Suicide of a 17-year-old girl in April 2013. Child B was an inpatient in a specialist adolescent mental health clinic under Section 3 of the Mental Health Act 1983 at the time of her death. B was admitted to the clinic due to concerns that she had an eating disorder and because she had been self-harming. B lived with mother and step-father until January 2012 when she moved in with her boyfriend and then later her father. Although B's living arrangements were initially agreed by mother, she soon afterwards wanted B to return home. Family were known to services including Targeted Youth Support Service (TYSS) who worked with B, her mother and step-father to try to rebuild their relationship. Review was undertaken using the Partnership Learning Review model. Identifies areas for learning and development, including: contact with children's services should be considered when a young person presents with significant mental ill-health and where there are concerns about the impact of family dynamics on protective factors; and formal consideration should be given to sharing the details of Community Treatment Orders (CTOs) with agencies providing services to young people placed on CTOs, including schools and colleges. Includes Hertfordshire Safeguarding Children Board's response to the areas for learning and development.
      
Title: Serious case review: re Young Person “B”: died April 2013 aged 17 years. LSCB: Hertfordshire Safeguarding Children Board Author: Ron Lock Date of publication: 2015 This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.   HSCB – Serious Case Review re B – Overview Report July2014         Serious Case Review Re Young Person “B” Died – April 2013 Aged 17 years      Independent Report Author – Ron Lock March 2014 – revised with the Inquest findings in May 2014 1  HSCB – Serious Case Review re B – Overview Report July2014 Contents Introduction    1.1 – 1.4     Page 3 Purpose of the Serious Case Review 2.1 – 2.2     Page 3 Summary of the facts   3.1 – 3.30     Page 4 Analysis: Knowledge of background information  4.1 – 4.7     Page 9 Effectiveness of services: - prior to mental health concerns   5.1 – 5.21     Page 10 - emergence of an eating disorder 5.22 – 5.27     Page 14 - safeguarding concerns    5.28 – 5.31     Page 15 The Use of the Mental Health Act 6.1 – 6.10     Page 16 Communication with the parents 7.1 – 7.15     Page 18 Inpatient care from Jan 2013  8.1 – 8.19     Page 21 Predictability and preventability 9.1 – 9.3     Page 25 Areas for learning and development 10.1 – 10.7     Page 26  The Serious Case Review Process – Appendix 1      Page 28            2  HSCB – Serious Case Review re B – Overview Report July2014 Introduction 1.1 This Serious Case Review was undertaken following the death in April 2013 of a young woman at the age of approximately 17 ½ years.  The circumstances of her death suggested at the time that this young woman, who will be referred to as “B”, took her own life.     1.2 The Hertfordshire Safeguarding Children Board (HSCB) decided that the circumstances of B’s death met the criteria to undertake a Serious Case Review (SCR) and that it reflected relevant government guidance that “an SCR should always be carried out when a child dies…….including where a child died by suspected suicide,….. and where the child was detained under the Mental Health Act”1 1.3 At the time of B’s death in April 2013, she was an in-patient in a specialist adolescent mental health clinic under Section 3 of the Mental Health Act 1983 due to concerns that she had an eating disorder, but additionally that she had been self-harming.   B had first been seen by a doctor because of possible anorexia in June the previous year and because of the seriousness of her condition, had been immediately admitted to the in-patient clinic (Care UK) where she remained for five months.   Following a second admission in January 2013, it was considered during March and April 2013, that B was making progress with her mental health and accordingly had her supervision ratio reduced and had been allowed home to visit her father.  Although presenting in good spirits on returning from the home visit, it was on the following day that B was found unconscious in a classroom where she was found with a ligature round her neck.   Three days later she was pronounced dead. 1.4 The Inquest into B’s death was held in April 2014, after the work of this Serious Case Review had been completed.   The Inquest recorded that the medical cause of B’s death was: -         a) Hypoxic2 Brain Injury, b) Hanging, and c) Anorexia Nervosa and Depression.  The Inquest’s findings in relation to the circumstances in which B came to her death were recorded as follows: “We are satisfied and so we are sure that on general observation the evidence presented demonstrates that (Young Person B) consciously and knowingly undertook an act with the intention of ending her life.   This act occurred on the 14th April 2013 at Care UK by means of hanging, using bunting as a ligature and a locker handle as a ligature point.”   The Coroner’s conclusion as to B’s death was “Suicide”. Purpose of the Serious Case Review  2.1 The purpose of a Serious Case Review (SCR) is to provide a “rigorous, objective analysis of what happened and why”3 and to “Identify improvements which are needed and to consolidate good practice”4.   Additionally, SCRS should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; 1 Chapter 4, paragraph 12, Working Together to Safeguard Children – A guide to inter agency working to safeguard and promote the welfare of children – HM Government - March 2013 2 Brain Hypoxia is decreased oxygen in the brain – there is a risk of this condition if the person is choking, suffocating or in cardiac arrest 3 Chapter 4, paragraph 1,  Working Together - March 2013 4 Paragraph 7, Chapter 4, Working Together - March 2013 3                                                             HSCB – Serious Case Review re B – Overview Report July2014 • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected  and analysed, and •  Makes use of relevant research and case evidence to inform the findings.5  The Local Safeguarding Children Board is then required to “translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children”.6  2.2 The details of how the SCR was conducted and of the process used, are contained in an appendix at the end of this report.    Summary of the facts The factual information pertaining to B and her family falls into distinct periods of time. Autumn 2010 – end of 2011 3.1 This first period relates to when B was living at home with her mother and step-father and their children.   She had been living with her mother since her parents’ divorce some years earlier, which had generally been acrimonious and for which a Children’s Guardian had been involved by the courts. 3.2 The first key event in the timeframe for this SCR occurred in the autumn of 2010 when B took a small overdose of Paracetamol following a family argument.  She was just over 15 years old at this time.    An appointment at the Child and Adolescent Mental Health Service (CAMHS) shortly afterwards, identified the overdose incident as “out of the blue”.  B’s mother responded that there was no need for a follow up appointment and so CAMHS closed the case.   At this time B was doing extremely well at the independent school she was attending. January 2012 – April 2012 3.3 During January 2012 B’s mother and step father raised strong concerns about B’s relationship with a new boyfriend, and the school became involved in trying to mediate, but shortly after, B moved in with her boyfriend’s family for weekdays, and at the same time B made contact with her father for the first time in two years, and then spent weekends with him.   Although this arrangement to live with the boyfriend’s family was initially with B’s mother’s agreement, she soon afterwards wanted B to return home and tried to enlist the help of the school in this respect. 5 Paragraph 10, Chapter 4, Working Together - March 2013 6 Chapter 4, Paragraph 7, Working Together - March 2013 4                                                             HSCB – Serious Case Review re B – Overview Report July2014 3.4 In March 2012, the head teacher sought advice from Children’s Services and they confirmed that B did not meet the child protection thresholds and that the school were responding appropriately in the circumstances to B’s mother’s concerns.  Shortly after however, at the mother’s request, the school did make a referral to the Targeted Youth Support Service (TYSS), who then conducted a brief assessment of B’s circumstances.   The outcome of the assessment was that B was happy continuing at her school (she was still attaining very good academic results) and living with her boyfriend’s family (she had her own room) until she could move to her father, with whom she had now resumed contact.   The assessment also considered that there were no safeguarding concerns.  In these circumstances, TYSS considered that they had no further role.  B did not want the counselling she was offered and was clear that she did not wish to return to live with her mother and step-father.  B was approximately 16 ½ years old at this time. 3.5 After the Easter holidays, B started living with her father full time, with plans to change to a new school in this new locality, following completion of her exams. May 2012 – November 2012 3.6 At the time when B was on study leave from school and only attending for examinations, B’s father sought advice from the school on 21st May 2012 because of his mounting concerns about B not eating and that she was starting to look visibly gaunt.   On the 25th May 2012, the school applied for “special considerations” on behalf of B to enable her to gain some flexibility in respect of the examination arrangements whilst she was in need of medical attention. 3.7 At her GP appointment a few days later, it was recorded that B had lost approximately a stone in weight (based on B’s stated previous weight) and that she now had a Body Mass Index (BMI)7 of 14.6.   An urgent referral was made to the local CAMHS.    3.8 Following two CAMHS appointments and an attendance at A&E department an urgent referral was made to a specialist in-patient clinic (for eating disorders) and B was admitted there on the 21st June 2012.   As she had changed her mind about wanting to be admitted, and was attempting to leave and determined to be unsafe, B was detained in the clinic under Section 5(2) of the Mental Health Act8.   An assessment was undertaken by the psychiatrist and on the next day, B’s in patient status was changed to Section 2 of the Mental Health Act9 3.9 Immediately prior to this, B started at her new school (a secondary school nearer to her father’s home) but just attended for a few days prior to her admission to the specialist clinic.  7 A widely used diagnostic tool, the body mass index measures the body fat based on the weight and the height of an individual.  While a healthy BMI is in the range 19 - 25, a BMI index of 17.5 is considered to be an informal indicator of anorexia nervosa. 8 Section 5 (2) of the Mental health Act 1983 allows for compulsory detention for a person who is already an inpatient, for up to 72 hours by the doctor in charge of the case. 9 Sec. 2 of the Mental Health Act 1983 allows a person suffering from a mental disorder to be admitted to hospital for an assessment of their mental health and to receive any necessary treatment.   The person can be detained for up to 28 days. 5                                                             HSCB – Serious Case Review re B – Overview Report July2014 3.10 Later in June, there was communication between the 6th Form Heads of both B’s current new school and her former school, when arrangements were made for B’s file to be sent to the current school, once authorised by the head teacher to do so.   Ultimately however, it was the academic reports only which were sent to the father.  No other school records in respect of B were sent through to the new school although this school nevertheless made links with the specialist in-patient clinic in order to arrange for work to be sent for B to do. 3.11 On the 2nd July 2012, B agreed that her father could let her mother know that she was in the clinic, but that she did not wish to see her.   Once informed of her inpatient care, B’s mother telephoned the clinic and requested contact with her daughter, but B was clear that she did not want her mother to know the details of her care and would need to think about contact.  For the remainder of July there was communication between the clinic and B’s mother when she was appraised of her daughter’s wishes not to have contact, and B’s mother provided some background information about the family. 3.12 During the first two weeks of July 2012, B occasionally needed to be fed by a naso-gastric tube.   She was still saying that she did not want to gain weight because she considered she was too fat.   Whilst in the clinic, B was prescribed anti-depressant medication (Fluoxetine) and Olanzepine which is an anti-psychotic drug used to treat eating disorders where anorexic thinking is very fixed. 3.13 On the 17th July 2012 the specialist clinic wrote to Hertfordshire Children’s Services to inform them that B as a child/young person would be an inpatient with them for a period in excess of 12 weeks.   On the 19th July 2012 B was placed on Section 3 of the Mental Health Act10 to enable her inpatient care to be extended beyond the 28 days.     3.14 There were some minor self-harm incidents (scratches on her arms) leading to B’s jewellery being removed by the clinic and she had also pulled out her naso-gastro tube.   As a result of serious concerns for further self-harm and suicide on the 23rd July 2012, B was placed on Level 4 supervision11.   A week later, the tube was removed because B had started eating solid foods – she was then placed on Level 3 supervision12.   3.15 At the beginning of August 2012 B agreed to speak with her mother on the phone which was the first direct contact between them since B had moved in with her boyfriend’s family approximately six months earlier.  3.16 B had not achieved the predicted A grades for her AS subjects studied at her previous school though achieved grades A, B and C and she requested to repeat Year 12 at her new school.  B was now 17 years old. 3.17 B further self-harmed by scratching, and attempted to abscond from the clinic, but there had also been some successful outings with her father and boyfriend, and by September and 10 Sec. 3 of the Mental Health Act 1983 allows a person to be admitted (or retained) in hospital for treatment up to a period of 6 months, which is necessary for the person’s health and safety and for the protection of other people, and that the treatment cannot be provided unless the person is in hospital.   11 Level 4 supervision meant that at all times B had to be within arm’s reach of a member of staff. 12 Level 3 supervision meant that at all times B had to be within sight of a member of staff. 6                                                             HSCB – Serious Case Review re B – Overview Report July2014 early October 2012 B had been compliant, with her weight continuing to increase.   However, at a family session at the clinic on the 8th October 2012 B took the view that upon her eventual discharge from the clinic, she should again be able to reduce weight and was angry that she would be in receipt of after-care following discharge from the clinic.  It was also discovered that B had again self-harmed at home at this time by cutting her arm. 3.18 Following some progress from that time, and no more self-harm incidents, by the 30th November 2012 B was discharged home to her father and placed on a Community Treatment Order13 (CTO) which included conditions to maintain her weight target and to work with the local CAMHS team.   December 2012 – mid January 2013 3.19 During this seven week period, B remained at home with her father and siblings on the CTO apart from a brief return to the specialist clinic for three days in mid-December, because she was skipping meals and self-harming.   Following an overdose and an attempt to hang herself at home approximately a month later, and with B’s continued concern about being overweight, she was admitted via the local hospital A&E Dept. for one night to an acute adolescent mental health unit before again returning to the specialist in-patient clinic.  There was a discussion between the consultant psychiatrists from each of the units when it was agreed that the specialist clinic for eating disorders remained the most appropriate placement.  B was readmitted to the clinic the next day on the 18th January 2013. January 2013 – March 2013 3.20 A few days after her return to the clinic B grabbed a shower hose with strength and force and tried to wrap it round her neck whilst showering.   She was then supervised throughout the shower and the hose was replaced in the supervised bathroom by a fixed shower head.   There were also instances at this time of B hitting her head against a wall and attempting to throw herself down the stairs 3.21 The CTO was revoked on the 24th January 2013 and B was once again detained on Section 3 of the Mental Health Act.  She was again assigned Level 4 (1:1 supervision) and this was increased to 2:1 supervision when moving to different parts of the building as she had attempted to abscond at the beginning of February 2013 and needed three members of staff to restrain her.  B was noted to have low mood, guilt and high suicidal ideation.   Her medication was increased.   3.22 With B’s agreement, between 15th February and 1st March 2013, the clinic tried unsuccessfully to contact B’s mother in order to discuss with her whether direct involvement could now be established.   13 A Community Treatment Order (as part of a revision of the Mental Health Act 1983) enables a mental health patient to be discharged from hospital but where it is still appropriate for the person to receive treatment for their health, safety and the protection of others.  Conditions are included for the person to be available for examination when requested.  Discretionary conditions can also be applied where relevant. 7                                                             HSCB – Serious Case Review re B – Overview Report July2014 3.23 On the 13th March 2013 B attended the first tier Mental Health Tribunal14 to appeal against her Section 3 detention in the specialist clinic.   It was not apparent that B had modified her thinking in terms of her attitude to eating and her weight.   The outcome of the tribunal was that the statutory criteria for her detention had been met and that B would remain on Section 3. 3.24 Following some improved behaviours and no further self-harming by B, it was agreed to allow her outside with staff for walks and also to allow her to attend a concert at the O2 Arena, with three members of clinic staff in attendance.  This took place on the 22nd March 2013 and went well with no issues. 3.25 A decision was made two days later to allow B to have two visits home to her father for the up and coming bank holiday weekend at the end of March 2013.   These were reported to have been successful with no issues and it was noted within the clinic that B’s mood was steadily improving. April 2013 - events leading to B’s death 3.26 By the 11th April 2013, it was decided that the supervision arrangements would be reduced in that B would be under normal staff supervision (general observation and checked hourly) for the period 8.00 a.m. to 9.00 p.m. and she would return to Level 3 supervision from 9.00 p.m.   There was a supervised dormitory where staff could monitor the well-being of the patients constantly through the night. 3.27 There was a planned day home on the 13th April 2013 which both B and her father reported went well when she returned later that day to the clinic.   Unknown to staff at that time, B attempted to use a shower hose that evening as a ligature but was interrupted by another patient on the unit.  B and the patient agreed not to inform staff of the incident. 3.28 On the evening of the 14th April 2013, it was reported by staff at the time of handover at 7.15 p.m. that B was in a communal area and was settled with other patients and that they had no concern about her mental state at that time.   She had been visited by school friends earlier in the day and this appeared to have gone very well – they had been laughing and joking and there was a pillow fight.   B reported during the early evening that she felt she was managing her time off the Level 3 and 4 supervisions well and that her time at home with her father was very good. 3.29 Staff observed that B was still in the communal area at 8.00 p.m. and it was subsequently reported that she told another patient that she was going off to write a letter.  When she did not return by 8.20 p.m., staff went to look for her.   B was found in a classroom, having pushed a table behind the door.  Staff gained access and found that B had used some bunting from the window as a ligature around her neck and tied it to a door on a cabinet 14 The Mental Health Tribunal hears applications for people detained under the Mental Health Act 1983 (as amended by the 2007 MH Act) or living in the community following the making of a conditional discharge, or a community treatment or guardianship order.   The main purpose is to review the case to direct the discharge of a patient where the statutory criteria for detention are not met. 8                                                             HSCB – Serious Case Review re B – Overview Report July2014 (three feet high from the ground) and had slumped forward.  B was unconscious at the time and was transferred to hospital intensive care. 3.30 B was pronounced dead on the 17th April 2013 after failing to regain consciousness.    _______________________________________________________________  Analysis  4. The extent to which B’s family background information was known and able to inform effective professional interventions 4.1 The family background of the parental divorce and of protracted disputes between them was generally known by the independent school which B attended, and of some of the impact this had had upon B and her siblings. 4.2 The detailed work by Cafcass15, following the appointment of a Children’s Guardian in 2005/06, ended in 2009, was not formally shared with any other agency.   This was understandable in that it was court mandated work and there was no formalised process which required it to be shared with other agencies.   However if the level of upset and anxiety to the children caused by their parents’ actions following the divorce generated significant concerns for their emotional well-being, then there could have been a referral to Children’s Services or to CAMHS.  However, this period of professional involvement predates the period of analysis for this SCR although it did require extensive work with the family which tried to resolve family disputes about contact arrangements, and accusations and counter accusations about parenting behaviours.   4.3 Overall, this meant that for example, when B’s school made contact with Children’s Services in March 2012 to seek advice, (prior to the referral to TYSS), Children’s Services held no information about any previous family problems to inform their response at that time that B’s circumstances did not meet the threshold for their intervention.  Based on what was known, this was an appropriate decision in the circumstances.  4.4 Similarly, at the time of the CAMHS appointment for B in October 2010 for an overdose, if the background information had been known, then there was the potential that this intervention may have taken a different focus.   Ultimately however, the finding at that time was that it was a one-off incident and there had been no history of self-harming, so even with the benefit of hindsight, it is not possible to say what difference, if any, knowledge of the previous family difficulties, could have made.  In effect, CAMHS closed the case on the advice of the mother, although B would have been separately communicated about this decision.   With the presenting circumstances at the time, it would not have been expected for CAMHS to have acted any differently. 4.5 It was apparent that this background of disharmony between the parents continued and an acrimonious relationship between them was sustained, despite limited communication 15 “Cafcass” - Child and Family Courts Advisory & Support Service 9                                                             HSCB – Serious Case Review re B – Overview Report July2014 between them.  This undoubtedly had a continuing impact upon B and her siblings who all now lived with their father.  This background and B’s estranged relationship with her mother was a feature of later therapeutic work for B and her father with CAMHS and with the specialist in-patient clinic.   Therefore whilst the detail may not have been known of the past family difficulties, it was occasionally discussed in therapy sessions and so the impact of this background was known to the professionals providing the therapeutic input at this time.   4.6 The mother has maintained in her contribution to the SCR that her daughter’s care in the specialist in-patient clinic was based only on background information supplied by the father and by B herself, and that this information “might be economical at best and possibly misleading at worst”.  Further communication from the mother to the clinic at this time did give other background information, raising concerns about the quality of the earlier father-daughter relationship.  In their response on the 31st July 2012, the clinic stated that this background information had been passed on to the clinical team working with B.   In this respect therefore, a potential gap in background information appeared to have been at least partially filled. 4.7 Clearly the disharmony between the parents, their very limited communication with each other, and the lack of contact between B and her mother from February until August 2012, presented a difficult situation for involved professionals to deal with, in their attempts to respond to B’s needs and difficulties.   Nevertheless the first school worked with B’s mother and stepfather when B lived with them, and her father was the active involved parent whom professionals worked with once he had taken responsibility for his daughter in early 2012.  This was in the context that the parents cared for B quite separately, and there was never any suggestion of a joint approach to parenting, and so in this way the professionals only ever worked with the parent who was responsible for B at that time.   This was understandable and appropriate in the circumstances. 5. The effectiveness of services delivered to B and her family Professional interventions prior to the emergence of mental health/eating disorder concerns 5.1 B’s first school (an independent school) during the SCR period was a school where B worked to a high level academically and was very popular socially.   In this way this school very much met B’s needs and she appeared to be enthusiastic and very settled there.    5.2 The school however were not aware of B’s overdose in October 2010 – neither CAMHS nor B’s mother informed the school at the time.   There would have been no formal process whereby CAMHS needed to inform the school unless they considered that the school had a particular role to play, and there was agreement from the family to inform them.   In fact within school, just a week after the overdose, B’s school report identified no concerns about her in Year 10 and for the year 2010.  She had an excellent academic report at this time.   B continued to progress within school and for example a year later the school reported that B “is grabbing all the opportunities that are offered to her and making the most of them”.    Therefore, it appeared that there was nothing which would necessarily have been gained from the school knowing about the early overdose. 10  HSCB – Serious Case Review re B – Overview Report July2014 5.3 The school however became involved at a different level during January/February 2012 in trying to help resolve the relationship problems that emerged once B’s mother and step-father became very unhappy about B’s relationship with a new boyfriend.   The outcome was that B would move to live with her boyfriend’s family – this had been initially agreed between the boyfriend’s mother and B’s mother.  It was only immediately after this that B made contact with her natural father and also arranged to stay with him at weekends. 5.4 Because of the intensity of the concerns within the family and of the mother’s request for B to return home, the school head made telephone contact with Hertfordshire’s Children’s Services to seek advice.   This was a very appropriate response to the situation and the contact was able to confirm that as a 16 year old, B had rights and that the child protection threshold had not been met.   Private fostering arrangements were explained, which in essence meant that because of her age, formal legal requirements in this respect did not apply. 5.5 The school continued to be involved over the following month via numerous communications from the mother and some from the natural father and at one stage the school head offered to hold a meeting between the parents to discuss the problems.   Overall however, the school were correct in their responses to the family that where B lived, and the parenting arrangements were a matter for them, and that the school’s prime concern was that these problems should not upset B’s academic progress.   5.6 The mother was concerned that the school had allowed B’s relationship with the boyfriend to continue, and she considered that he was a bad influence on her.  It was not however the responsibility of the school to make decisions about B’s relationship with a boyfriend although they did in fact attempt to resolve the situation and responded to parental contact, but ultimately it was not a role which they were obliged to take on.  There was no evidence to support the maternal concerns and B was continuing to do well at school.  The agreement reached for the school to make a referral to TYSS was nevertheless a useful step forward in trying to bring some objective expertise into the process. 5.7 Whilst the mother apparently accepted that the referral was necessary, she made a formal complaint to the school about the delay in actioning this.  TYSS became involved from the middle of March 2012. 5.8 The role of TYSS was to assess the situation and to try to support B and her mother and step father to try to rebuild their relationship.  A major part of the mother’s concern was that B was in a sexual relationship with her boyfriend and that he may be using drugs.  Whilst the maternal concerns about a sexual relationship existing were understandable, this was a matter for B who was over 16 at this time, and her boyfriend who was a little older. 5.9 The risk assessment completed over a period of approximately two weeks at the end of March 2012, was conducted in as sufficiently detailed a way as the circumstances required.   B was seen on her own and the accommodation at her boyfriend’s family was also visited.   The school gave their views and information to TYSS, who in summary had no concerns about the boyfriend and his family.  The assessor spoke with B’s natural father but only had e-mail communication with B’s mother.   The latter arrangement was not ideal, in that 11  HSCB – Serious Case Review re B – Overview Report July2014 although the mother did not apparently give her contact details to the assessor, without that direct contact it would have been difficult for the assessor to have really understood the dynamics between mother and daughter.   In this way it would therefore have been difficult to have achieved the initial purpose of the intervention which was to try to build this relationship. 5.10 However, B presented as quite clear that she did not want to return to her mother’s care, though recognised that the arrangement at the boyfriend’s home was temporary to enable her to finish her exams and then move permanently to her father’s home.  It was appropriate that B was offered counselling and mediation but she declined this.   As part of the mother’s contribution to the SCR, she maintained that TYSS had incorrectly accepted everything at face value instead of being thorough, diligent and properly investigating her concerns. 5.11 There was no evidence that B’s mother’s suggestion of drug use by the boyfriend was pursued other than receiving the general reassurances from the school about him and the assessment that the relationship between the two young people appeared generally positive.  The boyfriend was not the subject of the assessment and the work undertaken with B was sufficient in this respect for the assessor to reach the view that the relationship was not harmful to her. 5.12 Additionally the Individual Management Review (IMR) conducted by a senior manager within TYSS considering the quality of the assessment at this time, said that B was in good physical health and that there was no indication that B was suffering from any eating disorder.  This statement was made in the later knowledge that B ultimately had an eating disorder.  In fact such a concern had never been included in the original referral that was made, and there was no separate record that this was a concern of any professional at this time.  5.13 Although the mother’s concerns were understandable in that she had had no contact with her daughter for approximately two months, the level of concern about B’s situation did not meet a high threshold of concern for TYSS, and the assessor had been assured by three meetings with B, that she was not at risk of harm.  Conversations with B’s father and with the boyfriend’s parents appeared to confirm they were happy with the arrangements and had made appropriate plans for the future after the exams had finished.   In this scenario, there was little more that needed to be done.   Overall this assessment was satisfactory, appropriate to the circumstances and the outcome was also appropriate – there was no evidence presented within the assessment which suggested that B was at any level of risk but that she was intelligent, thoughtful and clear about the decisions she was making to not return to her mother’s care, and to instead eventually live with her father. 5.14 As part of her contributions to the SCR, B’s mother said it was her belief that the boyfriend’s mother took B to the GP and that this was the beginning of B’s self-harming and eating disorder.  The mother’s position is that she should have been told of these concerns and that more appropriate attention needed to be given to these concerns by professionals. 5.15 Whilst there were two occasions when B’s mother understood that B saw a GP in late February and late March 2012, when absent from school, there were no GP records to 12  HSCB – Serious Case Review re B – Overview Report July2014 substantiate that any attendance at the GP surgery took place.  The father however recalled that B went to her GP in late March with an upset stomach which led to her initially cutting back on food, although not to any significant extent.   Nevertheless, there was no record of any concerns about self-harming or eating problems at those times.   The mother’s view is that these problems were known to the father and to professionals (i.e. the first school and the TYSS) but that the details of these were withheld from her and thereby meant that she did not appreciate the level of concerns and could not respond or intervene appropriately to help her daughter.    5.16 Within the chronology compiled by all involved agencies, there was no reference to B having an eating disorder or losing weight until the father formally reported this on the 21st May 2012.   It was therefore not recorded as a formal concern to any professional until that time.    There is however other information which could be construed as contradicting this position in that the CAMHS letter back to the GP in June 2012 after B’s first session there, said that regarding her weight, “there had been a rapid deterioration since her very distressing separation from her mother in February”.  Also in a letter from the specialist in patient clinic in January 2013 to CAMHS, it stated that “Dad had noticed things developing significantly at the end of March 2012.  Her significant weight loss of around 10 kg took place in the previous three months with her eating virtually nothing for the last month”.   B herself claimed that her problems with eating began when she started secondary education, some years earlier. 5.17 What the father chose to do in respect of concerns for his daughter are not a matter for this SCR and in his contribution to this report, he is strong in his recollection that his daughter’s weight loss was a dramatic one over a short period at the end of May 2012, even though the stomach upset in late March 2012 led to her eating less.   It was also not until May 2012 that the school expressed concern about B’s weight, though acknowledging that she had always been a slim young woman. 5.18 It was not therefore apparent that either the school or TYSS had any recorded concern about significant weight loss or regarding any eating disorder in respect of B from as early as February or March 2012.  By the time that the eating disorder became a problem, TYSS were no longer involved, and the school made an immediate response in late May by their letter to try to relieve some of the pressures upon B of the school exams at that time.   5.19 I therefore find no evidence that any professional had any knowledge about an eating disorder for B, or self-harming prior to the end of May 2012.  The content of the letters referred to above (Para 5.16) seemed to have reflected generalised comments taken from discussions with B and her father rather than the result of assessments on the basis of medical information.   However, the details within the letters should have been much clearer about the evidence upon which they were making such statements.  The problem of self-harming did not become known to professionals until late July 2012 and by this time CAMHS and the specialist in patient clinic were involved.  Therefore I do not consider that any professional acted inappropriately at an earlier time as claimed by B’s mother. 5.20 B’s mother has also claimed that she was lied to by the school head teacher and not told of her daughter’s condition at the time of the school formally hearing her earlier complaint 13  HSCB – Serious Case Review re B – Overview Report July2014 (about the way that the head teacher dealt with their concerns at the time of B’s move to her boyfriend’s home) in late June 2012, and that in failing to do so, the head teacher abused her position of trust.   It was the fact that there was no contact between mother and daughter or with B’s father which meant that B’s mother was unaware of the level of concerns about B’s weight loss at this time.   However, it could not be expected that the school should be a go-between in this situation and it was not part of their professional responsibility to inform the mother of her daughter’s condition, who as far as they were concerned no longer had any involvement with B.   The school had liaised fully with B’s father as her carer at the time of the concerns emerging and had acted appropriately in response to those at that time.  Also at the time of this complaint hearing, B was attending a new school.   Whilst B’s mother’s frustrations and anger can be understood that she did not know of her daughter’s worrying condition whilst the father and some professionals did, it cannot be said that the school failed to act appropriately in these circumstances by not informing her.    5.21 The school were informed by B and her father that B would be leaving the school at the end of the summer term - she was saying that she would prefer to live with her father and change to a school near his home. Professional interventions at the time that concerns of an eating disorder emerged 5.22 From the records available to this SCR, it was the father who was the first to express concern, initially via the school that B had not been eating much since she had moved to the boyfriend’s home but that she was now looking visibly gaunt.  It was then a few days later (28th May 2012) that the GP identified loss of weight and an eating disorder.  The school had at this time written to the GP to express their concerns about B’s recent weight loss. 5.23 As mentioned previously, it was difficult to accurately identify from records over what period of time B’s significant weight loss occurred, but it was clear that it was not until the father’s expression of concern that professional intervention commenced. 5.24 It was certainly true when B was seen by the GP, who then made an appropriate urgent referral to CAMHS, that her weight loss was already at a significant level with her BMI score very low and enough to reflect anorexia.  It was noted in the referral that the speed at which the weight is lost can generate a high medical priority.   Although it took more than a week before CAMHS received the GP referral and then a further week before the appointment was attended, this time period was not a significant issue in that ultimately B’s needs were appropriately assessed and responded to.  It is understood that the system for dealing with eating disorders has changed since this time with a speedier referral process by the immediate use of fax now being in place. 5.25 The high level of concern for B’s condition at the CAMHS appointment attended by her and her father was that she needed to go straight to A&E for medical and physical checks.   The hospital gave advice to B and her father about the level of nutritional drinks she needed to take.  Overall the initial response to the weight loss was appropriate and focussed on the immediate need to get B’s weight increased.   However, three days later it was very clear that B was very unwell at the CAMHS appointment, with her responses recorded as 14  HSCB – Serious Case Review re B – Overview Report July2014 “generally falling within the more extreme instances of anorexic thinking (denial)”.  It was therefore appropriate that a referral was made for B to be admitted to the specialist in-patient clinic.   In essence, attempts had been made for B to respond to the advice she had been given and to use the support of her father, in order to regain weight, but as this had clearly been unsuccessful, the referral for in-patient treatment was unavoidable and appropriate. 5.26 In the midst of these concerns, B started her new secondary school and from their perspective she presented as fine and happy although she was soon unwell and did not attend on her second day.   Despite the level of concerns at her independent school, this new school had not received any information about B prior to her starting.   Also this new school had not raised any concerns about B’s presentation or weight.  It was the father who alerted the school about the CAMHS assessment and the low weight problems.   The school were also informed of B becoming an in-patient at the specialist clinic and it was prompt and helpful for the school to arrange for work to be sent there for B. 5.27 There was a breakdown in communication between B’s schools in that the independent school failed to send information to the new school in respect of B even though the respective 6th form heads had agreed that this should happen. B’s stay in the new school was very limited because of her hospitalisation, and so ultimately this breakdown in communication had limited impact on the ability of the new school to provide the appropriate responses and care of B.  However in other circumstances this could have been significant and it was a failing that the appropriate information was not transferred to the new school as part of good professional practice.   It needs to be noted however that B was now over 16 years old and not of compulsory school age, so the transfer of information was not covered by normal procedures applicable for school age children.   However, because there were considerable concerns about B’s well-being at this time, then from a safeguarding perspective, the transfer of information was important. Consideration of safeguarding concerns regarding the eating disorder. 5.28 During this period of time when B’s weight loss was very worrying, there was no consideration that the safeguarding aspect needed particular attention.   For example, there was no record of whether a referral to Hertfordshire Children’s Services was discussed or thought appropriate from a safeguarding perspective, from the hospital or by CAMHS at the point when they first became involved with B.    5.29 The Hertfordshire procedures16 suggest that, if at any stage a professional is concerned that the child is in need of protection, a referral is made and that the usual child protection procedures would be followed whereby a child protection enquiry or an assessment will be conducted.  B’s anorexic behaviour was in itself a form of self-harming, although both CAMHS and then the specialist in-patient clinic were endeavouring to address B’s needs at this time, and had done so as a matter of urgency.   There was a professional view (which was confirmed by practitioners who attended the Learning Events) which was that the father 16–Paragraph 6.20; Self-harm and Suicidal Behaviour - Hertfordshire Safeguarding Children Board – Child Protection Procedures 2013 15                                                             HSCB – Serious Case Review re B – Overview Report July2014 was caring and supportive to B and was doing all that was asked of him by the professionals.  In this respect therefore B was not a child in need of protection that warranted a referral to Hertfordshire Children’s Services in that B’s current care was being managed with the appropriate level of intervention and urgency by the involved agencies.  5.30 Once it was clear to the specialist clinic that B would need to remain with them because of her eating disorder as an inpatient for a period greater than three months, they informed the local authority (Hertfordshire Children’s Services) of this by letter in mid-July 2012.   This was a requirement under Section 85 of the Children Act 198917 and the letter was clear that it was for information purposes only and not a referral.   Nevertheless the Act does require the local authority to take reasonable steps to enable them to determine whether “the child’s welfare is adequately safeguarded and promoted” whilst accommodated and “whether they should exercise any of their functions under the Act with respect to the child”18.   As B had not by this time been an inpatient for three months, then the assessment team who received the letter considered that no assessment was required of Children’s Services and that they expected  the clinic to inform them if B became an inpatient for longer than three months. 5.31 The clinic had met the requirements of the Children Act by informing the local authority in advance that B would be with them for more than three months and in fact included the discharge date of mid-November in the letter, meaning that B would be with them for five months.   Therefore the Children’s Services decision to wait for the clinic to refer back to them after the three month period was incorrect as the clinic had already discharged its legal responsibility by informing them at an early stage.   This meant that there was no further communication between the clinic and Children’s Services, and therefore that Children’s Services were not in a position at a later date to make any informed decision about whether they needed to become involved or not.  As this period of B’s inpatient care increased, self-harming became a concern, which was something which Children’s Services were not aware of.   Overall, therefore the legal notification process had no impact upon B’s care within the inpatient clinic and Children’s Services had not utilised the opportunity to consider whether their additional involvement was necessary or not.   6. The use of the Mental Health Act to provide services to B 6.1 The first use of the Mental Health Act 1983 was at the time of B’s admission to the in-patient specialist clinic on the 21st June 2012, when she changed her mind and wanted to leave.   Her father wished her to remain and receive treatment although she remained determined to leave.  Because of the seriousness of her condition, then to place B on Section 5 (2) of the act meant that she needed to remain for a minimum of 72 hours.   This was an appropriate use of the Mental Health Act. 6.2 This arrangement allowed for a mental health assessment to be conducted which identified that she would need naso-gastric feeding if B did not manage her calorie intake herself.   It 17 Sec 85 (a) & (b) states that “where a child is accommodated by any health authority for a consecutive period of at least three months or with the intention on the part of that authority of accommodating him/her for such a period, the accommodating authority will notify the responsible authority”. 18 Sec 85, (4) (a) & (b) Children Act 1989 16                                                             HSCB – Serious Case Review re B – Overview Report July2014 was sensible in the circumstances to then place B on Section 2 of the Mental Act to assess her mental health and for her to receive the necessary treatment.   B’s father was in agreement to this approach and confirmed in his contribution to this SCR that he considered the in-patient clinic to have acted responsibly and appropriately with B. 6.3 In November 2012, when it was reported that four consecutive week-ends home for B with her father and siblings had gone well, a further mental health assessment was conducted in the in-patient clinic when it was decided to place B on a Community Treatment Order (CTO) and to discharge her from in-patient care. 6.4 In the presenting circumstances, a CTO appeared to be an appropriate way to proceed as it would allow and encourage B to manage her own behaviours with her father’s and her siblings’ support, and would properly test out her ability to continue to increase her weight. 6.5 In effect, with B still maintaining that she was fat and then when some serious self-harming episodes took place, it was soon apparent that the CTO was not working and required her to be readmitted on two occasions back to the specialist in-patient clinic.  It was concerning that on the first of these occasions when she returned for three days, the appropriate paperwork had not been completed by the psychiatrist, meaning that the return to the clinic was not compliant with the Mental Health Act.   The subsequent letter to B to explain this mistake identified that the return to the clinic therefore needed to be viewed as voluntary on that occasion.   Technically this was correct but it was not apparent that B experienced the short readmission as a voluntary episode.   Neither she, nor her father challenged what had occurred and ultimately the mistake had no real significance on the treatment that B received – it was right that she needed to be back in the clinic at that time.   The failure to sign the appropriate paperwork appeared to be an isolated incident, acknowledged by the psychiatrist, rather than any generic problem. 6.6 On the second of these occasions, on the 18th January 2013, B returned and remained resident in the clinic and this led to the CTO being revoked and again replaced with a Section 3 placement.   In effect, B had only been resident at home for a short initial period of four days and then for approximately a month over the Christmas period before it became necessary to return her to in-patient care and revoke the CTO. 6.7 It therefore posed the question about the relevance of the CTO and that with such a serious suicide attempt being made whilst at home; whether it was appropriate to discharge B at that time.   By then the Section 3 had been in place for four months so had just a further two months to continue and so it did seem that B’s progress needed to be tested.   The week-end home success in November 2012 was no doubt a key determinant that a CTO was the appropriate next step.   However it was on the later weekend that she self-harmed by scratching herself and on the previous week-end, had lost weight, so in this way, these weekends were not fully successful. 6.8 Nevertheless, the alternative would have been to continue with the Section 3 arrangement which would not have really tested any progress or change.   Also B’s father utilised the services of CAMHS and the in-patient clinic at this time to get attention to any crisis during 17  HSCB – Serious Case Review re B – Overview Report July2014 the CTO, and the clinic were very prompt and appropriately responsive in re-admitting B for a short period so soon after the CTO had been introduced. 6.9 In many respects the CTO had little time to show its effectiveness but ideally for a community order to be successful, then those working with B in the community should be aware of the arrangements and requirements of the CTO, so as their interventions could support it.   Whilst CAMHS were aware and integral to the work of the CTO in that they provided the therapeutic input to B and her family whilst under the auspices of the order, the new school was the other agency involved in providing input to B.   This school however were not informed of the CTO and of its conditions and yet by this time, B had again started to attend there. 6.10 From the mental health perspective there appeared to be no appreciation of the need to involve the new school by, as a minimum, explaining the details of the CTO.  There was no evidence that the matter had been discussed with B and her consent to share, sought.   The reasons for not sharing this information appeared to be primarily because the school were not perceived as having a direct role in the implementation of the CTO.   It was also unclear whether it was CAMHS or the in-patient clinic which had any responsibility for sharing information with other agencies involved with B in the community.   As CAMHS were providing the mental health services in the community, then ideally it should have been them to share information with the school.   To not to have done so meant that any observations of behaviours, peer relationships etc., and of any changes of these within school, were not available to add to any emerging picture of how B was managing day to day life.   As far as the school were concerned, B’s discharge could have meant that she had conquered her problems and was no longer a concern from a mental health perspective, and yet this was some way from the truth.  This was poor practice and appropriate communication should have taken place with the school in order to be able to gain a fuller picture of how B was managing her life outside of the clinic environment. 7. Professional involvement and communication with the parents 7.1 As part of their contribution to this SCR, B’s mother and step-father have raised concerns about the lack of engagement with them (and with B’s mother particularly) by professionals, especially with regard to the occasions when concerns began to emerge about B’s health and when the Mental Health sections were applied to ensure she remained in the specialist in-patient clinic. 7.2 At the time of the involvement of mental health services, it was apparent that B was residing with her father and she was clear that she had no intention to return to her mother’s care, and the lack of contact between B and her mother since she had moved out some four months earlier, reflected this position.   Therefore in their early urgent dealings with B, it was only the father who was involved with the mental health practitioners in trying to resolve the presenting problems. 7.3 As there was an early decision to invoke the Mental Health Act in order to ensure that B was detained in the clinic, then the mother has maintained that it should have been her rather than the father who was involved in that decision.  From her perspective she was clear that 18  HSCB – Serious Case Review re B – Overview Report July2014 it was she who had provided the longest period of day to day care for B and that it was therefore inappropriate to exclude her from any discussions about B’s care at this significant time.  Her view was also that B had not suffered any mental health difficulties in her care, and that this meant that she could have provided some alternative solutions to the presenting difficulties. 7.4 Whilst it was very understandable that the mother felt that she should have been informed and consulted about the decisions to ensure that B received specialist in-patient treatment, in essence there is no formal or legal requirement for the mental health professionals to do so.  They were working very closely with the father who had maintained a high level of involvement with the different professionals.   Also, as he held Parental Responsibility (along with B’s mother), and was the current carer, it was viewed as appropriate that it was he, as the nearest relative, with whom these decisions needed to be made.   There is no legal requirement that it is the parent who has had the longest period of care of a child who takes precedence, and in fact if two parents have Parental Responsibility, legally it is the elder who is deemed legally to be the “nearest relative”.   (It is understood that the father is the older of the parents).   Furthermore the Mental Health Act stipulates that if the patient is living with or being cared for by a relative, then that person would be deemed to be “the nearest relative”.19   Also the Children Act identifies that “where more than one person has Parental Responsibility for a child, each of them may act alone and without the other in meeting that responsibility”20.   7.5 Also, from the time of the admission, B was clear that she did not want her mother to know, was not intending to live with her, and would not initially give her consent for her to be informed of the admission.   B had the legal right to make this decision and that “If a competent child (aged 16 and 17 years) requests that confidentiality be maintained, this should be respected unless a doctor considers that failing to disclose information would result in significant harm to the child.”21  7.6 It could be argued that B might not be “competent”, because she needed to be admitted to the clinic under a Mental Health section, but there was nothing to suggest that to not inform or consult the mother would have resulted in significant harm to B.   It was also considered by the mental health professionals involved with B, that whilst B did not accept the seriousness of her eating disorder, she was in other respects able to make coherent decisions such as her wish for confidentiality.   The position centres on whether or not B was Gillick/Fraser”22 competent and also importantly in B's case whether she had sufficient capacity to make the decision that she did.  According to the evidence of B’s situation at the time, she was Gillick competent.   In terms of the issue of Gillick/Fraser competency, if B was of sufficient maturity to understand the decision she was making and its implications, then 19 Sec 26, Mental Health Act 1983 20 Section 2(7) The Children Act 1989 21 Consent to Treatment in Children (Mental Capacity and Mental Health Legislation) – Patient Plus article written for health care professionals - 2013 22 “Gillick competency and Fraser guidelines refer to a legal case which looked specifically at whether doctors should be able to give contraceptive advice or treatment to under 16-year-olds without parental consent. But since then, they have been more widely used to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions”.  NSPCC Factsheet July 2012 19                                                             HSCB – Serious Case Review re B – Overview Report July2014 legally professionals involved in her care would be obliged to abide by the decision not to inform other third parties including relatives.23 7.7 B would need at the time of making her decision sufficient capacity (capacity being situation specific) to make the decision not to allow her mother to have access to her information.  In B's case this would be particularly important given that she was receiving in patient treatment for her Mental Health. The legal presumption in relation to capacity is that an individual has capacity to make a particular decision unless proven otherwise.24 7.8 Soon after the first admission, CAMHS discussed with the father that it would be relevant to inform B’s mother and he agreed to discuss this with B who then gave permission to inform the mother of the admission but not of the details of her condition.   This occurred nine days after B’s first admission, and did demonstrate that the clinic professionals had considered B’s mother’s situation and that she should be made aware of her daughter’s admission.   Although B’s mother then made immediate contact with the clinic, B did not want any direct contact at that time and her mother was duly informed of this by the clinic. 7.9 Relatives other than the “nearest relative” do have the right to apply to the county court to have the nearest relative displaced on certain statutory grounds, but even if B’s mother had taken this route, it would have been doubtful whether the grounds would have been met.   Additionally insofar as matters of urgency, the Care Quality Commission recommend that mental health practitioners should consult with persons other than the nearest relative who are or have been involved in the patient’s care, and take their views into account.   However, those involved in B’s care needed to respond to her wish for confidentiality from her mother, and they managed this in an appropriate way.   Once B’s mother knew of the admission, she sent information to the clinic about family background matters, so ultimately this information and her views were considered in the treatment that B received.  7.10 Because B’s mother was not contacted at the outset of the mental health interventions and nor at subsequent key events when the Mental Health Act sections for detention or treatment were changed, then it is not possible to say whether her involvement would have made any difference to the success or otherwise of interventions that followed.   In terms of capacity to consent to mental health treatment, there is reference in the relevant act to the need to consider the “best interests” of the patient, and that for a child this includes the “views of the parents”.    However this still remained linked to the wishes and feelings of the patient, which were quite clear in these circumstances that B, as a person over the age of 16 years, did not want contact or to discuss her circumstances with her mother.    7.11 The Mental Health Tribunal, held in March 2013 ratified the current arrangements for B in that they remained necessary in order to meet B’s mental health needs. 7.12 Because of the continuing conflict between the natural parents, there was no communication between them at this time and the mother had no contact with her 23 Gillick v West Norfolk and Wisbech Area Health Authority and another House of Lords ( 1986) 1 AC 112, [1985] 3 All ER 402 24 Section 1 of The Mental Capacity Act 2005 A person must be assumed to have capacity unless it is established that he lacks capacity. 20                                                             HSCB – Serious Case Review re B – Overview Report July2014 daughter and knew nothing of B’s problems until she was informed that she was resident in the specialist in-patient clinic.  How the parents managed their joint parenting responsibilities and their communication was a matter for them.   The main focus for the SCR process is whether the professionals acted appropriately within the law and in the best interests of B, in their communication with the two parents.   Within the circumstances presented at the time, the actions by professionals were understandable and complied with relevant legislation and professional guidance. 7.13 In terms of the therapeutic interventions with B, it was unfortunate that the one telephone contact that she had with her mother whilst in the in-patient clinic seemed to unsettle B rather than aid her improvement.   In the circumstances of the mother knowing so little detail of what had transpired with her daughter, it was difficult for her to know how best to respond to B.   If one of the mental health professionals had helped prepare the mother for this first conversation with her daughter, without contravening B’s wish not to disclose the details of her treatment, this may have improved the outcome.  7.14 It was during her second admission to the clinic under the Section 3 arrangement that following therapeutic sessions with B, who expressed ambivalent feelings towards her mother, that it was considered it might be useful to involve the mother in future therapeutic sessions.   Telephone calls and a letter were subsequently sent to ask B’s mother to get in touch and although the mother did not respond to these requests, it was nevertheless appropriate that such attempts were made as a means of trying to progress and improve B’s mental health.   B’s mother felt that the lack of information in the letter and that she did not know that B was again resident in the clinic, led her to not know the full reasons for their wish to seek contact with her. 7.15 At the time when B placed the ligature round her neck, and which led to her death three days later, the father initially did not inform B’s  mother but the clinic considered they had a duty of care to over-ride this.  In the end the father did inform the mother, but it did show that the clinic had considered the importance of B’s mother being informed at this most significant time. 8. The period as an in-patient from late January 2013 under the final Section 3 arrangement 8.1 It was following serious suicidal behaviour of an overdose and an attempted hanging by B during four days in mid-January 2013 under the auspices of the CTO, when it was clear that she needed to be readmitted to a specialist hospital.   By this time, B had lots of self-harm wounds on the arms, though these were generally superficial.  It was from the A&E attendance at this time, that an assessment by the psychiatric team identified the need for B to be urgently admitted to a relevant adolescent unit.  This was a very appropriate response, although there was poor recording of the actions and decisions within the hospital.    8.2 The situation was somewhat different than the earlier occasion in June 2012 when the hospital and CAMHS initially became involved, in that on this occasion, the presenting problems were significant suicidal behaviours rather than solely the eating disorder.   It was clear that B’s urgent safety was the priority, and this was addressed, although there was no consideration by the hospital or by CAMHS whether a referral to Hertfordshire Children’s 21  HSCB – Serious Case Review re B – Overview Report July2014 Services would also be appropriate or helpful in these different circumstances.   Whilst under the CTO it had not been considered appropriate to involve Children’s Services, it was now clear that use of the CTO had failed to address the presenting problems and so potentially a different approach was needed.  8.3 Because it was quickly very clear that in-patient treatment was necessary, involving Children’s Services would not have added to the decisions and actions which were being taken at that time and no doubt any advice from Children’s Services would have been to proceed with the plan to provide intensive in-patient mental health care.  Nevertheless, whether to involve Children’s Services or to seek their advice, should have been given some consideration and recorded accordingly.   Children’s Services had previously been informed of B’s earlier five month period of inpatient treatment in 2012, and made no response to that, so there could have been some consideration on this later occasion, with the situation clearly more concerning, whether there was now a need for their separate involvement and joint working with the mental health services.   Nevertheless the role of a CAMHS social worker was already available and able to provide the duties and functions of a local authority social worker.   B’s second period of admission from January 2013 was not for a consecutive period (there were periods of weekends at home) and was not greater than three months and so there was no legal requirement at that time for the clinic to again inform Children’s Services. 8.4 From the time of the CTO, a care coordinator from CAMHS had been appointed, whose role was to take an overview of what was happening and to coordinate services as necessary.  However, the care coordinator role in effect became a passive one, being a recipient of information from the clinic, once B was again an inpatient there. 8.5 There was potentially a role for the care coordinator to sustain a role with the family outside of the work being undertaken in the clinic, to focus on the source of some of B’s difficulties and how the family could help to address these.   This could of course also have potentially involved B’s mother and step-father at this time.   However, it was understandable from this point on that the focus was very much on B within the specialist clinic and that the father was well engaged in this and in trying to support his daughter’s recovery.  Work with the family would have been stepped up if there was a plan to discharge from the clinic, and it would not have been normal practice for a care coordinator to have significant direct involvement whilst the individual concerned was an inpatient.    8.6 The immediate response at the time of crisis in mid-January 2013 was for B to be admitted to an Adolescent Mental Health Unit, although she only remained there for one day where she refused to eat.  A discussion was appropriately held between consultant psychiatrists from both this unit and the specialist in-patient clinic where B had previously stayed.   As a result of this discussion it was agreed that to return to the clinic would be the most appropriate for B’s needs which were still seen as predominantly anorexia.   The transfer arrangements were therefore quickly made. 8.7 Whilst it was apparent that the eating disorder was the main issue for B in that it appeared to be her distorted body image which led to the self-harming and suicidal behaviours, the suicidal behaviours had now reached a much more concerning level, for example with B 22  HSCB – Serious Case Review re B – Overview Report July2014 stating quite clearly that she wanted to hang herself.   As part of the father’s contribution to the SCR, whilst he was very praise worthy of the work of the specialist in-patient clinic and in no way critical of them, he wondered whether the specialist focus needed to be on the self-harming and suicidal behaviour rather than the anorexia, and therefore whether the clinic remained the most appropriate placement. 8.8 It was clear that this issue had been the subject of discussion at the outset of the placement back to the specialist clinic, and that B’s refusal to eat when placed in the other unit had supported the decision that the clinic with the specialist anorexia knowledge and services would be more appropriate.   Even though it was clear that B was unhappy about returning to the clinic, it was here that knowledge of her condition was known and that a relationship had been established with the father who had previously regularly attended family therapy sessions there with his daughter.   Also, there was evidence that there were clear supervision arrangements in place to care for adolescents who were vulnerable from self-harming behaviours. 8.9 On balance therefore it appeared to be a reasonable decision that B was placed back into this clinic which specialised in eating disorders.  8.10 From the beginning of this final period of B’s inpatient treatment, it was clear that the self-harming and suicidal ideation was being taken seriously with periods of one to one and two to one supervision being put in place and her medication being increased appropriately. However, even as part of these strict supervision arrangements, B attempted to abscond and also tried to self-harm by using a shower hose, on two occasions putting her hand into a “fly zapper” and by picking at scabs.   This tended to show the determination that B displayed in her behaviours for much of January though to mid-March 2013, but that overall the supervision arrangements had prevented any significant self-harm injury. 8.11 It will be a matter for the Coroner’s Court to consider the circumstances and cause of B’s death, although this SCR has had sight of the Serious Incident Requiring Investigation Report25 which has reviewed the circumstances of B’s care at this time in the clinic and of the events of 14th April 2013, when B was found with a ligature round her neck, and from which she did not recover consciousness.   The overall finding of the investigation, undertaken by a non-executive director of Care UK, the umbrella independent organisation for Care UK (the specialist clinic for eating disorders) was that “It is difficult to identify how on the basis of the information available and the context in which the care was being provided, anything could have been done to prevent the patient committing the act of serious self-harm or this subsequently resulting in her death”.   8.12 As part of their contribution to this SCR, B’s mother and step-father strongly disagree with the way in which that investigation and review was conducted (partly in that it was not independent) and of its findings, and has claimed that information has been suppressed and that this potentially reflects criminal behaviour on the part of some professionals.   This SCR has not identified such concerns. 25 Serious Incident Requiring Investigation Report – Dr Ian McPherson, Non-Executive Clinical Director 10 June 2013 23                                                             HSCB – Serious Case Review re B – Overview Report July2014 8.13 It is important to note that whilst the investigation report identified that nothing different could have been done to prevent B’s death, it then goes on to make five recommendations for changes to practice within the clinic.  These are: -  1. Clinical Care - It is recommended that Care UK Mental Health Division review the training they provide to staff in assessing and managing patients who present with risks of serious self-harm and ensure that a consistent model is used with appropriate adaptions for particular conditions and environments, reflecting current best practice. 2. Staff and multidisciplinary working – It is recommended that the review of staffing and multidisciplinary working already underway at Care UK prior to the incident, needs to take into account the possibility of large numbers of patients who may be admitted with more complex needs, including those at risk of serious self-harm. 3. Physical Environment – It is recommended that the review of potential ligature points at Care UK already undertaken since January 2013 needs to be considered in the light of this incident and agreement reached about any further action to remove physical risks, or in the event that this is not feasible or desirable in terms of the overall environment needed for therapeutic care, how these risks should be managed when caring for patients who present risks of serious self-harm. 4. Suicide Prevention Audits – it is recommended that regular Suicide Prevention Audits should be introduced across Care UK Mental Health Services, overseen by the Integrated Governance Team but actively involving managers and staff reflecting current best practice for inpatient care with appropriate adaptions for particular conditions and environments. 5. Arrangements for Shared Learning – The learning from this event needs to be disseminated across all units of Care UK’s Mental Health Division. As part of the clinic’s contribution to this SCR, we have been furnished with evidence of the positive progress of these recommendations.   8.14 The presence of bunting in a unit where self-harming was a concern in respect of its inpatients, did require explanation and whether it should have been in place.   It is understood that the bunting which B used as a ligature had been put up as part of activities by other inpatients and that it was situated in a classroom that patients only usually attended when accompanied and supervised by staff.   In this way the investigation report did not consider that it should have been removed and the bunting was not seen by clinic staff as presenting a significant self-harm risk.  Nevertheless, B accessed the classroom unknown to any member of staff, so it clearly did represent a risk which should have been recognised.  If the classroom was not meant to be accessed without staff in attendance, then it should have been locked. 8.15 Furthermore, recommendation number 2 above reflects the need to review how staff are trained in the assessment and management of self-harm.   This training should be a fundamental component of staff knowledge and experience, so to request a review implies that staff may not have been sufficiently trained in this area.  However the report does not go that far but identified the dilemma of treating high risk patients in that; “A highly risk averse approach could reduce the potential for incidents of self-harm but would also be 24  HSCB – Serious Case Review re B – Overview Report July2014 counter to giving the patient the opportunity to experience greater independence and to learn to manage their emotional stress”.   The review of training should therefore consider how this dilemma can be addressed effectively by staff.   The training matrix supplied by the clinic to inform progress against the recommendations and to inform this SCR, suggests that a comprehensive range of training is in place. 8.16 From mid-March 2013 there was some evidence of B making progress and this reflected a reduction of the supervision arrangements to level 3 and then just three days before the fatal incident, the supervision arrangements were again reduced to the normal level, meaning that B had to be seen and monitored at least hourly by a member of staff but that from 9.00pm she would need to be within sight of a member of staff.  It was during the evening prior to 9.00pm that the incident of B accessing the classroom and using the bunting as a ligature took place. 8.17 In the long term it would not have been appropriate to sustain B to high levels of supervision, but also any decision to decrease this needed to be based on an accurate assessment of positive change.   There was certainly evidence of a reduction in her self-harming behaviour and for example it was noted that on the 18th March 2013 that B had not self-harmed for ten days and that a few days after that she acknowledged wanting a life and to return home to her father.   This was then supported by some successful weekends at home and attendance at a concert at the 02 arena with three staff members which appeared to go well.    There was one incident of self-harming on the 26th March 2013 when she had used a paper clip to make superficial cuts to her arm and the response was to offer new strategies to B to cope with her desire to self-harm. 8.18 The timing of when to reduce supervision of B was therefore a crucial one and appeared to have been made within a context of diminishing risks of self-harm and some evidence of B making progress in respect of a possible return home in the future.   The decisions to change the supervision arrangements were clearly made at regular team meetings between involved practitioners.   No environment can be strict enough to eliminate all risks and the clinic, as well as needing to provide a safe environment for its residents, also had to provide a culture whereby its residents could progress towards discharge and a level of independence.   8.19 A Care Quality Commission unannounced Inspection26 occurred at the clinic a month after B’s death (it was not related to the death) found that the standards were met in the five key areas of service provision. 9. Prevention and predictability 9.1 Because B had self-harmed in the past and had demonstrated suicidal ideation, it cannot be said that the eventual tragic outcome was unpredictable – there was always a possibility that such an event could occur.   What was important from the perspective of this SCR was 26 Care Quality Commission (CQC) Inspection Report – Care UK Clinic 17th May 2013 – 5 areas inspected “Respecting and involving people who use services”, “Care and welfare of people who use services”, “Management of medicines”, “Supporting workers” and “Assessing and monitoring the quality of service provision” - Report published June 2013. www.cqc.org.uk  25                                                             HSCB – Serious Case Review re B – Overview Report July2014 whether the professional interventions were appropriate in the prevailing circumstances and throughout the time that B and her family were in receipt of services. 9.2 B was well liked by the professionals who came in contact with her and they were committed in their involvement in trying to help her.   This SCR has not found that there were any occasions when procedures were not followed or legal requirements not addressed which adversely impacted the delivery of care and services to B. 9.3 Studies have shown that “most adolescent suicides are unplanned and that other studies have found that only 25% of completed suicides by adolescents show some evidence of planning”27.  In the way that B presented on the evening of the 14th April 2013, there was no immediate indicator that she was contemplating suicide. 10. Areas for learning and development NB: It will be the Hertfordshire Safeguarding Children Board to decide whether and how to implement the areas for learning and development identified below. 10.1 Whilst not significant to the outcomes for B, if information is not promptly transferred about pupils at the time when they move schools, particularly when there are welfare concerns, then the new school’s ability to address any safeguarding concerns or to meet the pupil’s academic, social and emotional needs could be compromised.   10.2 There should always be consideration of the need to make contact with Hertfordshire Children’s Services when a young person presents with significant mental ill-health, especially in relation to self-harming and where there are concerns about the impact the family dynamics may have on the young person in terms of any risk or protective factors.   This contact should include information gathering and discussion about whether there is a need to make a referral and how a full psychosocial assessment can be undertaken.   10.3 Hertfordshire Children’s Services should review its approach to dealing with notifications that children are likely to be detained by a health authority for at least three months.  These are received under section 85 of the Children Act 1989.    10.4 For Community Treatment Orders in respect of young people to be as effective as possible, formal consideration should always be given to the details of the order being shared with those agencies providing significant services to the young person within the community, including schools and colleges which they attend.  10.5 It is important that A&E departments record decisions and recommendations made in respect of a young person’s attendance with mental health issues, to ensure records are available to support future treatment decisions and for reference if there are repeat A&E attendances.   27 Deliberate Self-Harm in Adolescence- Fox, C and Hawton, K – 2004 – Jessica Kingsley Publishers. 26                                                             HSCB – Serious Case Review re B – Overview Report July2014 10.6 The recommendations and actions identified in Care UK own internal investigation contain significant learning for other similar establishments.  The Hertfordshire Safeguarding Children Board should take the necessary action to ensure that they are brought to the attention of such establishments and that the LSCB in which Care UK is situated is made aware of these recommendations in order that their implementation can be monitored.  10.7 The findings from this SCR and the areas for learning and development need to be disseminated to relevant professionals in Hertfordshire working with young people with serious mental ill-health, and with the staff and management of Care UK clinic. Ron Lock                      27  HSCB – Serious Case Review re B – Overview Report July2014  Appendix 1  The Serious Case Review Process 1. The HSCB chose to use a learning model to undertake the review consistent with the principles in the government guidance.   This model is referred to as a Partnership Learning Review, and formed the basis of the work of the SCR and is attached as an appendix to this report.  2. An independent Lead Reviewer, Ron Lock, was appointed to lead the SCR and to compile the Overview Report.   Ron Lock has considerable experience in safeguarding children and young people, including involvement in SCRs in other parts of the country, and had no connection in a professional capacity with the management of this case within Hertfordshire.  3. Senior managers from Hertfordshire were appointed to be part of the SCR Team, whose role was to assist with the scrutiny and analysis of professional practice in the case.  They had had no direct involvement in the case and were the:  -   Named Nurse for Safeguarding Children, Hertfordshire Community NHS Trust -   Head of Child Protection, Children’s Services, Hertfordshire County Council (later replaced for final meeting by the Service Manager North Hertfordshire and Stevenage, Hertfordshire Children’s Services. -   Child Psychiatrist and Named Doctor for Safeguarding, Hertfordshire Partnership University NHS Foundation Trust -   Business Manager, Hertfordshire Safeguarding Children Board  4. The SCR Team met on three occasions, chaired by the independent lead reviewer, in order to progress the SCR and to provide comment in respect of draft Overview Report.  The independent HSCB chair was appraised of progress of the SCR and attended two of the SCR Team meetings to contribute to the analysis of practice.  Members of the SCR team were also very active in their contribution to the two one-day Learning Events which were conducted with frontline practitioners and their line managers.   These meetings were held in order for as many of the practitioners and line managers who had worked with the family as possible, to contribute to the SCR team’s understanding of the detail of the work that had been undertaken with the family and to contribute to the analysis of professional practice.    The local agencies who had involvement with the family and who were represented by these professionals at the Learning Events, were:   - Cafcass - West Herts Hospital NHS Trust - Hertfordshire Partnership University Foundation Trust  - Hertfordshire Constabulary - Independent School (first school) - Hertfordshire Secondary School (second school) - Specialist In-Patient Clinic (for eating disorders) 28  HSCB – Serious Case Review re B – Overview Report July2014 - Solicitor (involved in early court proceedings in respect of contact and residency of the children) - Hertfordshire Children’s Services (Targeted Youth Support Services) - Children and Adolescent Mental Health Services (CAMHS)  5. The outcome from these Learning Events, which were chaired by the Lead Reviewer for the SCR, was clarification of the factual details of the work undertaken with the family as well as verbal and written contributions to the analysis of practice which in turn informed the key lessons learned from the work undertaken with this family.   The findings from these Learning Events have been included within the body of the report in terms of both the factual and analysis components.   Additionally to ensure greater understanding of particular parts of the work with the family, the Independent Author spoke individually with some of the practitioners and managers.  6. At the outset of the SCR process, detailed chronologies were requested from all of the involved agencies as identified above, of their involvement with the family from October 2010 which reflected the time when it was understood that Young Person B first self-harmed.  Each person completing the chronologies (the Individual Agency Representative) was also asked to complete an additional summary of commentary and analysis of the professional practice within their agency.   They also completed a separate document to identify any organisational or contextual factors which may have impacted on the work with the family.   Relevant professional letters, e-mails and reports were also viewed as part of the SCR process, and a Serious Incident Investigation Report written after the death of Young Person B to review what transpired at the in-patient clinic, was also considered in detail.   Furthermore, the Targeted Youth Support Services decided to conduct an Individual Management Review for their own purposes of learning, which was quite separate from the SCR process, although it was nevertheless viewed as part of the work of the SCR team.   All of this material was collated and reviewed by the SCR Team, and the factual contents of the chronology were fully shared with all attendees at the Learning Events.  7. B’s parents were separately interviewed by the Lead Reviewer and the HSCB Business Manager, her father once and her mother and step father were seen on two occasions.   E-mail and telephone contact also took place in order to check on facts and opinions as the SCR progressed.  In this way, both natural parents have been actively involved in the process.   Their contributions to the SCR have been included and identified within the body of the report where appropriate. __________________________________________________________ 29       Board Response to Serious Case Review - Young Person B  Introduction  The case of Young Person B, a 17 year old girl, was referred to the Hertfordshire Safeguarding Children Board (HSCB) in April 2013.  The girl had been diagnosed with an eating disorder in 2012 which had resulted in her being detained under the Mental Health Act in a clinic outside Hertfordshire which specialised in managing eating disorders.  Whilst detained, she committed suicide in that clinic.  The national guidance for carrying out case reviews in (Working Together to Safeguard Children 2013) specifically requires that a Serious Case Review (SCR) is carried out when a young person dies while being detained under the Mental Health Act.  In keeping with this guidance, Phil Picton, Independent Chair of HSCB commissioned an independent lead reviewer, Ron Lock, to complete a SCR for the case. His SCR Report was formally accepted by the Strategic Board of HSCB at its meeting on 23rd July 2014.  The purpose of the SCR has been to investigate the circumstances of the case and to identify any areas for learning and development which would benefit the services provided by agencies to vulnerable children and young people. The Working Together guidance requires that SCR reports are published together with the Board’s response to the report.  This document is the Board response to Young Person B’s SCR.    The detailed process of the investigation carried out by Ron Lock is included as an Appendix at the end of the SCR report. In addition to professionals and managers from a number of agencies, B’s mother, father and stepfather contributed significantly to the development of the report and its areas for learning. The Board wish to thank them for their cooperation and contributions during a particularly difficult time. Since completion of the report, Young Person B’s mother has raised a number of concerns about the accuracy of the report as she disagrees with some of the comments and conclusions reached by the reviewer. These have been considered by the Independent Chair of HSCB and discussed with Board members but they are not considered to justify alteration to the report or reinvestigation of the case. It is Young Person B response to findings report final - Jan 2015   however, pointed out that where the phrase “family sessions” is used in the report for meetings between Young Person B and professionals in the residential clinic, these meetings did not involve B’s mother.  In addition to the SCR investigation, the Coroner for the district in which B died, held an inquest into her death.  This inquest took place over a number of days with a jury and legal representation. Before the inquest, the coroner and parties involved were provided with the draft version of the SCR report to assist in the hearing.  The finding of the coroner was that B had intentionally ended her life and his verdict was ‘suicide’.  In reaching the verdict, neither the coroner nor the jury made any adverse comment about the involvement of agencies, however the Coroner has written a formal letter to Care UK, the company which manages the clinic, asking them to require all staff to routinely carry ligature cutters to enable speedy assistance if there are future attempted hangings in the clinic.  Section 9 of the SCR report starting on page 25, states that “This SCR has not found that there were any occasions when procedures were not followed or legal requirements not addressed which adversely impacted the delivery of care and services to B”.  Section 10 of the SCR Report (page 26) summarises seven ‘areas for learning and development’ which have become apparent during the investigation.  The Board’s response to each of these is set out below following each finding. The response to Findings 2 and 5 is contained in one section as the actions to address them complement one another.  Findings and the Board’s Response  Finding 1: “Whilst not significant to the outcomes for B, if information is not promptly transferred about pupils at the time when they move schools, particularly when there are welfare concerns, then the new school’s ability to address any safeguarding concerns or to meet the pupil’s academic, social and emotional needs could be compromised.” (Young Person B SCR Report, para 10.1)  Board Response to Finding 1:  Young Person B response to findings report final - Jan 2015   B attended two schools during the period of the review, firstly an independent school and then a state secondary school. As set out in the report, the first school did not effectively transfer information about B’s health to the second school when it was requested. Within a few days of starting the second school, B was detained under the Mental Health Act and did not go back to the school for some months.  Owing to this detention, the lack of effective information sharing on this occasion did not affect her care. However, it was a potential problem for B’s care and anecdotal evidence provided to the Board by other schools suggests that difficulties in passing information between schools about transferring pupils’ health and welfare is not limited to this particular case.  Without such information sharing, there is a risk that pupils will not be appropriately safeguarded and that schools may fail to fulfil their obligations under the Education Act.  The Board has been assured that the two schools involved with B have both changed their approach to requesting and supplying such information as a result of this case.  However the lessons need to be learned across all schools in Hertfordshire. In order to do that the Director of Children’s Services is discussing this finding with the Head Teachers’ Social Care Reference Group which she chairs.  The Group, which includes Heads from a wide range of schools, is being asked to identify improvements to the systems used by schools to manage such information transfers.  The Director of Children’s Services is also ensuring that the circumstances of the case and the need for effective sharing of the health and wellbeing information about a child at the time they transfer between schools is included in training and briefings for head teachers and other relevant members of school staff. This is being done through the existing arrangements for communications with head teachers on key issues.  In doing this, schools will be referred to the Hertfordshire Children’s Services document, ‘School Safeguarding Practice Guidance on Pupil Safeguarding Records’ which is available via the Hertfordshire Grid for Learning.  Whilst these guidelines are already included in the training for school’s ‘Designated Safeguarding Person (DSP)’, this case will be used to highlight the potential risks of not following the guidelines.  All training and resources including a termly newsletter for DSP’s are available to all schools in Hertfordshire, including those in the independent sector.  Monitoring and Evaluation of the Implementation of the Response to Finding 1  Young Person B response to findings report final - Jan 2015   Schools are supported in assessing their own effectiveness by a range of audit tools provided by Hertfordshire Children’s Services which enable them to monitor their safeguarding provision and to support their statutory requirement to provide a regular safeguarding report to their governing body.  This is further supported by training for governing bodies on safeguarding issues.  HSCB will require an update from Children Services during 2015 to assure it that these actions have been completed.  It will then consider what means is most appropriate to collect information from schools to ensure that the transfer of information between schools on pupils health and wellbeing is taking place effectively.     Finding 2: “There should always be consideration of the need to make contact with Hertfordshire Children’s Services when a young person presents with significant mental ill-health, especially in relation to self-harming and where there are concerns about the impact the family dynamics may have on the young person in terms of any risk or protective factors.   This contact should include information gathering and discussion about whether there is a need to make a referral and how a full psychosocial assessment can be undertaken.” (Young Person B SCR Report, para 10.2)   and  Finding 5: “It is important that A&E departments record decisions and recommendations made in respect of a young person’s attendance with mental health issues, to ensure records are available to support future treatment decisions and for reference if there are repeat A&E attendances.” (Young Person B SCR Report, para 10.5)   Board Response to Findings 2 and 5:  Finding 2 highlights an issue for NHS service providers and particularly Accident and Emergency Departments (A&E).  Finding 5 is specifically about attendances at A&E. They are jointly responded to because of this overlap.  Young Person B response to findings report final - Jan 2015   Hertfordshire Partnership University NHS Foundation Trust (HPFT) provides specialist mental health services for children and young people (CAMHS) within the County.  It works closely with hospitals, A&E departments and other practitioners to ensure that patients with mental health needs are effectively safeguarded.  In doing this, it is usually the first specialist service to deal with mental health patients.  The Managing Director of CAMHS has initiated an action plan to address Findings 2 and 5. The plan focuses on: • ensuring that whenever CAMHS professionals are approached to consider diagnosis and treatment for young people, they include the family context of the young person and the potential benefit of psychosocial assessments in their deliberations, • changing policies to ensure that referrals to Children’s Services are proactively considered and that this consideration and resulting decision is recorded. • A&E Departments improving recording when decisions are made about a young person who attends with mental health issues, so that better information is available if the young person re-visits A&E.  Monitoring and Evaluation of the Implementation of the Response to Findings 2 & 5.  The action plan will be monitored by CAMHS’ senior management team and hospitals will be required to confirm that they have implemented the changes and briefed staff on what is expected.  Progress on the overall action plan will be monitored by the two Hertfordshire Clinical Commissioning Groups and will be reported to HSCB in February 2015.  At that time the Board will identify any further auditing or sampling work needed to ensure the system is effective.   Finding 3: “Hertfordshire Children’s Services should review its approach to dealing with notifications that children are likely to be detained by a health authority for at least three months.  These are received under section 85 of the Children Act 1989” (Young Person B SCR Report, para 10.3)   Board Response to Finding 3:  Young Person B response to findings report final - Jan 2015   Hertfordshire County Council Children’s Services has reviewed the way it responds to notifications under section 85.  These notifications are now being proactively considered by its Targeted Advice Service (TAS) with the purpose of effectively identifying if a Young Person is in need of support services.  In addition, the circumstances of this SCR have been included in training for staff within TAS so that they fully understand the rationale for the new approach.  Young Person B response to findings report final - Jan 2015   Monitoring and Evaluation of the Implementation of the Response to Finding 3  During February 2015, HSCB will receive a report on the numbers of section 85 notifications and the action taken in response to them.   Finding 4: “For Community Treatment Orders in respect of young people to be as effective as possible, formal consideration should always be given to the details of the order being shared with those agencies providing significant services to the young person within the community, including schools and colleges which they attend.” (Young Person B SCR Report, para 10.4)  Board Response to Finding 4:  Hertfordshire County Council Health and Community Services (HCS) are responsible for the procedures around Community Treatment Orders (CTOs).  They employ the Approved Mental Health professionals (AMHPs) who provide the ‘second opinion’ whenever a CTO is being considered as a means of re-introducing a patient back into their community.  The Director of HCS is implementing an action plan to ensure that AMHPs prompt staff to involve all relevant agencies, including schools and colleges, in implementing the plans for CTOs.  This includes sharing appropriate information about the patient’s needs and care plan.  In doing this the AMHP Operational Group will specifically consider this SCR report.  In considering the report and particularly this finding, HCS has suggested to the Board that the issue of involving schools and colleges in supporting students who are subject to a Community Treatment Order is wider than merely Hertfordshire.  As a result, the Board will share the learning on the involvement of schools and colleges in Community Treatment Orders more broadly through such organisations as the Royal College of Psychiatrists. Young Person B response to findings report final - Jan 2015   Monitoring and Evaluation of the Implementation of the Response to Finding 4  The implementation of the action plan will be overseen by the AMHP Operational Group in Hertfordshire.  That Group will report the progress on the action plan to HSCB in February 2015.  Regarding the wider sharing of the learning from this finding, the Board will receive a report from its Business Manager in February 2015 explaining how that learning has been disseminated outside of Hertfordshire.   Finding 6: “The recommendations and actions identified in Care UK’s own internal investigation contain significant learning for other similar establishments.  The Hertfordshire Safeguarding Children Board should take the necessary action to ensure that they are brought to the attention of such establishments and that the LSCB in which the clinic is situated is made aware of these recommendations in order that their implementation can be monitored” (Young Person B SCR Report, para 10.6)  Board Response to Finding 6:  Clinics such as the one attended by B have patients placed with them by commissioners working on behalf of NHS England.  A director from the South Midlands and Hertfordshire Area Team of NHS England sits on the HSCB Strategic Board.  Together with the Chair of the Board, this representative is writing to all other NHS Area Teams which commission such specialist services.  This letter is giving a synopsis of the case, the key findings of the SCR, the learning identified by Care UK in its internal report and the comments of the coroner about the benefit of carrying ligature cutters in such residential facilities. The Area Teams are being asked to inform their specialist providers of the learning so that others can take into account the issues raised by B’s case and to ensure that the appropriate issues identified in the case is included in commissioners monitoring of contracts with clinics.     The letter will also be copied to the CQC (the inspection organisation for such clinics) so that CQC can consider the learning as it develops its own approach to inspection and standards in premises providing care.  Young Person B response to findings report final - Jan 2015   The Board has already discussed the case with the Independent Chair and Business Manager of the Local Safeguarding Children Board for the area where the clinic is located.  It is providing a copy of the SCR report and this response to that Chair for his information and to enable that Board to ensure that both the recommendations contained in Care UK’s internal report and the Coroner’s letter about staff carrying ligature cutters are effectively implemented.  Monitoring and Evaluation of the Implementation of the Response to Finding 6  The circulation of the letters and any responses will be reported to the Board in February 2015.  Finding 7: “The findings from this SCR and the areas for learning and development need to be disseminated to relevant professionals in Hertfordshire working with young people with serious mental ill-health, and with the staff and management of clinic.” (Young Person B SCR Report, para 10.7)  Board Response to Finding 7:  The SCR report is being used by the Board to develop both briefing and training material for the children’s workforce across the County.  The training sub-committee of the Board is developing a plan to ensure that this is done comprehensively and delivered effectively.  In some circumstances this will be by material solely focusing on this case and in others it will be incorporated into existing learning programmes which focus specifically on mental health issues or ‘lessons’ from case reviews.  Both of these topics feature regularly in the Board’s own multi-agency training.  The SCR Report and Board Response will be sent to the NSPCC for inclusion in their national repository of SCRs so that it is available for wider analysis and research particularly by those researching similar cases and developing new initiatives for young people’s health and welfare.  Monitoring and Evaluation of the Implementation of the Response to Finding 7  The training sub-group of HSCB will report on the progress of the plan to the Board in February 2015.  The outcome of this briefing and training work in affecting the Young Person B response to findings report final - Jan 2015   actions of professionals in carrying out their work will be included in the on-going programme of training evaluation which is reported annually to the Board.    Conclusion  The Case Review Group of HSCB will receive a full update on the progress on these findings in February 2015 and the following Strategic Board meeting will receive a summary report from that Group.  An overview of the progress will be published in the HSCB Annual Report for 2014 -15 by the Autumn of 2015.  Young Person B response to findings report final - Jan 2015 