Attempted suicide of a boy aged under 16-years-old in 2019. Harry had experienced significant neglect, trauma, emotional and mental health difficulties whilst living with his mother, step-father and siblings in Scotland; subject to child protection plan in 2016. In 2017, Harry moved to live with his father in England. Incidents of self harm; suicide attempts on five separate occasions prior to the incident in 2019. Harry's recollection of the incident, resulting in him being admitted to Child and Adolescent Mental Health Services (CAMHS) is that someone tried to kill him, however there is no evidence to confirm this. Ethnicity or nationality of Harry is not stated. Learning includes: a greater appreciation of the impact of early childhood adversity and trauma and the importance of using this information to inform decision making and safety planning; importance of information sharing across borders and agency boundaries; the need for prompt action to secure the appropriate type of support and intervention when young people experience an acute and serious mental health episode. Identifies areas of good practice. Uses the SILP (Significant Incident Learning Process) methodology. Recommendations for the Safeguarding Partnership include: to inform the Child Safeguarding Practice Review Panel about the apparent lack of explicit guidance about the transfer of school records across borders in Scotland and England; to review and amend guidance and procedures on the management and information sharing practices between local community based child mental health services, acute health settings and community health services for situations where children re-present to an acute setting.
      
    Serious Case Review No:  2020/C8290  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.   CLASSIFIED INFORMATION – FINAL VERSION         Serious Case Review Review report Harry Independent Reviewer: Kevin Ball      This report is strictly confidential and must not be disclosed to third parties without prior discussion and agreement with the Safeguarding Children Board. The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies involved.     CLASSIFIED INFORMATION – FINAL VERSION    Contents Page  1.Introduction   1  2. Process for conducting the review   1  3. Family composition & contribution to the review   2  4. Relevant case details  4.1. Relevant background information prior to the time-frame under review 4.2. Relevant information during the time frame under review 4.3. Key episode 1: September to November 2018 4.4. Key episode 2: January 2019  2 – 6  5. Findings & analysis  5.1. The use of history to inform risk assessment, safety planning & intervention  5.2. The quality of the strategy discussions & subsequent assessment and/or investigation  - September 2018 Strategy discussion in response to Harry’s paracetamol overdose - January 2019 Strategy discussion in response to Harry’s suicide attempt  5.3. The quality & effectiveness of any cross border & transfer issues identified  5.4. The quality of information sharing between agencies  5.5. Evidence of the voice of the child being sought, heard and acted on  5.6. The effectiveness of maintaining a focus on the child’s safety & needs throughout  5.7. The provision of training & supervision to the workforce about the identification or & response to abuse, neglect & maltreatment, particularly relating to adolescents  5.8. The quality & effectiveness of the mental health pathway between services   6 - 22  6. Good practice   22  7. Conclusion   23  8. Recommendations   23   1  1. Introduction 1.1. A Local Safeguarding Children Board (LSCB) commissioned a Serious Case Review based on information which supported a professional view that a child, aged under 16 years, attempted to take his own life in early 2019. The child’s recollection of the incident is that someone tried to kill him however there is no supporting evidence to confirm this account. The child, who for the purposes of this review will be known as Harry1, had experienced a difficult childhood having suffered neglect, trauma, emotional and mental health difficulties whilst living with his mother in Scotland. Reports indicate that Harry tried to end his life on five separate occasions prior to the incident in 2019.  1.2. The response by those agencies in the run up to the suicide attempt as well as the immediate management of Harry at the time of the incident has come under the spotlight and as such, there are concerns about the way in which agencies worked together to safeguard Harry’s safety and welfare.  1.3. By way of a summary of the findings and learning, the following factors have emerged; - Harry had experienced significant abuse and neglect in his earlier childhood whilst living with his mother in Scotland. When he moved to live with his father in England information about Harry’s history was not effectively shared. Although this is unlikely to have altered Harry’s behaviours and attempts to self-harm or take his own life, it disadvantaged agencies attempts to support Harry at the times when he was most likely to have needed help. - The extent to which Harry’s earlier adverse childhood experiences were not fully appreciated by the professional network in the local area in England, resulting in further assessment opportunities not being prioritised – which, had they been, might have then informed safety planning. Practice was not fully informed by knowledge about the trauma he had experienced.  - Following Harry’s serious attempt to take his own life, the initial response by services was quick and efficient however it soon became apparent that delays in securing him an appropriate placement in a specialist mental health provision began to impact on safety planning and care management.  2. Process for conducting the review 2.1. The LSCB agreed that this SCR would be undertaken using the SILP methodology2, which engages frontline staff and their managers in reviewing cases and conforms to the expectations as set out in statutory guidance3. The review was conducted by Kevin Ball who is an independent safeguarding consultant, an experienced chair and author of SCRs, and SILP associate reviewer. He is fully independent of the LSCB and its partner agencies.   2.2. Single agency reports4 were completed providing individual agencies with the opportunity to consider and analyse their practice and any systemic issues. In completing these reports it has                                                            1 Harry is the pseudonym chosen by the child subject of the review.  2 SILP – Significant Incident Learning Process.  3 Working Together 2015 (under which this SCR was commissioned), HM Government.  4 Agencies that have contributed to this review are:  - Children’s Social Care                 - County Education Department        - NHS Trust - Adult Social Care                 - Children’s Services in Scotland         - Local charity providing counselling - Clinical Commissioning Group       - Specialist Hospital for Children - Police                   - NHS Foundation Trust   2  allowed agencies the opportunity to reflect on their practice, capture learning and make recommendations for improving their own practice. Following these reports being submitted practitioners, managers and agency safeguarding leads came together for a multi-agency workshop. All agency reports were shared in advance and the perspectives and opinions of all those involved at the time were discussed at the event. This group then reconvened to examine the first draft of the SCR report and further help shape the learning. 2.3. It was agreed that the time-frame under review would be from the May 2017 when Harry moved to the local area in England to live with his father until January 2019 following Harry’s most recent suicide attempt.  Relevant background information is also captured. 3. Family composition & contribution to the review 3.1. Relevant family members in this review are:  3.2. Gaining the contribution of family members has been an important consideration for this review. The Independent Reviewer met with Harry’s father and his contributions have been helpful in shaping the learning from this review. In discussion, the father was clear about not knowing the full extent of Harry’s history from when he lived in Scotland having not had contact with him for a long time. He was also clear about the struggles of adjusting to living with, and caring for, Harry when he moved back to live with him from Scotland after a gap of seven years. These issues are expanded upon in the findings and analysis section.  3.3. The Independent Reviewer also met with Harry, who was keen to offer his perspective. In discussions, Harry described many of the highs and lows of his recent life and his thinking behind some of his actions.  He also commented on some of the interactions he had with different professionals in recent times and how some were really helpful and others were less impactful. These are examined in the report. The Independent Reviewer and LSCB acknowledges the contribution of Harry and his father to this review and is grateful for their input. 4. Relevant case detail 4.1. Relevant background information prior to the time-frame under review  4.1.1. Concerns about Harry living with neglect are first recorded as emerging in 2012 whilst he was living with his mother, step-father and siblings in Scotland. Home conditions were described as poor and despite intervention by the local Children’s Services in Scotland, conditions fluctuated.  4.1.2. The first recorded suicide attempt by Harry (an attempted strangulation) was in March 2015 during which he had tied an electric cable around his neck. He was taken to Hospital in Scotland and subsequently received a psychiatric assessment which judged him safe to return home. Later that year concerns emerged about parent mental health, alongside ongoing concerns about the children living in a neglectful home environment and the mother being physically abusive towards Harry. Harry went to live with members of his extended family in Scotland for a few weeks in the local area to assist the situation but also began to seek contact with his birth father. 4.1.3. In September 2016 concerns reached the point that the local Children’s Services in Scotland convened an Initial Child Protection Case Conference which resulted in Harry and his siblings Family member:   Known as: Subject child -   Harry Father to subject child -  Father Mother to subject child -  Mother Siblings to subject child -   Siblings  3  judged as at risk of suffering significant harm and that they would be subject to a child protection plan with their names of the Child Protection Register5. 4.1.4. In October 2016 Harry expressed a wish to return to live with his father. This request was alongside foster placements being sought for Harry in Scotland whilst him living with his extended family. Harry had had a seven year break in his relationship with his father, but was open to going into foster care if his extended family were unable to care for him and it was not possible to return to his father’s care. In November 2016 Harry and siblings were accommodated on a voluntary basis under section 25 of the Children (Scotland) Act 19956 due to the squalid and neglectful home conditions. Harry and siblings names were removed from the Child Protection Register in late 2016. 4.1.5. Harry spent Christmas of 2016 with his father in England with a view to a permanent move. In February 2017 the Children’s Social Care local to the review in England were requested by the Children’s Services in Scotland to conduct a home visit to confirm the father’s circumstances, who at the time was living with other adult family members. The father had voiced some early reservations about Harry coming to live with him however he had already approached a local school that Harry had expressed an interest in attending. Harry moved to the local area in England in May 2017, settled into school well, made friends and had joined local clubs. He remained concerned about his siblings’ welfare. 4.2. Relevant information during the time frame under review 4.2.1. In September 2017 a member of the school pastoral team noticed old cut marks on Harry’s wrists; these were reported to his Head of Year and was advised that these related to historical frustrations before moving to the area. 4.2.2. In November 2017 Harry was excluded from school for two days due to assaulting another pupil. In December Harry had a new patient examination at the GP Practice by a Health Care Assistant; there was no exploration about mental or emotional health as the template for recording such matters did not provide a prompt for asking these questions.  4.2.3. In June 2018 school records indicate that Harry disclosed to the member of the school pastoral team that he had tried to kill himself on many occasions, including an attempt at poisoning by taking 16 paracetamol tablets and hanging himself. The school response was swift in that an emergency GP appointment was sought for the following day; however Harry’s father was not made aware of these initial efforts by the school. Harry reported being unable to talk with his father about his feelings at this time. A member of the school staff took Harry to the GP appointment and he went into the appointment by himself. Once informed, the father was supportive and willing to work with the school. The GP made a referral to a local counselling service. Also in June, Harry came into school with a swollen eye and cut; despite efforts by school staff to elicit an explanation Harry would not account for the injury. This information was passed to the MASH7 with concerns about Harry’s mental health, his negative thoughts and being agitated, and reporting that the adults in                                                            5 In Scotland children can be subject to a plan and their names placed on a Child Protection Register if they have suffered, or are likely to suffer, significant harm.  6 Section 25 - Children (Scotland) Act 1995 places a duty on a local authority to provide accommodation for any child who, residing or having been found within their area, appears to them to require such provision because (a) no-one has parental responsibility for him; (b) he is lost or abandoned; or (c) the person who has been caring for him is prevented, whether or not permanently & for whatever reason, from providing him with suitable accommodation or care.  7 MASH – Multi-Agency Safeguarding Hub   4  his life had let him down. The father was kept informed and was reported to be working actively with professionals to support his son.   4.2.4. In July 2018 Harry was seen by a GP and described feeling overwhelmed at times and that he had thought about harming himself. He was concerned about how this might impact on his career choices. The plan agreed was to review him in two weeks. At the two week review Harry reported feeling happier and more positive. By this time Harry had also engaged with the local counselling service following the referral by the GP.  4.3. Key episode 1: September to November 2018 4.3.1. In September 2018 Harry was taken to the local County Hospital having taken 30 – 40 paracetamol tablets. The overdose only came to light through the intervention of a friend whom Harry had messaged late at night. The friend then sent a text to Harry’s father telling him. There was also evidence of physical self-harm (cuts to his wrist with a knife and old burn marks on his arm). Harry had disengaged with the counselling service by this time, not attending scheduled sessions.  CAHMS and Children’s Social Care were contacted and a Strategy discussion8 was held. Harry was assessed by CAMHS at this time and judged as at high risk of self-harm. Whilst in Hospital Harry disclosed multiple previous suicide attempts from the age of eight years, which included hanging and drinking bleach. He also alleged that his mother had tried to kill him by strangulation when living with her in Scotland.  4.3.2. The outcome of the Strategy discussion, further information gathering and risk assessment by Children’s Social Care, Police, CAMHS, the Hospital staff, and school was that Harry should be admitted to a tier 49  Child & Adolescent Mental Health Unit in another area. A place was found in a unit in a nearby city area however there was a delay in him being admitted. Harry has subsequently reported that during the intervening period whilst waiting to be admitted he had an accompanied outing from the Hospital with a Support Worker which allowed him plenty of opportunities to abscond to a bridge. Eventually Harry was admitted to the specialist tier 4 Unit on a voluntary basis.  4.3.3. Plans had been made to hold an Initial Child Protection Conference however this was later cancelled due to his admission to the specialist tier 4 Unit.   4.3.4. Harry was admitted to the specialist tier 4 Unit mid-September and then discharged mid-October, having benefitted from a phased return home and into school during this in-patient stay. Whilst in the Unit the local area community CAMHS service maintained contact by phone and attended a review. 4.3.5. In November Harry spoke to a Social Worker about his continued worries for his siblings. Harry also assaulted another pupil and was excluded for one day. The community CAMHS team had resumed their contact with Harry now he was back in the community setting. Records indicate that the case was closed to Children’s Social Care in mid-November following the completion of a Child & Family Assessment.                                                             8 Strategy discussion is convened under Section 47, Children Act 1989; where a local authority has reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make such enquiries as they consider necessary to enable to them to decide whether they should take any action to safeguard or promote the child’s welfare.  9 A tier 4 provision is a specialist Child & Adolescent in-patient unit commissioned by NHS England.   5  4.3.6. During a residential school trip Harry was involved in an incident involving alcohol with some other pupils, for which Harry was heavily implicated. Harry was also concerned about his relationship with a girlfriend on this trip. 4.4. Key episode 2: January 2019 4.4.1. The day after the return from the school trip Harry was taken by air ambulance to a specialist Hospital for Children following a serious suicide attempt by hanging whilst at home. Police found unused prescribed anti-depressant medication, alcohol and a drug related item10 in his room; no cannabis was found. Following significant emergency medical intervention Harry recovered and was transferred to the local County Hospital.  4.4.2. At the same time as the transfer section 47 enquiries11 were initiated by Children’s Social Care alongside discussions by mental health professionals about the best course of action. Risk assessments were completed whilst Harry was in the Hospital and a plan was agreed that a specialist tier 4 bed was needed; ideally for a voluntary admission as the least restrictive option12. A referral was made to seek a bed. Advice was given to a Paediatric Consultant to apply section 5 (2) of the Mental Health Act 198313 and to call the Police if Harry attempted to leave the Hospital. A Registered Mental Health Nurse assessed Harry at this time as having no insight into his suicide attempt and likely to attempt suicide again; he was noted to be anxious and agitated and unable to sleep at night. In discussion with the Social Worker and mental health worker Harry stated he had no memory of the event and thought that someone must have tried to kill him; he maintains this perspective to this day. CAMHS expressed a view that the father was struggling to care for Harry, particularly given the trauma Harry had experienced in his earlier life and the impact this was now having on him. 4.4.3. Six days after this incident, and whilst still in Hospital, agency staff were providing staffing cover on a 1:1 basis however Harry went into an open outdoor play area on a third floor balcony on the Hospital Ward, having removed a glass panel from a play area, and attempted to abscond (or possibly harm himself); he was pulled back to safety by his father who was visiting at the time. Support from both the Police and Fire & Rescue Service was provided. Police remained on the scene for over three hours. Harry was given sedative medication to help him settle. The exact details of how this incident was then managed once Harry had been safely removed from the balcony are unclear with conflicting accounts of whether Harry was held using section 5 (2) powers or section 5 (4) powers14. The findings and analysis section examines this lack of certainty.  4.4.4. The following day Harry was found trying to interfere with window locks, position himself near exits and having a bottle of aftershave. At this stage the staffing ratio had been increased to 2:1 and keeping Harry in sight at all times. A specialist tier 4 bed was not available for another two days.                                                            10 A grinder is an accessory often associated with drug use.  11 Section 47 – Children Act 1989, allowing a local authority  which provides the local authority with a duty to make enquiries as considered necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare, where there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm.  12 Mental Health Act 1983: Code of Practice, Department of Health, 2015, HM Government,  13 Section 5 (2) is a temporary hold of an informal or voluntary service user on a mental health ward in order for an assessment to be arranged under the Mental Health Act 1983.  This ensures their immediate safety whilst the assessment is arranged. This can last up to 72 hours.  14 A Section 5 (4) is a temporary nursing holding power to ensure the immediate safety of a hospital in-service user while assessment by a doctor is arranged. This can last up to six hours.   6  Harry stated that he planned to leave the Hospital later, resulting in agency nursing staff stating that they would need Police support to restrain him if required.  Advice was given about increasing the use of sedatives if necessary. Harry attempted to leave the Hospital, as he had stated he would earlier. The agency Registered Mental Health Nurses refused to restrain him (despite being appropriately trained) which led to him kicking down the Hospital Ward’s locked doors and leaving the Hospital. Police found Harry in a public space later that night and returned him to the Hospital in the early hours of the morning under section 136 Police powers15. The plan was to assess Harry under the Mental Health Act about whether detention16 was necessary. The following day a tier 4 bed became available. Harry was admitted and went on to receive appropriate treatment. 5. Findings & analysis 1. The case is subject to review because there are concerns about the way in which agencies worked together to safeguard and protect Harry. This is against a background of known, and knowable, information about Harry’s history, namely one of experiencing significant harm and neglect whilst in his mother’s care in Scotland. Additionally, and with the benefit of outcome bias, questions have been raised about whether Harry continued to experience a degree of neglect having moved to live with his father. Questions have also been raised about the effectiveness of the arrangements to keep Harry safe whilst in Hospital following his serious and near fatal attempt to take his own life.  2. The following sections therefore examine these issues and seek to understand the quality and effectiveness of the multi-agency safeguarding response to Harry. It considers practice issues as well as drawing on systems thinking concepts17 as a way of making sense of some aspects of how this case was managed. Learning points for improving practice have been emphasised that can be used by practitioners, managers and trainers.  5.1 The use of history to inform risk assessment, safety planning & intervention 5.1.1. Statutory guidance18 at the time stated ‘… understanding risk involves judgement and balance. To manage risks, social workers and other professionals should make decisions with the best interests of the child in mind, informed by evidence available and underpinned by knowledge of child development …’. Statutory guidance also stated of assessment and analysis ‘… decision points and review points involving the child and family and relevant professionals should be used to keep the assessment on track. This is to ensure that help is given in a timely and appropriate way …’.   5.1.2. Although outside of the timeframe under review, the local Children’s Services in Scotland have reviewed their records and noted that there was no consideration given to seeking historical information prior to 2012 when they first became involved with the family, as preparation for the Initial Child Protection Conference held in 2016. They recognise that this was a missed opportunity to fully understand Harry’s early childhood history during a period of time when they had significant                                                            15 Section 136 of the Mental Health Act 1983 allows a Police officer to move a person to place of safety, or detain them in a place of safety if they are already in one, if they appear to be suffering from a mental disorder and are in need of immediate care or control.   16 To detain someone under the Mental Health Act 1983 is to formally detain them if their own safety, of the safety of others, is at risk, and they fail to cooperate on a voluntary basis.  17 i) Systems thinking for safety: Ten Principles – A White paper, Eurocontrol, 2014 ii) A systems approach to policy evaluation, Caffrey, L., & Munro, E., The London School of Economics and Political Science, 2017, iii) Systems approaches to managing change: A Practical Guide, The Open University, 2010.  18 Working together to safeguard children, 2015, p.24, HM Government.  7  involvement with him and his family. Harry’s view of the social work services when in Scotland is one of them not offering much help or support.  5.1.3. Harry moved to England and to the area that commissioned this review in the spring time of 2017. This provided a natural point, in the overall process of case management for a handover of information between one local authority to another. This handover point can be viewed, as outlined by statutory guidance cited above, to provide an opportunity to ‘… ensure that help is given in a timely and appropriate way …’. The quality of this handover opportunity was poor, resulting in an ineffective transfer of information which could have been used to inform safety planning and intervention.  5.1.4. Prior to him attending the local school in England a meeting took place between Harry’s Social Worker from Scotland and school staff. No information regarding Harry’s prior attempts to self-harm were disclosed at this meeting, other than him potentially having some emotional needs as a result of earlier childhood neglect. Information shared gave no indication that a risk management plan would be required. So, although some information was shared by the local Children’s Services from Scotland it was incomplete and only went part of the way to assisting the School manage Harry. Critically, the local Children’s Services in Scotland did not advise the School about Harry’s status as a Looked after Child, nor of the historical episode of being on the Child Protection Register. There was also no formal notification19 to the local areas Children’s Social Care about this status. They acknowledge that this was not good practice, not their usual practice and that the matter is being addressed. This is further examined in section 5.3.  Learning point: The handover of information from one team, service or authority creates an opportunity for risk management plans to falter or fail due to the transition from one system and set of professionals to another. Ensuring timely, well-coordinated and effective handover arrangements is important when managing risks to children. 5.1.5. In November 2017 Harry was excluded from school due to assaulting other students. The circumstances of the exclusion i.e. the assault were discussed with the MASH by the school. Records examined confirm that this was the first point that MASH became aware of Harry; having not received any information from the local Children’s Services in Scotland about Harry moving into their area several months earlier. On the basis of the presenting information the discussion with the MASH was treated as information only and understandably did not require further action from Children’s Services. No history was gathered at this stage as it was not considered necessary. Harry’s father has also relayed that he had little idea about the extent of Harry’s troubled past; knowing that he had attempted to self-harm but not attempted suicide. 5.1.6. In December 2017 Harry had a new patient examination with a Health Care Assistant. Whilst covering many subject areas the recording template used by the GP Practice did not offer a prompt for discussion of mental or emotional health. His mental and emotional health and history was therefore not discussed or considered. As a new patient, this triggered a request by the GP Practice for Harry’s previous GP record to be sent through from Scotland. Despite the request being sent, Harry’s previous GP records were not received until August 2019.  Learning point: GP records can provide a valuable source of information, not only for the GP but also potentially for other professionals when concerns arise. Ensuring the timely exchange of information from one GP Practice to another, regardless of local authority area or geographical boundaries is important when working with vulnerable children.                                                             19 A notification as might be expected under The Children Act 1989 guidance and regulations: Volume 2: care planning, placement and case review, June 2015, HM Government.   8  5.1.7. A referral was appropriately sent to MASH from Harry’s school in June 2018 following his disclosures about his past to the member of the school pastoral team but also the injuries; the referral alluded to some of Harry’s history which had been provided by the local Children’s Services in Scotland.  In discussion, Harry spoke very positively about the school pastoral team, stating that their approachability was exactly what he needed at that time. MASH did not seek further information at this time as the outcome of the screening process and further discussion between the school and Harry’s father showed that the issues were being dealt with by the GP alongside consideration of him accessing CAMHS support. This point in time highlights a potential information gathering and assessment opportunity for the MASH and Children’s Services; however, it has to be weighed against the knowledge that there appeared to be a plan in place to support Harry, the father seemed supportive and at this time there was nothing to indicate Harry was in need of other services other than emotional/mental health support.  5.1.8. Harry also attended a GP appointment in June 2018 describing low self-esteem, low mood and that he had made plans to harm himself.  Records and discussions indicate that the GP was not especially concerned about Harry’s presentation as he generally seemed ‘… chatty and cheerful and reported not to be actively suicidal ...’20. However, the records do not indicate whether Harry’s emotional or psychological history were explored to inform any assessment or intervention. This episode reflects conflicting and discrepant information; on the one hand Harry describing feeling low and making plans to harm himself, whilst on the other hand appearing cheerful. In such situations, for all professional involved, it is important to try to reconcile these contrasting accounts, especially when working with adolescents who display vulnerability. Whilst Gillick competence/Fraser guidelines21 and the involvement of Harry’s father were considered at the time by the GP this is not fully recorded. Harry attended a further two appointments in July during which he described feeling worse at the first, but then better at the second appointment. Harry confirmed that he was happy to talk with his father about his GP attendances but also gave consent for a referral to a local counselling service. At this stage Harry was not reporting he was considering actively harming himself and a priority referral to CAMHS was not judged necessary. In discussion with Harry, and with his benefit of hindsight, he felt that he was possibly looking for more from the GP, but he was uncertain about the exact nature of what he was looking for. As before, the GP notes from Scotland had still not been received so there was no historical context for the GP to place Harry’s presentation and their observations of him. This episode has resulted in a recommendation for the GP, and Practice, to ensure standards, as set out by the General Medical Council, are fully adhered to in terms of recording. The episodes also reflect that for Harry his emotional and mental health was somewhat erratic and unsteady. Given the fluctuations in Harry’s presentation a referral to CAMHS could have been considered alongside the referral to the counselling service, however the GP made a rational evaluation of the information presented. Information could also have been shared with the School Nursing Service. The reason given for not passing information to the School Nursing Service was knowledge that its resources were stretched.  Learning point: One Service or professional cannot make a decision on behalf of another Service about whether someone in need of support will, or will not, be eligible for services. A needs led decision should be considered rather than a resources led judgement.                                                            20 CCG submission to the review.  21 Like adults, young people (aged 16 or 17) are presumed to have sufficient capacity to decide on their own medical treatment, unless there is significant evidence to suggest otherwise. Children under the age of 16 can consent to their own treatment if they are believed to have enough intelligence, competence and understanding to fully appreciate what's involved in their treatment. This is known as being Gillick, or Fraser, competent, https://www.nhs.uk/conditions/consent-to-treatment/children/, accessed 03/06/2019.   9  5.1.9. As a result of the episodes outlined above, when Harry was first admitted to the Paediatric Ward in September 2018 following a paracetamol overdose very little was known about him (key episode 1). The MASH were contacted by the NHS Trust Hospital; this resulted in historical information being requested by the MASH, and received, from the local Children’s Services in Scotland within 24 hours. This information included history about him being looked after, child protection concerns in relation to the significant neglect he had experienced, information about his thoughts of self-harming, a brief chronology and some case notes which included information going back to 2015. This process worked well and clearly provided sufficient background information for services to risk assess and consider safety planning. A referral was then made to the local NHS Trust Child & Adolescent Mental Health Services (CAMHS) for a formal mental health assessment.   5.1.10. This series of events highlights that it was not until the occurrence of an acute episode that sufficient background information was gathered. Given the conflicting and inconsistent accounts Harry had given to the GP it underlines the difficulty and challenges professionals face when assessing risk and trying to make informed decisions about the management of risks – particularly mental health, which can remain somewhat hidden. Research22 notes ‘… Many of the stresses that contribute to suicide risk are common in young people, most of whom overcome them without too much difficulty. For a minority, however, the stresses are serious and the risks are real. For this reason, distress in young people should not be dismissed as transient or trivial. … The circumstances that lead to suicide in young people often appear to follow a pattern of cumulative risk, with traumatic experiences in early life, a build-up of adversity and high-risk behaviours in adolescence and early adulthood, and a "final straw" event. This event may not seem severe to others, making it hard for professionals and families to recognise suicide risk unless the combination of past and present problems is taken into account …’.  5.1.11. Research also highlights ten common themes in suicide by children and young people; emphasising the critical importance of needing to have access to historical information about an individual in order to provide the best opportunity to effective safety planning. A number of these are pertinent to this case. Themes include; - Family factors such as mental illness              - Academic pressures, especially related to exams - Abuse and neglect                 - Social isolation or withdrawal - Bereavement experience of suicide                - Physical health conditions with a social impact - Bullying                              - Alcohol and illicit drugs - Suicide-related internet use                - Mental ill health, self-harm and suicidal ideas  Learning point: Gathering information about a child’s earlier life experiences to inform assessment and decision making is crucial to providing the best possible response to a child’s distress. Examining this history may provide clues about the impact of cumulative risk factors, earlier trauma and events which may potentially trigger self-harm. 5.1.12. It is clear that from this point forward Harry’s history was taken into consideration to inform risk assessment, safety planning and intervention as it resulted in him being admitted to a specialist tier 4 Unit. It is however interesting to note that whilst Harry’s admission to the tier 4 Unit was correctly pursued on a voluntary basis (being the least restrictive option), from a community based GP perspective there were elements of biased thinking during consultations. These consisted of wishing to protect against any adverse impact any admission might have had on his intentions to pursue a particular career path; this is despite him reportedly continuing to express suicidal thoughts. The bias was in favour of supporting Harry’s career chances versus his more immediate needs. Although this                                                            22 Suicide by children and young people, National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester, p.7, 2017.  10  did not alter the pathway – which was the correct one at the time – it is important for non-specialists in community settings to reflect on this and learn when assessing mental health.  Learning point: Risk management and decision making should be based on a comprehensive assessment of the situation, historical information, professional judgement and analysis, especially in situations where the stakes may be high. It is good practice to seek a fresh perspective to be a ‘devil’s advocate’ with your decision making. 5.1.13. In discussion, Harry spoke about the need for practitioners, no matter what their profession, to make it clear to young people that they were there to offer help and support when faced with a young person who was describing highs and lows in life.  5.2. The quality of strategy discussions & subsequent assessment and/or investigation 5.2.1. As cited above, decision and review points are important junctures to ensure case management is effective in meeting the safety needs of a child. The review has thus far confirmed that the handover of the case from one authority to another was not effectively used, and therefore as a decision and review point was a missed opportunity. In this case there were two Strategy discussions held; one in September 2018 and a further one in January 2019. These two points provided an opportunity to gather information and reflect on its meaning in order to inform next steps and any requirements for safety planning.  September 2018 Strategy discussion in response to Harry’s paracetamol overdose:  5.2.2. From a procedural point of view the Strategy discussion was held within timescales and attended by the appropriate professionals, including children’s social care, Hospital staff, police, school and CAMHS.  CAMHS provided a written report, as did the GP who was unable to attend the meeting in person.  The CAMHS report states that Harry was receiving counselling at that time but was reportedly not finding this helpful. 5.2.3. Reports indicate that Harry had been open and forthcoming about his history and had also reported that he had been street homeless, using drugs and alcohol at one point in his life, but this was no longer an issue for him.  The potential for this does not appear to have been factored into the safety planning or the assessment which followed nor is it clear if Harry’s self-reporting was followed up and verified. In discussion, Harry’s father has conveyed a sense of frustration around this time when Harry appeared to increasingly be taking more control of his life, with the father increasingly losing any sense of control he may have had with Harry. This reflects a struggle that many parents experience at a time of transition for a parent – child relationship, with young people increasingly becoming more autonomous. 5.2.4. Information that was included in the Strategy discussion appears comprehensive, and included; - History which included details about abuse and maltreatment suffered. - Harry’s father being somewhat resistant to social services involvement and there being relationship difficulties between him and Harry. 5.2.5. Information that was not included in the Strategy discussion, as recorded includes; - No explicit reference to Harry’s previously reported attempts to take his own life whilst living in Scotland. - No information about Harry’s home situation given the household composition.  5.2.6. The Strategy discussion record shows that the focus of discussion was about the immediate concern and needing to manage Harry’s safety. It concludes with an agreement that the threshold  11  had been met to conduct further enquires and assessment and with a recommendation that there should be an Initial Child Protection Conference.  5.2.7. The record shows that the immediate safety plan was for Harry to remain in Hospital and for further enquires to be made about a specialist tier 4 Unit. Otherwise there are six actions noted for the immediate and short term; these are quoted as; 1. Section 47 joint with health [this is procedurally incorrect] 2. Hospital discharge planning should he discharge into community 3. Flags on Police system 4. Police to be informed if he tries to leave Hospital [the interpretation of this has been questioned] 5. Ongoing assessment for tier 4 bed 6. ICPC date set to take place 14 days after the Strategy discussion (if needed) Learning point: It is important that records of meetings, and especially action points, are clear, not ambiguous and procedurally correct in order to avoid misinterpretation or confusion. All professionals responsible for Chairing meetings should be reminded about the need to check minutes and meeting records to ensure there is absolute clarity in the written word. 5.2.8. The assessment by the local area’s Children’s Services did not commence until November, two months after the presenting issue. The reason given for this delay is that the Social Worker had a high caseload at that time and needing to prioritise casework based on an evaluation of risk. As Harry had been admitted to a specialist tier 4 Unit the risk of further harm was being managed which also contributed to the decision not to prioritise the assessment. However, the assessment involved just one visit to see Harry and family in November, did not maximise the opportunities available to visit Harry whilst in the specialist tier 4 Unit, nor assess his family on their own before his discharge and be involved in discharge planning. The single assessment visit was also mostly conducted by a Social Worker but did include the contributions of a community CAMHS worker and a CAMHS Psychologist, who continued to work with Harry’s father and Harry’s school during this time. Despite this, it can be argued that this delay in assessment work was a missed opportunity for the local authority Children’s Social Care to mark a point in time in terms of Harry’s overall needs and safety, attempt to forge a positive working relationship with Harry’s father and inform any further intervention for all agencies involved.  5.2.9. The decision that an Initial Child Protection Conference was not necessary as Harry was in a tier 4 Unit is a debatable one. The decision was not based on an examination of the threshold as full enquiries had not been concluded, but because he was in a place of safety. Practitioners involved with Harry have confirmed that, on balance, this was the correct decision given the safety plan created however have expressed a view that rather than the child protection route being closed there was an opportunity to consider Child in Need or Early Help support as an alternative offer. Any alternative offer however had to be weighed with the need for consent but also knowing that the father and Harry were not asking for additional help. This is despite knowing that there were relationship tensions between themselves, and the father admitting to his struggles in adjusting to having Harry living with him. Learning point: Providing the right sort of help at the right time may make the difference to children and families. Working with parents and children to build an early help offer that is creative, tailored and flexible may reduce the need of further intervention at a later date.   12  5.2.10. From a system thinking perspective, this episode can be described as a trade-off23. Trade-offs are a system thinking concept. Work in complex systems is impossible to assign, predict and prescribe completely. Demand fluctuates, resources are often limited and goals often conflict. Frequently, the choices available to us are not ideal and we are forced to make trade-offs and choose sub-optimal courses of action. Trade-offs, such as these, help us understand system behaviour and system outcomes. The trade-off in this case was that the Social Worker prioritised other cases over beginning an assessment of Harry’s case because his immediate safety was being managed and there appeared to be balancing factors which seemed to mitigate against any future risk of harm. Management oversight at this time was inconsistent. Operating context is important; these practice issues had been identified by Ofsted in the inspections in recent previous years and, despite many improvements, also in 201924. 5.2.11. The balancing factors mitigating against further danger to Harry were; the family clearly stated that they did not want any additional support from Children’s Services; Harry was in a specialist tier 4 Unit for part of the time but then had committed to his engagement with CAMHS (who had reported that the suicide risk had reduced); Harry reported no concerns about living with his father and family and had returned to school and appeared to be enjoying it; and the father had developed a stronger relationship with the school. Harry’s father’s has described Harry being inconsistent in his behaviours and that he was trying to accommodate to Harry’s fluctuating behaviour by giving some leeway in his expectations of him. At times, he accepts that this stepped too far in the wrong direction with, for example, buying him some bottles of cider. The father’s view was that he was struggling to know how best to respond; this may, at times, have been viewed by professionals as not caring, not paying attention to Harry’s behaviour or being neglectful. The allocated Social Worker, through assessment work completed, expressed a view that ‘… Harry’s father on the one hand distrusted professionals and on the other hand wanted to be led by them, for fear of getting things wrong and the potential serious consequences in terms of Harry’s welfare ...’.  This correlates with the view of others involved with the family but also that the father experienced some struggles in managing some of Harry’s behaviours and the circumstances in which he now found himself. Examples of these struggles included difficulty putting boundaries in place to manage Harry, managing work alongside caring responsibilities, Harry’s use of high sugar drinks, alcohol use, and Harry not adhering to taking his prescribed medication.  5.2.12. Given any remaining risk had the appearance of being managed, Children’s Services closed their involvement, however records and discussion confirm that the outcome of the assessment undertaken was not shared with partner agencies, nor were the Police informed of Harry’s discharge from the specialist tier 4 Unit. Given one of the agreed actions of the Strategy discussion (as worded in the record of the meeting) included keeping the Police informed, this practice fell short of expected standards and good practice. See learning point above at 5.2.7. 5.2.13. Harry’s father expressed pride and being impressed with the way Harry had recovered after his discharge from the specialist tier 4 Unit. Harry was described as achieving well at school, enjoying sport and appeared to be engaged with services. At this time Harry’s father thought progress was being made and the future was looking more positive. Harry himself has also described the following weeks as positive and feeling good.  January 2019 Strategy discussion in response to Harry’s suicide attempt:                                                             23 Trade-off - as cited a) Learning into Practice: improving the quality and use of serious case reviews, Masterclass 2: Systems thinking, SCIE & NSPCC, 2016 and b) Systems thinking for safety: Ten principles – A White Paper, Eurocontrol, 2014.  24 Ofsted inspection reports.    13  5.2.14. The Strategy discussion held in January 2019 provided the professional network with a second opportunity to evaluate the situation. A telephone Strategy discussion took place on the day of the incident and was then followed up two days later with a meeting – reflecting timely action all-round by relevant agencies. At the time Harry’s family were already engaged with relevant services i.e. the School and CAMHS and appeared to be managing the situation, and Harry appeared to be open with those adults he was having contact with. Only seven days before Harry had had a therapy session with CAMHS and had denied having any suicidal thoughts. Again, this highlights the difficulty for professionals and Harry’s father and other family members in predicting behaviour or self-harming attempts.  5.3. The quality & effectiveness of any cross border & transfer issues identified 5.3.1. Research25 about other serious case reviews states that ‘… multi-agency meetings with professionals involved in a case can encourage information to be shared and roles to be clarified, improving multi-agency working and allowing professionals to gain a holistic view of the case …’.  5.3.2. The local Children’s Service in Scotland Social Worker requested social work visits to Harry’s father to ascertain the suitability of the home environment should Harry move back to live with his father. These requests were made towards the end of 2016 and did not take place until early 2017.  The local area Children’s Services visited and provided feedback to the Children’s Services in Scotland. This resulted in a telephone discussion between the two Services to verify information provided however there was no confirmation about a permanent move to live with his father.  5.3.3. The Social Worker from the local Children’s Services in Scotland visited the school in England in June 2017 when Harry was in transition. It appears some information was shared and there is reference to email exchanges about securing a school placement. However, with the benefit of hindsight the School’s perception is that the local Children’s Services in Scotland had not fully shared information with them in 2017, notably the gravity of Harry’s earlier abuse and life experience. Learning point: All professionals need to remain actively curious about information given to them that indicates harm and risk to children, and then sharing it with those who have responsibilities to keep children safe. Probing and seeking clarity about information which suggests future risks, is good practice. This is especially so at critical transfer points in case management.  5.3.4. It is evident that Harry remained a Looked after Child and there was no exchange of information or notification about his current status. Information about Harry’s background was not effectively transferred by the Children’s Services in Scotland to services locally during the timeframe under review until there was a serious incident in September 2018. Having reviewed their records the Children’s Services in Scotland have confirmed that they did not communicate directly with the local Children’s Services in England to confirm he had moved and was residing outside of their area. They have reported that it was their intention ‘… to keep the case open for at least 3 months and longer if required to ensure that his care was secured with his father ...’26 .  Information transfer is documented as being fragmented and disjointed.  The Children’s Services in Scotland have acknowledged that their management and practice of this transfer was not to the expected standard and that this is being examined with the relevant practitioners.  The reason given for this not happening appear to be related to the belief that the Children’s Services Social Worker thought                                                            25 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 116, University of Warwick & University of East Anglia, May 2016.  26  Children’s Services in Scotland submission to the review.   14  there was no longer a need to be involved so no action was taken to inform the local area of Harry’s move.  5.3.5. Practice for transfer of cases which relate to child protection issues within Scotland is supported by national guidance27, as is practice for transfer within England being supported by guidance28. Similar arrangements and expectations exist in relation to Looked after Children around placements across England and Wales based on guidance29. However this case has highlighted a potential gap in guidance for the transfer of case responsibility and notification from Scotland into England or Wales.  5.3.6. Additionally, it has highlighted the same lack of procedure of information sharing from a schools records perspective. Guidance in England30 refers to the need to share information if a child transfers to Scotland, but not if a child moves from Scotland into England. Scottish guidance31 only refers to practice within national borders, not across it. Harry’s school in England appeared to make reasonable efforts to seek previous information however this was not forthcoming. Learning point: Guidance and procedures already exist to support local authorities and professionals to exchange information across local authority areas. Good practice dictates that this should naturally be extended to cover the sharing of information across national borders within the United Kingdom.  5.3.7. The case has also highlighted that the local Children’s Services have reported experiencing significant problems in obtaining information from the Children’s Services in Scotland, citing numerous attempts, which have required escalation.  Similarly, the Children’s Services in Scotland have also highlighted a problem in gaining information from the local Children’s Services in England about Harry’s current care arrangements so as to keep Harry’s mother informed. The reasons outlined above may be contributory factors, 5.3.8. The NHS Trust Hospital has highlighted information sharing problems following Harry’s discharge from the specialist tier 4 Unit in October 2018. No information about Harry’s mental health at discharge or an on-going management plan were received from the Unit, nor any update from local Children’s Services about the outcome of their assessment. This is despite the Hospital staff being involved in the initial Strategy discussion in September 2018. Hospital records do include a summary of involvement by CAMHS which include risks associated with Harry’s cannabis use, his potential for worsening suicidal ideations and conflict between Harry and his father. Again, this portrays fragmented information sharing practices.  5.3.9. The challenges associated with patient care when transfers across border and services have been raised by the review; in particular relating to the transfer between the specialist Hospital for Children and local Hospital outlined in key episode 2. At the point of transfer, Harry’s medical needs were mostly resolved however his mental state had yet to be assessed; the judgement and decision by the specialist Hospital was that Harry’s mental health needs were best assessed by the local service that knew him and who could then provide the consistency of care. This resulted in him                                                            27 National Guidance for Child Protection in Scotland, 2014, p. 101, The Scottish Government.  28 Working together to safeguard children, chapter 3, 2018, HM Government.   29 The Children Act 1989 guidance and regulations: Volume 2: care planning, placement and case review, June 2015, HM Government.   30 Common Transfer file guidance, June 2019, HM Government, Common Transfer file: CTF 19 guide  31 Scottish Government: Children missing from education   15  being transferred to the local Hospital without having had any mental health assessment; however the local CAMHS was informed of the incident and issues. Given that Harry had made a serious, and near fatal, suicide attempt (although this was not his account of the incident) and required significant medical intervention to keep him alive, the appropriateness of the transfer decision has provoked much debate. This has prompted further impartial oversight; the decisions taken at this time have been judged as reasonable and appropriate, and in accordance with guidance32.  5.3.10. The local GP Practice had requested the previous medical notes held in Scotland. As stated above, the notes have only recently been transferred. The GP Practice has learnt from this episode and now has a system in place to ensure records are requested verbally by the safeguarding professional, and a verbal handover given regarding any concerns. It is hoped that even if there are significant delays in future, appropriate information is sought in a timely manner. 5.4. The quality of information sharing between agencies 5.4.1. Statutory guidance33 in place at the time for England refers to the need for effective information sharing practices between professionals and local agencies. 5.4.2. Information set out above has already highlighted a lack of information sharing between the Children’s Services in Scotland and the local Children’s Services in England. The crucial point where information sharing would have been the most valuable was once arrangements had been confirmed that Harry was to commence living with his father around June 2017.  This may have resulted in a more timely opportunity to engage Harry and family with support services.  5.4.3. Harry’s School have examined their information sharing practices and judged them to be effective and robust, with clear systems and processes in place. There is no evidence to indicate this not to be the case, with the School being pro-active in their response to Harry when he made disclosures to the member of the school pastoral team, their subsequent response to ensuring he attended a GP appointment, their sensitivity in dealing with Harry participating in school trips, and their attendance at meetings. As stated, Harry’s view of the school was that they were very helpful and supportive. The school have reflected that they are clear that if they had known more about Harry they are likely to have offered him more support. The school has highlighted that they feel they were left managing risk and support for Harry around October 2018 when he had been discharged from the specialist tier 4 Unit and was reintegrated back into school. A multi-agency support plan, greater than just the involvement of mental health professionals would have been beneficial at this stage and reflects the point made above about a creative early help offer that might have been appealing to the father and Harry.  5.4.4. From a GP perspective information only became available about the extent and gravity of Harry’s troubles following the September 2018 paracetamol overdose incident. The GP provided a report for the September 2018 Strategy discussion and the NHS Foundation Trust CAMHS exchanged information in a detailed and timely manner and included a comprehensive mental health assessment, relevant family, psychiatric, educational and medical history.  This is similarly the case following Harry’s suicide attempt in January 2019 with information from the MASH Nurse sharing information with the GP Practice resulting in Harry’s situation being discussed within the GP Practice at the multi-disciplinary meetings. A representative from the GP Practice was also invited and attended the Strategy discussion and received minutes afterwards.                                                             32 National Clinical Guideline Centre - Major trauma: service delivery, NICE Guideline NG40, February 2016 & NHS standard contract for major trauma service (all ages), NHS England, 2013.  33 Working together to safeguard children, 2015, HM Government.   16  5.4.5. None of the local Children’s Services Social Workers have raised concerns about the quality or timeliness of information received from other agencies during the course of the involvement, other than the difficulties experienced in obtaining information from the Children’s Services in Scotland.  5.4.6. Based on the information in the Approved Mental Health Practitioners (AMHP) report it is clear that there was good information sharing between the CAMHS team and the AMHP Service. 5.5. Evidence of the voice of the child being sought, heard and acted on 5.5.1. Statutory guidance34  describes expectations about a child centred approach to keeping children safe; ‘… anyone working with children should see and speak to the child; listen to what they say; take their views seriously; and work with them collaboratively when deciding how to support their needs …’.  5.5.2. The Children’s Services in Scotland have considered their practice in their direct contact with Harry, highlighting that there is ample evidence of them noticing and hearing what he was saying. They have reflected that because Harry was an articulate and mature young man it is possible that some of the issues he shared were responded to in a similar fashion, with professionals missing the points that he, as a 14 year old child, was telling them. Examples of this include in September 2016 Harry reflected with the Social Worker about ‘becoming very like his father’, that that is the ‘root’ of the problem between him and his mother.  He also talked about his ‘plan to assassinate his mother’. Harry had highlighted his pressing need for a decision about moving to his fathers in the consultation document used for his Looked after Review in March 2017, highlighting a further example of how Harry’s views were secured.  5.5.3. Harry’s school have conveyed a clear sense of working with Harry and ensuring his views and needs were considered. This has been evidenced by their records reflecting Harry’s comments, him being assigned a male sports mentor/key worker given his love of sport and expressed struggles with female members of staff. The school also supported attempts to deal with his anxiety about his younger sibling’s welfare by trying to contact the social worker in Scotland. As noted, from discussions with Harry he felt the school had a positive impact on his life and he spoke highly of their support. 5.5.4. The NHS Trust Hospital have confirmed many examples of them seeking and obtaining Harry’s views, wishes and feelings by both paediatric staff and agency staff.  Recordings are made several times each day throughout each of the two admissions. This includes hearing his concerns about his younger sibling.  5.5.6. Following discussion with the GP Harry was referred to the counselling service in June 2018. The GP considered his competence and respected Harry’s wishes to be seen alone but also encouraged him to discuss the consultation with his father. 5.5.7. The local Children’s Services Social Worker allocated between September and November 2018 has cited examples of seeking and obtaining Harry’s views. This included capturing Harry’s ongoing worries for his sibling which resulted in the Social Worker discussing the issue with Harry’s father but also writing to the Director of the local Children’s Services in Scotland expressing Harry’s concerns about his sibling.  A copy of this letter was shown to Harry. This was again followed up by the next allocated Social Worker in January 2019.  5.5.8. Although the Police had been aware of Harry since the September 2018 incident they only met with Harry once, in January 2019 when he absconded from Hospital. Police used their powers                                                            34 Working Together 2015, p.10, HM Government.  17  under Section 136 of the Mental Health Act on this occasion, following information passed to them by the Hospital and from their previous knowledge of earlier incidents. They detained Harry and returned him to Hospital for his own safety clearly demonstrating having his best interests in mind.   5.5.9. The NHS Foundation Trust evidence that all interventions were informed by Harry’s views at the time, with opportunities provided to Harry during CAMHS therapy sessions and consultations. This also applied to joint work with the father.  5.5.10. One moment that does highlight learning is at the point that Harry took an overdose of paracetamol in September 2018 he informed a friend that he had done this. The friend sent a text to Harry’s father who then made arrangements for Harry to go to Hospital. The text was sent at around 11pm but not seen by the father until 3am, when he woke for work.  Learning point: Children and young people should not be expected to hold information about actual or potential risk of others; supporting them to share information so that adults can act on it is an important message for parents, carers, schools and public health agencies to convey. Helping children and young people to understand the limitations of social media messaging and having a range of options to use when worried about something is an important life skill. Parents, carers, schools and public health agencies have a role to play in this education.  5.5.11. As cited in section 5.1 unless a child’s history and the cumulative impact of adverse life events is understood it can be very difficult to predict attempts to self-harm or end life. In this case Harry was inconsistent in his statements and responses indicating at times feeling settled and not having suicidal ideation but also openly stating he would try to take his own life if given the opportunity. Such situations reflect a real dilemma for professionals in knowing how best to respond, needing to balance the available evidence, the likelihood of self-harm with intent, with proportionate, legal and ethical interventions. Learning point: Often it is not possible to completely eliminate risk of harm to children and reduce it to something that can be controlled or predicated by a range of professional inputs.  5.6. The effectiveness of maintaining a focus on the child’s safety & needs throughout 5.6.1. Statutory guidance35 states, ‘… it is vital that every individual working with children … is aware of the role that they have to play and the role of other professionals …’.  5.6.2. Harry’s school have highlighted that up until the incident in September they had limited knowledge of Harry’s background and their focus was therefore on managing his emotional health. Following the paracetamol overdose and Harry’s reintegration back into school their focus shifted to being involved in the management of his mental health and safety – feeling like a step change and more serious than managing emotional health. They have expressed concern that they appeared to be operating in a relative vacuum for some of the time and that the situation needed a multi-agency risk management plan. Given the gravity of Harry’s overdose attempt and the unfolding realisation by agencies involved with the Strategy discussion that Harry had experienced considerable trauma in his earlier life, the hope for a multi-agency management, or support, plan is not unreasonable. Whilst the involvement of the NHS Trust Child Mental Health Services provided considerable support, the use of an Early Help Plan may have been better suited to managing the circumstances. This also needs to be placed in the context that Harry had only recently moved back to live with his father after several years of living apart, and that the level of parenting skill required by the father to support Harry would have been challenging for any adult. Agencies did                                                            35 Working Together 2015, p. 9, HM Government.  18  not consider an Early Help Plan. The use of such would have provided a more co-ordinated response from agencies. Embedding the Early Help Pathway remains a priority for the Partnership. 5.6.3. The GP that met with Harry in June and July 2018 was not overly concerned about Harry’s presentation to believe more immediate action was necessary; this was based on Harry’s self-reporting and appearance as his previous medical records had not been received despite them being requested. The referral to counselling services can therefore be viewed as proportionate as there was no additional information available to the GP to consider an alternative pathway i.e. a referral to CAMHS. The need for safety planning and risk management was not obvious and the episode was not considered to be dangerous or high risk. On this basis the GP made a sound decision that was child focused based on the limited information available. 5.6.4. From the NHS Trust Hospital’s perspective the incident in January 2019 has confirmed a number of areas of learning for them, with three particularly standing out.  5.6.5. Firstly, Harry once admitted, went to the open outdoor play area where he considered absconding or harming himself. He had been left in his father’s care and without 1:1 supervision from a member of staff – despite the risk assessment that he needed an appropriate level of 1:1 care at all times by an agency Registered Mental Health Nurse. This care plan and expectation was known about by the member of staff being reinforced verbally on two separate occasions. However, review of the records and discussions with staff have revealed that there was no clear written care plan available resulting in a possible lack of clarity and certainty about what was meant by continual 1:1 observation – thereby compromising Harry’s safety. The standards of professional practice on this particular issue are being investigated in a parallel process to this review.  Learning point: It is important that day to day management/ care plans are documented so as to achieve consistency of understanding across all staff who may be working with a child. This also ensures clearer handover to new staff and provides a benchmark about what is required and expected to keep a child safe.  5.6.6. Secondly, as part of the management of this incident once Harry had been talked down from the immediate risk on the balcony the on-call Psychiatrist advised using sedative medication. This was delayed it seems because the Consultant Paediatricians were not certain about a sedative being used in these situations. This has highlighted no clear process or policy about responding to such situations and resulted in an internal recommendation to remedy this gap.  5.6.7. Thirdly, Harry had openly expressed that if he had not been formally detained on the Hospital by midnight he would leave; supervision was increased to 3:1 of agency staff. He followed this action through with apparent relative ease, kicking the Ward door open and evading staff. The Trust have noted ‘… the hospital records made by an RMN stated that they would be unable to restrain and would require police support if Harry required physical restraint. The records give an insight to the reasons, for example they recorded they were concerned about physical harm to Harry and themselves. The internal review and discussions with ward staff indicate that staff were unaware that the RMN’s would not restrain Harry. The NHS Trust has asked the agency to investigate this as part of the complaint referred to earlier. In fact the paediatric ward staff on duty did try to physically restrain him from leaving but were unable to stop him …’36 .  This episode has highlighted that Harry’s safety was compromised and there is a need to ensure all staff members are aware of the care plan, are suitably qualified and trained to perform the tasks and expectations associated with a care plan i.e. de-escalation and physical restraint, and that the Hospital need to develop a                                                            36 NHS Trust submission to the review.  19  policy that supports staff in responding to threats of absconding from children but also actual incidents of absconding.  5.6.8. The Police response to the above incidents were timely, effective and child focused. They attended the Hospital when requested to assist with the management of the balcony incident although took advice from those staff dealing with the situation about the extent of their involvement with Harry so as not to inflame the situation. The attending Officer was asked whether the Police would detain Harry under Section 136 of the Mental Health Act for an assessment. This request was not supported as staff were advised that it was not appropriate given Harry was already in a ‘place of safety’. This request further reflects the confusion by Hospital staff about the use of legal intervention to safeguarding a person’s safety and welfare.  5.6.9. The Police’s response to Harry following absconding was again, timely, efficient and child focused with them returning him to the Hospital. Once returned to the Hospital it was clear that there was a lack of willingness, or understanding, by Hospital staff to detain Harry should he choose to leave again. The Officer therefore remained until the Mental Health Team arrived to conduct the relevant assessment on Harry.  5.6.10. Over the timeframe under review local Children’s Services have noted that Harry had three different Social Workers. One worker was allocated during the September to November 2018 episode (key episode 1) and then on re-referral two workers dealt with the case from point of referral through to allocation. In turn, this also meant different management oversight. Continuity of worker is an important principle when working with vulnerable children; it supports an opportunity to build more trusting and meaningful working relationships and is more child focused. Children and families should not necessarily be expected to understand the complexities of internal work load management systems. Experiencing continuity and the opportunity to build a rapport with those designated to offer support might be seen as a reasonable expectation from any child and family; reducing the number of workers involved from first contact to the point of ongoing support can be beneficial to all involved. Harry’s father has conveyed this as being something that would have made the whole situation around Harry’s two admissions to Hospital easier to deal with, highlighting that a single coordinated point of contact would have been helpful. Instead, having multiple practitioners contacting him was somewhat confusing. 5.6.11. From a system thinking perspective this can be described as organisations having to manage the interactions and flow of workload. From a service user perspective having a consistent flow to interactions and communications with professionals is desirable, regardless of the different function each worker may have. Where the flow is interrupted by changes in workers or new people entering the situation, it can cause confusion, frustration and anxiety; this was the father’s experience. In an ideal multi-agency partnership arrangement, and when a lead professional role may be designated, managing the flow of communications is a critical task.   5.6.12. In discussion, Harry was clear that having changes in Social Worker but also nursing staff was not helpful. It allowed little opportunity to build a relationship and often felt uncomfortable due to having to recount information. Of particular note, Harry reflected on the number of staff that were supervising him whilst in hospital and that it would have been preferable to have just one of two people watching him (when in bed sleeping) rather than a larger number.  Learning point: Case management systems ideally need to support the principle of continuity of worker for children and families rather than multiple changes.  Learning point: When there are multiple professionals involved in supporting a child and family it will be important for those professionals to reflect on the actual experience of the child, and family,  20  and whether it is possible to assign a lead professional who can act as a single point of contact across the multi-agency group. 5.7. The provision of training & supervision to the workforce about the identification or and response to abuse, neglect and maltreatment, particularly relating to adolescents 5.7.1. Statutory guidance37 sets out expectations relating to ensuring staff receive appropriate supervision, support and training to respond to their child protection responsibilities.  5.7.2. School staff, local Children’s Services, Adult Social Care, NHS Foundation Trust, the GP Practice and the Police have cited opportunities they have available to seek and acquire relevant training but also confirmed that staff involved with Harry were appropriately trained and supported.  5.7.3. Some aspects of information submitted to this review support a view about there being indicators of neglect in the parent – child relationship i.e. supervision of Harry’s medication. Generally though, evidence submitted describes a situation whereby Harry’s father, and other adult family members, were accommodating to having an adolescent in the family home who was struggling with a number of issues – and which are not necessarily directly indicative of neglectful parenting. Those involved in the review have reflected on the challenges of assessing such circumstances and the benefit of assessment tools to support and guide practitioners. The use of, for example, the Graded Care Profile which is used in the local area may not be the most appropriate assessment tool to help practitioners in such circumstances especially in situations where adolescent trauma38, impulsivity, emotional and mental health may be the presenting issues.  5.7.4. The Clinical Commissioning Group (CCG) Safeguarding team offers support and advice to GP Practices relating to safeguarding as part of a quality assurance programme. As part of this the CCG conduct dip sampling to evidence the effectiveness of training and interventions. Auditing, as part of this review process, has highlighted that there is no evidence to indicate whether supervision or support was sought about Harry. Whilst this may not necessarily be indicative of a trend it is important to learn from this. Learning point: Seeking a fresh perspective from a peer, or using a multi-disciplinary meeting forum to discuss complex, perplexing or cases of concern may be a valuable step to take in confirming the actions taken are positive, and/or opening new pathways which provide greater support and safety.  5.7.5.The NHS Trust Hospital have confirmed that there is a 94% compliance rate for paediatric nursing and medical staff to be appropriately trained and have the necessary skills and knowledge about safeguarding children. The Trust will want to ensure all staff are appropriately trained to achieve full compliance. The following other areas have been highlighted as needing further attention; - Clinical supervision arrangements for the nurses within the Emotional, Health and Well Being Team are lacking.  - Specific training for medical staff in the use and prescription of sedative medication for acutely distressed children and young people. - The use of section 5 (2) of the Mental Health Act 1983.                                                            37 Working Together 2015, p.53, HM Government.  38 Adversity and Trauma-Informed Practice, A short guide for professionals working on the frontline, June 2019, Young Minds, Adversity & Trauma-informed practice   21  - Specific training for staff concerning children’s emotional health and wellbeing, plus the use of de-escalation techniques, to increase staff confidence is needed.  5.7.6. The Children’s Services in Scotland have rightly identified that there is a training issue relating to transferring cases across geographical borders to other authorities in terms of good practice and the effective management of risk to vulnerable children. Learning point: Assessing, and responding to adolescent neglect, trauma, self-harm and attempts at suicide can be challenging. Learning39 from other Serious Case Reviews about adolescent suicides highlights the importance of working together and that ‘… behaviour should be viewed as symptomatic of other underlying problems and difficulties. The cause of the behaviour should be explored and addressed through multi-agency support …’.  5.8. The quality & effectiveness of the mental health pathway between services 5.8.1. From the GP perspective the referral pathway is clear; had Harry presented as needing a more immediate assessment the GP knew to refer to CAMHS. This pathway is available on the mental health NHS Trust website and work has been undertaken to ensure all GP Practices are aware of this procedural expectation.  5.8.2. Key episode 2 has highlighted a lack of clarity and knowledge by relevant professionals about paediatric mental health pathways. The episode has revealed confusion about the pathway, uncertainty about risk categorisation and disjointed working arrangements across different services based in the Hospital. 5.8.3. Considerable developmental work improving risk assessment, safety planning and interventions for children who self- harm or are in mental health distress, had taken place in the 12 months prior to Harry being admitted to Hospital in September 2018. Developments included extending the availability of CAMHS practitioners out of hours, new risk assessment processes and the introduction of a Hospital based health and emotional wellbeing team consisting of a Registered Mental Health Nurse (RMN), a trained paediatric nurse and emotional health and wellbeing support workers. As a result of these developments not all systems and processes had been fully embedded or tested, potentially accounting for some of disjointed practices occurring.  5.8.4. The NHS Trust Hospital have identified the following procedural points to learn from; - There is no defined process by which the nurse in charge assesses risk and documents decision making, including the escalation to Hospital managers, to determine when it is safe to admit a child if the risk assessment indicates a Registered Mental Health Nurse is required but not available. Practice at the time was that a risk assessment was made to determine the level of supervision and care required whilst awaiting a formal CAMHS assessment. This had been only recently implemented and Harry was assessed as being high risk and needing 1:1 support from a Registered Mental Health Nurse. As a RMN was not available at the time of admission the Nurse in charge made a decision that it was safe to admit Harry until a RMN became available. - There is an inconsistent understanding about when, and how, risk assessments should be used which results in uncoordinated care and a disjointed care plan potentially being created. Differences in understanding highlight that some staff believe that a risk assessment should end once a formal mental health assessment has been achieved whilst others believe it is an ongoing process and requirement. It has also revealed that two risk assessment processes could run in parallel with one another and potentially producing different outcomes and risk management plans; one being conducted by Hospital staff and the other by CAMHS staff. This                                                            39 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014, p. 118, University of Warwick & University of East Anglia, May 2016.  22  is evidenced by the incident when Harry was judged by CAMHS as at high risk of self-harm in the community but was permitted out into town with a support worker; later Harry stated that he had opportunities to go to a bridge, presumably with an intent to jump. In this respect, care planning should make clear reference to; the level of supervision required; prescribed medication and include formal consultation between the Psychiatrist and the responsible Consultant Paediatrician.   - The lack of a clear pathway, agreement and management strategies was also confirmed when a request for Harry to be moved to the adult psychiatric unit was refused, resulting in an increased staffing ratio to supervise Harry. The move was requested as a result of the delays in securing a tier 4 Unit bed and the challenges with keeping not only Harry safe on the children’s unit in the Hospital, but also other children who were also admitted at the time. There is a need to develop a clear protocol to determine under what, if any, circumstance it would be appropriate to admit a child onto an adult mental health unit.  5.8.5. This confirms not only a training need across all staff who will work with children in the Hospital and the need for a robust paediatric mental health care pathway for children admitted on to a Hospital, but also disjointed working protocols between CAMHS and the Paediatric Team in the Hospital, who have ultimate responsibility for the child patient.   5.8.6. A patient informally admitted to the Hospital does so giving consent and therefore is within their rights to choose to discharge themselves. The Section 5 (2) power of the Mental Health Act 1983 allows an informal patient to be detained for up to 72 hours. It would be used as a temporary measure if the patient’s mental health had deteriorated and they had become a risk to themselves and others and would be pending a further assessment by an approved mental health professional and two doctors i.e. a psychiatrist and a paediatrician. This was not used with Harry and it is evident that there was confusion about whether, and how, it could be used; ‘… there was considerable confusion about the use of Section 5(2) powers with NHS Trust staff being given conflicting information by CAMHS staff, the [clinical] director for the local Trust providing mental health services and the Local Authority Approved Mental Health Practitioner. This led to failure to apply powers and it could be argued that Harry‘s absconsion … may have been prevented if correct processes had been in place supported by training and education in the use of Section 5(2) …’40. The issue of when a child may, or may not, be admitted to an adult mental health ward should be clarified by the local NHS Trust. 6. Good practice 6.1. It is important to capture any good practice. Providing examples of good practice is a way of reinforcing positive behaviours and strategies so as to improve better outcomes for children. Examples include; - Harry was facilitated by the school to identify his own key person; a member of staff to whom Harry could go to if needed. In his father’s absence, a member of staff accompanied Harry to the GP Practice to ensure that he got there and went in to see the GP. - The school asked for support from CAMHS to write a support plan for Harry; this was widely shared to enable staff to understand his needs. - The quality of the partnership working – active, timely and regular – from the community based CAMHS service with Harry, Harry’s father and other agencies throughout. Harry was particularly complimentary about the psychological support offered to him.  - The member of the school pastoral team noticing cut marks on Harry’s wrists and reporting these. Harry was very positive about this individual member of staff.                                                            40 NHS Trust submission to the review.  23  - The NHS Trust’s Health and Emotional Wellbeing Support Worker’s prompt, calm and skilled approach to Harry during the incident where he was on the balcony edge, supporting the father, de-escalating the situation and returning Harry to the Hospital and seeking assistance. - The Police’s timely and sensitive response to Harry standing on the balcony whilst in Hospital. - The Police’s subsequent response to locating Harry once he had absconded from Hospital, returning him to the Hospital and waiting to offer support if it were needed. - A representative from the GP Practice attending subsequent Strategy discussions to share information, and ongoing review of Harry’s case at Practice multi-disciplinary meetings.  - The actions of the first allocated Social Worker in responding to Harry’s worries about his sibling and spending time with him to gain his views, wishes and feelings. 7. Conclusion 7.1. This Serious Case Review has examined the circumstances around a child, under 16 years of age, who made an attempt to take his own life. Although the child’s account of the incident differs to that of the professionals involved it is clear that the child was vulnerable, unhappy and in need of support. The review has gathered and analysed documentary information from all of the agencies involved over a period of nearly two years, whilst also recognising relevant background information. It has benefitted from the involvement of many of the practitioners involved with the child and gained their perspectives about what happened, and why events may have occurred as they did. Positively, the review has also gained the child’s perspective as well as the father’s viewpoint.  7.2. The review has identified a number of areas where practice could have been strengthened. These include:  - A greater appreciation of the impact of early childhood adversity and trauma and the importance of using this information to inform decision making and safety planning. - The importance of information sharing across borders and agency boundaries. - The need for prompt action, avoiding delay, to secure the appropriate type of support and intervention when young people experience an acute and serious mental health episode. 7.3. The review has captured learning points for use by practitioners, managers and trainers. As a result of this review agencies that have contributed have been able to identify learning that can be taken forward internally. Action plans have been provided by each agency involved, and where relevant and appropriate to do so, improvements have been initiated. It is the role and responsibility of the Safeguarding Partnership to monitor, scrutinise and challenge progress against single agency action plans. The report concludes with a number of recommendations for the multi-agency Safeguarding Partnership which may strengthen practice.   8. Recommendations 8.1. The following additional recommendations are made for the Safeguarding Partnership; 1. To ensure the learning from this Review is disseminated across the multi-agency safeguarding partnership to practitioners and managers. 2. To seek assurance that the actions identified by each partner agency, as a result of this Review, have been managed, implemented and embedded in a timely manner. 3. The Safeguarding Partnership to seek assurance from schools/colleges that they will raise children and young people’s awareness about the limitations of social media when worried about someone  24  else’s welfare and the need to consider a full range of options for getting help, advice or support. See section 5.5.10. 4. The Safeguarding Partnership to inform the Child Safeguarding Practice Review Panel of the specific finding about the apparent lack of explicit guidance about the transfer of school records across borders in Scotland and England. See sections 5.1.4. & 5.3.4. – 5.3.6.  5. The Safeguarding Partnership to inform NHS England regarding the findings of this review and the continuing issues regarding an apparent national shortage and challenges of availability of tier 4 beds. See sections 4.4.2. – 4.4.4. 6. The Safeguarding Partners to also contact NHS England and advise them regarding the difficulties in obtaining medical records from across national borders. See section 5.1.6.  7. The Safeguarding Partnership to request through the regional Partnership Board Business managers meeting that the regional ‘West Midlands Safeguarding Network protecting children who move across local authority borders’ guidance is reviewed and amended to reflect a wider set of circumstances in which children may move across national borders and where legislation, guidance and expectations may be different. See section 5.3.6.  8. To seek a review, and amendments where necessary, to the guidance and procedures around the management and information sharing practices between local community based child mental health services, acute health settings and other relevant community based health services for situations where children re-present to an acute setting. See sections 5.3.8 & 5.8.1 – 5.8.6.  As part of the review of the guidance and procedures the Safeguarding Partnership should write to local commissioners and request i) they consider access to additional mental health support for children who are experiencing severe emotional and mental health issues when reviewing local commissioning arrangements for emotional help and well-being support services. Commissioners should consider the service response for children who do not engage with emotional help and well-being support services, requiring a more assertive engagement by local services to prevent escalation of risks. and ii)) request that local commissioners also consider options within future commissioning arrangements for appropriate  step down provision for young people  following discharge from tier 4 Units. See section 5.6.2.    