Death of a 16-year-old boy by apparent suicide in February 2018. Mario initially lived with mother and maternal grandmother with siblings 1 and 3 and moved in with father and sibling 2 a year later; his parents had divorced in 2010. All four siblings were subject to child protection plans in April 2013 due to emotional abuse arising from parental conflict and domestic abuse, with Mario's case closing in April 2014. School raised concerns over Mario's mood due to defacing school equipment and a teacher overhearing him discussing suicide; referred him to an in-school counselling service. Mario disclosed physical abuse by father on two occasions and the school contacted the multi-agency safeguarding hub (MASH) for advice. Sibling 1 reported that Mario was possibly anorexic to MASH and had seen Mario self-harming at his father's house. Mario used school computers for web searches relating to suicide and self-harm which were blocked but not reported to school. Ethnicity/nationality unknown. Findings include: practitioners viewed Mario in isolation from concerns about his wider family; advice provided to school by MASH was not consistent with safeguarding policy and practice; Mario was not linked to domestic abuse incidents at his mother's house; and the counselling service's safeguarding policy and practice requires development. Makes recommendations including: increase awareness of the antecedents of suicide amongst children and young people; share learning with schools in the local authority; and ensure assessments consider the needs of siblings not living in the household.
      
 Title:  Mario (Case A18): serious case review: overview report. LSCB: Bury Safeguarding Children Board Author: David Mellor Date of publication: 2018  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.                                           Bury Safeguarding Children Board  Serious Case Review  Mario (Case A18)   SERIOUS CASE REVIEW  OVERVIEW REPORT    Report Author:  David Mellor Date:    26 October 2018   Commissioned by: Bury Safeguarding Children Board                                                             2  Contents 1.0 Introduction ............................................................................... 4 2.0 Terms of Reference ..................................................................... 4 Lines of enquiry ..............................................................................4 3.0 Glossary ...................................................................................... 5 4.0 Synopsis ..................................................................................... 7 Significant events which took place prior to October 2016 ....................8 October 2016 to 4th February 2018 .................................................. 12 2017 ........................................................................................... 16 2018 ........................................................................................... 22 5.0 Views of Family ......................................................................... 23 6.0 Analysis .................................................................................... 29 How effectively did agencies respond to any disclosures made, or concerns expressed, by Mario? ....................................................... 29 To what extent did agencies consider the impact on Mario of concerns affecting the child’s wider family? .................................................... 32 To what extent did agencies consider the impact of domestic abuse on Mario and take appropriate action in response? ................................. 35 To what extent was information about concerns affecting the wider family appropriately shared with agencies providing support to Mario? . 36 To what extent were agency interventions with Mario informed by relevant prior concerns? ................................................................. 38 To what extent did practitioners adopt a ‘think family’ approach when interacting with Mario and his family? .............................................. 38 To what extent did practitioners listen to Mario’s voice? Were his wishes and feelings heard and understood? ...................................... 39 To what extent did practitioners remain sufficiently child focused when they faced challenges to engaging with Mario and his family?. ............ 40 To what extent were safeguarding children procedures followed? ........ 41 Mario’s parents indicated that they would like the review to address the extent to which they (the parents) were informed about concerns about, and support provided to, Mario. ............................................ 43 Good practice ............................................................................... 44 7.0 Findings and Recommendations ............................................... 44 Awareness of suicide antecedents ................................................... 44 Recommendation 1 .......................................................................... 46 Dissemination of learning to schools ................................................ 47 Recommendation 2 .......................................................................... 47                                                             3  Suicide Prevention ......................................................................... 47 Recommendation 3 .......................................................................... 47 ‘Think Family’ ............................................................................... 47 Recommendation 4 .......................................................................... 48 Recommendation 5 .......................................................................... 49 Recommendation 6 .......................................................................... 49 Recommendation 7 .......................................................................... 49 MASH response to disclosure of physical abuse ................................. 49 Recommendation 8 .......................................................................... 49 Access to harmful websites............................................................. 49 Recommendation 9 .......................................................................... 50 Doki Doki Game ............................................................................ 50 Information Sharing ...................................................................... 51 Recommendation 10 ........................................................................ 51 Safeguarding policy and practice ..................................................... 51 (Single Agency) Recommendation 11 .............................................. 51 Recommendation 12 ........................................................................ 52 References ....................................................................................... 52 Appendix A ...................................................................................... 53 Single Agency Recommendations .................................................... 53 Appendix B ...................................................................................... 55 Process by which SCR completed and membership of the SCR Panel .... 55                                                                4  1.0 Introduction 1.1 On 4th February 2018 a young person who will be referred to in this report as Mario died after apparently taking his own life.  1.2 Following Mario’s death, Bury Safeguarding Children Board decided to conduct a serious case review (SCR) on the grounds that a child had died and that there were lessons to be learned from the way in which agencies worked together with the child and his family.  1.3 The Safeguarding Children Board commissioned David Mellor to be the independent lead reviewer for this SCR. David is a retired chief police officer and former independent chair of safeguarding children and adults boards who has over six years experience of conducting SCRs and other statutory reviews. He has no connection to Bury or any of the agencies involved in this case. An SCR panel was established to oversee this review and membership of this group and a description of the process by which this SCR was carried out is shown in Appendix B. 1.4 An inquest into the death of Mario will take place in due course.  2.0 Terms of Reference 2.1 The period covered by this SCR is from October 2016, when serious concerns about the impact of domestic abuse on Mario’s wider family arose, until the date of Mario’s death on 4th February 2018.  Significant events which took place prior to October 2016 are also included within the scope of the review. 2.2 It was also decided that the SCR would explore the following key lines of enquiry: Lines of enquiry  To what extent did agencies consider the impact on Mario of concerns affecting the child’s wider family?  To what extent was information about concerns affecting the wider family appropriately shared with agencies providing support to Mario?                                                             5   To what extent did practitioners adopt a ‘think family’ approach when interacting with Mario and his family?  To what extent did practitioners listen to Mario’s voice? Were his wishes and feelings heard and understood?  How effectively did agencies respond to any disclosures made, or concerns expressed, by Mario?  To what extent were safeguarding children procedures followed?  To what extent did agencies consider the impact of domestic abuse on Mario and take appropriate action in response?  To what extent were agency interventions with Mario informed by relevant prior concerns?  To what extent did practitioners remain sufficiently child focused when they faced challenges to engaging with Mario and his family?  How effectively was Mario’s suicide related internet use monitored?  Mario’s parents indicated that they would like the review to address the extent to which they (the parents) were informed about concerns about, and support provided to, their son.   3.0 Glossary A Child in Need (CiN) is defined under the Children Act 1989 as a child who is unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services; or a child who is disabled. Child and Family Assessment (CAFA) The purpose of the assessment is to determine if there is identifiable evidence of risk or identifiable significant harm to the child or whether they are unlikely to achieve or maintain a reasonable standard of health or development or they have a disability. Domestic violence and abuse is any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members                                                             6  regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse:   psychological   physical   sexual    financial  emotional Controlling behaviour is a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.  Coercive behaviour is a continuing act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim. Independent Domestic Violence Advisor (IDVA) Their main purpose is to address the safety of victims at high risk of harm from intimate partners, ex-partners or family members in order to secure their safety and the safety of their children. Serving as a victim’s primary point of contact, IDVAs normally work with their clients from the point of crisis to assess the level of risk, discuss the range of suitable options and develop safety plans.  Multi Agency Risk Assessment Conference (MARAC) is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists from the statutory and voluntary sectors. A victim/survivor should be referred to the relevant MARAC if they are an adult (16+) who resides in the area and are at high risk of domestic violence from their adult (16+) partner, ex-partner or family member, regardless of gender or sexuality.                                                              7  (SafeLives) DASH (Domestic Abuse, Stalking and “Honour”-based violence) is a commonly accepted tool which was designed to help front line practitioners identify high risk cases of domestic abuse, stalking and ‘honour’-based violence and to decide which cases should be referred to the Multi Agency Risk Assessment Conference (MARAC) and what other support might be required.  Sanctuary Scheme is a multi-agency victim centred initiative which aims to enable households at risk of violence to remain in their own homes and reduce repeat victimisation through the provision of enhanced security measures and support. Section 47 Children Act enquiry – Children’s Social Care must carry out an investigation when they have “reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer significant harm”. The enquiry will involve an assessment of a child’s needs and those caring for the child to meet them. Team Around the Child (TAC) This approach brings together relevant practitioners to address the needs of the child or young person. The team works together to plan coordinated support from agencies to address problems in a holistic way. The TAC process is focused on children and young people before they reach the threshold for social care intervention.  4.0 Synopsis 4.1 Mario was born in 2002 and was the youngest of four siblings born to mother and father. Mario’s elder siblings will be referred to chronologically as siblings 1, 2 and 3. After Mario’s mother and father divorced in 2012, mother subsequently gave birth to another child with a different partner who will be referred to as child 5. 4.2 As previously stated the primary focus of this SCR is on relevant events which took place during the period from October 2016 until Mario’s death on 4th February 2018. However, significant events which took place prior to October 2016 will also be addressed.                                                              8  Significant events which took place prior to October 2016 4.3 Mother and father separated in 2012. Initially mother and siblings 1, 3 and Mario moved in with maternal grandmother whilst sibling 2 remained with father. The separation of mother and father was acrimonious and mother was referred to a Multi-Agency Risk Assessment Conference (MARAC) in October 2012 after several incidents in which father was regarded as the perpetrator and mother as the victim of domestic abuse.  4.4 Children’s social care became involved with Mario in November 2012. At that time Mario was missing sibling 2, experiencing some difficulties in his relationship with mother’s new partner (partner 1), and struggling with literacy at school where he was behaving disruptively at times. He was frequently described as ‘angry’ and began staying with his maternal grandmother. (Mother, siblings 1, 3 and Mario had moved out of maternal grandmother’s home by this time).  4.5 Around March 2013 Mario left mother and moved to live with father and sibling 2. It was said that all the children resented partner 1, particularly Mario. (Father’s address was approximately five miles from mother’s address). 4.6 In April 2013 all four siblings were made subject to child protection plans under the category of emotional abuse arising from continuing parental conflict and domestic abuse. It was agreed that Mario and sibling 2 would be referred to Child and Adolescent Mental Health Services (CAMHS) although father questioned both this referral and their further engagement with children’s social care. Although Mario appeared quite resistant to engaging with his social worker, by September 2013 he was perceived to be ‘safe and well’ in his father’s care and doing well at school. During a review child protection conference meeting held the same month improvements were noted in respect of Mario and sibling 2, whilst less progress was considered to have been achieved in respect of siblings 1 and 3. Also in September 2013 mother was again referred to MARAC as a victim and father as the perpetrator of domestic abuse.  4.7 In February 2014 Mario and sibling 2 were ‘stepped down’ from child protection plans to monitoring as children in need as their needs no longer                                                             9  justified child protection arrangements. They both continued to reside with father where the atmosphere was described as ‘calm and relaxed’. In April 2014 the cases of Mario and sibling 2 were closed to children’s social care. 4.8 Mario transferred to his secondary school in September 2014. Mario’s primary school head teacher appears to have shared some information about Mario’s history, specifically that he was living with his father and had been removed from a child protection plan whilst the siblings who were living with mother remained on a child protection plan. By October 2014 siblings 1 and 3 had also been removed from their child protection plan after a positive assessment of mother’s parenting capacity. 4.9 During September 2014 conflict between father and sibling 2 led to the latter moving back to mother leaving Mario as the only sibling living with father. Sibling 2 alleged that father had assaulted him. The police were involved but decided to take no further action. During that month father took Mario to hospital A&E where he was treated for pain to his ribs said to have been the result of an assault by sibling 2. After X-rays revealed no fractures, Mario was discharged home. Following the departure of sibling 2, all of Mario’s siblings were then attending a different school to him. 4.10 Following his return to live with mother, sibling 2 became involved in a domestic incident with mother’s new partner (partner 2) in December 2014 to which the police were called. Team Around the Child (TAC) arrangements were put in place to support the family at this time and sibling 2 went to live with maternal grandmother for a period. 4.11 In early 2015 concerns arose over Mario’s school attendance and under achievement in a number of subjects. He received support in school for literacy difficulties. Father was finding it difficult to attend parents’ evenings and when separate appointments were made he cancelled them on more than one occasion because of work commitments. 4.12 During May 2015 Mario was found to have been damaging school computer keyboards and a monitor. This led to concerns about Mario’s low mood and his                                                             10  habit of picking at the skin on his fingers. He was provided with a ‘doodle pad’ to try and prevent him defacing school equipment. Later that month Mario commented in class that his holiday destination would be ‘to go to Hell’. His teacher also overheard a discussion between Mario and a fellow pupil in which committing suicide was referred to. The teacher judged that Mario was not saying he intended to commit suicide. From discussions with Mario, teaching staff formed the view that he was experiencing low mood as a result of an accumulation of issues including feelings of failure, getting into trouble at school and fear of how his father would respond to the news that he had been damaging school computer equipment. The school decided to offer Mario pastoral support in the hope that a trusting relationship would develop which could allow Mario to be more forthcoming about his worries. 4.13 The following month Mario was excluded from school for two days after swearing at a member of staff. When Mario’s father was informed he expressed the view that his son had not been treated fairly.  4.14 In January 2016 concerns arose over Mario’s school attendance record although it was noted that two of his main absences were due to a ‘gastro bug’.  4.15 On 16th March 2016 Mario damaged a computer mouse at school. When spoken to by his head of year, Mario expressed concern about what his father would say when he found out he was in trouble again. He disclosed that his father shouted at him and had hit him and grabbed him in the past. He was also worried about being removed from father’s care. Mario disclosed that he had three siblings who lived with mother, that he worried about mother, that her partner (partner 2) had been ‘kicked out’, that the partner had ‘smashed her car up’, that his mother and father had split up 3 or 4 years previously ‘due to fighting’ and that ‘social services had been involved’.  4.16 The school contacted Bury Multi-Agency Safeguarding Hub (MASH) for advice on how to proceed. The MASH noted Mario’s allegation that father had hit him and informed the school that Mario’s siblings were open to children’s social care although Mario was not. The advice from the MASH was for the school to further explore Mario’s relationship with his father and to arrange a further                                                             11  consultation with MASH if required. The head of year spoke to Mario again who reiterated that father shouted and hit him and had slapped him on the cheek in the past. However, Mario appeared to become more settled and when a second contact was made with the MASH, their advice to the school head of year was to ring father and ‘judge his response’ before deciding on what action to take, including further contact with the MASH if necessary. 4.17 The school contacted father who was said to have adopted a supportive tone towards Mario. Mario later confirmed that he had gone home and had a ‘good chat’ with his father who had admitted he sometimes went overboard with his shouting and would try and control this in future. Mario agreed to a referral to Relateen, an in-school counselling service provided by the Relationship Hub. The referral form stated that the reason for making it was ‘anxieties – lets worries build up’. The referral form also stated that Mario’s father was aware of the referral. Mario was placed on a waiting list.  4.18 During April 2016 mother contacted the police to say that her ex-partner (partner 2) was harassing her by texting and calling her. When the police attended mother alleged that partner 2 had taken her car without consent in January 2016 and crashed it. She alleged that he had forced her to take responsibility for the crash. Fearful of partner 2, mother said she made a false report to her car insurance company stating that she had been the driver of the car at the time of the incident. The insurance company had recently contacted her to advise that they had become aware that she had made a false statement about the incident. This news had prompted her to contact the police. A DASH (Domestic Abuse, Stalking and “Honour”-based violence) risk assessment was completed which assessed mother as being at ‘high’ risk of domestic abuse. The case was referred to MARAC and referrals were made to children’s social care and other partner agencies. The referrals linked Mario to mother. Partner 2 was arrested the same day.  4.19 Also during April 2016 Mario was placed on report as a result of concerns about his academic progress.                                                              12  4.20 On 4th May 2016 MARAC considered the domestic abuse incident involving mother and partner 2. MARAC was informed that there was a history of violent and controlling behaviour by partner 2. Bail conditions were in place although partner 2’s parents lived near mother’s home. Mother was said to have rejected the suggestion that she and her children move elsewhere. Mother stated that she was no longer in a relationship with partner 2, had no contact with him and was exploring obtaining a restraining order. MARAC was informed that mother’s children were open* to children’s social care and that the service was attempting to complete a children and families assessment (CAFA) but mother was said not to be engaging in this process. (*Mario was not open to children’s social care at that time so it seems that he was not included in the CAFA).  4.21 On 29th May 2016 sibling 1 contacted the police to report that eight males including partner 2 had attended mother’s house and had assaulted mother. The police attended and mother, who was visibly upset, refused to disclose what had happened. Sibling 1 repeated her allegation that men had turned up at the address and attacked mother and had since left. The officer assessed the risk as ‘standard’ and made no referrals. Mario was not linked to this incident. 4.22 On 14th September 2016 Mario received a school detention after an altercation with another pupil. Mario became distressed and was seen by a school first aider to whom he disclosed that he was afraid of how father would respond when told about the incident. He said he was worried about father hitting him and disclosed that he had hit him on the previous Sunday (three days earlier). The school reflected on the advice previously received from the MASH and sought more information from Mario, who said he had ‘back-chatted’ father who had then grabbed his arm which caused Mario to bump his eye on the sofa. Mario had no visible marks as a result of the incident. The school then telephoned father in Mario’s presence and decided that it was safe for Mario to return home that evening. October 2016 to 4th February 2018 4.23 During the early hours of Sunday 9th October 2016 mother was assaulted by partner 2 whilst they were staying in a hotel in Blackpool with child 5. At the                                                             13  time partner 2 was on pre-charge bail in respect of the earlier assault on mother in the Greater Manchester Police area (Paragraph 4.18). Partner 2 was subject to bail conditions in respect of this earlier assault which stated he was not to contact mother or enter the road on which she lived in Bury. 4.24 Mother reported the incident to Lancashire Constabulary but declined to make any complaint against partner 2. She was noted to have recent marks on her face and bruising to her eyes which was fading. Partner 2 had left the scene prior to police arrival. Mother and child 5 were moved to another room in the same hotel. Mother co-operated with a DASH risk assessment during which she disclosed that partner 2 had previously assaulted her, that the violence was getting worse and that he had made threats to kill himself during previous arguments. Mother was assessed as being at ‘high’ risk of domestic abuse and this information was passed to Greater Manchester Police (GMP) to facilitate a local MARAC referral.  4.25 Two days later partner 2 made counter allegations of assault against mother. He was located and arrested by GMP for his alleged assault on mother in Blackpool. He was then transferred to the custody of Lancashire Constabulary. No details of any outcome of this arrest have been shared with this SCR. 4.26 Mother returned to her home in Bury on Sunday 9th October 2016 and was visited by officers from GMP who repeated the DASH risk assessment, also concluding that mother was at ‘high’ risk. Mother provided a statement of complaint to GMP which stated that following an argument over money, partner 2 repeatedly punched and kicked her resulting in bruising to her eyes and arms. Mother was referred to MARAC and referrals were also made to children’s social care and ‘health’. A safety plan was put in place for mother. In the documentation completed for GMP’s Public Protection Investigation Unit (PPIU) no reference was made to Mario. 4.27 A strategy meeting took place on 11th or 12th October 2016 following concerns that mother was maintaining a relationship with partner 2 and, as a result, this was exposing sibling 2, 3 and child 5 to the risk of domestic abuse. (Sibling 1 was an adult by this time). The outcome of the strategy meeting was                                                             14  that sibling 2, 3 and child 5 were to be referred to an initial child protection conference (ICPC).  4.28 On 2nd November 2016 the referral in respect of the assault on mother was discussed at a MARAC meeting. The outcome was for the Independent Domestic Violence Advisor (IDVA) to contact mother and establish whether partner 2 had access to mother’s home address, in particular whether he had keys to the address. It appears that no further action was being taken in respect of the Blackpool incident ‘due to injuries to both parties’.  4.29 On 3rd November 2016 Mario attended an initial meeting with a Relateen counsellor at school at which there was a brief exploration of his worries and feelings. 4.30 A week later Mario attended a second meeting with the counsellor during which there was more time available to explore issues. He reported being angry around people. He disclosed that his parents had separated when he was younger and he lived with father. He said he rarely had contact with mother with whom he was angry for being in abusive relationships and had told her this. He was also said to be angry with mother for not contacting him. He said he had good relationships with father, an aunt and his maternal grandmother.  4.31 At the next meeting with the counsellor on 17th November 2016, Mario spoke of meeting with his mother who had a black eye which she told him had been caused by falling out of bed. Mario questioned the truthfulness of his mother’s explanation and expressed concern that she was seeing an ex-boyfriend who he had heard had been released from prison. (Presumed to be partner 2) Mario said he was worried about child 5 witnessing domestic violence ‘because she (child 5) was hitting out’. Following this session, the counsellor discussed Mario’s case in supervision and it was decided that the counsellor would speak with Mario about sharing his concerns with the school safeguarding lead or head of year. 4.32 One week later (24th November 2016) Mario saw his counsellor again and said that he thought his family did not consider his feelings important and so he                                                             15  didn’t want to talk to them about his feelings. The counsellor spoke with her supervisor over the telephone and subsequently spoke to the head of year at Mario’s school about the concerns raised by Mario during the counselling meeting dated 17th November 2016 (Paragraph 4.31). The school state that this conversation did not take place until 23rd January 2017 (Paragraph 4.42). However, Relateen state that this conversation with the school head of year had taken place by 24th November 2017 although the concerns raised by Mario were not put in writing until 26th January 2017 (Paragraph 4.44). 4.33 On 28th November 2016 an attendance improvement support report was completed in respect of Mario. This would enable a programme of support to be put in place to improve his school attendance which was categorised as ‘poor’. 4.34 A further meeting took place between Mario and his counsellor on 1st December 2016 at which Mario expressed anxiety about meeting mother ‘and family’ and how he would talk to them. The counsellor responded by giving Mario an exercise to complete at home which was intended to help Mario with ‘emotions and positive thoughts’. The counsellor subsequently discussed the case in supervision once again where the possibility of inviting Mario’s father to a counselling meeting was discussed. It was thought that it would be helpful for Mario to discuss his worries about his mother with his father. 4.35 On 5th December 2016 Mario was seen by his GP in company with father. Mario had an upper respiratory tract infection and had had a frontal headache since the previous day. He had a dry, sore throat and said he felt sick. Father said Mario had lost weight recently. The GP arranged for a blood test to investigate the weight loss. The possibility that Mario was suffering from a viral illness was also considered by the GP. Two days later Mario’s blood results came back as ‘essentially normal’. The blood tests were to be repeated in 4-6 weeks but Mario did not attend the GP practice for these tests. There is no indication that Mario’s weight was monitored over time. 4.36 On 15th December 2016 Mario met his counsellor and spoke of his worries about no-one wanting to employ him. He agreed that it would help if father came to a counselling meeting.                                                             16  2017 4.37 On 13th January 2017 children’s social care completed Section 47 enquiries (which had presumably been initiated following the 11th or 12th October 2016 strategy meeting (Paragraph 4.27)) and concluded that as child 5 had been present when partner 2 assaulted mother on 9th October 2016, the case should progress to an initial child protection conference (ICPC). 4.38 On 18th January 2017 a school nurse carried out a home visit to mother’s address in order to share information from her report to the forthcoming ICPC. 4.39 The following day Mario saw his counsellor for the first meeting of the new year. He said he had had a good Christmas break and had spoken to father about coming to a future meeting to discuss his mother’s safety ‘and domestic violence’ but thought father might be too busy with his work. The counsellor was to seek the permission of the school for the involvement of father.  4.40 On 20th January 2017 the ICPC took place. According to the children’s social care chronology sibling 3 and child 5 were made subject to child protection plans under the category of emotional abuse as a result of domestic violence. According to school nurse and police records sibling 2 was also made subject to a child protection plan. Mario was identified as a sibling in the school nurse report but was noted to have resided with father for some time and his contact with his siblings was said to be ‘not known’. The police record of the ICPC states that Mario was designated as a ’significant other’. Police markers were placed on the addresses of mother, father and maternal grandmother.  4.41 On 23rd January 2017 a school nurse completed a health assessment in respect of sibling 3 as part of the child protection plan. Sibling 3 reported low mood for which mother was said to be contacting their GP for support. Sibling 3 expressed concerns about mother’s ex-partner who he said had ‘abused and terrorised’ his mother. Sibling 3 was accessing mental health services and had open access to his school nurse drop in. The school nurse subsequently liaised with sibling 3’s school who intended to refer him to the Relateen counselling service.                                                              17  4.42 On the same date, Mario’s counsellor contacted the school head of year to discuss the safeguarding concerns first disclosed by Mario on 17th November 2016 (Paragraph 4.31). These concerns were articulated as Mario used to live with mother but went to live with father after witnessing domestic violence. Mario was said to maintain contact with his mother who was said to have had a number of abusive relationships. Mario was said to have never witnessed domestic abuse but had noticed that his mother had a black eye which she had claimed had been caused by falling out of bed. He had heard father and his maternal grandmother discussing the domestic abuse. He believed that ‘when things got bad’ mother and child 5 went to stay with maternal grandmother. Mario was concerned that child 5, who was two years old, was witnessing domestic violence. After receiving this information, the head of year was advised by school senior management to telephone the MASH, speak to the school nurse and request they contact the health visitor. The school is unable to confirm whether Mario was in fact referred to the school nurse. The counsellor was asked to write up the concerns she had shared in respect of Mario so that they could be passed to the school’s safeguarding lead. 4.43 The next day (24th January 2017) Mario’s counsellor informed the school that she was sending the safeguarding concerns in respect of Mario to her line manager to read through. The school responded by saying that the written details of the safeguarding concerns were needed as soon as possible as the MASH was said to be waiting for them.  4.44 On 26th January 2017 the written safeguarding concerns in respect of Mario were shared with the school head of year. Later that day the school contacted the MASH by telephone to confirm the contents of the report provided by Relateen. A children’s social care contact note dated the following day recorded that they had been informed by Mario’s school that he had seen mother with a black eye and suspected that her partner was responsible although mother claimed that she had fallen out of bed. This information was shared with the social workers supporting sibling 3 and child 5’s social worker. On the same day, Mario met his counsellor and said he had not seen his family for a month. He said                                                             18  he worried about his own future relationships. The counsellor informed Mario of the actions she had taken in response of his disclosures about the impact of domestic abuse on his mother and child 5 and Mario was said to be pleased about this.  4.45 On 30th January 2017 Mario’s counsellor asked the head of year whether he was allowed to ‘fiddle with blu tac in class, and the head of year confirmed that he was.  4.46 On 2nd February 2017 Mario’s counsellor reviewed the value of the counselling with him. Mario said that the counselling wasn’t making things better or worse but that he wanted it to continue. During the meeting Mario disclosed that he spent a lot of time staring at the ceiling at weekends. (Father said that Mario often stared at the ceilings whilst lying down on his bed or the settee and listening to music on his headphones. He didn’t perceive this as an indication of low mood).  4.47 On 6th February 2017 sibling 3 attended the school nurse drop at his school and during the course of the conversation said that mother was experiencing some difficulties in seeing Mario. However, in his next counselling meeting three days later, Mario said he was looking forward to going for a walk with mother. 4.48 On 16th February 2017 Mario met his counsellor and said he had enjoyed his walk with mother. He was invited to consider places where he felt safe and his response was ‘at his friends’. Mario was also invited to consider his hopes for the future which he said were a ‘dog and a family’. 4.49 On 27th February 2017 partner 2 contacted the police via 999 to report that mother had stolen his phone. He said he was ringing from his parent’s address. He said he was tired and wished to go to bed and so the response to the incident was delayed. An officer subsequently attended and a DASH risk assessment was completed which assessed risk as ‘medium’. When reviewed by a specialist officer the risk was adjusted to ‘standard’.  4.50 Later the same date sibling 3 attended A&E with ‘disturbed thoughts’ and was seen by CAMHS. The following day (28th February 2017) sibling 3 was taken                                                             19  to hospital by the ambulance service after he had contacted them to say that he felt suicidal and could do ‘something stupid’ following a family argument. Sibling 3 was later discharged. The hospital notified the school nurse of his school and a referral was sent to the Healthy Young Minds (HYM) service. HYM noted that sibling 3 was subject to a child protection plan and that a risk management plan was in place for him of which his social worker was aware.  4.51 On 2nd March 2017 Mario saw his counsellor who told him that children’s social care ‘had decided that no further action was needed with mother’, about which Mario was said to be relieved. It appears that Mario was misinformed by the counsellor. The school had apparently advised the counsellor that ‘no further action’ was required of her in respect of documenting Mario’s concerns. It appears that the counsellor had understood the term ‘no further action’ to refer to outcome of Mario’s concerns. The counselling sessions were again reviewed and Mario said he thought they were helping and wanted them to continue. 4.52 On 6th March 2017 sibling 3 was seen by HYM and told them that he did not have any thoughts of self-harm or suicide. After discussion with sibling 3’s social worker, it was decided that CAMHS would monitor his mental health thereafter.  4.53 The following day sibling 1 telephoned the MASH to express concern that Mario was anorexic. Enquiries were made with school, health services and father. Mario was described as a ‘nervy young man’ who bit his nails. Father said that Mario was having a growth spurt, that he had already taken him to the GP and planned to take him again before Easter. (There is no record of father taking Mario to the GP at that time). The MASH asked the school head of year to speak with Mario. When spoken to Mario said that ‘things were a lot better’. The MASH decided to take no further action. Mario was invited to the school nurse drop in at his school but did not attend. 4.54 On 9th March 2017 Mario attended counselling and said he had plans to go hiking with friends during the school holidays, adding that he wanted to ‘feel peaceful away from everyone’.                                                              20  4.55 On 14th March 2017 the school nurse discussed sibling 2 and sibling 3 in safeguarding supervision. Sibling 3 was reported to be living with his maternal grandmother and sibling 2 was reported to be living with his girlfriend. Mario was also discussed and was noted to continue to live with father. The emotional impact of domestic abuse on the children was discussed. 4.56 On 16th March 2017 Mario met his counsellor and discussed his shyness with people. In response the counsellor outlined strategies for coping with this. 4.57 On 23rd March 2017 Mario saw his counsellor and expressed concern that people might think he was ‘weird’ and therefore not like him. The counsellor helped him reflect on the friends who knew and liked him. 4.58 On 4th April 2017 a review child protection conference took place at which it was decided that sibling 2 and 3 and child 5 would continue on a child protection plan under the category of emotional abuse. Mario was mentioned as a significant other but mother was said to have ‘very limited contact’ with him.  4.59 On 19th April 2017 a MARAC meeting took place at which sibling 1 was referred as a victim and partner A as the perpetrator. Partner A was said to be in prison and his release date was to be ascertained. Concerns about this relationship continued for a number of months. Amongst the concerns raised was possible contact between partner A and sibling 1’s siblings. Mario was included in the list of siblings considered.  4.60 On 4th May 2017 Mario met his counsellor and disclosed that he had been avoiding coming to the meetings (last session attended was on 23rd March 2017) because he ‘got nervous talking’ but wished to continue the meetings. He went on to disclose that a friend had self-harmed in February. The counsellor advised Mario that she may have to report this disclosure. The counsellor subsequently discussed the matter in supervision where it was agreed that the counsellor would talk to Mario about helping the friend, who Mario had now identified by name, talk to an adult or possibly talk to Mario as an alternative. Another option discussed was for the counsellor to report the incident to school.                                                             21  4.61 On 7th May 2017 mother contacted the police via 999 to report that her ex-partner (partner 2) had visited her address and been banging on the door. She described him to be drunk and aggressive. The police attended and concluded that no offences had been disclosed. The incident was risk assessed as ‘medium’ and later adjusted to ‘standard’ when reviewed by a specialist officer. Referrals were sent to children’s social care, ‘education’ (not including Mario’s school) and ‘health’. 4.62 On 18th May 2017 Mario met his counsellor and it was agreed that the counsellor would report the self-harm incident involving his friend to the school head of year. Mario was said to be struggling to understand why his friend had self-harmed. 4.63 On 24th May 2017 father contacted school to say that Mario was too upset to attend school that day as sibling 2’s girlfriend had given birth the previous night and that the child had died shortly after birth. Various members of school staff were advised but it is unclear whether Mario’s counsellor was informed at this point. On the same date mother contacted her health visitor ‘in a distressed state’ to pass on the same news. The health visitor planned to make a home visit to mother to offer emotional support and discuss the emotional impact on sibling 2 and child 5. 4.64 On 15th June 2017 Mario attended a meeting with his counsellor. Two meetings had been cancelled owing to the counsellor being unwell. A discussion took place about working towards ending the counselling when the current school academic year came to an end. Mario said he wanted to work on self-confidence and dealing with anxiety until then. Apparently it is usual practice to end counselling before the school summer holidays. 4.65 On 20th June 2017 a school nurse saw sibling 2 at his girlfriend’s house for checks on his growth, hearing and vision. He disclosed that the recent loss of the baby had had an impact upon him emotionally and he had suffered anxiety and panic attacks. He was advised to self-refer to his GP and the Healthy Minds service.                                                              22  4.66 On the same date a core group meeting in relation to the child protection plan for sibling 2, 3 and child 5 was cancelled because of unavailability of staff. The meeting was rearranged for 5th July 2017 but no details of the meeting have been shared with this review. 4.67 On 11th July 2017 Mario and another pupil were warned after homophobic bullying and name calling another pupil. The head of year was to monitor the situation.  4.68 Two days later Mario attended his final counselling appointment after missing three successive meetings, although two of these were because special events were taking place within the school. Mario said he thought the counselling had helped but was happy to end the sessions. He disclosed that he had had some time off school as a result of a family bereavement. He indicated that this difficult experience had somehow helped him to feel more mature and confident.  4.69 A review child protection conference took place on 20th September 2017 at which it was decided that siblings 2, 3 and child 5 were no longer to be subject to child protection plans. They were to be monitored for a short period as children in need. Siblings 2 and 3 had moved back to live with mother. Sibling 2 was hoping to study engineering and sibling 3 had achieved well in his GCSEs and had recently started college. Once again, mother was reported to have very little contact with Mario.    4.70 The first child in need meeting in respect of siblings 2, 3 and 5, which had been scheduled to take place on 24th October 2017, was cancelled and on 27th November 2017 their cases were closed to children’s social care.  4.71 On 28th November 2017 Mario attended his GP in company with father. He complained of having general aches and pains for almost three weeks and said he felt dizzy on standing at times. Blood samples were taken for testing and found to be normal. 2018 4.72 On 12th January 2018 Mario attempted to make a series of web searches on school computers relating to ‘how to kill myself’ and ‘how to tie a noose’. All                                                             23  searches were blocked by Smoothwall which is a system which prevents access to inappropriate websites. At that time, the system was unable to flag up searches on the school computer which gave rise to concern and so Mario’s searches were not escalated. 4.73 On 17th January 2018 Mario and other pupils were involved in a name calling incident during class which led to sanctions being issued to some of the pupils. No sanction was issued to Mario. 4.74 On 18th January 2018 Mario attempted to make a series of web searches on school computers relating to ‘why shouldn’t I commit suicide?’ and ‘Kill me’. Mario had attempted to disguise the ‘why shouldn’t I commit suicide?’ searches by randomly adding numbers to the text of the question. He succeeded in gaining access to page setting out sources of support. The ‘kill me’ searches were again blocked by Smoothwall. 4.75 The following day Mario attempted to make a series of web searches relating to ‘suicide tablets’ which generated images of tablets. 4.76 On 4th February 2018 Mario was found dead at his home address after apparently hanging himself. Mario had been alone in the house at the time.  5.0 Views of Family 5.1 Mario’s mother, father and maternal grandmother chose to contribute to this SCR. It had been decided not to invite Mario’s siblings to contribute to the review on the grounds that they may find the experience distressing. However, when the independent lead reviewer visited mother to enable her to read the final SCR report, sibling 1 was present and wished to contribute to the review.  5.2 Father said that Mario had lived with him for a number of years and so he saw him every day. Both parents said that Mario loved computer games, the outdoors including climbing, swimming, hot tubs, the sea and the beach. Father described Mario as happy in his life, adding that though his son had good and bad days at school he would set off early for school each day and always return home happy.                                                              24  5.3 Father had a slight concern that Mario had to make all the effort in order to meet up with his friends. They didn’t call on him. He called on them and he would often return home early from visiting a friend and say that the friend had not been available because he was doing something else. However, he said that much of Mario’s contact with friends and his siblings was online. Father said he would often walk past Mario’s bedroom in the evening and hear him talking and laughing with one of his brothers over skype whilst simultaneously playing a computer game with them.  5.4 Mother said she generally saw Mario at her mother’s home two or three times a week. She said that Mario’s maternal grandmother often collected him from the home he shared with his father and drove him to the metro station from which he caught a tram to school. She would also collect him from the same metro station at the end of the school day. If mother was visiting her mother’s home, Mario would often call in to see his mother after being collected from the tram station at the end of the school day.  5.5 In the last two years of Mario’s life, mother said she had found it difficult to encourage him to visit her at her home. She attributed his reluctance to visit her to the fact that he was going through his teenage years and would rather ‘be with his mates’. 5.6 Mother said that Mario had a good relationship with his maternal grandmother, with whom he would have conversations whilst she was transporting him back and forward to the metro station. Mother said that her mother recalled Mario asking her questions about the ‘afterlife’ after his paternal grandfather died in November 2017. 5.7 The death of his paternal grandfather was one of two bereavements Mario experienced in 2017. As well as being present alongside other family members when his paternal grandfather died, Mario also arrived just after his nephew (sibling 2’s son) died shortly after birth in May 2017. His parents said that the death of his nephew ‘broke Mario’s heart’. They said that after suffering these two bereavements, Mario began questioning ‘why deaths had to happen’.                                                             25  5.8 Mother disclosed that both Mario’s elder siblings were aware that he was self-harming by cutting his arms. Mother added that sibling 1 had seen him cutting his arm in the bathroom at father’s house. This was later confirmed by sibling 1 who said she had seen Mario cutting his wrist with a razor blade around the beginning of 2017. Mother said that she had been unaware of Mario self-harming. Father said that sibling 1 had had told him that Mario had cut his arms but that when he (father) spoke to Mario about it, he denied that he had cut himself and let his father check his arms for marks on that occasion. Father said he monitored the situation thereafter but never saw any marks on Mario. Maternal grandmother saw marks on Mario’s wrist in the month before he died which she suspected were self-harm cuts. (Mario did not disclose self-harming behaviour to any practitioner although several fellow pupils interviewed by the police after Mario’s death said that they were aware that he cut his arms). 5.9 Father said that Mario’s secondary school had provided him with learning support as a result of his dyslexia but that this had stopped at the end of year 9. He said he was expecting the support to resume in January or February 2018. He said he didn’t know why the support had been interrupted but had assumed it was something to do with resources (See Paragraph 6.41 for the school explanation that Mario no longer met the criteria for Special Educational Needs (SEN) support. The school adds that Mario had not been diagnosed with dyslexia). 5.10 Mario’s parents said that he enjoyed art and had expressed an interest in a career in animation. He spent a lot of time drawing at the kitchen table at home. Father added that Mario began drawing the characters from the Doki Doki computer game although he (father) didn’t know anything about the game or the characters until after Mario’s death. Both parents expressed concern about the themes of the game having a dangerous impact on children who played the game. Mother said she believed Mario purchased the Doki Doki game soon after it became commercially available in September 2017.  5.11 When asked if they had any other concerns about Mario, mother said that he had had a ‘self-image problem’ in that he didn’t like the way he looked and                                                             26  often said he was ugly. She added that Mario had felt this way for a number of years. Both mother and father said that Mario was thin, with ‘no fat on him’, despite ‘eating like a horse’. Father said he took him to see the GP twice about this issue and that blood tests were taken which were found to be normal. The GP was reassuring and said that Mario was thin because of a growth spurt. His parents said he was 6’ 1” in height at the time of his death. Mother said that she felt that it was not unusual for teenagers to worry about their self-image and had expected Mario to pass through this phase in his life. 5.12 Father and mother added that Mario had a fear of going into shops on his own and was very reluctant to do so. His mother attributed this to ‘social anxiety’. 5.13 Both parents said that they felt let down by Mario’s school and the counselling service to which the school referred him. They said that his school had not told them about Mario talking about suicide and had not told them that they had referred him to Relateen. Father said he was the parent with whom Mario’s school had contact and would have expected them to have told him about the above issues (The school acknowledges that father was not informed about the conversation in which Mario mentioned suicide, but state that he was advised of Mario’s referral to counselling – see Paragraph 6.42). His parents were also concerned that Mario’s attempts to access suicide related websites on school computers had not led to immediate action (See Paragraphs 6.50 to 6.53. The school adds that ‘immediate action’ was taken to block Mario’s access to the websites). Mother added that she didn’t really have a relationship with Mario’s school as all of his siblings had attended a different secondary school.  5.14 Maternal grandmother said that she saw Mario most days during school term time as she would often drive him to the Metro station to catch the tram to school. She would often pick him up at the end of the school day. If mother was visiting maternal grandmother’s house with child 5, Mario would sometimes call in and spend time with them at the end of the school day. 5.15 Maternal grandmother said that in her opinion Mario was in fear of father. He worried about doing anything which would get him into trouble with father.                                                             27  She said that Mario was even worried about letting father know that she (maternal grandmother) had given him a lift to or from school in case that angered father. She said that father discouraged Mario from visiting mother and also restricted him from seeing his siblings. She felt he did this in order to continue to exercise some control over mother. Maternal grandmother said that Mario had told her that father had said he would kill himself if Mario left him to return to mother. (Father said that he never discouraged Mario from visiting mother’s house, adding that sometimes Mario did not enjoy his visits to mother).  5.16 She said she became very worried about Mario’s weight loss when she saw him in September 2017. This was straight after the school summer holidays during which she had seen less of him. She says she was shocked at how much weight he had lost. He seemed to have had a growth spurt but this could not account for how thin Mario appeared. Maternal grandmother expressed her concerns to other family members but added that father wasn’t very good at taking Mario to see his GP. She mentioned an example of Mario having a persistent nose bleed which she said he needed to see his GP about. She says she kept asking Mario if his father had arranged a GP appointment yet and Mario said he hadn’t.  5.17 Maternal grandmother said she was aware that Mario often missed out on breakfast and so she would carry some breakfast bars in her car so that he could eat them whilst she drove him to the Metro station. She added that he would sometimes bring home the sandwiches he had taken to school for lunch. He would ask her to get rid of the sandwiches for him before he left her house to go home to his father at the end of the school day. She said that she would ask him why he hadn’t eaten his sandwiches and he replied that he didn’t like them. When she said that he should tell his father so father could make him sandwiches he liked, Mario said that doing this would only get him in trouble. (Father responded to these comments by saying that Mario chose not to eat breakfast from time to time and had sometimes told father he had eaten breakfast when this was not the case. Father said he also became aware that Mario had thrown away his lunchtime sandwiches. He added that Mario had asked for school                                                             28  dinners instead but father had told him that he could not afford to pay for them. Father said he took Mario to see his GP about weight loss and that this had been ‘all sorted’. (See Paragraph 4.35)) 5.18 During the month before his death, maternal grandmother noticed a number of cuts on Mario’s wrist. She said that one of the cuts looked quite deep. She said that Mario had been trying to cover up the cuts with the sleeve of his school blazer. When she asked Mario about the cuts he said that they had been accidentally caused by a bush. She said that she didn’t think this explanation was true. 5.19 Sibling 1 briefly contributed to this review. She said that father was physically abusive to Mario and that she had seen him hit Mario and sibling 2. She added that when Mario and sibling 2 were living with father, they had told her that father had told them to say nothing to the social workers who were working with them at that time.  5.20 She also said that she had become very worried that Mario had developed an eating disorder and that this had prompted her to contact the MASH in March 2017 (Paragraph 4.53). 5.21 Mother and father were given the opportunity to read and comment on the final draft of this report. Mother read the report and said she was satisfied with the report and its findings. The only comment she made was that she had worried about how sibling 2 and Mario would get on in their father’s care. She said she based her worry on how strict father had been with the children prior to the divorce and the threats of violence he had made against her which had led to his referrals to MARAC. She said that she had raised her concerns with a social worker but that no action had been taken. Father separately read the report and also said he was satisfied with the report and the findings. He commented that he felt that ‘physical abuse’ had been over-emphasised. He acknowledged that he sometimes lost his temper with Mario and ‘clipped him around the ear’ and slapped him. However, he said that Mario was ‘never beaten’.                                                              29  6.0 Analysis 6.1 In this section of the report the terms of reference questions for this SCR will be considered in turn. How effectively did agencies respond to any disclosures made, or concerns expressed, by Mario? 6.2 During May 2015 Mario commented in class that his holiday destination would be ‘to go to Hell’. His teacher also overheard a discussion between Mario and a peer in which committing suicide was referred to (Paragraph 4.12). From discussions with Mario, teaching staff formed the view that Mario was not saying he intended to commit suicide but was experiencing low mood as a result of an accumulation of issues including feelings of failure, getting into trouble at school and fear of how his father would respond to the news that he had been damaging computer keyboards and a monitor at school. The school decided to offer Mario pastoral support in the hope that a trusting relationship would develop which could allow Mario to be more forthcoming about his worries. Given, the school’s lack of awareness of the wider family issues which may have been affecting Mario at that time, the school’s response was appropriate, although Mario’s father is critical of the decision not to inform him that Mario had discussed suicide (Paragraph 5.13). The school had a telephone conversation with father in response to this incident in which some of Mario’s difficulties at school were discussed. It would have been helpful if that discussion had included reference to Mario’s comments about suicide. 6.3 In March and September 2016 Mario made separate disclosures of physical abuse by father to members of school staff. Both disclosures appeared to have been prompted by Mario’s fear of father’s reaction to him getting into trouble at school. In the first disclosure Mario alleged that his father had hit and slapped him in the past (Paragraph 4.16). This prompted dialogue between the school and the MASH which ultimately led to the matter being resolved by Mario’s head of year speaking with father over the telephone. The positive tone of this conversation                                                             30  gave the school confidence that Mario could be allowed to return home at the end of the school day and a follow up conversation with Mario the next day appeared to confirm that he and his father had had a positive exchange in which father had said he would try and restrain his tendency to ‘go overboard’ in future. However, sharing Mario’s disclosure with the person who was alleged to have abused him, had exposed Mario to the risk of further abuse from father.  6.4 Children’s social care now take the view that the MASH response was not appropriate as Mario’s behaviour had deteriorated in school, he was clearly worried about how his father was going to respond and had stated that he had been hit by father previously. Consideration should have been given to initiating child protection enquiries under Section 47 of the Children Act. The MASH had a much fuller knowledge of wider family concerns than the school at this point, although Mario did begin to disclose some of these concerns to his head of year at this time. The school was unaware that father had previously been referred to MARAC for domestic abuse (Paragraph 4.3) and it is unclear whether MASH took this fact into account when advising the school how to respond. 6.5 The second disclosure of physical abuse in September 2016 (Paragraph 4.22) was more serious because on this occasion Mario gave a recent date for the physical abuse and this incident represented an escalation. Father had been advised by the school following the March 2016 incident and had apparently committed to adjusting his behaviour towards Mario. Yet six months later Mario alleged he had been assaulted by father again. However, the school decided that as this incident was similar to the previous incident, the approach they adopted to the first incident would be followed. No contact was made with the MASH on this occasion but the approach which had emerged from the discussion between the school and the MASH in respect of the March 2016 incident was replicated.  6.6 It seems clear that the approach adopted by the MASH in March 2016 de-escalated the response to Mario’s first disclosure of physical abuse and strongly influenced the school’s response to his second disclosure. The possibility that the MASH may be in possession of relevant information about Mario and/or his wider family which could have had a bearing on deciding how to respond to Mario’s                                                             31  second disclosure did not apparently occur to the school. Nor did the school apparently give sufficient weight to the information Mario had shared with them about his family circumstances when he made his first disclosure of physical abuse in March 2016 (see Paragraph 4.15).  6.7 On 17th November 2016 Mario disclosed to his Relateen counsellor his suspicion that mother had been assaulted by a former partner and not been truthful about the cause of an injury Mario had noticed. Mario expressed particular concern about the impact of child 5 witnessing domestic violence involving mother and her ex-partner. After consulting with her supervisor, the counsellor discussed the disclosure with Mario’s head of year. Relateen state that this discussion took place by 24th November 2016 whilst the school state that the discussion did not take place until 23rd January 2017 (Paragraph 4.32). Whichever version is correct, there was an exceedingly long delay in alerting the MASH to the concerns raised by Mario. The concerns were not put in writing by Relateen until 26th January 2017 (Paragraph 4.44). 6.8 It appears that the focus of Relateen may have been primarily on the impact of the domestic abuse on Mario and that the urgency of making a safeguarding referral in respect of child 5 (then aged two) received less emphasis. At the time that Mario made the disclosure to his counsellor in November 2016 agencies were aware of the domestic abuse and siblings 2, 3 and child 5 had been referred to ICPC and Section 47 enquiries initiated (Paragraph 4.27). Mario had not been considered by partner agencies to be at risk. A prompt referral at that time may have drawn Mario and the potential impact of the domestic abuse on him to the attention of agencies, although when Mario’s disclosure was belatedly referred to MASH in January 2017, it did not achieve the effect of raising the awareness of agencies to the potential impact of domestic abuse in mother’s household on Mario (Paragraph 4.44). 6.9 A further issue Mario disclosed to his counsellor was self-harm by a friend (Paragraph 4.60). This again raised concern about their safeguarding practice in that some emphasis was placed on Mario consenting to the sharing of information relating to the pupil with school. And the suggestion that Mario might                                                             32  be asked to encourage the other pupil to report self-harm did not appear to have much to commend it. The pupil needed professional adult intervention and there was the issue of how further exposure to his friend’s distress might affect Mario. 6.10 In March 2017 a concern was expressed on behalf of Mario by sibling 1 (Paragraph 4.53) who reported to the MASH that Mario might be anorexic. Enquiries were made with the school, Mario’s school health practitioner and father. No evidence was identified to substantiate sibling 1’s concerns about her brother.  Father was advised to take Mario to see his GP and responded by saying that he had already done this and was planning a follow up appointment before Easter. He added that Mario was experiencing a growth spurt. Father had taken Mario to see his GP in December 2016 (Paragraph 4.35) when he told the GP that his son had lost weight recently. Blood tests were ‘essentially normal’ but there is no evidence that the blood tests were repeated after 4-6 weeks as planned nor is there evidence that Mario’s weight was monitored subsequently. Father did not take Mario to see his GP ‘before Easter’ 2017. He did not take Mario to see his GP until November 2017 (Paragraph 4.71) when anorexia was not raised as an issue. On that occasion blood tests revealed nothing abnormal.  6.11 The disclosure from sibling 1 did not result in enquiries being made with Mario’s GP which was a missed opportunity. The MASH did contact Mario’s school health practitioner who invited him to a school health drop in which Mario did not attend and, in respect of which, no follow up action was taken. This was a missed opportunity for the school health practitioner to proactively engage with Mario. To what extent did agencies consider the impact on Mario of concerns affecting the child’s wider family? 6.12 Either of Mario’s disclosures of physical abuse could have led to an assessment. Had any assessment been carried out it seems likely to have shed light on the range of concerns affecting his wider family which may have been impacting on Mario’s health and wellbeing. Given the missed opportunities to carry out assessments of Mario, the challenge for agencies in contact with his wider family was to fully consider the impact of these concerns on Mario.                                                              33  6.13 There were several occasions when risks to Mario were considered by practitioners. Mario was linked to the allegation of domestic abuse mother made against partner 2 in April 2016 (Paragraph 4.18) but was not included in the CAFA completed by children’s social care in response to this incident (Paragraph 4.20). The police placed markers on the addresses of mother, maternal grandmother and father after mother’s domestic abuse allegations against partner 2 in October 2016 (Paragraph 4.40). Mario was identified as a sibling in the school nurse report prepared for the ICPC in January 2017 and Mario was also noted to be a ‘significant other’ in the police record of the same meeting. (Paragraph 4.40) He was included in the list of sibling’s concern was expressed about, as a result of the relationship between sibling 1 and partner A (Paragraph 4.59). 6.14 On other occasions, risks to Mario were not considered. He was not linked to the domestic abuse incident involving mother and partner 2 reported to the police in May 2016 (Paragraph 4.21) nor was he initially linked to the domestic abuse incident which took place in Lancashire in October 2016 (Paragraph 4.26) or considered as part of the Section 47 enquiries which followed. Mario was not linked to further domestic abuse incidents involving mother and partner 2 in February 2017 (Paragraph 4.49) and May 2017 (Paragraph 4.61). 6.15 However, when Mario was linked to concerns affecting mother and his siblings there was an assumption that he had very limited contact with mother (Paragraphs 4.58 and 4.69) or the level of contact was not enquired into. Agencies generally appeared to take an unhelpfully narrow view of what constituted ‘contact’ between mother and Mario, focusing on the frequency of physical visits to her address. In her contribution to this review, mother has acknowledged her difficulty in encouraging Mario to visit her address (Paragraph 5.5) but says she saw him regularly at his maternal grandmother’s address (Paragraph 5.4). Additionally, it seems clear that Mario enjoyed substantial contact with some of his siblings through skype and playing computer games online (Paragraph 5.3). It is also clear that he was sensitive to concerns affecting                                                             34  the lives of his siblings from the disclosures he made to his Relateen counsellor in respect of child 5 (Paragraph 4.31). 6.16 Another factor in the risks to Mario being overlooked or downplayed was the judgement that because he was not resident with mother, he was at no immediate risk of harm. This was a valid judgement to make. It was right for the primary focus to be on the siblings who were resident with mother and therefore at immediate risk of emotional abuse arising from domestic abuse. However, having excluded Mario from risk considerations because the risk to him was not immediate, Mario remained excluded when agencies moved beyond consideration of the immediate risks. In the final two years of Mario’s life a considerable number of non-immediate risks were beginning to accumulate which did not become visible to practitioners. 6.17 Mario’s needs may have received greater attention had father been involved in child protection meetings in respect of Mario’s siblings. He retained parental responsibility for sibling 2 and Mario but did not appear to have been formally invited to participate in decision making in respect of them.  6.18 Health visiting, school nursing and Healthy Young Minds had a varying amount of contact with Mario’s siblings. Mario was evidenced in all his siblings’ health records as part of the family composition but there was little enquiry into his wellbeing. Once again, the fact that he was living at a different address appears to have diminished professional curiosity in respect of Mario.  6.19 Mario had a different school health practitioner to his siblings. Therefore, whist the school health practitioner for his siblings was aware of the challenges the children were facing when living at mother’s address, Mario’s school health practitioner was not privy to that information. Mario is clearly evident in the genogram which forms part of the (school health practitioner) safeguarding supervision documentation in respect of his siblings but the impact on Mario of the challenges faced by his siblings was not considered in safeguarding supervision.                                                             35  To what extent did agencies consider the impact of domestic abuse on Mario and take appropriate action in response? 6.20 A 2012 children’s social care assessment identified that siblings 1, 2, 3 and Mario had all been emotionally affected by their exposure to historic domestic abuse and the ongoing conflict between mother and father. Exposure to domestic abuse can causes serious physical and psychological harm to children (1). However, research studies tend to focus on children living in a household in which domestic abuse is present. Mario and his siblings were exposed to domestic abuse between mother and father but Mario was no longer a member of the household during the period in which there was domestic abuse between partner 2 and mother. Physical distance from the household in which the domestic abuse was taking place may have reduced the impact on Mario although he benefitted less from the potential protective factor of immediate sibling support. 6.21 After moving to live with father, the police only intermittently recorded Mario as an affected sibling in respect of domestic incidents involving mother and partner 2. The omission of Mario may have been influenced by the wording of DASH guidance and the phrasing of the questions contained within the DASH risk assessment. The safelives guidance on DASH completion refers to the ‘presence’ of children whilst additional questions which GMP has added to the DASH refer to children who ‘live in the household’. Whilst this seems appropriate to enable immediate risks to be identified, there is a risk that the DASH wording diverts attention away from children not present or living within the household. 6.22 A direct impact of omitting Mario from referrals arising from domestic abuse incidents is that no information was sought from Mario’s school health practitioner. 6.23 When Mario moved to live with father and sibling 2 in March 2013 there is no indication that this generated any professional concern arising from father’s prior referral to MARAC as a perpetrator of domestic abuse in November 2012 and his subsequent such referral in September 2013. From September 2014 Mario was the only sibling living with father. Mario’s maternal grandmother has                                                             36  advised this review that in her opinion, father limited Mario’s access to mother and his siblings. Mario voiced fear of father’s reaction when he got into trouble at school and his maternal grandmother also expressed the view that Mario was in fear of father. It seems possible that Mario may have exchanged one household in which he experienced a difficult relationship with mother’s then partner for a household in which he may have been in fear of, or experienced, physical abuse. To what extent was information about concerns affecting the wider family appropriately shared with agencies providing support to Mario? 6.24 As Mario accessed universal services only from the point at which his case was closed to children’s social care in April 2014, the agency which provided the majority of support to Mario was the secondary school which he attended from September 2014 until his death. 6.25 When Mario transferred to his secondary school in September 2014 his transfer documentation included no information about prior safeguarding concerns and stated that no agencies were currently engaged with him. However, Mario’s primary school head teacher shared limited information about his history, specifically that he was living with his father and had been removed from a child protection plan whilst his siblings who were living with mother remained on a child protection plan (Paragraph 4.8). (This wasn’t completely accurate information as sibling 2’s case had also been closed to children’s social care in April 2014). 6.26 It is not known how much further information Mario’s primary school was aware of. Mario’s case had been closed by children’s social care five months prior to his transfer to secondary school so it would have been correct to say that there were no agencies involved with him at the time of his transfer. His parents were under no obligation to share information about the family’s contact with agencies with Mario’s primary or secondary school. 6.27 However, as Mario’s siblings attended a different secondary school, were known to a different school health practitioner, and Mario’s school had no contact with mother, the concerns in respect of Mario’s wider family were largely                                                             37  unknown to Mario’s school until March 2016. From that point on, his school’s awareness of concerns relating to Mario’s wider family gradually increased. When Mario made his first disclosure of physical abuse by his father in March 2016 (Paragraph 4.16) he told his head of year that he had three siblings who lived with mother, that he worried about mother, that her partner (partner 2) had been ‘kicked out’, that the partner had ‘smashed her car up’, that his mother and father had split up 3 or 4 years previously ‘due to fighting’ and that ‘social services had been involved’.  6.28 Mario’s school acquired further insight into issues affecting Mario in January 2017 when Relateen shared their report about the disclosure made to his counsellor in November 2016 (Paragraph 4.31). At this point the school was advised that Mario maintained contact with his mother who was said to have had a series of abusive relationships. Mario had noticed that his mother had a black eye which she had claimed had been caused by falling out of bed. He had heard father and his maternal grandmother discussing the domestic abuse. Mario believed that ‘when things got bad’ mother and child 5 went to stay with maternal grandmother. Mario was concerned that child 5, who was two years old, was witnessing domestic violence.  6.29 Although the school had little information formally shared with them, they had become informally aware of many of the concerns affecting Mario by January 2017 and had also dealt with Mario’s two disclosures of physical abuse by his father. The school had referred Mario to Relateen but there is no indication that all the information they had accumulated about the concerns affecting Mario were brought together, examined as a whole and informed action taken to support him thereafter. Nor was the information obtained about Mario by the school shared with the Relateen counsellor. The formal opportunity for the school to share information with Relateen is via the referral form but the referral form in respect of Mario contained only a very brief justification for the referral. The school has advised this review that opportunities for informal sharing of information about pupils receiving counselling are limited by workload pressures.                                                               38  6.30 The school appears to have shared no information about Mario with his school health practitioner. To what extent were agency interventions with Mario informed by relevant prior concerns? 6.31 Prior allegations of domestic abuse against father were unknown to Mario’s school when he made his two disclosures of physical abuse by father. When the school discussed Mario’s first disclosure of physical abuse with the MASH, it is unclear whether the MASH considered prior allegations of domestic abuse against father but there is no indication that they shared these with the school. To what extent did practitioners adopt a ‘think family’ approach when interacting with Mario and his family? 6.32 Since 2008, when the Cabinet Office published Think Family, a literature review of whole family approaches (2), a more holistic understanding of people’s lives and more joined-up approaches to delivering services – especially for those families who are experiencing multiple challenges - has been encouraged. The Think Family approach places an emphasis on ensuring that the support provided by children’s, adults’ and family services is well co-ordinated and focused on the problems affecting the whole family.  6.33 It follows from this that when helping individual family members, it is important to take wider family needs into account. In respect of Mario this was often not the case. He was frequently seen as a child who lived with his father the nature of whose contact with mother and his other siblings was either not considered or insufficiently explored. This is a key area of learning which emerges from this review. 6.34 The question of whether practitioners should have considered making an adult safeguarding referral in respect of mother was discussed by the SCR Panel established to oversee this review. Mother was referred to MARAC as a victim of domestic abuse on several occasions. This SCR has insufficient information about any care and support needs mother may have had to make an informed                                                             39  judgement about what might have been the outcome of any adult safeguarding referral in respect of mother.  6.35 To better inform this SCR, a learning event was arranged to which practitioners who had had contact with Mario and his family were invited. This was a well attended event at which practitioners provided valuable insights. However, awareness of the Think Family agenda appeared undeveloped.  To what extent did practitioners listen to Mario’s voice? Were his wishes and feelings heard and understood? 6.36 The decision to refer Mario to Relateen provided Mario with an opportunity to discuss issues of concern to him confidentially in a supportive environment. A degree of trust appeared to be built up because he began to make disclosures about issues which were worrying him from an early stage. The first disclosure related to his concern that child 5 was being adversely affected by the domestic violence and abuse he suspected a former partner had inflicted on mother. This was the clearest possible indication that Mario was profoundly affected by events which were taking place in mother’s household.  6.37 The manner in which this disclosure was responded to in safeguarding terms will be considered later in this report, but Mario appeared to be communicating something of great importance; that despite the fact that he lived separately from mother and his siblings, events which took place in their household had a substantial effect on Mario’s emotional health and wellbeing. 6.38 Mario’s two disclosures about his fears of father were not raised in the counselling meetings but came to light after he got into trouble at school and became worried about how father would react. The first of these disclosures led directly to the referral to Relateen and the counselling began around two months after the second disclosure. However, the opportunity to further explore Mario’s disclosures about father in the counselling meetings was not taken because there is no indication that the school shared this information with Relateen.  6.39 It could also have been of value to further explore Mario’s damaging of school computer equipment in the counselling meetings as behaviour is a means                                                             40  of communication. Again, information about the computer damage does not appear to have been shared with Relateen. 6.40 The school noticed a reduction in what were considered to be signs of anxiety in Mario, such as ‘doodling’ ‘fiddling’ and ‘picking the skin on his fingers’. Mentoring support, the referral to Relateen and being provided with blu tac to ‘fiddle with’ were all believed to have contributed to progress in this area. 6.41 The school has advised the review that Mario was on the Special Educational Needs (SEN) register in respect of ‘learning difficulties’. He was supported by a Special Learning Difficulties teacher in respect of literacy skills for a period but this ceased when his literacy skills improved to the point at which he no longer met the criterial for SEN support. He continued to receive learning mentor support to assist him to make greater progress in some subject areas. 6.42 Mario’s school attendance was of concern throughout his time at secondary school. There was a period of improvement in 2014-15 following his referral to the school attendance team. However, Mario’s overall attendance remained around 86%. The school regards any attendance under 96% to be ‘poor’. It is unclear whether any underlying reasons for unsatisfactory school attendance emerged from the intervention of the school attendance team. To what extent did practitioners remain sufficiently child focused when they faced challenges to engaging with Mario and his family. 6.43 There were some difficulties engaging with Mario and his family in earlier years (Paragraph 4.6). Mario’s school experienced some issues in engaging with father at times (Paragraph 4.11) and never had any contact with mother. 6.44 As previously stated father says that he was unaware of Mario’s referral to Relateen. School records indicate otherwise but are not conclusive on this point. The possibility of inviting father to attend a counselling meeting was explored for a time. When considering this possibility as an option, it seems likely that his Relateen counsellor was unaware of Mario’s earlier allegations of physical abuse by father.                                                             41  6.45 The decision to end Mario’s counselling with Relateen appears to have been influenced in part by the end of the school year. Given that Relateen provide an in-school counselling service one can understand that the six weeks school holiday period would represent a disruption in a regular programme of meetings but Mario had made a number of disclosures during the counselling meetings, had demonstrated low mood throughout the period in counselling, had just experienced a bereavement (Paragraph 4.63 and 4.65) and had been involved in homophobic bullying two days prior to the final counselling meeting. Although Mario said that he had taken something positive from his experience of bereavement, it might have been prudent to re-engage with Mario after the school holidays to see whether he needed to continue with counselling. However, the counsellor advised Mario that should he need to return to counselling in the future he could access the service by speaking to his head of year. This review has been advised that demand for in-school counselling services is high and that there is always a waiting list. More urgent referrals to counselling are given higher priority however. 6.46 The Relateen counsellor had been concerned about Mario’s continuing low mood, which had shown no improvement over the period he had participated in counselling. Relateen considered referring Mario to Healthy Young Minds but decided that he did not meet the threshold. Relateen uses a young person’s evaluation system for monitoring mental health and well-being. This evaluation system was introduced by Relateen after a previous SCR and was designed by the Child Outcomes Research Consortium (CORC) and monitors anxiety, depression, self-harm and trauma session by session. Mario was consistently monitored as having no thoughts of self-harm and considered to be in the range of ‘mild to moderate’ difficulties. No referral to his GP appeared to have been considered. To what extent were safeguarding children procedures followed? 6.47 As previously discussed, Mario’s first disclosure in respect of father merited a formal safeguarding response (Paragraph 6.4) and his second disclosure should have been referred to the MASH by his school.                                                              42  6.48 The contact with MASH by sibling 1 on Mario’s behalf resulted in a response which was limited in some respects. No contact was made with Mario’s GP and there was no follow up when Mario did not attend the school drop in offered by the school health practitioner. 6.49 Mario’s disclosure to Relateen about his fears for child 5 was not referred to the MASH for over two months. There is some dispute over when this disclosure was shared with the school by Relateen but the practices of Relateen were not conducive to prompt safeguarding referrals as they made the safeguarding referral through the school rather than directly themselves and a report needed to be prepared by the counsellor’s supervisor before a referral could be made. These practices do not appear to be consistent with effective safeguarding policy. Additionally, in responding to this disclosure Relateen appeared to focus insufficiently on the possibility that the two year old child 5 could be at immediate risk.  6.50 Relateen has advised the review that the reason why any safeguarding referral is made through the school is that the school is likely to have much more information about the pupil and the pupil’s family than a counsellor. Whilst it is likely to be the case that the school will have a fuller picture of the pupil’s needs than the counsellor and the school is likely to have greater familiarity and contact with specialist safeguarding services, in this case the practice of making a safeguarding referral through the school led to an unacceptable delay in making the referral. 6.51 Additionally, Mario’s counsellor appears to have incorrectly advised Mario that no further action was being taken in respect of Mario’s concerns about Child 5 (Paragraph 4.51). It is questionable whether it was appropriate for one potential response to Mario’s disclosure that a friend had self-harmed was for Mario to talk to him (Paragraph 4.60).  How effectively was Mario’s suicide related internet use monitored? 6.52 Between 12th and 19th January 2018 Mario attempted to search the internet for suicide related material on school computers (Paragraph 4.72, 4.74                                                             43  and 4.75). It is not known specifically what prompted Mario to attempt these searches. 6.53 The school advises that computer use in class is generally monitored by the teacher using ‘AB Tutor’ which allows the teacher to view all screens in use.  If a pupil searches for inappropriate or explicit content, the aforementioned Smoothwall system would redirect the user to a blocked internet page and log the search as a blocked searched term.  AB Tutor allows the classroom teacher to monitor the usage of all active screens in the room.  However, it does not flag up search content. 6.54 School technical staff can monitor pupil’s internet searches on request from staff in response to any concerns.  There was no reason for the school to have been monitoring Mario’s internet searches during that period. At that time there was no system in place to monitor blocked pupil internet searches due to the high volume of blockages taking place. The school has advised the SCR that on one day there were over twelve thousand attempts to access blocked content. 6.55 In March 2018 Smoothwall upgraded the functionality of the school’s system allowing notifications to be made of blocked pupil internet searches in high risk safeguarding categories, including areas such as criminal activity, abuse, adult content, bullying, radicalisation, substance abuse and suicide. Real time alerts are now made to the school safeguarding team in respect of high risk internet searches.  Mario’s parents indicated that they would like the review to address the extent to which they (the parents) were informed about concerns about, and support provided to, Mario.  6.56 The school maintained contact only with father. Mother’s details were not provided to the school and mother made no contact with Mario’s school herself. Although contact was made with father after Mario’s conversation with another pupil about suicide (Paragraph 4.12), Mario’s reference to suicide does not appear to have been disclosed to father at that time. Additionally, father states that he was unaware of Mario’s referral to Relateen. The school referral to                                                             44  Relateen states that father had been informed. Mario’s parents were also concerned that Mario’s internet searches of suicide related websites had not been prevented by the school. As previously stated, the school had a system in place to block access to harmful sites but no system to highlight pupil attempts to access the most concerning websites at that time.  Good practice 6.57 This review disclosed a number of examples of good practice:  The school head of year managed to elicit significant information about wider family concerns from Mario.  The school’s decision to refer Mario to Relateen provided Mario with an opportunity to discuss issues which were worrying him in a supportive and confidential environment.  There were several occasions when Mario was linked to concerns affecting the children in mother’s household including the decision to place a police marker on the address where Mario lived with father following domestic abuse concerns arising from mother’s relationship with partner 2.  7.0 Findings and Recommendations 7.1 In order to maximise learning from this SCR it has been necessary to consider some of the difficulties experienced within Mario’s family. No judgement of Mario’s family is intended. All families experience difficulties from time to time. Many families need help and support. The reason it has been necessary to focus on the dynamics of Mario’s family is to highlight the need for practitioners working to support families to consider all children in the family even where one or more siblings may be living elsewhere. Awareness of suicide antecedents 7.2 Key factors in self-harm and suicide in adolescents include genetic vulnerability and psychiatric, psychological, familial, social, and cultural factors. The effects of media and contagion (an increase in suicidal behaviours through                                                             45  exposure to suicide in one’s family, peer group or through media reports) are also important, with the internet having an important contemporary role (3). 7.3 To his parents and to the practitioners in contact with Mario, his death was completely unexpected. A 2017 University of Manchester study Suicide by children and young people (4) categorised a number of suicides of children and young people as ‘out of the blue’ deaths in that there had been ‘no contact with any services or agencies, no history of self-harm, no indication of suicidal thoughts or intent, and never seen by a GP or at A&E for mental health problems or for self-harm’.  7.4 However, Mario’s apparent suicide was not an ‘out of the blue’ event. On closer inspection, several of the antecedents of suicide in children and young people had been present to an extent in Mario’s case. The University of Manchester study identified the following antecedents of suicide in people under the age of twenty (5):  Contact with social care/local authority services  Contact with CAMHS (at any time)  Self-harm by cutting  Psychiatric diagnosis  Looked after Child  Bereaved  Experienced abuse  Bullied  Self-harm by self-poisoning  Contact with Youth Justice/Police (at any time)  Excessive alcohol use  Illicit drug use  No service contact 7.5 In Mario’s case he had been in contact with social care when subject to child protection measures and in subsequent referrals to the MASH; he had been referred to CAMHS some years prior to his death; whilst no practitioner in contact with Mario was aware of any self-harm, sibling 1 noticed that Mario cut himself                                                             46  around a year prior to his death and made father aware of this and Mario’s maternal grandmother noticed cuts to his wrist in the month prior to his death; he suffered two bereavements during the year prior to his death and he experienced emotional abuse as a result of domestic abuse and also experienced physical abuse. 7.6 Additionally, Mario demonstrated consistently low mood during his counselling meetings, was affected by concerns about his mother and siblings, was worried about his body image, was subject to family concerns about anorexia and began to actively explore suicide in the month prior to his death. He had also been playing the Doki Doki computer game during the months prior to his death in which one of the potential endings involves self-harm and suicide. 7.7 Unfortunately, no practitioner in contact with Mario or his family was aware of all of these issues. In general, practitioners viewed Mario in isolation from the concerns about his wider family. Had any assessment of Mario been completed when opportunities arose after his two disclosures of physical abuse and after sibling 1 contacted the MASH to express concerns about anorexia, it may have been possible to better understand the many issues which had begun to impact upon Mario’s emotional health and wellbeing. 7.8 The first recommendation arising from this review is that it would be of benefit to practitioners to have increased awareness of the antecedents of suicide in children and young people in order that their efforts to provide support to children are informed by these antecedents. It is therefore recommended that this SCR is used as a case study to, amongst other things, increase awareness of the antecedents of suicide amongst children and young people.  Recommendation 1 That Bury Safeguarding Children Board make use of this SCR as a case study to, amongst other things, increase awareness of the antecedents of suicide amongst children and young people.                                                             47  Dissemination of learning to schools 7.9 Additionally, Mario’s school has identified significant learning from this case which is indicated in their single agency action plan (Single Agency Recommendations are shown in Appendix A). It would be of value to all secondary schools in the local authority area to benefit from Mario’s school’s learning. It is therefore recommended that Bury Safeguarding Children Board ensure that the dissemination of learning from this SCR includes the sharing of Mario’s school’s learning with all secondary schools in the local authority area. Recommendation 2 That Bury Safeguarding Children Board ensure that the dissemination of learning from this SCR includes the sharing of Mario’s school’s learning from the case with all secondary schools in the local authority area. Suicide Prevention 7.10 The government strategy for preventing suicide in England (6) requires each local area to put a suicide prevention plan in place. It is understood that the Bury suicide prevention strategy is nearing completion. Public Health England’s guidance on local suicide prevention planning emphasises the need for the local plan to provide better information and support to those bereaved or affected by suicide (7). The Head Teacher of Mario’s school is very critical of the lack of support the school received from the local authority following Mario’s death. It is therefore recommended that this SCR report is shared with Bury Suicide Prevention Group in order that the learning arising from the SCR can inform local efforts on suicide prevention.  Recommendation 3 That Bury Safeguarding Children Board shares this SCR overview report with Bury Suicide Prevention Group in order that the learning arising from the SCR can inform local efforts on suicide prevention including the local action plan.  ‘Think Family’  7.11 Mario’s needs were generally considered in isolation from the concerns affecting his wider family. He was the only one of his siblings who lived with his                                                             48  father following the return to mother of sibling 2. When concerns arose in respect of mother and Mario’s siblings, the potential impact on Mario was often overlooked. When his needs were considered he was not unreasonably perceived to be at no immediate risk, but risks to Mario beyond the immediate were rarely considered. His contact with mother and his siblings went largely unexplored and when it was considered, an unhelpfully narrow view of what constituted contact was taken. Links did not appear to be made between Mario’s disclosures of physical abuse by father and father’s domestic abuse history. 7.12 Many practitioners at the learning event which informed this SCR did not appear to be entirely familiar with the Think Family approach. This approach might well have helped practitioners in contact with Mario and his wider family to have taken a more holistic view of Mario’s needs. It is therefore recommended that Bury Safeguarding Children Board and partners consider how to embed the Think Family approach in the way in which partner agencies work to support families in Bury and consider what systems need to be enhanced or put in place to support practitioners in this. This SCR could be a valuable case study to assist in raising practitioner awareness of Think Family. Recommendation 4 That Bury Safeguarding Children Board and partners consider how to embed the Think Family approach in the manner in which partner agencies work to support families in Bury and consider what systems need to be enhanced or put in place to support practitioners in this.  7.13 Consistent with the Think Family approach, it is also recommended that children and family assessments should include consultation with both parents with parental responsibility. This review has received no indication that father was involved in assessments of the children residing with mother for whom he had parental responsibility. It is also recommended that children and family assessments should consider the needs of siblings even if not resident within the household where concerns have arisen. It is also recommended that MARAC should consider the impact of domestic violence and abuse on all siblings even if not resident in the immediately affected household.                                                             49  Recommendation 5 That Bury Safeguarding Children Board obtain assurance that children and family assessments will include consultation with both parents with parental responsibility. Recommendation 6 That Bury Safeguarding Children Board obtain assurance that children and family assessments will consider the needs of siblings even if not resident within the household where concerns have arisen. Recommendation 7 That Bury Safeguarding Children Board share a copy of this report with the local Community Safety Partnership in order that the latter partnership can obtain assurance that MARAC will consider the impact of domestic violence and abuse on all siblings even if not resident in the immediately affected household. MASH response to disclosure of physical abuse 7.14 When Mario’s school contacted the MASH following his first disclosure of physical abuse by father (Paragraph 4.16), the advice the MASH provided to the school was not consistent with safeguarding children policy and practice and unhelpfully de-escalated the situation. The advice provided by the MASH on this occasion also strongly influenced the school’s unsatisfactory response to Mario’s second disclosure of physical abuse by father (Paragraphs 6.3 – 6.6). Therefore, Bury Safeguarding Children Board may wish to gain assurance that the advice provided to partner agencies by the MASH is consistently sound. Recommendation 8  That Bury Safeguarding Children Board obtains assurance that the advice provided to partner agencies which contact the MASH is consistently sound. Access to harmful websites  7.15 Mario’s attempts to visit suicide related internet websites on school computers in the month prior to his death represented an opportunity to intervene and could conceivably have been a ‘cry for help’ from Mario although                                                             50  he attempted to disguise some of the searches. However, at the time Mario made the internet searches the school had a system for blocking access but no system for flagging up searches of harmful websites. The school has now remedied this by enhancing the functionality of their system (Paragraph 6.55). It is therefore recommended that Bury Safeguarding Children Board obtains assurance about the effectiveness of the additional functionality introduced in Mario’s school, recommends and promotes the introduction of such functionality throughout secondary schools in Bury and gains assurance that secondary schools have a robust process in place to intervene when pupils attempt to access suicide related websites. Recommendation 9 That Bury Safeguarding Children Board obtains assurance about the effectiveness of the additional functionality introduced in Mario’s school, recommends and promotes the introduction of such functionality throughout secondary schools in Bury, including the independent school sector and gains assurance that secondary schools have a robust process in place to intervene when pupils attempt to access suicide related websites. Doki Doki Game 7.16 Concerns have been expressed in Bury and elsewhere about the impact of the Doki Doki game on children who play it. Practitioners in contact with Mario were unaware of his access to the game and would probably have been unaware of the concerns about the game at that time. It is not known whether the Doki Doki game was a factor in Mario’s death. His parents fear that this may have been the case. The Coroner for Bury has taken steps to ensure that concerns about the game have been circulated to practitioners. In view of the absence of evidence of the impact of the game arising from this review, and the evidence that there were many other factors which could have impacted upon Mario’s apparent decision to end his own life, it is not felt appropriate to make a recommendation unless further information comes to light.                                                              51  Information Sharing 7.17 Mario’s school felt that they had insufficient information about the concerns affecting Mario’s wider family to safeguard him effectively. Although some information was passed to them on Mario’s transfer from primary school the formal transition document contained no information about the prior involvement of services with Mario and his family. The school gradually became aware of concerns affecting Mario’s wider family but this SCR identifies a concern about how fully information relevant to safeguarding pupils is shared at the point at which pupils transfer in to secondary schools, from primary school or when moving secondary schools. It is therefore recommended that Bury Safeguarding Children Board seek assurance that information about safeguarding concerns is appropriately shared at the point at which pupils transfer into secondary schools. Recommendation 10 That Bury Safeguarding Children Board seeks assurance that information about safeguarding concerns is appropriately shared at the point at which pupils transfer between schools. Safeguarding policy and practice 7.18 Relateen provide in school counselling for pupils at Mario’s school and other schools. This SCR indicates that Relateen’s safeguarding children policy and practice requires some development to ensure it is consistent with best practice. It is therefore recommended that Bury Safeguarding Children Board obtain assurance from Relateen that their safeguarding policy and practice, supported by staff training, is improved in order to address the learning arising from this SCR. This is a single agency recommendation but Relateen provide a service to a number of schools. (Single Agency) Recommendation 11 That Bury Safeguarding Children Board obtains assurance from Relateen that their safeguarding policy and practice, supported by staff training, has been improved in order to address the learning arising from this SCR.                                                             52  7.19 Relateen would have been better equipped to support Mario had fuller information about the concerns the school had about Mario been shared with Relateen at the time of initial referral and subsequently. It is therefore recommended that Mario’s school consider adding a recommendation to the single agency recommendations to which they have already committed. This additional single agency recommendation would be to improve information sharing with Relateen at the point of initial referral and during the period of counselling provided to the pupil concerned.  7.20 Bury Safeguarding Children Board may also wish to gain an awareness of the counselling services which schools in the local authority area commission for their pupils and obtain assurance that schools are offered guidance on the commissioning of such services. Any guidance offered by the local authority could address issues such as the counselling service’s safeguarding policy, information sharing etc. Recommendation 12 That Bury Safeguarding Children Board gains an awareness of the counselling services which schools in the local authority area commission for their pupils and obtain assurance that schools are offered guidance on the commissioning of such services.  References: (1) Retrieved from http://www.safelives.org.uk/sites/default/files/resources/Final%20policy%20report%20In%20plain%20sight%20-%20effective%20help%20for%20children%20exposed%20to%20domestic%20abuse.pdf (2) Morris, K, Hughes, N, Clarke, H, Tew, J, Mason, P, Galvani, S, Lewis, A and Loveless, L (2008) Think family: a literature review of whole family approaches. Cabinet Office Social Exclusion Task Force. (3) Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22726518                                                             53  (4) Retrieved from http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/cyp_2017_report.pdf (5) ibid (6) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/430720/Preventing-Suicide-.pdf (7) Retrieved from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/585411/PHE_local_suicide_prevention_planning_practice_resource.pdf  Appendix A Single Agency Recommendations Children’s Social Care  Social Work assessments should be strengthened to routinely include the “think family” approach. Children should not be seen in isolation.  Consideration needs to be given in regards to siblings living at separate addresses when children are made subject to Child Protection plans. The conference should consider children who regularly visit the household and how they will be protected from Domestic Violence and the emotional impact of it. Greater Manchester Police  Recording details of strategy discussions prior to Initial Child Protection Case Conference.     Consider the impact of DA on children who are not present at the incident or who do not reside at the address on a permanent basis but who may visit frequently.                                                                 54  Pennine Care NHS Foundation Trust (school health practitioners)  To support PCFT practitioners to adopt a ‘think family’ approach when working with families where siblings are living in different addresses and attending different schools.  To ensure PCFT health visiting and school health documentation includes enquiry about contact with siblings who are living in different households is considered and evidenced with records to enable a comprehensive risk assessment and support being put in place for children and there are robust information sharing pathways between different PCFT practitioners working with siblings,  To ensure PCFT Safeguarding Supervision documentation identified siblings living at different addresses are included in the process.  To ensure the PCFT request for health information for MARAC Pathway includes previous requests are considered in the response so each request is not considered in isolation.  To ensure the PCFT MASH request for health information pathway is robust particularly where there has been an allegation by a child. To ensure PCFT safeguarding supervision documentation to ensure siblings living at a different addresses are included in the process.  Relationship Hub  To incorporate questions about video games or suicide forums as part of our practice.  To arrange a continuous professional development meeting with practitioners to look at issues around:  - liaison with school staff;  - requesting written feedback from the school following a referral to external agencies as to action taken  - for that written information to be shared with counsellors                                                             55  School  IT systems to include real time alerts when pupils access inappropriate material.  At least two points of contact for each pupil on management information system.  Telephone MASH when any disclosure made by a pupil.  Improve safeguarding record keeping to enable a full chronology to be viewed when concerns arise.  Improved information about pupil’s family circumstances on transition to the school.  Schools to have consistency in the pastoral system staffing (Head of Year to remain with their year group as they move through school where possible).  Safeguarding policies to include specific guidance on expectations regarding self-harm.  Schools to ensure access to inappropriate games is blocked where possible.  Improved communication between agencies. Social Housing Provider   Provider should obtain/record details of any children not living within the tenancy household to enable comprehensive data sharing when appropriate.   Provider should ensure the voice of the child is considered when completing a Sanctuary Safety Plan.  Appendix B Process by which SCR completed and membership of the SCR Panel. An SCR Panel of senior managers from partner agencies was established to oversee the SCR which was chaired by the independent lead reviewer. The membership of the panel was as follows:  Strategic Lead, Children’s Social Care.                                                             56   Head of Safeguarding and Designated Nurse, Bury Clinical Commissioning Group.  Detective Sergeant, Greater Manchester Police.  Lead Officer, Early Years Service.  Head Teacher, Mario’s Secondary School.  Designated Teacher Safeguarding Children, Mario’s Secondary School.  Named Nurse for Safeguarding, Pennine Care NHS Foundation Trust  Manager, the Relationship Hub  Consultant in Public Health  Strategic Lead, Education  Manager, Social Housing Provider  Senior Administrative Support Worker, Bury Safeguarding Children Board  David Mellor, Independent Lead Reviewer It was decided to adopt a systems approach to conducting this SCR. The systems approach helps identify which factors in the work environment support good practice, and which create unsafe conditions in which unsatisfactory safeguarding practice is more likely. This approach supports an analysis that goes beyond identifying what happened to explain why it did so – recognising that actions or decisions will usually have seemed sensible at the time they were taken. It is a collaborative approach to case reviews in that those directly involved in the case are centrally and actively involved in the analysis and development of recommendations. Agency reports including chronologies which described and analysed relevant contacts with Mario and his family were completed by the following agencies:  Bury Children’s Services  Secondary School attended by Mario  The Relationship Hub  Pennine Care NHS Foundation Trust  Greater Manchester Police  Social Housing Provider                                                             57  Additional reports were also provided by Bury NHS Clinical Commissioning Group and Lancashire Constabulary. The Coroner also shared information gathered by the Coroner’s Officer which was relevant to the SCR. The SCR Panel analysed the chronologies and identified issues to explore with practitioners and managers at the learning event facilitated by the lead reviewer. This event was well attended by representatives of the various disciplines involved in this case.  The lead reviewer then developed a draft report which reflected the chronologies and the contributions of practitioners and managers who had attended the learning event. With the assistance of the SCR Panel, the report was further developed into a final version and presented to Bury Safeguarding Children Board. Mario’s mother, father, maternal grandmother and, to a limited extent, sibling 1 contributed to this review and were also provided with an opportunity to read and comment on the final draft of this SCR overview report. 