Death of a 16-year-old of dual heritage, in May 2014, as the result of an accidental overdose. Child E was in out-of-borough residential care at the time of the incident. Child E was born with serious narcotic withdrawal symptoms and went on to suffer chronic neglect and possible sexual abuse in early childhood. A pre-birth child protection conference decided it was not necessary to make Child E subject to a protection plan. Child E's siblings were made briefly subject to child protection plans in 2000 and the police twice exercised their powers of protection to remove the children before care proceedings were initiated for Child E and siblings in 2001. A final care order was obtained in 2002 and Child E was placed for adoption in 2004. This placement broke down in 2008 after which Child E had a number of placements in a range of settings, including secure units. Child E's birth parents had a history of substance misuse, violent and criminal behaviour. Child E had a history of: fire starting; self-harm and suicide attempts; substance misuse; mental illness and emotional dysfunction. Issues identified include: optimistic interpretation by professionals of birth family's ability to care for Child E; high risk matching of Child E with a lone female adoptive parent with a medical condition; lack of formal adoption support plan; dispute between local authorities over who was responsible for Child E; ongoing uncontrolled contact between Child E and birth family; and poor discharge planning from residential mental health care. Recommendations include: mental health trust should develop and maintain a risk register of looked after children from each of the local authorities; and contact with birth parents should be carefully monitored by social workers and action taken if it starts to negatively affect the child or placement.
      
 Title:  Serious case review: Child E. LSCB: Sutton Local Safeguarding Children Board Author: Fergus Smith Date of publication: 2015  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                                                                                                                                                                            CONFIDENTIAL  SUTTON  LOCAL SAFEGUARDING CHILDREN BOARD   SERIOUS CASE REVIEW     CHILD E    FERGUS SMITH  05.03.15     This report remains the property of Sutton LSCB  Page 2 of 146   FOREWORD On behalf of Sutton Local Safeguarding Children Board, I want to say that we are all deeply saddened by the premature death of this young person who attracted the interest and care of a great many people. Our sympathy goes to the family and friends who did a great deal to help but were powerless to influence the factors that led to the death.   The findings of the coroner were accidental death as a result of a drug overdose following treatment that had lowered the tolerance to drugs. The young person was aged 16 years at the time of death in May 2014 whilst in the care of an out-of borough residential unit.    The report attempts to portray what it would be like for Child E to grow up in an environment of substance-misuse dependent parents, chaotic home life and exposure to violence and traumatic events. Although there are no words to articulate Child E’s early childhood experiences, there is significant evidence to explain the challenging behaviour and emotional dysfunction that led to the premature death.   There is also the story that goes beyond this report, which is about a young person attracting the care and interest of many people who helped in the best way they possibly could in very difficult circumstances.  The young person expressed their thoughts on self-harm through the written medium, which showed intelligence and insight into the circumstances of their complex and disrupted life. At the end, Child E expressed a sense of loss for their sister and a bond with their brother.  The author’s conversations with the adoptive mother show a dedicated and loving parent who has suffered the loss of her child. Our thoughts are with her and also go to the many extraordinary carers in the local community who try to make a difference to children who have been severely damaged in their early childhood years.     Christine Davies CBE, Independent Chair of Sutton Local Safeguarding Children Board      Page 3 of 146       CONTENTS 1 INTRODUCTION 4 2 REVIEW PROCESS 12 3 BIRTH TO ‘PLACED FOR ADOPTION’ STATUS 17 4 PLACEMENT FOR ADOPTION TO ITS BREAKDOWN 24 5 RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 34 6 ANALYSIS 87 7 FINDINGS AND CONCLUSIONS 117 8 RECOMMENDATIONS 125 9 BIBLIOGRAPHY 129 APPENDIX A: TERMS OF REFERENCE 132 APPENDIX B: BIOGRAPHIES 137 APPENDIX C: MEMBERS OF THE SCR PANEL 138 APPENDIX D: LSCB STATEMENT 139 APPENDIX E: LSCB ACTION PLAN 141 APPENDIX F: GLOSSARY OF ABBREVIATIONS 145  Page 4 of 146  1 INTRODUCTION  1.1 BACKGROUND AND DECISION TO INITIATE A SERIOUS CASE REVIEW 1.1.1 Child E (a British child born to a White mother and a dual heritage White and African-Caribbean father) died in early May 2014, some six months short of their 17th birthday. Child E was subject of a Care Order and at the time of their death placed by the London Borough of Sutton in a residential unit in Calderdale. The Coroner’s report subsequently indicated that the cause of death was opiate toxicity and there was evidence that Child E had been using ‘class A’ drugs1 in the weeks before their death. The Coroner’s verdict in the inquiry was ‘Accidental Death’. 1.1.2 Child E had a very lengthy history of involvement with a range of services and agencies. Following serious neglect and abuse in early childhood, Child E had been placed for adoption in 2004 (aged six).  1.1.3 An Adoption Order was granted in late 2005. Chronic difficulties persisted and Child E (aged 11) subsequently re-entered the care system in 2009 when, having moved to live with relatives of their adoptive parent, and they were accommodated by Sutton Children’s Social Care.  1.1.4 From 2009 until their death, Child E had numerous placements in a range of settings that included secure and psychiatric units.  1.1.5 All child deaths are routinely reviewed by multi-agency panels in each Local Authority. At a joint Sutton and Merton Child Death Overview panel in May 2014 it was agreed there were a number of concerns about the services that had been provided to this very troubled young person. A recommendation was made to the independent chairperson of Sutton’s Safeguarding Children Board that a ‘Serious Case Review’ be instigated. 1.1.6 The chairperson supported that recommendation and determined on 18.06.14 that there would be a Serious Case Review. The Department for Education and regulatory bodies Ofsted and Care Quality Commission were subsequently notified of that decision.  1.1.7 The remainder of Section One explains the purpose, conduct and contents of the Serious Case Review and provides an executive summary. Sections Two - Six explore the experiences of Child E during the period defined by the appended terms of reference (i.e. from birth to death), evaluates the services and systems that sought to support and safeguard the young person and offers overall conclusions and recommended system improvements.                                                   1 Class A drugs e.g. Heroin, Cocaine, Ecstasy and LSD are considered to be the most harmful and attract the most serious punishments and fines.    Page 5 of 146  1.2 PURPOSE AND CONDUCT OF THE SERIOUS CASE REVIEW PURPOSE 1.2.1 Regulation Five of the Local Safeguarding Children Boards Regulations 2006 requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with procedures in Working Together to Safeguard Children HM Government [latest edition 2013]. 1.2.2 A ‘serious case’ is one in which abuse or neglect is known or suspected and either the child has died or has been seriously harmed, and there is cause for concern as to the way in which the Local Authority, its LSCB partners or other relevant persons have worked together to safeguard the child.  1.2.3 Its purpose is to:  ‘Establish what lessons can be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children   Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result and   As a consequence, improve intra and inter-agency working and better safeguard and promote the welfare of children’ 1.2.4 A Serious Case Review is not concerned with the precise cause of death or attribution of culpability, which are matters for the Coroner and criminal courts respectively.  1.3 CONDUCT  Independent LSCB Chair 1.3.1 Christine Davies, CBE was appointed the Independent Chair of Sutton LSCB 2014. Christine had previously worked with Children’s Social Care Services as the Chair of the Improvement Board, and is now steering and strengthening the effectiveness of Sutton’s multi-agency safeguarding partnership.  Independent authorship 1.3.2 An experienced independent lead reviewer Fergus Smith (author) was commissioned to undertake this review in accordance with the Terms of Reference (Appendix A).  Independent Serious Case Review Panel Chair 1.3.3 The Serious Case Review panel was chaired by Marion Davis, a qualified social worker with extensive experience of Children’s Services as a  Page 6 of 146  practitioner and manager. Since retiring as a Director of Children’s Services, she has undertaken the role of independent chairperson of a Local Safeguarding Children Board. 1.3.4 Please see Appendix B for a fuller biography of the LSCB Chair, Serious Case Review Chair and Serious Case Review Author. Panel members 1.3.5 A Serious Case Review Panel was established, chaired by Marion Davis. All relevant agencies involved with Child E and their family were invited to be part of the Panel. Individual Management Reviews (IMRs) or background reports were requested from 20 agencies. Please see Appendix C for a list of Panel members. 1.4 ARRANGEMENT OF THE OVERVIEW 1.4.1 The remainder of this report is laid out as follows:  An executive summary of the full report   A comment on the effectiveness of the Serious Case Review process   A brief summary of what was known of the birth family before Child E’s birth  A more detailed account of agencies’ involvement broken into periods: from birth to being placed for adoption; the adoption and its breakdown; and from the adoption breakdown and Child E again becoming ‘Looked After’ until their death   An analysis of the extent to which records demonstrate best practice with respect to the issues in the terms of reference i.e. Working Together to Safeguard Children 2013 [relevant statutory guidance] and additional case-specific points  Overall findings and conclusions   Practical recommendations for the LSCB and member agencies that are specific, measurable, achievable, realistic and timely (SMART)  A glossary of abbreviations  A bibliography of general and case-specific literature of relevance 1.4.2 Reports produced for this Serious Case Review totalled 2,000 pages and provided a very large volume of detail. In an attempt to produce an accessible document, though all the material submitted has been read and evaluated, only the most significant of events or issues are reproduced in this overview. 1.4.3 The limited quantity of educational material in this report will be apparent to the reader. It reflects the unintended result of Child E being moved around the  Page 7 of 146  country as often as they were and the consequent dependence upon non-mainstream (often residential units’ in-house) provision. 1.4.4 Insofar as the planning and delivery of services to Child E were dominated by their survival and health-related needs, the Serious Case Review panel determined it should award the greater priority to the acquisition and analysis of social care and health records. 1.5 EXECUTIVE SUMMARY Personal history 1.5.1 In May 2014 Child E (aged 16), who was subject of a Care Order to the London Borough of Sutton, died from what a preliminary post mortem examination indicated was the result of opiate toxicity. It appeared that Child E had been using Class A drugs in the weeks prior to their death. 1.5.2 Child E’s birth mother (and a generation earlier for similar reasons, their maternal grandmother) had been a long-standing source of concern to Police, Health Agencies and Children’s Social Care in Norfolk (Child E’s area of origin). Both those adults have a lengthy history of drug and alcohol abuse and the mother of Child E has an extensive criminal history (much of it related to prostitution and alcohol-fuelled violence).  1.5.3 A pre-birth Child Protection conference was held in September 1997 and concluded that it was not necessary to make Child E subject of a Child Protection plan. However, at the birth the following month and as a consequence of the mother’s continuing misuse of drugs, Child E manifested serious narcotic withdrawal symptoms and required a very significant amount of medical treatment before and following discharge home. 1.5.4 After years of intermittent involvement by Norfolk Children’s Social Care, in September 2000 Child E’s siblings (but not Child E) were made subject of Child Protection plans and Care Proceedings were initiated. Child E and siblings were eventually made subject of interim Care Orders. Child E was placed with their maternal grandmother and subsequently in two foster homes. A full Care Order was obtained in late 2002, by which time Child E was five years old. About 18 months later Child E was ‘placed for adoption’ with a single female recruited, assessed and approved by the Catholic Children’s Society. 1.5.5 Within months of placement, Child E’s disturbed conduct had triggered a referral to the Marlborough Centre (a national child and adolescent psychiatric service now provided by the Central and North West London NHS Foundation Trust). 1.5.6 In November 2005, when Child E was just over eight years old and had been placed in their pre-adoptive home for about 20 months, an Adoption Order  Page 8 of 146  was granted with the consequence that ‘parental responsibility’ transferred exclusively to the adoptive mother (referred to in this report as ‘Ms AM’). 1.5.7 Child E’s behaviour remained very challenging. In 2007, when 10 years of age, they succeeded in initiating a fire at home so serious as to render the accommodation un-inhabitable for several months.  1.5.8 In February 2009 Child E (aged 11), by then living in Hammersmith and Fulham, refused to return to Ms AM. With her agreement, Child E went to stay with her brother and sister in law, who lived in Sutton. 1.5.9 Within six months of that move, Child E is understood to have taken their first overdose (anti-bacterial cleaner) which was followed a month later by a second (Paracetamol), sufficiently serious to require admission to hospital. During 2010 -2011, by which time Child E had been re-accommodated under s.20 Children Act 1989, there were approximately a dozen more reported or professionally confirmed episodes of self-harm (some potentially life-threatening). 1.5.10 With the consent of the Secretary of State (required by law because Child E was then less than 13 years old), a Secure Accommodation Order was made in April 2010. Sutton Children’s Social Care initiated Care Proceedings in late 2010 and interim Care Orders as well as further Secure Accommodation Orders were made during 2011.  1.5.11 By February 2012, Child E was made subject of a full Care Order to Sutton, meaning that the adoptive mother and the Local Authority henceforth shared parental responsibility.  1.5.12 Throughout the period of review, the level of contact by birth mother and grandmother seems to have exceeded that which has been anticipated by Norfolk Children’s Social Care (and certainly the level recommended in an independent report commissioned by that agency to address the issue of optimal post-adoption contact). 1.5.13 Ongoing (uncontrolled and increasingly uncontrollable) contact by the birth family served to undermine the formally agreed arrangements and left an already damaged child with impossibly split loyalties. 1.5.14 In adolescence, Child E’s challenging and harmful (and increasingly criminal) conduct continued and running away from placements became frequent, often encouraged and facilitated by members of the birth family. 1.5.15 By late 2012, and in addition to a number of medical difficulties consequent upon misuse of drugs, psychiatric diagnoses for Child E (then 15) included:  Complex attachment disorder  Post-traumatic stress disorder  Complex grief reaction  Page 9 of 146   Features of Attention Deficit Hyperactivity Disorder (ADHD) 1.5.16 The possibility (in addition to the more immediate risk of depression, self-harm and misuse of alcohol and drugs) was mooted of an emerging ‘personality disorder’2. 1.5.17 Child E’s conduct continued to prove more than could be managed in available open environments and the difficulty in identifying any unit willing to accept them necessitated placements at considerable distance from Sutton. 1.5.18 Secure care (initially welfare, and latterly psychiatrically-oriented) successfully prevented access to alcohol, drugs and, to a limited extent, further damaging contacts with the birth family. They were also able, to a degree, to reduce Child E’s violent or more varied criminal conduct. 1.5.19 No provision was able to provide enough support or therapy to ensure that Child E, upon transfer from involuntary psychiatric in-patient status to placement in their final Children’s Home, had developed sufficient insight, sense of self-worth or emotional self-regulation to stay safe and avoid re-entering a well-established pattern of substance misuse and deliberate, negligent or accidental self-harm. Findings  1.5.20 The full report provides a more detailed account of the following broad findings. 1.5.21 Even before birth, Child E had been significantly disadvantaged in consequence of the lifestyle of their birth mother and (potentially) by the longer-term physiological results of being born physically dependent upon Phenobarbitone and oral Morphine.3   1.5.22 The records of Child E’s early years in Norfolk illustrate ongoing chronic, and at times severe, physical and emotional neglect, as well as the distinct possibility of sexual abuse as a result of proximity to or involvement in the birth mother’s occupation as a ‘sex worker’. 1.5.23 There was insufficient appreciation of the abundant evidence that the birth family, across generations, was extremely dysfunctional and that continuing dependence or involvement would inevitably damage Child E. In consequence, there was a very belated recognition of the need for a formal Child Protection plan. In spite of numerous crises and periods of temporary fostering, there was also a very significant delay before an application for a Care Order was finally initiated in late 2001, when Child E was four years old.                                                  2 Personality disorders create a maladaptive pattern of thoughts, feelings, and behaviours that can cause serious detriments to relationships and other life areas. 3 Decision-making within a Child’s timeframe R Brown and H Ward, Childhood Wellbeing Centre, October 2012  Page 10 of 146  1.5.24 In early 2004 the adoption panel of Norfolk Children’s Social Care had formally approved the match of Child E with the single female previously approved by the Catholic Children’s Society. A pre-existing medical condition of that individual  (epilepsy) later featured in the difficulties that developed in the relationship between adoptive mother and child, but the issue that appears to have been of central significance was that of a very high level of challenging behaviours manifested by Child E, e.g.:  Severe difficulties with sleeping  Tantrums and physically threatening behaviour towards the adoptive mother 1.5.25 Challenging conduct was apparent from the outset of the pre-adoption placement. Ms AM showed a remarkable level of perseverance before she applied for, and after being granted, an Adoption Order. Given Child E was then aged only 10, their determined and successful effort to render the adoptive home un-inhabitable by setting fire to it was an early example of extreme emotional disturbance and distress. 1.5.26 Following the breakdown of the adoption in late 2009, manifestations of Child E’s disturbance grew increasingly acute. Even before adolescence Child E was reportedly misusing drugs and alcohol, regularly threatening and perpetrating violence toward carers and others and there were sexually concerning behaviours. Each of the numerous failed placements served to reinforce attachment difficulties. As Child E’s behavioural record worsened, it made ‘placement choice’ less and less likely. In spite of Child E’s rejection of her, the unconditional commitment of Ms AM existed up until the young person’s untimely death. 1.5.27 The most significant weaknesses (described in greater detail in the full report) in the services provided to Child E and the birth, and later adoptive, family were:  Inadequate pre and post-natal planning and unjustified delays prior to initiating Care Proceedings in Norfolk  For such a damaged and challenging child with anticipated continuation of birth family influence, a questionable choice of a single female adopter (with some pre-existing medical difficulties) and insufficient post-adoption support  An ongoing tendency to underestimate the risk of significant harm whilst in receipt of services from Hammersmith and Fulham and Sutton Children’s Social Care and insufficient appreciation of Child E’s then ‘lived experience’ (which would have justified initiation of Care Proceedings in the former borough)  An apparent reluctance and, on occasions, explicit failure by some social work staff to involve the adoptive mother Ms AM, who retained her lawful right to exercise parental responsibility and remained of critical importance to Child E until their death  Page 11 of 146   A large number of social workers after admission to care in Sutton  A lack of compliance with a number of regulatory obligations applicable to Looked After Children as well as with some internal Children’s Social Care policies in Sutton  Whilst accepting that the choices became increasingly limited, use of a very large number of placements with insufficient rationale provided for their selection (other than those providing secure care)   Insufficient awareness across Health and Care agencies of the unhelpfully complicated regulatory basis on which specialist health services were / are to be commissioned  Latterly, whilst providing effective enough direct care during Child E’s detention under the Mental Health Act, confusion and inadequate communication, especially between mental health agencies, and a poorly managed discharge from St Andrews hospital to Child E’s final placement 1.5.28 Given the probable damage with which Child E entered the world, the traumas experienced whilst left with the birth family, the subsequent decade of failed relationships and placements and little certainty about the future, this young person’s life chances were limited. 1.5.29 A well-established pattern of risky behaviours suggested that a shortened life (whether by accident or intention) was, over time, more likely than not. To that extent, Child E’s premature death was ‘predictable’.  1.5.30 Had the collaboration of all involved agencies been better informed and more efficiently managed (especially in the transition from psychiatric care in 2014), there is a real possibility that Child E’s death could at least have been postponed.  1.5.31 However, on the basis of the totality of evidence made available to this Serious Case Review, it has to be concluded that very different decisions by a number of agencies would need to have been made at several critical points in Child E’s life in order to have altered the course of events that led to their death.   Page 12 of 146  2 REVIEW PROCESS  2.1 RELEVANT AGENCIES 2.1.1 A chronology of contacts with Child E or commissioning of relevant services was requested from the agencies listed in Table 1 below. Table 1: agencies invited to contribute  Sutton Children and Young People Learning Directorate (to include work of its ‘Looked After Children’ nurse) NHS England (General Practitioner Services) Sutton Youth Offending Team Children and Family Court Advisory and Support Service (Cafcass) Epsom and St Helier University Hospitals NHS Trust South West London and St George’s Mental Health NHS Trust Sutton and Merton Community Services Royal Marsden NHS Foundation Trust The Marlborough Centre Norfolk Children’s Social Care South London Legal Partnership Calderdale Children’s Social Care  Westminster Children’s Social Care Devon Children’s Social Care Metropolitan Police Kings College London Liver Unit Hammersmith and Fulham Children’s Social Care Yorkshire Ambulance Service Croydon / Mayday Hospitals National Clinical Assessment and Treatment Service (NCATS) London Ambulance Service Colchester Hospital Musgrave Hospital Taunton Shrewsbury Hospital Companions Unit Staffordshire West Sussex CAMHS Beechfield Secure Unit West Sussex Harold Wood Clinic Essex Taunton CAMHS Birmingham Children’s Hospital Fort William Hospital Leverton Hall Secure Unit Gwent CAMHS Northampton General Hospital Essex Children’s Social Care CAMHS Calderdale Essex Young People’s Drug and Alcohol service Queens Hospital Romford South Essex Partnership St Aubyn’s Hospital Colchester Colchester Hospital Norfolk  Norwich Hospital Lifeline Calderdale Sutton Clinical Commissioning Group  Page 13 of 146  2.1.2 More detailed Individual Managements Reviews (IMRs) were sought from:  Children and Family Court Advisory and Support Service (Cafcass)  Sutton Children and Young People Learning Directorate  Child E’s last Residential Care Provider (GBA Care)  Epsom and St Helier University Hospitals NHS Trust  Sutton Clinical Commissioning Group (GP Services)   South West London and St George’s Mental Health NHS Trust  Norfolk Children’s Social Care  Hammersmith and Fulham and Westminster Children’s Social Care (now, with Kensington and Chelsea, a ‘Tri-borough Consortium’)  South London and Maudsley Partnership  Sutton and Merton Community Health Services hosted by Royal Marsden NHS Foundation Trust  Sutton Clinical Commissioning Group  St Andrews Hospital Northamptonshire  Birmingham Children’s Hospital   Kings College Hospital   Huntercombe Hospital   Sutton’s Services for ‘Looked After Children’ nursing (until 31.12.12)  South West Yorkshire Partnership Foundation Trust  Metropolitan Police  South West Yorkshire Partnership Foundation Trust (Calderdale CAMHS) 2.1.3 NHS England belatedly submitted a brief explanatory letter. A comprehensive health overview was provided by an independent expert commissioned by Sutton’s Clinical Commissioning Group (CCG). The original timetable for the Serious Case Review and actual dates (if different) are shown below. Table 2: timetable of Serious Case Review Agreed meeting dates Planned (and actual)  Serious Case Review committee to agree panel membership, etc  Panel meeting 1 09.07.14 Panel meeting 2 22.09.14 Panel meeting 3 29.10.14 Panel meeting 4 16.12.14 Panel meeting 5 04.02.15 Completion and return of individual chronologies 25.07.14 (revised to 15.08.14, and final received in December) Final integrated chronology  31.07.14 (revised 22.09.14, 29.10.14, and final version received 18.12.14) Draft IMRs 15.09.14 (revised to 31.10.14, 07.11.14)  Final IMRs 05.10.14 (revised to 07.11.14 and all (save NHS England) actually provided by 28.01.15)    Page 14 of 146  Health overview report 07.10.14 (revised to 08.12.14 - received 26.01.15 and 19.02.15) Draft Overview 05.11.14 (revised to 12.12.14 and a preliminary draft supplied on 09.12.14; draft 1 on 28.01.15) Draft 2 presented to LSCB. 05.12.14 (submitted 19.02.15) Involvement of adoptive mother August and December 2014 Involvement of birth family Attempted January 2015 – failed Meeting with adoptive mother to discuss report May 2015 Publication date End of June 2015 Learning event / conversations with professionals Will happen after publication of this report 2.2 FAMILY INVOLVEMENT 2.2.1 The independent overview author and panel chairperson held an initial meeting with Ms AM. The process to be followed was explained and her contribution to the review invited. 2.2.2 Ms AM was re-involved in December 2014 at a point when basic facts had been established and lines of enquiry defined. She was able to provide valuable information and insights and the author and all panel members are immensely grateful that, in spite of her grief about the loss of her child, she was willing to share her experiences and opinions of the various services provided over the years and across the country.  2.2.3 Because they had remained involved and were (to a greater and lesser extent respectively) a major influence in Child E’s pre and post adoption development, the birth mother and birth father were also invited by letter to contribute to this Serious Case Review. Uncertainties associated with their lifestyle, including their current whereabouts, required careful management. At the point of completion of this ‘draft two’, letters to last known addresses have been deemed ‘undeliverable’ by the Royal Mail. 2.3 BRIEFING OF AND DISCUSSIONS WITH RELEVANT PROFESSIONALS 2.3.1 When events and their timing had become reasonably certain, a list of relevant professionals was compiled and arrangements made to have individual discussions. This draft two incorporates the responses of those individuals and has influenced the recommended service improvements.  2.3.2 A learning event for local professionals will also be convened to provide an opportunity to share and debate the learning points listed in Section Seven. 2.4 TRANSPARENCY AND CRITIQUE OF PROCESS 2.4.1 The merged chronology, though delayed, was very well presented and this facilitated the exploration of the extensive records within it.  2.4.2 Whilst some were delivered many weeks after agreed deadlines, Individual Management Reviews were generally good or at least adequate and provided sufficient information and commentary to provide a high level of confidence about the conclusions drawn and recommendations made. The health overview was extremely comprehensive.  Page 15 of 146  2.4.3 It is hoped that the involvement of key professionals during the course of this Serious Case Review has served to increase its accuracy and fairness, as well as to increase the level of acceptance of its outputs, and hence commitment to, implementation of the report’s recommendations. 2.5 GENOGRAM  2.6 HOME ADDRESSES / PLACEMENTS Table 3: Child E’s locations Date Address Status Location Comment 1997- 2001 Address 1 Home with birth mother (and ? father) Norfolk Included eviction and temporary co-habitation as a whole family with grandmother 01.11.01 Address 2 Maternal grandmother Norfolk Placement made during Care Proceedings 18.01.02 – 18.10.02 Address 3  Foster carers  Norfolk  18.10.02 – 13.02.04 Address 4  Foster carer Norfolk A ‘bridging’ placement prior to placement for adoption 13.02.04 – 2006 Address  5 With adoptive mother Kensington and Chelsea Placed for and later  adopted 2006-2008 Address 6 With adoptive mother Westminster  2008 – 01.04.09  Address 7 With adoptive mother Hammersmith and Fulham Then missing / with birth family 01.04.09-22.04.09 Address 8 Adoptive aunt and uncle Sutton s.20 though actually at Ms AM’s home part-time 22.04.09 -25.06.09  Address 9 Foster carer  Ealing Carer unwilling to retain Child E  26.04.09-26.06.09 Address 10 Foster carer ? location  15.05.09 -? Address 11 Children’s Home Dover  Castle Care Home                   Child E  Deceased     Not known S2 Deceased  Birth father of child E Adoptive father Birth mother of child E Adoptive mother Ms AM Adoptive mother S3 S4 S5 S1 Maternal grand mother  Page 16 of 146  Date Address Status Location Comment 04.06.09- 18.10.09 Address 12 Children’s Home Hove Dalton House (also Castle Care)  19.10.09 -07.02.10 Address 13 Adoptive aunt / uncle  Sutton  Following two days in hospital; a private arrangement 08.02.10 23.03.10 Address 14 Foster carer  Croydon Now  ‘Looked After’  24.03.10 Address 15 Emergency foster carer    25.03.10 Address 16 Children’s Home Croydon Hillcrest 23.04.10-26.04.10 Address 17 Secure Unit Devon Atkinson  26.04.10-11.06.10 Address 18 Children’s Home Essex Orchards Home Service Colchester 11.06.10- 27.08.10 Address 19 Therapeutic Children’s Home West Wales Morlowe 27.08.10- 25.11.10 Address 20 Secure Unit Devon Atkinson 25.11.10-21.10.11 Address 21 Children’s Home Somerset Cobblestones 21.10.11-12.12.10 Address 22 Secure Unit Essex Leverton Hall 12.12.11-13.12.11 Address 23 Children’s Home  Newport Wales Glen Wye 13.12.11- 03.04.12 Address 24 Children’s Home Newport Wales  Oakfield  03.04.10- 06.06.12 Address 25 Secure Unit Merseyside St Catherine’s  06.06.12-06.08.12 Address 26 Children’s Home Pembrokeshire Wales Bryn Melyn  06.08.12- 29.09.12 Address 27 Two bedded Home Shropshire Upper Woodcote Farm (missing from 17-28th September) 29.09.12 05.12.10 Address 28 Secure Unit Essex Leverton Hall Secure Unit 05.12.12- 10.12.12 Address 29 Rehabilitation Centre Stafford Shropshire Failed  10.12.12- 21.12.12 Address 30 Secure Unit West Sussex Beechfield 21.12.12- 10.05.13 Address 31 Secure Unit Essex Leverton Hall 10.05.13-01.06.13 Address 32 Adult Psychiatric Hospital Essex St Aubyns 01.06.13-16.08.13 Address 33 Specialist Adolescent psychiatric hospital   Norfolk Huntercombe Hospital  16.08.13-06.04.14 Address 34 Specialist adolescent psychiatric hospital   Northamptonshire St Andrews 07.04.14 – death on 06.05.14 Address 35 Children’s Home West Yorkshire Duke House (Child E was actually present from 28.03.14 on leave from St Andrews)  Page 17 of 146  3 BIRTH TO ‘PLACED FOR ADOPTION’ STATUS FAMILY HISTORY  3.1 PREVIOUS GENERATION AND OLDER SIBLINGS 3.1.1 Information supplied by Norfolk Children’s Social Care revealed that Child E’s maternal grandmother had experienced a series of violent relationships with alcoholic men who lived off her earnings as a sex worker. One child had been adopted and another (Child E’s mother) had been taken into care (aged eight) and spent time in several foster homes and residential units before (aged 15) becoming pregnant with her first child, Child S2 (Child E’s half-sibling). 3.1.2 Following an unsuccessful attempt to ensure their welfare by means of a Child Protection plan, on 30.11.92 S2 and another half-sibling S3 (then aged eight and five respectively) had been taken into the care of Norfolk Children’s Social Care and were, three years later, adopted by their foster carers. For reasons that remain unknown, their adoption was opposed by the Local Authority.    3.1.3 Within days of the birth of Child E’s older sibling S4 in October 1992, that sibling had also been made ‘subject of a Child Protection plan’. In January 1993, whilst the siblings S2 and S3 (who were still fostered) remained subject of Protection plans, S4’s name was removed from the list of those subject of a Protection plan. That implied some improvement in the home circumstances, though with fewer children there, the pressures on the parents would anyway have been less. 3.1.4 Mother (then two – three months pregnant) was arrested as a result of a drunken Domestic Violence incident during a contact visit with the siblings S2 and S3 in September 1993. S5 was born in April 1994. 3.1.5 There were several incidents of Domestic Violence during 1995 / 1996 and mother’s alcohol misuse continued unabated. At a Child Protection conference in September 1996, S4 and S5 were made subject of Child Protection plans for the ‘likelihood of emotional abuse’. 3.1.6 The family was reportedly visited regularly by SW1 from September 1996 to March 1997, during which time the birth mother claimed to have stopped drinking. She was though, together with Child E’s birth father, in receipt of prescribed Methadone and using Heroin ‘on top’. All four children remained subjects of Child Protection plans. For a period the family lived in temporary accommodation as a result of ‘trouble with a travelling family’. 3.1.7 Little information about the man acknowledged to be Child E’s father was captured by records kept by Norfolk’s Children’s Social Care. It appears that Child E’s paternal grandmother was White and paternal grandfather was dual heritage African American / White origin. The issue of ethnic origin was one that would trouble Child E in later years.  Page 18 of 146  3.2 PRE-BIRTH CONFERENCE 3.2.1 Ongoing concerns about mother’s misuse of drugs and alcohol and numerous prosecutions for offences linked to prostitution (an eventual total of 78 as well as nearly 20 other offences) prompted a pre-birth Child Protection conference about Child E in July 1997.  3.2.2 Because of the apparent progress shown by mother (attendance at ante-natal appointments and assertions that she was trying to stop drug dependency) Child E was not made subject of a Protection plan at birth later that year. Indeed, information supplied indicates that the other children ceased to be subject of Child Protection plans on 08.07.97 and that the case was closed the next day.  3.2.3 Comment: in view of the family history, nature and duration of the parents’ substance misuse, this appears to have been a very optimistic conclusion and, in view of Child E’s drug-dependent condition at birth, one based on inaccurate reassurances from the parents. 3.2.4 As a result of the birth mother’s substance misuse, Child E was born drug dependent and suffered seizures4, requiring a total of two and a half months of treatment with Phenobarbitone and oral Morphine before and following discharge 11 days after birth, into the care of the birth mother. 3.2.5 In June1998 S3 left their adoptive home and returned home. Nothing further is known about this event. A further violent incident is known to have taken place at the family home in November of that year, apparently associated with a feud about the supply of drugs. There was a further incident in January 1999 when the children present were used as a shield to prevent access by police officers.  3.2.6 The family again became an open case to Norfolk Children’s Social Care though by February 1999 it was determined that the quality of care for Child E and siblings was acceptable and the case was again closed.   3.2.7 Comment: even based upon the partial account provided by Norfolk’s Individual Management Review it is clear that the level of need and risk was being greatly underestimated and case closure was an ill-informed decision.                                                  4 Almost all drugs are known to cross the placenta and in the embryonic period (up to eight weeks) and can have significant teratogenic effects i.e. causing malformations. During the subsequent ‘foetal period’ when the major structural development is complete the impact is more subtle. It can include direct impacts such as abnormal growth and/or maturation, alterations in neurotransmitters and their receptors and /or maturation or indirect through a pharmacological impact upon the mother. Established risks to pre-natal exposure are intra-uterine growth retardation, low birth weight, foetal alcohol syndrome and congenital abnormalities. Long term adverse effects can be on height, weight, memory and perception, behaviours (impulsivity and attention), reduced cognition, poor language development, risk of ADHD and oppositional defiant disorder, hyperactivity and externalising behaviours (aggression and bullying continuing through adolescence and manifesting in anti-social behaviour, offending and substance misuse).  Page 19 of 146  3.2.8 Accounts of the time confirm that the maternal grandmother was party to birth mother’s ongoing sex work and that the children were sometimes present. Child E was on one occasion believed to have ingested some of mother’s prescribed Methadone, though this was not confirmed following medical assessment. Other occasions on which mother was drunk in charge of her children are recorded. 3.3 INITIAL CHILD PROTECTION CONFERENCE 3.3.1 About a year after case closure, some two weeks before the birth of S1, the unborn child and siblings (excluding Child E) were made subject of Child Protection plans. This was prompted by a community midwife’s referral about mother’s failure to attend ante-natal appointments or the Drug Centre, as well as her ‘on-top’ use of illicit drugs. The decision that Child E’s situation did not require a Protection plan apparently reflected the fact that they were gaining weight and meeting developmental milestones. 3.3.2 Comment: whilst each child must be considered in their own right, it was extremely unlikely Child E was not being damaged by the neglectful environment in which they lived. 3.3.3 Nothing in the information supplied suggests that there had been any material improvement in standards of emotional or physical care over time. Child E’s siblings ceased to be subject of Protection plans following review conferences in May and September 2000 and the case was closed after the latter meeting (contrary to the guidance in the then current version of Working Together to Safeguard Children 1991, which emphasised the need to offer ongoing support after a child was no longer thought to be in need of a Protection plan). 3.4 EXERCISE OF POLICE POWERS OF PROTECTION 3.4.1 Within two weeks of case closure, mother became drunk and left her children in a pub. Local Police exercised their powers under s.46 Children Act 1989 and removed them. No details of their return home or of the next few months have been provided by Children’s Social Care, though concerns clearly remained. Police information confirms that mother was still earning money as a sex worker. The health overview refers to an NSPCC assessment and Child E’s revelation that they had shared a bed with mother as she ‘serviced’ a client. 3.4.2 Comment: no confirmation has been provided that this evidence of sexual abuse / neglect triggered enquiries under s.47 Children Act 1989. 3.4.3 Further referrals to Children’s Social Care were made by Police and Education Welfare respectively in January, February and March 2001. The home was described as chaotic, mother often drunk and the children unfed and dirty. The referrals prompted re-opening of the case and completion of an initial assessment. No decisive action was taken and the case was again closed on 03.07.01 with Education and Health Services asked to monitor the family. By  Page 20 of 146  then the adoption of S2 had reportedly broken down and they were back with the birth family. 3.4.4 Comment: the unusual return to a birth family of a child placed for or perhaps actually adopted (records are ambiguous) may have reinforced the determination of mother and Child E to achieve the same sort of unofficial rehabilitation in later years. 3.4.5 Police again exercised powers of protection in 2001 when an (intoxicated) mother was involved in a fight. The children were transferred to the care of the Local Authority but immediately returned to their mother. This was a further missed opportunity for decisive intervention. 3.5 INITIATION OF CARE PROCEEEDINGS / INTENDED LEVEL OF CONTACT WITH BIRTH FAMILY 3.5.1 A crisis point was reached in September 2001 when Child E’s family was evicted by Norwich City Council and moved in with maternal grandmother. A month later the grandmother left her own home because she could not cope with the family’s behaviour. Child E’s family was then evicted and apparently moved back to their previous home which was reported to have no supply of water, gas or electricity. An anonymous referral described the children as ‘filthy, the older caring for the younger family members and mother shouting and screaming’. 3.5.2 Presumably these events served to increase the levels of concern about Child E. Following a Child Protection conference on 12.11.01 (at which all four children were registered under the category of neglect and emotional abuse), Children’s Social Care initiated proceedings under s.31 Children Act 1989 i.e. the Local Authority contended that Child E was suffering or likely to suffer ‘significant harm’ as a result of inadequate parental care. 3.5.3 The initial court hearing was on 06.12.01 and, whilst the legal proceedings were being pursued, Child E and three siblings were placed back with their maternal grandmother. The parents were not legally represented. The grandmother was apparently willing for the court to remove an injunction that prohibited the parents from visiting her home to contact the children. Mother was remanded to prison at this time in consequence of her criminal conduct and released in late February 2002. 3.5.4 Comment: although a decision that had been ratified by a court, the decision (in the light of her known history) to entrust the children to the grandmother’s care was unduly optimistic.  3.5.5 Sutton Children’s Social Care records derived from other agencies indicate an Emergency Protection Order was granted on 01.01.02 and Child E had been moved to emergency foster carers5. The report provided by Norfolk offers an                                                  5 An Emergency Protection Order (s.44 Children Act 1989) can be issued by a court if it has reasonable cause to believe that a child is suffering or is likely to suffer significant harm unless s/he is removed to or retained in a  Page 21 of 146  alternative explanation and refers to an independent assessment of the ability of the maternal grandmother to care for any or all of the children. It concluded that she lacked the capacity and on 18.01.02 Child E and siblings were removed. 3.5.6 An assessment of Child E by a paediatrician for the purposes of the legal proceedings concluded that they were developmentally delayed, possibly because of the chaotic social circumstances, and were six to nine months behind in terms of self-care. The probable influence of prenatal exposure to opiates was recognised by that doctor.  3.5.7 A further expert report provided by a clinical psychologist described Child E as the most needy, and recommended placement in a family as the only, or anyway youngest, child. This psychologist thought Child E was already showing signs of ‘reactive attachment disorder’6. His recommendation was for indirect only contact twice a year for parents and direct contact annually for the grandmother. 3.5.8 Comment: the importance of preventing un-managed contact by parents (or unauthorised contact by the grandmother) was not sufficiently kept in mind across the years.  3.5.9 Records are insufficiently clear to determine with which siblings Child E was initially placed but during the course of the year, S5 was moved to an alternative foster home. 3.5.10 Comment: loss of siblings can be as traumatic and damaging as the loss of a parent7. 3.5.11 The parents did not attend the later court hearings, in father’s case because he had begun a six-year prison sentence for violent and drug-related offences. Records suggest that a final Care Order was obtained on 23.10.02 at which point Child E was separated from S1 and placed in a ‘bridging’ placement prior to being placed for adoption. A report of Child E’s behaviours in the months following referred to them as being very demanding in the classroom and finding it hard to work. At times Child E would only play on their own or sulk in a corner. Records suggest that school attendance was also a concern during 2003. 3.5.12 ‘Family finding’ in early 2003 included Child E being featured in four editions of ‘Be My Parent’8 as well as being circulated amongst an East Anglian                                                                                                                                                          place of safety. A second possible ground is that enquiries being conducted by the Local Authority or NSPCC are being frustrated by unreasonable refusal of access to the child. 6 Reactive Attachment Disorder (RAD) is described in clinical literature as a severe and relatively uncommon disorder that can affect children. RAD is characterised by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way (the ‘inhibited form’) or can present itself as indiscriminate sociability, such as excessive familiarity with relative strangers (the ‘disinhibited form’). 7 See for example ‘We Are Family’ – sibling relationships in placements and beyond, edited by Audrey Mullender BAAF 1999  Page 22 of 146  consortium of Adoption Agencies. Of 18 responses generated, all either withdrew or were deemed unable to meet Child E’s extensive needs. 3.5.13 Child E’s birth mother had by then accrued over 50 convictions, mainly for loitering for purposes of prostitution in Norwich. She was imprisoned for a proportion of the time that Care Proceedings were being pursued. Throughout Child E’s childhood, the birth mother accrued many dozen more convictions, for sex work and unrelated crimes of dishonesty and violence. 3.5.14 Records supplied refer to ‘goodbye visits’ with siblings and maternal grandmother which (given that contact did actually continue) was an inaccurate description and may have added to Child E’s confusion. 3.6 ASSESSMENT AND APPROVAL OF ADOPTIVE MOTHER 3.6.1 Whilst the Care Proceedings were being conducted, in mid-July 2002, assessment of the single female who was to become Child E’s ‘adoptive mother’ (Ms AM) had been completed by the Catholic Children’s Society and she was formally approved on 16.07.02.  3.6.2 The records supplied to this Serious Case Review initially provided no explanation of the sort of child or family circumstance for which Ms. AM was thought suitable. Nor was any explanation provided of the evaluation of the significance for any placed child of her epilepsy (which was to trigger some future significant concerns for Child E). 3.6.3 The Serious Case Review panel sought to better understand the assessment, approval and support of Ms AM. On 13.01.15 a very clear and helpful supplementary report was supplied by an adoption specialist commissioned by Norfolk County Council. Her report provided detail about the efforts made to identify an adoptive family for Child E and the fact that this included a successful effort to reduce the original frequency of Court-endorsed post-adoption contact with members of the birth family. A No Contact Order was made at the time of the Adoption Order. 3.6.4 The report also confirmed that Ms AM’s medical condition was fully evaluated (and her epilepsy described by a neurologist as ‘very mild’) and that she had not experienced a seizure for two years. Subsequent formal reviews of need prompted the engagement of the Marlborough Clinic as described later in this report. 3.6.5 The report also clarified that Ms AM had not initially sought a financial allowance, but that the option had been kept open for three years and a basic allowance, actually enhanced from 2005 (and maintained at a reduced rate after Child E again becoming a ‘Looked After’ Child) until it finally ceased in April 2010.                                                                                                                                                           8 ‘Be My Parent’ is a magazine published regularly by the British Association for Adoption and Fostering (BAAF) and features and promotes the possibility of adoption for ‘hard to place’ children  Page 23 of 146  3.6.6 Efforts were made (via Norfolk’s Adoption and Family Finding Unit) to sustain the agreed ‘letterbox contact’ in the period 2004 - 2011, though confidentiality was compromised when Ms AM’s phone number was discovered by an older sibling of Child E. From then on, Child E became vulnerable and drawn into the birth family’s damaging dynamics.  Page 24 of 146  4 PLACEMENT FOR ADOPTION TO ITS BREAKDOWN 4.1 PLACEMENT 4.1.1 The local Adoption Panel had approved the match between Child E and Ms AM on 10.12.03 and, following introductions that began on 04.02.04, Child E started at a new school (school 3) on 01.02.04 and was ‘placed with a view to adoption’ with Ms AM on 13.02.04.   4.1.2 Comment: there was a significant delay between approval as a potential adopter in 2002 and a ‘match’ being identified. Ms AM informed the Review that prior to Child E being suggested, she had explored the possibility of another child. Child E’s introduction process (at only nine days duration including entering a new school) was very rapid. 4.1.3 A report by a children’s guardian in January 2004, for anticipated adoption proceedings, recommended twice yearly direct and twice yearly indirect contact with maternal grandmother. Nothing further was added to what was initially deduced (and has since been confirmed by Ms AM) as the proposal for annual ‘indirect only’ contact by birth parents.  4.1.4 At an initial review, Child E was recorded as happy to be in the placement and noted to need support to understand why they could not live with their birth family. Nonetheless, by the time of the second review some three months after arrival, the level of Child E’s challenging behaviour was such that Norfolk’s Adoption and Family Finding Unit referred them to the Marlborough Clinic in London. Symptoms described included severe difficulties with sleeping, tantrums and physically threatening behaviour toward Ms AM. Child E was described as controlling, craving affection from adults but responding well to consistent parenting. 4.1.5 Of significance, given the difficulties that lay ahead as a consequence, information supplied by Norfolk Children’s Social Care suggests that Ms AM was ‘in agreement with proposed plans for face to face contact with the maternal grandmother and Child E’s siblings, as well as indirect contact with birth parents and siblings and half siblings.  4.1.6 Comment: the report supplied by Norfolk indicates that the formal position in the then care plan was face to face contact with maternal grandmother and S4 and S5 twice a year, and ‘letterbox contact’ only with birth parents. 4.1.7 Norfolk had commissioned an independent report from a clinical psychologist.  In December 2003 the psychologist alluded to the distress shown by Child E before and after contact with maternal grandmother as well as his view that ongoing contact was in the child’s interest only if the grandmother was able to support Child E’s (and siblings’) placement with a new family. The report concluded that annual face to face contact and indirect contact twice a year  Page 25 of 146  was an acceptable level if the grandmother could set aside her own needs. He envisaged a managed contact with all the children in a neutral setting. 4.1.8 Though she provides no detail, Norfolk’s report author indicates that grandmother continued to view contact in terms of her needs, not the children’s. 4.1.9 Comment: the issue of post-adoption contact with the family of origin is always significant. In this case it represented one of the major systemic weaknesses in the service delivery of agencies seeking to meet Child E’s physical and emotional needs. 4.1.10 A third review in January 2005 noted Child E’s growing attachment to Ms AM. Contact with maternal grandmother and one or all of the siblings was ongoing. In February 2005, Child E and Ms AM lived for while with her parents before moving into a new home in Kensington and Chelsea. Over 20 months elapsed after the placement before Child E was, in late 2005, adopted under the Adoption Act 1976 (the new Adoption and Children Act 2002 was implemented about a month later). The delay has been explained by Ms AM as her acting on advice of the then involved Norfolk staff to take matters slowly. 4.2 POST ADOPTION PERIOD 4.2.1 No formal post adoption support plan was supplied and, given the extremely high level of need being manifested by Child E, the level of support provided seems to have been insufficient. Norfolk, as the placing authority, was responsible for post-adoption support by virtue of the then current regulations9. Though Ms AM has acknowledged ongoing support from SW1, reports supplied were insufficiently clear about the level and nature of contact maintained with Ms AM. Formal records indicate that the Adoption Agency closed the case on 01.02.06, two months after the Adoption Order had been obtained.  4.3 REPORT OF MS AM’S SEIZURE 4.3.1 In April 2006, Child E (then aged eight and a half years old) called an ambulance for Ms AM, whom, it was later decided, had experienced an epileptic seizure. A commendable follow-up by Westminster Children’s Social Care confirmed that Ms AM was not seeking additional support from that agency. 4.3.2 In December 2006 Child E called Police to report that they were scared of Ms AM and that she was rude to them. The context of this call was that she had asked Child E to finish a phone conversation with maternal grandmother. Upon notification from the Police of this incident, Westminster Children’s                                                  9 Adoption Support Services (Local Authorities) (England) Regulations 2003, which from December 2005 were replaced by the Adoption Support Services Regulations 2005   Page 26 of 146  Social Care wrote and encouraged the involvement of the Marlborough Family Service. 4.4 FIRST FIRE RAISING INCIDENT 4.4.1 On 01.02.07, Child E (aged 10) tried, failed and on a second occasion succeeded, in burning down the family home. Ms AM’s view is that Child E may have just been ‘playing’ on the first occasion (she reported to the author that Child E was fascinated by fire). It is, though, beyond doubt that Child E started a serious fire that endangered their own and others’ lives. A re-referral to the Marlborough Service was made next day.  4.4.2 Child E had joined ‘school 4’ in Westminster in June 2006. Some internal reports describe a highly disturbed child who presented serious difficulties alternately bullying others and then complaining of being bullied. A re-referral to the Marlborough Family Service was made. At this time the first of several school exclusions occurred as a result of violence toward other pupils. 4.4.3 Comment: the school reports seen relating to Child E’s time in Westminster contrast sharply with those (provided by Ms AM) for their previous school where Child E’s effort grades were nearly all ‘good’ and achievements at worst ‘average’. 4.5 CONTACT WITH BIRTH FAMILY MEMBERS  4.5.1 Levels of contact between Child E and their birth parents and siblings had been agreed and (although not confirmed in the report provided by Norfolk) enshrined in court-imposed conditions in accordance with the Adoption Act 1976. In August 2007 the first example of what became a recurring pattern of unauthorised contact began when S2, Child E’s 21 year old adopted half-sibling (since deceased, but then living with their birth mother) made contact by phone. Fortnightly calls persisted and there is no record of professionals’ attempts to contain that source of stress. 4.5.2 In response to the variety of difficulties being experienced, in September 2007, Norfolk Children’s Social Care asked the Catholic Children’s Society to assess the family’s ‘adoption support needs’. In parallel to this, a ‘Child in Need’ assessment was also undertaken by Children’s Social Care in Westminster, where Child E and Ms AM were by then living.  4.6 REPORTS BY CHILD E OF CONCERNS 4.6.1 A curious incident occurred in late September 2007 when Child E reported to Police that they were being followed by an older male. Child E was unable to offer any further details and no further action was possible. About a month later, Child E spoke of an attack by a man ‘sent by birth mother’ some months earlier. Child E subsequently admitted to a teacher that they had fabricated this story (some three years later Child E expressed similar and apparently  Page 27 of 146  unfounded anxieties about a planned abduction by the birth mother’s then boyfriend). 4.7 S.47 ENQUIRIES IN RESPONSE TO ALLEGATION OF PHYSICAL / SEXUAL ABUSE 4.7.1 On the day of Child E’s 10th birthday in 2007, Child E complained to Police that a lodger at their home had ‘hurt Child E’s arm’ and ‘brushed her breast past’ Child E. Enquiries were completed within a week and confirmed that the adoptive mother and the lodger (also referred to as a tutor) had used mild physical chastisement to try to control Child E’s conduct (which had included running out of the home and threatening to jump off scaffolding). They agreed to develop alternative disciplinary methods.  4.7.2 It is understood that the Westminster Children’s Social Care response to this incident included the completion of a ‘core assessment’10 by the allocated social worker. That assessment confirmed that the adoption was at risk of breaking down.  4.7.3 The difficulties of contact with the birth family were cited as of real significance. The core assessment also referenced a comprehensive assessment of post adoption support needs completed by the Catholic Children’s Society in November 2007. That agency had reportedly recommended that the adoption allowance continued unchanged (its level was unspecified; it appears to have been ‘basic’ rather than ‘enhanced’ and also seems to have been prematurely terminated). Therapy three times a week at the Marlborough Service had also been recommended. 4.7.4 After completion of its core assessment, Westminster Children’s Social Care closed the case in January 2008. 4.7.5 During the Autumn term of 2007 and into early 2008, Child E was being supported in school by means of a teaching assistant and attending two (later three) sessions per week of therapy at the Marlborough Family Service with ‘therapist 1’.  4.7.6 There were further incidents of bullying and considerable contact between adoptive mother, school and the Marlborough Service, including a ‘multi-agency network’ meeting in mid-November 2007. 4.7.7 By June 2008, a ‘team around the child’ meeting at the Marlborough Service had formed the view that a residential environment was required for Child E. In July 2008 Child E spoke to an individual (thought to be school counsellor) about sexual abuse by Child E’s birth father. This information was shared with the adoptive mother who indicated that Children’s Social Care was aware of Child E’s early history and that the reference might be to Child E’s parents having sexual intercourse in front of all the children in the family.                                                  10 A ‘core assessment’ is a standardised framework that captures and analyses a child’s developmental needs, parent/’s capacity and relevant family and environmental factors.  Page 28 of 146  4.8 FURTHER S.47 ENQUIRIES IN RESPONSE TO AN ALLEGATION OF PHYSICAL ABUSE 4.8.1 Difficulties relating to Child E’s conduct with other pupils (chiefly bullying) persisted throughout 2008. On 01.09.08, Child E disclosed an incident to their teaching assistant in which Child E claimed to have been abused by their adoptive grandmother, tutor and adoptive mother. Children’s Social Care and Police apparently completed enquiries and determined that no further action was required. 4.8.2 Child E repeated and embellished this account about a month later, although no further information about these allegations has emerged. 4.9 ‘SCHOOL ACTION PLUS’ STATUS  4.9.1 By November 2008 Child E’s educational needs (attitude to learning and other pupils and poor attendance) resulted in ‘school action plus’ status11.  4.10 SECOND FIRE RAISING INCIDENT / INITIAL ASSESSMENT 4.10.1 A reference in the chronology provided to Child E setting fire to the home is dated 01.11.08 (though it might actually be a reference to the incidents of February that year). A response by Hammersmith and Fulham Children’s Social Care indicates that Child E and Ms AM had by then moved to that borough. 4.10.2 The Marlborough Service noted some improvement in ability to distinguish fantasy and reality but that Child E ‘has not developed the degree of resilience [they] will need to protect [themselves] through what is likely to be a turbulent adolescence’. The recommendation of that service was a ‘therapeutic boarding school as the resources for holding things together have already been stretched to the limit’. 4.10.3 Comment: subsequent events show this to have been an accurate appraisal and a well-informed recommendation. 4.10.4 Enquiries under s.47 Children Act 198912 were said to have been planned and undertaken by SW2 from Hammersmith and Fulham. An initial assessment (rather than the core assessment routinely triggered by such enquiries) was reportedly completed. It described the known history, Child E’s recent contact with the birth family and referred to a need for consistent containment and specialist emotional support. Ms AM and Child E were seeking respite                                                  11 In response to ‘school action plus’ status, external support services, both those provided by the Local Authority and by outside agencies, will usually see a Child, in school if appropriate and practicable, so that they can advise subject and pastoral staff on new individual education plans (IEPs), with fresh targets and accompanying strategies, provide more specialist assessments that can inform planning and the measurement of a pupil’s progress, give advice on the use of new or specialist strategies or materials, and in some cases provide support for particular activities. 12 A Local Authority is obliged to make enquiries under s.47 if it suspects a child is suffering or is likely to suffer significant harm  Page 29 of 146  arrangements. A conclusion that there was a need to undertake an assessment of special educational needs was reached. 4.10.5 A poorly attended ‘transfer in meeting’ was convened on 20.11.08 and Westminster’s core assessment shared. Ms AM confirmed that Child E was at that point seeing the birth siblings and maternal grandmother three times a year. She also indicated that she was awaiting individual sessions at the Marlborough Services and was in receipt of an adoption allowance from Norfolk. No formal notes were kept of this meeting at which neither school, Norfolk Children’s Social Care or the Marlborough Service were present (though the latter provided a detailed report and offered a further meeting). 4.10.6 It would appear that there was some confusion about the status of the case and the consequent attribution of responsibility i.e. was Child E a ‘Child in Need’ and was the family still in receipt of post adoption support? Ms AM at this point was seeking a boarding school for Child E. No records have been provided of a planned joint Norfolk / Hammersmith and Fulham visit on 24.11.08. 4.11 MEDICAL CRISES 4.11.1 In December 2008 Child E (who should have been at school) complained via the national charity ChildLine of being cold, not being fed enough and of Ms AM’s tiredness and general ill-health. Ms AM was at the time in bed suffering from ‘flu which was confirmed when Police attended the home at the request of SW2. 4.11.2 On 15.12.08 Ms AM experienced a further seizure which, in the absence of any contingency arrangements, necessitated Child E being cared for by the adoptive grandmother for three days. The borough subsequently arranged, for the next six months, a potential respite carer should the problem reoccur.  4.11.3 In the course of the contact with Ms AM during this Serious Case Review, she reported that her seizures had, until this date, been nocturnal and typically mild (she likened their impact to waking up from a dream slightly disoriented). 4.11.4 Comment: given Ms AM’s known vulnerability to seizures, a contingency plan should have been formulated by Norfolk Children’s Social Care and made known to all relevant parties.  4.12 RUNNING BACK TO BIRTH FAMILY 4.12.1 At the end of January / beginning of February 2009 (dates provided vary) Child E ran away for first of what became numerous occasions. It is understood that this episode had been planned by the birth maternal grandmother and/or the now adult and previously adopted S2. Whilst back in Norfolk, Child E made contact with these individuals as well as both birth parents.  Page 30 of 146  4.12.2 Police exercised their powers under s.46 Children Act and Child E was returned to Hammersmith and Fulham. Child E then refused to stay with Ms AM (or indeed even be in the same room) and went instead, on or about 05.02.09, to Ms AM’s brother and sister in law who lived in Sutton. 4.12.3 The maternal grandmother emailed Hammersmith and Fulham to complain of observed marks on the arms of Child E. On enquiry, Child E made no allegations that they reflected physical abuse within the adoptive family. 4.12.4 Passing references were made at this period of Ms AM’s financial difficulties and of Child E’s claim that she gambled on-line. Ms AM herself was advancing the possibility of using a named placement in Horsham (a non-maintained boarding and day special school rated as ‘outstanding’ by the regulator Ofsted). 4.12.5 Hammersmith and Fulham records indicate that the ‘school was advised of return and warned about fire raising and that [Child E] will run again’. This poorly constructed note has been interpreted to mean that the school was, on the basis of the incident in February 2008, referring to the ongoing risk of fire raising, coupled to a prediction that Child E would run away again. 4.12.6 Comment: professionals’ records should always be unambiguous. 4.12.7 The head teacher spoke with SW2 and relayed the willingness of the school to accept Child E if an SEN statement were to recommend a need for it. A record dated 09.02.09 indicated that Child E was behaving better and would go home until a boarding school place became available. The need to review contact arrangements with the birth family was noted though the language implies something more flexible and conciliatory than insisting upon the conditions identified as in Child E’s interests by the Norfolk clinical psychologist. 4.12.8 At this stage, a local family support service (Family Assist), the Marlborough Service, Hammersmith and Fulham and Norfolk Children’s Social Care (as well as a local provider of respite care) were all trying to help. Child E initiated a complaint that SW2 had referred in front of others to Child E’s fire-setting (though neither the occasion to which she may have been referring, nor the response to Child E’s complaint, is clear from material submitted to this Serious Case Review). 4.12.9 A core assessment was completed in February 2009 (Child E was then 11 and a half years of age). It concluded that Child E was demonstrating risky and challenging behaviours, did not feel part of their adoptive family, had sleep difficulties, was unable to detach from their birth mother (contact with the birth family was described as ‘problematic’), and was not doing well at school. In summary Child E was insecure and anxious. An ‘identified strength’ (not wholly confirmed by subsequent events) was that Child E had a strong relationship with the maternal adoptive uncle’s family.  Page 31 of 146  4.12.10 The records of the local Family Assist agency confirm that Child E had not resumed school following return from Norfolk. The plan at this time was to overcome Child E’s clear ambivalence about Ms AM so that they could resume living with her and then attend boarding school.   4.12.11 A management decision was made in Hammersmith and Fulham that Child E was best regarded and responded to as a ‘Child in Need’.13 It was noted that Ms AM was being supported by means of a Catholic Society support group and (with respect to the management of contact with birth family) by Norfolk’s Adoption Team. The plan that emerged included the presumption that Ms AM would pursue the option of a boarding school (the view of the Marlborough Service was that Child E was too much for any one individual to manage). 4.12.12 As at late February, the Hammersmith and Fulham school was unable to cope with Child E on-site and had resorted to sending work home i.e. to the adoptive uncle and aunt for Child E to undertake. Ms AM had apparently made a formal request for Child E to be assessed and (in all probability) statemented.  4.12.13 Comment: details of how Norfolk’s Adoption Team sought to manage the continuing impact of the birth family’s conduct has not been made available to the Serious Case Review and reports about Child E’s schooling have been extremely limited. Though clearly a ‘Child in Need’, Child E’s behaviours from this point onwards meant that they was often additionally ‘at risk of significant harm’.  4.12.14 A reference has been seen to birth mother, contrary to agreed contact arrangements, taking Child E to Cambridge and meeting more than one of the half-siblings. By 06.03.09 Child E was back with Ms AM and had returned to school. Records indicate that contact with siblings now equated to three times a year. 4.12.15 Child E claimed at a multi-agency meeting at the Marlborough Service (at which point the 11 year old conducted an impressive PowerPoint presentation of the birth mother before her drug-dependency) that they wished to start afresh with Ms. AM. However, by the end of March and reportedly encouraged by members of the birth family, Child E was again threatening to run away. 4.12.16 After a further crisis on 27.03.09 when Child E ran away and had insufficient money to reach the intended destination of Norwich, Hammersmith and Fulham (commendably) supplied a support worker who stayed with Child E and Ms AM over the weekend. Child E ran away again three days later and, following discussion between Police and the out of hours service of Children’s Social Care, was returned to Ms AM. Some reports completed by the allocated                                                  13 A ‘Child in Need’ is defined by s.17 Children Act 1989 as one who is unlikely to achieve or maintain, or have the opportunity to do so, a reasonable standard of health or development without provision of services by a Local Authority or if her/his health or development is likely to be significantly impaired, or further impaired without such services [there is an additional, in this case irrelevant, disability criterion].  Page 32 of 146  support worker suggest that those staff, rather than Ms AM, were, on occasions, the primary carers for Child E. 4.13 EMERGENCY AND CONSEQUENTLY TEMPORARY PLACEMENTS  4.13.1 Though Child E had previously lived with them in an informal arrangement, on 01.04.09 Child E was (following a family meeting and with Ms AM’s consent) accommodated under s.20 Children Act 1989 and formally ‘placed’ with the adoptive aunt and uncle (Ms AM’s brother and sister in law). Child E was on the edge of school exclusion but no agreement had been reached about formal SEN assessment. 4.13.2 The records provided by Hammersmith and Fulham also refer to events during April which imply that Child E might have returned temporarily to Ms AM; e.g. ongoing supply of domiciliary support workers and a report of a depressed mother spending much time in bed whilst the support worker supervised Child E. Reference is also made to a ‘recent seizure’ suffered by Ms AM.  4.13.3 Comment: conversations with Ms AM have confirmed that she was at this time feeling isolated and more vulnerable (though her commitment to Child E was and remained undiminished). 4.13.4 Though the details are unavailable, some respite care was provided during April. Records also refer to acute financial difficulties being experienced by Ms AM at this period, some related to costs incurred when Child E had set fire to their then home. Some later records of the local ‘Family Assist Service’ refer to a plan to help Ms AM seek an enhanced adoption allowance. 4.13.5 Child E’s re-location and change of status made little difference to running back to the birth family. Some three weeks after the move to the couple who were deemed to be relative / friend carers, Child E ran back to Norfolk and phoned from the grandmother’s mobile, though refused to confirm their actual whereabouts. 4.13.6 A placement with Hammersmith and Fulham foster carers in Hayes was made on 22.04.09 after the birth family admitted that Child E was with them. Threatening, destructive and self-harming behaviour (scratching their arm with a pin until it bled) was seen at a therapy session the next day and triggered admission for a psychiatric assessment at hospital 1. The foster carers (whom Ms AM suspects had not been told of the fire raising incident before the placement) refused to accept Child E back. 4.13.7 Comment: it is of critical importance (and a regulatory requirement) that any substitute carer is provided with all relevant information before or at the time of placement.  4.13.8 At a professionals’ meeting that day, understandable criticisms were made of Norfolk Children’s Social Care for not making and enforcing more effective post-adoption contact arrangements.  Page 33 of 146  4.13.9 On 25.04.09 Child E was placed with a different foster carer with additional round the clock family support. Reports indicate that a ‘succession of support workers refused to work with Child E because of offensive and insulting behaviours such as spitting and threatening assault’. Child E (by then still less than 12 years of age) was believed to be drinking and smoking regularly. 4.13.10 Child E’s birth family’s efforts to undermine the arrangements made continued e.g. Child E received a letter from the maternal grandmother which included £30, four rolled up cigarettes and a lighter. Child E’s observed conduct suggested that they were also extremely anxious to maintain contact with members of the birth family, which by then included a sibling who had also been adopted; e.g. approaching passers-by to borrow their mobiles to call members of the birth family. 4.14 SELF-HARM EPISODE ONE 4.14.1 A sad and telling response a subdued Child E made to a teacher toward the end of April, when asked about self-imposed scratches on the arms, was that ‘when I am feeling this pain, I am not feeling anything else’. This modest example of self-harm would later escalate into numerous and some life-threatening episodes. 4.15 EDUCATIONAL NEEDS 4.15.1 In their contribution to the statement of special educational needs being developed at this time, the Marlborough Service wrote to Hammersmith and Fulham and described a ‘grave risk’ that the limited progress that Child E had made in therapy would be lost, were they to become a pupil at a mainstream secondary school. The clinic staff advocated instead use of what they described as a ‘secure therapeutic residential school’. 4.15.2 A comparable view was expressed in an educational psychology report of 07.05.09 which recommended ‘intensive therapeutic support in a small, safe environment …to secure [the] physical and emotional well-being’ of Child E. A paediatrician’s view at the time was that Child E required, in addition to being taught in a small group, an urgent referral to a Child and Adolescent psychiatrist for further assessment.  Page 34 of 146  5 RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 5.1 INTRODUCTION 5.1.1 Some of the latter paragraphs of Section Four describe emergency responses to Child E’s rejection of Ms AM. This section addresses the period from May 2009, when it appears that a formal decision was made that Child E would need more than just a temporary alternative home, through to Child E’s death in May 2014. 5.1.2 A routine medical assessment for a Looked After Child was completed on 08.05.09 and revealed no conditions that would adversely impact on future learning, though significant behavioural needs were recognised. 5.1.3 On 09.05.09 Child E’s case was allocated to SW3 in the ‘Looked After Children’ team of Hammersmith and Fulham Children’s Social Care. At a home visit a week later, Child E was verbally abusive toward SW3 and indicated that they could, if they wished to, run away or have the birth family collect them.  5.1.4 Descriptions by school staff at this period mirror those of Ms AM and speak of massive outbursts of uncontrollable frustration and hostility toward carers or others in authority. 5.1.5 A request was initiated on 12.05.09 for a therapeutic residential placement based on the breakdown on Child E’s adoptive placement and a belief that no foster home could offer the containment, and ensure receipt of, secondary education, which Child E was due to begin in September. Hammersmith and Fulham approved the request and contemplated joint funding by Social Care and Education Services. A search for suitable placements was begun on 14.05.09. 5.2 RUNNING BACK TO BIRTH FAMILY / PLANS FOR RESIDENTIAL CARE 5.2.1 Within two days of the threats to do so, Child E ran away to Norfolk and was traced two days later to a sibling’s house. The then foster carers refused to have Child E back and so Child E was placed in a residential unit in Dover.  5.2.2 A formal decision that Child E would not return to Ms. AM appears to have been made at a ‘network meeting’ at the Marlborough House Family Service on 19.05.09. The meeting also concluded that contact with the birth mother was damaging. Child E’s aggressive behaviour necessitated physical restraint at this time and on one occasion Child E’s anger was such that they frothed at the mouth in a manner that prompted a 999 call. Attending paramedics described Child E’s behaviour as a ‘fit of rage’.  Page 35 of 146  5.2.3 Comment: no notes have been found of this meeting. A decision of this magnitude should have been made at a statutory review (required by virtue of s.26 Children Act 1989 and (at that time) the Review of Children’s Cases Regulations 1991 as amended). The first such review was due within four weeks of Child E being formally accepted into s.20 accommodation and placed with the adoptive aunt and uncle. 5.2.4 In early June 2009, after an outburst at the placement, Child E was detained in a cell overnight and received a formal reprimand for criminal damage and assault. Child E was consequently transferred, on 04.06.09, to an alternative placement in Hove. There (aside from some unauthorised absences and associated misuse of alcohol) Child E appeared to settle and attended off-site schooling.  5.2.5 A statutory review on 22.06.09 noted the more settled behaviour and Child E’s clear refusal to spend even holidays with Ms AM. The birth mother had reportedly threatened to kill herself if Child E were to refer to Ms AM as ‘mum’ (a good example of the split loyalties Child E felt then and later). A personal education plan (PEP) was still awaited at this point. 5.2.6 On 29.06.09 SW3 contacted the National Clinical Assessment and Treatment Service (NCATS)14 consultant psychiatrist 1 to request an assessment. It is thought that its results were available by 17.11.09, though apparently not ‘inputted’ into agency records for over a year. The recommendations of psychiatrist 1 included that Child E should not return to Ms. AM. 5.2.7 Comment: as well as the delay in updating records, the contents of the assessment (see below) seem not to have informed actions as quickly as they could have done. 5.2.8 A formal statement of special educational needs was completed in August 2009 and recommended use of a specialist placement for pupils with emotional, social and behavioural difficulties and referral for further psychiatric assessment, as well as optical and hearing tests. 5.2.9 On 09.09.09 Child E’s birth mother overdosed and was hospitalised. Ms AM agreed that Child E should visit, and went on to assist with the visit, the birth mother.  5.2.10 Comment: the commitment shown by Ms AM was then and remained remarkable. 5.3 SELF-HARM EPISODES TWO AND THREE 5.3.1 Whether preceding or following a second statutory review on that day is unclear, but only four days after the birth mother’s overdose on 10.09.09,                                                  14 NCATS is a ‘fourth tier’ NHS Service working in partnership with the NSPCC and consisting of psychiatry, social work, psychotherapy.  Page 36 of 146  Child E reported to have drunk anti-bacterial cleaner and was admitted to hospital. The incident may have reflected Child E’s ongoing chronic anxiety about what was happening within the birth family.  5.3.2 Upon discharge from hospital, Child E ran away to a cousin’s home in Norfolk and was also harboured again by the birth mother. Police records indicate that a decision was made not arrest or prosecute the birth mother because of ‘her chaotic lifestyle and a huge range of issues’. Police records refer also to an understanding that Ms AM had told Child E that there could be henceforth regular contact with the birth family. Ms AM’s own description is that she was struggling at this time and later, to sustain formally agreed contact arrangements and was acutely aware of the risk of Child E running away and placing themselves at greater levels of risk.  5.3.3 The second review had been chaired by the same IRO1 as the first and he noted that the proposed psychiatric assessment was still outstanding. 5.3.4 A further set of (it appears) linked events occurred in October 2009, when Child E became very angry during a phone conversation with the birth mother, because she had resumed use of Cocaine. Child E subsequently became subdued and withdrawn and a few days later took an overdose of Paracetamol and was in hospital for two days. Upon discharge, Child E spent a few days with the maternal adoptive aunt. Tables of all known or reported episodes of self-harm or recorded overdoses of drugs / alcohol is included in the analysis in Section Six. 5.3.5 Records of the social worker’s supervision on 15.10.09 indicate that a decision was made at that time to instigate Care Proceedings (though a further year elapsed before that response was actually initiated by Sutton’s Children’s Social Care). 5.4 DISCHARGE FROM ‘LOOKED AFTER’ STATUS / RECOMMENDATIONS OF NATIONAL CLINICAL ASSESSMENT AND TREATMENT SERVICE (NCATS) 5.4.1 On 19.10.09, against the advice of Children’s Social Care, Ms AM in consultation with her sister, formally discharged Child E from accommodation. The plan was that, until Child E’s relationship with Ms AM had improved, Child E would live with the maternal uncle and aunt in Sutton and attend a local school. 5.4.2 Comment: insofar as a decision had already been made to initiate Care Proceedings, this event could justifiably have triggered notice of such legal action. 5.4.3 A letter from SW3 in Hammersmith and Fulham provided a briefing on the case and confirmed that it had been the intention in that borough to seek a Care Order so as to share parental responsibility with Ms AM.  Page 37 of 146  5.4.4 The NCATS report (commissioned by Hammersmith and Fulham when Child E was resident there) became available at this time. Its recommendations included that its contents should be shared with Sutton (on the reasonable presumption that this was the Local Authority in which Child E was to reside from then on). 5.4.5 The remaining operational recommendations were that:  Sutton Children’s Social Care should open Child E’s case   An initial Child Protection conference should be convened  A legal planning meeting should also be arranged  Sutton complete an assessment of Ms AM with a view to possibly rescinding [sic] the Adoption Order  A local Child and adolescent psychiatrist and a psychologist should assess Child E  The ‘Contact Order’ [sic] with birth mother should be reviewed and a revised contact agreement formulated  NCATS should review with the new professional group in Sutton 5.4.6 Comment: references to rescission of the Adoption Order and a review of what was called a Contact Order suggest some confusion about relevant law. Adoption Orders cannot, in circumstances such as these, be revoked and no Contact Order existed with respect to the birth mother. Those comments aside, the other recommendations made good sense. 5.4.7 An email that emerged in the course of this Serious Case Review indicates that NCATS followed up to ensure that Sutton read and responded to its report (though SW3’s records failed to capture that exchange). A review meeting was offered by NCATS for 28.01.10 and was later cancelled as described below. 5.4.8 SW3 from Hammersmith and Fulham initiated a referral to Sutton which was responded to by SW4. An exchange of correspondence then ensued which focused on (unspecified) tasks that it was contended the former borough should have completed before Sutton would accept responsibility. A Hammersmith and Fulham record indicates a management decision of 06.11.09 that the borough would support the work but that, because Ms AM, Child E and the adoptive uncle and aunt lived in Sutton, it had lead responsibility. 5.4.9 Comment: given that Child E’s intended future home was to be in Sutton (whether with Ms AM or her brother and sister in law, and without regard to any boarding school attendance) Child E was ‘ordinarily resident’ there and Sutton was accountable for service provision. 5.4.10 Ms AM herself initiated contact with Sutton’s ‘Referral and Assessment’ team on 04.11.09 and SW4 completed an ‘initial assessment’. She recommended a referral to the ‘Joint Adolescent Service’ (JAS) to work on relationships; to  Page 38 of 146  another service for a mentor and to the Child and Adolescent Mental Health Service (CAMHS) for support with respect to Child E’s substance misuse. 5.4.11 A meeting was held on 17.11.09 with Child E, SW3, Ms AM and her sister. Child E made it clear that they did not want the adoptive mother to be called ‘mum’ and wanted to live with her sister. Ms AM recalls Child E stating that the birth mother said she would kill herself if Child E were to call her ‘mum’. She spoke also of isolation within her wider family and of her concern that schooling be sorted out. 5.4.12 At a professionals’ meeting a week later, arrangements for GP registration (to enable Sutton CAMHS to accept a referral) and other immediate needs were discussed. SW3 also initiated arrangements for a family group conference (FGC) and a referral to the borough’s adoption team to offer support to Ms AM.  5.4.13 Comment: the differing views about the accountable borough served to distract professional attention from Child E’s needs, which were, even then, substantial. 5.5 ALCOHOL OVERDOSE ONE 5.5.1 A month later on 11.12.09 Child E presented at the A&E department of hospital 2 by ambulance as a result of excessive alcohol consumption, reported to have occurred in the course of a family party. The report provided to the medical staff included a reference to Child E’s extreme level of anger and to the fact that (aged only 12) they claimed to be ‘allowed to drink under supervision’. All relevant notifications were initiated by the hospital staff. 5.5.2 The day after the above incident, Child E phoned ‘ChildLine’ to report that they were homeless, had banged their head the day before and had a headache. An ambulance was called and Child E brought back to hospital 2, though no treatment was required. Child E reportedly went to stay ‘for the moment’ with the adoptive aunt and her partner. 5.6 PROVISION OF LOCAL SERVICES 5.6.1 Child E’s first contact with a Sutton CAMHS professional followed a referral from GP1 and was on 06.01.10. Child E was seen by a registrar grade psychiatrist 2. The results of that consultation was the following report: ‘an impression of a 12 year old... who has had difficult early life experiences and attachment problems leading to behavioural problems; no acute medical history; currently in a stable environment and both [Child E] and family with which [they] is staying are happy’. Risk factors were noted to be meeting Ms AM on their own, substance misuse, poor sleep pattern and change from any regular routine.  Page 39 of 146  5.6.2 The CAMHS recommendation was that ‘support from Local Authorities [sic] continues’. Psychiatrist 3 discharged Child E from CAMHS with a ‘re-referral if required’. GP1 was duly informed by a letter copied to Children’s Social Care. 5.6.3 Comment: these reiterations of what was already known were unlikely to have informed immediate management of Child E nor assisted future placement planning. 5.6.4 Child E was placed on the roll of school 5 for January 2010 and nominally remained a pupil there until the end of March when they moved out of the area. In fact, Child E attended little, if at all in that period. 5.6.5 The offer by NCATS of a review meeting on 28.01.10 was withdrawn on 21.01.10 as a result of a lack of any response by Sutton. 5.6.6 Comment: this represented a significant lost opportunity for the formulation of an agreed multi-agency analysis of needs and risks.  5.7 ALCOHOL OVERDOSE TWO 5.7.1 A further hospital admission via ambulance occurred in the early hours of 07.02.10 when Child E drank to excess with (as reported by Child E) a 56 year old whom they had met at a theatre at which the adoptive aunt worked. Child E claimed they had invited them back to sleep with them. The out of hours social worker planned to, and may have actually contacted, Child E’s birth mother. Records are insufficiently clear to be certain. 5.7.2 Comment: Child E’s birth mother no longer had parental responsibility. Ms AM, although not at that time living with her adopted child, still held exclusive parental responsibility. The absence of any follow-up at the time to the Child Protection implications by health staff at hospital 2 was followed up by the ‘Named Nurse’ who compiled the chronology of events for this Serious Case Review.  5.7.3 In fact the Police had followed up the alleged events but in due course and because Child E refused to confirm the allegations, no further action was possible. The alleged perpetrator has since died. Child E’s then carers declined take Child E back when due for discharge from the paediatric ward. Child E was instead placed with a short-term foster carer who lived in Croydon (thus once again becoming a ‘Looked After’ Child). The decision to provide this emergency accommodation was later approved by a ‘children and families’ panel chaired by the then ‘executive head’ of Children’s Social Care. 5.7.4 Comment: records suggest a continuing reluctance to accept that Child E was by then the responsibility of Sutton. Legal advice was to be sought. 5.7.5 Child E added to the difficulty of finding a placement by insisting to not be placed with a Black carer; the rationale being that Child E blamed their dual heritage father for abusing the birth mother and for the mess Child E was in.  Page 40 of 146  5.7.6 Child E received an initial health assessment on 19.02.10, well within the time limit defined in statutory guidance. The need for a referral to CAMHS was recognised and initiated. 5.8 ALCOHOL OVERDOSE THREE 5.8.1 Child E arrived back from a visit to the birth mother on 21.02.10 so intoxicated that the then foster carer took Child E to A&E. Child E’s level of aggression was such that involvement of Police was contemplated, though not actually sought. 5.9 SELF-HARM EPISODE FOUR 5.9.1 A fortnight after the above events, on 01.03.10, Child E took a further confirmed overdose (16 500mg tablets of Co-drydamol)15 and required further hospital treatment. Medical notes indicate that Child E was worrying about the birth family. They do not indicate the source of the tablets. 5.10 SUTTON STATUTORY REVIEW ONE 5.10.1 Though no details have been provided, it is clear that an initial s.26 review was held on 03.03.10 chaired by IRO2. Child E was still in hospital at that time so was unable to participate. Next day at a ‘children and families panel’ chaired by the executive head of the Children and Families Service, a further reference is made to the belief that case accountability lay with the borough from which Child E had moved. The record states that legal advice had been sought though Sutton’s Legal Service has been unable to locate any such request. 5.10.2 On 09.03.10 following its receipt of a Metropolitan Police notification (termed a ‘Merlin’), Sutton and Merton Community Health Services followed up and discussed Child E with the Looked After Children (LAC) nurse (at that time an employee of Sutton’s Children’s Social Care). 5.11 HEALTH ASSESSMENTS 5.11.1 In February / March 2010, triggered by the initial health assessment, efforts were made to collate from various health sources an account of Child E’s history e.g. immunisations and current medical needs.  5.11.2 On 10.03.10 Child E was seen by consultant psychiatrist 3 from Sutton CAMHS who concluded that the child fell under the category of depressive conduct disorder and attachment disorder. She considered Child E to be a moderate risk to themselves and others and that ‘by helping [Child E] focus on                                                  15 Co-drydamol is an analgesic containing Paracetamol and an opiod Dihydrocodeine, can be addictive if taken regularly and is toxic to organs such as the liver. Not normally prescribed to those aged less than 12, it is contra-indicated in those who use illicit drugs.  Page 41 of 146  [their] own strengths and areas of high ability’, they might develop what she described as an alternative ‘script’ for themselves. 5.11.3 In discussions a week later, between SW5 from the Joint Adolescent Service and medical staff at hospital 3 in Croydon, it emerged that Child E had informed the examining doctor they were ‘sexually active’ and had injected drugs and shared needles with their drug-using mother. Child E (then aged twelve and a half years old) was judged to be ‘Gillick-competent’16 and the wish that the adoptive mother should not be told was accepted. SW3 was reportedly concerned that Child Protection issues were implied by the child’s medical condition and planned to seek management advice.  5.11.4 Comment: the examining doctor’s reported view is of grave concern. SW3’s cautious thinking was commendable but seems not to have been progressed to the required s.47 enquiries, which would have provided Police with an opportunity to investigate the alleged crimes. The episode represents a significant missed opportunity. 5.11.5 Child E’s aggressive reaction to SW3’s wish to discuss the implications of the above revelation caused Child E’s foster carer to decline return to her care. Child E was threatening to kill themselves and stated that they should have been left with the birth mother. Child E was moved on 24.03.10 to an alternative carer and then next day to a children’s home in Croydon. No other follow-up to the revelation of sexual activity (which is better described as sexual exploitation) has been located; e.g. it does not appear that Police were informed. 5.11.6 Comment: by virtue of being aged less than 13, anyone engaging in sexual intercourse with Child E would have been guilty of rape (as per s.5 Sexual Offences Act 2003) and potentially liable to life imprisonment. 5.12 CHANGE OF LEGAL STATUS AND FIRST USE OF SECURE ACCOMMODATION 5.12.1 A proportion of the material submitted suggests there was some confusion about the legal status of Child E. Though Child E had initially been accommodated with the adoptive mother’s consent in October 2009, they had been subsequently removed from that status by Ms. AM and (in an informal arrangement within the extended adoptive family) went to live with the adoptive aunt and uncle.  5.12.2 When that private arrangement broke down in February 2010, Child E had again been accommodated under s.20 Children Act 1989 and placed, in accordance with the then relevant Arrangements Regulations 1991 (since                                                  16 ‘Gillick competence’ (now generally called Fraser competence after the leading Law Lord who ultimately passed judgment on the issue) is a term used in medical law to decide whether a child (16 years old or less) is able to consent to her/his own medical treatment, without the need for parental permission or knowledge i.e. does s/he have sufficient understanding to make an informed judgment? The standard is based on a decision of the House of Lords in the (contraception-related) case of Gillick v West Norfolk and Wisbech Area Health Authority [1985] 3 All ER 402 (HL).   Page 42 of 146  superseded by the Care Planning Regulations 2010, themselves amended in 2011 in 2013). 5.12.3 Comment: at face value it seems clear that, by virtue of the adoptive mother’s stated intention that Child E live with her extended family in the borough (i.e. it was intended that this would now be the child’s ordinary residence), Child E had become a Sutton resident. Records suggest that an Assistant Team Manager emailed a request for a legal opinion on 29.03.10 and that there were exchanges between the boroughs’ respective lawyers on 07.04.10. No confirmation of such exchanges has been traced. 5.13 ALCOHOL OVERDOSE FOUR 5.13.1 Within days of being placed at the Croydon unit, Child E ran away, accompanied by a 12 year old described as ‘sexually active’. Having alerted Child E’s ex-carer to the 12 year old child walking off with a gang of youths, Child E was found in an intoxicated state in Islington and returned to that Home by Police. The incident was notified to Children’s Social Care. 5.14 SELF-HARM EPISODES FIVE AND SIX 5.14.1 Child E once again ran back to the birth mother on 08.04.10, having learned she had taken a further overdose. On the advice of the Unit staff Police evaluated Child E as ‘high risk’. In a pattern similar to that of 2009, Child E followed the birth mother’s example and overdosed about week later (19.04.10); this time, Child E claimed, on Codeine, Ibuprofen, crack Cocaine, Speed, Marijuana and alcohol. 5.14.2 An attempt to obtain advice from a Croydon CAMHS psychiatrist and psychologist was thwarted by Child E’s behaviours. The advice from those professionals and the physician who had attended Child E at this latest A&E presentation was that a secure unit was needed. 5.14.3 In what may or may not have been a separate incident, Child E, on 21.04.10, was taken by Police to hospital 3 in Croydon, having taken, it was believed by officers, a drugs overdose. 5.14.4 Croydon CAMHS liaised with and involved colleagues in Sutton CAMHS and Children’s Social Care in a joint assessment at hospital 3. Child E was not assessed at suicidal and on the understanding that a Secure Accommodation Order had been obtained that day (23.04.10), Croydon CAMHS ceased service provision.    Page 43 of 146  5.15 SECURE ACCOMMODATION ORDER ONE AND SELF-HARM EPISODE SEVEN 5.15.1 Child E’s behaviours (violence and desperate need for drugs) proved unmanageable and, as noted above, Sutton had sought and obtained approval from the Secretary of State to place Child E in a secure unit17.  5.15.2 Upon being told of this, Child E locked themselves in a bathroom and claimed to have 18 Paracetamol (records later sent to the child’s GP cited Ibuprofen). Child E’s actions necessitated a diversion via A&E, where tests indicated that they had not taken as many tablets as claimed. As a result of the advice by a duty children’s guardian from the Children and Family Court Advisory and Support Service (Cafcass), only an interim Secure Accommodation Order had been issued. Child E was finally placed at a secure unit in Exeter, pending (according to records supplied) a transfer to a therapeutic unit in Essex, whose service included weekly psychiatric input. 5.15.3 The notes made by the duty children’s guardian officer indicate that Sutton was also planning to seek a Care Order (in accordance with advice offered by Counsel on this occasion). Though the court requested that a children’s guardian be nominated by Cafcass, none was available until the end of September that year (a result of a steep rise in public law applications from Local Authorities). 5.15.4 The children and families panel at a further meeting on 15.04.10, ahead of Child E’s second statutory review, agreed to the development of a ‘permanency plan’ rooted in the conclusions of work completed in Hammersmith and Fulham. The panel noted or required the following:  A need to explore an alternative placement as the Croydon unit was breaking down  Identification of a therapeutic placement previously set up by Hammersmith and Fulham  An approach to Norfolk to establish the pre-adoption work completed  A need to assess the likely impact of contact by birth mother and birth grandmother  Clarity about sibling contact  A ‘missing person’ strategy was required  Risk assessment associated with fire raising was required  The social worker needed to develop a case chronology and include educational records  The social worker should bring the case back to panel before Child E’s second s.26 review                                                  17 Under regulation four of The Children (Secure Accommodation) Regulations 1991 a child less than 13 years old may only be placed in secure accommodation if prior consent of the Secretary of State is obtained.  Page 44 of 146  5.15.5 The children’s guardian was noted to be planning to challenge Sutton CAMHS’ decision that it could not (on the basis of distance) provide a service to Child E. No evidence has been seen to confirm that she did so. 5.15.6 The transfer to the unit in Colchester was delayed whilst a hospital investigated Child E’s complaint of black stools. Child E refused to accept treatment and Ms AM’s consent was sought and given instead. The medical view was that Child E had an ulcer but they also noted they had been sniffing petrol. 5.15.7 Comment: Ms AM has indicated she was neither consulted nor told about Child E’s removal from secure care and placement at the Essex unit. Its proximity to the birth mother made possible a predictable visit and a distressing assault (by spitting) on staff. That event and later interference by the birth family caused Child E considerable distress. This example of poor placement choice and exclusion of the lawful parent could not have been discerned from the records provided, suggesting there is scope for improvement. 5.15.8 Because Child E appeared to settle at the new unit the hearing scheduled for 04.05.10 was vacated. On 01.05.10 Child E again ran away to birth mother’s address in Norwich and later admitted that they had consumed ‘speed’ whilst there. 5.16 SELF-HARM EPISODE EIGHT 5.16.1 On 05.05.10, hospital 4 in Colchester reported to Sutton Children’s Social Care that Child E had presented there with self-inflicted razor cuts to both arms. A fortnight later, the birth mother was actively involved in assisting Child E to leave the home without permission. Police found and returned the child in the early morning.  5.17 SUTTON STATUTORY REVIEW TWO 5.17.1 At the time of a second review on 28.05.10, Child E had no allocated social worker and the planned core assessment had not been started. Though the process of decision making is not clear, in mid-June 2010 Child E was again transferred, this time to a ‘specialist therapeutic residential unit’ in West Wales.  5.17.2 Whilst there, Child E exhibited a high and consistent level of aggressive behaviour, self-harming and running away. A further core assessment was begun by SW6 whom it appears had by then been replaced by SW4/5. 5.17.3 Child E revealed at this time that they had a recently born baby which had died a week later. The story of the baby and its death was later found to have been fabricated.   Page 45 of 146  5.18 SELF-HARM EPISODES NINE AND TEN 5.18.1 On the same day as the above revelations, Child E was again hospitalised as a result of reported anal bleeding. Residential staff suspected that Child E had ingested fragments of a broken light bulb. It remains unclear what had actually occurred. 5.18.2 Child E, by July 2010, was reasonably settled, continued to be rejecting of Ms AM and was angry that Sutton did not possess what Child E claimed would be documentary evidence from Hammersmith and Fulham or Norfolk about agreed contact with the birth mother. 5.18.3 Comment: there did seem to be some lack of confidence about the originally agreed post adoption contact arrangements (as well as the huge ongoing challenge of their enforcement). Ms AM’s understanding is that the original agreement had been that neither parent nor elder sibling S2 were to have direct contact though they were to be allowed annual indirect contact (by card / letter); maternal grandmother was to be allowed twice yearly direct contact; three times per annum contact on neutral ground was to be allowed with siblings S5, S4 and adopted S1. 5.18.4 Child E appeared to have self-harmed again on 26.07.10 by ‘swallowing glass’. Child E was hospitalised and given symptomatic treatment. The claim that they had swallowed glass was not medically confirmed. 5.19 CASE ALLOCATION TO ‘LOOKED AFTER CHILDREN’ TEAM 5.19.1 Because it was by then assumed that Child E would remain in long-term residential care, their case was transferred to a SW7 in Sutton borough’s ‘Looked After Children’ team. 5.20 FIRE RAISING INCIDENT THREE 5.20.1 On 26.08.10 the West Wales Home reported that Child E had set fire to a mattress. As a result of the incident, one member of staff had suffered from smoke inhalation and another went ‘off-sick’ with stress. The unit, in consequence, required the removal of Child E (in March of the following year, Child E was given a ‘Police warning’ about the incident). 5.20.2 A decision was made by Sutton to apply for a further Secure Accommodation Order and meanwhile the Local Authority exercised its discretionary powers to place Child E in secure accommodation for up to 72 hours. The belated consent of the Secretary of State (Child E was still less than 13 years of age) was obtained on 01.09.10. A week later, with Child E’s support (implying some level of insight), a Secure Order lasting until 12.10.10 was issued.  5.20.3 At the court, the children’s guardian from Cafcass expressed concern that the stated plan in early 2010 to seek a Care Order had not been progressed.  Page 46 of 146  5.20.4 In the early days of the second period at the secure unit in Devon, Child E made it clear that they wished to kill themselves. 5.21 LIFE-THREATENING SELF-HARM EPISODE 11  5.21.1 On 16.09.10, about a week after a further interim Secure Order was obtained, Child E was found lying on their bedroom floor having a convulsion. They had tied a T-shirt around their neck. Child E’s level of violence toward responding paramedics was so great that transporting to a hospital was considered too risky. Instead, Child E was to be left with staff observing them at intervals of no more than five minutes. 5.21.2 A children and families panel meeting also on 16.09.10 determined that Care Proceedings should be initiated. Its conclusion was ratified on 24.09.10. What was recorded as a Secure Accommodation review (due within 28 days of placement in such accommodation) was also completed on 16.09.10. Next day, the acting head of service refused to authorise a further assessment by NCATS, because it would have cost significantly more than use of local experts. The children’s guardian reportedly said she would challenge this. No evidence has been seen to confirm that she (nor IRO2 who was in agreement with her) did so. 5.21.3 Comment: in hindsight, failing to draw upon the experience and knowledge of Child E’s needs that was held by NCATS was a missed opportunity. 5.21.4 In a conversation with the appointed children’s guardian from Cafcass, Child E referred to the adoption as having been good to start with but that they were scared when Ms AM had epileptic fits. The frequency, severity, impact on Child E and extent to which such factors had been taken into account prior to approval as a potential adopter remain uncertain.  5.21.5 Ms AM’s recollection (supported by information latterly provided by Norfolk) is that her medical condition was fully evaluated during her adoption assessment. She described her infrequent seizures as mild and largely nocturnal though recalled that the stress and fatigue in dealing with Child E back in Hammersmith and Fulham had led to an atypically severe day-time seizure. 5.22 SELF-HARM EPISODE 12 5.22.1 Later, on 23.09.10, Child E self-harmed again, this time by reportedly ingesting two AA batteries from a remote control device. The presence of two AAA was confirmed via x-ray. Child E suffered no ill effects and no treatment was required.    Page 47 of 146  5.23 STATUTORY REVIEW / APPLICATIONS FOR INTERIM CARE ORDER 5.23.1 A third s.26 review was held on 27.09.10 and a Care Plan filed with the court on 28.09.10, with a view to a Hearing at Croydon Family Proceedings court on 12.10.10. Child E continued to indicate by means of notes for staff and an assertion that they had deliberately cut their legs (albeit refusing to show the evidence for this claim) that they wished to die. 5.23.2 Suttons’ own clinical psychologist at this point recommended an assessment by a forensic clinical psychologist. On 29.09.10 an application under s.31 Children Act 1989 for a Care Order was initiated and the first hearing was on 12.10.10. Usefully, the same Cafcass guardian as previously involved with secure accommodation applications was appointed to act in Child E’s best interests.  5.24 SELF-HARM EPISODES 13 AND 14 5.24.1 On the 30.09.10 Child E swallowed a single AA battery. A check up at hospital determined that no further action was needed as the battery was already in their bowels. Notes left for staff reinforced concern that Child E wished to kill themselves.  5.24.2 Comment: some previous self-harm attempts may have been fabricated or exaggerated by Child E; episodes 12 and 13 were confirmed by virtue of the tests completed. 5.24.3 On 12.10.10 an interim Care Order and Secure Accommodation Order were made, effective until 26.11.10. Child E supported these measures and suggested that they would show that they could change their behaviours whilst in secure accommodation. The court granted permission for a psychiatric and psychological assessment of Child E to be completed. 5.24.4 Psychiatrist 4 concluded a month later that Child E showed no sign of major mental illness and that no evidence of enduring depression was evident. She referred to them becoming flooded with anxiety particularly at bedtime possibly linked to abandonment and loss. Her view was it was now unrealistic to terminate contact with the birth family. 5.24.5 Child E would, the psychiatrist thought, continue to suffer mental health difficulties and self-harm. She recommended that although Child E did not require treatment and that psychotherapy was contra-indicated, Children’s Social Care should identify a private consultant to provide the child with a consistent overview and seek a structured 52 week school with the possibility of move-on to a foster home. 5.24.6 Comment: the view that contact with the birth family was inevitable and needed to be managed (a view shared by the psychologist) was a radical challenge to the existing Care Plan. Neither that view nor the recommendation of ongoing psychiatric overview seems to have been effectively progressed.  Page 48 of 146  An assumption has been made that the reason for recommending commissioning a non-NHS psychiatrist is that psychiatrist 4 knew that it would be hard to obtain the required service from any local CAMHS.  5.24.7 On 12.10.10 an interim Care Order and a three month Secure Accommodation Order was granted. Because of its complexity the case was transferred to the High Court. 5.24.8 On 23.10.10 Child E was thought to have swallowed four small pieces of glass and was taken to A&E. No injuries were detected. 5.24.9 Child E at times found involvement in planning too much to manage but seemed to have met with and offered some view to the children’s guardian on 08.11.10, when she attended the Secure Unit for a professionals’ meeting. 5.24.10 Sutton’s LAC nurse 1’s first involvement seems to have been on 13.10.10 when she emailed the then social worker about Child E’s unknown immunisation status which had been captured at the initial health assessment. No evidence has been located to confirm that the issue was ever resolved. 5.25 COLLECTIVE VIEWS OF CHILD E’S CONDITION / CIRCUMSTANCES 5.25.1 The meeting on 08.11.10 included the consultant psychiatrist 4 and consultant forensic psychologist whose respective reports were discussed. The meeting was chaired by Sutton’s team manager TM1. The following features of Child E’s condition and circumstances were shared:  An IQ of 86, though this under-represented the child’s ability  A ‘pseudo-maturity’  Presents as more psychologically healthy than they are  Self-harm provoked when strong feelings overwhelm their ability to articulate things about which anxious; serves to release tension  ? Mid-range attention deficit hyperactivity disorder (ADHD)  ? Dyslexia  At risk of fire setting  Medium to high risk of violence in future  Worrying features pointing toward personality difficulties later in life 5.25.2 Comment: Ms AM is certain she was not interviewed by the psychologist and not provided with a copy of the report, possibly a further example of failing to work in partnership. 5.25.3 The likelihood of further self-harming episodes was acknowledged but the view was that Child E should not remain in secure accommodation and that psychotherapy would not help as it would encourage them to dwell on the past  Page 49 of 146  The recommendation from the psychologist was for fostering by a couple; one of whom should be a strong male role model. The psychiatrist favoured a residential setting.   5.25.4 Sutton’s ‘children and families panel’ decided days later that Child E should not remain in secure accommodation; the preferred option was ‘specialist fostering’ but because of delays in sourcing a suitable placement and expiry of the Secure Order on 26.11.10, the child would require an interim placement. The Care Plan being drafted for the purpose of Care Proceedings, was for annual contact with the birth mother and twice yearly contact with the birth grandmother.  Child E was persisting in refusal to have contact with Ms AM. At a further Hearing on 23.11.11, the children’s guardian was in agreement with the Local Authority proposals and the Court granted a further interim Care Order. 5.25.5 Comment: it is unclear whether contact was to be direct (and supervised or not) or indirect. Records confirm that the children’s guardian had spent some time with Child E and spoken with birth mother, grandmother and Ms AM. 5.26 FURTHER PLACEMENT CHANGES OF PLACEMENT / SCHOOLS 5.26.1 The move on 25.11.10 from secure accommodation to a three-bedded unit in Somerset (with only one other resident and provision of an in-house cognitive behavioural therapist) proved difficult for Child E, who asked to be returned to the secure unit. 5.27 SELF-HARM EPISODE 15 5.27.1 Child E was reported by staff at the new placement to have ingested 14 Paracetamol tablets on 12.12.10, though they were not distressed and had apparently offered no explanation of what the trigger for this action might have been. Somerset Partnership NHS Trust CAMHS records capture Child E’s regret about this overdose and routine discharge back to this placement. 5.27.2 Sutton Children’s Social Care was apparently contemplating a case transfer to its ‘Transition Team’ when Child E reached their 14th birthday; the rationale being that they might require services even after becoming (at 18) an adult.      5.28 SUTTON STATUTORY REVIEW THREE AND REVIEW HEALTH ASSESSMENT  5.28.1 A further s.26 Children Act 1989 review chaired by IRO2 was completed on 10.01.11. It noted that Child E had self-harmed once since the move to Somerset in November but had not run away. At this review Child E asked to see all of their case files from each Local Authority that had been involved with them and their family. The review of health needs, which should have preceded the s.26 review, was completed on 26.01.11 (three months late) and  Page 50 of 146  its results were not seen by the Designated Doctor until the end of March 2011. 5.28.2 Meanwhile, Child E’s case had been transferred back from High Court level to the Croydon family proceedings court, where a further interim Care Order was granted on 19.01.11. 5.28.3 Sutton’s children and families panel was again involved and is reported to have concluded on or around this date that the borough would not agree an assessment of Child E’s birth mother but would support a social work assessment with input from the Marlborough Service. 5.28.4 Comment: in the light of what was known about the birth family, it seems unlikely that anyone could justifiably have been contemplating any form of rehabilitation. 5.28.5 A health review on 26.01.11 noted that Child E had stopped taking their prescribed Propranolol (an anxiety-reducing medication) but was still meeting with a psychotherapist once or twice per week. Child E reported smoking 20+ roll-ups per day and did not wish to stop. The young person complained of abdominal pain and pain on urination and was advised to consult their GP. A follow-up confirmed that they had done so.  5.28.6 The use of a Recovery Order (s.50 Children Act 1989) was considered at this time to extricate Child E from members of the birth family to whom Child E had run away. In fact Child E chose to return to the placement on 11.02.11 after an unauthorised absence of about a week. 5.28.7 Child E was, by this time, being less co-operative with the in-house therapist. That individual referred to Ms AM as being ‘passive-aggressive’ in her dealings with Child E and stated that he was concerned about her contact with Child E. 5.28.8 The issue of contact between Child E and Ms AM featured in court proceedings at this time. At a directions hearing on 07.03.11, Sutton was ordered to complete a social work assessment of the value of future contact between them by 18.04.11 (this was to be considered at a hearing on 26.04.11). 5.28.9 SW8 met Ms AM twice and produced a seven page report on which it is understood the psychologist later depended for her expert opinion.  5.28.10 A report from the placement, received on 08.03.11, noted that Child E had ceased use of prescribed Propranolol soon after admission with a subsequent worsening of behaviour. Since re-starting use of the medication this behaviour was reported to have improved.  Page 51 of 146  5.28.11 Without regard to the professional views of the meaning or value of contact, Child E asked Ms AM to visit and she did so on 27.03.11. Child E also had what was reported to be a positive contact with sibling S1.  5.28.12 On 15.04.11 Child E went missing. It was established that the young person was with the birth family and was returned by the Police on 27.04.11, after the High Court had issued a ‘Collection Order’ that required the birth family to co-operate or be in contempt of court. It is understood that Child E had been staying with the partner of their (since deceased) elder sibling S2. As a result of the involvement of the High Court, the Care Proceedings were transferred back to that forum. 5.28.13 The health overview refers to a ‘joint planning panel’ (Primary Care Trust and Children’s Social Care) that met monthly between September 2010 and April 2011 and included discussion about Child E’s complex needs. It is unclear what its relationship was with the Children’s Social Care children and families panel, nor whether its output provided clarity about funding for meeting the mental health needs of Children placed out of borough. 5.28.14 Sutton’s Children and families panel was asked by SW8 on 28.04.11 to address the recommendation previously made by consultant psychiatrist 4 for CAMHS oversight until Child E reached 18. The result of that was an assessment by psychiatrist 4 was to be funded and the local CAMHS psychologist 3 was to provide an overview of Child E’s psychological needs in accordance with ‘Looked After Children’ procedures.  5.28.15 Psychiatrist 4’s response (in July 2011) to the request was to remind the borough of her previous recommendation and to raise the possibility of corporate neglect if no clinician had been overseeing / reviewing Child E’s medication for six months. She indicated that the level of support Child E needed would never be available from any local CAMHS. 5.28.16 Comment: psychiatrist 4’s sound advice about the limits of any local CAMHS was lost in the events that followed. 5.29 FURTHER HIGH COURT ORDERS 5.29.1 At a further High Court Hearing on 05.05.11 more substantive measures were introduced. Child E’s birth mother and birth maternal grandmother were prohibited from aiding or assisting Child E from running away from care or harbouring them. Penal notices were attached and a Prohibited Steps Order was granted against both individuals. Child E’s interim Care Order was renewed again with a proposed final three day hearing in October. This represented the first time that the law was used to try to control the birth family’s damaging interference.   Page 52 of 146  5.30 SELF-HARM EPISODE 16 5.30.1 On 13.05.11 Child E was reported to have self-harmed again following a distressing phone call from the birth mother. Records so far supplied do not specify what form the self-harm took nor what action may have been considered in the light of the High Court’s very recent directions. 5.30.2 It would appear that Child E, following the latest self-harm incident, was seen by a specialist nurse in Taunton CAMHS. Child E confirmed they did not want treatment and were, they said, planning to initiate an injunction against the birth mother. 5.30.3 By 07.07.11 Sutton’s children and families panel was updated and it made four recommendations, one being that the case should be referred for joint funding by Children’s Social Care, Education and Health (which suggests the same recommendation at the last panel had remained outstanding). 5.31 SUTTON STATUTORY REVIEW FIVE 5.31.1 IRO2 once again chaired Child E’s fifth s.26 review, which was convened at the young person’s placement on 06.06.11. The account provided speaks of Child E being very hostile, especially toward the female manager of the placement, and seeking to take over the meeting. The cognitive behavioural therapist provided several recommendations about how staff should seek to manage Child E’s conduct. 5.31.2 Child E continued to be absent from this placement and seems to have gravitated on each occasion toward members of the birth family. Child E’s conduct within the placement (trashing their room) also led to a charge of criminal damage on 13.06.11 (for this and a similar incident in July the young person was later sentenced at Taunton youth court to a three month Referral Order). 5.31.3 Comment: unsurprisingly some of Child E’s conduct became regarded and responded to as ‘criminal’. However, the rate of placement change effectively undermined any meaningful work by members of local Youth Offending Services. This Serious Case Review has concentrated on safeguarding, care and mental health-related events and decisions. 5.32 SELF-HARM EPISODE 17 5.32.1 Child E was again hospitalised on 17.06.11 when, following an argument with staff, they were reported to have taken an overdose of 27 Paracetamol. Somerset has a record of an overdose though no detail and the health overview report has been unable to confirm which hospital was involved. Child E was subsequently clear that they would not accept a CAMHS input.   Page 53 of 146  5.33 LEGAL MEASURES 5.33.1 On 29.06.11 Sutton sought a s.34(4) Children Act 1989 Order (for planned refusal of contact) and penal notice with respect to contact between Child E and the birth mother.  5.33.2 Comment: it remains unclear why the earlier Orders of the High Court were considered insufficient or not acted upon.  5.33.3 At a hearing on 13.07.11 an order under s.34(4) Children Act 1989 and a Non Molestation Order (NMO) under part IV Family Law Act 1996 were issued (breach of the latter can trigger imprisonment for up to 5 years). The court decided that birth mother was to make no further attempt to communicate with Child E before 27.10.13. Child E had already briefed local solicitors to seek to end birth mother’s harassment using the Protection from Harassment Act 1997, but a hearing of that application had not been due until late August. 5.33.4 Child E’s behaviour in placement continued to be demanding and they ran away on more than one occasion. On 24.08.11 Child E had become aggressive toward staff and had threatened to throw a pan of boiling water over a female staff member. Child E had actually inflicted a bite to a hand and other injuries to the faces, legs and arms of staff. The young person’s subsequent arrest and later court appearance triggered an extension of their Referral Order to a period of six months. 5.34 ACCOUNTABILITY FOR CLINICAL OVERSIGHT 5.34.1 Interim Care Orders continued to be granted over the Summer of 2011. The forensic psychologist 1 who had previously seen Child E wrote in a report dated 26.08.11 that the time for fostering had now passed and that the young person should remain at the current placement where (she thought) they were benefitting from the cognitive behavioural therapy. 5.34.2 The psychologist’s report included her understanding that local Taunton CAMHS would not offer a service because Child E had originated from outside its area. She advised that Sutton CAMHS liaise with their equivalents in Somerset to confirm funding and identify the scope for treatment viz: medication review, assessment for depression and self-harm ideation. No assessment for dyslexia as previously recommended had been progressed, though the recommended use of an occupational therapist may have been progressed by the LAC nurse. 5.34.3 An assessment of dyslexia was attempted by a Somerset educational psychologist but abandoned because Child E was uncooperative. The day after the unsuccessful attempt to begin this assessment, Child E committed a serious assault on a member of staff and was arrested.  5.34.4 An addendum report by psychiatrist 4 expressed satisfaction with the current placement and concern about Child E’s avoidance of education and physical  Page 54 of 146  activity. She renewed her recommendation for psychiatric oversight. Comments made to the children’s guardian during this period confirmed that Child E did not wish to have further contact with Ms AM and thought she should lose her parental responsibility. 5.35 STATUTORY REVIEW SIX AND REVISED CARE PLAN 5.35.1 Although only three months since the last (very challenging) review, the same IRO2 chaired Child E’s fifth review on 12.09.11. Discussion was constrained by the young person’s agitated and angry attitude e.g. they were threatening toward their social worker and to IRO2 as they left. A revised Care Plan committing to this placement was submitted for the purpose of Care Proceedings on 21.09.11. 5.35.2 Child E was arrested on suspicion of robbery on 25.09.11 though the case was dropped the next day. By 03.10.11 the view formed by the therapist regularly meeting Child E was that they had become more dangerous. The therapist advised a 2:1 staff ratio for a period of time. The next day Child E was sentenced at Somerset Youth Court to a six month Youth Rehabilitation Order and three months’ use of an electronic tag, with a curfew from 19-00 to 07-00 hours. Child E later breached the terms of the curfew. 5.36 POTENTIAL USE OF INTRAVENOUS DRUGS / ATTEMPT TO RESUME CONTACT BY MS AM 5.36.1 Staff from the Somerset placement called Police on 13.10.11 when they suspected that Child E had injected illicit substances into their hand. New and used syringes were found, though no drugs. Child E (who had told another resident that they was injecting Heroin) refused any medical help and was monitored in their room by means of half-hourly observations. 5.36.2 On 14.10.11 Ms AM reportedly rang the Emergency Duty Team of Sutton’s Children’s Social Care. She was seeking contact with Child E which was reportedly refused. 5.36.3 Comment: though there were explicit and lawful constraints on contact by the birth mother, no evidence existed that justified limiting contact with Ms AM. She was, by law, entitled to presume reasonable contact. 5.36.4 On 19.10.11 Child E returned from an unauthorised absence of over 24 hours apparently under the influence of drugs (injected Heroin was suspected). They were taken to hospital 5 but refused treatment. Child E claimed a £45 per day habit and to have been using for three or four weeks and injecting in the last three or four days. The consultant at A&E commendably contacted the residential unit where an urgent initial assessment with a specialist substance misuse worker was organised for next day. There is some suggestion that the residential unit initially resisted accepting Child E back.  Page 55 of 146  5.36.5 Comment: if Child E’s claims were accurate, it seems likely that access to those sums of money would, of necessity, have been through acquisitive crime and/or sexual exploitation. 5.37 SECURE ACCOMMODATION ORDER TWO AND DECISION TO WITHDRAW CHILD E FROM SOMERSET PLACEMENT 5.37.1 On the advice of the local CAMHS manager, a second Secure Accommodation Order was sought and obtained on 21.10.11 and Child E was placed in Leverton Hall in Essex. The children’s guardian appointed for Child E’s previous civil law appearances was involved and supported the one month order that was granted.  5.37.2 A new GP registration was completed on 24.10.11 and Child E was assessed by a nurse practitioner and seen by a doctor a couple of days later. Child E disclosed use of crack cocaine, Heroin, cannabis, speed and alcohol, claiming that their habit was costing £10 - £20 per day. Child E thought that they might be experiencing withdrawal symptoms. 5.37.3 The negative result of a test conducted by Taunton CAMHS raised doubts about the accuracy of Child E’s claims to have been ‘using’ within two days of the test administered. Similarly an elaborate account by Child E of a local homeless male who first injected them, though investigated by Essex Police and a suspect arrested, could not produce enough evidence for the Crown Prosecution Service (CPS) to prosecute. 5.37.4 A ‘placement planning meeting’ convened 10 days later on 31.10.11. SW8, a YOT worker, unnamed placements manager, LAC specialist nurse and the assistant team manager of the Children’s Social Care LAC team were present. Aside from focusing on the current placement (the proper purpose of such a meeting) the group decided that an alternative to the Somerset Unit should be sought. 5.37.5 Comment: a decision to change placement is amongst the most significant to be made for any Looked After Child. It should, whenever possible, be made at a statutory review chaired by an independent reviewing officer. Child E was also approaching Key Stage Four when changes impact on GCSE courses and any move requires the prior approval of a ‘nominated officer’ (regulation 10 Care Planning, Placement and Case Review (England) Regulations 2010 as amended). 5.37.6 An ‘experts / professionals meeting’ was ordered by the court and, chaired by Child E’s solicitor, met about a week later on 07.11.11. Psychiatrist 4 and psychologist 1, who had been previously involved, participated by phone. The meeting appeared to agree that the three bedded placement in Somerset was now too small and lacked sufficient staff. The meeting formed the view that the next placement after the secure unit would need to be bigger, have more staff, include on-site education and offer a linked therapist and physical activity.  Page 56 of 146  5.37.7 Comment: the same experts had previously advised against a move out of the Somerset unit and the recently submitted s.31A Care Plan had presumably supported its continuation. It is unclear why ‘more staff’ would benefit Child E. Records of this same meeting apparently also allude to a residual belief by one of the experts that Hammersmith and Fulham was (for unspecified reasons) responsible for CAMHS input. A reference was made to some current difficulties in the relationship between Sutton Local Authority and the Primary Care Trust (PCT). 5.37.8 Child E at this time refused to wear glasses as recommended by an optician and it seems as though this particular health need was not addressed again. 5.37.9 The ‘secure accommodation review’ a few days later on 16.11.11 considered the use of a placement in Wales even though it did not have the recommended on-site education. Child E (who was this time supported by a mentor and representative from Voice of the Child in Care) wanted a foster home. 5.37.10 Comment: it seems clear that (for wholly understandable reasons) there was insufficient knowledge of or confidence in the facilities that might consider accepting Child E. Even with hindsight, it is not obvious which one/s might have been more effective. 5.38 STATUTORY REVIEW SEVEN 5.38.1 The Children’s Social Care report confirms that a further s.26 review was chaired by IRO2 on 22.11.11 (well in advance of its due-date). It noted a need on one occasion for Child E to have been restrained, but no further self-harm. 5.38.2 About 10 days later (on 01.12.11) a health assessment review, prompted by Sutton’s LAC nurse 1, was undertaken by the Designated LAC nurse in Essex. This individual also completed a transfer form prior to Child E’s transfer to Wales and her report notes that the young person was ‘not happy ’about the further move. 5.38.3 At a ‘Directions Hearing’ on 24.11.11 the High Court ordered the Local Authority to serve its final Care Plan by 27.01.12. 5.39 FURTHER PLACEMENT CHANGES AND ONGOING DIFFICULTIES  5.39.1 It appears that Child E was transferred to Greenfields Adolescent Care unit in Wales on 12.12.11. Records suggest Child E was moved again next day to an alternative placement called Oakfields because (Child E claimed) they had been offered cannabis on their first night. 5.39.2 Comment: records fail to explain how the decision was made or by whom. 5.39.3 Child E’s conduct at the new unit remained challenging. During their time there, Child E was arrested for being drunk and disorderly and was reported  Page 57 of 146  missing on a number of occasions. Following appearances at the local Youth Court in January 2012, Child E eventually received a nine month Youth Rehabilitation Order, 24 hours reparation work and a three month curfew monitored by an electronic tag. Supervision was to be provided by Newport Youth Offending Team (YOT). 5.40 SUTTON STATUTORY REVIEW EIGHT 5.40.1 A s.26 review, again chaired by IRO2 was convened on 04.01.12. Though calm before it, Child E was again very disruptive during it, making it clear that they would not attend school. An allegation that Child E had been mistreated when restrained by staff was looked into by the local Children’s Social Care and concluded to be unfounded. 5.40.2 At a routine appointment with a local GP on 09.01.12, the doctor noted that records from Child E’s previous GP had not yet arrived and took unusually clear and comprehensive notes of what Child E told her/him, including complaints of insomnia and previous use of hypnotics. Child E was seen again a week later and complained of palpitations and back pain which they attributed to Child E being restrained by staff the night before. 5.40.3 In a conversation with SW8, who completed a visit toward the end of January 2012, Child E told her that they liked the current Home, and said they wanted to contact S3 (26 year old half-sibling) and S5 (17 year old sibling) with whom Child E had had recent phone contact. SW8 informed Child E that S4 (19 year old sibling) no longer wanted contact. Child E explained that they found it difficult to talk about Ms AM. 5.40.4 At a further presentation to the GP later in the month it was apparent that Child E had unauthorised new (infected) tattoos. 5.40.5 Comment: the minimum age at which an individual can be given a tattoo without parental consent is 18 (s.1 Tattooing of Minors Act 1969). 5.40.6 During February 2012 Child E continued to breach curfew requirements and to be absent without permission. Child E was also arrested for driving without a licence, un-insured and taking a vehicle without the owner’s consent. SW8 maintained contact with the Welsh placement. 5.40.7 Comment: it is not generally understood that registration as a social worker in England has no status in Wales. Professional practice in that country (or indeed Scotland or Northern Ireland), such as fulfilling regulatory duties as an allocated worker visiting a Looked After Child, requires separate registration in the relevant country. 5.41 REFERRAL TO GWENT CAMHS 5.41.1 On 08.02.12, SW8 wrote to Gwent CAMHS, explained Child E’s history and sought support for the recommendation from psychiatrist 4 of psychiatric  Page 58 of 146  oversight until Child E attained their 18th birthday. The response remains unknown. 5.42 FINAL HEARING OF CARE PROCEEDINGS 5.42.1 The final Hearing of the Care Proceedings began on 09.02.12. Because Child E’s views were at odds with those of the children’s guardian appointed to represent their best interests, Child E was separately represented by a solicitor.  5.42.2 Child E’s wish was to leave care and return either to their birth mother or father. The solicitor sought discharge of the existing s.34(4) Order and an adjournment until the birth mother and grandmother’s ability to offer care was assessed. The application was dismissed and final Care Order made. The Court’s Judgement included a ‘Disclosure Order’ to Norfolk County Council for documents from the Care and Adoption proceedings there, that could inform a future claim by Child E for negligence. There was to be no disclosure to Child E until they were 18. 5.42.3 Child E continued to leave the Home without permission, though generally returning of their own accord (they were missing from the unit on 18 occasions during February alone). Child E was becoming aggressive, especially toward female staff. There were further examples of driving-related offences (for which they was bailed and later sentenced to an 18 month Youth Rehabilitation Order with Intensive Supervision and Surveillance, three month curfew and a six months’ driving ban) and an ongoing refusal to co-operate with the YOT staff. 5.43 FIRE RAISING EPISODE FOUR 5.43.1 On 20.02.12 Child E set fire to their bedroom. The Fire and Rescue Service and Police attended. Child E was taken to hospital though refused to be medically examined. 5.44 PROFESSIONALS’ MEETING  5.44.1 In the light of Child E’s continuing refusal to engage or co-operate, a ‘professionals meeting’ (membership has not been confirmed) was convened in Sutton on 13.03.12. A decision was made to seek a ‘12 week activity placement’ and follow that with an alternative long-term Home. 5.44.2 Comment: once again a significant decision was made without recourse to a statutory review, involving all relevant stakeholders e.g. adoptive parent and chaired by an IRO. The reasons for believing that Child E’s behaviours would improve in yet another placement were not obvious.  Page 59 of 146  5.44.3 SW8 visited Child E soon after the above meeting and introduced their new social worker SW9. Child E was noted at that time to be working well with their drug and alcohol workers and with a therapist. 5.44.4 Comment: this positive picture contrasts with a significantly more negative one painted by the record of a professionals’ meeting on 13.03.12. 5.44.5 A transfer summary helpfully provided by SW8 noted that Child E at this point had had 10 placements since becoming Looked After by Sutton (in large part a measure of the challenge that Child E’s needs represented). 5.44.6 In response to reports of Child E’s challenging conduct whilst in placements, what was described as a ‘strategy meeting’ chaired by IRO2 was attempted on 03.04.12. It had to be adjourned because of Child E’s disruptive conduct in the home (whose staff were trying to contribute by phone). Child E denied any activity or being provided with drugs by adults. 5.44.7 It emerged that during Child E’s latest period of absence without authorisation, they had been in Norwich rather than having stayed locally. 5.45 SUTTON STATUTORY REVIEW NINE AND A FURTHER REVISED CARE PLAN 5.45.1 How the s.26 review held on 03.04.12 related to the postponed strategy meeting is unclear. At the former meeting Child E said that they found it hard to get on with the only other resident who (Child E claimed) was trying to get them sent back to a secure unit. It also became clear in the course of discussion that the provider had not been informed of the decisions made at the professionals’ meeting. 5.45.2 Comment: aside from the intrinsic weakness with respect to membership and rationale of the professionals’ meeting in mid-March, the failure to even alert the service provider (or Child E and, it seems, Ms AM) of the plan to move Child E was very poor practice. 5.46 SELF-HARM EPISODE 18, SECURE ACCOMMODATION ORDER THREE AND FURTHER PLACEMENT CHANGES 5.46.1 On or about 12.04.12 Child E, who was missing at the time, was found in a tent within a garage at the rear of the Home in the company of two non-residents. They showed signs of Heroin use and were taken to hospital, where they refused any treatment. 5.46.2 In response to the latest self-harm episode, Sutton established that there were no vacancies in the previously used Leverton Hall and exercised its discretion to use secure care for up to 72 hours. It transferred Child E to St Catherine’s, Merseyside. On 16.04.12 a three month Secure Accommodation Order was (with Child E’s agreement) obtained. LAC nurse 1 followed up Child E’s known health needs at this time by means of completing a health assessment review.  Page 60 of 146  5.46.3 SW9 made a prompt visit to Child E in the new placement on 18.04.12. A few days later Child E’s solicitor emailed to complain about the distance and consequent difficulty of access to Child E’s family. The solicitor sought a transfer back to Leverton Hall. 5.46.4 The children’s guardian was re-involved and was critical of Sutton’s failure to set out clearly what the intended ‘LAC psychologist’s review process’ [what that meant remains uncertain]. She also criticised the failure to confirm commissioning arrangements for the recommended ongoing CAMHS input (Somerset had declined to accept responsibility for children from other Local Authorities). 5.46.5 Comment: the ongoing confusion about which organisation was accountable for elements of Child E’s health care is explored in Section Six. 5.47 SUTTON STATUTORY REVIEW 10 5.47.1 A 10th s.26 review (this one chaired by Sutton’s interim executive head of safeguarding) was convened only a month later on 04.05.12. The report evaluating the LAC nurse service contribution indicates that the review health assessment completed at this time noted the use of anxiety-reducing medication though not by which clinician it had been prescribed. 5.47.2 On 06.06.12, for what was planned as a 12 week experience, Child E had been allowed to participate in an ‘outdoor pursuits’ expedition in Scotland provided by Bryn Melyn Care. On 08.06.12 Child E’s lawyer emailed Sutton’s Legal Department to claim that Child E was not being allowed contact with birth relatives in accordance with an agreed list. A reply indicated that a revised list was to be drawn up and that contact would be supervised by St. Catherine’s staff. 5.47.3 Comment: no explicit written arrangements for contact with birth family members have been provided to the Serious Case Review e.g. specifying where and how contact might be supervised. 5.47.4 Birmingham Children’s Hospital Liver Unit liaised with SW9 during June 2012 and sought Child E’s current location so that they could be told of the results of recent blood tests.  5.47.5 Though in principle the responsibility of Sutton’s YOT, the large number of placements and the temporary nature of the current one rendered it unclear and difficult to determine which YOT could manage the Youth Rehabilitation Order. Though of little practical relevance, Telford YOT agreed in late August to ‘care-take’ the case. 5.48 SELF-HARM EPISODE 19 AND DEATH OF S2 5.48.1 According to the chronology provided, on 23.06.12 Child E was taken to hospital 6 in Scotland having taken a combination of painkillers and anti- Page 61 of 146  depressants whilst on a 12 week activity / adventure experience. They were then admitted to Inverness hospital 7. Nothing further is known about these episodes. 5.48.2 Child E’s eldest half-sibling S2 died on 24.06.12, apparently from an overdose of Heroin supplied by their mother’s partner at the latter’s home address. 5.48.3 Child E’s advocate contacted ATM1 a couple of days later to raise the fact that Child E remained unaware of the death. ATM1 indicated that in consultation with the secure unit and to avoid the risk of Child E simply running back to the birth family that a managed meeting with the maternal birth grandmother was being contemplated. Child E was told of the death next day. 5.48.4 Child E called ATM1 and expressed a wish to spend a weekend with the birth grandmother. They also informed her that the birth mother had been, as a result of S2’s death, ‘arrested for attempted murder’. 5.48.5 Child E was taken to Norwich so that they could see the birth family and view the body of half-sibling S2. Child E’s return from the time spent with the birth grandmother was difficult (and included a reluctant acceptance of the young person staying overnight with her). The episode ended with Child E running away from Bryn Melyn escorts who had been sent to collect them on the evening of 02.07.12. 5.48.6 Sutton applied to the High Court and was granted a Collection Order which was implemented the next day when Police returned Child E to the placement. Child E allegedly assaulted a police officer en-route but no further action was taken about the incident. 5.48.7 The funeral of S2 was held on 09.07.12 and was attended by Child E who ran away after it.  A further Collection Order was sought, obtained and executed. 5.48.8 SW8 at Child E’s request sought and obtained agreement from the long-term partner of the birth mother to compete a DNA test. Child E did not believe that this individual was their biological father. 5.48.9 Comment: the results are unknown and may not have been made available to Child E. 5.48.10 In late July Child E was once again arrested for taking and driving away and related offences (after an appearance at Gwnedd Youth Court on 06.09.12, Child E was sentenced at South Essex Youth court on 21.11.12 to a 12 month Conditional Discharge, an endorsed licence and a 12 month disqualification). 5.48.11 The assessment period having concluded, Child E was, on 07.08.12, placed at Upper Woodcote Farm in Shropshire (a two bedded unit offering 1:1 and, if need-be, 2:1 staff ratios).   Page 62 of 146  5.48.12 Child E had further consultations with a local GP as well as a referral via her/him to the local hospital 8. Nothing significant was found and inevitably the lack of medical records rendered more difficult for the doctor the challenge of diagnoses. Plans were made to rule out pancreatitis, provide pain control and complete blood tests. Non-specific abdominal pain was thought to be related to ‘E-coli’ (a common cause of food poisoning). Child E’s liver function was normal. 5.49 SELF-HARM EPISODE 20; FOURTH SECURE ACCOMMODATION ORDER AND FURTHER CHANGE OF PLACEMENT AND SOCIAL WORKER 5.49.1 After some uncertainty about their condition, Child E was taken to A&E at Royal Shrewsbury Hospital on 31.08.12 and was diagnosed as having taken Heroin intravenously into their right arm. Having been assessed by CAMHS at the hospital and judged not to be a suicide risk, Child E was discharged to the current placement. 5.49.2 On 17.09.12 Child E ran away to Norwich. The High Court granted a further Collection Order and Child E was eventually found by local Police on 29.09.12. In their absence, a further strategy meeting had been held on 20.09.12. The meeting was chaired by the head of Sutton’s Looked After Children Service and included the company’s psychologist.  5.49.3 Those in attendance were told that Child E’s liver was fragile and that another overdose of alcohol or drugs could be fatal. It was concluded that Child E needed a ‘specialist rehabilitation placement’. The location of such a facility was not specified. 5.49.4 When found on 29.09.12, Child E was moved directly to Leverton Hall (where they had been placed previously). A further Secure Accommodation Order was obtained for a period of 30 days on 02.10.12. In the chronology provided, legal papers refer to an overdose on 30.08.12.  Though precisely when is unclear, it appears that SW8 had been replaced by SW9 in August or September 2012. 5.49.5 ATM1 sought a psychiatric assessment from Sutton CAMHS on 08.09.12 and was advised by psychiatrist 3 that she had not seen Child E for over two years; required work should be commissioned by the CAMHS local to the placement. 5.49.6 Comment: Statutory Guidance on Promoting the Health and Well-being of Looked After Children DCSF/DH 2009 indicates that Sutton and Merton PCT (later CCG) would have been liable to finance the work. Psychiatrist 3 was anyway helpfully asked to contribute a planned professionals meeting on 28.11.12. 5.49.7 A letter from the Liver Unit to the GP with whom Child E was registered on arrival at Leverton Hall acknowledged the difficulties of providing adequate medical care when the patient was moving around so much. The letter also  Page 63 of 146  referred to Child E’s anger about what they considered conflicting health advice. During further GP consultations in Autumn 2012 Child E was prescribed Codeine for what they claimed was chronic abdominal pain. 5.49.8 A further Secure Accommodation Order was made on 01.11.12 and directions made for an experts meeting to be held with psychologist 1 and a psychiatrist 5. An opinion was being sought about what triggers Child E’s running away and possible strategies to deal with it; recommended treatment programme for drug usage; contact with birth and adoptive family; identity issue; placement post-treatment and possible therapeutic inputs as well as advice on services post-18. 5.49.9 Psychiatrist 5’s report was received on 14.11.12 and concluded Child E:  Had a complex attachment disorder  Had post-traumatic stress disorder  Was manifesting a complex grief reaction and  Showed features of attention deficit hyperactivity disorder (ADHD) 5.49.10 Psychiatrist 5’s view was that Child E was at risk of depression and deliberate self-harm, drug and alcohol misuse and emerging personality disorder. She recommended anti-psychotic medication to assist in self-regulation (not because Child E was psychotic) when not in a secure environment. She supported the proposed use of a named placement. 5.49.11 Comment: its subsequent rapid failure casts doubt on the suitability of the placement.  5.49.12 Those in attendance at the professional meeting convened on 26.11.12 (TM1 ATM1, SW9, Children’s guardian, psychiatrist 3) had sight of the above psychiatric report. Psychologist 1 participated by phone. 5.49.13 There was a consensus that Child E needed to be linked to a local CAMHS and that Psychology (not constrained by catchment area or GP registration) could take on reviews of mental health. The extent to which that (intrinsically confusing) proposal was considered to be in Child E’s best interest and the extent to which it was a pragmatic response to ongoing confusion / disagreement about those responsible for commissioning secondary health services is unclear. 5.49.14 Supervised contact with the birth family was agreed albeit the birth mother’s lack of commitment would, it was recognised, continue. Contact with S4 needed to await a sustained sign of commitment before its initiation. The practical actions agreed recommended were:    Page 64 of 146   A meeting with S4 to discuss increasing contact  An assessment by SW9 of how contact with the rest of the birth family might be managed  Involvement of the leaving care team (LCT) and Adult Services to facilitate continuity of service delivery  Family therapy for S4 and Child E to be sought from the proposed placement (Companions)  That Ms AM should remain in contact with Child E  A referral should be made to the Tavistock clinic to seek the recommended psychiatric oversight until Child E reached adulthood  A dyslexia assessment once Child E settled at the new placement 5.49.15 Comment: though a fair degree of consensus existed, the views of psychiatrist and psychologist with respect to contact with Ms AM and the value of psychoanalytical psychotherapy differed significantly. 5.49.16 Records do not confirm that the agreed follow-up conversation with psychiatrist 5 was achieved. The notes of the meeting summarised in the merged chronology refer to Cobblestones [a much earlier placement] which suggest that psychologist 1’s report was the old one prepared when Child E was in Somerset. 5.49.17 With respect to the uncertainty of funding sources, Sutton’s ‘Head of Children’s Services’ (understood to be the director) usefully provided a practical way forward. On 29.11.12 he approved funding of consistent therapeutic input for Child E. The health overview suggests Sutton’s ‘shadow’ CCG (the erstwhile Sutton and Merton PCT) had agreed to fund provision of a local CAMHS whilst Child E was placed at Leverton Hall. 5.49.18 During November, LAC nurse 1 initiated her first direct contact with Child E when she wrote to them about a failure to attend an (unspecified) appointment. She has described a more active involvement with Child E from this point onwards. 5.50 FURTHER CHANGE OF PLACEMENT AND SOCIAL WORKER 5.50.1 A one day taster at the selected rehabilitation placement apparently went well and Child E was moved to Companions Young Persons Rehabilitation Centre in Stafford on 05.12.12. A scheduled court hearing was vacated in the belief that secure accommodation was not required. Within days, staff at this new placement were struggling to manage. An early report referred to Child E’s use of cannabis. SW9 asked S4 to contact Child E and offer support.  Page 65 of 146  5.50.2 Comment: SW9’s initiative was at odds with the more cautious approach toward involving this birth relative agreed at the late November professionals’ meeting. 5.51 FIRE RAISING EPISODE FIVE AND PLACEMENT BREAKDOWN 5.51.1 Within a week of arrival, Child E’s aggressive and disruptive conduct at this placement had necessitated a call to the local Police for physical support. On 09.12.12 Child E tried to set fire to the Unit, destroyed property and allegedly killed the Unit’s pet rabbit which was found dead having had its leg broken. After the incident Child E reportedly left the Unit with the intention of going to see S4 (whose location at that time is unknown to the author). Child E was later returned by Police who had found them at Stafford Station. Child E seemed remorseful and feared being returned to a secure setting. In response to this conduct, the placement was formally terminated by Companions. 5.51.2 A plan to transfer Child E the next day (10.12.12) to Beechfield Secure Unit in Sussex was delayed when they ran away. They were located hiding behind a shed and restrained until Police returned and completed the transfer. Low level anti-psychotic medication was recommended to calm them down. 5.51.3 On 12.12.12 at the Inner London Family Proceedings Court, a 30 day Secure Accommodation Order was granted and psychiatrist 5, previously commissioned for her opinion, was consulted. She recommended that Child E be seen urgently by a named West Sussex psychiatrist who could prescribe a low level dose of anti-psychotic medication. 5.51.4 On the same day as the above hearing, a review health assessment was completed by the Unit’s specialist nurse. Child E was seen by a GP with whom they had been registered on arrival at Beechfield Secure Unit. The consultation was an exceptionally thorough one. Unsurprisingly, no medical records were available and the doctor was dependent upon Child E’s own account of their history. In providing it, Child E acknowledged the last use of Heroin had been three months ago. This GP increased Child E’s ongoing prescription of Codeine (to relieve abdominal pain that may or may not have been related to Hepatitis C). 5.51.5 This GP sought contact with psychiatrist 3, who, on 13.12.12, sent an email explaining her historical link and recommending accessing the local CAMHS so that they could consider any need for medication. 5.51.6 On 13.12.12 SW10 took over from SW9 as Child E’s social worker and within a week was emailed by the specialist LAC nurse from Sussex Community Health Trust who forwarded the advice of the consultant paediatrician at Birmingham Children’s Hospital viz: that Child E needed to remain in long term secure accommodation so that their Hepatitis C could be effectively treated. 5.51.7 Comment: the proposal that Child E should be detained for the purpose of medical treatment raised significant ethical and legal issues. It is thought that  Page 66 of 146  risks associated with non-compliance or refusal were adequately explained to Child E. 5.51.8 On 17.12.12 this GP undertook a ‘home visit’ to examine Child E who was complaining of a number of symptoms. He prescribed Tramadol to be taken in addition to the Codeine already prescribed (both are pain killers). The doctor also received communication from the clinic in Birmingham advocating Child E’s retention in secure care so that the treatment for Hepatitis C could be administered in an environment free of drugs and alcohol. 5.51.9 An addendum to psychiatrist 5’s report, received by Children’s Social Care, recommended therapeutic input and cognitive behavioural strategies for Child E whilst in secure care. Child E had become quite withdrawn. A GP who had prescribed Codeine and Tramadol (for an assumed viral illness) as well the consultant psychologist 2 thought Child E was suffering from depression rather than anxiety. The GP consequently prescribed Citalopram anti-depressants. 5.51.10 Comment: all significant material including the psychiatric report should have been shared with Beechfield before or at admission. 5.51.11 At a secure accommodation review on 20.12.12, chaired by Sutton’s head of service and at which Ms AM was present, it was decided to accept Child E’s stated preference and move the young person back to Leverton Hall where they was familiar with staff and routines. 5.51.12 Following the above review, Child E wrote to Ms AM and challenged her real motives for the adoption. They received what was evaluated as a ‘thoughtful and kind’ letter soon after Christmas. 5.52 SECOND PLACEMENT AT LEVERTON HALL 5.52.1 Transfer back to Leverton Hall was completed on 21.12.12. Child E’s initial response to the unit they had left less than three months’ earlier was positive and the young person was looking forward to some planned contact with S4. 5.52.2 On Christmas day, however, Child E was reportedly the main instigator of disruptive, damaging and violent behaviour lasting about six hours, in which significant damage was done. Until a call by SW10 to Child E on 27.12.12, the social worker had been unaware of this incident. During that conversation Child E spoke of a ‘good Christmas’ and lots of presents from S4. 5.52.3 At a visit by the children’s guardian, she noted that Child E wished to proceed with the required treatment for their Hepatitis C and agreed with the need to remain in secure care to ensure that such treatment would be effective.    Page 67 of 146  5.53 LAC REVIEW 11 5.53.1 An overdue s.26 review was convened on 03.01.13 and was apparently attended by S4 as well as Child E, who participated well. 5.53.2 A further two month Secure Accommodation order was obtained on 09.01.13. On 11.01.13 there was a further incident of threatening behaviour necessitating physical restraint. An escorted trip to the grave of S2 where Child E met S5 and S3 was completed without incident. 5.53.3 The (unnamed) GP at Leverton Hall was not prepared to continue to prescribe Citalopram unless the rationale for its use was provide by the GP from Beechfield (as on previous occasions, the transfer of medical records had not kept up with Child E’s rate of transfer). This ethical / professional dilemma seems to have been resolved in that Child E did continue to receive anti-depressants and painkillers.  5.53.4 On 15.01.13 Child E was noted to be shocked and overwhelmed by the news that half-sibling S4 had been arrested and charged with two counts of child abduction and ‘grooming’ a child (he later pleaded guilty with respect to the first two charges). Child E had apparently expressed a hope that one day they might be able to live with S4. Child E shared with the senior mental health nurse that, if they had not been in secure care, the news would probably have prompted them to kill themselves. Child E asked that the dosage of prescribed anti-depressants (then a relatively low 10mg Citalopram once a day) be increased because they felt that their mood state was lowering.  5.53.5 This same nurse shared with SW10 a few days later a 20 page document composed by Child E in which they articulated their feelings toward S4 and deceased half-sibling S2. Child E had formed a trusting relationship with the senior mental health nurse who maintained contact after Child E moved on. 5.54 ARRANGEMENTS FOR REQUIRED SPECIALIST MEDICAL TREATMENT 5.54.1 Because of Child E’s suicidal thinking, specialist hospital 9 deferred treatment of the confirmed Hepatitis C18 pending a psychiatric assessment (the injections can apparently trigger a side effect of suicidal thinking).  5.54.2 Comment: recognition of this young person’s vulnerability showed a welcome sensitivity. 5.54.3 At this time, Child E continued to receive weekly sessions with a drugs and alcohol worker and sought to increase their frequency. Sutton YOT asked                                                  18 Chief amongst Child E’s health problems was the Hepatitis C infection. This virus is typically transmitted via blood to blood contact (sharing razors or toothbrushes or un-sterilised needles whilst injecting drugs). An estimated 49% of those injecting drugs have Hepatitis C. It is also possible to acquire the virus through anal sexual intercourse and, although this is not confirmed in records seen, Child E was exposed to the risk of all forms of sexual exploitation from an early age.  Page 68 of 146  Harlow YOT to discharge its responsibilities whilst Child E remained in Essex and, with effect from February, it appears that this occurred. 5.54.4 Child E was brought back to the specialist hospital 9 in the Midlands on 12.02.13 by Sutton’s LAC nurse 1 (supported by Child E’s key-worker and three security staff). The meeting ended prematurely when Child E reportedly refused treatment. Psychiatrist 6, who completed Child E’s assessment of suitability for what would be prolonged Hepatitis C treatment, concluded in February that the young person did not suffer from a psychiatric disorder and treatment should not be delayed. 5.55 REVIEW AND FURTHER USE OF SECURE ACCOMMODATION 5.55.1 At a review of the use of secure accommodation on 18.02.13, it was judged that its ongoing use was justified and (in part informed by the opinions of the unit’s clinical psychologist) a decision was made to apply to the court for a further six month Order. On this occasion, Child E acknowledged to their social worker that they continued to crave drugs and alcohol.  5.55.2 At a consultation with a GP on 26.02.13 Child E shared a concern about one of their ears sticking out more than the other and a referral was made to a specialist. 5.55.3 Comment: the relevance of this is that it suggests Child E was looking to the future and was (like most adolescents) concerned about their appearance. 5.55.4 A further (six month) Secure Accommodation order was obtained on 01.03.13. The rationale for the court’s decision was to allow professionals to meet so as to discuss the required Hepatitis C treatment and to ensure a period of stability that would facilitate therapy and prevent Child E from carrying out the threat to kill themselves if not placed in secure care. It was hoped that, at the end of the six months, Child E might move on to non-secure linked placement Leverton House. 5.55.5 Records indicate that the social worker raised with the then ‘executive head of safeguarding’ the anomaly that the local provider of independent visitors19 was unable to provide one for a child / young person living out of the borough. 5.55.6 Comment: need is likely to be greater for a child placed away from family and friends. 5.56 REPORTED SELF-HARM EPISODE 21 5.56.1 Following the revelation on 04.03.13 of Child E’s further self-harm (a reported attempt, two days earlier, to hang themselves with a shoe lace), the senior                                                  19 Under s.23ZB Children Act 1989 a Local Authority must, in circumstances defined in regulations, offer a child/young person an independent visitor. The need for such an appointment should be considered at each s.26 review.  Page 69 of 146  mental health nurse completed and transmitted to Sutton Children’s Social Care an updated risk management plan to include a named member of staff allocated to Child E at the start of each shift and observations at intervals of 15 minutes.  5.56.2 Sutton Children’s Social Care agreed to fund 1:1 supervision (at a cost of £500 per day extra). SW11 sought the agreement of psychiatrist 5 to become the ‘named psychiatrist for [Child E] and offer therapeutic and psychiatric input for the following three years’. The psychiatrist indicated that she was reluctant to agree until she had met Child E again. 5.56.3 The level of concern about Child E remained high and the senior mental health nurse advised that their room should be cleared of all items that could be used for self-harm. Emails were exchanged between Leverton Hall and Sutton where the strategic director of Children’s Services became directly involved. 5.56.4 Psychiatrist 6 (attached to Leverton Hall) met Child E on 06.03.13 and determined their level of depression was such that an adult dose of 20mg per day of Prozac was required. A decision was made that medication would need to be administered in liquid form. It appears that the psychiatrist liaised with psychiatrist 3 at Sutton CAMHS and its medical director. The mental health nurse continued to see Child E twice weekly and made contact by phone every evening. She also liaised closely with Child E’s therapist who was providing weekly sessions. 5.56.5 Comment: later reports refer to ‘mentalisation therapy’20 supervised by psychiatrist 8.  5.57 SELF-HARM EPISODE 22 AND MENTAL HEALTH ASSESSMENTS 5.57.1 At 23.15 on 06.03.13 Child E is reported to have made a further attempt (using a shoelace they refused to relinquish) to hang themselves. Staff had found the young person and cut away the lace, which had left a ligature mark around their neck. Sutton’s strategic director of Children’s services became directly involved and is reported to have instructed that Child E was to be awarded top priority. Staff were to treat Child E ‘as though [they] were their own child’. 5.57.2 Comment: direct involvement and content and clarity of instructions were commendable. 5.57.3 On 07.03.13 psychiatrist 6 again assessed Child E and determined they were not ‘sectionable’ under the Mental Health Act 1983. Child E was prepared to be a voluntary patient at the local hospital 10 for further assessment and support. Whilst awaiting a bed, a member of staff was allocated 24 hours a                                                  20 Mentalisation-based treatment (MBT) is a form of psychodynamic psychotherapy, developed and manualised by P. Fonagy and A. Bateman. MBT was designed for individuals with borderline personality disorders who suffer from disorganised attachment and fail to develop a mentalisation capacity within the context of an attachment relationship.  Page 70 of 146  day. When informed, Sutton’s strategic director instructed SW10 not to agree to the proposed transfer and that treatment must continue at Leverton Hall.  5.57.4 Comment: that decision represented a realistic appraisal of the risk of Child E running away or otherwise harming themselves in a non-secure environment. The accuracy of that judgment was reinforced by comments made next day by Child E in an angry exchange with their social worker. 5.57.5 Psychiatrist 3 from Sutton CAMHS met Child E again on 13.03.13, alone and then with psychiatrist 6. It was agreed that Child E remained ‘high risk’ and needed to be monitored 24 hours per day. A further appointment was offered and the psychiatrist also wrote to Child E and agreed to meet them again in May. 5.57.6 Child E’s anti-depressant medication was to be reviewed and the possibility of an additional ‘mood stabiliser’ is noted in the report of the Mental Health Trust. 5.57.7 SW11 was about to leave Sutton (as was her manager) and sought to ensure an adequate handover. It was noted that only with the director’s approval could the 24 hour per day observation be removed. SW11 later sought an agreement for her successor to continue visits once / twice a week. 5.57.8 Comment: the relevant minimum frequency of such visits was six weekly so ‘once or twice a week’ illustrated the level of concern as well as commitment by SW11. 5.58 SELF-HARM EPISODE 23 AND FOLLOW-UP TO MEDICAL NEEDS 5.58.1 On 25.03.13 Child E ingested six prescribed pain-relieving tablets which they had managed to secrete and they were hospitalised. A request by Sutton’s strategic director of Children’s services for 2:1 staffing was declined by the assistant head of care at Leverton Hall who regarded the proposal as impracticable and one that would not make the situation safer. Child E was known to be carrying a shoe lace though staff were unable to remove it. 5.58.2 A professionals’ meeting convened at specialist hospital 9 on 11.04.13 determined that Hepatitis C treatment should not proceed whilst Child E was so suicidal. Monthly enzyme tests were agreed upon and that the required liaison would be via Sutton’s LAC nurse 1. A revised plan for care was based upon a presumption that Child E would try to kill themselves. A high level of (inevitably intrusive) surveillance was instigated and caused Child E to become extremely angry with SW11.  In spite of their level of depression and chronic distress Child E was able to contribute to a review of their personal education plan (PEP) and special educational needs (SEN). 5.58.3 The health overview points out that with effect from 01.04.13 funding for ‘tier four’ placements became the responsibility of the National Commissioning Board at NHS England (London). Also at that time the services of LAC nurse 1 began to be delivered via a Sutton CCG contract with SMCS.  Page 71 of 146  5.59 TRANSFER OF CASE ACCOUNTABILITY AND NEW SOCIAL WORKER  5.59.1 With SW11 due to leave on 23.04.13, a new SW12 based in the Leaving Care Team was nominated to become Child E’s social worker. A transfer meeting was convened on 15.04.13. Meanwhile funding had been secured for a ‘mentor’ (presumed to mean an independent visitor) and Leverton Hall was asked to suggest potential local sources of such a service. 5.60 SELF-HARM EPISODE 24  5.60.1 SW11 had been informed on 14.04.13 that a plan by Child E to hang themselves two days earlier with a shoelace acquired from another resident had been prevented. Meanwhile steps were initiated to obtain, via LAC nurse 1, a second opinion about the required Hepatitis C treatment from the specialist hospital 14 in London. 5.60.2 On 09.04.13 the 18-month Youth Rehabilitation Order was revoked though a 12 month Conditional Discharge and a driving ban remained in place.  5.61 SELF-HARM EPISODES 25 AND 26, POTENTIAL MENTAL HEALTH ASSESSMENT AND SERIOUS ASSAULT 5.61.1 Psychiatrist 3 made contact by phone with the Unit’s psychiatrist 6 on 22.04.13 to be updated on events. 5.61.2 On 24.04.13 Child E told staff that they had swallowed a battery from a remote control device. Accompanied by four staff the young person was taken to hospital next day (they had initially refused to go) where it was confirmed that they had ingested four batteries. The possibility of an assessment under the Mental Health Act 1983 was raised on 25.04.14 whilst Child E remained a patient in hospital 11. The newly allocated SW12 and senior mental health nursed advised that this would offer no advantage and no assessment was undertaken. 5.61.3 On 01.05.13 Child E claimed to have ingested a further single battery but the hospital was unable to confirm this. Two days later, an assault initiated by Child E became so violent that three staff needed A&E treatment and Child E had to be locked in their room so as the ensure the safety of everyone on the unit. 5.61.4 Staff observed Child E through the window of their room though their efforts were effectively thwarted when they blocked the window using photos of their family. 5.61.5 When staff entered the room, they found Child E to be hanging from the ceiling. The young person was re-admitted to hospital 11 and spent two nights there. Records indicate that Child E had obtained the cable used from another resident and had created the disturbance in the hope that they might be locked in their room.  Page 72 of 146  5.61.6 Comment: if Child E really had planned the event as has been suggested, it points to a very serious attempted suicide. 5.61.7 Concern was rising at this time amongst staff at Leverton Hall about their ability to keep Child E safe. On 07.05.13 a local CAMHS ‘Crisis and Assessment’ team met with Child E but concluded that they were not sectionable because they were willing to enter a psychiatric ward voluntarily. 5.61.8 Psychiatrist 3 from Sutton visited Child E (who was being segregated from other residents) on 08.05.13 and expressed the view that an assessment under the Mental Health Act 1983 should have been completed immediately after the recent self-harm episodes. Her view and that of psychiatrist 6 was that Child E was now sectionable. 5.61.9 Apparently because there was no bed available, the local approved mental health practitioner (AMHP) reported that it was not possible to undertake the requested mental health assessment. It is assumed that the anticipated assessment was to have been done whilst Child E was an in-patient. 5.62 UNCERTAINTY ABOUT ACCOUNTABILITY FOR MENTAL HEATH ASSESSMENT 5.62.1 Records indicate confusion at practitioner level about which Mental Health Trust was accountable for the urgently required mental health assessment. Whilst a suitable bed was awaited, a mental health nurse was deployed to Leverton Hall. 5.62.2 The advice being given by the mental health nurse at Leverton Hall was that South West London and St George’s Mental Health Trust was accountable for the cost of a mental health assessment. The local approved mental health practitioner (AMHP) also expressed the view that his agency would only offer a service if the patient originated from a significant distance and Sutton was not considered to be sufficiently distant. The health overview has confirmed that responsibility for Children requiring tier four placements at this time rested with the National Commissioning Board at NHS England (London). 5.62.3 Comment: commendably Sutton’s strategic director for children cut through the confusion and unhelpful delay by agreeing to fund the cost of assessment (whether this reflected confidence in his understanding of the government’s expectations of commissioning or a willingness that Children’s Social Care would anyway meet the costs directly is uncertain).  5.63 TRANSFER TO PSYCHIATRIC HOSPITAL 5.63.1 A strategy meeting on 08.05.13 was chaired by Sutton’s head of LAC Service. Psychiatrists 3 and 6 agreed that Child E was a high suicide risk and admissible under the Mental Health Act 1983. If Child E was not sectioned, it was agreed that they should remain at Leverton Hall. On 10.05.13 Child E (apparently without any involvement of SW12) was moved to a local adult  Page 73 of 146  psychiatric (low) secure unit St Aubyns under s.2 Mental Health Act 198321. SW12 subsequently experienced considerable difficulties in attempts to contact with St Aubyns (20 calls were made and five messages left yet no responses were received). When she finally managed to make contact, she was told that Child E was refusing food and drink. 5.63.2 Child E later indicated to SW12 that they had shared, with psychiatrist 7, a number of traumatic life events about which they had previously felt too inhibited to speak. Child E spoke again of those events a couple of days later in a conversation with the Leverton Hall senior mental health nurse. 5.63.3 Comment: these events (real or imagined) referred to serious crimes. It would appear that Police were not notified.  5.64 SELF-HARM EPISODE 26 AND TRANSFER TO MEDIUM SECURE UNIT 5.64.1 On 22.05.13 Child E was admitted to hospital for having swallowed a battery and underwent keyhole surgery (a laparoscopy) to remove it (a later medical record refers to a ‘laparotomy’ – a procedure involving a medium to large incision). It seems neither of the parties with parental responsibility (Ms AM or Sutton Children’s Social Care) was informed of the episode or had provided consent. St Aubyns, in response to concerns expressed by Sutton’s head of Looked After Children’s Service, failed to explain how Child E had been able to source the battery or why communication / consent had not been accomplished. 5.64.2 By 28.05.13 the strategic director for Children’s Services at Sutton was briefed by the head of the Looked After Children’s Service that St Aubyns considered Child E to require a higher level of security than was possible there. A transfer to a medium secure unit such as St Andrews in Northamptonshire was being explored. On 06.06.13 Child E was transferred to a s.3 Mental Health Act 1983 (a Treatment Order)22. There is a suggestion that, by then, Child E was experiencing auditory hallucinations (voices in their head).  5.65 SELF-HARM EPISODE 27 5.65.1 On 11.06.13 Child E told staff that they had swallowed four AAA batteries and claimed to have chewed them before swallowing them. On the same day Child E was transferred to Huntercombe Hospital in Norwich (a low secure unit). At A&E the batteries were seen via x-ray to be intact and were allowed to pass through the intestines without medical intervention. 5.65.2 Comment: a further ‘low’ rather than a ‘medium’ secure unit was necessitated whilst a bed in the latter type of hospital became available.                                                  21 S.2 Mental Health Act 1983 allows the detention of an individual for up to 28 days (for the purpose of assessment) if s/he is suffering from a mental disorder and two registered medical practitioners and an ‘approved mental health practitioner’ agree that this step is necessary for the protection of the individual or others. 22   A s.2 Treatment Order can initially last up to six months. It is instituted in the same manner as s.2, following an assessment by two doctors and an ‘approved mental health practitioner’.   Page 74 of 146  5.65.3 SW12 was in contact at this time with the local social worker dealing with S4. The benefit of planned and supervised contact with Child E was discussed. SW12 also discussed and arranged with hospital staff a heavily supervised visit to the grave of S2 by Child E. 5.65.4 The value of ongoing contact by the mental health nurse from Leverton Hall was discussed by SW12 and the individual concerned. SW12 and Child E favoured such an arrangement if payment could be secured. Huntercombe opposed the ongoing involvement of the Leverton Hall senior mental health nurse. 5.65.5 SW12 apparently learned from the above nurse of the imprisonment of Mrs AM’s brother for offences against his then seven year old niece in 2000. Child E reported that Ms AM had acknowledged that her brother had admitted the offences to her at the time (though denied them to Police).  5.65.6 Child E asked why the adoption, which post-dated the above events, had been allowed to proceed and why they had later been allowed to live with this man and his wife. Child E made no allegations about their own treatment whilst there. 5.65.7 SW12, who had become case accountable only two months previously, was about to leave, necessitating case transfer to a SW13. 5.65.8 Comment: the rapid turnover of social workers was very unhelpful to Child E. 5.66 SELF-HARM EPISODES 28 – 32 5.66.1 A series of self-harm episodes followed in quick succession. Though no further detail has been made available, it appears that on 25.06.13 following an assault by Child E, on a member of staff, Child E tried to tie ligatures and had to be physically prevented from so doing. 5.66.2 On 29.06.13, having barricaded themselves into the ‘seclusion area’, Child E tied a ligature and next day ingested an AAA battery as well tying a ligature. The young person was brought to A&E but no medical treatment was deemed necessary. A follow-up visit some days later revealed that the batteries remained intact. 5.66.3 On 12.07.13, in what appears to have been a distinct episode, Child E swallowed an unspecified number of AAA batteries. Though brought to A&E no medical treatment was required. ‘Antacid’ medication was recommended. 5.66.4 In mid-July responsibility for the medical needs associated with Hepatitis C was transferred to specialist hospital 14 who continued to liaise with LAC nurse 1.  Page 75 of 146  5.66.5 On 17.07.13 Child E made what has been calculated to have been their 32nd attempt at significant self-harm, when they tied a ligature with a sock and also attempted to strike staff. 5.66.6 A few days later, Huntercombe informed Sutton Children’s Social Care that Child E had complained about the manner in which they had been restrained. Which occasion was being referred to or what the outcome of this formal complaint may have been, has not been included in material seen. 5.67 CARE PLANNING APPROACH (CPA) MEETING, TRANSFER TO MEDIUM SECURE UNIT AND NEW SOCIAL WORKER 5.67.1 At a ‘Care Planning Approach’ meeting on 31.07.13 some unit staff expressed the view that Child E required a medium secure unit. After debate it was determined that the decision be deferred until a further such meeting on 07.08.13.  5.67.2 SW13 from Sutton’s Looked After Children (LAC) team was allocated on 05.08.13. The head of service for Looked After Children discussed the case with psychiatrist 8 who had been recommended by the previously involved psychiatrist 5. 5.67.3 It was agreed that psychiatrist 8 would offer support to staff at Leverton Hall because Child E’s current mental health precluded direct therapy. 5.67.4 Comment: the proposed arrangement was predicated on Child E’s return to Leverton Hall which in practice, was never achieved. 5.67.5 By the time of the CPA meeting on 07.08.13 it was reported that Child E had made some improvements. On 12.08.13, they allegedly damaged hospital property and punched a member of staff whom they had specifically chosen to be on observation duty. Police were involved to what seems to have been significant disorder and a Summons was later issued in relation to the event. 5.67.6 Next day Child E spoke to SW13 and claimed that they felt unsafe at the hospital as there was insufficient staff. A counter-allegation of assault by the member of staff involved in the incident of 12.08.13 was shared with the ‘Local Authority Designated Officer’ (LADO). On the basis of a CCTV recording showing Child E chasing and assaulting the person concerned, the LADO determined that no further safeguarding action was required. 5.67.7 In an exchange reminiscent of that of late May, a transfer to a medium secure unit such as St. Andrews in Northamptonshire was being sought. The unit to which Child E was admitted on 16.08.13 is a 12 bedded medium secure unit for young people aged 13-19 on admission who have psychiatric, psycho-social, psychological and emotional difficulties and who are detained under the Mental Health Act 1983.  Page 76 of 146  5.67.8 On admission Child E was observed to be acutely unwell with a grossly swollen knee; to be hot and unable to walk. Emergency treatment was provided at hospital 12 where the diagnosis was of torn ligaments. 5.67.9 Comment: no explanation was been provided for these significant injuries but it seems likely that they were a consequence of what some accounts describe as ‘a riot’ on 12.08.13. 5.67.10 A decision was made jointly by Sutton and Essex YOT that formalised what was anyway the de-facto position viz: that the primary need was to address Child E’s mental health needs and that Court Orders for criminal acts needed to be revoked (Child E’s 18 month Youth Rehabilitation Order was reported to have been revoked on 09.04.13). 5.67.11 St Andrews queried the value of the ongoing involvement of the nurse from Leverton Hall. They feared that it would render it more difficult for Child E (who was already disinclined to engage) to develop therapeutic relationships. Interestingly, the report provided by St. Andrews reported daily phone contact with Child E’s sibling [which one was not specified] and Ms AM. 5.68 LAC REVIEW 12 5.68.1 An overdue s.26 Children Act 1989 review combined with a ‘hospital managers’ review was convened on 25.09.13. The meeting was chaired by IRO3 and concluded that Child E should remain at St Andrews under s.3 Mental Health Act 1983. It also ‘confirmed the decisions made at a strategy meeting on 20.09.12’. 5.68.2 Comment: the reference to a meeting over a year previously raises doubts about the availability of outputs of the last s.26 review in January 2013.  5.68.3 It emerged next day that Child E had admitted to secreting shoe laces on their person and in bedding. They had also started to rip up clothing to make a ligature. As a result of these revelations, Child E was placed in un-tearable clothing. 5.69 SELF-HARM EPISODE 32 5.69.1 On 02.10.13, in what was the 32nd significant self-harm episode, Child E swallowed one or two batteries from a TV remote control (accounts vary) and was hospitalised overnight as a precaution but required no specific medical treatment. Worryingly, this episode is not included in the report from St. Andrews, which instead provides a positive picture of the Autumn period. Its report does refer to an unspecified number of visits by Ms AM and a ‘younger sibling’ of Child E (presumed to be 14 year old adopted S1). 5.69.2 There followed further telephone exchanges between the Leverton Hall senior mental health nurse and SW13. They agreed that the degree of involvement of the nurse needed to be reduced and the relationship curtailed.  Page 77 of 146  5.70 MENTAL HEALTH TRIBUNALS / CARE PLANNING APPROACH (CPA) MEETING 5.70.1 During October Child E spoke of accepting the s.3 Treatment Order which would have rendered the Tribunal scheduled for 21.11.13 unnecessary. Child E did, though, express a wish to be placed nearer the birth family. 5.70.2 Discussions were held at this period between managers of the Leaving Care and LAC team and (on an assumption of eventual case allocation to the former) the potential for joint work over the next year considered. 5.70.3 By a CPA meeting on 02.11.13, at which some progress was noted, Child E was seeking a Tribunal review of their Treatment Order. A week later and apparently on legal advice, Child E withdrew the application for a Tribunal and the scheduled event on 21.11.13 was cancelled. 5.70.4 A health assessment review on 16.12.13 was completed by LAC nurse 1. Child E was to be seen by specialist for a review of liver function. 5.70.5 The Children’s Social Care Individual Management Review reported that from the record of a phone conversation on 24.12.13 between St Andrews SW14 and Sutton’s SW13 neither thought that Child E should be discharged at that time. They were of the view that Child E needed an opportunity to experience going out into the community while a plan was made for their future placement. 5.70.6 At a Tribunal on 10.01.14 it was concluded that Child E no longer needed to be ‘on section’ but that this should not formally end until an alternative placement had been found. A review date was agreed eight weeks later with an expectation that a suitable placement would by then have been identified. SW13 made initial enquiries of Duke House in Halifax on 31.01.14. 5.70.7 Having pleaded guilty, Child E was sentenced on 14.01.14 at Norfolk Youth court for the assault on a staff member at Huntercombe and associated breach of the Conditional Discharge. 5.70.8 Records confirm that a place at Duke House was selected in early February. The placement had access to education, therapeutic resources as well as drug and alcohol services. It also apparently had the capacity to prepare young people for independence. Aside from Child E’s needs for a placement, they were scheduled to start medical treatment for Hepatitis C in April. Introductory visits to the proposed new placement began in mid-February and on 27.02.14 SW13 confirmed the borough’s commitment to the placement. Introductions were carefully managed and showed some initially positive signs. 5.70.9 Comment: the author has been told 40-50 potential placements were considered and 12 explored in more detail. Duke House had been recommended by another Local Authority.   Page 78 of 146  5.71 ESTABLISHING SOURCE OF MENTAL HEALTH MONITORING POST-DISCHARGE 5.71.1 Correspondence in early March indicates that the issue of mental health services for Child E if they were to move to Halifax was recognised and being negotiated by St Andrews. The view reportedly expressed by an identified individual in Calderdale CAMHS is that they were reluctant to provide a ‘responsible clinician’ because this was usually the responsibility of the local CAMHS. She also apparently expressed uncertainty about what was anyway required since the proposed placement included therapeutic services. A decision from a senior manager in Calderdale CAMHS was said to be awaited. 5.71.2 The Calderdale team manager was subsequently reported (in Sutton Children’s Social Care records) to have expressed concern at the uncertainty about Child E’s needs and on 05.03.14 sought a four week transition to include some authorised time outside of Child E’s current detained status.  5.71.3 Comment: the manager’s cautious view was, given Child E’s history, wholly justifiable. 5.71.4 Throughout the remainder of March / April there were many emails (copies of a proportion made available) within which the question of which agency should fund required services and who should become the ‘responsible clinician’ was addressed. Calderdale CAMHS wished to be funded if it was to take on the role. 5.71.5 It appears that, initially without reference to the individual or her agency (Sutton CAMHS), that St Andrews and Calderdale CAMHS agreed psychiatrist 3 should become the ‘RMO’ (a term assumed here to be the same as ‘responsible clinician’).  5.71.6 Comment: a distance of over 200 miles would have significantly limited her value. 5.71.7 Though records and reports supplied do not offer detail, it seems that by 07.03.14 psychiatrist 3 (in spite of having raised clear and wholly justifiable concerns about any such proposal with the Local Authority, Trust Named Nurse and her medical director) was thought by some to have accepted the role of ‘responsible clinician’ at the point of Child E being discharged. Sutton’s SW13 and the St. Andrew’s SW14 anyway both confirmed that this was their understanding in emails to Duke House on 07.03.14 and 08.03.14 respectively. 5.71.8 Psychiatrist 3 had (justifiably) raised the possibility, given the fragility of Child E’s mental health, of a ‘Community Treatment Order’23. It is unclear whether this commendable caution was adequately considered. It seems to have been generally accepted amongst all involved professionals that since the move to                                                  23 A Community Treatment Order would allow a recall to detained status if mental health deteriorated significantly.  Page 79 of 146  St. Andrews Child E had developed better coping mechanisms and had not exhibited risky behaviours since October 2013. 5.71.9 During March there was a series of exchanges between the future care providers and Sutton and Calderdale CAMHS. Arrangements such as registration with a local GP were completed prior to Child E’s transfer. A Calderdale CAMHS manager queried on 12.03.14 (as did her colleague on 25.03.14) what was anyway required of her service in that Child E was to be provided with therapy from CCATS24. 5.71.10 According to information provided by St. Andrews, a planned meeting on 13.03.14 to which psychiatrist 3 had previously agreed to contribute by phone did not proceed because she could not be located on the day. Psychiatrist 3 has confirmed to the author that she received no call that day. St. Andrews has also indicated that an un-identified case manager in NHS England was consulted and agreed to speak with Calderdale CAMHS about transfer of care. The brief report latterly received from NHS England does not confirm that communication. 5.71.11 On 18.03.14 psychiatrist 3 had emailed all parties to endorse the need for a local CAMHS and recognised this would need to be funded by what she described as ‘Sutton’ (and on that basis copied in the CCG ‘commissioners’). SW13 on the same day informed the placement that Calderdale CAMHS would provide a responsible clinician but that funding confirmation was still awaited. 5.71.12 Comment: SW13’s ‘confirmation’ was well-intentioned though premature. 5.71.13 St. Andrews contacted Calderdale CAMHS on 20.03.14 in an attempt to negotiate s.117 Mental Health Act aftercare before the Tribunal scheduled a week later. Calderdale could not provide a representative and indicated that it ‘required more time to process the referral and assess Child E’s needs’. 5.71.14 Comment: with a Tribunal imminent and a follow-on placement identified, there was still little certainty and even less consensus about who would fulfil ‘responsible clinician’ or ‘care co-ordinator’ roles. 5.71.15 Ms AM visited Child E at Duke House during a week’s leave permitted by St Andrews between 20.03.14 – 27.03.14 (they had already spent what was noted to be a successful stay there the weekend before). St. Andrew’s Individual Management Review indicates its understanding that, even as late as 24.03.14, Sutton CAMHS had not liaised with Calderdale CAMHS. This assertion conflicts with the author’s understanding, rooted in assurances contained in the chronology and in the reports provided by the Trust responsible for Sutton CAMHS and (in late January 2015) by the South West Yorkshire Partnership Foundation Trust. Liaison had begun in early March.                                                  24 CCATS is an independent source of psychological assessment and treatment for children, young people and adults.  Page 80 of 146  5.71.16 On 25.03.14 the team manager of Calderdale CAMHS raised her concerns with SW14 at St Andrews about a lack of clarity about the role proposed for her agency. She wrote that it was ‘irresponsible to discharge Child E without a comprehensive multi-agency community care plan in place’. She proposed a four week transition and a meeting at the end.  5.71.17 Comment: the manager’s caution was wholly justified but her suggestion did not prevail.  5.71.18 At the Mental Health Tribunal convened on 27.03.14, Child E’s formal discharge was deferred until 07.04.14 on which date s.3 Mental Health Act detention would cease and a discharge planning meeting was to be held. 5.71.19 Comment: though Duke House records refer to a ‘planning meeting’ on 31.03.14, it did not include or involve critical psychiatric / psychological expertise. 5.71.20 In the course of collation of material for this Serious Case Review it was discovered that the minutes of the Tribunal of 27.03.14 had not been inputted to the client information database of Sutton Children’s Social Care and nor had reports provided to it from hospital and community staff. Child E had contact with S5 on 01.04.14 and was noted to be distressed by their state of health. Duke House was liaising at this time with CCATS.  5.71.21 A record dated 01.04.14 of an exchange between an interim manager of Sutton CAMHS with SW13 suggests that there still remained confusion about the respective roles and responsibilities of CAMHS professionals. A difference of opinion between an unnamed consultant psychiatrist in Calderdale CAMHS and its manager was referred to, with the former agreeing to provide support and the latter indicating that this was not possible. 5.71.22 It is currently unclear whether she was aware of the apparent or alleged agreement reached with her own consultant psychiatrist in March when the interim Sutton CAMHS manager indicated her agency could not offer a service across such a significant distance. 5.71.23 On 03.04.14 the key worker at Duke House confirmed to SW13 that Calderdale CAMHS had agreed to provide a service including ‘responsible clinician’ role, medication if needed and emergency treatment. Confirmation of funding via Sutton CAMHS was, though, still being awaited. 5.71.24 Comment: it is unclear how this proposed arrangement for service delivery as described could be reconciled with the reported agreement of 07.03.14 by psychiatrist 3 to assume responsible clinician status. The Individual Management Review from South West London and St George’s Mental Health Trust indicates a different understanding and indicates ‘it was finally agreed that CAMHS in Calderdale would provide local support and services and this would be funded by Sutton CCG. Psychiatrist 3 would maintain a ‘consultative role’ for the multi-agency network and for Child E’.  Page 81 of 146  5.71.25 In the same conversation between Duke House manager and SW13 a reference was made to a difficult phone conversation that Child E had managed with the birth mother. Later records suggests that the birth mother may, during their conversation, have encouraged Child E’s use of Heroin. 5.71.26 Child E was seen again at Kings College Hospital and treatment options for their Hepatitis C condition discussed. 5.71.27 On 05.04.14 SW13 and psychiatrist 3 had a phone exchange in which they agreed upon the damaging impact on Child E of the birth mother’s calls. SW13 (justifiably) expressed doubts about the possibility of entirely preventing them. 5.72 S.117 MENTAL HEALTH ACT 1983 AFTERCARE / DISCHARGE PLANNING 5.72.1 Child E’s detention under s.3 Mental Health Act 1983 ended at midnight on 07.04.14. A meeting to plan aftercare had been convened that day, all involved parties having been emailed ahead of it to specify required actions. 5.72.2 Present at this last and vitally important meeting were SW14 from St. Andrews, the head of Calderdale CAMHS, a forensic psychologist, a CCATS representative (the independent source of psychological assessment and treatment for children, young people and adults) and a Duke House staff member. Apologies for absence were noted for St. Andrews’ responsible clinician psychiatrist 9, Sutton CAMHS’ (assumed) ‘responsible clinician’ psychiatrist 3 and Child E’s allocated SW13. 5.72.3 St. Andrews’ Individual Management Review acknowledges that the outcome of the above meeting was that ‘Calderdale CAMHS has no responsibility for Child E’s case and therefore, s.117 ‘after care’; Sutton CAMHS was currently responsible for providing a responsible clinician and a care co-ordinator’. 5.72.4 Comment: Three professionals of critical importance in agreeing a robust s.117 plan were (for reasons that have not been explained or justified) absent. The unsurprising result was further confusion e.g. the indefensible assumption that, by default, Sutton CAMHS was accountable for the case. A subsequent email sent by the manager of Duke House on 14.04.14 indicated that the responsible clinician and care co-ordinator roles had remained unallocated and that Calderdale CAMHS required more clarity about its proposed role versus that of CCATS.    Page 82 of 146  5.73 LAC REVIEW 13 5.73.1 On 08.04.14 what was to be the final statutory review was convened at Duke House. It was again chaired by IRO3. SW13’s report reflected the increased stability of Child E’s mental health but recognised that they had been protected for some time from the temptations of alcohol and other drugs. 5.73.2 Child E become quite agitated during the review and a break was required. In conversation with SW13, Child E was already expressing frustration about the restrictions being imposed on their movements. SW13 and the key worker signed and countersigned respectively the ‘Placement Plan’. 5.73.3 On 10.04.14 SW13 visited Ms AM and her brother who was temporarily living at the address following his release from prison. The purpose of the contact was to determine the possibility of a home visit by Child E. Ms AM’s brother agreed that he could find an alternative place to stay in the event of a visit but would like to see Child E with whom [he said] he had ‘got on well’.  5.74 MENTAL HEALTH AFTERCARE 5.74.1 Also on 10.04.14 the manager of Duke House suggested 14.04.14 as a possible date for convening Child E’s ‘mental health state review’. Next day the interim manager of Sutton CAMHS spoke with SW13 to indicate that psychiatrist 3 had referred Child E to the CAMHS in Halifax, where a consultant psychiatrist had (she reported) agreed to provide support, though the Halifax manager was maintaining that this was not possible. 5.74.2 It appears that CCATS sought clarification on 14.04.14 about the programme of support that was being put in place for Child E. Meanwhile, Child E’s physical health was being addressed when they were seen again at specialist hospital 14 and offered advice about treatment options. 5.74.3 On 21.04.14 Child E sold their iPhone (which LAC nurse 1 has indicated was precious to them) for a ‘significant sum of money’. No report had confirmed what Child E did with the proceeds other than that they managed (in spite of being under 18 years of age) to commission a second tattoo. 5.74.4 Comment: it seems likely that such an urgent need for money was to purchase drugs. 5.74.5 Days later on 23.04.13 (in advance of the formal decision made on 25.04.14 in Sutton) SW13 received an assurance by phone from the Duke House manager that Calderdale CAMHS had agreed to provide a ‘responsible clinician, medication if needed and any emergency treatment.’ He reported that ‘Sutton CAMHS was just waiting on funding’ (from which source was unspecified).   Page 83 of 146  5.75 FUNDING DECISION AT ‘JOINT PLANNING PANEL’ 5.75.1 On 25.04.14 at a highly significant ‘joint planning panel’ Sutton’s CCG commissioning manager reportedly formally agreed to fund intervention by Calderdale CAMHS. On the same day as that decision was made, psychiatrist 3 spoke with SW13 about the damaging impact of birth mother’s contact with Child E. Psychiatrist 3 referred also to a planned phone conference on 01.05.14 to complete Child E’s mental health assessment.  5.76 RESUMED MISUSE OF DRUGS 5.76.1 Just over two days later (00-15 on 28.04.14), Duke House reported to local Police (and Sutton’s Emergency Duty Team) Child E’s failure to return home after agreed free-time. The ‘duty hub inspector’ deemed the incident a ‘temporary absence’ which was to be reviewed, in accordance with local Force policy, at noon. In the event, Child E returned at 02-55. In a later conversation between the manager and SW13, the former is noted as saying he was uncertain whether Child E had consumed any drugs. Child E had been irritable, their pupils appeared small but they had denied any misuse and had settled in their room.  5.76.2 Duke House consequently proposed, in view of worsening behaviours, a review of the Placement Plan, risk assessment and free-time arrangements. 5.76.3 Comment: because Child E was subject to neither a Secure Accommodation, nor a Treatment Order under the Mental Health Act 1983, ‘free time’ was necessarily a matter of negotiation. Given Child E’s risky track record and in the light of previous senior management preparedness to ensure their survival by means of deprivation of liberty, more decisive action could and should have been agreed by means of discussion and action by Sutton Children’s Social Care and the placement. 5.77 ASSESSMENT OF LOCAL DRUGS AGENCY 5.77.1 Later on 28.04.14 Child E initiated contact with a local specialist agency (Lifeline), and was offered an initial appointment next day. Though guarded in what they said, Child E did confirm the current placement. Next day Child E returned to Duke House with a member of staff from the agency and disclosed use of Methadone and Heroin. Residential staff responded by completing a ‘without consent’ room search. No illicit substances were found. 5.77.2 On 29.04.14 SW13 was informed in a phone call from the manager of Duke House that Child E had told the drugs worker from Lifeline that they had smoked Heroin during this period of un-authorised absence. Also that day (a Tuesday) a specialist nurse from specialist hospital 14 was phoned by Sutton’s LAC nurse 1 and told that Child E had admitted use of Heroin ‘the Sunday before’ (the nurse has confirmed this meant 27.04.14). It was agreed that a planned biopsy could anyway proceed.  Page 84 of 146  5.77.3 At the initial appointment at the local substance misuse agency Child E disclosed information that indicated significant levels of risk:  The frequency, pattern and dosage of substance misuse  High risk behaviour consequent upon substance misuse  Medium risk of vulnerability and exposing themselves to harm via grooming / coercion for sexual abuse  A perception of social isolation and no local friends 5.77.4 The key vulnerabilities were identified as being sexual health / vulnerability, poor mental health, risk of overdose, self-harm / suicide, risk of blood-borne infections and safeguarding concerns within Child E’s placement. Child E sought time to consider whether they needed substitute medication / treatment. The health overview report revealed that tests organised by Lifeline had confirmed recent use of Heroin and Methadone, thought likely to have occurred during an unauthorised absence. 5.77.5 Psychiatrist 3 made contact by phone on 30.04.14 and was told that Child E had used Heroin that weekend. She expressed concern about the young person’s access to a mobile phone and the open door policy of the Home. The unit later obtained agreement from Ms AM and Child E’s SIM card was confiscated. 5.77.6 Comment: preventing a teenager from accessing a mobile would be extremely difficult. 5.77.7 At the request of Child E, on 30.04.14 an aunt whom they claimed lived locally was contacted by the worker from the substance misuse agency. The available services and confidentiality policy were explained. The identity of the ‘aunt’ is unknown to Ms AM and not apparent from records. 5.77.8 A biopsy was undertaken by hospital 14 on the same day and records confirm that the medical specialist and psychologist made it clear that the proposed treatment plan required cessation of the use of all illicit drugs. The health overview report provided confirmation (which had not been seen in other sources) of Sutton CCG’s agreement to fund intervention from Calderdale CAMHS whilst Child E remained at Duke House. 5.77.9 On 01.05.14 Child E attended an appointment with the local substance misuse agency. Options including use of prescribed medication were discussed. Child E expressed uncertainty about whom they could trust and wanted time to think about their options. The risks identified were continuing use of (injected) Heroin. On the same day it appears that SW13 and Child E’s key worker met and explored the possibility of a new placement. A ‘risk assessment’ originally formulated in March was updated and Child E’s free-time reduced to 30 minutes per day for the next week.   Page 85 of 146  5.77.10 Comment: it remained unknown from whom and how Child E had sourced drugs so a reduction of free time could not sufficiently constrain further access to illegal substances. 5.78 ONGOING CONFUSION ABOUT CLINICAL ACCOUNTABILITY / FINAL CONTACTS AND CONCERNS  5.78.1 On the same day psychiatrist 3 emailed an unknown and unspecified number of involved professionals. She referred to the badly managed transition from in-patient s.3 treatment to a therapeutic community and the still present confusion about who was holding the clinical risk for Child E. She emphasised the need for local psychiatric input and that her role could only be ‘nominal’. 5.78.2 Comment: the net result of the intrinsically confusing records summarised above suggest that Calderdale CAMHS had accepted that it would provide the required service subject only to funding from Sutton’s CCG. 5.78.3 Next day (02.05.14) SW13 made what was to be her final visit to Child E. Her records capture Child E’s wish to be treated more like an adult, frustration and anger and a tendency for these feelings to be taken out on those around the young person. SW13 indicated her appreciation of Child E’s feelings but that the risks associated with their behaviours meant some restrictions remained necessary. 5.78.4 On the same day as SW13’s visit, Child E’s key-worker was phoned by the local substance misuse service who talked through the options that had been discussed with Child E (about which they was still thinking). The agency offered reassurances that any safeguarding concerns would be raised immediately with the placement and other relevant agencies. 5.78.5 A visit to sibling S4 was being planned. Duke House captured in their records for 02.05.14 a contact by a person described [confusingly] as the ‘responsible clinician’ at the local CAMHS and an appointment with him/her for 09.05.14. Arrangements for the therapy to be provided by CCATS appear to have been agreed at a meeting of some involved professionals. 5.78.6 On 06.05.14 psychiatrist 3 followed up her earlier expressions of concern by emailing psychiatrist 9 (the responsible clinician at St. Andrews) to highlight a ‘lack of commitment by the in-patient team to the care of Child E’. Psychiatrist 3 indicated that Child E was a ‘high risk case who had already deteriorated significantly in the four weeks since discharge and whose placement might break down due to drug consumption’. Liaison with Calderdale CAMHS had been extremely difficult and Child E allocated a care co-ordinator only recently. 5.78.7 Psychiatrist 3 repeated her earlier assertion that Child E should have been placed on a Community Treatment Order as a transitional arrangement after several months subject to a s.2 Treatment Order. Finally psychiatrist 3 pointed out than she had been sent no reports about Child E during their stay at St  Page 86 of 146  Andrews nor at the point of their discharge. Psychiatrist 3 was sufficiently concerned to notify the Care Quality Commission (CQC) of these issues though it remains unknown precisely what information was shared with that body. 5.78.8 In May 2014 Child E was found unresponsive in their bedroom and pronounced dead by a doctor who was summoned. An initial post-mortem examination on 08.05.14 suggests that Child E died from opiate toxicity. An Inquest was opened and adjourned on 26.06.14.  Page 87 of 146  6 ANALYSIS 6.1 INTRODUCTION 6.1.1 During the extensive period considered by this Serious Case Review, there have been significant changes with respect to law and regulations, professional roles and responsibilities and in consequence, to statutory and non-statutory guidance issued by government to local authorities and National Health Service settings. 6.1.2 A strategic example of organisational change is the transfer of responsibility in April 2013 of the functions of the former ‘Primary Care Trusts’ to ‘Clinical Commissioning Groups’ and a contemporaneous shift of responsibility for commissioning ‘tier four’ provision such as St. Andrews to NHS England. As explained elsewhere, such restructuring, seems to have underpinned the confusion surrounding the mental health services latterly offered to Child E. 6.1.3 A local example of evolving structures and commissioning arrangements is that, in the period from Child E becoming Looked After by Sutton Children’s Social Care to their death, the organisational context of the specialist ‘Looked After Children’ nurse changed significantly. Until 01.01.13 she was employed directly by Children’s Social Care. She then became managed by Sutton and Merton Community Services (SMCS), with which organisation a service specification / service level agreement had been made by Sutton’s Clinical Commissioning Group (CCG).  6.1.4 This above example of organisational change did not have a direct adverse impact on Child E in that the service was still provided by the same professional. However, the health overview highlights the fact that whilst an employee of Social Care, the post holder had no capacity (nor was there any contractual requirement / service level agreement) for strategic input i.e. the person was wholly pre-occupied with operational work. 6.1.5 Evaluative comments about decisions taken or judgments arrived at take account of the above factors and when thought necessary, a brief explanation of law or regulation is provided in footnotes.   6.2 CHILD E’S PERSPECTIVE 6.2.1 Because Child E cannot any longer speak for themselves, it is right to consider in advance of an analysis of professional services, the world as Child E experienced it, first as a small child and later as an adolescent. 6.2.2 Child E was a helpless victim in a lengthy series of circumstances and settings. The earlier ones were entirely beyond their control and for those arising in their later years to which Child E contributed, the demands of those circumstances and settings exceeded the young person’s limited capacity to develop sufficient coping mechanisms.  Page 88 of 146  6.2.3 These issues are explored in detail in later sections but from Child E’s perspective, their adverse experiences may be encapsulated as being:  In utero, exposure to the immediate adverse developmental results (raised levels of damaging chemicals) in response to chronic maternal stress and the further adverse impact on their development and functioning of mother’s misuse of alcohol and drugs  Once born, the absence of routines for feeding, sleeping and availability to Child E of a parent-caregiver  The impact of the erratic and unpredictable conduct of the substance-dependent parents with Domestic Violence a frequent and frightening occurrence    Disruption of relationships with vital attachment figures such as parents and siblings as a result of periods in the care system  Witnessing at close proximity mother’s ‘sex working’ (and possibly being a victim of sexual abuse)  When moved to alternative care, ongoing uncertainty about its duration or the extent of contact with early attachment figures  The specific anxieties triggered by witnessing Ms AM’s epileptic seizures (possibly reminiscent of ill-understood memories of inebriated and threatening parents and a fear that they might die)  The longer term heightened risk (as suggested by current research) of Child E’s own substance dependence because of their pre-birth and early life exposure to alcohol and Class A drugs  As mobility increased with age, increasing exposure to substance-misusing / criminal individuals / sexual exploitation whilst missing  Extreme fragmentation of ordinary and significant relationships (family, friends, school) with the consequence loss of continuity (on average Child E was moved from one location to another at intervals of less than six months during their 16 years of life)  Unintended medical consequences and associated risks associated with substance misuse (abdominal pain, Hepatitis C, sexually transmitted diseases)  Latterly, the unhelpful influences of extremely disturbed individuals in both secure accommodation and in the psychiatric unit which became Child E’s penultimate placement  The impact of learning of the prosecution of S4 (with whom Child E had hoped to live one day)  Page 89 of 146  6.2.4 Aside from numerous re-locations, Child E’s personal crises (self-harm / overdoses and serious alcohol misuse respectively) have been tabulated to highlight the extreme distress (contrary to their presentation) Child E actually felt. The young person’s impressive ability (aged 12) to offer a PowerPoint presentation about their mother before she became drug-dependent belied the formal testing as of low average intelligence with some specific learning difficulties and little effective secondary schooling. That episode and various accounts by those who knew and worked with Child E refer to a charm and a real (at times precocious) ability to engage with adults. This may be characterised as ‘pseudo-maturity’. 6.2.5 As recognised by the majority of professionals who worked with Child E since their first entry into Care, they had a serious attachment disorder and were never able to find a way of reconciling their anxiety about and loyalty to their birth family (especially mother) with receipt of love from their adoptive mother and later care and treatment from professional carers. Child E’s responses to the chronic stress experienced were predominantly self-destructive, though they also showed themselves capable of aggression toward the more vulnerable. Table 4: Confirmed and self-reported self-harm episodes Confirmed  Self-reported 27.04.09 Observed by teacher: reportedly self-inflicted scratches on both arms (may be same as those seen at Marlborough four days earlier)  14.09.09 Claimed to have drunk anti-bacterial fluid 01.03.10 Overdose of 16 500mg Co-codamol 13.10.09 According to NCATS, hospitalised after ingesting Paracetamol 24.04.10 Overdose of Paracetamol (18 reported, medical assessment indicates fewer) 19.04.10 Overdose of codeine, Ibuprofen, ‘Speed’, marijuana and alcohol 05.05.10 Observed self-inflicted razor cuts 21.04.10 Taken by Police to Croydon A&E [may be same incident as on 19.04.10] 16.09.10 Ligature around neck 28.06.10 Staff report of ingested broken glass (as reported by Child E) 30.09.10 Confirmed ingestion of one AA battery plus ‘suicide’ notes left 26.07.10 Claimed to have ingested broken glass 13.05.11 Confirmed multiple lacerations of arm 23.09.10 Claimed ingestion of two AA batteries 12.04.12 Observed collapse (Heroin overdose assumed)  23.10.10 Staff thought Child E had swallowed four small pieces of glass 23.06.12 Confirmed overdose of pain killers and anti-depressants 12.10.10 Claimed ingestion of 14 Paracetamol 04.03.13 Report by staff of Child E’s attempt to hang themselves 17.06.10 Claimed Paracetamol overdose   Page 90 of 146  Confirmed  Self-reported 06.03.13 Confirmed attempt to tie ligature 01.08.12 Police transported Child E to A&E (Heroin overdose assumed) 04.04.13 Confirmed ingestion of four batteries 25.03.13 Reported overdose of prescribed medication 01.05.13 Confirmed ingestion of one battery  22.05.13 Confirmed ingestion of one battery  01.06.13 Confirmed ingestion of four AAA batteries  25.06.13 Observed attempt to use a ligature  29.06.13 Observed attempt to use ligature and overdose  12.07.13 Unknown number of batteries ingested  17.07.13 Observed attempt to tie a ligature  02.10.13 Confirmed ingestion of two batteries   Table 5: Serious alcohol misuse episodes 1 12.12.09 Drunk and violent at a family party, later hospitalised via A&E 2 07.02.10 Alcohol overdose; admitted via A&E  3 21.02.10 A&E presentation intoxicated 4                          28.03.10      Returned home by Police intoxicated 5 16.12.11 Arrested and held in custody for being drunk and disorderly 6.3 WERE PRACTITIONERS SENSITIVE TO THE NEEDS OF THE CHILDREN IN THEIR WORK, KNOWLEDGEABLE ABOUT POTENTIAL INDICATORS OF ABUSE OR NEGLECT, AND ABOUT WHAT TO DO IF THEY HAD CONCERNS ABOUT A CHILD’S WELFARE?  PRIOR TO PLACEMENT FOR ADOPTION 6.3.1 The difficulty of establishing a comprehensive account of the involvement of Norfolk Children’s Social Care risks painting a more negative picture than is justified about Child E’s earliest experiences. 6.3.2 However, based on the evidence that has been made available, the responses prior to and following Child E’s birth seriously underestimated the risks to which the child would self-evidently have been exposed and the consequent damage in the short and long term. 6.3.3 Even at the pre-birth conference, the fact that a verbal assurance from the birth mother that she would relinquish misuse of drugs was accepted at face value is (if accurate) extraordinary. 6.3.4 It remains unclear to what extent medical or drug agency information / expertise and opinion had been made available to the meeting but mother’s  Page 91 of 146  lengthy track record of failure and her ongoing use of alcohol throughout her pregnancy offered powerful evidence that she was incapable of delivering on that promise.  6.3.5 Child E’s medical condition at birth would have caused them considerable distress. The acceptance by Children’s Social Care of the family’s continuing chaotic drink and drug-fuelled lifestyle showed a high level of insensitivity to the impact on Child E (and siblings). Observations of other professionals such as health visitors and teachers referred to dirty, ill-fed and clearly seriously neglected Children. Few if any strengths within the family were identified. 6.3.6 The rationale for making the siblings and the unborn S1 but not Child E subject of Child Protection plans entirely overlooked the cumulative damage of physical and emotional neglect25. Even when several more examples emerged of inadequate parental care, there was no adequate statutory intervention. 6.3.7 The initiation of Care Proceedings in Autumn 2001 was very belated and had left Child E exposed to unnecessary suffering. Unsurprisingly a paediatric assessment completed in the course of the legal proceedings highlighted a significant developmental delay and concerns about the impact of Child E’s pre-natal exposure to opiates. 6.3.8 Expert opinion from the clinical psychologist was already directing attention toward an attachment disorder and the importance of managing contact and minimising damage consequent upon contact by birth relatives. 6.3.9 Even when a Care Order was obtained and a plan for adoption agreed, the difficulty in identifying a suitable potential adopter illustrates the level of challenge that Child E’s behaviours and circumstances represented. PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN 6.3.10 The records (social worker’s and medical adviser’s) associated with the assessment and matching of Ms AM as Child E’s adoptive mother were not made available to this Serious Case Review. It is therefore unclear why it was thought that a single female with a susceptibility to epileptic seizures was a good match for a disturbed, anxious, aggressive and challenging child. Viewed across time, the placement choice, given Child E’s age and predictable needs for emotional and physical containment, carried a significant risk of failure. 6.3.11 The significant delay between approval as an adopter by the Catholic Children’s Society and subsequent matching and placement of Child E was unclear from records but has been explained by Ms AM’s preferences with respect to those she might be able to adopt.                                                  25 See for example ‘Missed Opportunities: Indicators of Neglect’ Research Report, Childhood Wellbeing Research Centre Brandon et al, November 2014  Page 92 of 146  6.3.12 At the adoption proceedings, the children’s guardian seems to have concurred with the plan (though no formal contact plan was submitted to the Serious Case Review) for indirect / letterbox contact only by parents. 6.3.13 The fatal flaw in what initially seems to be a sensible balance between the need for development of a secure attachment to Ms AM and links to significant family members such siblings and grandmother was that the latter (as highlighted by the involved psychologist) was unable to sublimate her needs for contact and act in a way that was driven by her grandchild’s needs rather than her own. 6.3.14 It would seem that Ms AM was open to and supportive of the plans for contact though may well have imagined that such events would be planned and/or supervised rather than reflecting impulsive or conspiratorial acts by birth mother, grandmother and later Child E. 6.3.15 It remains unclear to what extent robust arrangements had been made for the challenges that Child E was likely to present (a comprehensive assessment of post-adoption support needs was commissioned in 2007 from the adoption agency that had approved Ms AM but reasons for the two year delay remain rather unclear). 6.3.16 By 2006 Ms AM and Child E were living in Westminster and its Children’s Social Care showed a sensitivity to Child E’s needs when it offered its own and later recommended Marlborough Service involvement. Significant levels of education and therapeutic services were provided during 2007- 2008 and there appears to have been an appreciation of Child E’s special educational needs and probable requirement for a residential environment. 6.3.17 Intermittent allegations by Child E of abuse or neglect by Ms AM and others appear to have been taken seriously and investigated. They were not upheld and were concluded (justifiably) to reflect Child E’s pre-existing difficulties. 6.3.18 During 2009 a plethora of agencies were trying to support Child E’s placement. It would seem as though attempts to ensure even transitional forms of educational provision were largely unsuccessful. 6.3.19 From this point onwards, the extent to which contact with the birth family (including Child E’s mother with whom there should have been only annual letterbox contact) was ‘managed’, reduced and over time disappeared. 6.3.20 Contact with any member of the birth or extended family became a choice exercised by them or by Child E and was not rooted in Child E’s best interests. 6.3.21 Hammersmith and Fulham showed a commendable level of sensitivity towards Child E’s needs in April 2009 when it provided domiciliary support workers on a shift basis and (in response to the wishes of Child E and Ms AM) respite care.  Page 93 of 146  6.3.22 The report provided in mid-2009 from the Marlborough Service, as well as that of a local educational psychologist, both showed a well-informed and sensitive appreciation of the need to source an alternative to mainstream secondary education. RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 6.3.23 Insensitivity to Child E’s substantial needs was shown when the assessment provided by the National Clinical Assessment and Treatment Service (NCATS) seems not to have been fully addressed in the care planning (and was not inputted to Hammersmith and Fulham’s records for over a year). 6.3.24 Though there were some inaccuracies with respect to law in the NCATS recommendations, they were sensitive to Child E’s needs and offered further support from that Service. It is unfortunate that efforts that might have been directed toward drawing on the expertise available from that source was instead diverted into a minor dispute between Hammersmith and Fulham and Sutton as to which borough was now responsible for Child E. Sutton’s decision not to respond to the offer of help from NCATS represented a significant lost opportunity. 6.3.25 Once Child E had been registered with a local Sutton GP, it became possible for a referral to be made to the local CAMHS. The assessment by psychiatrist 2 that followed in January 2010 now appears optimistic and to have underestimated the seriousness of Child E’s condition. By the time Child E was seen again by Sutton CAMHS, they had overdosed twice (in Croydon) and been assessed by that borough’s CAMHS. 6.3.26 The responses by Sutton’s Emergency Duty Service and hospital 2’s staff to Child E’s ingestion of excessive amounts of alcohol in February 2010 were ill-informed and insensitive. It appears that the social worker (who also mistakenly attributed a ‘private fostering’ status to Child E living with the adoptive uncle and aunt)26 overlooked the fact that the Child E’s birth mother no longer held parental responsibility, whilst Ms AM did. The hospital in turn failed to notify Children’s Social Care of a significant event with Child Protection implications. 6.3.27 Psychiatrist 3’s assessment in March 2010 was that Ms AM was being unduly and unhelpfully critical of Child E’s birth mother. She concluded that Child E was not exhibiting symptoms of mental illness, but was unhappy and feeling more stress which was related to conflicted feelings about attachment and loyalty to the birth family. She correctly predicted that Child E was at risk of continuing self-harm by cutting, overdosing or intoxication.  6.3.28 When seen by a doctor at hospital 3 in March 2010, the implications of Child E’s acceptance that they were, at 12 and a half years old, sexually active and injecting drugs were not sufficiently appreciated by medical staff. SW3 was concerned that Child E was by definition the victim of unspecified sexual                                                  26 A child is only ‘privately fostered’ if s/he is living with a non-relative for over 27 days.  Page 94 of 146  offences though it remains unclear what she did about that or what response she may in turn have received. It is reasonably certain that no strategy discussion with Police was completed as it should have been. 6.3.29 Police showed a welcome sensitivity when, in response to Child E running away in April 2010, they were defined as ‘high risk’. The decision later that month to seek approval from the Secretary of State and seek a Secure Accommodation Order showed an appreciation of Child E’s acute needs and the risks to which they were being exposed when able to access drugs and alcohol. Insofar as Ms AM was unable to exercise her parental responsibility to any useful effect, the decision by Sutton Children’s Social Care to seek a Care Order (and hence share parental responsibility) was justified, albeit belated. 6.3.30 When the children’s guardian became involved with the Care Proceedings in late 2011 she demonstrated a very thorough approach to her task and spent time with Child E as well as the birth and adoptive families. The fact that the same individual dealt with Child E for purposes of later secure accommodation applications was helpful. 6.3.31 The ‘children and families panel’ convened in April 2012 responded positively to the concerns of SW8 and agreed to fund a further assessment by psychiatrist 4. Her response recognised and reminded Children’s Social Care that Child E’s needs exceeded what could be expected of any local CAMHS. 6.3.32 In spite of the Prohibited Steps Orders issued against mother and grandmother in May 2011 at the High Court, those individuals continued to encourage and facilitate Child E running back to Norfolk. The ambivalence and distress the young person felt is evidenced by their self-harming immediately after a phone call from the birth mother and the following discussions with a solicitor (never followed through) to use the Protection from Harassment Act 1997 seek an injunction against the birth mother. 6.3.33 Sutton did apparently recognise the need to control the damage to Child E arising from uncontrolled contact and obtained further orders under s.34(4) (planned refusal of contact) and a Non-Molestation Order under the Family Law Act 1996 in July 2011.  6.3.34 In spite of mother’s continuing flouting of all such orders, no penalties were ever applied. In fact, over time, family contact was accepted as a fact and even at times facilitated. 6.3.35 A welcome example of sensitivity to Child E’s very particular needs arose in early 2013 when hospital 9 in the Midlands sought a psychiatric assessment before running the risk of increasing suicidal ideation (a potential side effect of the medical treatment require to tackle the Hepatitis C infection). 6.3.36 SW11’s recognition that an independent visitor might provide a continuity of relationship with a safe and reliable adult illustrated an appreciation of how fragmented Child E’s past and current links with adults had been.  Page 95 of 146  6.3.37 The agreements by Children’s Social Care in March 2013 to meet the significantly increased costs associated with the need for very close supervision, to continue use of the secure placement and to award the case top priority were commendable. The high frequency of visits by SW11 at this time also illustrated the efforts that were being expended to meet this young person’s needs. 6.3.38 Although later embroiled in the widespread confusion over accountability for commissioning the required provision, psychiatrist 3 from Sutton CAMHS was clearly sensitive to and very concerned about Child E. 6.3.39 The poorly managed discharge from Child E’s penultimate placement which is addressed below illustrated a worrying lack of sensitivity to the young person’s need as well as to professional colleagues.  6.4 DID THE ORGANISATION HAVE IN PLACE POLICIES AND PROCEDURES FOR SAFEGUARDING AND PROMOTING THE WELFARE OF CHILDREN AND ACTING ON CONCERNS ABOUT THEIR WELFARE?  PRIOR TO PLACEMENT FOR ADOPTION 6.4.1 Aside from the primary legislation that applied at the time (the Children Act 1989 implemented in October 1991) and the then current editions of the statutory guidance Working Together to Safeguard Children, the Individual Management Review from Norfolk confirmed the availability of local procedures of what was then called the ‘Area Child Protection Committee’ (the discretionary forerunner of the now statutory Local Safeguarding Children Boards). 6.4.2 Whilst the decisions emerging from them have been challenged at earlier parts of this overview, it is clear that Norfolk Children’s Social Care (which was then a service dedicated to children and families within the larger ‘Social Services Department’) convened Child Protection conferences and maintained what would have then been labelled a ‘Child Protection register’. 6.4.3 Though the material latterly submitted from Norfolk confirms the existence of a family-finding function within its organisation, nothing is known about the policy or procedural expectations of the time e.g. at what point in a case of long-term neglect was legal advice to be sought or legal action to be taken or what was the target time to identify a potential adopter for a pre-school age child. The supplementary report recently received does confirm that the adoption specialists recognised and acted to try to control the type and frequency of contact with Child E by members of the birth family. PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN 6.4.4 Norfolk’s adoption procedures would have required a post adoption contact plan. It remains uncertain whether one was sufficiently developed or effectively shared with Ms AM.  Page 96 of 146  6.4.5 It appears that Child E’s case was regularly reviewed after the placement for adoption. Responses to events that arose after Ms AM and Child E moved to London during 2005, indicate that both Westminster and Hammersmith and Fulham possessed relevant policies and procedures (since 2003 all boroughs have been committed to complying with All London Child Protection Procedures number of allegations or reports of crime made by Child E during 2007-09 were responded to in accordance with relevant procedures by Police or the relevant borough’s Children’s Social Care. 6.4.6 In efforts that ultimately proved unsuccessful, Hammersmith and Fulham complied well with their child in need policies and procedures when support workers were deployed to work shifts within the adoptive home. RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 6.4.7 The efficiency with which Child E’s educational assessment and later statementing were completed is questionable. This may be wholly accounted for by Child E’s rapid change of placements and lack of co-operation; it may also reflect the very limited educational material submitted to this Serious Case Review. 6.4.8 The regularity of s.26 Children Act 1989 reviews, each independently chaired provides an assurance that appropriate policies and procedures existed and were followed. 6.4.9 However, a recurring example of a failure to follow the relevant policy and procedures may be seen by a number of examples of decisions made by staff within Hammersmith and Fulham and in Sutton’s Children’s Social Care to remove Child E from a placement without recourse to such a review:  A Hammersmith and Fulham ‘network meeting’ on 19.05.09  At Sutton’s  ‘placement planning meeting’ of 31.10.11  A decision made by an unknown individual in Sutton on 12.12.11 in response to Child E’s claim that they had been offered cannabis at the first unit used  At a ‘professionals’ meeting on 13.03.12 6.4.10 On the basis of the partial information provided to the Serious Case Review panel, the role and authority of Sutton’s ‘children and families panel’ may need to be clarified. That panel considered the case of Child E at least twice. On 28.04.11 it reportedly agreed to the funding of an assessment by psychiatrist 4. At a further presentation of the case on 07.07.11 it concluded that Child E should be referred for joint funding via another (unspecified) process. The links with processes accountable for individual case planning and with funding decisions for specialist health or educational resources are not obvious. 6.4.11 In early January 2012 Child E made a further allegation of being mis-treated when staff at the secure unit restrained them. Though the details of the response have not been provided, it is clear that the relevant Local Authority  Page 97 of 146  (Essex) conducted formal s.47 enquiries and concluded that Child E’s allegations were unfounded. 6.5 WHAT WERE THE KEY RELEVANT POINTS / OPPORTUNITIES FOR ASSESSMENT AND DECISION MAKING IN THIS CASE IN RELATION TO THE CHILD AND FAMILY? DO ASSESSMENTS AND DECISIONS APPEAR TO HAVE BEEN REACHED IN AN INFORMED AND PROFESSIONAL WAY?  PRIOR TO PLACEMENT FOR ADOPTION 6.5.1 The most significant opportunities for protection-oriented assessment and decision-making in the period prior to Child E’s placement for adoption were:  The pre-birth conference in July 1997  An incident in January 1999 when the children were used as human shield to resist entry by police officers  The initial Child Protection conference in February 2000  The occasion requiring exercise of ‘Police Powers of Protection’ in September 2000   Completion of an ‘initial assessment’ by a social worker in Spring 2001  A further incident in August 2001 (an intoxicated birth mother fighting) when Police Powers of Protection were again exercised 6.5.2 Without further information, it is not possible to distinguish the extent to which the opportunity for decisive action that was lost in January 1999 (children being used as a shield) was the responsibility of Police and/or Children’s Social Care. 6.5.3 The failure to sufficiently acknowledge at the Child Protection conferences, after the exercises of Police Powers of Protection or via the initial assessment, the extent of damage already being done to Child E (and siblings) was clearly the responsibility of Children’s Social Care. 6.5.4 Even when Care Proceedings were finally initiated, the decision, in the light of her known history, to place Child E with the maternal grandmother appears unduly optimistic. 6.5.5 In the light of the elapse of some 13 years and incomplete material it is not possible to determine whether these lost opportunities reflected poor individual practice and/or a wider organisational culture that placed the threshold for intervention too high and was unduly biased toward maintaining children in their families at all costs. 6.5.6 The decision that Child E should be adopted was a rational and justified one albeit the level of damage already inflicted by their experiences represented a real challenge for any potential adopter.  Page 98 of 146  6.5.7 In the light of the parents’ and grandmother’s anti-authority and oppositional history and the conditional recommendation about post-adoption contact provided by the independent psychologist, an opportunity for more stringent conditions with respect to frequency or more formal supervision would have been helpful. 6.5.8 No material has been seen that would illuminate the decision made by the Catholic Children’s Society to approve Ms AM as a potential adopter (nor for which categories of children). Nor have the grounds on which Norfolk’s Adoption Panel ‘matched’ Child E and Ms AM been supplied. 6.5.9 Clearly, a court later approved an Adoption Order which confirms that the arrangement was lawful and believed to be in Child E’s best interests throughout their life. However, in the knowledge of what was then known about the challenges Child E and the birth family might be anticipated to represent, the notion that a single female (who had some relevant pre-existing medical difficulties) could reasonably be expected to cope is open to question. PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN 6.5.10 Ms AM having waited some time for a child to be placed, the introduction of Child E appears to have been very rapid. Records are insufficiently clear to indicate whether this was a considered and deliberate approach. A more gradual introduction might have highlighted some of the challenges to come and enabled a more considered approach. 6.5.11 Ms AM has explained the time that elapsed between Child E’s placement and her application to adopt as reflecting the advice received from the involved social workers to take things slowly. 6.5.12 The possibility of Child E boarding at the relatively close location of Horsham and returning home for the holidays emerged in early 2009. Records do not explain why this realistic option was lost. It may simply have been overtaken by Child E re-entering the care system when formally accommodated under s.20 Children Act 1989 and placed with the adoptive maternal uncle and aunt.  RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 6.5.13 The failure to make decisions about changes of placements only at statutory review has already been outlined. Aside from complying with the relevant regulations and statutory guidance27 the value of a properly constituted review is that:  It is independently chaired (ideally with the advantage of the same independent reviewing officer (IRO) on each occasion thus affording a measure of continuity)                                                  27 ‘Review of Children’s Cases Regulations 1991 as amended’ and, with effect from 01.04.13 the ‘Care Planning, Placement and Case Review (England) Regulations’, plus what was volume three (Family Placements) and is now volume four (Fostering Services) of statutory guidance.  Page 99 of 146   It will generally include the child / young person concerned so that her/his wishes and feelings can be shared   All those who have a legitimate interest can be there or anyway be represented e.g. involved professionals and the persons who hold parental responsibility 6.5.14 An opportunity to extract more understanding and informed support from NCATS was lost in January 2010 when Sutton (possibly SW4) did not respond to the offer of follow-up by that Service. 6.5.15 A one-off opportunity for what could have been a decisive moment arose when in March 2010 Child E (aged twelve and a half) revealed to an examining doctor at hospital 3 that they were sexually active and had shared needles with the birth mother. Child E’s wish not to inform Ms AM was (mistakenly) accepted. The social worker, with whom the examining doctor quite properly shared the information, was alert to the Child Protection and criminal implications of Child E’s story and may well have followed up on her recorded intention to seek management advice. There is though, no evidence of professional follow-up e.g. involvement of the Police.   6.5.16 The only clear consequence was that Child E’s anger at their social worker being told of these revelations sufficiently frightened the then foster carer for her to decline to resume care of Child E. 6.5.17 The decisions to seek permission to apply for a Secure Accommodation Order in April 2010 and again in October 2011 and October 2012 were wholly justified and the agreement on the appointed children’s guardian as well as the court issuing the requested Orders adds weight to the view that deprivation of liberty was justified and necessary. 6.5.18 The question of whether Child E was suffering from any form of mental illness remained an issue in 2010 - 2011. Psychiatrist 4 at Christmas 2010 concluded that Child E’s symptoms were best regarded as being flooded with anxiety, though she recognised that the child would continue to experience mental health difficulties.  6.5.19 The intrinsically helpful suggestion of psychiatrist 4 that a private psychiatrist should be commissioned to offer oversight proved, regrettably, to be beyond the capacity of the involved professional network to organise as Child E continued to be moved around the country. 6.5.20 Sutton’s children and families panel in November 2010 regarded ‘specialist fostering’ as in Child E’s best interest when they left secure accommodation. The need for an interim placement whilst it was sought was recognised. In fact, further crises overtook any search for specialised fostering that might have been initiated (no evidence has been provided to confirm any such search).  Page 100 of 146  6.5.21 By 2011 there was agreement between the Local Authority and the children’s guardian about the planned frequency of contact with Child E’s birth family. No rationale for the proposed annual contact with the birth mother or confirmation about whether it was intended to be direct (supervised or not) or indirect appears in records. It might have been rooted in a reluctant acceptance that she and Child E would, regardless of directions, meet as and when they wished to. 6.5.22 In November 2011 the process by which a decision was made to transfer Child E to a unit in Wales was questionable. An ‘experts / professionals’ meeting ordered by the court early that month had concluded that the then placement in Somerset was unsuitable and recommended use of a larger one with on-site education, a linked therapist and physical activity. 6.5.23 Child E (apparently supported by an unidentified mentor and/or representative from the Voice for the Child in Care) expressed a wish for a foster home. In fact, Child E was moved in December to a unit in Wales, which did not have on-site education and within 24 hours to an alternative unit owned by the same independent provider.  6.5.24 There was a further example of reactive planning (and poor team work) when a professionals’ meeting in March 2012 decided without reference to the then placement in Wales (and possibly to Child E themselves) to provide a 12 week activity break and then move Child E to an alternative placement.  6.5.25 In May 2013 there was confusion across agencies about who should commission the urgently required mental health assessment of Child E (then believed to be ‘sectionable’ by Sutton CAMHS psychiatrist 3 and being temporarily segregated from other patients at hospital 11 in Essex). 6.5.26 The decision-making trail that took Child E from Leverton Hall to St Andrews via St Aubyn’s and Huntercombe low secure psychiatric units is incomplete but there is little doubt that Child E did require the level of security that St Andrews was able to provide. 6.6 DID ACTIONS ACCORD WITH ASSESSMENTS AND DECISIONS MADE? WERE APPROPRIATE SERVICES OFFERED / PROVIDED, OR RELEVANT ENQUIRIES MADE, IN THE LIGHT OF ASSESSMENTS?  PRIOR TO PLACEMENT FOR ADOPTION AND PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN 6.6.1 As indicated elsewhere, it is difficult to understand how those present at the Child Protection conferences in Norfolk, when Child E was a baby and toddler, could conclude that the child was, in some unspecified manner, less affected than the siblings by the chaotic and chronic neglect that had prevailed over years in more than one generation of the birth mother’s family.   Page 101 of 146  6.6.2 The impact of domestic abuse on the children in a family was less well recognised a decade ago than it is now, but with the partial picture that emerges from the county’s Individual Management Review, it appears that there was no holistic and rigorous assessment completed until the belated Care Proceedings in 2001. 6.6.3 The decision to seek a Care Order seems to have been driven more by the practical issue of eviction than any appreciation of the insidious life-long impact of the physical and emotional neglect being experienced by Child E and siblings. RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 6.6.4 The single most significant example of actions not in accordance with previously assessed need was the gradual diminution and finally near total absence of controlled contact with Child E’s birth family.  6.6.5 As indicated elsewhere, this systemic weakness of case management arose from a mixture of professional confusion, insufficient awareness of legal options, Ms AM’s wish to satisfy Child E’s demands as well as some conflicting advice from experts about the value or inevitability of future contact. From a relatively early stage, Child E’s own actions also undermined the formal contact arrangements understood to have been enshrined in their Care Plan. 6.6.6 Though not strictly a ‘professional assessment’, the issuing by the High Court of a Prohibited Steps Order in May 2011 and a Non-Molestation and s.34(4) Order a month later, represented an authoritative view of Child E’s needs at the time. There was, though, in spite of the mother’s further flouting of those Orders, no action taken to bring her before the Court.  6.6.7 Some involved experts disagreed about the form of placement that was in Child E’s best interests; e.g. in November 2011 the psychologist favoured fostering and the psychiatrist, residential care. Records do not explain the extent to which placements were selected to meet needs within Child E’s care plan. It is safe to conclude that there was in practice very limited choice.  6.6.8 In spite of the proposal by psychiatrist 6 that Child E should be transferred as a voluntary patient to a nearby hospital 10, the strategic director in Sutton usefully adopted a cautious approach and required that any treatment be administered in the more secure environment that Leverton represented. 6.6.9 In spite of the confusion described above about how to complete the required assessment by an ‘approved mental health practitioner’ (AMHP) a pragmatic approach was adopted and a mental health nurse was deployed to support Child E’s ongoing placement at Leverton Hall. 6.6.10 Child E’s final placement was selected after an extensive search of potential alternatives. It remains uncertain whether there were any enquires made of its  Page 102 of 146  Ofsted rating or track record with respect to those young people with whom it claimed to work (though it was recommended by at least one previous user). 6.6.11 The (belated) provision of an independently authored Individual Management Review has provided reassurance that the planning for and use of the final placement was (setting aside systemic and individual failures amongst mental health specialists) satisfactory. 6.6.12 There was in the last month of Child E’s life a missed opportunity when no strategy discussion or meeting was initiated in response to their claim to have used Heroin. 6.7 WERE THERE ANY ISSUES, IN COMMUNICATION OR SERVICE DELIVERY, BETWEEN THOSE WITH RESPONSIBILITIES FOR WORK DURING NORMAL OFFICE HOURS AND OTHERS PROVIDING OUT OF HOURS SERVICES? PRIOR TO PLACEMENT FOR ADOPTION AND FROM PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN 6.7.1 The limited level of detail for the period prior to Child E’s placement for adoption prevents an informed response to this element of the general terms of reference.  6.7.2 Police officers were involved in December 2008 when Police completed a home visit following Child E’s complaints and in response to Ms AM’s epileptic seizure. They were later frequently involved in the process of tracing and/or returning Child E to their home address. Records do not indicate any difficulties. RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 6.7.3 Examples of ill-informed responses by Suttons’ Emergency Duty Service and hospital 2 have been cited; i.e. in response to Child E’s allegation about a 56 year old in 2010, the failure by health staff to notify Police or Children’s Social Care and the unjustified exclusion by a duty social worker of Ms AM who held parental responsibility, and possible inclusion of the birth mother from whom parental responsibility had been removed, was poor practice. 6.7.4 In October 2011 there was a further unjustified interference in the exercise of parental responsibility when Ms AM sought contact with Child E and was refused by an unnamed member of Sutton’s Emergency Duty Team.    Page 103 of 146  6.8 WHERE RELEVANT, WERE APPROPRIATE CHILD PROTECTION OR CARE PLANS IN PLACE, AND CHILD PROTECTION AND/OR LOOKED AFTER REVIEWING PROCESSES COMPLIED WITH?  PRIOR TO PLACEMENT FOR ADOPTION 6.8.1 Whilst Norfolk clearly had the relevant infrastructure in place to process the results of several s.47 enquires, the failure to recognise the need for a Child Protection plan for Child E and indeed for permanent substitute care has already been acknowledged elsewhere in this report. PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN 6.8.2 There was insufficient detail in the material supplied to evaluate the quality of Norfolk’s early care planning. Care Proceedings were very prolonged and it appears that substantive permanence planning was deferred until obtention of a full Care Order. Current expectations would for earlier parallel planning. RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH Child Protection Enquiries 6.8.3 Each of several allegations of abuse by Child E or a member of the birth family was responded to appropriately by the relevant Local Authority.  6.8.4 Though not apparently associated with any complaint or allegations, the significant injuries noted by Northampton hospital 12 in August 2013 were not explained in the material submitted. It seems likely that they were a consequence of the ‘riot’ in which Child E had been involved some days earlier. 6.8.5 There was also a further occasion which should have been responded to by initiating s.47 enquiries viz: when Child E revealed to an examining doctor at hospital 3 they had been sharing needles with the birth mother and what was (in terms of law anyway) serious sexual abuse. 6.8.6 A final opportunity for initiating s.47 enquiries was missed when the news that Child E had reported use of Heroin in early April 2014 was received. S.26 Looked After Child Reviews 6.8.7 Only two s.26 Children Act 1989 reviews were slightly delayed in the period that Child E was in Sutton’s care. The remaining 11 in the period from March 2010 to their death in May 2014 were on time or had appropriately been brought forward. 6.8.8 The majority of those reviews were chaired by the same independent IRO3 which provided a useful level of consistency (and some by very senior managers). However, as referred to elsewhere, the fact that some highly  Page 104 of 146  significant decisions had been taken outside of the review process (possibly without consultation or notification of the IRO) suggests a systemic weakness. 6.9 WHEN AND IN WHAT WAY, WERE THE CHILD’S WISHES AND FEELINGS ASCERTAINED AND TAKEN ACCOUNT OF WHEN MAKING DECISIONS ABOUT THE PROVISION OF CHILDREN’S SERVICES; WAS THIS INFORMATION RECORDED?  PRIOR TO PLACEMENT FOR ADOPTION 6.9.1 Though clearly constrained by virtue of age, no material from Norfolk Children’s Social Care suggests that Child E’s ‘lived experience’ (far less their feelings) were captured in the records that informed that agency’s decision-making. 6.9.2 Aside from the question of what sense Child E was able to make of their chaotic and unpredictable life whilst with their immediate and extended birth family, the rapidity of the introduction to Ms AM provides insufficient reassurance that their behavioural or perhaps articulated responses were captured and informed the choice of permanent carer. 6.9.3 The clinical psychologist commissioned at the time of the 2002 Care Proceedings was able to establish, from direct work, some understanding of the significant harm Child E had suffered even by the age of four. Sadly, that damage was later compounded by a collective inability to control the negative impact of the birth family’s ongoing conduct.  PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN 6.9.4 It seems probable that the direct work undertaken by therapist 1 at the Marlborough Service enabled Child E’s ‘voice’ to be more audible to the growing number of involved professionals and adoptive mother. 6.9.5 As well a teaching assistant who provided one to one support in the classroom, a school counsellor in 2008 was sufficiently trusted by Child E to be told the child’s memories of sexual abuse whilst at home. 6.9.6 The involvement of the Joint Adolescent Service (JAS) in 2009 offered Child E several opportunities to directly contribute to their future living arrangements and it was at this time that they specified a preference for living with their adoptive aunt. RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 6.9.7 The NCATS report of Autumn 2009 was apparently informed by a substantial amount of direct exploratory and therapeutic work with Child E. An apparent Children’s Social Care failure to respond to the offer of further support from NCATS unintentionally limited the extent to which the child’s voice influenced at that time, planning for their future.  Page 105 of 146  6.9.8 The decision by the examining doctor in March 2010 to accept Child E’s stated preference not to inform Ms AM of using drugs and being sexually active was a serious individual misjudgement and has been challenged elsewhere. 6.9.9 The decision to transfer Child E to Wales in 2011 was against their wishes, though the decision in December 2012 to transfer Child E from Beechfield back to Leverton Hall accorded with their wishes and, insofar as they were familiar with and felt secure at the latter placement, was a sound practical one. 6.9.10 The continuity of oversight represented by the deployment of the same independent reviewing officer (IRO3) for the majority of the reviews provided a potential opportunity for Child E’s wishes and feelings to be ascertained and incorporated into case planning. Records of these events do not confirm in what proportion of reviews it was possible in advance of the meeting (best practice) or anyway to otherwise establish the views of Child E. 6.9.11 Child E felt sufficiently relaxed and trusting in May 2013 to share with Leverton Hall’s mental health nurse and the psychiatrist 7 from St Aubyn’s Hospital some earlier examples of being traumatised and a victim of crime, as well as admitting the commission of a specified criminal offence. Those admissions were not further explored or shared with Police. 6.9.12 Though later challenged by the Huntercombe hospital in Norwich, it seems likely that the continuity of care provided by the ongoing involvement of the senior mental health nurse from Leverton Hall after Child E’s transfer in June 2013 was helpful from Child E’s perspective and in accordance with their stated wishes. 6.9.13 No evidence was provided to confirm that the examining doctor sought reasons for, or initiated any notifications about, the reasons for Child E’s significantly swollen knee and associated fever in mid-August 2013. 6.10 WAS PRACTICE SENSITIVE TO THE RACIAL, CULTURAL, LINGUISTIC AND RELIGIOUS IDENTITY OF THE CHILD AND FAMILY AND HOW WAS THIS EXPLORED AND RECORDED?  PRIOR TO PLACEMENT FOR ADOPTION 6.10.1 Norfolk Children’s Social Care records did capture the ethnic origin of Child E and of the birth parents. Those facts were subsequently diluted and records from agencies later involved were either ‘colour-blind’ i.e. there was no record of the issue or erroneously recorded Child E as simply ‘White British’. PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN AND RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 6.10.2 Records of most agencies from the date of Child E’s placement with Ms AM onward fail to capture the child’s ethnic origin / any religious affiliation or report on them as issues of relevance.  Page 106 of 146  6.10.3 In fact, Child E’s ethnic origin became a significant source of stress e.g. based upon their understanding of how they had been conceived (a dual heritage father), they expressed an antipathy toward the use of Black carers when in 2010 they needed an emergency placement. Any detail of how this mis-informed prejudice was addressed by those subsequently working with Child E has not been apparent from the material provided to the Serious Case Review. 6.10.4 A later example of Child E’s discomfort about their identity and heritage arose when at Child E’s request in the Summer of 2012 SW8 sought and surprisingly obtained agreement from the long-term partner of the birth mother to complete a DNA test. Child E did not believe that this individual really was their biological father. The result of the DNA test (if it was actually completed) and confirmation of the identity of the male in question remain unknown. 6.11 WERE SENIOR MANAGERS OR OTHER ORGANISATIONS AND PROFESSIONALS INVOLVED AT POINTS IN THE CASE WHERE THEY SHOULD HAVE BEEN?  PRIOR TO PLACEMENT FOR ADOPTION AND FROM PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN 6.11.1 The limited detail provided render it impossible to know at which points senior managers were involved prior to Child E’s last entry to care. The fact that Care Proceedings were instigated in Norfolk (albeit belatedly) is clear evidence that, at least by 2001, senior managers had authorised the required protective action. RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 6.11.2 From the point Child E re-entered the care system through to their death there were numerous examples where Sutton’s senior managers recognised the exceptional nature of the challenges presented by Child E and authorised professional judgements or significant budget expenditure. 6.11.3 In December 2012 a secure accommodation review was chaired by the then head of Sutton’s Children’s Social Care. During Child E’s final placement at Leverton Hall in 2013 it is clear that the strategic director was heavily involved in emailed exchanges with the senior management of that unit about the financing of significant additional costs required to keep Child E safe.  6.11.4 The director was further involved in insisting that Child E be retained at Leverton Hall rather than being transferred for treatment at a less secure local hospital. 6.11.5 Psychiatrist 3 (Sutton CAMHS) became personally re-involved on 08.05.13 when she made the trip to renew her acquaintance with Child E at Leverton Hall.  Page 107 of 146  6.11.6 Sutton’s head of Looked After Children’s services became personally involved in May 2013 when she challenged the low secure St Aubyns about Child E’s access to the batteries they ingested. The director was later directly involved in the debate that ended with Child E’s transfer to St Andrew’s medium secure unit. 6.11.7 The head of Looked After Children’s services was again involved in August 2013 when she sought to negotiate the involvement of psychiatrist 8 for purposes of future case oversight. 6.11.8 The individual management review provided by Children’s Social Care indicates that a clearer appreciation of an existing ‘need to know’ practice guidance note should have prompted SW13 and her manager to re-involve the strategic director in the protracted and difficult multi-agency exchanges prior to and after Child E’s discharge from St. Andrews. 6.11.9 The more obvious need for placements that could manage Child E was a dominant feature, and together with the fact of active involvement of expert psychiatrists and psychologists, offers sufficient explanation of why Sutton’s LAC nurse 1 did not feel a need to bring the case to the attention of the Designated Doctor. 6.12 WAS THE WORK IN THIS CASE CONSISTENT WITH EACH ORGANISATION’S AND THE LSCB’S POLICY AND PROCEDURES FOR SAFEGUARDING AND PROMOTING THE WELFARE OF CHILDREN, AND WITH WIDER PROFESSIONAL STANDARDS? PRIOR TO PLACEMENT FOR ADOPTION AND PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN 6.12.1 On the basis of the limited information made available about the period whilst Child E lived in Norfolk, it appeared that the Child Protection infrastructure (initial and review conferences etc.) existed, though the decisions made at such forums were of questionable professional value. 6.12.2 During the adoptive family’s contacts with non-universal agencies in Westminster and Hammersmith and Fulham, the responses were wholly consistent with the then London-wide policies and procedures. The decision in the latter borough to ascribe ‘Child in Need’ status to Child E appears to have been a justifiable one. RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 6.12.3 From the point of re-entry to the care system, initially s.20 Children Act 1989 and later subject of a s.31 Care Order, Child E was in receipt of a high level of support from the (unfortunately high number of) allocated social workers and the many placements they experienced.   Page 108 of 146  6.12.4 Though the sources of risks were those arising from running away (misuse of drugs and alcohol as well as sexual exploitation and acquisitive / aggressive crime to generate the required funds) it was the risk of self-harm that came to be perhaps more clearly recognised and highlighted. 6.12.5 Records are insufficiently detailed to be confident that best practice such as return / safe-home interviews were always conducted; but there is no suggestion that any involved staff were insufficiently aware of the high level of risks to which Child E was frequently exposed. 6.12.6 The early use of secure accommodation applications was entirely justified and (insofar as it required the special permission of the Secretary of State) an indication of sensitivity to Child E’s substantial and complex needs. 6.12.7 Child E’s revelations in mid-May 2013 to both psychiatrist 7 and Leverton Hall’s senior mental health nurse should have been discussed with Police. 6.12.8 The means by which choice (insofar as there was choice) of placement was made is not clear from case records and might reflect under-informed practice. Of particular relevance is the need to better understand how Child E’s final placement was selected. St. Andrews report that the unit had been selected by SW13 but this is very unlikely. A lack of detail and transparency is evident in the majority of the non-secure placements made. 6.13 WERE THERE ORGANISATIONAL DIFFICULTIES BEING EXPERIENCED WITHIN OR BETWEEN AGENCIES? WAS THERE AN ADEQUATE NUMBER OF STAFF IN POST? DID ANY RESOURCING ISSUES SUCH AS VACANT POSTS OR STAFF ON SICK LEAVE HAVE AN IMPACT ON THE CASE? WAS THERE EVIDENCE OF GOOD PRACTICE? PRIOR TO PLACEMENT FOR ADOPTION AND PLACEMENT FOR ADOPTION UNTIL ITS BREAKDOWN 6.13.1 There was insufficient information provided to comment on this issue with respect to Child E’s experiences prior to the breakdown of adoption and consequent re-entry to care in 2009. 6.13.2 In the case of the initial reluctance in Sutton to accept responsibility for Child E, this appeared to be more about individual intuition than either policy or a reflection of resourcing difficulties. There is anyway little evidence that it delayed provision of the required services. RE-ENTERING CARE SYSTEM TO CHILD E’S DEATH 6.13.3 A sharp rise in Public Law applications during 2010 (generally attributed to adverse Media and government reactions following the much-publicised ‘Baby Peter’ Serious Case Review in Haringey) has been offered as an explanation of a delay of some five months before a children’s guardian could be allocated.  Page 109 of 146  6.13.4 Usefully though, that same individual (with whom Child E seemed to relate to well) was allocated for purposes of the several further court applications, thus providing a helpful degree of consistency from an experienced professional outsider committed to acting in Child E’s best interests. 6.13.5 The refusal of an unidentified Sutton Children’s Social Care ‘service manager’ in mid-September 2010 to agree funding for an assessment from a named NSPCC specialist cannot be sufficiently evaluated without information about the proposed purpose and what added value it was thought that bringing in another professional might have had.  6.13.6 The capacity to ensure that the same independent reviewing officer (IRO3) dealt with Child E for the last several reviews provided a helpful level of continuity. 6.13.7 The clear professional tension between Sutton CAMHS and St. Andrews, which was rooted in the widespread confusion about commissioning accountability, has been explored elsewhere. CASE-SPECIFIC ADDITIONAL ISSUES 6.13.8 In addition to the standardised questions above, several more case-specific ones have been considered. In those instances where a case-specific issue has been adequately addressed within the response to the more general questions, a reference is made to the relevant location.  6.14 WAS THE PLANNING AND INTERVENTION UNDERTAKEN IN THE EARLY PART OF CHILD E’S LIFE RELEVANT, TIMELY AND EFFECTIVE? COULD / SHOULD THINGS HAVE BEEN DONE DIFFERENTLY 6.14.1 Insofar as it can be discerned from material supplied from Norfolk, the well-known history of Child E’s family and the near certainty that prolonged exposure to it would be damaging for them or any other sibling was insufficiently appreciated. 6.14.2 Norfolk’s interventions in the first several years of Child E’s life seems to have been under-informed and slow. The evidence for Care Proceedings was available at or before birth and the years that elapsed before such a response was made were profoundly damaging to Child E. 6.14.3 A decade has elapsed since Norfolk’s Children’s Social Care was working with Child E’s family and, following critical Ofsted inspections it is understood that there have been radical changes in the services provided. 6.14.4 For the above reason and cognisant of the fact that only a single agency perspective was contained within the (anyway limited) reports supplied by Norfolk, no technical recommendations have been provided in section 7. Instead, a proportionate response would be to supply a copy of this report to  Page 110 of 146  Norfolk’s Safeguarding Children Board and suggest that it (or its executive summary) is included in ongoing training on neglect.  6.15 WAS CHILD E GIVEN ADEQUATE SUPPORT WITH THE COMPLEX RELATIONSHIP THEY HAD WITH THE BIRTH FAMILY PARTICULARLY MOTHER? TO WHAT EXTENT DID THIS RELATIONSHIP IMPACT ON CHILD E’S DEATH AND COULD IT HAVE BEEN MANAGED MORE EFFECTIVELY? 6.15.1 From information supplied it is clear Child E was adopted under the provisions of the Adoption Act 1976. It seems that the plan had been for:  Only indirect / letterbox contact with birth parents and S2  Twice yearly direct and twice yearly indirect contact with birth grandmother  Direct contact with siblings S4 and S5 twice a year 6.15.2 Without regard to the specificity of original directions / agreed arrangements (e.g.it seemed uncertain whether the permitted direct contact was to be supervised or not) records indicate that, over time, they became unclear, inconsistently and ineffectively monitored and (by Child E’s family and Child E) breached. 6.15.3 Records provide offer little evidence of attempts in 2007 by then involved professionals to challenge what became fortnightly phone calls to Child E by half-sibling S2, who had returned to live with their birth mother. It seems highly likely that Child E’s birth mother would also have taken the opportunity to speak with her child at this time. 6.15.4 By early 2009 the pull being exerted by the birth family was encouraging Child E to run back to Norfolk. No information has been provided to indicate that any action was taken against family members either by Norfolk (the originating Local Authority) nor Hammersmith and Fulham (the borough in which the child was then living).  6.15.5 From the former’s perspective, if its Adoption Team had been committed to three years post-adoption support, the period had expired. From the latter’s borough’s perspective, the focus was on local and direct support of Child E in the adoptive home, as opposed to addressing how the birth family’s interference might be reduced. 6.15.6 The frequency of contact with siblings became an estimated three times per annum during 2009 and there were further examples of birth mother’s flagrant disregard of the direction / agreement for indirect contact only. 6.15.7 Hammersmith and Fulham’s commitment of resident support workers operating on a shift basis in an attempt to support Ms AM was commendable but could at best only be a partial temporary measure. No legal action was  Page 111 of 146  initiated against the birth family who continued to undermine Child E’s various temporary placements that year. 6.15.8 In late 2009 the NCATS report commissioned by Hammersmith and Fulham raised the possibility of a ‘re-negotiated’ arrangement for contact with the birth mother. It is unclear whether the staff there had ever met birth mother or were aware of her full history. With hindsight, this element of their otherwise helpful report appears unduly hopeful. 6.15.9 By mid-2010 there still seems to be a level of ambivalence about contact e.g. the ‘children and families panel’ of April 2010 noted ‘a need to assess the likely impact of contact by birth mother and grandmother’. The evidence to that point made it very clear that the contact (because of drugs and associated people and behaviours) posed immediate physical risks as well as reinforcing the significant emotional damage already inflicted upon Child E. The real challenge (possibly an insurmountable one) was to devise strategies to constrain the family’s conduct and thus minimise risks to Child E. 6.15.10 By late 2010 a view was emerging (initially from psychiatrist 4) that it had become unrealistic to terminate Child E’s contact with the birth family. By 2011 there were court-directed responses to the latest example of Child E running to or being harboured by birth family members.  6.15.11 By Summer 2011 more serious consequences i.e. penal notices had been attached to a Prohibited Steps Order and to the then interim Care Order. A Non Molestation Order was also obtained. In spite of the existence of these various Orders, it seems as though there continued to be a reluctance to use them. 6.15.12 In May 2012 Child E, through a solicitor, suggested to the borough’s Legal Department that Sutton was failing to allow sufficient contact in accordance with ‘an agreed list’. The response is said to have indicated that a revised list was being drawn up. Neither the lists nor the response provided have been made available to this Serious Case Review. 6.15.13 By 2012 - 2013 records suggest reduced professional concern about contact with birth family and more about the general risks associated with Child E running away from placements. Thus, legal measures such as Collection Orders were used to return Child E but no punitive action was initiated against those who had been harbouring them.  6.15.14 Reflecting on why the critical post-adoption arrangements failed to meet Child E’s (high level) of needs suggests that:  The original care plan was optimistic in its presumption that the birth family members had the capacity or willingness to act in Child E’s interests rather than their own  Page 112 of 146   Any original specificity may have become diluted as Child E moved from one location to another and a growing number of professionals became involved  There seemed to be (until early 2011) little awareness of the legal steps that might be taken to constrain the damaging conduct of birth family members  Ms AM’s understandable wish to meet Child E’s expressed wishes and sustain their relationship prompted her to accept, by late 2009, a higher level of contact than had been assessed as helpful  The NCATS report in late 2009 / early 2010 and later the view of psychiatrist 4 served to reduce the level of certainty or confidence about limiting birth family contact  Child E’s own high level of chronic anxiety about the birth mother and family meant that (aside from the intrinsic difficulties within the adoptive home) they were attracted to and actively involved in responding and initiating unauthorised contact   Finally, there was the unpredictable sudden death of S2 and Child E’s understandable (and difficult to resist) wish to attend the funeral 6.15.15 More recently, the impact of Child E’s older sibling’s offences against children added to their levels of distress. 6.16 WAS ADEQUATE AND TIMELY SUPPORT PROVIDED TO CHILD E AND ADOPTIVE MOTHER DURING THE PERIOD OF ADOPTION?  6.16.1 The absence of any details of explicitly labelled ‘post-adoption support’ in the original Individual Management Review from Norfolk implies that none was planned or provided. However, Ms AM was able to confirm considerable contacts with named workers from Norfolk and records from the other Children’s Social Care agencies that subsequently became involved do refer to contact by Norfolk’s Adoption Team.  6.16.2 Contact probably reflected implementation of a formal plan in that a reference had been made whilst Child E lived in Westminster to the rate at which an adoption allowance was being paid to Ms AM. During her period in that borough Ms AM also attended adoption support groups provided by the Catholic Children’s Society (the agency which had approved her as an adopter). 6.16.3 Ms AM’s own recollection is of support being provided by individual staff from Norfolk but was not certain about the period of time to which she was entitled to post-adoption support.  Page 113 of 146  6.17 WAS THE SUPPORT FOR CHILD E’S MENTAL HEALTH PROBLEMS EFFECTIVELY CO-ORDINATED? WAS COMMUNICATION BETWEEN MENTAL HEALTH AGENCIES ADEQUATE AND TIMELY?  6.17.1 The simple response to the above question is that the support for Child E’s mental health problems in the last few months of life was not well co-ordinated and that communication between mental health agencies (as well as others) was inadequate. 6.17.2 Underpinning the responses of all involved agencies was a poor level of understanding of the (intrinsically confusing) expectations of commissioning specialist mental health services for an individual placed outside the area in which s/he is ordinarily resident. 6.17.3 On top of that generalised confusion, there was poor communication and an insufficiently patient-centred approach shown by St. Andrews hospital. 6.17.4 Against the backdrop of ignorance of national policy and disappointingly self-centred debate, the final opportunity to negotiate s.117 after-care arrangements that would optimise the prospects for Child E was lost when three key professionals failed to attend the meeting on 07.04.14; and Child E was discharged on an entirely unjustifiable presumption that Sutton CAMHS psychiatrist 3 would, in spite of distance, minimal involvement and her previously reported opposition, be able to fulfil a responsible clinician role. 6.18 WERE PROCEDURES FOLLOWED FOR CHILD E’S PLACEMENT MOVES IN THE LAST YEAR OF LIFE? WAS ADEQUATE CONSIDERATION GIVEN TO HOW THESE TRANSITIONS SHOULD BE MANAGED AND WERE DECISIONS RECORDED AND ACTED ON? 6.18.1 A systemic weakness that is apparent not just in the last year of life but throughout a large proportion of Child E’s multiple moves is that they were not preceded by an independently chaired s.26 review. 6.18.2 Chapter three of volume two, Care Planning, Placement and Case Review which has the status of statutory guidance, sets out the need to consult and involve the relevant independent reviewing officer in all of the more significant case planning decisions. 6.18.3 At the very minimum regulation 11 Care Planning, Placement and Case Review (England) Regulations 2010 as amended, requires that, before a child is placed outside the area of the responsible authority (i.e. Sutton, since late 2009), the recommendation must be approved by a ‘nominated officer’. Before approving such a move that nominated officer must consult a number of key individuals, including the parent/s, child and relevant IRO.  6.18.4 With effect from January 2014 a further obligation was imposed. By virtue of regulation 17 of the Children’s Homes and Looked After Children (Miscellaneous Amendments) (England) Regulations 2013, the above Care  Page 114 of 146  Planning Regulations were further amended so that a ‘placement at a distance’ (defined as one beyond a responsible Local Authority’s adjacent authority/ies) required the explicit consent of the director of Children’s services and that a copy of the care plan be provide in advance to the Local Authority in which a child is to be placed. 6.18.5 None of the material supplied confirms the identity of the nominated officer in Children’s Social Care nor that the relevant steps required by those regulations to involve her/him (for Child E’s final move, the director of Children’s services) was followed. 6.18.6 An additional issue about which central government was sufficiently concerned to legislate was that of moving a pupil at key stage four, i.e. when aged 14/15 and (usually) pursuing GCSE courses from one educational setting to another. 6.18.7 Prior to moving a pupil at key stage four, a nominated officer must be satisfied about a range of issues listed in regulation 9 Care Planning, Placement and Case Review (England) Regulations 2010 as amended. This also includes consulting the IRO. 6.18.8 Partial exclusion clauses exist with respect to some of the basic duties in the case of a placement made in an emergency when some of the obligations can be fulfilled after the event. No confirmation has been provided that this option was used either. 6.18.9 Regulation 11 of the amended Care Planning Regulations also requires the responsible authority to notify (preferably in advance and, if not, then within five working days) a number of individuals and organisations of any placement made outside of its own area. This may have occurred in the case of the four placements made in the last 12 months of Child E’s life but no evidence to confirm that has been adduced (and a representative from the Calderdale Local Authority was able to confirm that no such notification had been received from Sutton prior to or following Child E’s placement there). 6.18.10 Clearly, the concerns about Child E’s immediate safety and mental health dominated professional thinking in 2013 - 2014 and formal processes such as Mental Health Tribunal Reviews became of central importance in establishing ‘next steps’. This may have inadvertently diminished the potential value of care planning at s.26 reviews. 6.18.11 Whilst resident at St. Aubyns, there were clearly some difficulties in maintaining sufficient communication with Sutton Children’s Social Care. The surgery undergone by Child E following emergency presentation at Colchester hospital 4, without the knowledge of that authority or Ms AM, suggests further confusion in one or both those agencies. 6.18.12 The subsequent transfer to Huntercombe appears to have been uneventful and the move on to St. Andrews in mid-August 2013 was either ‘managed well by Huntercombe and consistent with local procedural requirements’ or was  Page 115 of 146  ‘effected without consultation with the care authority’ – the respective and differing accounts of the hospital and Children’s Social Care. 6.18.13 Without regard to efforts made by involved individuals, Child E’s move from St Andrews to their final placement was poorly managed by the hospital and left them vulnerable. 6.18.14 The Placement Plan of April 2014 was evaluated as ‘rather thin’ by the author of the Children’s Social Care Individual Management Review. It did include a detailed risk assessment but no clear ‘plan B’; e.g. there was no provision for substantially increasing staffing if Child E began to abscond (a tactic that had been adopted in some previous placements).  6.19 WERE CORRECT AND TIMELY DECISIONS TAKEN BY PROFESSIONALS WORKING WITH CHILD E IN THE FINAL PLACEMENT REGARDING SUSPECTED DRUG USE AND POTENTIAL ACCESS TO DRUGS? WERE THESE RECORDED AND SHARED APPROPRIATELY BETWEEN AGENCIES? 6.19.1 The independently authored Individual Management Review evaluating the services provided by Duke House was significantly delayed and arrived only on the day that the first draft of this overview had to be submitted (others arrived even later). 6.19.2 The report (though lacking some detail) was very clearly written and its contents corroborate accounts of events derived from other records and confirm some deductions made by the author of this overview. 6.19.3 Setting aside the issue of how the placement was chosen (about which comments is provided elsewhere), nothing in the report suggests that staff were anything other than attentive and committed. 6.19.4 Response to Child E’s unauthorised absence and reported use of illicit substances were carefully considered, albeit insufficient. The actions taken by staff were also communicated in a timely fashion with relevant others. 6.19.5 The disclosure of Heroin use should have been immediately communicated to SW13 and triggered s.47 enquiries and an agreed adjustment to the Placement Plan. 6.19.6 A regulatory failure by the residential care provider that was not recognised in its  submitted report was that of overlooking regulation 12B of the Children’s Homes Regulations 2001 introduced by regulation seven of the Children’s Homes and Looked After Children (Miscellaneous Amendments) (England) Regulations 2013.  6.19.7 This regulation which came into force in January 2013 requires the ‘registered person’ for a Children’s Home to provide written notification to the area in which the Home is located of every admission and discharge. No such  Page 116 of 146  notification was provided to Calderdale which would in consequence have had no knowledge of this young person’s presence in its area.  Page 117 of 146  7 FINDINGS AND CONCLUSIONS 7.1 FINDINGS 7.1.1 Given Child E’s extreme mobility (at least 35 addresses in 16 years), the fact that it proved very difficult to trace all the numerous and fragmented records about Child E’s health is unsurprising and should not be taken as an indicator of systemic weaknesses. The clear findings emerging from a very large volume of material examined are relatively few in number and are highlighted below. 7.2 INADEQUATE PROTECTION AND PLANNING BY NORFOLK CHILDREN’S SOCIAL CARE 7.2.1 Child E, both before and after birth, was poorly served by Norfolk Children’s Social Care. The ante-natal planning was naïve and unduly optimistic and the assessment of risk and need following the birth was wholly inadequate. 7.2.2 The decision to initiate Care Proceedings was very belated and during the course of them, there was a failure to recognise that a family deemed too threatening for the social worker to visit during the Care Proceedings was likely also to be too dangerous for a small child to live in. 7.2.3 The use of the maternal grandmother under the then Placements with Parents etc. 1991 regulations was appropriate to consider but, in view of her personal history, unduly optimistic to actually try. 7.2.4 The precise basis on which the High Court Judge during Care Proceedings in 2012 issued a ‘Disclosure Order’ to Norfolk is unknown. It seems though that the intention was to enable Child E (when they reached the age of majority) to initiate a legal claim for neglect against Norfolk Council.  7.2.5 The contents of this report offer a substantial amount of evidence that Child E was indeed significantly disadvantaged by an unjustified failure to protect them from damaging early experiences in their immediate and extended family.   7.3 MS AM’S ASSESSMENT, APPROVAL AND MATCHING WITH CHILD E  7.3.1 Limited information has been provided to the Serious Case Review panel about the assessment of Ms AM or on what basis she was thought to be a suitable match with Child E. 7.3.2 Given that Child E was already exhibiting very challenging behaviour and manifesting a form of attachment disorder that was unlikely to resolve rapidly, the decision to match them with a lone female carried a significant risk of failure.  Page 118 of 146  7.3.3 The extent to which the medical adviser was able to predict the likelihood, frequency or possible consequences of her seizures on Child E (who had already experienced drunken / collapsed parents) remains unknown, though Ms AM’s own account of its mild, infrequent and generally nocturnal occurrence offers some reassurance. 7.4 POST ADOPTION SUPPORT 7.4.1 No formal ‘adoption support plan’ has been seen though material latterly provided indicates that Norfolk Children Social Care had considered the anticipated need and agreed with Ms AM that regular reviews would provide an opportunity to recognise and response to whatever form it took. 7.4.2 Whether the likely level of need was sufficiently recognised at the time of adoption remains unclear but Norfolk Children’s Social Care (via its Adoption Team) did in 2007 commission an assessment of Ms AM’s support needs.  7.4.3 Westminster later met the cost of further involvement of its in-house Marlborough Family Service and later still (in 2009) Hammersmith and Fulham commissioned the provision of an assessment by the National Clinical Assessment and Treatment Service (NCATS). 7.5 DISPUTE ABOUT RESPONSIBLE LOCAL AUTHORITY 7.5.1 The dispute between Sutton and Hammersmith and Fulham about which borough was responsible for service provision in 2009 was an unnecessary and unhelpful distraction. It has not proved possible to locate any legal advice that may have been given at the time. To the author, it seems clear that the responsibility did properly fall to Sutton and was (reluctantly in the case of some staff) accepted. 7.5.2 Though the dispute represented a distraction, no evidence has emerged to indicate that it delayed the provision of service to Child E or their family. 7.6 CONTACT WITH BIRTH FAMILY (ORIGINAL INTENTION AND SUBSEQUENT MANAGEMENT) 7.6.1 An independent clinical psychologist had, at the time of the original Care Proceedings, qualified his support of any form of contact by Child E’s birth grandmother. The impact of his carefully calibrated observation i.e. that such contact if it was to be constructive had [emphasis added] to be rooted in what was best for Child E (as opposed to being what the grandmother wanted or thought was her right) was, across time diminished and lost – possibly because:  The certainty of a regular defined period was easier to keep in mind than a judgment-call about motivation  Page 119 of 146   The distinction between permissible contact by siblings versus Child E’s grandmother (and whether either or both had to be ‘supervised contact only’) was intrinsically complex to define and manage  The changes of personnel (especially the large number of social workers in Sutton) and imprecision of records rendered the maintenance of a clear and confident position difficult  Even when as young as nine or 10, Child E succumbed to the emotional pressure from the birth mother, or other birth family members to renew contact and increasingly initiated as well as colluded in re-exposure to their physically and emotionally dangerous environment 7.7 DIAGNOSES / DIFFERING EXPERT VIEWS 7.7.1 Though never definitively diagnosed, Child E clearly had significant attachment difficulties. Although attachment to mother and siblings had by any standards been insecure, it was to them not Ms AM, that Child E generally gravitated.  7.7.2 Ms AM was also able to describe and provide evidence for Child E’s ongoing written communication with her during their last year of life. The letters were articulate and leave the reader in no doubt about the love and respect Child E felt for Ms AM. Sadly, the attitude struck and actions taken by members of the birth family had constrained Child E’s total commitment to the parental relationship Ms AM consistently offered. 7.7.3 As early as 2008 (when Child E was 11) those planning the future were faced with a variety of expert opinions, some congruent with one another, some contrasting:  The Marlborough Service in Westminster concluded in June 2008 that Child E needed to be placed in a residential setting and later that year and again in mid-2009 recommended a ‘therapeutic boarding school’  An educational psychology report of May 2009 also recommended ‘intensive therapeutic support in a small, safe environment…’  Psychiatrist 1 from NCATS suggested later in 2009 that Child E should not return to Ms AM and favoured re-negotiating contact with the birth mother  Psychiatrist 4 also felt it was unrealistic to terminate contact with Child E’s birth family and favoured use of a residential setting  Psychologist 1 instead favoured fostering 7.7.4 Though not shared with the Serious Case Review panel, Child E’s statement of special educational needs completed in August 2009 recommended a  Page 120 of 146  specialist placement for pupils with emotional, social and behavioural difficulties. The possibility of the school in Horsham considered by Ms AM some months earlier was not apparently pursued, perhaps because of more dramatic incidents occurring throughout the remainder of 2009. 7.7.5 The damaging influence of original family members such as the birth mother and grandmother was recognised by Sutton staff. Attempts to control it were inevitably constrained by Child E’s continuing emotional dependence upon those individuals and consequent habituated running back to one or other. Child E remained until their death seriously conflicted between a loyalty toward the birth family and adoptive mother Ms AM. 7.7.6 The effectiveness of attempts to control birth mother and grandmother might perhaps have been greater if implementation of the various court orders had been more energetically pursued and (though a more speculative conclusion) if case planning had more explicitly included Ms AM (who in spite of Child E’s stated rejection of her, maintained contact and remained a figure of real value to them, perhaps the only individual in their world they could trust).  7.8 TURNOVER OF SOCIAL WORKERS / UNCERTAIN RATIONALE FOR PLACEMENT CHOICE  7.8.1 The large number of allocated social workers was self-evidently unhelpful for Child E and Ms AM and rendered the professional task for each successive worker more difficult. The problem of recruitment and retention was, and remains as at early 2015, a national challenge as well as a local problem. Some national government initiatives e.g. Step up to Social Work (for graduates seeking a fast-track toward professional social worker status) are already in place though the benefits of that scheme will not be immediate. 7.8.2 Meanwhile, some local action is required and the recommendations in Section Eight include one relating to recruitment and retention. In spite of the large number of placements, very little evidence of a rationale or confirmation of their records of achievement was found. 7.8.3 In a couple of cases (including the final placement), Child E was sufficiently involved to allow a preliminary visit/s and agreement. In most cases, it appears that the ‘choice’ originated in a more pragmatic approach i.e. what was available and which institutions would accept Child E?  7.8.4 There is no evidence that the regulatory requirements that should have preceded or immediately followed any terminations and choice of new placement since April 2011 were satisfied. A more consensual and careful approach to placement planning might have at least reduced the number of failed placements.   Page 121 of 146  7.9 CONFUSION ABOUT ‘CLINICAL LEAD’ AND ‘RESPONSIBLE COMMISSIONER’ ROLE SUTTON V CALDERDALE 7.9.1 There was widespread confusion in 2013-2014 amongst and within agencies about two important issues:  Who was or should be the ‘lead clinician’ (as defined by the Mental Health Act 2007) and  Which organisation was liable to pay for treatment at St. Andrews or further community services 7.9.2 The author’s understanding is that, until 31.03.13, the responsibility for commissioning secondary or more specialised health services rested with the then Primary Care Trust relevant to the ‘responsible Local Authority’ i.e. Sutton and Merton PCT. The role of PCTs was largely replaced with effect from 01.04.13 by Clinical Commissioning Groups (CCGs) and from that same date, NHS England acquired the statutory responsibility for commissioning specialised ‘tier four services’. 7.9.3 In the light of the intrinsically complex and rapidly introduced changes to commissioning of specialist health services introduced by central government, the confusion that prevailed within and across the involved agencies about the respective responsibilities of local and out-borough CAMHS and/or CCG is unsurprising.  7.9.4 The report submitted by Sutton’s CCG and the health overview offer explanations of the complex national and local structural changes with respect to commissioning of services and linked professional roles, such as Designated Doctors and Nurses, introduced in 2013. It seems likely that their intrinsic complexity represented a further obstacle to a shared appreciation of who should or could do what to ensure that appropriate mental health services were identified and commissioned.  7.9.5 Both authors refer to Principles for Managing Quality in Specialised Commissioning Including the RASCI Template published in August 2014 and intended to clarify the commissioning landscape. It fails to do so and a recommendation for action by NHS England is included in Section Eight. 7.10 POOR CASE MANAGEMENT, ESPECIALLY DISCHARGE FROM ST. ANDREWS HOSPITAL  7.10.1 Without diminishing the hospital’s welcome ability during 2013 - 2014 to keep Child E safe whilst a s.3 Mental Health Act 1983 in-patient, the planning for and actual discharge to the community was poorly managed. There was, in particular, insufficient effective involvement of Sutton CAMHS, where psychiatrist 3 had expressed a willingness to assist and a comparable lack of sufficient and effective engagement with Calderdale CAMHS.  Page 122 of 146  7.10.2 The net result of poor discharge planning, primarily within St Andrews and arising in a context of muddle and dispute about clinical and financial responsibility, pitched Child E into a professional environment which was insufficiently prepared and lacked a multi-agency consensus about ‘next steps.’ In the light of Child E having previously been recognised as very high risk, this could have been tackled by means of an effective meeting at sufficiently senior level of all relevant agencies.  7.11 ACCESSIBILITY OF DRUGS FOR OVERDOSING 7.11.1 Setting aside the poor transition with respect to psychiatric support (described above), the move to Duke House had involved considerable discussion, planning and time-limited stays using leave periods authorised whilst Child E was subject to s.3 detention.  There is little evidence to suggest, in the very brief period that Child E spent in the final placement, that their unsurprising need to return to misuse of drugs and/or alcohol could been prevented by the residential staff who seemed to be sufficient in number and focused on Child E’s needs. 7.11.2 The self-reporting of Heroin use should have prompted immediate notification of SW13. She, in turn, could have initiated s.47 enquiries and followed the internal notification of senior managers ‘need to know’ guidance note. The internal response at Duke House (taken in consultation with Ms AM) to remove access to the SIM card linked to Child E’s iPhone (which they had part-exchanged to raise cash) was pragmatic but could not be sufficient.  7.11.3 The meeting of 01.05.14 at which the Placement Plan was reviewed and risk assessments updated discussed the recent self-reported use of Heroin but identified no other evidence of heightened risk.  7.12 CONCLUSIONS AND LEARNING 7.12.1 Emerging from the above findings are the following overall conclusions / learning points:  Child E was likely to have been born with significant neurological damage, leaving them with physical and psychological vulnerabilities  The impact of those intrinsic vulnerabilities was compounded by neglect, emotional and possibly sexual abuse experienced before Child E’s placement outside of the immediate and extended family  By the time Child E was placed for adoption, and later actually adopted, the impact of any neurological damage was also overlain by a serious attachment disorder with the net result that Child E’s developmental progress and life chances were significantly reduced  Page 123 of 146   A pattern of risky behaviours and still developing mental health difficulties suggested that a shortened life was (whether by accident or design) more likely than not i.e. a premature death was ‘predictable’  Had the efforts of all involved agencies in Child E’s final year of life been more efficiently managed (in particular the discharge from St Andrews) e.g. had all the known risk factors been addressed collectively at a multi-agency meeting there was a real possibility that Child E’s death might have been postponed  Very different decisions by a number of agencies would need to have been made at several critical points in Child E’s life in order to have altered the course of events that led to their death. 7.13 LESSONS EMERGING AND REFLECTIONS ON ‘WHY?’ 7.13.1 Pre-birth and neo-natal risk assessment are of critical importance to a child’s life chances. Parental reassurances e.g. ‘I have / will relinquish misuse of drugs / alcohol’ should carry less weight than carefully recorded observations of actual behaviours in agency records. 7.13.2 Reflection: Involved professionals may be fearful (sometimes justifiably) of parental physical reactions to more decisive action by Children’s Social Care, may be themselves ambivalent about permanency planning by means of substitute care and/or may be aware of the variation across courts in interpretation of thresholds for opposed Care and Adoption hearings. 7.13.3 Impact of a physically and emotionally neglectful early childhood, though the extent to which it will occurs in individual cases remains extremely difficult to evidence, can have profound lifelong impact28,29 arguably of a greater magnitude than more episodic physical or sexual abuse.  7.13.4 Reflection: determining the optimum time to initiate protective action is rendered difficult by the absence or rarity of major crises. It is therefore of critical importance to collate and evaluate information about cumulative and prospective damage. 7.13.5 The purpose and impact of post-adoption / permanent fostering contact must be distinguished one from the other. 7.13.6 Reflection: though for many children well managed contact is in their interests and sometimes an element of a Court Order, its actual impact must be                                                  28 Decision-making within a child’s timeframe Working Paper 16 Childhood Wellbeing Centre R Brown and H Ward October 2012; see also its critique The Child’s timeframe – a neuro-scientific perspective Prof. David Wastell, Prof. Sue White and Ann Lorek,  14 Gray’s Inn Square, 22 May 2013 29 Core-info.cardiff.ac.uk (‘Core Info. Cardiff Child Protection Systematic Review) from which NSPCC and other articles on neglect are derived  Page 124 of 146  monitored and robust action taken if it begins to adversely impact on the child and/or to undermine a stable permanent placement.  7.13.7 Partnership with those holding parental responsibility is an expectation of the Children Act 1989 and its supporting statutory / non-statutory guidance; it offers in most cases the best opportunity to develop and deliver plans which make use of the lifelong commitment shown by most parents. 7.13.8 Reflection: the turnover of individual professionals and increasingly the agencies delivering services makes the ongoing involvement of those who have parental responsibility of even greater importance.  7.14 IMPROVEMENTS ALREADY MADE 7.14.1 Before, or during the course of, this Serious Case Review, a number of improvements have been made to local services, thus removing any need for a recommendation in the following section:  Sutton’s Children’s Social Care by means of the recruitment and retention strategy developed over the last year has significantly reduced its turnover of social workers  Sutton’s Clinical Commissioning Group is planning to review the Designated Nurse function and strengthen the quality assurance role of the health provision and oversight of those Looked After Children who are the responsibility of Sutton’s Children’s Social Care   Page 125 of 146  8 RECOMMENDATIONS 8.1 INTRODUCTION 8.1.1 As a result of the learning from this Serious Case Review, a need for some improvements to local or national services has been identified. The recommendations for each agency below have been accepted by Sutton’s Local Safeguarding Children Board. Their efficient and timely implementation is being ensured by means of an accompanying action plan that specifies how and when and by whom tasks are to be completed.  8.2 RESPONSIBILITY FOR IMPLEMENTING RECOMMENDED CHANGES RECOMMENDATIONS  INTENDED IMPACT   SUTTON SAFEGUARDING CHILDREN BOARD  NATIONAL  1. The Board should inform the DfE and DH of a need to review or clarify national arrangements for emergency Mental Health Act assessments for under 18s who are ‘out of area’ (current A&E assessment arrangements may offer a practical methodology)  Greater clarity and professional confidence 2. NHS England and Public Health should issue clear and simple guidance to Clinical Commissioning Groups and Local Authorities explaining which agencies are accountable for financing and providing quality assurance of ‘tiers 1-4’ of child and adolescent mental health services  Sufficient understanding amongst commissioning managers and operational staff in health and social care settings LOCAL   3. The Board should confirm that the Sutton’s Clinical Commissioning Group (CCG) and the local Child and Adolescent Mental Health Service (CAMHS) have negotiated a lawful and practical policy / protocol for the commissioning of services Children / young people whose ordinary residence is in the borough and who require ‘tier two to tier three’ mental health services   Clarity about available provision, how to access it and which agency is liable for payment 4 The Board should confirm that existing training programmes adequately cover attachment theory and the value of ‘child-centred’ contact with birth family as well as the central importance of historical records / chronologies  An increased probability that case planning is rooted in evidence-based needs assessments of children  Page 126 of 146  RECOMMENDATIONS  INTENDED IMPACT 5 The Board should also seek confirmation from each member agency that there is ongoing agency-specific record keeping training – by 31.05.15  More complete and accurate records that evidence the capture of all relevant information including ethnic origin and religious affiliation 6 The Board should provide Norfolk Safeguarding Children Board with a copy of this report (or its executive summary) so that it has an opportunity to evaluate the quality of current Child Protection and care planning  An opportunity to evaluate qualitative changes of practice across time    SUTTON CHILDREN’S SOCIAL CARE    7 Internal procedures should be amended so that there is an assumption of a multi-agency planning meeting with all relevant agencies, when any complex case becomes (through a Child attaining ‘ordinary residence’ status) the responsibility of the London borough of Sutton or recognised as ‘very high risk’ Providing the opportunity for clearer and more consensual planning and deployment of all available resources 8 Children’s Social Care should:  Evaluate the extent to which it possesses or can rapidly access up to date information about the suitability of residential units   Require that the rationale for choices made and processes followed in making a placement are incorporated into an individual’s case record  Ensure via briefings / training that relevant staff are familiar with current ‘Care Planning Regulations’  If a placement is made in another UK country ensure that social work services are provided by an individual registered as a social worker in that country  Ensure that the staff of its out of hours / emergency duty service have been sufficiently trained with respect to law and statutory guidance relevant to parental responsibility - by 31.05.15    Better informed choice of placements   More comprehensive records     Regulatory compliance   Ensuring professional indemnity for case accountable staff   Increased certainty of lawful and sensitive responses 9 All staff should be reminded of the existing ‘need to know’ procedure for alerting senior managers to especially challenging cases / issues  Greater familiarity with ‘practice direction no.12’  Page 127 of 146  RECOMMENDATIONS  INTENDED IMPACT ST. ANDREWS HOSPITAL  10 St. Andrews management team should review its discharge planning  (including escalation arrangements internally and to Mental Health Tribunals) To ensure that vulnerable patient are not discharged before an agreed and robust multi-agency s.117 or informal after-care plan is in place and is known to and accepted by all relevant parties  SOUTH WEST LONDON AND ST. GEORGE’S MENTAL HEALTH TRUST  11 CAMHS Governance and the named safeguarding Children doctor and nurse for the South West London and St. George’s Mental Health Trust should develop and maintain a risk register of ‘Looked After Children’ from the five local authorities covered who are placed in mental health provision – by 31.05.15 By monthly reviewing via the Trust CAMHS governance structure, there should be greater clarity and regular opportunities to escalate case if the need arises   SUTTON CLINICAL COMMISSIONING GROUP (CCG)  12 Local partners who lead on commissioning services for Children need to ensure that there is an appropriate forum for developing ‘joined up’ commissioning intentions and plans, including the particular issues relevant to those who are ‘Looked After’  Clearer and more holistic commissioning practice for the more vulnerable end-users 13 When the CCG is commissioning mental health services for Looked After Children with complex mental health needs, it will need to ensure access to specialist mental health advice and seek expertise from the designated clinician for Looked After Children Better informed case planning 14 As lead commissioner for the health of Looked After Children, the CCG should lead a review of specific services (which should also inform service specifications for the ‘designated’ doctor and nurse roles) An improved professional infrastructure 15 The CCG must seek assurance that health providers in Sutton have processes and systems in place to respond to Child sexual exploitation. Raised sensitivity to this source of risk 16 The CCG should discuss sharing relevant findings from this Serious Case Review with Sutton Local Safeguarding Children Board.  If agreed, the report will be shared with Public Health England to inform wider professional learning and development   Better informed professional partners  Page 128 of 146  RECOMMENDATIONS  INTENDED IMPACT 17 The CCG should ensure that new guidance from December 2014: the Model Specification for Tier two and three CAMHS is embedded in commissioning arrangements for children in Sutton. Raised awareness of currently required arrangements   Page 129 of 146  9 BIBLIOGRAPHY General  Working Together to Safeguard Children, HM Government 2010 and 2013  Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose and Julia Barnes DCSF 2008   Analysing Child deaths and serious injury through abuse and neglect: what can we learn? A biennial study of Serious Case Reviews 2003-2005 Marian Brandon, Pippa Belderson, Catherine Warren. David Howe, Ruth Gardner, Jane Dodsworth, Jane Black, DCSF 2008  A Study of Recommendations Arising from Serious Case Reviews 2009-2010 M Brandon, P Sidebotham, S Bailey, P Belderson University of East Anglia and University of Warwick  Understanding Serious Case Reviews and their Impact a Biennial Analysis of Serious Case Reviews 2005-07 Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren and Black DCSF 2009  Building on the learning from Serious Case Reviews: A two-year analysis of Child Protection database notifications DFE – RR040 ISBN 978-1-84775-802-6 2007-2009  Learning Lessons, Taking Action: Ofsted’s evaluations of Serious Case Reviews 1April 2007 to 31 March 2008 Published December 2008  Ages of Concern: learning lessons from Serious Case Reviews: a thematic report of Ofsted’s evaluation of Serious Case Reviews from 1 April 2007 to 31 March 2011  Learning Together to Safeguard Children: A ‘Systems’ Model for Case Reviews March 2009 SCIE  New learning from Serious Case Reviews: Marian Brandon et al RR226 DfE 2012   Personal Guide to the Children Act 1989 / Child Protection CAE Ltd www.caeuk.org  Case-specific   Missed Opportunities: Indicators of Neglect Research Report  Childhood Wellbeing Research Centre /DfE Brandon, Glaser, Maguire, McCrory, Lushey and Ward, November 2014  We are family – sibling relationships in placement and beyond Ed. Audrey Mullender BAAF 1999  In the Child’s Time: Professional Responses to Neglect’ Ref. number 140059 February 2014  Page 130 of 146   What Works in Preventing and Treating Poor Mental Health in Looked After Children? Luke, Sinclair, Woolgar and Sebba Rees Centre Oxford August 2014  Office for National Statistics (ONS) drug-related deaths 2012/13  Managing Self-harm in Young People Report of Royal College of Psychiatrists October 2014  Report by the Comptroller and Auditor General Department for Education: Children in Care HC 787 SESSION 2014-15 27 November 2014  Principles for managing quality in specialised commissioning including the RASCI template NHS England 2014                                     Page 131 of 146  [This page has been intentionally left blank]  Page 132 of 146  APPENDIX A: TERMS OF REFERENCE   Terms of Reference Serious Case Review (SCR) Version 2 (FINAL) CHILD E  Introduction Child E died in May 2014 at the age of 16. They were a Looked After Child and living in a residential unit at the time of death. The Coroner’s report indicates that the cause of death was opiate toxicity and there is evidence that Child E had been using Class A drugs in the weeks before their death. Child E had a long history of involvement with a range of services and agencies. They were born in Norfolk and adopted in 2004. In 2008 the adoption broke down and they became Looked After by the London Borough of Sutton. From 2008 until death, Child E had a number of placements in a range of settings, including secure units. They made several apparent suicide attempts and had been sectioned under the Mental Health Act. Child E was not under a section at the time of death. Ofsted have been advised that, due to Child E’s long and complex history and involvement with many agencies and services, we anticipate that the review may take longer than the standard six months.   This is version two of the Terms of Reference dated 07/08/2014. As information emerges there may be some changes to the Terms of Reference (TOR), particularly regarding agency involvement. New versions of the TOR will be created and shared with the panel.  1. Purpose of the SCR In line with the government’s guidance in Working Together to Safeguard Children 2013, the SCR will aim:  To establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children.    To identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result.    To improve inter-agency working and better safeguard and promote the welfare of children.     Page 133 of 146  2.  Scope of the Serious Case Review:  2.1. The Serious Case Review will consider all agency activity and involvement from Child E’s birth in 1997. However, due to the long and complex history and to try to maximise understanding and identify learning points from more recent activity, agencies will be asked to consider three distinct periods of Child E’s life:  A. The period from birth to being placed for adoption between October 1997 and February 2004 B. The period after being placed for adoption between February 2004 and February 2009  C. The period from when Child E’s adoption broke down in February 2009 and they became a Looked After Child until their death in 2014.  2.2. All agencies will be asked to complete chronologies which date from Child E’s DOB or the first date of their involvement.   2.3. Agencies who were involved with Child E during period C, from 2008 until death, will be asked to complete an Individual Management Review.  2.4. Further information regarding Period B will be obtained from Court documents and Child E’s family before final decisions are made about Individual Management Reviews for this period.   2.5. Norfolk Children’s Social Care will be asked to do an Individual Management Review (IMR) for Period A (and will be asked to extend the IMR to later periods if relevant subsequent). Additional agencies may be asked to complete IMRs depending on information emerging from chronologies from this period.  2.6. Particular attention should be paid to times of transition between agencies and within agencies.  2.7. See the table (6) below for more details of Chronologies and IMRs   3. Chronology and IMR Agencies will be asked to complete IMRs as per the guidance above which will follow the guidance below. Templates for the chronology and IMR will be provided by Sutton LSCB and must be used by all agencies.       Page 134 of 146  4. Analysis: Each IMR author will consider the following Working Together questions and address those that are relevant.   4.1. Were practitioners aware of and sensitive to the needs of the children in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare?  4.2. When, and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services? Was this information recorded?  4.3. Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?  4.4. What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way?  4.5. Did actions accord with assessments and decisions made? Were appropriate services offered/provided, or relevant enquiries made, in the light of assessments?  4.6. Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services?  4.7. Where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with?  4.8. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded?  4.9. Were senior managers or other organisations and professionals involved at points in the case where they should have been?  4.10. Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards?  4.11. Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations?   Page 135 of 146  4.12. Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?  4.13. Was there sufficient management accountability for decision making?  5. Specific Questions to consider in this case  5.1. Was the planning and intervention undertaken in the early part of Child E’s life relevant, timely and effective? Could / should things have been done differently?  5.2. Was Child E given adequate support with the complex relationship they had with their birth family, particularly the mother? To what extent did this relationship impact on Child E’s death and could it have been managed more effectively?   5.3. Was adequate and timely support provided to Child E and their adoptive mother during the period of their adoption?   5.4. Was Child E’s adoption breakdown in 2008 and subsequent re - entry into the care system managed appropriately?   5.5. Was the support for Child E’s mental health problems effectively coordinated? Was communication between mental health agencies adequate and timely?   5.6. Were procedures followed for Child E’s placement moves in the last year of their life? Was adequate consideration given to how these transitions should be managed and were decisions recorded and acted on?  5.7. Were correct and timely decisions taken by professionals working with Child E in their final placement regarding their suspected drug use and potential access to drugs? Were these recorded and shared appropriately between agencies?  6. Organisations to be involved in this SCR  IMRs or background reports will be requested from the relevant agencies in relation to their involvement with the family / household members. The below list is subject to alteration as additional information emerges. The TOR will be revisited at each panel meeting:  7. Involvement of the family  Members of the family will be contacted where possible and informed of the nature and purpose of the Serious Case Review by the LSCB Business Manager and the Independent Chair of the Serious Case Review.   Page 136 of 146  Family members will subsequently be invited to participate in the review process by the overview author.    8. Legal Advice The panel will be supported as necessary by a legal advisor from the local authority team who was not involved in this case as required.  9. Timescale The Serious Case Review, having commenced on 6th June 2014 should be concluded by 6th November 2014 and submitted as a final report before 5th December 2014.  To ensure this timescale is met the following dates have been agreed for IMR authors:          10.  Family members Each agency to compile a chronology and management review of their involvement with family members.                Action Date  Chronologies 15/08/14 Draft IMRs 05/09/14 Final IMRs 05/10/14 Draft Overview Report 05/11/14 Final Overview Report  05/12/14 Report to LSCB 17/12/14  Page 137 of 146  APPENDIX B: BIOGRAPHIES Christine Davis, CBE, Independent Local Safeguarding Children Board Chair, which is a statutory function under Working Together Guidance (2013, 2015)  Christine Davies, CBE was appointed the Independent Chair of the LSCB in Sutton in April 2014. Christine had previously worked with Children’s Social Care Services as the Chair of the Improvement Board, and is now steering and strengthening the effectiveness of Sutton’s multi-agency safeguarding partnership.   Christine has extensive experience in Education and Children’s services leadership and delivery and is a current Trustee of the Early Intervention Foundation (EIF) and a member of the Youth Justice Board for England and Wales. She has created, developed and delivered national organisations and local services, securing a national reputation for excellence and performance. Christine has worked with every Local Authority in England and many in Wales, over 80,000 schools, Health Services, Police Authorities, Children’s Charities and the voluntary sector. She has advised the UK Government for over 14 years, covering education; safeguarding and child protection; child poverty; early years; special educational needs; early intervention and youth offending.  Independent SCR Overview Chair   Marion Davis is a qualified and registered Social Worker with over 30 years experience in children's social care.  She held a range of practitioner and management appointments before serving as Director of Children's Services in Warwickshire from 2005 - 2011. She was President of the Association of Directors of Children's Services for 2010/11.  Since taking early retirement she has worked as an independent children's services consultant, including having been an independent chair of an LSCB and acted as an adviser to the House of Commons Education Select Committee.  She was awarded the CBE for services to children and young people in the 2012 New Years Honours.  Marion Davis has declared her independence from the London Borough of Sutton and confirmed that she had no previous knowledge of this case prior to being commissioned by Sutton LSCB to become the Child D Independent SCR overview author.    Independent SCR Overview Author  Fergus Smith, an independent SCR Overview Author, was commissioned from CAE Ltd (www.caeuk.org), an independent consultancy. Fergus is a qualified Social Worker with experience of over fifty Serious Case Reviews as overview or Individual Management Review author. He has lead on the formulation of policies, procedures and protocols and has experience of auditing of Duty and Assessment through to Adoption Services.  Page 138 of 146  APPENDIX C: MEMBERS OF THE SCR PANEL  Independent Chair SCR Panel  Independent Overview Report Writer  Cafcass Senior Service Manager, Cafcass  Health Designated Nurse Sutton CCG Clinical Children’s Services Director, Sutton and Merton Community Services Royal Marsden NHS Foundation Trust Designated Doctor - Sutton Clinical  Commissioning Group Named Nurse for Safeguarding Children, South West London and St George’s NHS Trust Health Overview Writer Epsom and St Helier University NHS Trust - IMR Writer Head of Paediatric and Neonatal Nursing Epsom and St Helier University NHS Trust Named Nurse for Safeguarding Children   Police Metropolitan Police - CAIT  Sutton Council Education Safeguarding and Well-being Lead, LB Sutton Head of Quality Assurance, LB Sutton Legal Services, South London Legal Partnership  Executive Head of Safeguarding, LB Sutton  Other Safeguarding Manager, Norfolk County Council Designated Nurse for Safeguarding Children, Calderdale Business Manager, Calderdale Safeguarding Children Board GBA Care LB Sutton Social Care IMR Writer Hammersmith and Fulham IMR Writer GP IMR Writer Tri-Borough LSCB     Page 139 of 146  APPENDIX D: LSCB STATEMENT   On behalf of the Local Safeguarding Children Board, I want to say that we are deeply saddened by the premature death of this young person at the age of 16 years. Our sympathy goes to the family and friends who did a great deal to help but were powerless to influence the factors that led to the death. The finding of the coroner was accidental death as a result of a drug overdose following treatment that had lowered the tolerance to drugs.     As the Independent LSCB Chair, it is my role to ensure that a Serious Case Review (SCR) finds an answer to the question ‘why’ when a child dies that has been in the care of the Local Authority.   I have read the report carefully and the review found that Child E’s life chances were limited from the beginning because of serious parental substance misuse and inter-generational family dysfunctions. Whilst no one can say that the pre-birth damage, caused by maternal drug use during pregnancy, would not have disadvantaged this child in later life, there are messages about the vital importance of interventions at the most critical stages of early childhood development and the damaging impact of parental neglect on child outcomes in later life.    A further answer is that there were critical points in Child E’s childhood where different decisions by professionals could have led to improved life chances. There was extensive agency involvement from pre-birth. Child E was subject to a care order at the age of four years and placed for adoption at the age of eight years. There was a lack of education records, in part due to Child E not having attended main stream school, which of course limited life opportunities as Child E entered adolescence. From the age of 10 years, Child E required secure and specialist care provision but  Page 140 of 146  sadly professionals failed to engage in a way that would have ensured protection from further harm and ultimately the premature death.   The LSCB met on 22 February 2015 and approved the recommendations of this report in full after careful consideration. The Board is deeply committed to implementing the recommendations and it is my role as the Independent Chair to hold agencies to account for completing the agreed actions. The lessons learnt from this review will be reflected upon within the LSCB and individual organisation’s learning and professional development systems. The SCR findings to establish ‘why’ will contribute to the substantial body of evidence of poor outcomes for children in care because of missed opportunities to intervene at critical childhood development stages.    Finally, there are important lessons to be learnt about the arrangements for substitute care for a child with complex behavioural and emotional needs, who requires care that is over and above what most single parents would be able to provide. There is evidence that Child E showed insight into the difficulties, and benefitted from the adoptive mother’s commitment, long after the breakdown of the placement.      Christine Davies CBE  Independent Chair of the Sutton Local Safeguarding Board   26 May 2015        Page 141 of 146         RECOMMENDATION  RATIONALE  ACTION  LEAD  BY WHEN  INTENDED IMPACT National 1. The Board should inform the DfE and DH of a need to review or clarify national arrangements for emergency Mental Health Act assessments for under 18s who are ‘out of area’ (current A&E assessment arrangements may offer a practical methodology). This review contributes to national learning by identifying a need to clarify accountability for undertaking emergency MHA assessments for under 18 year olds who are ‘out of borough’ at a national level. 1.1 To seek assurance that relevant central government bodies address the need for national guidance about emergency MHA assessments for under 18 year olds who are ‘out of borough’.  The Independent LSCB Chair.  June  2015 To ensure that the emergency mental health needs for under 18 year olds presenting at A&Es are assessed regardless of place of residency.    1.2 To seek assurance through LSCB QA processes that local A & E assessment arrangements appropriately address the need for emergency MHA assessments for ‘out of borough’ under 18 year olds.  Chair of LSCB Quality and Assurance subgroup.  Sept  2015 Where quality issues are identified, appropriate challenge will be presented to the local A & E department to improve arrangements to undertake emergency MHA assessments.  APPENDIX E: LSCB ACTION PLAN 1    Page 142 of 146   RECOMMENDATION  RATIONALE  ACTION  LEAD  BY WHEN  INTENDED IMPACT 2. NHS England and Public Health should issue clear and simple guidance to Clinical Commissioning Groups and Local Authorities explaining which agencies are accountable for financing and providing quality assurance as appropriate within established Child and Adolescent Mental Health Service (CAMHS) tier definitions.    This review contributes to national learning by identifying a need to clarify accountability for financing and providing quality assurance of CAMHS.   2.1. To seek assurance that relevant central government bodies clarifies accountability for financing and providing quality assurance of CAMHS. The Independent LSCB Chair. June 2015 To assure the Board that Sutton children and young people has access to CAMHS that comply with statutory requirements and demonstrate practice of a high quality.      2.2 To seek assurance from CCG/NHS E and LBS and Sutton CAMHS Partnership Board that there are appropriate governance arrangements for quality assuring local and externally commissioned CAMH Services. The Chair of the QA subgroup.  June 2015 Where quality issues are identified, appropriate challenge will be presented to the locally commissioned CAMHS service within the LSCB framework.       Page 143 of 146   RECOMMENDATION  RATIONALE  ACTION  LEAD  BY WHEN  INTENDED IMPACT Local 3. The Board should confirm that Sutton Child and Adolescent Mental Health Service (CAMHS) Partnership Board has negotiated a lawful and practical policy / protocol for the commissioning of services children / young people whose ordinary residence is in the borough and who require ‘tier two to tier three’ mental health services.  LSCB has a role to scrutinise and challenge the performance of partners to assure itself that agencies demonstrate compliance with statutory requirements and that there are robust arrangements for the commissioning of services to vulnerable children/young people.  3.1 To seek assurance from/ Sutton CAMHS Partnership Board that they have negotiated a lawful and practical policy/protocol for tier 2 and 3 CAMH services. The Chair of the QA subgroup July 2015    To assure the Board that the needs of children and young people requiring CAMH service are properly addressed within the local commissioning framework.  4. The Board should confirm that existing training programmes adequately cover attachment theory and the value of ‘child-centred’ contact with birth family as well as the central importance of historical records / chronologies.  There is a substantial body of evidence that an understanding of attachment theory is central to assessment of birth family contact.  It is well established that effective social work practice is to ensure that case records contain historical records in the form of chronologies  4.1 To assure the LSCB Case Review subgroup that social work and early help training programmes cover attachment theory and child-centred contact with birth family.  Head of Quality Assurance, People’s Services Sutton Council  Nov 2015     Evidence of assurance to the LSCB that partner agencies’ cover attachment theory and child centred contact in training programmes for social work and early help professionals.  4.2 To assure the LSCB Case Review subgroup that there is regular auditing of social workers maintaining chronologies in case recording.  Head of Quality Assurance, People’s Services Sutton Council  Aug 2015 Evidence of assurance to the LSCB that there is regular auditing of case chronologies within children’s social care.   Page 144 of 146   RECOMMENDATION  RATIONALE  ACTION  LEAD  BY WHEN  INTENDED IMPACT 5. The Board should also seek confirmation from each member agency that there is ongoing agency-specific record keeping training. SCR messages of learning commonly address quality issues in respect of case recording. Locally, it can be expected that social work case audits and S.11 audits identify training needs to ensure that case records are of a high quality.  5.1 To assure the LSCB Case Review subgroup that partners have appropriate arrangements in place to provide record keeping training.  Chair of the Learning and Development Group Sept 2015 Evidence of assurance to the LSCB that partner agencies’ cover record keeping training to ensure that records are maintained to expected standard.  6. The Board should provide Norfolk Safeguarding Children Board with a copy of this report (or its executive summary) so that it has an opportunity to evaluate the quality of current child protection and care planning.  This SCR identifies messages that are specific to Norfolk SCB quality assurance processes.  6.1 Ensure that Norfolk SCB has a copy of the Child E overview report and recommendations.  Head of Quality Assurance, People’s Services Sutton Council  Completed To ensure that recommendations from this SCR is implemented.     Page 145 of 146  APPENDIX F: GLOSSARY OF ABBREVIATIONS Abbreviation Meaning AMHP Approved mental health practitioner (a role required under the Mental Health Act 2007) CAMHS Child and Adolescent Mental Health Service CCG Clinical Commissioning Group  CCATS Coastal Child and Adult Therapeutic Services CPA Care Planning Approach  IMR Individual management review (a report provided by each agency to the Serious Case Review panel which is drafted by a suitably experienced author from within that agency who has had no supervisory or management responsibility for the case) LADO Local Authority Designated Officer LCT Leaving Care Team   Children’s guardian 1  GP1    School 1  School 2  School 3  School 4  School 5     Hospital 1  Hospital 2  Hospital 3  Hospital 4  Hospital 5  Hospital 6  Hospital 7  Hospital 8  Hospital 9  Hospital 10  Hospital 11  Hospital 12  Hospital 13  Hospital 14    Consultant psychiatrist 1  Psychiatrist 2  Psychiatrist 3  Psychiatrist 4  Psychiatrist 5  Psychiatrist 6  Psychiatrist 7  Psychiatrist 8  Psychiatrist 9  Psychiatrist 10  Psychologist 1   Page 146 of 146  Abbreviation Meaning Psychologist 2  Psychologist 3    Ms BM  Mr BF  Ms AM    SW1  SW2  SW3  SW4   SW5  SW6  SW7  SW8  SW9  SW10  SW11  SW12  SW13  SW14    TM1  ATM1    IRO1  IRO2  IRO3    Executive head of service  Interim head of service    Head of LAC Service    Therapist 1  Therapist 2  Therapist 3    Complex needs nurse  LAC nurse 1  LAC nurse 2    Senior mental health nurse    Child E LSCB Action Plan May 2015   RECOMMENDATION  RATIONALE  ACTION  LEAD  BY WHEN  INTENDED IMPACT National 1. The Board should inform the DfE and DH of a need to review or clarify national arrangements for emergency Mental Health Act assessments for under 18s who are ‘out of area’ (current A&E assessment arrangements may offer a practical methodology). This review contributes to national learning by identifying a need to clarify accountability for undertaking emergency MHA assessments for under 18 year olds who are ‘out of borough’ at a national level. 1.1 To seek assurance that relevant central government bodies address the need for national guidance about emergency MHA assessments for under 18 year olds who are ‘out of borough’.  The Independent LSCB Chair.  June  2015 To ensure that the emergency mental health needs for under 18 year olds presenting at A&Es are assessed regardless of place of residency.    1.2 To seek assurance through LSCB QA processes that local A & E assessment arrangements appropriately address the need for emergency MHA assessments for ‘out of borough’ under 18 year Chair of LSCB Quality and Assurance subgroup.  Sept  2015 Where quality issues are identified, appropriate challenge will be presented to the local A & E department to improve  RECOMMENDATION  RATIONALE  ACTION  LEAD  BY WHEN  INTENDED IMPACT olds.  arrangements to undertake emergency MHA assessments.   2. NHS England and Public Health should issue clear and simple guidance to Clinical Commissioning Groups and Local Authorities explaining which agencies are accountable for financing and providing quality assurance as appropriate within established Child and Adolescent Mental Health Service (CAMHS) tier definitions.    This review contributes to national learning by identifying a need to clarify accountability for financing and providing quality assurance of CAMHS.   2.1. To seek assurance that relevant central government bodies clarifies accountability for financing and providing quality assurance of CAMHS. The Independent LSCB Chair. June 2015 To assure the Board that Sutton children and young people has access to CAMHS that comply with statutory requirements and demonstrate practice of a high quality.   2.2 To seek assurance from CCG/NHS E and LBS and Sutton CAMHS Partnership Board that there are appropriate governance arrangements for quality assuring local and externally commissioned CAMH Services. The Chair of the QA subgroup.  June 2015 Where quality issues are identified, appropriate challenge will be presented to the locally commissioned CAMHS service within the LSCB framework.     RECOMMENDATION  RATIONALE  ACTION  LEAD  BY WHEN  INTENDED IMPACT Local 3. The Board should confirm that Sutton Child and Adolescent Mental Health Service (CAMHS) Partnership Board has negotiated a lawful and practical policy / protocol for the commissioning of services children / young people whose ordinary residence is in the borough and who require ‘tier two to tier three’ mental health services.  LSCB has a role to scrutinise and challenge the performance of partners to assure itself that agencies demonstrate compliance with statutory requirements and that there are robust arrangements for the commissioning of services to vulnerable children/young people.   3.1 To seek assurance from/ Sutton CAMHS Partnership Board that they have negotiated a lawful and practical policy/protocol for tier 2 and 3 CAMH services. The Chair of the QA subgroup July 2015    To assure the Board that the needs of children and young people requiring CAMH service are properly addressed within the local commissioning framework.  4. The Board should confirm that existing training programmes adequately cover attachment theory and the value of ‘child-centred’ contact with birth family as well as the central importance of historical records / chronologies.  There is a substantial body of evidence that an understanding of attachment theory is central to assessment of birth family contact.  It is well established that effective social work practice is to ensure that case records contain historical records in the form of chronologies  4.1 To assure the LSCB Case Review subgroup that social work and early help training programmes cover attachment theory and child-centred contact with birth family.  Head of Quality Assurance, People’s Services Sutton Council  Nov 2015     Evidence of assurance to the LSCB that partner agencies’ cover attachment theory and child centred contact in training programmes for social work and early help professionals.   4.2 To assure the LSCB Case Review subgroup that there is regular auditing of social workers Head of Quality Assurance, People’s Services Sutton Aug 2015 Evidence of assurance to the LSCB that there is regular auditing of  RECOMMENDATION  RATIONALE  ACTION  LEAD  BY WHEN  INTENDED IMPACT maintaining chronologies in case recording.  Council  case chronologies within children’s social care.   5. The Board should also seek confirmation from each member agency that there is ongoing agency-specific record keeping training. SCR messages of learning commonly address quality issues in respect of case recording. Locally, it can be expected that social work case audits and S.11 audits identify training needs to ensure that case records are of a high quality.  5.1 To assure the LSCB Case Review subgroup that partners have appropriate arrangements in place to provide record keeping training.  Chair of the Learning and Development Group Sept 2015 Evidence of assurance to the LSCB that partner agencies’ cover record keeping training to ensure that records are maintained to expected standard.  6. The Board should provide Norfolk Safeguarding Children Board with a copy of this report (or its executive summary) so that it has an opportunity to evaluate the quality of current child protection and care planning.  This SCR identifies messages that are specific to Norfolk SCB quality assurance processes.  6.1 Ensure that Norfolk SCB has a copy of the Child E overview report and recommendations.  Head of Quality Assurance, People’s Services Sutton Council  Complete To ensure that recommendations from this SCR is implemented.   