Death of a 16-year-old girl in January 2020 by suicide. Learning includes: the need for a clear model for managing high risk self-harming young people; ensure clarity between professionals about responsibilities to coordinate, and ensure timely information gathering and effective intervention; the importance of a family assessment to provide background context and allow opportunities to assess parenting capacity; ensure concerns and worries raised by a child are considered and investigated; ensure professionals exercise professional curiosity to ask more questions and understand what a child has experienced, and to learn what other agencies know; and ensure initial early interventions are appropriate for meeting the child's needs. Recommendations include: update the local documentation on self-harm and suicidal thoughts to develop an interagency team around the child model and procedure to assess and intervene with young people where moderate and high risks have been identified, ensuring that there is clarity about coordinated multi-agency care with clear plans and timely reviews; for young people where moderate and high risk of suicide has been identified, there should be a dedicated range of preventive and treatment resources available without long waits; and consider whether a new local response should be developed to prevent further deaths when a young person has died by suicide, considering new models for enhanced joint working and integrated provision emerging nationally.
      
    Serious Case Review No: 2022/C9822  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.    1 | P a g e  FINAL 17/07/2022         Child Safeguarding Practice Review   Concerning Marie                Lead Reviewer  Amy Weir MA MBA CQSW   2 | P a g e  FINAL 17/07/2022 Child Safeguarding Practice Review Marie  Aged 16 years at time of death.  Ethnic origin: White UK   CONTENTS   Executive Summary   3 1. Introduction and Background to the Review  6 2. The Review Process and Family Involvement in the Review  7 3. Background History and Involvement of agencies with Marie and her family 8 4. Marie’s Views and Experience 10 5. Analysis of agency involvement 13 6. Findings  15 7. Learning Points 16 8. Conclusions and Summary 19 9.   Recommendations for the Safeguarding Children Partnership  20  Appendices  Appendix A - List of References      22       3 | P a g e  FINAL 17/07/2022 Executive Summary  COMMENT FROM SOPHIA Sophia (Marie’s mother) wanted readers of the review to know that Marie was a loving child and that she would look after anybody, especially the ‘underdog’. If someone was upset, Marie would be there for them.  This report was written following the death in January 2020 of a young person, Marie, aged 16 years. It considers whether the agencies involved worked together effectively to address her needs and to keep her safe.   There were several different agencies involved with Marie – her school and college, her GP, Early Help, local and out of area Mental Health Services. Early in 2018, Marie saw her GP and said that she had regular thoughts of taking her own life by suicide. She was referred to local mental health services and was allocated to a Community Psychiatric Nurse. Her self-harming and suicidal thoughts continued, and she was referred to the waiting list for psychotherapy as well as counselling from RELATE. In November 2019 following self-harming episode she was admitted to a local CAMHs in-patient hospital; she was subsequently sectioned, placed in an out of area Psychiatric Intensive Care Unit (PICU) for 48 hours, prior to transfer to an out of area PICU closer to her home. Whilst in this PICU hospital she succeeded in ending her life with a ligature.   Findings  There was much positive effort and good practice in this case to support Marie and to keep her safe. There are also some areas for further consideration and development in relation to holistic inter-agency working and in relation to the local system and model for working with children who present with high-risk self-harming and thoughts of suicide.   The Review has identified some key learning themes.  √ Understanding what Marie’s daily life was like It is unclear how much was known or understood about Marie’s home circumstances. It is essential that a young person’s full circumstances and lived experience inform the assessment and analysis of their needs so that intervention is appropriate and effective in addressing key concerns and needs.  Understanding what a child sees, hears, thinks and experiences on a daily basis, and the way this impacts on their development and welfare, is central to protective safeguarding work. National Panel Annual Report (2020).  Even when she did talk about how isolated she felt and how stressful life at home was, the professionals working with her tended to focus on her mental health, her challenging behaviour and what was described as her “attention seeking” and manipulative behaviour. She was described as becoming over-dependent on  4 | P a g e  FINAL 17/07/2022 professionals and being prone to overreacting. There is little evidence that professionals were asking why she was behaving as she was. There was a tendency to look for causes within Marie herself and various assessments were completed for neurodevelopmental problems such as autism and Attention deficit hyperactivity disorder (ADHD). There was also a heavy reliance on her mother’s (Sophia) view of Marie as always having been difficult throughout her childhood. Marie shared a great deal of information, but she was not always heard.  √ Response to her changing risks and needs and √ Sharing of information in a timely and appropriate way Research shows that practitioners need to contribute to suicide prevention through greater awareness of the range of factors that may add to risk, and of the ‘final straw’ stresses that can lead to suicide.  This requires that agencies work together closely and jointly to unravel the complex interplay of risk factors, recognising that clear evidence of the causes of self-harm and stress may not always be visible. When, as in Marie’s case, young people are showing such high levels and frequency of self-harm and suicidal thoughts, there is a need for a holistic and comprehensive assessment to explore adverse childhood experiences, parenting capacity to protect and specifically the likelihood that the child is experiencing significant harm.  Trauma Informed practice that takes account of contextual risk issues is required across all agencies and these risks need to be shared. For Marie, these risks included the impact on her of the loss of her school friend through what Marie believed was suicide, her turbulent and unsupportive relationship with Sophia and the sexual abuse as well as threats and exploitation she experienced at home.  √ Working with family when their engagement was reluctant and sporadic Sophia was reluctant to engage with Early Help and was not proactive in seeking support for the whole family. The focus was entirely on Marie as the problem.  There is no substantial assessment of the whole family’s circumstances. It is difficult to see how the whole context of and cause of Marie’s needs and behaviours were understood.  In assessing risk in young people, it is important to appreciate, and factor in, the possible impact of childhood trauma or prior neglect so that contributory factors are appreciated. Comprehensive family histories and assessments are necessary and need to take account of any past and changing risk factors arising from extended family members. In Marie’s case, the involvement of her sister’s ex-partner in the family was highly significant but is barely mentioned in the records. When Marie mentioned him initially to her mental health practitioner and the threats he posed to the family, this did not prompt a safeguarding referral to Children’s Social Care.  √ Interagency organisational context and having a shared culture and practice model to achieve good outcomes For young people who are self-harming and making suicide attempts, there is not at  5 | P a g e  FINAL 17/07/2022 present the consistent use of shared, evidence-informed practice methodologies across the local agencies. Nor is there a shared holistic approach to assessment and intervention. There is a good, new guide on working with young people who self-harm but it does not provide a practice model.   There were gaps in information sharing and in joint working between the agencies involved with Marie. Marie was likely to suffer significant harm from her own behaviours and also, she was suffering harm by an abuser as she disclosed. However, this was not seen as safeguarding initially and the appropriate sharing and working together did not happen for many months. It seems that Community based CAMHS was seen as providing the main intervention for Marie.   However, proactive links were not made by that service with the GP, with Early Help or Children’s Social Care. The college contacted CAMHs directly and then there was some dialogue. When Marie disclosed that she had been abused to the Community CAMHS worker, this was not taken up and referred immediately by the practitioner. CAMHS was acting in isolation on the basis of some but not full information about Marie and her family circumstances. It was not until she was an in-patient in hospital that Marie’s allegations about abuse were taken seriously and responded to.   The shared interagency culture and practice model needs to work in a complementary, interprofessional and child-focused way to achieve the best possible outcomes for young people with complex needs.  The Safeguarding Children Partnership is taking forward the learning from this review.    6 | P a g e  FINAL 17/07/2022  1. Introduction and background to the review  COMMENT FROM SOPHIA Sophia (Marie’s mother) wanted readers of the review to know that Marie was a loving child and that she would look after anybody, especially the ‘underdog’. If someone was upset, Marie would be there for them.   1.1 This Child Safeguarding Practice Review was commissioned following the death of a young person, Marie aged 16 years. It considers whether the agencies involved worked together effectively to address her needs and to keep her safe.  1.2      All the names in this review have been anonymised. The child is known as young person Marie and her mother as Sophia within this report.  Marie was born in mid-2003. She died in an out of area PICU, where she was an in-patient detained under section 3 of the Mental Health Act, in January 2020 as a result of a ligature which she applied to herself. 1.3 The circumstances of Marie’s death led to a Rapid Review which was held in January 2020. Following the Rapid Review meeting, it was decided that there should be a multi-agency review of the agency responses to address her needs from February 2018. It was decided to undertake a Child Safeguarding Practice Review (CSPR). 1.4 The local Partnership NHS Trust commissioned a Sudden Untoward  Incident investigation which reported in March 2021. This was focused on the care  and treatment Marie received in the period from mid-December 2019 to mid-January 2020 when she was an inpatient in a local CAMHs acute adolescent unit and subsequently an out of area PICU.  1.5  This CSPR has been commissioned to consider the learning for the wider interagency  system about the care and support provided to Marie and her family between February 2018 to the date of her death in January 2020. 1.6 There is a continuing criminal investigation in process in relation to the allegations of  sexual abuse made by Marie against a previous family member.    7 | P a g e  FINAL 17/07/2022 2. The Review Process  2.1 The review has been conducted with due regard to the principles of fairness,  impartiality, thoroughness, accountability, transparency and above all with a focus on the experience of the young person, Marie. 2.2    The time period covered by this Child Safeguarding Practice Review is from February 2018 to the date of her death in January 2020. Some limited additional  historical information relevant to the review going back before these dates has also been considered in the review.  2.3    The Independent Reviewer is Amy Weir, who is an experienced independent safeguarding expert who is an appointed National Panel Reviewer.  2.4    A group of senior managers was convened to support the Reviewer and the process and to contribute to the consideration of the learning from the case.   2.5 Critical points in the case have been considered in the Report. Possible reasons for  actions taken at the time and learning, and improvements needed have been identified – including the significance of these insights for current practice. Where there was evidence of good practice in the case, this has also been noted. These findings will inform the SCP’s Learning and Development Plan. 2.6 The review has been conducted as a limited enquiry based on the Rapid Review Reports which were written by the agencies involved. Key contributory factors have been identified by the reviewer. The aim of this was to gain an understanding of how the interaction between the various factors influenced the way practitioners responded to and provided services to Marie. 2.7 The agencies involved with Marie were asked to contribute to the Rapid Review. 2.8  There was a commitment to seeking the views of the family. Sophia was the only person spoken to. Her views were, however, only gained at the conclusion of the review process as due to the circumstances of what had happened, she felt unable to contribute previously. 2.9    The review report sets out the findings – including the possible reasons for actions  taken or not taken at the time. The following themes were considered: • What factors contributed to practice decisions at the time?  8 | P a g e  FINAL 17/07/2022 • What could have been improved? • What good practice occurred? 2.10    The significance of these insights for current practice is also explored.  • If the same circumstances occurred now – what factors would influence the response?  • What learning and improvements have already been implemented? • What is working well now and what still needs to be improved?  3. Background History and Involvement of agencies with Marie and her family  3.1     Prior to 2018, there is very little information available about Marie and her family  within the agency reports provided.  3.2     Her mother (Sophia) and father appear to have had a violent, volatile relationship as  evidenced by contact with Police and Court action taken by Sophia.   3.3     The first significant involvement in relation to Marie was in 2018 when she saw the  GP and was referred to crisis mental health services. She was also receiving some  support from school including psychotherapy which was recorded by other agencies  as being counselling in relation to her saying that she was having suicidal thoughts. 3.4     Marie was involved with mental health services from February 2018 with community  CAMHs, in the local CAMHs acute adolescent unit, and subsequently as an inpatient  in the out of area PICUs in January 2020. 3.5     From February 2018, there were growing concerns about Marie and her mental  health. Marie had a history of self-harm and had made several attempts to take her  own life during the period covered in this review. Community CAMHS services were involved including Early Intervention CAMHs via Relate. 3.6     From March to October 2018, her school was very involved and work in  collaboration with Sophia, relying on her explanations. The records contain details of  the high level of risk for Marie’s self-harming. The school records describe Marie as   9 | P a g e  FINAL 17/07/2022 disclosing self-harm. Marie disclosed to a teacher that she had a pact with her father  that if she killed herself, he would kill himself. School records show that Marie had  said to another student that, apparently as a historic event, her stepfather had tried  to strangle her. The school discussed this incident with Sophia who said it was not  true which the school took at face value. Her behaviour was described as being  difficult and she was excluded on three occasions. These concerns appear to have been shared and discussed with Sophia who discounted them. They do not appear to have been shared with Children’s Social Care as would have been appropriate given  the likely harm mentioned by Marie and to ensure that her voice was being heard.  3.7     From March 2019, Local Authority Early Help services were involved after Sophia  said she could no longer care for Marie given her self-harming and the strained  relationship she had with Marie. Sophia did not engage beyond the first home visit with the Early Help intervention, and this was ended despite many efforts to engage with Sophia as there was said to be no meaningful engagement with the family. An assessment was not completed and nor was a “team around the child” or other  professionals’ meeting held to bring together the agencies involved or to consider the  need for escalation. This issue was raised in the Rapid Review process as having been a missed opportunity to protect Marie at an earlier stage.  3.8     Marie was admitted to hospital in early November 2019, and she remained in a hospital setting until she died. During her time in hospital, Marie was subject to a Mental Health Act section 2 and then section 3. Whilst in hospital, Marie made  disclosures about having been sexually abused and about her worries that another  family member might be at risk from abuse as well. These disclosures were referred  to the Police and Children’s Social Care.  A strategy meeting was held, and Section 47  enquiries were instigated to look at the disclosures made by Marie, and she also  alleged other family members might be at risk from abuse. 3.9    As concerns for her safety increased, Marie was moved to Psychiatric Intensive Care            (PICU) in December 2019. Subsequently, Marie shared at the PICU that she had had   10 | P a g e  FINAL 17/07/2022 low mood, had been self-harming and had suicidal thoughts since she was 12 years old when a family member started to abuse her.  3.10   When Sophia visited Marie in hospital, Marie would become upset. She also  appears to have had telephone contact with her father which also distressed her. At the end of December 2019, after a multidisciplinary team meeting at the out of area PICU, it was decided that all visits from family members should be supervised because of the acrimony which had occurred and because Sophia was asking Marie about her  sexual abuse disclosures. 3.11 She was moved to an acute adolescent unit shortly before her death because it was  believed her behaviours had improved and were less risky. However, in the few days’  prior to her death, there were several ligature incidents and she seemed very  distressed - for example punching a wall which led to increased observations of her.  3.12 At the time of her death, Marie was an inpatient in an out of area acute adolescent unit. At the time, she was detained under section 3 of the Mental Health Act.  4. Young Person, Marie’s Experience and Family Involvement in the Review  4.1     There is comparatively little recorded about Marie and her early experience within  the multi-agency case records. 4.2     It appears that her early family life was troubled by the acrimonious and violent  relationship between her parents. In her last few weeks, Marie spoke about worries  in relation to her father and his behaviour towards her. 4.3     Marie stated that the sexual abuse started from the age of 13 until 16, she raised  concerns that the alleged perpetrator had made threats to her and this seemed to be a worry for Marie as she stated that he had threatened to abuse another family member if she did not co-operate with him. A child protection section 47  investigation was conducted and a police investigation commenced. 4.4 Information from the section 47 Enquiry provided by CAMHS stated that Marie   11 | P a g e  FINAL 17/07/2022 described her lived experience as being very troubled. She described her home life as  chaotic and her relationship with Sophia as turbulent. She mentioned past  domestic violence and the family living in fear. There were restrictions about  contact and about going to certain properties. Sophia was working in the evenings  and her father was not around at all.  4.5 In hospital, Marie said that she had a poor relationship with Sophia and that she  had not been cared for as a child except by her sister. Marie also made allegations  about her father not keeping her safe. She also spoke about her distress at losing a school friend who she believed had died by suicide; she suggested that she was still  in contact with her dead friend and speaking to him. 4.6 It appears that Marie’s account of her childhood was that it was troubled and left her  feeling unsafe and not protected. Sophia described her as always having been a very  difficult child. There is no assessment available to clarify further how things were at  home.   4.7 As far as family involvement in this review is concerned, Sophia was contacted by the SCP to inform her that this review was being undertaken. There has been monthly contact with Sophia to update her on the progress of the review. When the Reviewer initially spoke to Sophia, she explained that she was at that stage not feeling  able to engage with the review because she was still so distressed and upset about what had happened.  She stated that she was still in a state of distress and did not yet feel ready to discuss Marie’s death with the Reviewer at that early stage which was understandable. However, after the review had almost been completed, Sophia agreed to speak to the Reviewer accompanied by her bereavement counsellor. 4.8 Sophia said that she had separated from Marie’s father before she was born.  Sophia said that Marie was her youngest of her four children. She said that Marie was difficult as a baby and always needed a lot of attention and was very active. Marie was chatty and clever and did well at primary school but she struggled at secondary  school. She still did well though she missed a lot of school.   12 | P a g e  FINAL 17/07/2022 4.9  Sophia said that Marie‘s behaviour changed in 2017 and that was when she took  her to see the GP. Marie was in a lot of trouble at school. Sophia felt that the school  was not supportive of Marie. They gave her a counsellor but Marie told Sophia that it  was no use. Marie was frequently self-harming and the school in Sophia’s view did  not keep her safe.  4.10  In August 2019, Marie’s sister and her children came to live with the family. Marie was upset about this and did not want them to be there. Sophia did not know why this was the case. Marie was already struggling before they came to stay. Marie increasingly went to her room and spent time there. She became very quiet and was not sleeping well. Sophia was working very long shifts and sometimes she worked up to 16-hour shifts because they were so short of staff. At the same time, she was trying to cope with Marie’s behaviour and problems at school and her self-harming. Sophia said that with hindsight, she might have thought differently. She knew Marie was  stressed but there was so much going on. Sophia was frustrated that the CAMHS early  intervention service did not communicate with her more so that she would have  known more about what Marie was saying. Sophia was onlyallowed into some  sessions with Marie. 4.11  Sophia could not recall Children’s Early Help being involved about Marie and the  family early in 2019.  Sophia said she could not recall this, but she did remember that  someone had left her a note when she was out.  4.12  Sophia said that she now really understands why Marie was so angry. She was “in a bad place”. She did not want to worry Marie any more than she already was. Sophia said that there was so much worry and she was mentally and physically exhausted by everything that was happening. She was working hard and Marie was in a very poor  state. They had been very disappointed when the CAMHS Community Psychiatric  Nurse (CPN) was ending his sessions with Marie who had apparently seen him and  these sessions as ‘a safe haven”. Sophia said she felt she was “walking on eggshells”  all the time.  She also said that she also feels the school neglected Marie. They did not   13 | P a g e  FINAL 17/07/2022 safeguard her. They should have been doing more. There should have been more  communication and listening. Lastly, she said she believes the hospital should have  stopped Marie from killing herself. Marie should have been safeguarded in hospital  and she would have been better off at home.  4.13 Marie’s father had wanted to continue to see Marie and he had regular contact with  her – initially supervised at a contact centre – but then at his home. However, when  she was about 14 years, Marie said she no longer wanted to have this contact though  she did establish some limited contact with him.   5.       Analysis of Agency Involvement  5.1     There was much positive effort and good practice in this case to support Marie and  to Keep her safe. Marie formed a positive relationship with her Community CAMHS  worker and she made some progress whilst she felt she could depend on this  relationship. Relate provided some counselling. However, there was no access to  further individual therapy or psychotherapy as it is recorded that when she was  referred that there was a long waiting list. When she was admitted to the local CAMHS  Acute Adolescent Unit in October 2019, she was provided with a range of support and  every effort was made to understand and improve her situation.  5.2     However, despite this positive practice, there are also some areas for further  consideration and development in relation to delivering a more holistic inter-agency  model of working with children who self-harm and attempt suicide.  5.3 There was a limited amount of recorded history about Marie’s parenting or her early  childhood experiences and the agencies involved prior to her sexual abuse disclosures,  did not seek to fill this gap in knowledge by completing a comprehensive family  assessment. As a result, there was no clear understanding of what may have  contributed to Marie’s self-harming and challenging behaviours. 5.4 There were several different agencies involved with Marie – her school and college,   14 | P a g e  FINAL 17/07/2022 her GP, Early Help and the local and out of area Mental Health Services.  5.5 Early in 2018, Marie saw her GP and said that she had been having regular suicidal  thoughts. She was referred to mental health services and was allocated to a  Community Psychiatric Nurse. Her self-harming and suicidal thoughts continued, and  she was referred to counselling from RELATE and put on the waiting list for  psychotherapy as well. In October 2019, following further self-harming episodes she  was admitted to the local CAMHs Acute Adolescent Unit she was subsequently  sectioned and placed in an out of area intensive care unit. Whilst in PICU she  succeeded in ending her life with a ligature.  5.6 The agencies involved with Marie - particularly the mental health services – were working in the main with her as single agencies and there is little evidence of  collaborative partnership working or team around the child processes. Prior her  admission to hospital, when issues of safeguarding arose initially, they were not fully  considered or shared immediately as required. The focus was mainly on Marie and her  mental health and suspected neurodevelopmental problems. For example, Marie told  her Community CAMHS worker that she had been abused by her ex-partner; she also  said that she slept with a knife under her pillow at home because she did not feel safe  there. The context in which her difficulties had arisen, and were being maintained,  was not fully considered. There do not seem to have been any visits to the home apart  from one Early help visit as Sophia did not keep any further appointments made with  her and the main source of information appears to have been Sophia. There was, it  appears, hardly any understanding or curiosity about the circumstances of Marie’s  early life or of any adverse childhood experiences she had lived through.  5.7 Marie tried to share her worries about what was contributing to her self-harming  behaviour both at school but in more detail with her community CAMHS worker. For  example she spoke about how she had been affected by what she regarded as the  suicide of a school friend and she stated that she had been physically and sexually  abused though initially she said this was by an ex-partner. However, it was not until   15 | P a g e  FINAL 17/07/2022 she was an inpatient in hospital that her worries and concerns were stated more  specifically, were heard and were acted upon.   6. Findings   6.1  The requirement on all professionals to share information and to work across  agencies was not always met and as a result there were gaps in the information held  and delay in assessing and understanding Marie’s needs fully. There were clear safeguarding concerns arising from Marie’s self-harming and suicide  attempts. Other disclosures made by Marie about being abused were not recorded fully  or shared on several occasions. However, when she was in hospital, these issues were  referred and acted upon appropriately.  6.2  There were missed opportunities to identify and assess Sophia’s capacity to  parent and to keep Marie safe. There was no overall family assessment or an  assessment of how Marie’s needs were being met or of what life was like at home for  Marie. There were no joint meetings or coordinated activities and a lack of  information sharing across agencies. Rather there was an individual response to  addressing her mental health and challenging behaviours in isolation without a full  appreciation of all the contributory factors to her behaviours and her distress. 6.3  Concerns and worries raised by Marie were not fully investigated or shared over a  long period. Early Help and Community CAMHs professionals lacked professional  curiosity to ask more questions and to understand what she had experienced and to  speak and learn from other agencies what they knew. Practice was reactive and did not  meet Marie’s need for the individual support she needed for reassurance and  validation. The Community CAMHS service offered her only a limited number of  sessions and she found it very distressing when there were plans finally to cease these  sessions after a further few sessions were agreed. While she was attending these  sessions, her behaviour was more stable and her self-harming lessened.  16 | P a g e  FINAL 17/07/2022  6.4 Early intervention both in CAMHS and Children’s Social Care and Early Help was not robust.  Community CAMHS Early Intervention via individual sessions and RELATE focused in the  main on seeing Marie which appears to have been the brief for that service. There is no evidence that there was consideration of or any assessment of her home and family situation. The referral from the Children’s Social Care service to the Early Help service  required an Early Help Assessment as well as other support to Marie. The assessment  was not completed – it appears because of lack of cooperation by the family. In the  context of Marie’s needs and behaviours this should have been taken back to Children’s  Social Care. All those involved could have been brought together to improve  understanding of Marie’s circumstances and to identify what help she needed.  7. Learning Points  √ LACK OF A CLEAR MODEL FOR MANAGING HIGH RISK SELF-HARMING YOUNG PEOPLE  The model for addressing the needs of a young person whose behaviour was high risk and life-threatening was limited. In Marie’s case there was repeated and severe self- harming together with persistent suicidal thoughts with evidence of actually planning  for suicide. Marie’s needs were seen predominantly as being about her mental health  and the behaviours thought to be arising from this.  It was not regarded or managed as  safeguarding and therefore, she was not seen as a child in need of interagency child  protection. The local model for working with children with acute mental health needs  was not clear and therefore, it was not effective or well-developed across local agencies.  It was not seen as safeguarding requiring a Tier 4 joint response as per the local Access  to Services guidelines even though the child’s actions and intentions were life- threatening.   Marie’s suicidal feelings were treated as purely mental health issues. This meant that   17 | P a g e  FINAL 17/07/2022 many of the factors contributing to the way she felt remained unaddressed. Her  behaviour was described at times as attention-seeking and manipulative. Young  people like Marie are at risk of significant harm from their own behaviour. Suicidal  feelings should be treated as a child protection issue and trigger a similar level of  response to children at risk of harm from others.  One of the doctors treating her in hospital in January 2020, identified the complexity of Marie’s needs. He described her mental health presentation as being “consistent with a history of complex trauma, given her early experiences and current family dynamics / functioning”. This opinion was contrary to the initial view that the main issue was Marie’s intrinsic mental health problems and neurodevelopmental problems such as on Autism spectrum disorder (ASD) or even ADHD per se. The trajectory of Marie’s case demonstrates a lack of appreciation of the importance of  understanding childhood earlier experience and the family context; the impact of trauma,  abuse and emotional harm on Marie’s functioning and coping capacities and how this may  present in mental health difficulties needed to be considered and appreciated.   √ LACK OF JOINT WORKING - There was a lack of clarity between professionals about responsibilities to coordinate and ensure timely, information gathering, and effective intervention. The safeguarding requirement on all professionals to share information and to work  across agencies was not met and as a result there were gaps in the known information  and delay in assessing and understanding Marie’s needs fully as was required to keep her  safe and to validate her expressed and shared concerns. There was a lack of clarity between professionals about responsibilities to coordinate and  ensure that timely information gathering, and effective intervention occurred to keep  practice child-centred and result in any clarity about roles and responsibilities for follow  up on action agreed or how / when a referral could or should be made to Children’s Social  Care.  The responsibility for involving partner agencies in assessment and information sharing   18 | P a g e  FINAL 17/07/2022 was not met. There were clear safeguarding concerns arising from Marie’s self-harming  and suicide attempts. Other disclosures made by Marie about being abused were not  recorded fully or shared on several occasions. Information about her disclosures was  insufficiently explored at some points and not discussed or shared with Children’s Social  Care. However, this situation changed when she was in hospital when the harm she had  suffered was referred and investigated by Police and Children’s Social Care.   √ LACK OF ASSESSMENT OF FAMILY AND BACKGROUND CONTEXT NOT EXPLORED There was a limited amount of known history about Marie’s parenting and the context in  which she was living. An assessment of parental capacity and motivation is an essential    requirement to keep children safe in the context of a child with acute life-threatening  mental health presentation.  There were missed opportunities to identify and assess Sophia’s capacity to  parent and to keep Marie safe. There was no overall family assessment and of how Marie’s  needs were being met or full consideration of what support was required to keep her safe.  There were no joint meetings or coordinated activities or information sharing. Rather there  was an individual response to addressing her mental health in isolation.  √ LACK OF PROFESSIONAL ENQUIRY and CURIOSITY Concerns and worries raised by Marie were not fully investigated or shared over a long  period. Professionals lacked professional curiosity to ask more questions and to  understand what she was and had experienced and to speak and learn from other  agencies what they knew. Practice was reactive and did not meet Marie’s need for the  individual support she needed for reassurance and validation. Overall, there seemed to be  a lack of curiosity about the causes of her behaviours and what stressors had contributed  to these. As a result, the treatment provided did not really seem to be attuned to her  particular past and experience. For example, the death of her friend by what Marie  believed to be suicide seems to have been a major preoccupation for her but it is not clear   19 | P a g e  FINAL 17/07/2022 what direct response this elicited. These omissions meant for Marie that her views were  not being taken seriously nor validated until shortly before she died.   √ APPROPRIATENESS OF INITIAL EARLY INTERVENTION RESPONSE.  LACK OF FORMALISED RISK ASSESSMENT Marie’s needs when considered together from 2018 were acute. Her behaviours were  high risk and various factors indicated the need for specialist Tier 4 intervention at an  early stage.  Early intervention both in CAMHS and Children’s Social Care and Early Help  was not robust and did not meet her needs. Community CAMHS intervention focused in  the main on seeing Marie and did not progress to assessing her home situation  sufficiently. The referral from the Children’s Social Care service to Early Help service  required an Early Help Assessment as well as other support to Marie. The assessment  was not completed – it appears because of lack of cooperation by the family. In the  context of Marie’s needs and behaviours this should have been taken back to Children’s  Social Care. All those involved could have been brought together to improve  understanding of Marie’s circumstances and to identify what help she needed and to  assess fully what help Sophia required to support and keep her safe.  8.  Conclusions and Summary  8.1  Efforts were made by the agencies involved to keep Marie safe. It is clear that all  the professionals who were involved did what they thought appropriate to care for her  and to keep her safe.  There was commitment from professionals and evidence of efforts being made to  support her and to prevent her from self-harming.  8.2 However, there was insufficient joint working to address her needs and to respond  to what she was saying about her lived experience. 8.3 Suicidal feelings tend to be regarded as, and treated as, mainly relating to the young  person’s intrinsic mental health. This means that many of the factors affecting the way   20 | P a g e  FINAL 17/07/2022 the child feels and contributing in the young person’s behaviour and mental health  remain poorly considered and be insufficiently addressed as contributing to their  distress. For example in Marie’s case, even when she was raising serious issues about  being harmed and abused these were not always immediately acted upon nor regarded  as contributory to how she was behaving and feeling.  8.4 Marie was at risk of significant harm from her own behaviour. Suicidal feelings are a  safeguarding issue and need a local collaborative response at a similar level as the   interagency response to a child at risk of harm from others. 8.5 Marie was for a long period determined to harm herself and had thoughts of, and  plans for, suicide for several years prior to her death. From the early agency  involvement, little is known about the family background in terms of Marie’s experience  of living in her family as a child. It appears from her own accounts towards the end of  her life that she felt isolated, under threat and unsupported. She also disclosed that she  had been sexually abused by a family member for many years. 8.6 By the end of 2019, her levels of stress were very high, and she required acute clinical  care in hospital. Although she had received some direct work with a Community CAMHS  CPN, she did not have the opportunity to access longer term therapeutic support as, for  example, there was a long waiting list for psychotherapy. Marie’s life seems to have  been sad and she does not appear to have had a long-term supportive relationship with  anyone in her family. 8.7 There are opportunities for the local agencies to consider new approaches to working  with young people who self-harm and who, in Marie’s case, exhibit a serious and  determined pattern of self-harming.  9. Recommendations for the SCP to consider and action   9.1  Some of the agencies involved with the family have identified a number of  recommendations. The implementation and impact of these actions will be monitored   21 | P a g e  FINAL 17/07/2022 by the Safeguarding Children Partnership. 9.2  In addition, the following recommendations are made to the SCP. They reflect the key learning from this review: √ The SCP to update the current document on Self Harm and Suicidal thoughts to specify and develop an interagency “team around the child model and procedure” to assess and intervene with young people where moderate and high risks have been identified. This will ensure that there is clarity about the local model for providing coordinated multi-agency care with clear plans and timely reviews.  √ The SCP needs to promote the new policy and guidance documents which has already been implemented by SCP as it is not clear to the Reviewer that these updated processes have been fully disseminated and shared to ensure that practitioners and every agency is aware of them and the learning from this case.  √ The SCP should be assured that, for young people where moderate and high risks of suicide have been identified, there is a dedicated range of preventive and treatment resources available without long waits. There should be consideration given by the three Safeguarding Partners to joint commissioning between NHS and LA. √ The SCP to consider whether a new local response should be developed to prevent further deaths when a young person has died by suicide. There are some new models for enhanced joint working and integrated provision emerging nationally.   22 | P a g e  FINAL 17/07/2022  Appendix A - List of References  • Doncaster Safeguarding Children partnership – Post suicide Intervention Protocol following a suspected child suicide (2021). (Personal Communication) • https://sussexchildprotection.procedures.org.uk/tkyzpz/children-in-specific-circumstances/self-harm-suicidal-behaviour-suicide • HQIP – Health Quality Improvement Partnership - Suicide by Children and Young People – National Confidential Inquiry (July 2017) • Local SCP procedures and guidance • Sudden Untoward Incident Report  • National Panel Annual report (2021) DfE • NICE (2004) Self-harm - The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care - National Clinical Practice Guideline Number 16 • NICE (2022) Depression in children and young people overview  • NSPCC (2014) Learning from case reviews briefing – Suicide. Summary of risk factors and learning for improved practice around suicide • West Sussex – Mental Health and Wellbeing Presentation (Jan 2022). (Personal Communication)  