Suicide of a 17-year-old boy in February 2013. Child F was looked after in supported accommodation at the time of his death. He had previously been a child in need and had moved in to supported accommodation following deterioration in his behaviour and mental health and increasing problems with family relationships. Mother had a history abusive relationships. Child F had a history of: mental health problems; substance misuse; periods of non-compliance with medication and non-engagement with support services and sudden fluctuations in mood and behaviour, especially towards family members. Identifies issues with the assessment, review and management of risk posed to and by Child F; the assessment of Child F's complex needs; the threshold criteria for social care intervention; and inter-agency understanding of child protection processes, medical terminology and the management of domestic abuse concerns. Sets out key findings using a systems model based typology developed by Social Care Institute for Excellence (SCIE) and puts forwards recommendations. Recommendations include: the safeguarding children board to ensure there are clear multi-agency plans for the management of homeless 16-17-year-olds and to notify the Department of Education about concerns that unregulated service providers are accommodating vulnerable young people; schools to develop use of the Common Assessment Framework (CAF) for permanently excluded pupils; and mental health services to ensure transition plans include provision of a consistent person to support the young person in the transfer from children's to adult services.
      
 Title:  Serious case review: Child F (Case B13): Overview Report LSCB: Bury Safeguarding Children Board Author: Dennis Charlton Date of publication: 2013  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.                           1   Bury Safeguarding Children Board  Serious Case Review  Child F (Case B13)   SERIOUS CASE REVIEW  OVERVIEW REPORT  Report Author:  Dennis Charlton Date:    21 August 2013   Signed:  Date: 21/08/13    Commissioned by: Bury Safeguarding Children Board  2 I can confirm that the Serious Case Review on Child F (Case B13) was submitted to the Extraordinary Bury Safeguarding Children Board (BSCB) meeting on Wednesday 21 August 2013.  BSCB members agreed to accept the Serious Case Review Overview Report and multi-agency action plan for submission.  I can confirm that BSCB endorse the recommendations made in the overview report and that the BSCB Executive Group will monitor their implementation.                       Gill Rigg       Independent Chair of BSCB   Signed: Date: 21 August 2013  3 CONTENTS CONTENTS ......................................................................................... 3  1.  INTRODUCTION ............................................................................. 4  2. TERMS OF REFERENCE .................................................................... 4  3. INDEPENDENCE OF THE SERIOUS CASE REVIEW ............................... 5  4. MEMBERSHIP OF THE SCR PANEL ..................................................... 6  5. METHODOLOGY ............................................................................. 7  6. FAMILY STRUCTURE ....................................................................... 9  7. NARRATIVE ................................................................................... 9  8. CRITICAL CASE ANALYSIS ............................................................. 45  9.   SUMMARY AND CONCLUSION ........................................................ 77  10. OVERVIEW REPORT RECOMMENDATIONS ....................................... 83  11. INDIVIDUAL AGENCY RECOMMENDATIONS ..................................... 84  APPENDIX 1 - RESEARCH SOURCES ..................................................... 89  APPENDIX 2 - MULTI AGENCY ACTION PLAN – CASE B13 (Child F) .......... 90          4 1.  INTRODUCTION 1.1 This Serious Case Review Overview Report is produced in accordance with the Bury Safeguarding Children Board procedures for conducting a Serious Case Review (SCR).   1.2 The reason for this Serious Case Review is because of the death of 17-year old young person (Child F). The young man was looked after by the local authority and placed in supported accommodation for young people aged 16 years and over. On the 3rd February 2013 Child F went missing. He was later found on the 4th February 2013 and had used a cord to hang himself.  1.3 Bury Safeguarding Children Board Serious Case Review Sub-Group met on the 13th February 2013 and made a recommendation to the Chair of Bury Safeguarding Children Board that the case met the criteria for a Serious Case Review. The Chair of Bury Safeguarding Children Board confirmed the decision to undertake a Serious Case Review.  1.4 At the point of completion of the Serious Case Review, the Coroner had adjourned the inquest. There were no other parallel processes.   2. TERMS OF REFERENCE 2.1 The time period over which events have been reviewed is the 1st September 2006 to the 4th February 2013. This time period covers the main agency involvement with Child F and his family from the point that he started attending secondary school.  2.2 The SCR panel agreed the following to be the key lines of enquiry for this review, but also requested that any other relevant information outside of the key lines of enquiry (e.g. historical information on the family to give context/background information) is included:   5 1. How did your agency collaborate and work with other agencies to undertake the following in relation to Child F: •    Assess risk •    Assess need •    Put services into place •    Review and manage risks •    Measure outcomes  1.1 How was the relationship between Child F and MF and family assessed?  1.2 What consideration did your agency give to the impact of domestic abuse, parental substance misuse and adult offending on the wellbeing of Child F?  1.3 Was information shared appropriately with other agencies and was information shared with your agency appropriately by other agencies?  2. What approach does your agency have to address the issue of young people not engaging/becoming disengaged with your service?  3. What indicators of self-harm/suicidal behaviour were presented and were these fully recognised, assessed and acted upon?  3. INDEPENDENCE OF THE SERIOUS CASE REVIEW  3.1 The author of the SCR Overview Report was Mr Dennis Charlton. He is an Independent Consultant in Child Protection with substantial experience in safeguarding children. Mr Charlton is a former Assistant Director of a local authority Children’s Service. He has undertaken a number of Serious Case Reviews both as an Overview Report author and also Chair of SCR Panels. He is accredited to undertake SCRs using  6 the Social Care Institute of Excellence (SCIE) systems approach. He holds a professional qualification in Psychiatric Social Work.  3.2 The Chair of the Serious Case Review Panel was Ms Hyde. Ms Hyde is Director of The Foundation for Families; a not for profit community interest company established in 2010.  Ms Hyde was CEO of Calderdale Women Centre for 14 years (between 1994 and 2009) and developed nationally acclaimed, high quality services and support for at risk women and families. Ms Hyde is currently working with local safeguarding children boards and their partners to improve safeguarding outcomes for children and young people living with domestic violence, substance misuse and parental mental illness and to support the development of a multi agency response to children and young people at risk of sexual exploitation.  Ms Hyde is currently the Independent Chair of several Serious Case Reviews and has designed and delivered three innovative Learning Reviews on behalf of local safeguarding children boards.  3.3 All of the Individual Management Reviews were undertaken by experienced managers, who had no direct management responsibility for the case.  4. MEMBERSHIP OF THE SCR PANEL  Ms Hyde Independent Chair SCR Panel  Service Manager, Safeguarding Unit Children’s Services, Bury Council  Acting Operations Manager, Greater Manchester Probation Trust  Development Officer, Bury Safeguarding Children Board  Lead Officer, Safeguarding for Schools & Extended Services  Detective Inspector, Serious Case Review Team, Public Protection Division, Greater Manchester Police  Designated Nurse, Bury NHS Clinical Commissioning Group  Specialist Nurse-Safeguarding,  7 Community Services Bury, Pennine Care Foundation NHS Trust  Designated Doctor, NHS Bury Clinical Commissioning Group  Child Safeguarding Lead, Pennine Care Foundation NHS Trust  Safeguarding Manager, Bury Adult Care Services  Children’s Services Manager, Barnardo’s  CAMHS Directorate Manager, Pennine Care Foundation NHS Trust  4.1 The Chair of Bury Safeguarding Children Board is Ms Gill Rigg.  4.2 The Overview Report author attended the SCR Panel meetings as an observer and to clarify any issues arising from the Individual Management Review Reports.  4.3 The SCR Panel received administrative support from a Senior Administrative Support Worker  5. METHODOLOGY 5.1 The Overview Report was undertaken following a systems approach. Analysis of the Individual Management Reviews explored significant events, for themes, that indicated either strengths or weaknesses in multi-agency safeguarding systems.  Individual Management Reviews were submitted by:  Greater Manchester Police Bury Children’s Services Social Care (including Leaving Care Service and Youth Offending Team) Pennine Care NHS Foundation Trust – Community Services, Bury Barnardo’s Pennine Care NHS Foundation Trust – Mental Health Services (including CAMHS and Early Intervention Service) Bury Children’s Services Learning Division (covering the Schools) Supported Accommodation Provider  8 GP Connexions  5.2  Overall the Individual Management Reviews (IMR) were comprehensive and of a good quality. The exception to this being the report submitted by the Supported Accommodation Provider, which was not completed adequately despite encouragement and offers of support from the Serious Case Review Panel. Regrettably the IMR from the Supported Accommodation Provider failed to follow the terms of reference of the Serious Case Review and as such the contribution from this agency was of limited value.  5.3  Specific Issue Reports were also requested from: Greater Manchester Probation Trust Manchester Mental Health and Social Care Trust Greater Manchester West Mental Health NHS Foundation Trust (The Adolescent Forensic Service)  Pennine Acute Hospitals NHS Trust Early Break (a service for young people engaged in substance misuse) Adult Care Services Transition Team  5.4  The Overview Report was written with the intention that it would be suitable for publication without any redaction.  It was also written with the intention that it should be used to enhance learning and improve practice.  5.5 MF was informed about the decision to undertake a Serious Case Review. She did not wish to contribute at this stage but asked to be informed about the findings.    9 6. FAMILY STRUCTURE Anonomysed name Relationship to Subject Address Child F subject Address B MF  Mother of subject Address A FF Father of subject Address C MP1 Father of sibling FS1  Address D MP2 Father of siblings FS2 and FS3 Address A FS1 sibling of subject Address A FS2 sibling of subject Address A FS3 Sibling of subject Address A   7. NARRATIVE  7.1  Child F started at High School 1 in September 2006. It was recorded that he appeared to make a good start.   7.2 There had been some previous agency involvement when the Health Visitor met with MF in August 2005 (the family had recently moved into the area). MF reported difficult relationships with men throughout her adult life. There was no contact or relationship between Child F and FF, although he had enjoyed a good relationship with MP1 until they divorced.  Child F was said to exhibit extreme behaviour including angry outbursts towards his sibling (FS1). He was also said to have expressed wishes to harm himself. MF suggested that “Psychology Services” had been involved in the past.   10 7.3  MF also reported incidents of domestic violence and said there had been separations between herself and her partner (MP2), because of violent incidents. She said that she had previously lived in a refuge for three months but had found it too difficult and returned to MP2. The current situation was that MP2 visited the family home frequently and MF felt that their difficulties could be resolved.  7.4  There were some incidents of physical aggression at High School 1 reported in October 2006 and school identified support services through peer support, and outreach support for anger management. By the end of the year Child F had a high level of attendance but his behaviour was seen as problematic. There were various interventions through fixed term exclusions, referrals for individual counseling to Relateen (a counseling service), and for anger management. Child F also spent time in the school Inclusion Unit.  7.5  There were indications from GP records that MF had received surgery on her nose in June 2008, following two assaults where her nose had been broken. The most recent assault appears to have been around June 2007. Both assaults were caused by her partner (MP2).  7.6  In May 2009 Child F was arrested and cautioned for possession of a small quantity of cannabis.  7.7 Child F was suspended from High School 1 in September 2009 after an incident when he seriously physically assaulted another pupil. This became a permanent exclusion, after the incident had been investigated.  7.8  In October 2009 there was a referral to the Youth Inclusion Support Panel YISP) from The Neighbourhood Anti Social Behaviour Team. This was in relation to neighbour nuisance. The work was aimed at early intervention with Child F, who had been identified as a child showing early signs of anti social behaviour. After some early difficulties in engaging with the family, MF expressed her concerns  11 about Child F, that she was frightened of his aggressive behaviour that seemed worse when he had been drinking.  7.9  Much of the focus of the YISP intervention was on anger management and assisting Child F to integrate with his peers.  7.10  Child F was referred to Bury Child and Adolescent Mental Health Services (CAMHS), by the Education Welfare Officer; the referral highlighted problems with anger and was related to his exclusion from school. MF was sent a letter from CAMHS confirming the referral and requesting that she contact CAMHS. This was essentially an “opt in” mechanism in place at the time.  7.11  An initial appointment was offered by CAMHS in December 2009. Records indicate that this appointment was not attended. A further letter from CAMHS was sent in January 2010, requesting MF to re-book an appointment.  7.12  In January 2010, Child F was one of a group of juveniles who were stopped and advised by the Police regarding anti-social behaviour. No further action was taken.  7.13  Child F and MF attended an initial appointment with CAMHS on the 9th March 2010. Key issues that emerged were: • Anger outbursts since 4-5 years of age • Numerous house moves • Breakdown of MF’s relationship with MP2 • MP2 imprisoned for drug offences • No contact with FF The main focus of work was on anger management and building self-esteem using a life story approach. There was also to be liaison with the Youth Inclusion Support Panel worker.  7.14  School health records indicate that Child F had demonstrated several violent outbursts in school.   12  7.15  On the 15th March 2010 MF contacted CAMHS to inform them that Child F had disclosed that he had experienced auditory hallucinations (hearing voices). He had not mentioned it at a recent appointment with CAMHS because he “had felt daft”. This led to an early follow up appointment on the 26th March 2010.  7.16  On 25th March 2010 Child F had a medical assessment by the Youth Offending Team Nurse. It was noted that he said that he heard voices telling him to hurt people and that he was waiting a Child and Adolescent Mental Health (CAMHS) appointment.  7.17  Child F was seen at CAMHS on the 26th March 2010. The review concluded that a referral would be made to the mental health, Early Intervention Service because of concerns about possible psychosis.   7.18  On the 13th April 2010 the Youth Offending Team (YOT) support worker wrote to High School 2 outlining serious concerns that Child F had disclosed that he was hearing voices that were telling him to harm people and seeing graphic images in his head. The support worker concluded that the concerns were such that Child F was not suitable for YISP intervention. The case was closed on the 3rd June 2010, with the YISP Support Worker sharing these concerns with CAMHS. MF had also complained to school that Child F had not received help with anger management.  7.19  An assessment by the Early Intervention Service, in mid April 2010, concluded that although Child F does experience pseudo hallucinations, he was not suffering from a psychotic illness and the voices were probably generated inside his own head. It was also felt that his paranoid thinking had increased since a physical assault, in a park, in 2008. This was viewed as a significant, traumatic event. Child F was discharged from the Early Intervention Service. This information was passed on to CAMHS.   13 7.20 There were a series of three CAMHS appointments with Child F at school during July 2010, and one appointment with CAMHS at the clinical centre. It was recorded that MP2 had a night at home (presumably on release from prison) and Child F was pleased to see him.  At this stage Child F was attending school 2. There were a number of incidents self reported by Child F where he had shown anger and aggression towards staff and peers.  GP records also noted Child F having a “moderate depressive disorder”.  7.21  In early July 2010 Child F was reported missing from home by MF following an argument between them. Child F had spent the previous night at a friend’s home but had not returned home that evening as expected. This appears to have been information that was also passed to Children’s Social Care by the Police. It was noted in Children’s Social Care records that the information was for Barnardo’s, presumably because of their role in following up children who had been reported as missing from home.  7.22  As a response to this “missing from home” incident, Barnardo’s sent a letter to the family home offering Child F an interview, but there was no response and the case was closed.  7.23  There was another “Missing From Home” referral to Children’s Social Care on the 12th August 2010 referred to in the Children’s Social Care IMR. This was not recorded by any other agencies and may be a reference to the incident in early July. It appeared that Child F had returned home and said that he had slept in the garden, refusing to say where else he had been. The referral stated that there was “no risk of self-harm or suicide”. The referral was closed by Children’s Social care with no further action.  7.24  Correspondence on GP records suggest that MF had, at this stage, requested her GP to seek a second psychiatric opinion in relation to Child F.   14 7.25  Child F was seen by a Consultant Child and Adolescent Psychiatrist in mid December 2010, because of concerns expressed by the CAMHS practitioner working with Child F that he was describing hearing voices (a male voice speaking to him directly). The voice was instructing him to harm himself and others.  Child F also disclosed that MP2 hit him once and threw him into a window. This was recorded in CAMHS documentation as being “father” but the dates suggest that it must have been MP2.  Concerns about the safety of siblings were recorded because of the nature of the hallucinations. Child F was referred to the Mental Health, Early Intervention Team. A physical health assessment had excluded physical causation of his presentation with hallucinations. MF was advised to continue high levels of supervision and contact CAMHS if she had concerns. There is no indication that the alleged physical assaults were referred to Children’s Social Care.  7.26  Child F was seen again by CAMHS (Consultant Child Psychiatrist) in mid January 2011. He appeared “no worse” and medication had helped with his sleeping. He was still having command hallucinations telling him to hurt others.  7.27  There was a home visit by the Early Intervention Team on the 20th January 2011. The trauma of the attack on him in 2008 was considered, by the family, to be a significant factor. Accepted by the Early Intervention Team for Cognitive Behavioural Therapy and referred to Psychologist for assessment of trauma. A further assessment home visit, on the 27th January 2011 looked at how Child F was coping with the voices he was hearing and what he thought it made him do.   7.28  Child F was sent home from High School 2 on two occasions in early February 2011 because of anger outbursts. On the 4th February 2011, Child F was reported to have experienced deterioration in his mental state. There is a report of him considering suicide by jumping off a  15 motorway bridge. He was saying that auditory hallucinations (second person command voice) were telling him to hurt himself.   7.29  There was a home visit by an Early Intervention Team practitioner on the 4th February 2011. Child F commented, “he felt that he might as well die to stop the pain”. Emergency support measures put in place to deal with the immediate position (In reach team, Emergency Duty Team).  There was a clinic letter from CAMHS (Consultant Child Psychiatrist) hypothesising that Child F may be experiencing drug induced psychosis.  7.30  On the 10th February 2011, Child F was admitted to a specialist mental health hospital unit, on an informal basis. He was continuing to hear both internal and external voices and was on medication for paranoia. It was alleged that he had pulled a knife on a younger brother but Child F denied this. Child F thought that people could read his mind and thought that MF wanted to get rid of him. It was recorded that over the next few days, Child F refused to see MF and MP2 (although MP2 was in prison at this time).  7.31  By the 14th February 2011, Child F was reported as being more settled in mood, although there were some residual psychotic symptoms. Child F indicated that he did not want to live at home when he was discharged. By the 25th February 2011 there were no longer any symptoms of psychosis. In early March 2011, Child F restarted school (High School 2) from the hospital unit.  7.32  On the 15th February 2011 there was a discussion between the Charge Nurse on the hospital unit and Children’s Social Care. Although the records are not explicit this seems to have been a preliminary discussion because discharge from the mental health unit was imminent. There was no one available from Children’s Social Care to attend a meeting on the unit planned for 21st February 2011. Minutes of the meeting were requested.   16 7.33  There was a written referral from the mental health unit to Children’s Social Care, dated the 17th February 2011, outlining that Child F was a patient on the Unit and had thoughts of harming others, including his younger brother FS1. This was essentially a safeguarding referral because of concerns about the safety of the siblings. The attached notes to the referral contains an action point that Children’s Social Care should be asked to provide home support or alternative accommodation. No action was taken by Children’s Social Care other than to record the information.  7.34  On the 2nd March 2011 the allocated social worker (SW1) attended a meeting at the mental health unit to discuss Child F’s discharge from hospital. It was noted that since admission Child F was still reporting he was hearing voices although no psychotic episodes have been witnessed by staff. Child F was refusing to return home to MF’s care. Child F was aggressive towards MF on the unit and had to be restrained to remain on the unit.  An Initial Assessment by Children’s Social Care was commenced following this meeting. It was noted that MP2 was in prison and that MF was expecting a baby in seven weeks.   7.35  There was an Initial Care Programme Approach (CPA) meeting on the 8th March 2011. These meetings are used to co-ordinate care and assess the needs of people with severe and enduring mental health problems. The meeting covered Child F’s history, health, housing situation, behaviour and mental health. Those attending the meeting were aware that Child F had reported hearing voices. Child F was offered Connexions support in school (High School 2).  There were some difficulties reported with Child F’s behaviour at school and MF also reported that she did not feel safe in child F’s presence.  7.36  A further Care Programme Approach meeting took place on the 15th March 2011 (Discharge Meeting). Key issues were Child F’s discharge from hospital and his unwillingness to return to the family home. On the 17th March 2011 the mental health unit informed the allocated social worker that Child F was being discharged to the care of his  17 uncle (MP2’s brother). Child F and MF were said to be happy about this arrangement. He was discharged on the 18th March 2011. There is no indication of any assessment as to the suitability of the uncle as a carer for Child F. It is unclear from the records exactly how long Child F stayed with his uncle, but the stay is unlikely to have been for longer than a few days.  7.37  The discharge letter from the Consultant Psychiatrist stated a diagnosis of a psychotic episode and also mixed disorder of Emotion and Conduct.  7. 38  Child F was seen in High School 2 by his Connexions Personal Advisor on the 24th March 2011. There was agreement to make a referral, known as a Central Point access referral, for alternative accommodation for Child F.  Much of the discussion had been about his unhappiness at home. At subsequent meetings with his Connexions Personal Advisor, Child F talked about the isolation he felt at home. There were also a number of alternatives explored in terms of accommodation.  Involvement by the mental health Early Intervention Team during this period in March 2011 also suggested there were ongoing behavioural problems at school.  7.39  A Care Programme Approach meeting (CPA) took place coordinated by CAMHS. Some of the key issues were: • CAMHS had made a decision to close the case • Child F was no longer taking medication • Continued support from Connexions and the Early Intervention Team  7.40  Continued difficulties were reported in High school 2 during these early stages, following discharge. He was seen in school by the Early Intervention Team practitioner on the 29th March 2011 and was reported as being more settled at school.   18 7.41  There were some difficulties in the Early Intervention Team practitioner engaging with Child F during April and May 2011. This seems to have been because of a mixture of examinations and also possibly because Child F was not enthusiastic about meeting. When he was seen in early June 2011 his mood was reported as fluctuating. By early June 2011 he was reported by the Early Intervention Team practitioner to be in a positive mood and rarely heard voices and had no suicidal ideation. It was also recorded that his mood seemed to fluctuate considerably between visits. He was described as being more settled with MF (it is unclear exactly when he had returned to the family home).  7.42  There was a Police referral to Children’ Social Care on the 20th June 2011. The Police had been called out to Child F’s school (High School 2) where he was lashing out at teachers and pupils and punching walls and doors. The referral stated that he does not get on with his MP2 who is on weekend release from prison. He was also said to be unhappy about MF’s new baby. Children’s Social Care did not identify any Child Protection issues. It was also noted that Connexions and a Mental Health Nurse were involved. The Police were informed that the referral did not meet the criteria for intervention.   7.43  During a home visit, on the 22nd July 2011, by the Early Intervention Team practitioner, Child F was reported as finding it hard to be at home, hearing voices telling him to harm others. Child F admitted to suicidal ideation although no intent was noted. One week later when a mental health review was held it was recorded that Child F was denying any psychotic symptoms. He was also being non compliant with medication. His mood was described as predominantly low.  7.44  At the mental health review, held on the 29th July 2011, attended by the Consultant Psychiatrist, Connexions worker and the Early Intervention Team practitioner. It was recorded that Child F was managing his thoughts and denied any psychotic symptoms. He  19 expressed a willingness to remain involved with the Early Intervention team but only through minimal visiting.   7.45  There was a Care Programme Approach meeting in August 2011 (probably 4th August 2011). It was reported that Child F was experiencing better family relationships, that he had joined a cage fighting club as an apprentice. (It should be emphasised that this was a legitimate sporting club activity). Child F was no longer taking medication and was not using drugs. The risk to himself and others was assessed as low.  7.46  Child F was reported missing from home by MF on the 5th August 2011. MF reported that her son was under the local mental health team and that he had voices in his head telling him to kill himself.  7.47  Later that day MF contacted the Police to report that Child F had returned home and was safe and well. He had apparently been with some friends.  Earlier in the day Child F had been seen by his Connexions Personal Advisor who reported that Child F was very angry and low, as his housing situation was not sorted. Child F reported that he was not sleeping or eating and was hearing voices. The Connexions Advisor contacted Children’s Social Care by telephone to confirm her actions had been appropriate.  At this stage it appeared that Child F was on a waiting list for a housing provider for accommodation.   7.48  Notes from the Early Intervention Team records state that Child F was willing to see the Locum Consultant Psychiatrist from Bury CAMHS on 1st September 2011. He denied any suicidal thoughts but still had thoughts of harming others.  7.49  There was considerable activity by the Connexions Adviser during September and October 2011 focused on facilitating accommodation for Child F and sorting out his benefits. Child F was attending his cage fighting apprenticeship on a daily basis.   20 7.50  MF contacted the Connexions Personal Advisor on the 7th November 2011 to inform them that Child F had “packed his bags and left home”. She was willing to allow him to return home and stated that nothing had happened to provoke his leaving.  7.51  Discussions between the Connexions Personal Advisor and the provider of the apprenticeship, suggested that Child F was unhappy because his “brother” had been drug dealing and MP2 had been home over the weekend, on release from prison, which had caused tension.  7.52  The following day, Child F presented at Connexions as homeless. There was some discussion with Children’s Social Care and the Housing Department, the outcome being that Child F would not be accommodated in the Crash Pad, as MF was willing to have him at home. The Connexions Advisor felt that the Crash Pad was not a suitable environment for Child F. The provider of the apprenticeship offered to accommodate him overnight as alternative arrangements could not be found.  7.53  This same debate continued the following day, with the same outcome, although there was seemingly a total family relationship breakdown, the Housing Department would not offer anything because MF was willing to have him back home. The discussions moved focus with the view that MF had stated that she was afraid of him therefore the Housing Department required a mental health risk assessment on Child F before they could consider possibilities of accommodation. The matter was eventually resolved with a risk assessment being provided by the Early Intervention Team and Child F was allowed to use the Crash Pad for the night.   Children’s Social Care records show that Child F was still at the Crash Pad on the 14th November 2011. It is not clear from the records how the placement was arranged. Children’s Social Care closed the referral on the 14th November 2011. The rationale being that Child F was settled at the Crash Pad and had support to ensure that his independence needs  21 were met. This approach by Children’s Social Care was clearly wrong and is commented on in detail in the Analysis section.  7.54  A response letter was received by Connexions from an Assistant Team Manager (Children’s Social Care) on the 15th November 2011. This was in relation to the telephone call from the Connexions Personal Advisor on 5th August 2011. The letter advised that an assessment under the Common Assessment Framework should be started. This suggests that Children’s Social Care did not consider the threshold for intervention as a child in need has been met. This was not an adequate response by Children’s Social Care and is discussed in detail in the Analysis section.  7.55  Child F was seen by his Connexions Advisor on the 15th November 2011. He reported a low mood and suicidal thoughts. He indicated that he intended to stay with maternal grandparents for a while. Child F was said to be negative about his relationship with MF.  7.56  During the latter half of November 2011 a new housing needs assessment was undertaken. There was also a violent incident at the Crash Pad, on the 21st November 2011, where Child F broke furniture and received a written warning about his conduct. There were also concerns expressed by the Crash Pad staff about his mood and not attending to his personal hygiene.  7.57  Child F was seen, on several occasions, throughout November 2011 by his Connexions Advisor. He was reported to be low in mood, missing his siblings and upset about the housing situation. He was reported as commenting that life was not worth living.  7.58  Information from Connexions records, in December 2011, suggests that Child F had been staying out a lot and was in arrears with his rent at the Crash Pad. Child F was also not taking his medication at this stage. By early December 2012 he agreed to go to his GP to restart medication for depression.   22 7.59  Child F failed to attend an appointment with the Early Intervention Team on the 7th December 2011, but did contact by telephone to discuss accommodation. It was noted that he was staying with MF. He was seen by the Early Intervention Team practitioner on the 12th December 2011. He was hearing a voice at this stage but refused hospital admission. An arrangement was agreed whereby he would stay at MF’s home during the daytime and sleep at the Crash Pad at night. Child F declined further visits from the Early Intervention Team practitioner, but agreed to telephone contact.  7.60  Child F was seen by Consultant Psychiatrist (CAMHS). It was recorded that his relationship with his family had broken down and he was living at the Crash Pad. He was diagnosed as suffering from a moderate depressive episode and commenced medication.   7.61  MF contacted the Police to report Child F missing on the 16th December 2011. He had disappeared after learning, from MF, that his mental health was to be assessed as an emergency case. She expressed concern about his welfare as he had been suffering from depression. He was considered to be high risk, as he had recently talked about voices telling him to kill himself. Details of the Police Report were referred on to the Police Public Protection and Investigation Unit, who in turn notified Children’s Social Care. This was dealt with by Children’s Social Care as a “contact” and closed with “No Further Action” required by Children’s Social Care. The rationale being that a Community Psychiatric Nurse was allocated to the case. Child F was taking medication and there were no child protection concerns. This was a very limited appreciation of “child protection” and is commented on in the Analysis section.  7.62  A meeting was held at Connexions to consider Child F’s accommodation needs. The Housing Department, Early Intervention Team and Connexions were in attendance. Discussions centered on the level of support Child F would require for his own tenancy. Given  23 the problems presented by Child F, the idea that he may be able to manage his own tenancy were unrealistic.  7.63  There were further contacts between Child F and the Early Intervention Team between mid December 2011 and mid January 2012. It was recorded that Child F remained well. There was also ongoing contact with Connexions who recorded that Child F had been staying out a lot, is unhappy at the Crash Pad and in rent arrears. He stated his intention of staying with grandparents over Christmas.   7.64  Child F self harmed by cutting on the 30th January 2012, and was admitted to a specialist mental health unit after being seen in A&E. He also disclosed to Crash Pad staff that he was hearing voices and described having very violent thoughts about hurting others. He was also said, by MF, to have been physically aggressive to her, when she was eight months pregnant.   7.65  By the 9th February 2012 there was no evidence of psychosis. There was a Care Programme Approach meeting at the hospital on the 10th February 2012. It was agreed that Child F could return to the Crash Pad. This accommodation was totally unsuitable and discharge to the Crash Pad should have been challenged.  Following a risk assessment, Child F indicated that, in the longer term, he wanted his own tenancy. MF had earlier reported that she felt Child F was relapsing because he was worried about coping independently. Home leave from the hospital unit was arranged and he was formally discharged on the 22nd February 2012. The diagnosis at this stage was of an Adjustment Disorder and Dissociative Symptoms. The auditory hallucinations were thought to be stress related rather than “frank psychotic symptoms”.  7.66  Ongoing contact with Connexions and the Early Intervention Team suggested that Child F was frustrated and deflated about progress with accommodation issues. There were also concerns about the strained relationship with MF.   24 7.67  On the 1st March 2012, the Police found Child F on a bridge over a motorway. He claimed to be out for a walk and was taken home by the Police patrol. Child F was reported to have engaged in general conversation with the Police Officer and there were not considered to be concerns about his mental health. Earlier that day Child F’s application for the tenancy of a flat had been unsuccessful.  7.68  Upon arrival at the family home, only MP2 was present, (MP2 had been released from a Prison sentence, on license, in early February 2012). Child F armed himself with a knife from the kitchen and lunged at MP2, making aggressive threats. He later claimed that MP2 threatened to kill him. Child F was arrested, with the Police Officer having to use a tazer stun gun to subdue him. Child F was taken to hospital and seen by the duty psychiatrist. The Police were informed that Child F was not suffering from a psychotic illness but did have depression for which he had been prescribed medication.  7.69  The Crown Prosecution Service reviewed the evidence and authorised that Child F should be charged. Because of the nature of the offence he was kept in custody overnight. The Youth Court concluded that Child F was not safe to be bailed to the Crash Pad and he was remanded to the Care of the Local Authority. The Youth Offending Team worker made an application for a Secure Children’s Home but no bed was available and after liaison with the Children’s Social Care Emergency Duty Team, a foster placement, approved to take young people in emergencies, was secured. Child F was subsequently convicted of common assault and sentenced to a three months Referral Order. This Order was later revoked because of Child F’s mental health issues.  7.70  There was also discussion between the YOT worker and the Strategic Lead for Health and Partnerships about the merits of a Mentally Disordered Panel dealing with Child F rather than him being dealt with through the Youth Court. Further discussion between the Strategic Lead for Health and Partnerships and the Police ruled out the  25 possibility of using the Mentally Disordered Panel because Child F did not have diagnosed mental illness. With hindsight, this was a very narrow understanding of mental illness.  7.71  There was discussion between the Emergency Duty Team social worker and the allocated Community Psychiatric Nurse (CPN). The view of the Community Psychiatric Nurse, according to Children’s Social Care records, was that Child F had never made a serious threat on his own life and was not a threat to his siblings. The Strategic Lead for Health and Partnerships also requested that the CPN expedite a referral for a FACTS Assessment (The Forensic Adolescent Mental Health Service).  7.72  The Police referred the case to Children’s Social Care, the referral being received the following day. The Police were expressing concern that the Crash Pad was not a suitable place for Child F to live. Child F had been living at the Crash Pad for several months at this stage.  7.73  An Initial Assessment was undertaken by Children’s Social Care, commencing 5th March 2012, followed by a Core Assessment.  The assessment process did not pick up information that Child F had a difficult relationship with MP2 and the records state “no” to questions about domestic violence and parental drug use as well as “no” to the question about whether he was previously known.   7.74  In March 2012, a Police internal intelligence report was made available for Police Officers coming into contact with Child F or in the event of him being reported missing. The intelligence report was clear that should Child F be reported as missing he should be considered as a risk to himself and others.  7.75  There was a difference of view in early March 2012, between Connexions and Children’s Social Care about whether Child F met the threshold for intervention as a child in need. This followed on from the incident on the motorway bridge on the 1st March 2012. A referral was  26 sent to Children’s Social Care by the Connexions Personal Advisor and after some debate Children’s Social Care agreed to reassess Child F.  7.76  There was an emergency multi-agency meeting held on the 5th March 2012 coordinated by the Early Intervention Team. The main focus seemed to be Child F’s future care status and accommodation. Also referral for forensic opinion was determined.  7.77  A place was found for Child F at a Supported Accommodation residential unit on the 9th March 2012. Child F was taken there by his Connexions Personal Advisor and allocated social worker. The placement was unregulated accommodation in that young people are expected to live there independently and was therefore not regulated by Ofsted. As Child F was no longer remanded in care it was decided that the placement would be under a Children in Need Plan and would be financed through Section 17 payments. This is discussed in detail in the Analysis section.  7.78  On the 13th March 2012 there was a Placement Planning Meeting, including completion of a Missing from Home Assessment. This meeting was attended by MF and the Community Psychiatric Nurse as well as the allocated social worker (SW2) and staff from the residential unit. It was agreed that Child F would remain at the unit for an initial three-month period. It was also noted that an assessment of the risk he posed to his siblings should be completed and taken to a Child Protection Conference. The Police, social worker, Connexions Advisor and residential unit staff were present. It was felt that because of previous incidents, Child F should be seen as high risk should he go missing.  7.79  The Plan was endorsed by the Service Manager Panel, a forum within Children’s Social Care, to ensure placements are appropriate. The allocated social worker was requested to complete the Core Assessment and take it to a Child Protection Conference. The Duty Independent Reviewing Officer was later to decline the request for a  27 Child Protection Conference, because Child F was living away from home and because MF had responded appropriately to Child F and his siblings, the threshold for significant harm was not met. The allocated social worker was advised to complete the Core Assessment and if the situation changed to refer it back for further consultation.  7.80  Early daily records from the residential unit describe Child F as being low in mood and very withdrawn. When MF visited on the 13th March 2012 he appeared angry, stating she was telling lies. This anger shown towards MF was not a totally consistent theme during these early stages of the placement. There is one recording, for example, that indicates his mood picked up after a visit by MF.  7.81  Throughout March 2012, there was ongoing contact between the Early Intervention Team and Child F. His mood appears to have fluctuated and there are reports of Child F “having a bad week” as well as Child F being happy with the new accommodation. By the end of March 2012, the Early Intervention Team recorded that the residential unit felt that Child F was fine and doing well. There were not considered to be any suicidal thoughts.  7.82  A referral was received by Barnardo’s from Children’s Social Care on the 19th March 2012, informing Barnardo’s that Child F had become a Looked After Child and requesting input from the child advocacy service (Children’s Rights Service provided by Barnardo’s). There were some delays in confirming where the placement currently was before it was ascertained that Child F was no longer of looked after status. Due to his age and mental health it was intended that he would be placed in a specialist residential unit, supported by Bury mental health services. The case was closed by Barnardo’s.  7.83  A Professionals Meeting was held on the 26th March 2012. Staff at the residential unit were querying Asperger’s/Autistic Spectrum Disorder. The Early Intervention Team were considering closing the case as  28 they felt that Child F’s difficulties were psychological rather than because of mental illness. The Plan at this stage was to: • Try to have assessment for Asperger’s syndrome - MF in particular was requesting this • Extend placement for a further 3 month period • Longer term move to supported lodgings  7.84  The following day, Child F was reported to be in a low mood and refused to call MF back after she had telephoned him.  7.85  Child F was reported missing, from his supported accommodation, on the 28th March 2012. Child F had informed a support worker that he intended to kill himself. He had also made an attempt to kill himself with a skipping rope a few days earlier. Child F was also seen by his Connexions Personal Advisor and gave a similar account about trying to hang himself. The Police circulated information that he was of medium risk.  Later that evening Child F telephoned staff at his supported accommodation to restated his intention to self-harm. He returned to his residential accommodation early the next morning. Child F told a member of the support staff that he wanted MF to suffer and see her crying over his grave.  The following day there were no suicidal thoughts reported. In a telephone conversation between the residential unit and the Early Intervention Team, Child F was reported as fine. MF visited him at the residential unit the same day and his mood was described as lifted.  Child F went to maternal grandparents for that weekend.  7.86  On the 3rd April 2012 Child F failed to attend a Psychology appointment. Barnardo’s also closed the case because as Child F was not looked after, he was not eligible for their service.  7.87  The YOT worker undertook a risk assessment using a standardised methodology (ASSET Assessment). This was completed on the 4th April 2012. This disclosed that there had been domestic violence in the family for 10 years and that he had lived in a women’s refuge with  29 MF in 2006. Child F also stated that he had intended to harm his MP2 and hated him. It noted that the previous week he had put a rope around his neck with the intention of hanging himself but it had not held his weight. He also said he had been on rail tracks and was thinking about throwing himself under a train.  7.88  The Core Assessment being undertaken at the same time suggested that Child F felt suicidal. The core assessment also noted MP2’s drug dealing and that Child F was frightened of MP2.   7.89  On the 10th April 2012, Child F attended an appointment with a Psychologist - the notes are not explicit but this seems to be the CAMHS Psychologist.  7.90  On the 16th April 2012, the Police were informed, by a friend of Child F, that he was on a bridge over the motorway and intended to jump. Friends and family, including MF, were at the scene. When Child F’s safety was secured he was detained under Section 136 of the Mental Health Act. As he appeared intoxicated he was initially taken to the A&E.  He was, after a mental health assessment, discharged to his residential unit. Both Police and the mental health unit referred Child F to Children’s Social Care.  7.91  By the 18th April 2012, Child F was described, by residential unit staff  as being in an excellent mood. This was consistent over the next few days and Child F spent the weekend with his grandparents.  7.92  The residential unit recorded that on the 24th April 2012, Child F became agitated and angry as MF was late in visiting him. Child F felt that MF was doing this on purpose to limit his contact time with siblings FS2 and FS3. Child F was described as thumping the walls and banging his head on the window. MF did visit with the siblings, There is no indication whether this had an impact on Child F’s mood.   30 7.93  There was a Child in Need Meeting on the 25th April 2012. Present were the allocated social worker, residential unit staff, Connexions Advisor and Early Intervention Team practitioner. There is no detailed information about the areas of discussion. It was however agreed that Child F was in an excellent mood and the placement would continue. It was confirmed that Child F was not a looked after child.  MF also contacted the GP to request a private referral for autism as this would be quicker than going through an NHS referral. Child F had given his written consent for such a referral.  7.94  An updated Core Assessment by Children’s Social Care (entry dated 4/5/2012) gave the following information: • Psychologist and Psychiatrist think he has an attachment disorder • Maternal grand parents no longer able to offer support because of his behaviour • There had been recent contact between Child F and FF - reported by MF as being positive • Child F not registered with a GP locally making it difficult to access GP services • Missed recent appointments with Psychologist • Is currently being assessed for Autistic Spectrum Disorder. MF was very unhappy about the “parental information” on the updated core assessment and wanted it removed.  7.95  Child F was reported missing by staff at the residential unit on the 7th May 2012. A suicide note had been found in his room. He had also phoned MF and told her he was going to commit suicide. The Police dealt with this as “high risk” and located Child F outside his residential unit in the middle of the night.  Child F was taken to a local hospital by the Police under Section 136 of the Mental Health Act. He was assessed and found to pose no danger to himself. During Psychiatric assessment Child F denied current suicidal ideation and was thought to be suffering from a depressive disorder of a moderate to severe nature. It was noted that he had stopped taking regular medication. It was felt that Child F would benefit from further psychiatric evaluation  31 but he refused informal admission.  He was discharged back to his residential unit and taken there by the Police Officers dealing with the incident. The reporting Police officer graded Child F’s vulnerability as high.  7.96  The build up to the incident seems to centre on a telephone conversation between Child F and MF on the 7th May 2012. MF had apparently cancelled a family day out for the coming weekend. This led to Child F shouting down the phone to MF and smashing furniture and glass before storming out of the building.  A few days after this incident, Children’s Social Care submitted a placement request to the Commissioning Team seeking 24-hour 1:1 support.  7.97  Early Intervention Team records show that there was a CAMHS meeting on the 14th May 2012 that Child F refused to attend. There was no representation from the residential unit.  The following day Child F was reported as being anxious and agitated, talking about MF in a negative manner. He then made a disclosure about domestic violence towards himself from MF and MP2, as well as neglect and abuse. Child F was recorded as saying “now do you understand why I hate her”.  7.98  A reflection session between the allocated social worker and Consultant social workers took place on the 16th May 2012.  Key points were: • The social worker was concerned that Child F was displaying high risk behaviour and the risk of suicide was increasing • The social worker did not feel that the placement was meeting Child F’s needs and he needed specialist care to address his mental health needs • The social worker expressed frustration that health had not always attended meetings and at one point were considering closing the case • It was noted that there may be a need for referral to the Complex Care Panel – because of Child F’s complex needs  32 • There was a need to refer to Extra Mile (Leaving Care Service) and the Core Assessment needed to be updated • There was also a query as to whether Child F posed a threat to his siblings It seems to be, at this stage, Child F was formally accommodated by Children’s Social Care, becoming a Looked After Child. The rationale being that the complexities of the case meant that it was necessary to secure Child F’s status.   7.99  There was a LAC statutory visit on the 17th May 2012. It was noted that Child F wanted to stay at the residential unit until he was 24 years old. It was also noted that Child F had made a disclosure to staff at the residential unit in relation to domestic violence and physical injury to himself by MP2. On the same day Child FS1 also sustained a fracture of his right clavicle and was treated at hospital.  7.100  On the 18th May 2012 a Care Programme Approach meeting was held. Consideration was made to the possibility of an assessment for Asperger’s Syndrome. It was also noted that Child F had failed to attend for his appointment with the CAMHS Psychologist. The Psychologist with CAMHS was later to close their involvement because of Child F’s non-attendance at appointments. There was some discussion about current risks. It was agreed that his present residential unit was a suitable placement but would need to be reviewed if Child F continued to present a risk to himself. Shortly after this meeting a Complex Case Panel report was completed in relation to ongoing joint Health/Social Care funding for the continuation of the placement.  7.101 The Police received a referral from Bury Children’s Safeguarding Team on the 21st May 2012. Child F had made allegations of historical physical abuse against MF and MP2. The allegations had been made to a member of staff at the supported accommodation.  A Strategy meeting between the Police and Children’s Social Care took place on the 21st May 2012. It was decided that no further action could be  33 taken as Child F was reported as saying that he would refuse to be interviewed or cooperate with a Police enquiry. MF had apparently been informed of the disclosure by the mental health practitioner and had notified the local authority that she would not allow any visits to the family home, unless reasons were put in writing. Later on the 28th May 2012 MF refused a home visit from Children’s Social Care and refused any discussion.  By the 24th May 2012, Child F was adamant that he wanted nothing to do with MF. His mood was recorded as being low at this stage.  7.102  Child F was seen by his Connexions Personal Advisor on the 25th May 2012. Child F shared information that he was having no contact with his family. There appears to have been reluctance on the part of Children’s Social Care to share the reasons why family contact was not taking place with the Connexions Advisor.  7.103 There was some internal discussion within Children’s Social Care asking why the issues regarding Child F’s siblings had not been progressed. This may have been in part because the allocated social worker (SW2) had left the organisation.  7.104 CAMHS received a fax from MF on the 1st June 2012 detailing a list of unusual behaviours that he had displayed since he was an infant. MF was later to write to Children’s Social Care (dated 16th June 2012) outlining her corrections to the Core Assessment. This was appended to the records.  7.105  There was a statutory LAC Review on Child F on the 7th June 2012.  The Early Intervention Team records, at this stage, were also indicating that Child F wished to remain living at his present residential unit address.  Child F had refused to attend a LAC medical recently. This was followed up with some energy and successfully by the LAC nurse.  Key themes were: • Child F expressed that he was doing better without contact with his MF  34 • Child F expressed the view that no one loved him • New social worker (SW3 allocated).  7.106 Barnardo’s received a referral from Children’s Social Care on the 11th June 2012 requesting advocacy, as Child F had become looked after by the local authority again. An initial assessment was undertaken by the Barnardo’s Advocacy Worker BW1). It was noted that Child F was requesting support with contact arrangements and financial entitlements.  7.107 A meeting took place on the 15th June 2012 between the Children’s Social Care Assistant Team Manager, the Community Psychiatric Nurse, MF and maternal grandmother. The purpose of the meeting seems to be to clarify the outcome of Sect 47 enquiries in relation to the children. The following key points came out: • The Core Assessment had concluded that there should be an Initial Child Protection Conference to look at the safety of the other children in the family • There were no ongoing Police enquiries because Child F would not make a complaint • More information was required about MF’s partner • MF denied any domestic violence, drug or alcohol use in the family. 7.108  MF and family moved to a Manchester address (around 16th June 2012).   7.109  Child F had contact with three siblings FS1, FS2 and FS3 on the 26th June 2012. He was described as anxious and excited but emotionally needy.  7.110 There was a LAC statutory visit on the 27th June 2012 by SW3. Child F engaged well with this visit. SW3 noted that Child F processed information very literally.  Later there was a serious incident where Child F tried to attack a peer with a metal bar.   35 7.111 There was another angry incident on the 29th June 2012 when Child F was due to stay with his grandparents for the weekend. He had been in an angry mood most of the day and when leaving the residential unit he pulled the van door off it’s runner, became aggressive towards his grandfather and went back to his flat where he smashed up furniture. Later MF collected him and Child F informed staff he was going to grandparents.  7.112 At the 3rd July 2012 the younger children had still not been referred to Manchester Children’s Social Care.  7.113  In July 2012 Child F had been allocated to a Personal Advisor (Extra Mile Leaving Care) who started an assessment. Child F indicated that he planned to go to College in September 2012.  Throughout July Child F had some contact with his siblings. Key events were: • He consistently refused to see the LAC nurse • A Learning Difficulty Assessment was undertaken in preparation for College – he started on the 4th September 2012 • The assessment in relation to autistic spectrum disorder was still awaited  • There was a statutory LAC visit on the 24th July 2012- care staff felt there were great fluctuations in his behaviour.  7.114  Child F was seen by the Leaving Care nurse. He engaged well and stated that he was feeling quite good. A Health Action Plan was produced. Child F agreed that the health assessment could be shared with the social worker, GP and carer but refused to allow MF to have a copy.  7.115 On the 31st July 2012 staff at the residential unit contacted the Police to report that Child F was in an aggressive mood and had slashed his own arm. When Police Officers arrived, the scene was described as calm. The wounds were superficial and treated by paramedics. Police Officers did not use their powers under the Mental Health Act.   36 7.116 In July 2012 Child F started work at the Extra Mile Project.  7.117 Staff at the residential unit contacted the Police, on the 5th August 2012, expressing concern about Child F, who had been self-harming, and was threatening to kill himself. Police Officers attended the residential accommodation to find Child F in a calm compliant state, with minor cuts to his arm. He was taken to hospital A&E for treatment and his own safety.  It was noted in the CAMHS documentation that there were raised concerns about Child F’s low mood and perceptual disturbances (recorded 6th August 2012).  7.118 When Child F was seen by CAMHS on the 8th August 2012 to review the autistic spectrum disorder assessment, it was noted that there was a significant and rapid deterioration, although the residential unit had not reported any concerns prior to this appointment.  Child F had suicidal thoughts and increased aggression. It was thought that cannabis use was a likely significant contributing factor.  7.119  There was a LAC Review on the 8th August 2012 that Child F attended.  • Child F presented in low mood • Child F reported that the Community nurse had not brought medication as arranged • There were two incidents recently of Child F cutting himself • When asked if he wanted to harm himself he replied “I’m leading up to it” • Child F said he was applying for College and wanted his own place to live • Staff in residential unit to monitor Child F and contact emergency services if necessary  7.120  In mid August it was noted, in Early Intervention Team records, MF was expressing concern about the suitability of the residential unit in caring for Child F. MF had been informed by the residential unit that  37 Child F had been unconscious and covered in vomit after using alcohol and cannabis. He had been taken to hospital by ambulance.   7.121 Child F was seen by the Consultant Psychiatrist and described thoughts and visions of harming others. It was felt that there were symptoms of depression with significant agitation. Child F disclosed thoughts about ending his own life but said he would not act on these thoughts. Child F reported that he was continuing to hear voices. He disclosed occasional use of cannabis. Medication was prescribed for his agitation – staff at the residential unit took responsibility for this medication, which Child F took occasionally, to aid sleep.  7.122 FF and paternal uncle visited him at the residential unit on the 16th August 2012. Child F was very anxious about the contact. They went out for the day to Manchester. Child F was reported as feeling the contact had been strained. There is no indication how this contact had been established and what Child F made of the relationship with FF.  7.123 There was a Care Programme Approach meeting held on the 17th August 2012. Attended by CAMHS (Consultant Psychiatrist), the Mental Health Practitioner from the Early Intervention Team, and MF. (Child F had been invited but did not attend as had a representative from the residential unit).  The main actions being: • Child F to remain at his residential unit • He would remain looked after (Section 20) by the local authority • His mood would be assessed by staff at the residential unit before he went out • Police were to be contacted if he was deemed to be at risk.  7.124 There was a visit to Child F, from a new Barnardo’s advocacy worker, on the 28th August 2012. Child F was described as chatty and positive.  On the 31st August 2012 another Barnardo’s social worker called at the supported accommodation to see Child F. In the event Child F was not seen as he was involved in a verbal disagreement with staff. A  38 further visit on the 3rd September 2012 was cancelled as Child F was out shopping with MF.   7.125 During the latter stages of August 2012 and the early September 2012, there were a number of mood changes, with Child F reacting badly to daily frustrations often over small events such as the telephone not working. There were occasions reported when he could be threatening and intimidating. Many agency efforts during this period were focused on sorting out Child F’s grants and benefits and stabilising him in College.  7.126 There were various communications between the Barnado’s advocacy worker and the local authority social worker and Child F’s Connexions Personal Advisor, throughout September 2012, seeking to clarify  funding arrangements for Child F. Child F started College on the 4th September 2012.   7.127 There was a CAMHS interview with MF on the 12th September 2012 in relation to the Asperger’s Syndrome assessment. A referral was also made by CAMHS to the Forensic Adolescent Consultation Team to seek their expert assessment of the level of risk towards others. It was noted that Child F’s placement may break down and the transition in Child F’s care as he was approaching 18 years of age may change the nature of risk.  7.128 There was an incident on the 14th September 2012 when Child F had returned from contact with MF. He went to his flat and proceeded to smash the furniture. Child F was pacing up and down and crying, stating that he was going to kill himself. He eventually calmed and was placed on 1:1 supervision throughout the night. MF was informed of the events. The following day MF called at the residential unit to see Child F. He refused to see her.   39 7.129 There was a further incident on the 16th September 2012 when Child F was throwing objects around his flat and refused to speak to staff. He calmed down when he received a telephone call from FF.  7.130 Child F had stopped attending College by the 17th September 2012. After four days of attending he had barricaded himself in his room and refused to leave. The Police had been called to get him out of his room.  Child F refused to speak to his Personal Advisor (Leaving Care) when she visited.  There were clearly concerns growing about his mental health during this period. Child F was refusing to take his medication and was “trashing his room”.  There was a specific concern about suicidal ideation with Child F producing a noose that he had formed.  There were some positive elements recorded, including contact with FF and paternal uncle. New medication also seemed to help in improving his mood.  7.131 It was noted (18th September 2012),that the local authority social worker had spoken to the Consultant Psychologist for LAC about their concerns about Child F. It was agreed that The Consultant Psychologist would not become involved, as Bury CAMHS already were. Early Intervention Team and CAMHS informed by Children’s Social Care about the level of concern including concern about the quality of the placement.  7.132 In late September 2012, MF reported to the health visitor that she was not suffering domestic violence and had separated from her husband (she had returned to live in the Bury area). MF reported that Child F visited the family home several times a week. It id not appear that issues of risk to the younger children were picked up again.  7.133 In early October Child F reported that he was not taking his medication any longer. He said that he had stopped going to College because he thought people were laughing at him.   40 7.134 There was also a new social worker from Adults Mental Health (Health and Social Care) introduced in October 2012.  7.135  A Professionals Meeting planned for the 12th October 2012 did not take place. There appears to have been some confusion about this meeting.  A professionals meeting took place on the 15th October 2012 to discuss planning with regard to transition in Child F’s care. There were concerns expressed about the suitability of the placement at the residential unit. Following this meeting strenuous efforts were made to try to identify a more appropriate alternative placement that would have been able to accommodate him beyond his 18th birthday but at the time of his death no suitable placement had been found.   7.136  Child F was seen by the Mental Health Practitioner (CAMHS) on the 16th October 2010. Recorded as being okay, no issues. Said to be looking forward to a semi pro fight (cage fighting activity).  7.137  Child F was seen by the Early Intervention Team practitioner on the 7th November 2012. His mental state was recorded as stable and no concerns were raised. It was recorded that the LAC Review had been cancelled. During this period in early-mid November there were no reports of Child F having angry outbursts or trashing his room or references to suicidal or violent thinking.  7.138  On the 9th November 2012, during a visit to Child F by the Barnardo’s advocacy worker, Child F again stated that he did not wish to move from his present placement.  7.139 On the 13th and 14th November 2012 there were reports from the residential unit that Child F had been very agitated and displayed aggressive behaviour. The reasons for this are unclear but it was recorded that he required increased staff support throughout the night. Child F made comments about killing himself.   41 7.140  Child F was seen for review by the Consultant Child Psychiatrist on the 16th November 2012. Child F was said to be complying with his medication (anti depressant). No concerns were noted.  7.141  There was a professionals meeting coordinated by CAMHS on the 19th November 2012. New information was shared: • Child F had set fire to “Gran’s” chair when he was 9 years of age • The residential unit had concerns about his cruelty to animals • There had been attempted intimidation of male staff at the residential unit • Child F had been diagnosed with Asperger’s Syndrome  7.142 There was a visit by the allocated social worker and a social worker specialising in transition for vulnerable young people. Child F refused to get out of bed to speak to them.  At this stage there were also reports of Child F displaying aggressive behaviour to a female peer and being in a low mood.  The case was allocated to a new social worker (SW4) in late November 2012.  7.143  There was a LAC Review held on the 30th November 2012. Focus on amount of support Child F would need through transition period. Child F and MF attended the review.  There was to be liaison with Manchester Leaving Care Service and Manchester Early Intervention Team to progress transfer in services for Child. By and large the transfer arrangements seemed to be very smooth.  It was also hoped to transfer Child F to more independent living arrangements. This Plan seems unrealistic and is commented on in the Analysis section.  7.144  Joint visit to Child F, on the 17th December 2012, by Early Intervention Team practitioners from Manchester and Bury. Child F refused to see them.  7.145  Child F was also visited by his allocated social worker on the 19th December 2012. There was agreement about small targets such as going to Connexions and picking up his own medication.  Plan aimed  42 at Child F moving to a less structured but quieter environment.  Child F also met his Children’s Rights Officer on the 19th December 2012 and they discussed goals relating to independent living.  7.146  On 21st December 2012, Child F went to grandparents for Christmas period. He returned to the residential unit on the 24th December 2012 and was angry and aggressive “smashing up” his flat. He refused to speak to grandparents.  7.147  On the 25th December 2012, Child F was stopped from leaving the residential unit. He was carrying a length of rope. Eventually he asked for medication and handed over the rope to a member of staff.  7.148  Child F was arrested for criminal damage on the 31st December 2012. This related to an incident when he “trashed” his room. It is unclear why there was an apparent change in the management of his behaviour on this particular occasion and it was reported to the Police, with residential staff advocating prosecution. He was reported by care staff as being restless all night with a strong smell of cannabis coming from his room. When his room was checked nothing was found.  7.149  In the very early hours of the 1st January 2013, staff at the supported accommodation contacted Police to report that Child F was smashing windows at the accommodation. Child F was reported as having been drinking alcohol and had not been taking his medication. When Police officers arrived, Child F was calm and described as remorseful. All parties agreed that the issue could be resolved through restorative justice and Child F apologised and agreed to clear up the mess and pay for the damage. It was believed that Child F had been angry and upset because MF had sent him a text wishing him a Happy New Year.  7.150  Several hours later, staff at the supported accommodation contacted Police to report that Child F had sent them and MF a text saying that he intended to commit suicide. Child F was telephoned by a member of staff and agreed to return on the condition that he was not “taken  43 away”. When he did return he appeared drunk and claimed he had no real intention of harming himself. Police officers concluded that at that time he posed no risk to himself or others and he was allowed to remain at the supported accommodation.   7.151 FF and paternal grandfather visited him on the 6th January 2013. Child F refused to see them. Child F ran off and threatened to hang himself. He had also put a ligature around his own neck on the 1st January 2013.  7.152  On the 7th January 2013, staff at the supported accommodation contacted Police to report that Child F was intent upon harming himself and was self-harming by biting his own wrists. As Child F had left the supported accommodation, prior to the arrival of the Police, a high risk Missing from Home search was immediately instigated.  Child F was later located and detained under Sect 136 of the mental Health Act and taken to hospital by the Police, accompanied by staff from the supported accommodation. Following a Mental Health Act assessment it was decided that it would not be appropriate to admit Child F to a Psychiatric ward.   7.153  Child F and MF were seen by Clinical Nurse Specialist, Forensic Adolescent Consultation and Treatment Team (FACTS) on the 8th January 2013. They were seen again by the Clinical Nurse Specialist on the 14th January 2013. At this meeting Child F disclosed a potentially serious incident of deliberate self-harm on the 1st January 1013, which involved him using a ligature. Following on from this information the Clinical Nurse Specialist contacted both the Consultant Psychiatrist (CAMHS) and the allocated local authority social worker to express concern about Child F’s ongoing thoughts of self-harm and also the plan for him to move to a less supportive environment when he was 18 years of age. Child F was also offered six therapeutic sessions to help with his social anxiety.   44 7.154  The allocated social worker visited Child F on the 11th January 2013 and found him upbeat and chatty. Discussed how difficult he finds it to engage people and his preparation for independence.  7.155  There was a joint home visit by the Early Intervention Team representatives (Bury and Manchester) for discussion about transfer arrangements. Child F was said to be more settled and up beat and chatty. Case transferred to a new practitioner in the Early Intervention Team.   7.156  There were various contacts by agencies throughout the rest of January 2013. Much agency energy was focused on ensuring a smooth transfer of both geographical (Bury to Manchester) and age related services (Child to Adult). It was significant that Child F was refusing to speak to grandparents. He had not been in contact with them since before Christmas 2012.  7.157  Child F was visited by the CAMHS Psychologist, on the 29th January 2013, in order to discuss the Asperger’s assessment. The draft assessment report was shared with Child F who was said to be quiet in response but not distressed.  7.158  On the 31st January 2013, staff at the supported accommodation contacted the Police to report that Child F had smashed a window after threatening staff and other residents. He was arrested for the damage and taken into custody. Staff at the supported accommodation were consulted about possible prosecution and expressed the view that prosecution was appropriate. Child F was charged and bailed to appear at the Magistrates Court. This was quite a significant change in approach by the residential unit.  During this period in January 2013 arrangements were also made for a transfer to a new Consultant Psychiatrist in Manchester.  7.159  Child F was reported by care staff as being in an excellent mood on the 1st February 2013.  45  7.160  On the 3rd February 2013, staff at the supported accommodation contacted the Police to report Child F as missing from home. He had been to visit MF but had left her house at 19.00 hours without saying goodbye to anyone. He was recorded as being high risk of self-harm because of his history.  The following morning Child F was found hanged from a tree in parkland. Police treated the death as a Special Procedure Investigation but concluded there to be no suspicious circumstances.   8. CRITICAL CASE ANALYSIS  How did your agency collaborate and work with other agencies to undertake the following in relation to Child F: •    Assess risk •    Assess need •    Put services into place •    Review and manage risks •    Measure outcomes  Assessment of Risk Early Assessment 8.1  There were some opportunities for an early assessment of risk in this case. It had been identified in August 2005, during health visitor contact with the family, that there were a number of concerns about previous domestic violence and also that Child F was demonstrating aggressive behaviour towards a younger sibling and threatening to harm himself. MF also said that Child F’s behaviour was worsening.  8.2  There was also information given to the health visitor, by MF that she and the children had lived in a refuge for three months because of domestic violence. Historical information indicates that there were some very serious incidents of domestic violence including significant bruising to MF’s body the day before FS2 was born (2004). Because of  46 house moves, between Bury and Manchester, by the family, some of the information about domestic violence may have been lost to an extent, however, by August 2005 at least some of the concerns about domestic violence were known to the Bury health visitor.  8.3  This information should have been shared with the school nurse and the family GP and could have established an early common information base for further collaborative action. There is no indication from any of the records that this information was shared with colleagues. It seems unlikely for example, from examination of the records, that the school nurse ever knew there was a history of domestic violence in the family.  8.4  There was further information about domestic violence incidents, held by the GP, leading to the need for an operation on her nose for MF. The last of the injuries was reported as being caused around June 2007.  This information was indicative that domestic violence, even if said to have been caused by an ex partner, was an ongoing feature within the family. Had the GP, health visitor and school nurse shared common information about domestic violence within the family, it may have offered some insight into the challenging behaviour being exhibited by Child F at that time. The information about domestic violence was to have a significant impact on the direction of the case at a later stage.  8.5  There was also information given by Child F to CAMHS, in the early stages of their involvement (16/12/10), that FF had “hit him once and threw him into a window in 2006. The TV got broken and someone set the house on fire”. Although this is recorded as FF, it is clearly MP2, given the dates and the fact that Child F never had contact with FF.    8.6  This adds considerably to the available information about domestic violence and suggests that Child F was living in a household where there was a high level of violence and intimidation. Unfortunately the information was not shared with other agencies. This emphasizes the  47 need for all agencies to collect information accurately, understand the significance of that information and to collaborate by sharing information.  8.7  There were concerns expressed by Child F’s secondary school (High School 1), leading to anger management input. There were some incidents of physical aggression at school reported in October 2006. Whilst Child F’s attendance was good, his behaviour was seen as problematic. There were various interventions through fixed term exclusions, referrals for individual counseling to Relateen, Child F also spent time in the school Inclusion Unit. He was permanently excluded from High School 1 in September 2009.  8.8  At the stage of exclusion, Child F was referred to CAMHS. Given the referral to CAMHS, and the transfer to another school for Child F, it would have been prudent for the school nurse to discuss their ongoing role with the other agencies. This would have encouraged a more collaborative approach and may have led to information about violence within the family being shared. The possibility of a “drop in” arrangement between the school nurse and Child F was too loose to have any impact.  8.9  During the early stages of Children’s Social Care involvement, there was limited evidence of a collaborative approach. There were a number of referrals to Children’s Social Care, prior to Child F’s remand into the care of the local authority. These were determined as being below the threshold for Children’s Social Care intervention. These included referrals for Child F being missing from home, serious mental health problems requiring hospital admission, unsuitable accommodation and threats of suicide.   8.10 There was an increasing build up of concerns, culminating in an admission to a specialist mental health unit, when Child F, expressed both suicidal thoughts and thoughts about harming others. It was only when discharge from the mental health unit was being  48 considered that Children’s Social Care undertook an Initial Assessment.  8.11 Within the Initial Assessment process, Child F was seen by the allocated social worker. There was also evidence that MF, maternal grandparents and professionals had been consulted.   8.12 The Initial Assessment, however, failed to identify any issues of domestic violence, or the issue of MP2’s imprisonment. The conclusion was that there were “no child protection concerns”, was seemingly based on a very narrow definition of safeguarding and did not adequately consider either Child F’s welfare or the welfare of his siblings. The conclusion also suggests a limited understanding of the continuum between children in need and child protection.  8.13  There is a sense that the gate keeping mechanism used by Children’s Social Care in the early stages of involvement with Child F and his family was too inflexible and their primary aim was to protect the agency from resource demands rather than identify children in need. This is an issue that has been identified in research on Serious Case Reviews (Brandon et al 2012).  8.14  In the early stages of Child F’s involvement with CAMHS there was an emphasis on the assessment of risk to others. This was understandable in the context of Child F’s first admission to the mental health unit. Part of the rationale for Child F not being discharged to his home address was to reduce the risk to his siblings. It should be added that Child F did not wish to return home at this point. Had the information about violence by MP2 been understood accurately it may have widened the scope of intervention.  8.15  The placement with Child F’s uncle was dealt with too casually by those professionals working with Child F. There was very little information available about the circumstances relating to the uncle and his capacity to manage Child F. There also should have been  49 more interagency assessment about whether it was appropriate for Child F to be cared for by his uncle, and what arrangements there were in place, if any, for supervision of any contact Child F might have with his siblings. There was also very little monitoring of this arrangement. At an early stage Child F had returned to the family, although the circumstances in which this occurred were not explicit. Ideally there should have been a risk assessment before the return home was considered.  8.16  There were also issues about whether risks were confined to his siblings or were more generalised. Child F, for example, although the extent of this fluctuated considerably, had said since December 2010 that he had thoughts about harming himself and others. There was no indication that his risk to the wider community was considered.  8.17   He had already been permanently excluded from one school because of a violent attack upon another pupil. The significance of this and the wider propensity for impulsive aggressive actions does not seem to have been considered as carefully as it should have been in consideration of placements.  8.18  A much better approach to the discharge would have been for Children’s Social Care in collaboration with CAMHS and the Early Intervention Team to undertake a more systematic assessment about the arrangements for Child F to live with his uncle and also for future placements. The closure of the case by Children’s Social Care on the 4th January 2012 was not appropriate. There were certainly enough identified needs and complexities to warrant a more detailed Core Assessment.  8.19  There was also a possible lack of clarity between agencies about follow up plans after discharge. The Children’s Social Care records there was to be no further action by Children’s Social Care and that High School 2 would undertake a Common Assessment Framework (a mechanism for agency assessments that fall below the criteria for  50 Children’s Social Care involvement). Conversely, CAMHS records say that Children’s Social Services involvement is to be “put in place”.  Risk Assessment at the Crash Pad 8.20   Child F packed his bags and left the family home on the 7th November 2011. He presented himself at Connexions as homeless on the 8th November 2011. This was clearly a critical incident that required agencies to be working closely together.   8.21   There seemed to be an impasse initially, based around the fact that MF said he could return to the family home if he wanted. Housing argued that this meant he could not be homeless. From the recorded information there seem to have been protracted discussions between Connexions, Housing Office, Children’s Social Care and the Early Intervention Team in order to access a place for Child F at the Crash Pad.  8.22  Discussions then focused on the level of risk that Child F might pose to other people. A place at the Crash Pad was eventually secured through a mental health assessment by the Early Intervention Team. It is interesting that this is the first time that Child F’s wider risk to other people in the community was considered.  8.23  There are significant issues of escalation of risk that were not adequately addressed by any of the agencies. The Crash Pad is intended as the name implies to be an emergency placement only. Child F remained there until the 1st March 2012 when he was arrested by the Police and subsequently remanded into the care of the local authority on the 3rd March 2012 and placed with emergency foster carers. Some of the wider issues about assessment of need with homeless young people are picked up in the following section (Assessment of Need). The concept of a young man with serious mental health problems living in the environment of the Crash Pad for over six months is unacceptable and may well have added unnecessarily to his poor mental health.   51  8.24  Over November and December 2011, there were a series of increased concerns about Child F’s mood whilst he was staying at the Crash Pad. On the 30th January 2012 he was admitted to the specialist mental health unit with low mood, suicidal ideation and auditory hallucinations instructing him to hurt himself and others. By the 10th February 2012 there was a significant improvement in symptoms and he was discharged. It was agreed that he could return to the Crash Pad following a risk assessment.   8.25  It is difficult to see how a risk assessment could support a return to the Crash Pad, or how a risk assessment could support an arrangement for an extremely vulnerable young man to live in emergency accommodation for this period of time. There should have been a formal challenge about these unsatisfactory arrangements. It should have been clear that the Crash Pad arrangement was likely to increase risk both to Child F and others.   Risk Assessment After Remand to Care 8.26  Child F appeared at Court on the 3rd March 2012 for attempting to stab his MP2, following an incident where Child F was threatening to jump from a Motorway Bridge. The Police had returned Child F to the family home and armed with two knives he attempted to stab MP2. The Police had to use a taser gun in order to subdue him. Child F was seen by the duty Psychiatrist at A&E and discharged from hospital to Police custody as there was no evidence of affective disorder or psychosis.  8.27  The risk assessment undertaken by the Youth Offending Duty officer had a solid foundation. The assessment was undertaken using recognised national guidance through ASSET documentation. In the course of the Assessment Child F disclosed that there had been domestic violence within the family for 10 years. Child F also talked about wanting to hurt himself. There was good evidence of  52 appropriate communication and collaboration between the YOT Duty Officer and the Duty social worker.  8.28   Child F was placed initially (as an emergency placement) in a foster placement. Given the emergency nature of the situation, this was a reasonable choice of placement. The risk assessment undertaken by the YOT worker was as full as possible in these circumstances. On the 9th March 2012 he moved to a residential placement, described as “supported lodgings”. As he was not remanded to the care of the local authority and young people were expected to live independently the residential establishment was not regulated by Ofsted. This is covered in more detail in the next section. It should be stated, however, that although there was ongoing consultation between mental health and children’s social care staff about the residential placement there was no real evidence from assessments that the placement was suitable and there was a distinct possibility that an inappropriate placement would heighten risks.  8.29  The level and source of risk was never determined properly. It had been decided in a Placement Planning Meeting held on the 13th March 2012 that the residential supported accommodation should be tried out for 3 months. It was also decided that a Core Assessment should be completed and an Initial Child Protection Conference held. The duty Independent Reviewing Officer declined to hold a Child Protection Conference on the basis that the Core Assessment had not been completed on the siblings, MF had responded appropriately to Child F and his siblings. No information from school had been collected on the siblings, hence the threshold for likelihood of significant harm was not met.  8.30  There are sound arguments that more information should have been collated prior to consideration about a Child Protection Conference. The focus was very much on the risk posed to the younger siblings of Child F. Given that there were consistent reports that Child F had experienced thoughts about hurting people (and command auditory  53 hallucinations) and that he was reported to have held a knife to a younger sibling there were potential risks to the younger siblings that could have been legitimately explored through the mechanism of an Initial Child Protection Conference. Section 47 Enquires, however, should have commenced when Child F was staying at the Crash Pad and having contact with his siblings.  8.31  This was particularly relevant given the likelihood that Child F would spend a considerable amount of time throughout the coming months having contact with his younger siblings. At one stage, for example, there was an arrangement in place for Child F to spend the daytime at the family home, returning to his accommodation at the Crash Pad in the evenings. Presumably this arrangement would have meant a strong possibility that Child F would have contact with his siblings.  8.32  There were also wider risks that had been identified in relation to the younger siblings and MP2. During the course of the ASSET assessment, completed in early April 2012, Child F had disclosed that there had been domestic violence for ten years within the family. This should have led to considerations about the safety of the younger siblings. The focus of any Section 47 enquiries should have encompassed possible harm to the children because of domestic violence.  8.33  These issues do not appear to have been picked up at the time, although they arose again, in May 2012, when Child F made further disclosures about domestic violence to himself inflicted by MP2. This led to a Strategy Meeting between the Police and Children’s Social Care. This was a sensible collaborative approach although a combination of Child F’s unwillingness to formalise the allegations, resistance by MF to allow the social worker (SW2) to visit the children, and poor case management by Children’s Social Care meant that the Core Assessment of Child F’s siblings was never completed.   54 8.34  The move to Manchester by the family, in June 2012 should have lead to a referral being made by Bury Children’s Social Care in relation to concerns about the children. There was no record on information held by Bury or Manchester that this referral had been made prior to the commencement of this Serious Case Review process. This is clearly a significant flaw in communication. It is likely that poor managerial oversight led to this problem.   8.35 Whilst at the Supported Accommodation, there were ongoing assessments of risk. A particularly key point in Children’s Social Care work was a session held, in mid May 2012, with the allocated social worker and consultant social workers. These sessions are designed to allow practitioners to reflect on complex cases. The allocated social worker made a number of points. • The social worker was concerned that Child F would kill himself either accidentally or intentionally • The social worker did not think that the Supported Accommodation was suitable for Child F’s needs • The allocated social worker was concerned about the risk that Child F may pose towards his younger siblings  8.36  Although concerns about the suitability of the placement were brought to a Complex Care Panel and joint funding agreed between Health and Children’s Social Care it was also acknowledged that concerns about the suitability of the placement remained and efforts were being made to find another placement. At the point of Child F’s death an alternative placement had still not been found. Although staff at the Supported Accommodation Residential Unit clearly made considerable effort to safeguard Child F, they were not resourced adequately to meet his needs and did not have the knowledge or skills necessary to manage this very vulnerable young man.   8.37 This issue is covered in more detail in the following section (Assessment of Need). A key point impacting upon finding a suitable placement lay with Child F’s mental health diagnosis. Without  55 the diagnostic status, of a “serious mental disorder”, he would not meet the criteria for specialist placement. This “criteria” seems particularly inflexible and leaves young people, where the diagnosis is as yet unclear, in an extremely vulnerable position.   Specific Issues - Assessment of Risk  8.38  Within the timeframe of this Serious Case Review, the Police dealt with eighteen incidents involving Child F. There is good evidence that throughout their dealings with Child F the Police responded both sensitively and appropriately. The potential for self-harm or suicide was taken very seriously. This is illustrated by the incident in April 2012 when it was reported to the Police that Child F intended to throw himself off a Motorway Bridge. The Police closed the Motorway, detained Child F for his own safety and escorted him to hospital.  8.39  There was also clear evidence that the Police took risk assessments by partner agencies seriously and also used their own intelligence about Child F’s previous history to help inform decisions about actions that were required.   8.40  There was also appropriate challenge about the rationale for medical decisions about Child F. Following the incident on the 7th May 2012, when Child F was found by the Police after being reported missing from the Supported Accommodation. As Child F was in an aggressive and volatile state he was detained for his own safety and taken to hospital. The decision of the examining doctors that Child F could return to his Supported Accommodation as he was receiving adequate support in the community was queried by the Police Officer who maintained a position that Child F was “high risk”, that the suicide attempts would continue and Child F may succeed in his attempts.  8.41  There are some significant problems in risk assessment for suicide prevention. Maximising the effectiveness of risk assessment is dependent upon there being good quality reporting systems of those working closely and directly with the young person. Frequent  56 fluctuations in behaviour or mood for example may escape a clinician in the course of a single review or consultation with the young person.  8.42   With Child F, these mood changes were constantly in flux. The Leaving Care Personal Advisor and the social worker for example both commented on how Child F had a different presentation each time they visited. “Sometimes he would be elated and at other times sad and lacking motivation. At his worst his thoughts were negative and he spoke of harming himself”.  8.43   Good quality reporting systems, however, in turn are extremely reliant on having staff who are suitably trained and experienced to pick up on the importance and meaning of changes in behaviour from the young person.  8.44  There had been concerns expressed about the Supported Accommodation because of the capacity of the staff to manage Child F’s difficulties, These concerns were expressed in a number of different areas.  • There were some incidents that were not being reported to the local authority allocated social worker. There was one particularly serious incident over the New Year 2013, where a telephone message from the Supported Accommodation Unit had been left for the allocated social worker when the urgency and seriousness of the incident should have led to contact with the duty officer • Reports from the Supported Accommodation had originally been built into the placement agreement on a monthly basis but had not been regularly produced • The level of support seemed less than the 30 hours per week that had been commissioned  8.45 All of these factors meant that there was not always a complete picture given of Child F’s changing presentations that would contribute to a more reliable risk assessment.   57 8.46  Child F presented at hospital on a number of occasions and was seen by duty Psychiatrists. These events occurred when there had been a serious incident and he was detained by the Police for his own safety. Child F was frequently intoxicated in these circumstances and was seen by medical staff who did not know him, were unfamiliar with the detail of his history. This coupled with his complex presentation and needs must have made formulation of a diagnosis difficult.   8.47  The Overview Report author is surprised that Child F was not admitted to hospital following the incident, on the 7th January 2013, when he had been detained and taken to hospital by the Police. On this occasion, Child F had been found by the Police with a shoelace around his neck. The assessment under the Mental Health Act decided that it would not be appropriate to admit him. There had been an incident a few days earlier when he had been found with a ligature around his neck. Child F was seen by practitioners from the Early Intervention Service and the Adolescent Forensic Service. There was no indication from the Serious Case Review documentation that the recent incident on the 7th January 2013 was discussed with him.  Assessment of Need 8.48   As would be anticipated, given Child F’s complex needs, there were a number of different agencies, with different foci addressing his needs.  8.49 There were concerns about Child F’s mental health, particularly in relation to psychotic symptoms. This was assessed by the Early Intervention Team. There was also a reassessment when psychotic symptoms persisted, in line with good psychiatric practice. It was identified that Child F required anti-psychotic medication and this was prescribed.   8.50  Child F was also referred for psychological therapy to treat symptoms of stress, following what was considered to be post-traumatic stress resulting from a physical assault he had previously experienced. Child F did not attend for psychological therapy. This seems to be a  58 significant gap in his treatment plan. Some systematic reviews of suicide prevention research suggest for example that “there are promising results in reducing repetition of suicidal behaviour and improving treatment adherence exist for cognitive therapy, problem solving therapy, intensive care outreach and individual psychotherapy” (Mann et al 2005).   8.51  It would also have been relevant to have considered psychological therapy for the impact of living in a violent household had there been a more clear understanding of these issues in relation to Child F.  8.52  From an early stage of intervention, Child F was placed on a Care Programme Approach (CPA) that is used to co-ordinate care and assess the needs of people with severe and enduring mental health problems. Child F was also given advice on the links between cannabis use, alcohol use and psychotic symptoms. His depressive moods were also monitored closely and he was prescribed medication when he met the criteria for a depressive episode.  8.53  There were some significant difficulties in assessing Child F’s needs. There is a good deal of evidence that Child F’s mood and symptoms were prone to very sudden fluctuations. There were also a number of occasions when Child F refused to take medication, making it more difficult to monitor the effectiveness of medication on symptoms. It is difficult to determine from the Individual Management Reviews how the medication was monitored.  8.54  There was additional mental health assessment through the Adolescent Forensic Service (FACTS). At the time of Child F’s death, this assessment was ongoing, although it had been identified that Child F presented with social anxiety and he was offered an initial six sessions to help him deal with this issue. This was a helpful intervention, although help for Child F with social functioning and anxiety should have been identified much earlier.   59 8.55  There was also an assessment of Child F in relation to the possibility of Autistic Spectrum Disorder This diagnosis was confirmed in October 2012 but not given to Child F until January 2013. The delay is thought to be because of capacity pressures due to funding reductions.   8.56  Overall the assessments of need undertaken by mental health services were comprehensive. The involvement of the Early Intervention Team because of symptoms of possible psychosis was appropriate as was the referral to the Adolescent Forensic Service.   8.57  There was evidence of good communication with other agencies through professional’s Planning Meetings and the Care Programme Approach. One element that may have caused some confusion for other agencies was the different diagnoses and that were being suggested. At various times there were suggestions of: • psychotic episode • mixed disorder of emotion and conduct • adjustment disorder • dissociative symptoms • depression • autistic spectrum disorder. •  8.58 It was not always clear from other agency information that all agencies understood the differences between these diagnostic criteria and what it might mean for Child F’s behaviour.  8.59  Although there appears to be a strong emphasis on diagnosis and monitoring of Child F’s progress there seems to be little direct involvement in therapy for Child F. It had been identified, for example that Child F was socially anxious but it was not until the involvement of the Adolescent Forensic Service that sessions for social anxiety were offered.  8.60  Similarly Child F clearly had problems with anger management and impulsivity. There did not, however, appear to be any therapeutic  60 input related to these issues. This raises some questions about cross agency collaboration and whether creative thinking about the role of the Psychologist working with Looked After Children (LAC) would have added therapeutic value. They could have had an important role to play in therapeutic help for Child F and were clearly willing to be involved. The input of psychological therapy should have been reconsidered in April/ May 2012 when it emerged that there had been domestic violence within the family over a lengthy period.  8.61   Referrals to Children’s Social Care about Child F’s homelessness, the lengthy placement at the Crash Pad and his mental health problems should have led to an assessment of need. The fact that they did not has implications for the threshold criteria that Children’s Social Care are operating to determine if children are in need.  8.62  As a homeless young person, there was a duty on the local authority Children’s Service to assess Child F’s vulnerability and to determine whether he needed to be accommodated under Section 20 of the Children Act or supported through Section 17 of the same Act. There was avoidance by Children’s Social Care of these responsibilities until the Criminal Court, in recognising Child F’s vulnerability, remanded him to local authority care. This was a serious shortfall in service provision. It is of concern that Children’s Social Care seemed unaware of the increased risk of self harm because of homelessness.  8.63  Similarly, when the remand period had expired, a decision was made to discontinue Child F’s looked after status. Given the very obvious level of Child F’s needs and his clear vulnerabilities, this was inappropriate. Child F should have retained his looked after status in order to ensure planning and monitoring processes were in place to support him. It was only when the Core Assessment had been completed that the need for LAC status was agreed.  8.64  There was a particularly unhelpful disagreement between agencies around Child F’s needs when he became homeless. It was clear that  61 Child F was vulnerable at this time and the situation called for a collaborative and joint approach from agencies. Initially, however, there was an unwillingness to acknowledge his homeless status (because MF was willing to allow him home). It was only when the debate moved, more realistically to the danger he might pose to others, that progress in obtaining Child F an emergency placement at the Crash Pad was achieved. One of the key lessons from this case is the need for a collaborative strategic approach in dealing with vulnerable young people who are homeless.  8.65 During the period in placement from March 2013, there was evidence of energetic and collaborative efforts in planning Child F’s future care and helping him in the transition to adulthood. His health needs were assessed and addressed by the Looked After Children nurse. His mental health was regularly reviewed by the Consultant Psychiatrist and his medication changed to manage presenting symptoms.  8.66 The allocated social workers (SW3 and SW4) along with the Personal Advisor (Leaving Care Service) and Connexions worker met regularly and exchanged information to support Child F. In particular, there were active attempts to help him manage his social isolation more effectively and involve him in positive activities to improve his social integration.  8.67 There were, however, major issues emerging about relationships within the family that were never addressed by practitioners. The use of empathetic relationships to explore and make sense of seemingly disturbed behaviour is an important tool for the practitioners. There is little evidence in this case that there was a focus on helping Child F unpick many of these feelings, particularly those about MF and his place within the family. There seems no thought, for example, about the sudden introduction of FF and the possible impact of this on Child F.    62 8.68 There was also a lack of appreciation of quite complex heritage issues and the meaning of these for Child F. Although Child F was White British, his younger siblings were mixed race and MP2 was described as mixed race. One of the critical issues repeatedly emerging from this Serious Case Review is Child F’s expressed feeling that he is not part of the family. Although issues of racial heritage were not specifically stated in the terms of reference of the Serious Case Review, it was disappointing that the Individual Management Reviews did not address this important area.  Putting Services in Place 8.69 In terms of mental health services, Child F had a comprehensive Care Package. There was evidence of plans in effect to transfer to an equivalent Adults Services package that included. • Consultant Psychiatrist review and medication • Individual therapy, including psychology • Social worker • Accommodation • Regular Care Programme Approach   8.70 Care coordination and coordination of services was well organised. Although there was a need for practitioners to change because of the transfer of services to Manchester, and the move to Adult services, the family and Child F were consulted about these service provision changes.  8.71 Once Child F became a Looked After Child within his residential Supportive Accommodation there was much more of a supportive structure to develop plans for services. The Personal Advisor (Leaving Care) and the allocated social worker (SW3) jointly undertook a needs assessment out of which a Pathway Plan was developed. There was a good deal of emphasis in the Plan to the need for Child F to build up a range of self-help skills as part of the Care Plan. This was sensible given the transition to Adult Services.   63 8.72   The Care Plan was not of a reasonable standard. This is not an issue relating only to this particular case. In general Care Plans, nationally, are not specific enough, with the young person’s needs being central to the Plan. This tends to mean that outcomes desired and actions required are seldom detailed enough to have any real meaning or relevance for the young person. There is also a tendency in complex cases for individual agencies to take on discrete tasks (agency related) without there being a well thought out joined up multi-agency joint response. In the various plans set out for Child F, for example, apart from one brief reference to “life story” work, there is no real indication that any ‘talking therapies” took place in relation to any agencies.  8.73 Reviews for the Care Plan were not within timescales and records of one significant Care Plan review were not written up until two months after the Meeting. This leaves those practitioners working with children without documented plans to refer to.  Review and Manage Risk 8.74 In relation to the Police, the review and management of the risk to Child F and others was coordinated by the specialist Police Protection Investigation Unit (PPIU). The response Officers who had dealt with Child F referred incidents to the PPIU. These incidents were then reviewed within the PPIU, particularly in relation to assessment of risk. The referring details of incidents were then sent to partner agencies, as appropriate.  8.75  There was evidence from the documentation that this process was very efficient in ensuring that good quality information reached agencies in a speedy and easy to follow format. It also meant that risk was continually reviewed. This highlights good practice in information exchange.   64 8.76  Mental health services, followed NICE guidance in their management and review of risk. It was recognised that Child F had most of the identified risk factors for self-harm.  8.77 Overall mental health services were well managed, with regular systems for monitoring and review. There was also evidence of the appropriate use of specialist services (Adolescent Forensic Service). Often specialist services brought into a case can offer an objective additional opinion. The identification, for example, that Child F may benefit from work on social anxiety was a useful contribution.  8.78  Transition from Children’s to Adult Services is always a potentially difficult time for the service user (and service providers) in terms of the introduction of new workers, sharing information and ensuring plans stay on track. The impression given, in examining documentation, is that the arrangements for managing transition were relatively smooth and well coordinated, although there were still major decisions to be made about a future placement.  8.79  There are possibly some queries raised about the different diagnoses being applied to Child F. This will have been complicated by the number of Clinicians who saw Child F and the circumstances in which they saw him. The issue is not so much that a formal, firm diagnosis was not made, rather that the diagnostic status has significant meaning for those commissioning services. This issue needs to be examined by Commissioning agencies.  8.80 Risk was reviewed and assessed by Children’s Social Care throughout their involvement from the point of being remanded in the care of the local authority. There was a good use of the social work consultant in reflecting on and reviewing risk when the social worker was expressing serious concerns about Child F harming himself.  8.81 When Child F was first placed in an emergency foster placement it was assessed that he did pose a risk to risk to other children and he  65 was moved to a residential unit. This was a planned and well-managed move in potentially difficult circumstances.  8.82 There should have been an assessment of the risk that Child F posed to his younger siblings. He had clearly resumed contact at the family home during his time at the Crash Pad. The need for such an assessment appears to have been completely overlooked.  8.83 The initial allegations about domestic violence and being physically assaulted by MP2 emerged during the ASSET assessment and were repeated by Child F to staff at the Supported Accommodation Unit in May/June 2012. Although there was a line manager request to commence an assessment through Section 47 Enquiries this did not take place. Similarly when the family moved geographical and administrative localities, the new local authority where the family had moved were not informed of concerns in relation to the family. This was a significant failing.  8.84  Risk assessments were in place at the Supported Accommodation unit, although it was unclear as to their quality or whether plans to manage risks were fully implemented. This was particularly important in the light of his frequent “missing from care“ status. There was a failure to consider the suitability of the accommodation in terms of Child F’s needs or whether staff had the skills or capacity to manage him safely. These issues were raised by both the allocated social worker and MF as well as doubts expressed by CAMHS. The risks in maintaining Child F at this placement should have been part of an ongoing formal assessment.  Measuring Outcomes 8.85  The measurement of outcomes in Children’s Social Care was through the Pathway Plan and the Care Plan. As indicated earlier in this Overview Report, the Care Plan was of poor quality and not detailed enough to have real meaning.   66 8.86 The Pathway Plan whilst covering more detail contains a litany of failures to meet Plans. These include “not in education or employment”; “not learning independence skills”. There was no indication of clear intended outcomes and the detailed actions required to achieve those proposed outcomes.  8.87  There were some outcome measures that were partially completed in Mental Health services. These included using a scale to monitor symptoms of psychiatric illness, particularly psychotic disorders. Had this been repeated at a later date it would have offered useful comparative information. Similarly another scale used to measure low mood was completed in December 2011 but was not repeated. Some of the difficulties in administrating these scales may have been due to Child F’s reluctance to complete some treatment modes.  8.88  The Supported Accommodation staff did complete daily records of Child F’s mood, for monitoring purposes but it is difficult to determine how accurate these records were or how useful they were in terms of monitoring Child F’s mood changes.  How was the relationship between Child F and MF and family assessed? 8.89   Overall, there was no formal assessment of the relationship between Child F and MF.  Connexions had some contact with MF but this was largely for information exchange purposes and mainly dealt with factual information such as benefits.  8.90 During Child F’s early life his behavior towards and interaction with MF were considered along with other developmental assessments. This information, held by community health agencies, is outside the timescale of the Serious Case Review but it does indicate a number of important points: • There was no evidence to support a diagnosis of Asperger’s syndrome within early developmental assessments  67 • Child F had exhibited behavioural difficulties, angry outbursts and aggressive behaviuor.  • Child F was described as having a difficult relationship with MF.  8.91 There was regular contact between Mental Health Services and MF. Practitioners were aware that the relationship between Child F and MF had broken down.  8.92  MF was described, by mental health staff, as being consistently warm and caring towards Child F. There was no formal relationship work as part of the therapeutic programme. This was particularly surprising as it was clear, from a reading of the documentation, that many of Child F’s emotionally heightened responses were linked to interactions with MF.  8.93  A reasonable hypothesis, from the available information, would be that there may have been some bonding issues because of the non-involvement of FF. Certainly early records describe a difficult relationship between a very young Child F and MF. The loss of MP1, who Child F viewed as a father and the later impact of domestic violence may have left Child F questioning his place within the family and leaving him with angry feelings towards MF. There are some occasions when Child F articulates this anger, linking it very much to feelings of not being wanted by MF.  What consideration did your agency give to the impact of domestic abuse, parental substance misuse and adult offending on the wellbeing of Child F? 8.94  Until May/June 2012 there was very little focus on the impact of domestic violence. This was essentially because domestic violence had not been recognised by key agencies as being a factor in this case. Where it had been recognized information had not been shared between agencies. This suggests a poor understanding of domestic violence and the impact on children, either directly or indirectly.   68 8.95 There was information available about domestic violence. Documentation from health visitor records, in 2005, shows that MF had bruising down the side of her body caused by her partner (MP2). This incident seems to have led to a “refuge being found” but the records indicate that MF went into labour and returned to the family home after the birth.  8.96  There was additional information about domestic violence contained in GP and health visitor records that refer to two serious incidents of domestic violence that occurred in January 2005 when MF suffered a fracture of her nose. The second assault was in June 2007 when MF suffered a nasal injury and was referred to ENT for surgical intervention. Child F was 9 years of age at the time of the first assault and 12 years of age when the second assault took place. Midwife records confirm the assault in 2005.  8.97 There was also information collected about violence shown towards Child F when the CAMHS assessment was undertaken in December 2010. Unfortunately this was recorded inaccurately as FF (not MP2) and as such it is likely that the significance was misunderstood.  8.98  Additional information about domestic violence was available in April 2012 when, in the course of completing the ASSET management assessment, Child F spoke about domestic abuse that had been occurring in the family for 10 years and how he had lived with MF in hostel accommodation in 2006. There is no indication that the significance of this information was acted upon.   8.99  Further information about domestic violence emerged in May 2012 when Child F told his care staff, at the Supported Accommodation unit, he had in the past been kicked and battered by MP2. Child F talked about missing out on his childhood and how home was not a safe place to be. He also alleged that MF was uncaring. There was a sense of Child F feeling that he had never been loved and there was considerable anger towards MF.  69  8.100  The information did lead to consideration between the Police and Children’s Social Care about the need to video tape an interview with Child F for evidential purposes. (Child F refused this and also declined to make a statement).  8.101  It also led to seeking further background information. This showed that although there was no additional information about domestic violence, MP2 had a criminal history of drug use and drug dealing. A decision was taken within Children’s Social Care to update the Core Assessment. Recorded notes show that by 31st May 2012 Children’s Social Care were actively looking at an assessment of Child F’s siblings.  8.102 By the middle of June 2012 MF and the children had moved to Manchester. It is unclear when the exact move took place, however, it is known that MF was informed of the concerns about domestic violence by the Community Psychiatric Nurse at the end of May 2012. It is unlikely that this sharing of information with MF was agreed between agencies and could have had a serious impact on the management of allegations.  8.103 A meeting between MF and Children’s Social Care representatives with Maternal Grandfather and the Community Psychiatric Nurse, on the 15th June 2012, sought to clarify these issues about domestic violence allegations and risk to the children. MF was opposed to the children being seen.  8.104  The opportunity to undertake an assessment was lost through a lack of decisive action and the move to Manchester meant that the local authority would pass over responsibility to another local authority (although this clearly did not happen until the Serious Case Review process identified that this was an outstanding action). There is evidence from Serious Case Reviews, on a national basis, that movement between geographical areas can lead to significant  70 problems in communication and information sharing. This Serious Case Review echoes those findings.  8.105 The key issue that is worrying is that there were extremely significant pieces of information that were not identified by either Children’s Social Care or Mental Health Services until 2012. Both CAMHS and Children’s Social Care had undertaken assessments without uncovering the significance domestic violence. Information was readily available from Health Visitor services and the GP about injuries to MF. This information does not seem to created any concern with the GP or Health Visiting service given that MF had two young children and MP2 returned to the family home in February 2012.  8.106 There are a number of implications. Significant elements of Child F’s behaviour and relationships may have been impacted on by his exposure to domestic violence. Research is explicit about the very serious impact domestic violence can have on children, either through a direct increased risk of physical injury, or the emotional distress of witnessing or being aware of violence (Cleaver et al 2010).  8.107 There can also be a serious impact on the capacity of the carer to fulfill their caring responsibilities to the children. There is an overall impression that Child F’s relationship with MF was strongly influenced by the exposure of the family to domestic violence.   8.108 Apart from immediate action to protect Child F’s siblings in May 2012, there should have been consideration of further work that could have taken place with Child F, as part of his Care Plan and Pathway Plan to address the issue of the impact of domestic violence upon him and how that had in turn damaged the relationship between Child F and MF. This area of work does not appear to have been considered by either Children’s Social Care or by Mental Health services.  8.109  There is also a serious issue about collecting and analyzing assessment material. Had there been discussions between the GP,  71 Mental Health services, Children’s Social Care and Health Visitor services, it is likely that the domestic violence issues would have emerged at a much earlier stage and given context to some of Child F’s responses. There were several opportunities when these discussions could have taken place. During the mental health assessments and the core assessment there were key opportunities to collect and share accurate information.  8.110  In terms of the management of domestic violence issues. There were opportunities to control some of these events. MP2 was released from Prison, on license in early February 2012. There was discussion between the Probation Service Offender Manager and Children’s Social Care as part of the arrangements for where MP2 would live whilst under license. At that time however Children’s Social Care had no information about previous domestic violence and had closed the case.   8.111 Similar discussions between the Offender Manager and the Police  Domestic Violence Unit confirmed that there were no domestic abuse incidents recorded. The first occasion the Offender Manager knew about the domestic violence incidents was when information was being collected for this Serious Case Review.  8.112 Had these incidents been known about it would have allowed a robust discussion between the Offender Manager and Children’s Social Care about whether MP2 would have been allowed to reside at the family address.  8.113 There was an additional opportunity to share information in April/May 2012 when the ASSET assessment revealed domestic violence and also when Child F spoke about incidents. The fact that the Offender Manager was not informed that domestic violence was a key factor suggests a lack of understanding by agencies about license conditions in these circumstances.    72 8.114 There is no documented information indicating that parental substance misuse or adult offending was ever considered by any of the agencies involved with Child F in terms of the impact on him. There was some work undertaken with Child F on his use of cannabis and alcohol but that seems to have had minimal impact.  Was information shared appropriately with other agencies and was information shared with your agency appropriately by other agencies? 8.115  Generally information sharing between agencies was reasonably good with evidence of regular and routine updating of individual agency involvement and sharing information on key events. As with any case as complex as this, there were some gaps in information sharing. These gaps, however, were critical in this case. • There were a number of examples where information from the Supported Accommodation unit was either not given or the need for urgency of information transmission was not appreciated ( the concerns in early January 2013 for example) • The failure of Children’s Social Care to pass on information to a neighbouring authority when the family moved accommodation, in June 2012, was potentially very serious • The failure of agencies to undertake a full and comprehensive assessment using accurate historical information was to have an impact on the understanding of the case • The action taken to inform MF about concerns about the other children in the family (May 2012) was inappropriate and may have impeded protective responses by agencies • Some agencies such as The Children’s Rights Service were not given information about domestic violence occurring in the family • The Probation Offender Manager was not given vital information about domestic violence that might have led to significant changes in the management of the case.  What approach does your agency have to address the issue of young people not engaging/becoming disengaged with your service?  73 8.116 There is good evidence that agencies were persistent in efforts to engage with Child F. In particular the Looked After Children Nurse carefully engaged with Child and the manager of the residential unit, leading to a successful intervention with Child F.  8.117 There was also very good engagement by the Leaving Care Personal advisor and also the Connexions worker.   8.118 Mental Health Services engaged reasonably effectively with Child F, although as with many young people, there were occasions when he refused to be seen or to complete elements of treatment, notably his medication. There was a delay in discussing the diagnosis of Autistic Disorder Spectrum with him. This seems to have been done thoughtfully and sensitively. It seems unlikely that this discussion had a bearing on the suicide.  It was disappointing that Child F was unwilling to see the Psychologist for therapy and it would have been helpful to consider other strategies to engage Child F in these therapeutic sessions prior to closing the case.  8.119 There was also ongoing engagement with Children’s Social Care through social workers, the Children’s Rights Service and there were examples of occasions when Child F had disclosed important information to care staff because of their engagement. There were however also occasions when Child F disengaged and refused contact. When this did occur, practitioners continued to actively retain contact with Child F.  8.120 What does stand out however, despite the involvement of numerous professionals, is that there is such little evidence of Child F’s feelings about his relationship with the family and particularly MF being explored. The marked ambivalence in this relationship does come out in flashes of anger during particular events and incidents. There is no indication that specific focused work on this relationship was considered. There should have been cross agency discussions about how to address this area of work. This does suggest weaknesses in the  74 child protection system in multi-agency work for determining where the responsibility for undertaking different elements of work lies. With some activities this will be straightforward, such as prescribing medication or developing a care plan. Other aspects of work, such as relationship input are not as clear and there are distinct possibilities that there will be assumptions about who is undertaking the work, with the outcome that important pieces of work fall between agencies are not adequately completed.  What indicators of self-harm/suicidal behaviour were presented and were these fully recognised, assessed and acted upon? 8.121  All of the agencies working with Child F at various times expressed concerns that Child F was high risk of self-harm. There was a long history of Child F threatening to harm himself and suicidal ideation. There were also occasions when there was a reported use of ligatures, including shortly before his death.  8.122 In relative terms Child F was at most risk during his period at the Crash Pad when his status of “homeless” significantly increased the risk factor.  8.123 There were also numerous concerns about mental health disorders including, psychotic symptoms, depression, and adjustment disorder. In particular Child F attended A&E on several occasions following suicidal ideation or behaviour. There was no consistency of follow up from his care coordinator and the Individual Management Review encompassing mental health services rightly points to the need for a protocol to ensure that there is such consistency and that multiple use of Section 136 triggers multi agency planning.  8.124 It was also known that Child F responded poorly to stress factors and had mood swings often with angry and impulsive behaviour. He had, also, from his accounts, experienced violence within his family and felt unloved and rejected.   75 8.125 There was, importantly, a history of repeat attempts and threats of self-harm, often in dramatic circumstances, such as locations on Motorway bridges. Adolescent suicide attempters are at risk for completed suicide theoretically because the attempt(s) break the taboo inhibiting self-harm and make suicide a potential option to problems (Beck – 1996). Elements of this thinking can be seen with Child F adopting self harming and suicidal options at early stages in stressful situations.  8.126 All of the evidence suggests that staff from different agencies took the risk of suicide very seriously indeed. This ranged from a Police Officer commenting on the likelihood that Child F would succeed if he continued his attempts at self-harm to the social worker expressing concern to her manager about the very high level of risk of Child F either killing himself accidentally or on purpose.  8.127 There was potential for some confusion between agencies about the level of risk. There had been a serious incident at the Supported Accommodation on the 18th September 2012 when Child F had completely trashed his bedroom. Child F spoke to the Personal Advisor (Leaving Care team) and he said that he was intending to kill himself and that “he would get it right as he was aware that if he got it wrong he would be sectioned”. On this occasion, Child F handed over a noose made from cable and shoelaces that he had tied together. This caused some alarm leading to a request for a Professionals Meting that took place on the 12th October 2012. It was noted at the meeting that his suicide risk was assessed as low to medium, although it was noted that his risk was heightened when he was intoxicated.  8.128 From a systems approach perspective Child F was in a high risk population. A number of measures would have been needed in order to minimise the high possibility of self-harm. The complexity of managing these different interacting elements was always going to be a serious challenge for agencies working with Child F. Although there  76 were clearly ongoing discussions between agencies and a number of professional and agency meetings, it was difficult to detect a very clear plan that all agencies were working to and had agreed that covered suicide prevention in this case. Such a plan may have included very practical measures such as monitoring of medication, through to psychological therapies, to social engagement activities, through to relationship work and future placements.  8.129 It is clear that many of these elements were present in work being undertaken with Child F. The complexity of how the elements relate to and interact with one another does mean, however, that very tight coordination is required between agency activities. There is not a sense that coordination was as rigorous as it needed to be in this case.  8.130 As important as indicators of self-harming behaviour are the factors that may protect adolescents from repeated attempts or completed suicide. There are some suggestions for example that an improved living environment may be a protective factor. Similarly adequate social relationships, strong support systems and high educational achievement have all been cited as possible protective factors. There was not enough systematic consideration given to some of these protective factors in this case.    8.131 Although Child F was clearly at high risk, current knowledge on the specific risk factors for adolescent completed suicide is not conclusive. The available research suggests that further understanding is needed on the mediating mechanisms of family related risk factors, and the role of anti-social and aggressive behaviour in adolescent suicide (Marttunen et al- 1993).   8.132 Similarly Spirito and Overholster (2003) comment that in general research that has attempted to predict suicidal behaviour has failed. Because of the low base rate for suicidal behaviour in the general  77 population it is not possible to predict that a given individual would make a suicide attempt or complete suicide in the near future.  8.133 The most effective strategy for managing suicide risk may involve protecting high-risk groups at high-risk times. In Child F’s case he was high risk because of his mental health and, for a time, his homelessness. His vulnerability may have been increased because of factors such as an impulsive cognitive manner, poor problem solving skills, ongoing family discord and social isolation. It is probable that for Child F’s high-risk times were triggered by stressful life events. The use of cannabis and alcohol may have had the impact of increasing the likelihood of impulsive or aggressive acts.  9.     SUMMARY AND CONCLUSION 9.1   Child F was a deeply troubled young man, who was at high risk of self- harm.  He was, however, both bright and articulate.  He also demonstrated an insight into his own situation. Despite the efforts of agencies to minimise the risks there were some very clear weaknesses in the coordination and provision of services.  9.2  The lack of involvement of some agencies prior to March 2012 was worrying. In particular, the decisions by Children’s Social Care that Child F was not a Child in Need, despite his homeless status and obvious emotional/psychological turmoil suggests that, if this case is typical, the threshold criteria for acceptance of referrals by Children’s Social Care is too high. This is addressed as Recommendation 1.  9.3  The placing of Child F, for an extended period, during 2011 to March 2012 in the Crash Pad was inappropriate and was likely to increase his loneliness and isolation. It was also likely to increase the risk factors. It was disappointing to note that there seemed to be a professional acceptance that this was the only placement alternative. It was always likely to have a negative impact on any therapeutic progress being made and should have been rigorously challenged. It  78 was also disappointing that there was a lack of coordination between various agencies in identifying appropriate accommodation for Child F at this time. The issue of accommodation for homeless young people is addressed as Recommendation 2.  9.4  Assessments were of poor quality. There was significant historical information that could have offered insight into Child F’s relationships within his family. In particular, the impact of domestic violence was not identified and its significance not understood until May/June 2012. Even then there was no evidence of work being undertaken with Child F or MF to explore the important issue of family violence. There was a continual backdrop, to this case of Child F’s anger towards MF that was never fully explored or appreciated. There was, for example, a particularly poignant discussion in May 2012 between Child F and his care worker where Child F articulated the reasons why he felt angry towards MF and her lack of care towards him. These areas of key relationships in his life needed to be followed up as fully as possible.  9.5   The consistent finding in Serious Case Reviews that historical information is not used properly, suggests that practitioners may not be equipped with adequate skills in collecting and analysing such information.  The Munro Review (2011) suggests that there are distinct components in a healthy whole systems approach that: • Enables critical thinking • Provides emotional support • Facilitates effective inter agency working The evidence from this Serious Case Review suggests systems need to be in place to encourage professionalism and critical approaches to practice. This would require both training and developing expertise, supported by systems, including that encourage such an approach. Without this fundamental change it seems likely that assessments will remain a weakness within child protection systems.  The issue of historical information is addressed as Recommendation 3.   79 9.6  There was generally good evidence of information sharing between agencies. The complexities of several agencies interacting and information being generated from multiple sources, however, suggests that even where there is a climate of openness and a willingness to share information there is a need for all agencies to be aware that the sharing of information is likely to be a weakness within systems. This is best illustrated through two examples. • Both the GP and health visitor (2004-2007) were aware that MF had sustained physical injuries because of domestic violence. That information was never made available to other agencies. Similarly it was known by the health visitor and midwife that MF had presented with extensive bruising just prior to the birth of Child FS2. This led to the placement in a refuge. This information should have led to concerns about MP2’s involvement with the family and the safety of the children. • When MF and the children moved to Manchester in June 2012, there should have been an automatic referral to Manchester about concerns in relation to domestic violence and the care of the children. There was no documented evidence that such a referral took place.  9.7    There were also some concerns that reports from the Supported Accommodation residential unit were not always adequately reflecting Child F’s challenging behaviour or his mood. In particular the incident on New Years day 2013, when Child F threatened to hang himself was not reported to the Early Intervention Team or the Social Care Duty Officer.  9.8    Although there were established mechanisms for ensuring that plans for Child F were in place, it was not always clear how those individual agency plans came together to form a corporate whole person plan. The LAC Care Plan, for example, was largely generalised and aspirational with very little detail about practical steps that were required. There was also no sense that the Care Programme Approach  80 and the LAC Care Plan interacted with one another, or whether there were areas of gaps in services between the two key plans.   9.9   There is a significant challenge for agencies here in ensuring that different planning mechanisms harmonise and there is a clear understanding of what each agency is doing and how that fits into the actions by other agencies. This requires a really sophisticated understanding of the roles of other agencies and is more likely to occur successfully when there is an established multi-agency mechanism such as a Child Protection Review process. However many cases, such as this one, are equally complex, and do not have the benefit of a Child Protection Plan. A more strategic approach to inter-agency work where there are clear and agreed plans and direction of agency input with monitoring of activities needs to be introduced.  This is addressed as Recommendation 4  9.10   Throughout the placement in Supported Accommodation, there were a series of meetings, (co-coordinated by Children’s Social Care or CAMHS), on a two monthly basis. Whilst the meetings were well attended and information was shared, there is a sense of a lack of direction with no clear plans being achieved. Although concerns were voiced and shared, there seems little evidence of a tight, structured understanding of who is doing what and how it fits in with the overall intended outcomes for Child F. It is noteworthy, for example that the assessment visit of the Adolescent Forensic Service Practitioner in mid January 2013 led to the Practitioner expressing concerns about plans to move Child F to a less supportive environment when he was 18 years of age. The concerns, which were realistic, were in relation to his coping abilities and quite correctly challenged the view that Child F could cope more independently.   9.11   A key example of this lack of direction lay with plans for the future placement for Child F. It had been generally accepted by those engaged with Child F that the current placement in supported accommodation was not suitable and that a more specialist placement  81 would be required, preferably where there was therapeutic input. At the stage of Child F’s death a future placement had still not been identified.  9.12   There was a failure to put in place effective Child Protection Plans in relation to Child F’s siblings. This was evident in the lack of a proper investigation into the risk Child F potentially posed to his siblings and also the risks that MP2 posed to the younger children. Even when the risk was identified, actions were not robust or effective. Recommendation 5  9.13  A major concern lies with agencies not understanding the nature and meaning of domestic violence in this case. Although there have been significant developments nationally in recent years about domestic violence, this case illustrates that in practical terms a number of agencies may still not be following appropriate procedures in the management of domestic violence. As research has evidenced that an Analysis of Serious Case Reviews found evidence of past or present domestic violence present in over half (53%) of cases (Brandon et al – (2009). it is extremely worrying, given the prevalence of domestic violence, it was not given the significance it merited in this case. Recommendation 6  9.14  It is of equal concern that there were gaps in agency understanding of key parts of child protection systems. The role of the Probation Service in the management of offenders had a critical role to play in this case. It was clear that some agencies did not understand that role in the context of safeguarding children. Recommendation 7  9.15   There was also evidence that practitioners found some of the mental health diagnostic terminology confusing and at times conflicting. It is clearly important that there is a shared understanding, at a functional level, between agencies of the language being used to describe mental health disorders. Recommendation 8   82 9.16  There have been concerns identified in this Serious Case Review about the use of accommodation for young people who are Looked After Children or Care leavers. This accommodation referred to as ‘supported accommodation” in this Serious Case Review is effectively called “supported lodgings” by providers. This means that the accommodation is not registered with Ofsted and not subject to the same level of regulation as, for example, children’s homes. This is a national problem that should be brought to the attention of Government. Recommendation 9  9.17  This is an extremely tragic case of a young man who through a combination of factors, as outlined in this Serious Case Review, appears to have taken his own life.   9.18  Prediction of self-harm and suicidal behaviour is not a straightforward science and it would not have been possible to predict with absolute certainty that Child F would commit suicide.  9.19  There were however so many repeated attempts and threats of suicide, alongside ongoing suicidal ideation that there is a sense of a very tragic inevitability. This was recognised by several of the practitioners working with Child F.  9.20  Similarly it is not possible to say whether Child F’s death was preventable. It is just not possible to know if different interventions would have had any positive impact on the outcome.   9.21  There are a number of lessons that can be learned, however, to improve services to vulnerable children and young people with similar problems to Child F. The challenge for all agencies is to ensure that those lessons are embedded in practice in the future.  9.22  This Serious Case Review has identified a number of areas where improvements in services and systems can be made. There has been a firm commitment by agencies to work towards implementing the  83 recommendations of this Review. Bury Children’s Social Care, for example, are actively undertaking a review of thresholds for accessing their services. Similarly Mental Health services have commenced work to improve multi agency planning where there are multiple Section 136 orders. This work and the implementation of all of the individual agency and Overview Report recommendations should make a significant contribution to the improvement of services.  10.   OVERVIEW REPORT RECOMMENDATIONS  1. Bury Safeguarding Children Board should review the application of thresholds for intervention for Children in Need (S17 Children Act).  2. Bury Safeguarding Children Board should ensure that there are clear and coherent multi-agency plans for the management of homeless young people, aged 16-17 years.  3. Bury Safeguarding Children Board should encourage and contribute to a suitably robust auditing exercise, focused on the accumulation, sharing and interpretation of case histories in the course of multi-agency assessments.  The purpose of this audit exercise will be to indicate whether all agencies are making optimal use of the information they hold and whether practitioners engaged in assessments are completing thorough and competent analyses.  4. Bury Safeguarding Children Board should review the different planning processes, for service users, across agencies in order to promote more effective corporate planning for inter agency safeguarding of children with complex needs.  5. Bury Safeguarding Children Board should ensure that all front line practitioners and their managers have the opportunity of learning lessons from this Serious Case Review.  84  6. Bury Safeguarding Children Board should review how agencies have implemented updated procedures and are monitoring practice standards in dealing with domestic violence.  7. Bury Safeguarding Children Board should examine safeguarding training programmes to ensure that there are no significant gaps in learning.  8. Bury Safeguarding Children Board should ensure that forums and mechanisms are in place for practitioners to share information, including the use of basic diagnostic terminology, about child and adolescent mental health.  9. Bury Safeguarding Children Board should notify the Department of Education about concerns, identified in the Serious Case Review, that unregulated service providers are accommodating vulnerable young people.  11. INDIVIDUAL AGENCY RECOMMENDATIONS  Mental Health Services  1. A section 136 of the Mental Health Act for a young person aged under 18 years and under should trigger prompt (within 7 days) follow-up by the patient’s own team, ideally the care-coordinator.  Multiple use of 136 in brief timescale should trigger multi agency planning.  2. Early Intervention Team (EIT) and CAMHS to ensure robust pathways which provide clarity about roles and responsibilities for jointly working with under 18s.  3. For there to be a protocol developed around the communication of discharges from Tier 4 for under 18s to their Community Psychiatrist.   85 4. To deliver awareness training around Autism Spectrum Disorder to inpatient staff on specialist mental health units and the Early Intervention Team.  5. An internal review should be completed within the Bury EIT service to review the impact on care of the service reconfiguration and any lessons learned be embedded in to future reorganisations within the Trust.   6. For children in looked after placements all attempts should be made to guarantee the involvement of the residential care staff in CPA processes.   7. Transition plans should ensure that a consistent person remains involved with young people for as long as is needed and that review of the pace and subsequent impact of changes to key staff is incorporated into the risk management plan.  8. To develop a CAMHS Directorate forum for consultation/case discussion about young people aged under 18 years who present with complexity and intermittent high risk and who span multiple agencies and mental health services.  9. To improve access to multi-agency training, including knowledge around the impact of domestic violence on children and young people.   Connexions 1.  Connexions to implement measures to improve information recording on the Core+ database.  2.  Good practice identified to be promoted to all staff.  Greater Manchester Police 1. A formal and detailed review of the new Mental Ill Health, Mental incapacity and Learning Disabilities policy and guidance is conducted  86 twelve months after inception to ensure it’s effectiveness in protecting those with vulnerabilities through mental ill health or disorder.  Bury Children’s Social Care 1. Southwark compliance: The agency should review its practice in respect of young people aged 16/17 to ensure that it has in place • Assessments that focus on the vulnerability of the young person • Interventions that can facilitate mediation between the young person and their families • A robust protocol with housing  2. Quality of assessments: The agency should develop practice standards and a quality assurance process that ensures assessments are of good quality and form a sound basis for planning for children.  3. Management oversight: The agency should develop practice standards and a quality assurance process that ensures management oversight of and involvement in cases is regular and proportionate to the needs of the case.  4. Construction of Care Plans: The agency should consider issuing practice guidance and offering training to social workers, their managers and Independent Reviewing Officers on the proper construction of Looked After Children Care Plans.  5. Reflective practice: The agency should continue the work it has started to introduce reflective practice as a regular element of case supervision.  6. Placements for Young People aged 16/17:  87 The agency should consider raising this issue through the Placements North West planning group and if appropriate at the Regional Safeguarding Strategic Leads group.  Barnardo’s 1. To review the referral and allocation systems in the service.   Pennine Care Foundation Trust, Community Services Bury 1. All health practitioners who have the responsibilities of assessing the needs of children must complete Level 3 Safeguarding training every three years. 2. Management and Clinical supervision must always include a section where supervisors check that supervisees have not encountered any unreported safeguarding issues and discuss safeguarding aspects of practice 3. Where health practitioners identify they are working with children from the same family eg health visitors, school nurses, children community team, they ensure that safeguarding concerns are shared. 4. To review and develop protocols for the processing of A&E notifications which are received by health visitors and school nurses. GP No recommendations were made. Supported Accommodation Provider 1. Ensure that when working with other agencies, staff need to obtain a named person in the absence of a named professional. 2. Continue with extensive placement plans and risk management.  All meetings to be recorded in depth and any cancellations to be recorded. 3. Managers to be trained on writing IMR reports.  88 Bury Children’s Service- Learning (Schools). 1. Schools to be more proactive in seeking information and must record any attempts made to contact other agencies for information.  2. Where invites are received to high level meetings every attempt should be made for a representative to attend.  3. Schools strongly advised of the importance of detailed and accurate record keeping, including some analysis of need and reflection on success of interventions.  Use of the SMART system to be further promoted and schools encouraged to use.  4. Develop use of CAF for permanently excluded pupils.          89 APPENDIX 1 - RESEARCH SOURCES  Beck, A (1996) Beyond belief: A Theory of modes, personality, and psychopathology. In Frontiers of cognitive therapy ed P. Salkovkis. Guilford Press , New York.  Brandon, Marian et al (2012) New learning from serious case reviews. Research  Report DFE-RR226. Department of Education. London  Brandon, Marian et al (2009) Understanding Serious Case Reviews and their impact: A biennial Analysis of Serious Case Reviews. Department of Education. London.  Cleaver, H et al (2010) Children’s Needs – parenting Capacity: The impact of parental mental illness, learning disability, problem alcohol and drug use and domestic violence on children’s safety and development. London. The Stationery Office (second edition).  Marttunen, Mauri et al (1993) Adolescence and Suicide: A Review of Psychological Autopsy Studies. Journal of European Child and Adolescent Psychiatry. Vol 2. Issue 1.  Munro Eileen (2011) The Munro Review of Child Protection. Stationery Office. London.  Spirito, Anthony and Overholser, James C (2003) Evaluating and Treating Adolescent Suicide Attmpters: From Research to Practice. Academic Press. New York and London.