Death of a 16-year-old boy by suicide in May 2021. Dawit had arrived in the UK from Africa in October 2020 to live with his sister after both his parents had died. His family had suffered religious persecution in their home country. Learning themes include: developing a clear pathway and protocol for unaccompanied children who do not have anyone with parental responsibility in the UK to ensure their needs are met; supporting the integration of migrant children into schools and the wider community that takes cognisance of their cultural, religious, physical, or emotional needs; and the role of the partnership in safeguarding unaccompanied minors who do not have anyone with parental responsibility in the UK. Makes no specific recommendations but reflections suggest: every child/family should be given the right advocate/support to navigate complex systems and bureaucratic processes, to ensure that they are not just matched up with universal services but are also supported to fully access them; there is a need to increase professionals' knowledge and confidence in being curious about and exploring parental responsibility; all services must commit to using high quality translation services for all spoken and written information and in a school environment good quality English as an Additional Language (EAL) support is essential; and children's social care should, once they have completed their child and family assessment, share the conclusions and outline plan with partners, including GPs, schools, and housing.
      
 Title:  “Dawit”: local child safeguarding practice review. LSCB: Lambeth Safeguarding Children Partnership Author: Lambeth Safeguarding Children Partnership Date of publication: 2022  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.                                  “Dawit” Local Child Safeguarding  Practice Review    Version 1: 15 March 2022   1 Introduction In May 2021, 16-year-old “Dawit” was found hanged in the building in which he resided. He was found by his younger brother. He was suspended by a rope. London Ambulance Service and Police attended. There was no suspicion of 3rd party involvement.   Following this tragedy, the Lambeth Safeguarding Children Partnership completed a Rapid Review in June 2021. Several areas for learning were identified in this process. However, the local rapid review panel agreed that there was the need for further exploration about how the partnership should adapt practice guidance to ensure that assessment is inherently multi-agency and that any child arriving in Lambeth, under similar circumstances to Dawit, is appropriately safeguarded.   Subsequently, the LSCP Executive agreed that a Local Child Safeguarding Practice Review should be initiated, and this takes the form of a learning event resulting in concrete changes to practice guidance and implementation.  Dawit’s story: A summary Dawit was born in an African Country. He had a large family of seven siblings (two sisters and five brothers). His family faced persecution because of their religious beliefs. In 2015, Dawit’s parents were both imprisoned. Around this time, two of his siblings were also imprisoned. In 2020, Dawit’s parents sadly passed away in 2020, with their death reportedly being attributed to abuse by the authorities in his home country.   Dawit’s sister, is a Lambeth Care Leaver, having previously arrived in the UK as an accompanied asylum-seeking child. On 30th September 2020 the sister’s Personal Advisor (from Lambeth’s  16+ Leaving Care Team) wrote to Lambeth’s No Recourse to Public Funds Team (NRTPF) to seek advice as the sister reported that she was bringing her brothers aged 14 and 15 over to the UK from Africa. Another sister had borrowed money to pay for their air fare. On 19th October 2020 the Personal Advisor was informed that her brothers were with her in the UK. They were reportedly living with their sister in a one-bedroom flat, where at least one of the brothers slept on the floor. They had arrived on 1st October 2020.   On 3rd November 2020, the 16+ Leaving Care Services referred Dawit and his brother to Children’s Social Care and a decision was made to undertake a Section 17 Child and Family Assessment. The assessment was completed on 5th January 2021. The outcome was for no further action as the assessment identified no concerns about the boys and it was thought that there was sufficient support in place for their sister to look after her brothers.  She did not have parental responsibility for her brothers. She continued to receive support from her Personal Advisor.     2 The assessing social worker noted concern about the impact of trauma, however both Dawit and his brother, as well as the sister from Leaving Care, said they were not ready to access counselling and resurface painful memories and would consider it later when they felt able to do so. Dawit said he had bad dreams, but he did not want to talk about them as he did not want difficult memories to re-surface. The sister reported that she felt emotionally supported by her PA, her previous foster carers, and some friends in London. The social worker advised they could access counselling via their GP.    The sister received Universal Credit and Housing Benefit and was studying at college when the boys arrived. It was thought that she was unlikely to get Child Benefit, due to the boys’ immigration status - so finance would be an issue. The sister was signposted to Asylum Help UK to get financial advice. She said she needed money to buy the boys winter clothes. The social worker contacted charities and managed to get a donation of new, unused winter clothes for the boys from the St Michael's Fellowship (a Lambeth-based community charity). The social worker also arranged for a one-off food parcel donation. The sister was given the phone number for Vauxhall Food Bank for future needs.  While Dawit’s brother had been offered a school place at a secondary school on 4th January 2021, it became known on the 23rd of April 2021 that the family were not aware of this. It was during a routine visit that the sister told her PA that she did not know what was happening in relation to a school place for her brother.  It appears that a letter regarding the school place was sent to the family. It is unclear if this letter was received. Regardless, the letter was written in English and the family were unable to read English. The PA contacted Lambeth Education Admissions and was advised that enquiries would have to be made directly with the school. The PA sent an email to the school, but the response is not on file.   When the PA visited the sister on 23rd April 2021, it was noted that she said she was doing well and looked in good spirits. The home was clean and tidy, and Dawit’s brother was present. The sister said she had some difficulties with her universal credit payments, as they had been deducted due to Dawit transitioning to college. The PA contacted Universal Credit and they explained that the sister would need to submit evidence that Dawit was on a course. The PA contacted Lambeth College and requested a learner agreement for Dawit so this could be submitted to the sister’s Universal Credit account.   In relation to Dawit, the PA was told post 16 applications to college for ESOL would need to be completed. The Personal Advisor was advised to contact a local college. Dawit was offered a place and he started on the 6th May 21, the day before he died. He attended school for 3 hours and, although he appeared withdrawn and shy, there were no safeguarding concerns raised that day. The College had not been given any information or handover information about Dawit’s history, significant trauma and family set up. Tragically, Dawit was found the next morning, having died by suicide.     3 Review questions The following questions set out the key lines of enquiry identified in the initial rapid review:  Question 1: How can we develop a clear pathway and protocol for unaccompanied children who do not have anyone with parental responsibility in the UK to ensure their needs are met?   Question 2: How can we support the integration of migrant children into schools and the wider community that takes cognisance of their cultural, religious, physical, or emotional needs? Question 3: What is the role of the partnership in safeguarding unaccompanied minors who do not have anyone with parental responsibility in the UK to ensure their needs are met?    Participating Agencies  The following agencies contributed to the LCSPR Learning Roundtable:  • Lambeth Children’s Social Care ● Lambeth Education & Learning Team ● Southeast London Clinical Commissioning Group (Lambeth) ● Guy’s and St Thomas’ NHS Foundation Trust ● The Metropolitan Police Service  Methodology  Representatives from partner agencies came together in an online meeting on 22 February 2022. During this learning workshop, participants explored the review questions, collaborated in identifying solutions, agreed recommendations and formulated an action plan to deliver the learning identified. These findings are shared in this report.   The event was chaired by Dr Efun Johnson, Lambeth’s Designated Doctor for Children Looked After.   To facilitate equal participation of all agency representatives, especially given the online format for the event, a digital tool, Axis, was employed. This allowed equal participation for all participants who could freely share and evaluate ideas.       4 Family Involvement Dawit’s brother and sister were notified of the review and were invited to contribute their voices and experiences to the review.   Governance The Review Learning Panel Meeting was Chaired by Dr Efun Johnson, Designated Doctor, Children Looked After, Lambeth. The report will be presented to the LSCP’s Serious Incidents & Reviews Subgroup, with final sign-off sitting with the LSCP’s Executive. The review’s recommendations and actions will be monitored and evaluated by the LSCP’s Performance and Quality Assurance Subgroup.    Learning Lessons learned from this local child safeguarding practice review will be disseminated via multi-agency briefing sessions, updated training materials and LSCP communications. Below are the key reflections in response to the review’s key questions.   Question 1: How can we develop a clear pathway and protocol for unaccompanied children who do not have anyone with parental responsibility in the UK to ensure their needs are met?  The multiagency panel agreed that a single multi-agency protocol was needed to ensure that all unaccompanied children, regardless of the route of their arrival in the UK, are appropriately safeguarded in a consistent way that all agencies understand. It was noted that there was an established process in place to ensure unaccompanied asylum-seeking children were given the most effective and timely support, and that we should use the processes and systems already in place and widely understood.  It was equally understood that no one single protocol can be employed without a full consideration of context. When considering Dawit’s case, partners recognised the need to foster a greater culture of consultation and professional discussion across the partnership. It was recognised that there is expertise available throughout the partnership and there is a need to better promote the availability of this knowledge, encouraging contact, discussion, and advice.   To ensure the loop is closed in any intervention or referral, it was agreed to ensure that every child/family should be given the right advocate/support to navigate complex systems and   5 bureaucratic processes, to ensure that they are not just matched up with universal services but are also supported to fully access them.   While not specifically relevant to Dawit’s story, the panel noted that the rates of notification for Privately Fostered Children are very low, so it is likely that we would potentially have the same challenges in identifying children without a carer with parental responsibility. This reflection suggests a need to increase professionals’ knowledge and confidence in being curious about and exploring parental responsibility.    Question 2: How can we support the integration of migrant children into schools and the wider community that takes cognisance of their cultural, religious, physical, or emotional needs?  The multiagency panel agreed that that to best support migrant children’s integration into schools and the wider community, a holistic approach is required. This would involve, for example, providing accessible information directly to children and families; an advocate to work alongside the child or family to support their integration into community groups and services; support for schools, and other universal services, with clear strategies to best support migrant children; and ensuring that all services make better, and more consistent use of translation services.   Exploring these ideas in more detail, the panel agreed that an introductory welcome pack on arrival could signpost local services, community, and support groups. It was noted that additional practical resources could also be provided, like the already available Separated Children packs. Linked to this, as well as the question above, was the identified need for a support worker or advocate to work alongside the child and family to facilitate integration into services and groups and follow up and liaise with other services as needed.  Regarding information for schools, education colleagues suggested that it would be helpful to articulate clear strategies that schools can use to support migrant children, which sets up some “non negotiables”, as well as examples of good practice, including resources to help operationalise them.   It was agreed to use existing school networks, for example the Lambeth Schools’ Designated Safeguarding Lead Forum, to create a safe space for school leads to drop in to discuss challenges, opportunities, ideas, and good practice with colleagues, as well as receive key information and training.   As was identified in the initial Rapid Review, all services must commit to using high quality translation services for all spoken and written information. It was recognised that in a school   6 environment, where this would be impractical for daily provision, good quality English as an Additional Language (EAL) support is essential.    Question 3: What is the role of the partnership in safeguarding unaccompanied minors who do not have anyone with parental responsibility in the UK to ensure their needs are met?   It was agreed that any assessments should ideally be holistic and multi-agency. This would not necessarily require one single coordinated assessment, which could prove logistically challenging. It would, however, require sharing of information as part of the assessment, as well as afterwards. As an initial practical step, it was agreed that Children’s Social Care should, once they have completed their child and family assessment, share the conclusions and outline plan with partners, including GPs, schools, and housing. It was recognised that this action would ensure that universal services are made aware and would likely trigger proactive outreach – from a GP making contact to initiate an appointment.   It was highlighted that on 7 November 2019 council officials in the London Borough of Camden sent a letter to directors of children’s social services nationally alerting them to learning from the council following the death of a child from Dawit’s home country who had died by suicide.  The letter stated that young, unaccompanied asylum-seeking children face a range of challenges including trauma, loss and separation, disconnection, language barriers and racism and that for some a stigma around mental-health problems makes them reluctant to accept help and support.   This led the panel to reflect on how the partnership has a role to play in keeping learning alive for professionals, as well as sharing new and ongoing learning, and how we track and monitor this. It was agreed that this should be reflected in all structures within the partnership – from the use of the partnership website and training programme to share new learning, as well as the outcomes framework and data dashboard monitored and evaluated by the partnership’s Performance & Quality Assurance Subgroup.   1  