Death of Child L aged 14 found hanging in her home in February 2016. A coroner's verdict found the cause of death to be 'death by misadventure'. Child L had attempted suicide on two occasions in the previous two years by taking overdoses and had a history of self harming from the age of seven. She had witnessed persistent domestic abuse from an early age. Maternal history of alcohol misuse led to mother's ill health including frequent seizures. Child L's grandmother, identified as a protective factor, was also seriously ill. Child L had contact with Child and Adolescent Mental Health Services (CAMHS) and Children's Social Care (CSC). A common assessment framework (CAF) and a Child in Need assessment were completed. Learning includes: keeping the focus on the child at risk when dealing with resistant parents or assessing parental capacity; critical thinking skills are necessary when assessing families with complex dysfunction; remaining attuned to the presence of unknown men. The recommendation is made that all children assessed as medium to high risk through self-harm or suicide are referred directly to CSC to coordinate multi-agency working.
      
 Title:  Serious case review report: Child L. LSCB: Rochdale Borough Safeguarding Children Board Author: Rochdale Borough Safeguarding Children Board Date of publication: 2017  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.                             Child L Final Report 11 Sept 2017 1     Serious Case Review Report      Child L   This report will be published in line with statutory guidance. In order to preserve the anonymity the author has:  Used initials to represent people  Avoided the exact use of dates                    Child L Final Report 11 Sept 2017 2 Contents  1. Introduction   2. Decision Making Process  3. Scope and Terms of Reference   4. Overview of what was known to Agencies  5. Analysis  6. Learning from the Review    7. Recommendations         Anonymisation Key   Designation  Referred to as: Subject Child Child L Mother of subject child  ML Father of subject child FL Social Worker  SW1  Practice manager Children’s Social Care PM1 Child Adolescent Mental Health Service (CAMHS) Practitioner MHP Alcohol Practitioner AP School Safeguarding Officer SSO Family Support Worker FSW  Hospital 1 – Fairfield General  Hospital 2 – Oldham Royal  Hospital 3 – North Manchester Hospital 4 – Rochdale Infirmary Hospital 5 - Tameside General        Child L Final Report 11 Sept 2017 3 1. Introduction  1.1 This Serious Case Review (SCR) concerns a child who died aged 14 years after she was found hanging at her family home.  A Coroner’s inquest was held in August 2017. After careful consideration of evidence from all the agencies referenced in this report a verdict was reached that the cause of death for Child L was ‘death by misadventure’. 1.2 On the evening leading up to the incident, family members had believed she had gone to her bedroom to listen to music. At the time of her death, following an attempted overdose approximately six months previously, Child L was actively known to Children’s Social Care, Early Help and Schools RBC,  and the Child and Adolescent Mental Health  Service as a Child in Need.   1.3 Child L lived with her mother (ML) and siblings in a family that had a closely connected relationship with their Maternal Grandmother (MGM).  Child L was a bright and capable child, she approached her school life with enthusiasm and had a firm friendship group. She enjoyed typical teenage culture and was noted to be especially happy to be attending a pop concert.  1.4 As a young child, Child L was exposed to serious and persistent domestic abuse and the separation of her parents. Child L worried a great deal about her mother’s physical health related to high levels of drinking and about the impact of this on her mother’s emotional availability to her. Child L’s relationship with MGM was experienced by her as compensating for some of the limitation she felt in relation to ML, and her world no doubt became a scarier place when MGM became terminally ill.    2.        Decision Making Process and Methodology  2.1.1 The determination as to whether a Serious Case Review was indicated was considered by the Serious Case Review Consideration Panel, who made a recommendation that a Serious Case Review should be convened on the basis that the criteria as listed in Schedule 5 of the Local Safeguarding Children Boards Regulations was met, namely 5(2,1,b,i) that a child has died, and 5 (2,1,b, ii).   Child L Final Report 11 Sept 2017 4 Regulation 5(2)(b)(i) includes cases where a child died by suspected suicide. This was endorsed by the Chair of Rochdale Safeguarding Children Board.   2.2 The Serious Case Review commenced in June 2016. The Review was overseen by a Review Panel of senior officers from participating agencies and an Independent Chair. An Independent reviewer was appointed to facilitate the progress of the Review and write an overview report.    2.3 Each agency involved with Child L provided a chronology of key contacts and activities in order to establish who did what and when. The accuracy of CAMHs contribution was compromised by the paucity of agency recordings in relation to this case and this presented some challenges in understanding how all of the agency activities unfolded and interacted.  2.4 The independent reviewer along with a representative from the Review Panel met with all of the key practitioners referred to in this report, including staff who had moved to new employers. This assisted greatly in understanding the perspective of individual practitioners and to some extent in reaching an analysis of how organisational systems and individual points of judgements impacted on Child L’s journey through services.    2.5 The Independent Reviewer also met with ML and FL, their contributions at a time of grief and confusion were greatly appreciated and valued in helping to understand the family dynamics that Child L lived within.   3. Scope and Terms of Reference   3.1 The timeframe for the Review was January 2015 to February 2016; this took into account all known contacts for Child L with child welfare agencies beyond universal services and provided a picture of her life through her schooling.  3.2 The Panel overseeing the Review agreed that in order to avoid a narrow and pre-determined focus from the start, detailed Terms of Reference would not be established in favour of allowing the issues of significance to flow from the unfolding consideration and analysis of multi-agency activities. To this end, each agency was   Child L Final Report 11 Sept 2017 5 asked to complete a self-analysis of the interventions that they perceived as key and provide the following:   commentary on each episode against policy, protocol, practice standards or compliance criteria;  an analysis of strengths and vulnerabilities of process and practice;  identification where gaps in safeguarding systems are exposed;  proposals for single agency learning and how this will be embedded from this review. 3.3 The meetings with practitioners enabled the Review to gain an understanding of what influenced their practice, decisions, and communications on both an inter and intra- agency basis. Practitioners were invited and encouraged to provide an appraisal of practice and an honest reflection of the context and conditions in which they were working.   4. Overview of what was known to Agencies  4.1 In the first seven years of Child L’s life, ten incidents of domestic abuse occurred that incurred a police response. The majority of the incidents included acts of violence which resulted in injuries to ML by FL and damage to the family home. Police records indicate that MGM was concerned about ML’s drinking in 2011.  4.2 In 2015 Child L completed school Year 9 with 95% attendance and a very positive report with regard to attitude to work. Child L was a capable student on track to achieve pass grades in GCSE subjects. Occasional unexplained absences were followed up expediently by the school attendance officer.  4.3 During the school summer holiday of 2015, the following significant events occurred:   police attended the family home in relation to an argument between Child L and ML.  Police information indicates that a referral was made to Children’s Social Care, however, there is no record of this within Children’s Social Care;   ML attended an Urgent Care Centre with regard to a head injury sustained three weeks earlier. ML stated that she was having intermittent seizures, before   Child L Final Report 11 Sept 2017 6 leaving without a consultation and declining to return when contacted by telephone. ML was noted to have bruises and had been drinking alcohol.  September to October half term  4.4 Child L returned to school at the beginning of Year 10. Two weeks into term, Child L was taken to the Urgent Care Centre at approximately 10pm by ambulance accompanied by MGM. Child L had telephoned a friend stating that she had taken 30 tablets, the friend told her mother who then contacted ML. Child L was seen by a Locum Doctor who recorded her mood as low with suicidal thoughts. Child L was noted to have self-laceration marks to her arms and stated that she had self-harmed since the age of 12 years caused by distressing issues which included her parents separating due to domestic abuse, MGM undergoing treatment for a serious illness and that a best friend had moved away.  The ambulance service contacted police, and, after speaking with Child L at the Urgent Care Centre the police made a referral to Children’s Social Care.  Child L was admitted to hospital, and consequently transferred to a hospital (2) which had a children’s ward.  The transfer protocol required Child L to be further triaged through the hospital (2) Accident and Emergency.  4.5 The following day, Child L was assessed by a nurse trained practitioner, MHP from the Child and Adolescent Mental Health Team. ML and MGM were present when the assessment was conducted, Child L presented as tired and weepy and the assessment noted the following significant information about Child L and the family:  Child L had a history of superficial self-harm since age 7 years;  ML had problematic alcohol use;  Child L felt she could not discuss her worries with ML  believing that ML would become annoyed;  Child L had been told not to talk to professionals as the family had contact with Children’s Social Care several years previously which angered ML;  Child L was enjoying school, had friendships, ate and slept well.       The assessment concluded that:   Child L Final Report 11 Sept 2017 7  the overdose was an impulsive act in the context of an argument with friends and complicated family relationships;  Child L was reluctant to talk in front of ML and MGM and that there was little positive interaction between Child L and ML;   there was no evidence of clinical depression;   safeguarding risk factors included parental mental health and alcohol misuse and domestic abuse with no services currently involved;  Child L was high risk.   The MHP formulated a care plan which included safety advice given to Child L’s carers, a follow up appointment in 7 days, information sharing with Child L’s school and consultation with Children’s Social Care regarding subsequent interventions. Child L was discharged to the care of ML.  4.6 A referral was received at the multi-agency safeguarding service (MASS). The referral from police indicated that Child L was experiencing hormonal changes and struggling to cope with associated moods, was feeling sad about her parent’s relationship and took approximately 25 tablets of ibuprofen and paracetamol. The referral was screened by the MASS and directed to the Early Help Service. An Early Help MASS support officer contacted Child L’s school who agreed that they would initiate a Common Assessment Framework (CAF)1 but if ML was not co-operative, then the case would be referred to Children’s Social Care for social work allocation.  4.7     To progress the CAF, MHP and the School Safeguarding Officer, SSO, arranged a visit to the family home. Although aware of the visit, ML was not at home to receive the professionals.  This was also the scheduled date of the seven day follow up visit by MHP, ML indicated however that this could not be facilitated because the family were moving home that day. The professionals noted however that there was no                                                  1 The CAF (Common Assessment Framework) is a way of offering early help to children and young people. Health services, schools and children’s services all work together to support the parents and child and prevent problems at an early stage.  The CAF is voluntary;   An assessment will be undertaken to find out needs and decide on what help is needed.  CAF is a shared assessment   One person, called a lead professional,  keeps the family  informed and co-ordinates the support    Child L Final Report 11 Sept 2017 8 indication at the home that the family were moving and the SSO emailed the MASS support officer to inform that ML had declined a CAF. The SSO advised that ML had denied drinking alcohol despite staff regularly noting the smell, that she had attended only two out of eight meetings arranged by the younger children’s school and was experiencing vacancies linked to epilepsy.  After further consultation with the MASS manager, the case was opened to Social Worker SW1 for assessment.  4.8 E-mail correspondence between MHP and SSO indicated that a one to one session was held between MHP when Child L was tearful and reluctant to discuss concerns openly. Child L reported being unable to talk with ML or MGM about what troubled her and referenced about 27 house moves.  MHP indicated that Child L would benefit from 1:1 support in school and that she would monitor the ‘flat mood’. MHP stated that Child L denied any current thoughts to harm herself, but ‘could not guarantee that [Child L] was not considering this again’. 4.9 Two weeks after the overdose incident SW1 met with ML in the family home and Child L in school. Child L told SW1 that nothing had changed at home, and that her relationship with ML was not a positive one. Child L reported that she worried about ML’s health which was deteriorating because she was not getting the medical attention that she needed.  Child L reported irregular contact with FL but the presence of some good friends.  4.10 Approximately one week later a Child In Need2 meeting took place with SW1, SSO and a Pastoral Officer from school, ML and MGM were present with apologies by the School Nurse.  MHP sent an email to SW1 prior to the meeting stating that she had seen Child L on two occasions, summarising that Child L was very tearful, fearful of talking about what was going on in the family and that ML had a boyfriend with whom she was out a lot. Child L reported that ML was using alcohol and cannabis and minimising Child L’s difficulties. MHP reported that Child L still had fleeting suicidal thoughts, mostly when alone stating  ‘…This is worrying as Child L  is                                                  2 A Child in Need is defined under the Children Act 1989 as a child who is unlikely to reach. or maintain a satisfactory level of health or development, or their health or development. will be significantly impaired, without the provision of services, or the child is disabled   Child L Final Report 11 Sept 2017 9 secretive, no one knew what she is thinking, and I am worried that one day she will do something again’. 4.11   The following day ML was taken by ambulance to hospital (3). She reported that she had five seizures during the day before leaving without seeing a Doctor.  That same day SW1 had telephoned ML to arrange a visit, ML said that she would not be available for four weeks because she was moving house. SW1 discussed the response with a Practice Manager who advised that an unannounced visit should be made. SW1 visited the home the following day, when MGM advised that ML was not home and was too unwell to meet with SW1.  4.12 SW1 made an appointment for one week later which she proceeded with despite ML protesting that she was not happy with the need to complete an assessment and would not co-operate with any professionals. MGM was present when SW1 arrived at the home and indicated that they did not need any support. The home was described as having a strong smell of stale alcohol and being very untidy.  When SW1 challenged this position is respect of Child L, both ML and MGM indicated that there was ‘nothing wrong with Child L’, that her behaviour was attention seeking which they were dealing with as family. SW1 indicated that refusal to engage in an assessment would result in a Child Protection Plan3 because the concerns were significant. On the advice of the Practice Manager 1 (PM1), SW1 re-iterated this position in a letter.  4.13 SW1 met with Child L in school one week later. Child L reported feeling low and that the relationship with ML was not good. Child L felt blamed by ML for Social Services being involved and this was making her feel bad. SW1 subsequently spoke with MHP and MHP recorded that SW1 was ‘looking to step the case up to child protection’ and also that Child L remained high risk as ML was not meeting the needs of her children.  4.14 The next day, ML attended the GP surgery reporting 4 seizures in the day. ML was taken to hospital (3) by ambulance. She was treated and advised to attend for follow                                                  3 Where a Child Protection Conference determines that a child is at continuing risk of Significant Harm, a multi-agency Child Protection Plan is formulated to protect the child. A Core Group of professionals, including the Lead Social Worker, are responsible for keeping the Child Protection Plan up to date and co-ordinating inter-agency activities within it.   Child L Final Report 11 Sept 2017 10 up with the GP. The hospital Accident and Emergency report to the GP concluded that ML was experiencing seizures and was alcohol dependent.   4.15 A further visit to the home was made by SW1 the following day and Child L’s older sibling indicated that ML was at MGM’s home. SW1 went to the home of MGM where ML stated that she had been in hospital due to seizures. At this visit it was recorded that both agreed to co-operate with a Child in Need plan.  4.16  The next home visit by SW1 was just after half term holiday. ML, MGM and Child L’s younger sibling were present. It was noted that the family were residing with MGM due to ML’s health.  SW1 was satisfied that MGM was a protective factor but that the problems were likely to be evident once the children returned to mother’s sole care.    October to December  4.17 A second Child in Need meeting was held, attended by SW1 and SSO, a primary school representative and School Nurse.  ML and MGM reported that they believed the meeting to be the following day, and MHP was not in attendance due to ‘unforeseen circumstances’.  Child L’s school attendance had dropped to 83% and she was described as looking ‘a bit lost and unhappy’. Although generally well presented, her appearance was described as dishevelled on occasion. It was agreed that SW1 would complete a Child and Family assessment and that a Graded Care Profile4 would be completed by a Family Support Worker (FSW).  4.18 Two days after the meeting, SW1 discussed this case in supervision and it was agreed that a Strategy Meeting would be initiated if engagement from ML could not be secured.  ML was not available for the next home visit but was available at the following attempt where she described as ‘engaging’. One week after this (mid November 2015), the Child and Family assessment was completed. It concluded that ML was now willing to engage with the Child in Need process, however, the family was lacking stability due to housing issues, and concerns for the children’s emotional needs as ML was chaotic at present. The assessment noted that the children had                                                  4 The Graded Care Profile (GCP) is an assessment tool designed to help practitioners identify when a child is at risk of neglect.   Child L Final Report 11 Sept 2017 11 spoken of ML’s alcohol use and how this is affecting them but that she was engaging with the GP for support. The Manager signed off the assessment indicating that a ‘robust’ Child in Need plan was needed with an escalation to child protection if ML disengaged.  4.19 Child L attended the school health Drop-In clinic with the School Nurse. The School Nurse thought Child L appeared happier although she reported things to be ‘about the same’.  4.20 Upon completion of the Child and Family Assessment, SW1 contacted MHP. MHP advised that she was continuing to meet Child L in school, described her as having low mood and indicated she would see her weekly. SW1 requested that a family therapy approach was introduced to enable Child L to build up the relationship with ML.  SW1 also made a home visit with the FSW to introduce the graded Care Profile. ML was found to be under the influence of alcohol with MGM and a boyfriend also present.  4.21 At the end of November, SW1 made a home visit with ML and all the children present. The home was observed to be more organised, the children’s bedrooms and food stores were observed as appropriate. Written records show generally a much more positive image was gained. It is now known that Child L was absent from school without explanation that day and later in the evening ML attended the Urgent Care Centre with chest pain that was said to have been present all day.  ML was admitted to hospital (4) for two days and an Alcohol Withdrawal Pathway was progressed. This included a referral to a specialist Alcohol Practitioners (AP).  4.22 A Child In Need meeting was planned and took place whilst ML was in hospital. The meeting was attended by SW1, SSO, and MGM. MGM indicated that Child L was seeking attention, and was ‘playing up’ when indicating concern for ML.  4.23 In early December MHP met with Child L. Child L was noted as looking tired , not sleeping well,  mood up and down, and became very tearful saying things were not going well at home. Child L disclosed the following information:   concern about ML’s health and substance misuse indicating that she (ML) was currently living with MGM due to her ill health;    Child L Final Report 11 Sept 2017 12  worries about looking after ML on occasions and being fearful of a seizure in  case she went to sleep and did not wake up;  that Child L was living at home with an older sibling aged 19, and that it was cold with no heating or food;  that ML and her partner smoke cannabis and drink alcohol and ML gets angry when she is intoxicated;  that Child L was staying with friends often and had taken a further overdose (2-4 tablets) at the end of October during the half term school break.  Child L had eventually told MGM who told her to tell MHP;   that Child L had hidden some tablets following the previous overdose and was having frequent fleeting suicidal thoughts with no intent. She also said however that when things get bad at home she will ‘just do it’;  that Child L had self-harmed on one occasion in early October.  Child L told MHP that she wanted to be ‘somewhere where she feels looked after’, because ML could not do this and Child L ‘didn’t want her life to be like this anymore’. The recording noted that MHP would request a meeting with SW1 and Child L. MHP shared the information by e-mail with SSO.  A telephone discussion is recorded by SW1 with MHP sharing this information and the social workers undertook a joint visit with Child L five days later 4.24 Prior to the visit to Child L, ML told the AP in a telephone call to arrange an appointment that she had been alcohol free for 11 days and was feeling positive. Child L told SW1 and MHP that she was staying frequently with a friend who had a flat or at another friend’s family home as well as having food at MGM’s home as the freezer in the home was broken and the house was cold. Child L talked about how ML and a boyfriend were smoking cannabis in the house and that when drunk, ML would say mean things to her and she at times tells ML that she wants to kill herself. Child L said that nothing had changed in her family and that she did not feel safe. Child L presented as angry with ML because she was not doing anything to address the problems, Child L stated that she had had enough.  MHP expressed concern about Child L’s friendships could place her additional risk due to knowledge of a young person that she was associating with. The recording of   Child L Final Report 11 Sept 2017 13 the visit stated that SW1 intended to discuss the concerns with a manager and possibly a strategy discussion would be held to agree a multi-agency decision on the way forward.  4.25 The next day, the FSW visited the home to complete the Graded Care Profile. ML told the FSW that Child L chooses to stay where she wants to which she considered to be ‘fine at her age’. The FSW noted that ML minimised the concerns that the children had about her health, reporting that she now had a counsellor and had been referred to a high level support team. ML continued to assert that Child L’s behaviour was attention seeking. An e-mail to the SSO from MHP indicated that Child L was seen the following day by SWC and was considered to be more settled and that Child L may have ‘an underlying depressive illness’. MHP wrote to ML advising that she intended to continue working with Child L, reiterating safety advice to lock away sharp objects and medication. MHP also wrote to the GP outlining the concerns and noting that Child L risk remains high.  4.26 SW1 discussed the concerns about Child L with a manager 6 days after the visit with Child L. It was agreed that SW1 should meet with ML to discuss  the concerns and to request access to her GP records, and that ML should be asked to ensure that Child L should stay in the family home rather than different friends’ houses. A decision was made to continue with a Child in Need Plan rather than escalate to a higher threshold of intervention. The next attempted home visit was made 8 days later, 2 days before Christmas.  4.27 In the week prior to Christmas, ML had a telephone conversation with the AP whereby she stated that she was alcohol free and did not want any further contact until the New Year. SW1 also contacted the AP and was told that there was a concern that the seizures reported by ML were alcohol related and that she had agreed to access high level support in the New Year. SW1 invited the AP to join a planned Child in Need meeting in January.  4.28 ML refused to allow SW1 into the family home when the next home visit was made. ML complained that SW1 had spoken to the AP and asked for food vouchers that she indicated the FSW had promised. No further contact occurred prior to the Christmas holiday.    Child L Final Report 11 Sept 2017 14 4.29 Between Christmas and New Year, Child L was taken to hospital (4) by ML after being found in a local field intoxicated. Accident and Emergency Consultant was aware that Child L had previously attempted overdose and was open to the CAMHS service. Child L was observed apologising to ML stating that she ‘did not want to die’. Child L was admitted to hospital (5).  The hospital informed Children’s Social Care EDT, CAMHS and a referral was made to an Alcohol Nurse linked to young people. This referral resulted in a letter to Child L and ML advising of alcohol services for young people. Child L was discharged the following day without further CAMHs assessment. Emergency Duty social workers made contact with MHP prior to undertaking a home visit following Child L’s discharge.  The social workers noted the home to be cluttered and smelling of cigarette smoke, whilst they were present an object was thrown at the window and ML contacted police. Child L was recorded as feeling ‘unwell but okay’. MHP recalled making a telephone call to Child L over this period but it is unclear when and there is no written record.   January 2016 onwards 4.30 When services resumed after the Christmas holiday, MHP sent an e-mail to SW1 asking ‘are we any further forwards with things’. MHP met with Child L in school and she indicated this was not a self-harm issue. Child L reported no improvements at home had occurred but denied any feelings of suicide or deliberate self-harm. MHP discussed with Child L behavioural therapy options but Child L did not want to consider this approach. The FSW saw Child L in school the same day, Child L told her that boys had bought alcohol and although she knew she was getting too drunk, she carried on any way and also smoked some cannabis. Child L said it was a stupid thing to do and it wouldn’t happen again. Child L talked of feeling ‘left out’ at home.   4.31 SW1 visited ML who agreed to attend a forthcoming Child In Need Meeting and advised that MGM was having tests in relation to as serious illness. The Child in Need meeting was held in the second week of the New Year and attended by SW1, ML, FSW, SSO, primary school, School Nurse and AP. The meeting discussed the following issues:  concern that Child L was given alcohol by a group of boys was a concern in respect of CSE;   Child L Final Report 11 Sept 2017 15  Child L’s school attendance had increased to 97%, although attainment was slipping;   the impact of ML’s alcohol misuse on her parenting capacity;  ML stated she had stopped drinking since November and was willing to accept the alcohol withdrawal pathway;   that the graded care profile does not indicate neglect. (This was completed for younger sibling only not Child L). 4.32 Subsequent to this meeting, ML did not attend the next two scheduled appointments with AP. After the second failed appointment, the AP contacted ML who indicated that she would ring within 2 weeks if she intended to continue with the service. ML made no further contact and the case was closed.  4.33 SW1 met with Child L who said that she had not seen MHP since before Christmas  MHP states a visit took place on 4th January that was not recorded) and that they would like to continue to see FSW. Child L indicated that she could no longer confide in MGM because of her poor health and a diagnosis of serious illness. ML told SW1 that she intended to meet with the AP two day later however this did not happen. SW1 praised ML for engaging with professionals and stated that if this continues the case could be managed at a CAF level.   4.34 At the end of January, SW1 discussed the case in supervision and reported improvements in ML’s engagement and that she was accessing alcohol services. It was noted that although concerns remained for Child L, services were now in place including the FSW. The record indicates that the manager noted this case may move to a CAF at the next meeting.  4.35 MHP saw Child L in school at the beginning of February. Child L was continuing to spend much time at the home of friends, reporting that there was no heating at home and ML was still drinking and smoking cannabis. Child L reported having to bring ML home from a local park where she was intoxicated and sat in mud. A home visit one week later by FSW found the home to be ‘a mess’, and when challenged about this ML admitted to drinking and smoking cannabis. ML had a burn to her leg sustained when she fell asleep drunk in front of the fire, and she said she had brought a male home the previous night which upset the children. Alerted to the   Child L Final Report 11 Sept 2017 16 deteriorating conditions by FSW, SW1 visited ML later in the day and suggested a referral to a Family Group Conference5. This was the last visit to the family home prior to the incident which caused Child L’s death nine days later.  4.36 ML did not attend an arranged appointment with the School Nurse to complete a health assessment for all of the children. The School Nurse advised SW1 that ML had not attended.  4.37  In the week prior to Child L’s death, a meeting took place with MHP where she considered Child L to be in a good mood, excited about going to a music concert. MHP discussed the forthcoming half term holiday, recognising school holidays were generally a more difficult time for Child L. A Safety Plan was re-iterated of contacting CAMHS, staying with friends, or attending Accident and Emergency if needed.  4.38 During February 2016, there was deterioration in Child L’s attendance to 89% and deterioration in attainment. A Child in Need Meeting was planned for after the half term holiday. SW1 discussed the case in supervision the day prior to Child L’s death. The discussion concluded that if ML can engage with alcohol services, than the case could be stepped down to CAF.  5.          Analysis 5.1 The period of multi-agency interventions for this review essentially cover a six month period from September 2015 to February 2016 with the first point of intervention being in relation to an attempted overdose when Child L was aged 14 years and 5 months.  Suicidal behaviour is a complex phenomenon that occurs along a continuum that progresses from suicidal thoughts, to planning and attempting suicide through to a worst case scenario of fatality. Children who talked to ChildLine (NSPCC 1999) about feeling suicidal were generally facing turmoil relating to a range of problems which had left them feeling desperate and unable to cope. It was noted that the common characteristic of such children were loneliness, low self-esteem and a belief that nobody cared about how they were feeling.                                                   5 Family Group Conferences are decision-making meetings which bring children and families and their wider support networks together to jointly find solutions to the difficulties the family are experiencing.    Child L Final Report 11 Sept 2017 17 5.2 An overdose attempt by such a young person is a shocking and frightening situation for most families, with access to professional help and support being valued and welcomed. The response to the attempted overdose demonstrated a timely approach to assessing the risk that Child L was exposed to underpinned by the use of a Trust Approved Risk Assessment (TARA) which addresses past history and current situation to identify factors that increase risk and factors that decrease risk.  Although Child L was assessed as suitable for discharge, she was also identified as high risk and therefore in need of a risk management plan. ML and MGM were present throughout the assessment of Child L, MHP noted a dismissive attitude toward Child L which was severely impacting her emotional distress and need for support and re-assurance. Child L was seen alone, but it must have been very difficult for her talk about her family worries whilst her two main care givers were close to hand but she was able to say that she felt an absence of emotional care and shared that she was concerned about ML’s drinking. Child L also stated that she had a history of self-harm from Year 7, suggesting longer term pain and distress indicative of an underlying issue and insecure attachment. Attachment theory argues that children are biologically programed to form an emotional bond with their caregiver and that an attachment figure will act as physical security and comfort to the child. An insecure attachment style can develop when the primary care giver is inconsistent in responding to the child in times of need so predisposing the child to become either preoccupied with maintaining contact or disengaging with the care giver. Insecure attachment styles impede socioemotional development and the development of coping strategies and problem solving skills. The observations of the parent-child interaction during the assessment suggested that the emotional difficulties of Child L needed to be explored in the context of the familial relationships that were impacting detrimentally on her resulting in a risk of significant harm. 5.3 The TARA assessment was limited in completion, with the factors that decreased and increased risk insufficiently developed. The Safety Plan referenced a need to consult with Children’s Social Care, however, it is apparent that based on her assessment or risk and the factors impacting upon this, MHP should have made a formal referral to   Child L Final Report 11 Sept 2017 18 Children’s Social Care but instead accepted working with the  SSO without challenging whether the case sat appropriately within the early help service. A referral directly to Children’s Social Care would have enabled a more informed focus on risk at the early stages of intervention.  The relationship between CAMHS and Children’s Social Care did not develop as a multi-agency partnership. Communication was limited to approximately five telephone calls or e-mails and one joint visit in December when Child L presented as very distressed about her living situation. The CAMHS service were not present at any of the three Child in Need meetings and had no shared Child in Need plan. Exploration of the activity undertaken by CAMHS has been hampered by an absence of contemporaneous recording, but from meeting with MHP it is evident that she was extremely concerned about Child L and expressed frustration that ‘something should have been done’.  5.4 The voice of Child L is evident throughout  agency records, to name but a few, there are many examples of her telling people how she was feeling and what she needed as follows:   September 2015 during CAMHS assessment Child L indicated that she could not discuss her worries with ML and that she was fearful about her mums physical health;  September 2015 Child L told SW1 at their first meeting that nothing at home had changed following the overdose and that she did not feel close to anyone in her family but wished that that she had a better relationship with her mother;  October 2015 Child L told the School Nurse that she ‘felt the same’ when asked how she was;  December 2015, Child L told SW1 and MHP that the home had no heating or food, she was staying away with friends for comfort and that she wanted to ‘be somewhere where she feels looked after’ and didn’t want her life ‘to be like this anymore’;  MHP recalls that Child L told SW1 that she wanted to move out of the house and that SW1 agreed to look into it;   January 2016, Child L told FSW that ML was drinking and this was causing problems;   Child L Final Report 11 Sept 2017 19  February 2016 Child L was tearful when meeting with MHP, again explaining home conditions as very poor without heating and ML drinking heavily;  February 2016. Child L advised the FSW that she was removing herself from the family home to protect herself from situations that make her feel low and anxious.  The extent to which her voice was heard and acted upon is questionable.   5.5 Child L is clear throughout the period of intervention that the ability of ML to meet her needs was compromised because of an alcohol dependency. Whilst this resulted in the Child in Need plan seeking to address ML’s dependent drinking, the manner in how this occurred was naïve. There is a significant discrepancy in recording and recall by MHP and SW1 in relation to whether Child L was offered assurance that consideration would be given to exploring alternative living arrangements. It was striking that the view of SW1 presented as somewhat out of step with the reality of this case when she described the death of Child L as a shock because she believed that the multi-agency plan was making progress. Given Child L’s descriptions of family life and how it was impacting on her emotional wellbeing, exploring the possibility of alternative care arrangements would seem like a reasonable course to follow.  5.6 SW1 was of the view that the family was assisted by the presence of MGM and that she provided an additionally protective factor. It is noted however that this view was not based on any particular assessment of MGM and in fact, very little was known about her history of parenting. ML reported during the course of this Review that MGM also had a problematic relationship with alcohol and that she herself had been exposed to high levels of domestic violence fuelled by alcohol. In this context there is a question about MGM’s ability to recognise risk, or challenge her daughter’s problematic drinking.  5.7 The Practice Manager who provided support and supervision to SW1 advised that to the best of his recall, the possibility of Child L moving away from the family home had never been discussed with him. Six days after the joint visit by SW1 and MHP when MHP states this was referenced as an option, SW1 had supervision with the Practice Manager. The records state that there were concerns about Child L’s   Child L Final Report 11 Sept 2017 20 ‘emotional wellbeing and the chaos in the household’ but the advice went on to say that SW1 should advise ML that in order for Child L to settle at home, ML was responsible for ensuring that Child L was sleeping in her own home rather than friends and family. This approach completely misunderstood the reasons why Child L was staying away from the family home and effectively dismissed one of her coping strategies that decreased risk and increased her resilience. Following the overdose in September, there was reference to CAMHs developing a Safety Plan however, this approach was not shared across agencies or reviewed as part of the Child in Need meetings. Similarly, whilst a Child in Need Plan was developed by Children’s Social Care, this was not effectively shared with partner agencies or systematically reviewed against the objectives and intended outcomes. Had this have happened, it would have been evident that the issues that impacted on Child L in September remained unchanged in the subsequent three multi-agency meetings.   5.8 From the outset of intervention, ML and to a lesser extent MGM indicated clearly that they believed Child L’s behaviour to be attention seeking and adopted a ‘no nonsense’ approach. For Child L this simply re-enforced her sense of worthlessness and hopelessness. The potential for support from child welfare agencies was also difficult for Child L to pursue as she  had clearly been warned off from bringing ‘social services’ into the family’s business. There are various references in agency records that indicate that Child L was concerned about being disloyal as this would break the family code. In the meeting with ML during this Review she presented as clearly presented a sense of strong family values that created an ‘us against the world’ mentality. She perceived that professionals only ever worked against her, and although she accepted her drinking impacted on Child L, she excused her addiction for a host of reasons.  5.9 The reluctance of ML to engage with agencies was apparent throughout this case, and this is why it is surprising that the Child and Family assessment concluded that ML was willing to work with the Department after an ongoing resistance and only one visit where she allowed SW1 to visit as planned. This is a clear example of what Brandon et al (2012) Learning from Serious Case Reviews describes as the rule of optimism that exists within social work and other helping professions. The rule of   Child L Final Report 11 Sept 2017 21 optimism originates from a desire to make a positive difference to the life of people that professionals work with and the need to believe in what they are doing. When at play, the rule of optimism can blind practitioners to what is really going on by believing that what they are seeing is progress through the filtering or minimising of areas of concern. The third Child in Need meeting set out a plan for ML to work with AP and without any real reason to be confident about this, the professionals simply anticipated that the intervention would work without considering the consequences of it not doing so.   5.10 SW1 was a practitioner of one years’ experience and needed consistent management support and challenge to apply a critical thinking style to a very complex case. ML would undoubtedly have been a very difficult client to work with, she was alcohol dependent, likeable and vacillated between aggressive and pitiful behaviour that would have invoked a range of complex emotional responses in any worker. It is in situations like this where high quality reflective supervision can make a difference in recognising the presence of that the rule of optimism and the tendency for practitioners to give parents too many chances whilst paving the way to adverse outcomes for children.  The social work supervision was an opportunity to spot the indicators of disguised compliance and ensure a continued focus on the impact of no change on Child L.  5.11 Although three multi-agency Child in Need meetings took place, there was a view amongst the professionals that attended that there was a greater focus on the younger sibling of Child L for whom previously there had been a CAF intervention. The decision to use the Graded Care Profile as a tool to assess neglect if executed well could have provided an opportunity to focus of the effects of neglect on Child L. Although not clear to multi-agency professionals at the time, it is now known that the profile was only completed on the younger child and not Child L. So although in the weeks running up to Child L’s death part of the rationale for considering stepping the intervention to down to a CAF level was that the Graded Care Profile did not indicate neglect, this did not address the unique neds of Child L. Research shows that practitioners are often more willing to intervene to protect younger children however  when this scenario was discussed with SW1 and the Practice Manager,   Child L Final Report 11 Sept 2017 22 both indicated that the organisational culture at the time strongly supported the need to act to protect older children, particularly in the light of learning from local and national enquiries.  5.12 The impact of alcohol abuse on children is one that is often underestimated and may be influenced by the fact that alcohol is a legal substance.  Any attempts to engage parents in treatment is based on a uniquely personal motivation cycle and voluntary engagement with services who have a predominantly adult focus. ML told the Independent Reviewer that she needed two cans of strong lager simply to stop her shaking upon waking each morning and there are numerous indicators that she was drinking very heavily.  The FSW told the Independent Reviewer that it was best to see ML in the mornings because she would be obviously under the influence of alcohol later in the day which made her less capable and amenable to work with. The school told the Independent Review that both ML and sometimes MGM smelt of alcohol, a comment that was echoed by the school nurse. It was telling to the Review Team that on one occasion ML incurred a significant burn by falling asleep too close to a source of heating. It appears that the working arrangements with ML around the effects of her drinking would have masked the professionals understating of the impact on Child L. Working with parents with addictions can be very frustrating,   broken promises and agreements are common and that is why the Child in Need process, when implemented systemically within a multi-agency structure, directs professionals to maintain the child as the focus of concern.  5.13 Overcoming long standing addiction is a major achievement for anybody and becoming alcohol free after many years requires a carefully planned series of interventions that would include medication to stabilise the physical cravings, counselling to gain an understanding of the underlying factors of the addiction alongside a planned and medically supervised detoxification. Sadly for the addicted individual, even If all those stages are successful the hardest work of remaining alcohol free then begins. Alcohol dependency is much more than a physical dependence so even when physical dependence is addressed the risk of relapse remains high. Whilst the Child in Need plan directed ML to engage with the AP, there was a gross naivety that this is what she would do, let alone an absence of an   Child L Final Report 11 Sept 2017 23 assessment of her capacity and desire for change. In the meeting the Independent Reviewer ML gave no indication that she accepted the need to cease drinking at that time and offered many reasons why she could not do this.  One can only conclude that the management oversight of this case was poor within Children’s Social Care, constancy of proposed weave between threshold applications should have been seen as a clear indicator that ML was not achieving consistent engagement.  5.14 This position raises the question of the possibility of challenge from other agencies in the partnership. MHP in her meeting with the Independent Reviewer expressed frustrations about how Children’s Social Care responded to Child L’s needs and this led to a discussion about why  a robust challenge was not made on behalf of Child L at the point MHP believed her needs were not being met. The CAMHs Lead advised the Lead Reviewer that MHP is an experienced practitioner who was considered to have a good understanding of risk. MHP advised that she believed that Child L was at a high degree or risk, and that from December onwards she was expecting that Child L would be offered accommodation as a looked after child. When this did not happen, MHP believed that requesting an update from SW1 constituted a challenge and said that she was unaware of the Escalation Policy overseen by the LSCB. MHP did say that she left a message for the Practice Manager although there is no record of this in either agency. MHP spoke of her access to professional supervision and support and reported that she had two separate supervisors which she found confusing. MHP said that she did have good access to daily management advice through the duty arrangements. The concern about the mental health Of Child L were rooted in the context of welfare concerns that needed to be addressed, and to this end it was critical that Children’s Social Care and CAMHs formed an effective partnership for Child L.  The CAMHS Lead advised that the supervisory arrangements were made clear to staff, with a Clinical Supervisor for clinical discussion and a management supervision to address issues personal to the supervisee. Discussion of cases through supervision however relied on practitioners identifying the case for discussion, and the Trust records indicate that this case was not discussed within the supervision framework although it should have been. It is acknowledged that MHP was operating a high case load, but had a tendency to readily seek new work. In   Child L Final Report 11 Sept 2017 24 public facing professions, it is not uncommon for ‘busy-ness’, or too much ‘doing’ to get in the way of, or become a substitute for high level thinking time. In order to effectively exercise professional judgement, professionals must be confident to challenge against the grain of other people’s thinking in meaningful manner. Analysis of Serious Case Reviews tell  us that it is common for there to be disagreement in safeguarding between those involved but that to lead to safe outcomes it needs to be openly acknowledged and addressed. Respectful and assertive challenge based on the desire for positive outcomes can stimulate and motivate other professionals, it is not uncommon in Serious Case Reviews for practitioners to wish they had challenged more as they reflect on practice and to accept the need to take affirmative action with the intention of protecting a child when respectful challenge is not working.  5.15 There can be no doubt of the impact that Child L’s death has had on the CAMHS practitioner and the painful reflections that she has undertaken. The Practitioner was able to share that CAMHS and CSC worked quite separately indicating that Child in Need meetings needed to have a greater priority in CAMHS.  MHP stated that she now realises that raising her concerns practitioner to practitioner provided insufficient challenge,  and that there was too much reliance and confidence that  ML would  change when she was not able to.  5.16 The last visit to the home on Child L was conducted by FSW ten days before her death. The FSW was alarmed to see a rapid deterioration in home conditions and that ML was not coping and admitting that she had resorted to drinking and using cannabis.  It was also noted that ML had placed the children at risk by bringing an unknown drinking partner into the family home overnight. This did not result in any direct consultation with Child L, and no further direct multi-agency work was undertaken prior to her death. SW1 advised that she was unable to make a visit to the family home because she was on a rota to provide duty cover all week, although this increased concern should undoubtedly have invoked an agency response. The Review can find no understandable reason as to why this information did not result in affirmative action, in particular as the AP had already shared that ML had not engaged with the alcohol service. The Review was advised by FSW that on occasion ML was racist in her language and manner to SW1, and it was interesting to note that   Child L Final Report 11 Sept 2017 25 this was not recorded in any of the supervision discussions. Discussion with SW1 on this matter revealed that she saw coping with racism as part of the job, and that her coping mechanism was essentially to disregard its presence and ‘not take it personally’. SW1 commented that this was acknowledged and challenged by FSW however, it is significant to note that the resistance to acknowledging racism may also have the effect of minimising its impact.  5.17 The final conversation between the Practice Manager and SW1 occurred the day before the death of Child L. The records of this conversation indicate that there is knowledge that ML is drinking heavily, that MGM’s presence as a support to the children is reduced because of a serious illness. The agreement then that because   the family were  settled in their own home and that the home conditions have been generally good enough, the case could be stepped down to CAF if ML engages with alcohol services (even though it was known she had not) is dismissive of the purpose of the intervention over five months. It is noticeable that this key management advice was given outside of a formal supervision session and lacked analysis or understandable rationale.  5.18 There is a sense that practitioners over empathised with ML who saw the illness of MGM as an excusable reason for drinking. I would suggest that ML would find many reasons to excuse her drinking, it was having a profound impact on Child L and ML needed to experience frequent challenge so as not to collude with her and break down her distorted image. Although the AP from an adult facing perspective felt she could do little more than close the contact after ML did not engage, she did advise SW1 of this so that the impact could be considered as part of the ongoing assessment of risk for the children. The AP recollected her experience of attending the Child in Need meeting, which she described as very informal without access to a written plan and no minutes being made available. It should be noted that Child L was neither advised of or introduced to organisations that provide specific emotional support to children who are affected by alcohol such as Al-a-Teen or Nacoa (national association for children of alcoholics) , and that potentially access to such support could have helped Child L feel less lonely.  Nacoa runs a helpline which can provide support at a time of crisis through the relative anonymity of a telephone call. Child L   Child L Final Report 11 Sept 2017 26 clearly felt different to her peers staring a ‘just want a mother like other people have’.  5.19 The Review was keen to explore the position of FL in Child L’s life. SW1 acknowledged that she did little to achieve engagement with FL because in her view, and that of MHP, Child L did not see her father as part of her life. When meeting with the Independent Reviewer, FL agreed that he did not see Child L often but that he did see her consistently. FL is upset that he was not told of the risk to Child L and reports that he could also have provided a good deal of contextual information about ML and her drinking habits. FL advised that he had served a prison sentence for domestic violence against ML, and that he very rarely went to the family home fearful that if ML ‘kicked off’ he would be  held responsible. FL advised that it was he who purchased the ticket for the pop concert that Child L enjoyed. FL presented as distressed during the meeting, and questioned if he had understood the difficulties she was in whether he could have provided a solution to her living arrangements. The tendency to exclude men and develop fixed thinking about what they can offer a child is commonly identified in Serious Case Reviews.   6. Learning from the Review   6.1 The use of existing multi-agency structures and processes is significant to responding to the needs of children who present a risk of suicide and self-harm. In particular, the use of a shared multi-agency plan with a focus on risk and resilience is critical to maintaining a focus on the child and achieving best outcomes. The analysis of this case demonstrates an inherent weakness in the approach to multi-agency working. SW1 as Lead Professional understood the need to approach the case using a model of multi-agency working, however, the practice fell short of achieving a consistent and cohesive team around the child and there was an absence of a meaningful Child in Need plan, a shared assessment of risk or identification of the resilience factors that could be built upon for Child L.  There is often a misunderstanding in practitioners mind that work that falls under a threshold of Child in Need has less status than work that is identified within the child   Child L Final Report 11 Sept 2017 27 protection arena and this can be reflected in the engagement of professionals. Children subject to Child in Need fall under the statutory requirements of Section 17 Children Act 1989, and professional must approach this with the same vigour as child protection work within Section 47 of the same act.  The Child in Need meetings with key practitioners absent led to a more limited appreciation of risk as well as an absence of challenge on behalf of Child L.    6.2 Working with resistant parents to achieve change through partnership provides significant challenges for single and multi-agency working and it is the duty of professionals to remain clearly focussed on the impact of any ongoing risk of harm to each individual child.  It is not uncommon for multi-agency professional to experience a level of resistance from families when there is a requirement for change. Working through the barriers of resistance is a common task that is achieved for the majority of families who come to the attention of additional welfare services but can be time consuming.  The challenge for the multi-agency partnership is to establish whether sufficient change can be achieved within a timescale that reflects the needs of the child. The analysis of the case shows an insufficient focus on how the child was coping an experiencing parenting whilst agencies were trying to engage ML in a process of change. Child L told several professionals how she was feeling, how the experiencing of parenting affected her and this went unheard. Every child is unique and the impact of parenting will be different based upon their individual relationships and levels of resilience. Child L told professionals she could not cope within her home environment and that this led her to take an overdose. Her attempts to find alternative living solutions were misinterpreted as her not conforming rather than her only means of achieving a degree of control over the issues she found very difficult to cope with.   6.3 The assessment of parental capacity for change must be central to any multi-agency plan of intervention. The complexity of assessing the potential and actuality of   Child L Final Report 11 Sept 2017 28 change in a parent with an alcohol/ substance addiction should be factored into children’s plans alongside an explicit understanding of the impact on the child.  Examination of this case reveals little indication of change on the part of ML, save an occasional statement of intent. The case management approach showed a very limited understanding of the reality of alcohol dependency and an over optimistic acceptance what ML’s reluctant acceptance to see an alcohol counsellor would mean. The level of oversight and support that both Child L and ML needed in the weeks and months leading up to Child L’s death was not fully appreciated, there was a passivity on behalf of professionals that did not achieve the level of challenge and questioning that was required to ensure that Child L was sufficiently safe.  This is evidenced by an undeveloped Child in Need plan, with an insufficient focus on identifying the impact on Child L should change not be achieved to enhance her welfare.  Critical to this case was an understanding of the psychology of alcohol dependence, there was strong evidence that ML was unable to cease drinking over a prolonged period, yet a belief that this could be achieved over a short period of time by the application of external pressure and expectation. The outcome of the third Child in Need meeting effectively placed unchecked trust in ML that she could and would use the support of an alcohol practitioners to gain control over her drinking despite all indicators of behaviour suggesting otherwise.  6.4 The role of management oversight is critical to helping practitioners achieve safe outcomes when working with resistance to change in long standing and deep rooted family dysfunction.   This reports suggests that both SW1 and MHP were at times struggling with how to respond to the issues this case presented, with SW1 maintaining a belief that ML could adapt and change her parenting once she had control over alcohol, and MHP believing that Child L should be offered alternative care. MHP was however unable to use organisational management processes to support the need for challenge to Children’s Social Care, and the management systems did not pick up the need to do so. MHP, although an experienced practitioner, had little understanding of how to challenge on behalf of a child and reported no knowledge of the LSCB procedures.   Child L Final Report 11 Sept 2017 29 SW1, a social worker in her first year of independent practice needed a much more challenging management approach, one which offered reflective thinking time to take a step back and review what was known, what research in practice reminds us and how to use of all this information to reach a judgement about what Child L needed.   6.5 Critical thinking skills are necessary when undertaking complex family assessments and the use of such skills must be embedded in organisational culture and practice.  Powerful thinking requires powerful questioning which does not always lead to comfortable answers. All practitioners are affected by inherent biases and we have to mitigate against the possibility of wilful blindness when faced with seemingly intractable scenarios.   Developing critical thinking skills is of the utmost importance for safeguarding partners and we are reminded of this through successive national enquiries and reviews. It is crucial therefore that organisations pro-actively dedicate some time to think about how their cultures and processes support and encourage this kind of thinking in the sure knowledge that for practitioners it may be a lot easier to ‘go with the flow’ and not think outside of presenting issues.  6.6 Multi-agency professionals must remain alert and attuned to the role of men in families, avoid a recognised tendency for fixed thinking and adopt and exploratory and inclusive approach.  It is striking that FL was neither informed nor consulted about the position of Child L, it is suggested that this is because Child L did not introduce her father as a source of potential support. From the professional’s perspective, it is possible that they were influenced by the knowledge that FL had been convicted and indeed served a prison sentence in relation to the assault of ML some years previously. ML had a right to know of the concerns about his children and Child L gave SW1 a contact number for him; whether he could offer support in terms of building resilience should have been explored. The failure to include men and in particular an absent father  in assessments of families is almost a cliché,  and the need to do so in order to understand a child’s whole circumstances must be continually re-enforced.     Child L Final Report 11 Sept 2017 30 6.7 Maintaining good records of agency contacts and interventions is necessary to achieve chronologies which help practitioners and agencies analyse risk robustly, ensure that assessments take account of all known information and patterns and review the impact of their work. The standard of record keeping in CAMHs fell much short of agency standards.  Whilst this has caused difficulties for this review, what is of greater concern is that this deficit had not been identified through usual management approaches and audits.  Whilst contemporaneous records in Children’s Social Care were not in themselves a matter of concern, there was concern about the availability of minutes from Child in Need meetings. Whilst it is not necessarily the sole responsibility of the social worker to minute the meeting (and in this instance one meeting was minuted by the school), it is the responsibility for Children’s Social Care as the lead agency to ensure this is achieved. Minutes of such meetings should be used to structure the review of actions in subsequent meetings. The absence of multiagency agreements will lead agencies to reach their own, maybe conflicting interpretations, of what was achieved.   7. Conclusion   7.1 This case is a particularly sad death of a child in circumstances where she was known to be distressed and that this distress had previously manifested itself in an overdose. It is evident from the first intervention that Child L felt very alone with worries that she perceived her peers did not have, and that speaking of the worries about her family outside of her family was a very difficult thing to do.  7.2 There is great discomfort for the two key agencies involved in assessing risk to Child L who have both accepted that more could and should have been done to support and listen to her.  7.3 The findings from this Review lead to some significant considerations for the Board as follows:   Child L Final Report 11 Sept 2017 31  Is there confidence that learning from previous reviews in respect of the challenges of assessing parental  capacity for change has been embedded  What can be done to support  agencies to build on a culture of respectful uncertainly and embed critical thinking styles across the organisation   Are multi-agency practitioners sufficiently equipped to understand the nature of substance abuse by parents and the impact on children   How can the voice of the child become more prominent in the application of threshold criteria  How can the partnership agencies demonstrate strengthened management  oversight for children at risk of harm  How are the processes which support multi-agency working maintained for all children across the spectrum of need  7.4 The Serious Case Review Panel considered how children at risk of self-harm and suicide could be better anchored into multi-agency structures which provide a high level analysis of risk and determine a multi-agency approach to support. To this end, it is recommended as a matter of urgency that all children assessed to be at medium or high risk of harm through self-harm or suicide are referred by the assessing agency directly to Children’s Social Care who will then coordinate a multi-agency professionals meeting, which could be a strategy meeting when significant harm or risk of significant harm is identified    