessons from this review for frontline practitioners and first line managers across the multi-agency network. The CHSCB should also consider providing bespoke briefings and materials for key designated and named leads in local services to enable them to cascade the lessons from this report and the parallel reports to frontline practitioners.                                                     48 Working Together to Safeguard Children 2018; Chapter 4:  Improving child protection and safeguarding practice; & Chapter 5: Child death reviews  63    7.  Appendix 1  The City & Hackney Safeguarding Children Board Response (CHSCB) and Partner Agencies’ Response to Rachel’s death  7.1  Following Rachel’s death, a Rapid Response meeting was convened by the City & Hackney Safeguarding Children Board under multi-agency guidance for responding to unexpected child deaths 49 . The Independent Chair of the CHSCB endorsed a recommendation that Rachel’s death did not meet the criteria for a Serious Case Review (SCR)50.  The National Panel of Independent Experts in SCRs agreed with this decision. There was no evidence noted that abuse or neglect were factors in Rachel’s death.  7.2  The Independent Chair agreed that a multi-agency Local Case Review should be undertaken to analyse what happened, why, and to identify any practice improvements that should be made by organisations to safeguard and promote the welfare of children and young people. The Terms of Reference are in Appendix 1. A Panel of senior managers from the agencies involved, who had not been personally involved in the work with Rachel and her family, or in its management, was convened and the CHSCB appointed an Independent Lead Reviewer to advise and to author the final report.   7.3  Rachel’s parents were invited to comment on the Terms of Reference and to contribute to the review. Members of Rachel’s family have done so. Articles that Rachel’s mother had written about Rachel’s death and a TV programme were reviewed.   7.4  The Mental Health Trust and the Hospital Acute Trust undertook a joint independent Serious Untoward Incident Review, led by the Mental Health Trust. That review was made available to this review by the CHSCB.   7.5  Those agencies which had been involved with Rachel and her family provided reports for the Panel to analyse. Practitioners and managers who had been directly involved with Rachel and her family were invited to meet with the Panel to share their experience and reflections on and learning from the case.   7.6  An inquest was concluded in July 2017. The oral evidence to the Inquest and the                                                  49 Working Together to Safeguard Children 2015, Chapter 5   50 Working Together to Safeguard Children 2015, Chapter 4  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf    64   Coroner’s judgement was considered as part of this review.   8.  Relevant findings from research into suicide by children and young people   8.1.  Understanding that there may be other young people like Rachel gives impetus to learning and improvement, to seek to develop local preventive responses and public health approaches when there may be earlier signs in a young person’s life. There are two relevant research studies led by The National Confidential Inquiry into Suicide and Homicide by People with a Mental Illness. The first is a review of suicide by young people under 25. The second is the Annual Report 2018, covering a wider field and age range but with additional relevant findings to this review. Not all the antecedents and themes identified in the cohort studied were applicable to Rachel, but some similarities can be seen. The full analysis from the research is too detailed to be included here but should be examined when considering local suicide prevention strategies for young people.   8.2.  Findings from Research Report:  Suicide by Children and Young People; The National Confidential Inquiry into Suicide and Homicide by People with a Mental Illness: July 201751. The research report gives a view of suicide by children and young people under 25 in England and Wales in 2014 and 2015.    8.3. The Key Messages from the 2017 Research are:    Suicide in children and young people is rarely caused by one thing; it usually follows a combination of previous vulnerability and recent events.   The stresses that we (the research) have identified in young people before suicide are common in young people; most come through them without harm.   Important themes for suicide prevention are support for or management of family factors (e.g. mental illness, physical illness, or substance misuse), childhood abuse, bullying, physical health, social isolation, mental ill-health, and alcohol or drug use.   Specific actions are needed on groups (we have) highlighted: (1) support for young people who are bereaved, especially by suicide (2) greater priority for mental health in colleges and universities (3) housing and mental health for looked after children (4) mental health support for LGBT young people.                                                   51 Suicide by children and young people. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester, 2017.  https://www.hqip.org.uk/wp-content/uploads/2018/02/8iQSvI.pdf   65    Further efforts are needed to remove information on suicide methods from the internet; and to encourage online safety; especially for under 20s.   Suicide prevention in children and young people is a role shared front-line agencies; they need to improve access, collaboration and risk management skills. A later, more flexible transition to adult services would be more consistent with our findings of antecedents across the age range.   Services which respond to self-harm are key to suicide prevention in children and young people and should work with services for alcohol and drug misuse, factors that are linked to subsequent suicide.   8.4.  Common themes identified in the research were:    Family factors (such as mental illness)   Abuse and neglect  Bereavement and experience of suicide (by others)   Bullying  Suicide-related internet use   Academic pressures, especially related to exams  Social isolation or withdrawal  Physical health conditions that may have social impact  Alcohol and illicit drugs  Mental ill health, self-harm and suicidal ideas  8.5.  The research sought to identify common antecedents for the young people in the cohort who were aged below 20, by gender.    The common antecedents were:    Previous contact with social care/local authority services (at any time)  A history of self-harm  Contact with CAMHS (at any time)  Self-harm by cutting   Psychiatric diagnosis   (Being or having been) a looked after child  Bereaved   Experienced abuse  Bullied  Self-harm by self-poisoning  Contact with youth justice/police (at any time)   Excessive alcohol use   All of these antecedents were found to have been more prevalent for females – but were also present for males.   Illicit drug use  No prior contact with services    These two antecedents were more prevalent in males under 20 – but were also present  66   for females.   8.6.  What the research findings say about prevention:      “The circumstances that lead to suicide in young people often appear to follow a pattern of cumulative risk, with traumatic experiences in early life, a build-up of adversity and high-risk behaviours in adolescence and early adulthood, and a ‘final straw’ event.”    The significant event may not seem severe to others and thus risk may be hard to recognise by family or professionals unless the history of past and present problems is also taken into account.    8.7.  A model for prevention is suggested for use at different ages and stages (see Figure 12 in the study for more detail of the model). The possible interventions include:    supporting vulnerable young children and their families  promoting mental health in schools to address bullying and online safety  services for self-harm and alcohol and drug misuse in young people   healthy workplace and campus initiatives, and   crisis services.    8.8.  Other dynamics to be noted in considering support and preventive services for particularly vulnerable young people are:    Bereavement services, especially when young people have been impacted by suicide of another person  Internet safety (particularly for under 20s) in relation to websites which give information about suicide methods  Greater staff awareness in front line services of suicide awareness and better multi-agency co-operation   Self-harm should be seen as a crucial indicator of risk suicide and should be taken seriously – even if it appears minor. This may be the most important area for local development with regard to suicide prevention for young people; including psycho-social assessment, prompt access to psychological therapies and services for co-occurring problems such as alcohol or drug misuse.     Additional Findings from the NCISH Annual Report October 201852 8.9. For children and young people under 20 who took their lives:  41% had been in contact with services (mainly CAMHS – 34%) in the previous three months.   Mental illness was reported in 40%. The most common primary diagnoses were affective disorders, especially depression.   Academic pressures overall were noted in 63%; with exam pressures being 27%.   Previous self-harm was found in 49% and suicidal ideas (at any time) was 59%.                                                   52 National Confidential Inquiry into Suicide and Safety in Mental Health, Annual Report: England, Northern Ireland, Scotland, Wales. October 2018. University of Manchester  https://www.hqip.org.uk/resource/national-confidential-inquiry-into-suicide-and-safety-annual-report-2018/#.W8CTcvZFyUk   67   8.10.  In 29% of all cases (any age) there had been a recent history of self-harm in the preceding three months. For under 25s this was 39%, with a higher proportion for females (51%). Patients with a history of self-harm more often had a diagnosis of personality disorder compared to other patients.   8.11.  For patients who died as a result of suicide who had a recent history of self-harm (within three months) immediate risk of suicide at the professional last contact was judged to be low or not present in 76% (all ages) – lower than the risk for patients with no recent history of self-harm. Risk was also assessed as lower in this group when seen a week prior to death; or in the longer-term risk assessments.  Author note: The research does not seek to explain this lower scoring in risk assessments for those with a recent history of self-harm. It would appear to be a dynamic to be considered in depth when undertaking such risk assessments where self-harm has been present.    8.12.  What could have reduced the risk (all ages)? Clinicians views were: Closer supervision, closer contact with the patient’s family, improved compliance with treatment, a decrease in caseloads and access to psychological treatment.  (See paragraph 170 of the report.)     68    9.  Reading  National Confidential Inquiry into Suicide and Safety in Mental Health, Annual Report: England, Northern Ireland, Scotland, Wales. October 2018. University of Manchester  https://www.hqip.org.uk/resource/national-confidential-inquiry-into-suicide-and-safety-annual-report-2018/#.W8CTcvZFyUk   Suicide by children and young people. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester, 2017. https://www.hqip.org.uk/wp-content/uploads/2018/02/8iQSvI.pdf   Transforming children and young people’s mental health provision, December 2017  A Green Paper   https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/664855/Transforming_children_and_young_people_s_mental_health_provision.pdf   Government Response to the Consultation on Transforming Children and Young People’s Mental Health Provision: A Green Paper and Next Steps, July 2018 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/728892/government-response-to-consultation-on-transforming-children-and-young-peoples-mental-health.pdf   An Evaluation of Phase One of the Youth Mental Health First Aid (MHFA) in Schools programme: “The training has given us a vocabulary to use.” Roberts-Holmes, G., Mayer, S., Jones, P. & Lee, S.F. (2018) Institute of Education, University College London, October 2018 Retrieved from MHFA England website: https://mhfaengland.org/mhfa-centre/research-and-evaluation/   The Good Childhood Report 2018: Summary; The Children’s Society, 2018  https://www.childrenssociety.org.uk/sites/default/files/good_childhood_summary_2018.pdf    Mental health and wellbeing provision in schools; Review of published policies and information Research report; October 2018 Rebecca Brown; Department for Education https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/747709/Mental_health_and_wellbeing_provision_in_schools.pdf  Young Minds Report on: A&E Attendance by young people with psychiatric conditions almost doubled in five years – new figures October 2018 https://youngminds.org.uk/about-us/media-centre/press-releases/ae-attendances-by-young-people-with-psychiatric-conditions-almost-doubled-in-five-years-new-figures/  Royal College of Psychiatrists Network for Community CAMHS: Our Standards  https://www.rcpsych.ac.uk/quality/qualityandaccreditation/childandadolescent/communitycamhsqncc/ourstandards.aspx  Mental health and behaviour in schools – revised guidance November 2018, Department for Education    69   https://www.gov.uk/government/publications/mental-health-and-behaviour-in-schools--2   10.   Useful Organisations / Resources  ChildLine https://www.childline.org.uk/   Mental Health First Aid Training – Schools Training Programme  https://mhfaengland.org/mhfa-centre/programmes/national-schools-programme/   Papyrus https://papyrus-uk.org/  Charity/campaigning organisation to promote awareness and research to prevent suicide by young people   Papyrus-Hopeline UK   https://papyrus-uk.org/hopelineuk/  Helpline and website for young people – and others who are worried about them   Royal College of Psychiatrists https://www.rcpsych.ac.uk/usefulresources.aspx   Samaritans https://www.samaritans.org/   Young Minds  https://youngminds.org.uk/resources/      