Attempted suicide of a 17-years-6-month-old young person in December 2016 resulting in significant and life changing injuries. The young person Darry exhibited behavioural and language concerns at secondary school which led to a move to a school for children and young people with special educational needs at age 15. From the beginning of Year 12 the school became concerned about Darry with evidence of increased anxiety, low mood, lack of interaction with peers and self-harm and referred Darry to CAMHS Learning Disability Team. A meeting with CAMHS, Special Educational Needs, school staff and mother in November 2016 summarised Darry's recent deteriorating mental state and mother's views regarding long term bullying, family losses and domestic abuse. Findings: young people with deteriorating mental health require a holistic multi-agency response which takes account of all factors and does not focus on the young person as the problem; self-harm is a serious issue which needs robust multi-professional action; referrals to children's social care need to make clear the concerns to enable a decision to be made on the best available information; there is professional confusion about the Mental Capacity Act as it relates to 16 and 17-year olds, particularly in the context of parental decision making and professional advocacy. Uses a hybrid version of a systems process. There are no recommendations in this overview.
      
    Serious Case Review No:  2018/C7429  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   1  Serious Case Review   “Darry”   QQQQQ     2  CONTENTS  Page Number Introduction and process of the Serious Case review (SCR) Why this Serious Case Review (SCR) was undertaken?  Family Background   Background circumstances of Darry   Process of the Review  Family Involvement in the Review  2. Chronology of professional involvement over a 15-month period 3. The Findings Finding 1: Professionals need to evaluate the most appropriate action to take to address parents/carers reluctance to accept services designed to improve the circumstances of children and young people.  Finding 2: Young people with poor or deteriorating mental health require a holistic multi-agency response which takes account of all the factors that might have caused their difficulties, rather than a focus on the individual young person as the problem.   Finding 3: Self-harm is a serious issue which needs robust multi-professional action, management and clarity about who should be the Lead agency  Finding 4: Referrals to Children’s Social Care (CSC) need to make clear the concerns to enable a decision to be made on the best available information. CSC need to provide feedback when concerns are not clear to help the multi-agency network improve. Where it is agreed that referrals do not meet the threshold for CSC services there should be a discussion about alternative courses of action such as an early help response to ensure that children and young people’s needs are met.  Finding 5: There is Professional confusion about the Mental Capacity Act (MCA) as it relates to 16-17 year, particularly in the context of parental decision making and professional advocacy.    3  1. Introduction and process of the Serious Case review (SCR) Why this Serious Case Review (SCR) was undertaken? 1.1 This SCR has been commissioned by QQQQQ Safeguarding Children’s Board (QQQQQ). This SCR was initiated as a result of Young Person D (known in this report as Darry1) attempted suicide at the age of 17 years and 6 months sustaining significant and life changing injuries. This attempt came after escalating concerns about previous self-harm, running away from home and low mood/isolation. The purpose of the SCR is to reflect on the professional response to Darry and the family over a 15-month period and considers what lessons can be learned to improve future practice. Family Background  1.2 Darry lives with Mother; Father left the family home 6 months into the review period. Darry is one of four siblings. Two siblings are older; the oldest, sibling 1, left home at age 18, the next sibling attended university and the youngest sibling is at secondary school. Darry has a very close extended family who support the family. The family is White British. The family were under acute financial pressure during the time under review, Mother had two jobs and worked long hours as a result of this. When father left the family home, these financial pressures were exacerbated.  Background circumstances of Darry  1.3 Darry attended mainstream junior and transferred in 2011 to secondary school with no school concerns. Darry exhibited some behavioural concerns initially and mother and Darry later reported widespread bullying, but the school were not told about this at the time. The parents asked for a statutory assessment of special education needs to be undertaken but were told that the criteria had not been met and that the current school met Darry’s needs. Speech and Language support was provided to address Darry’s communication skills difficulties. A Community Paediatric Assessment was planned regarding possible Autism but Mother declined the appointment because she was not clear what this was for.   1.4 There were growing concerns about Darry behaviour and language at secondary school, and many meetings were held with the parents.  A                                                                  1 All names hav e been anonymised 4  behavioural and pastoral contract was set up and support provided. Darry’s engagement in learning began to further decline and she was unhappy; in September 2014 an Education Health and Care Assessment (EHCR) was started and this led to the move at aged 15 to a school for children and young people with special educational needs. Darry was assessed as having a mild learning disability at this time. Process of the Review 1.5 This review has been undertaken using a hybrid version of a systems process and this was agreed in the frame of reference during the commissioning process. Chronologies of agency involvement with single agency reflections on practice were commissioned (see appendix 1 for a full list of agencies) and face to face and follow up telephone interviews were conducted with most of the professionals involved with the family; it was not possible to interview all as some professionals had left their posts, but these people had only brief contact with Darry and the family. Many of the core records, assessments and reports/email correspondence held by agencies were also reviewed. Several conference calls were conducted to clarify key information. The Findings of the review were drawn from an analysis of the knowledge of those professionals involved with Darry, the chronologies and records provided and information regarding best practice and research. The review team is grateful for all those who contributed to the SCR process. 1.6 This SCR was overseen by an independent reviewer (see appendix 2) and her work has been assisted by a panel of multi-agency senior safeguarding professionals (see appendix 3).  The panel met three times over a 9-month period and helped with the initial analysis and development of key themes/Findings and then commented on 4 draft reports and approved the final version. 1.7 The Final report was presented to the safeguarding Child’s Board/Adult Board in March and June 2018. Family Involvement in the review  1.8 The independent reviewer met with mother, Darry and maternal aunt twice as part of the review and maternal grandmother attended the second meeting. These meetings were facilitated by the current social worker. Darry did not feel able to speak but agreed to listen to what others said. The family’s views are incorporated into the body of the 5  report. The independent reviewer is grateful for their contribution. The siblings were offered the opportunity to contribute to the review but did not feel able to.    6  2. Chronology of professional involvement over a 15-month period Emerging Concerns about Darry’ emotional wellbeing  2.1 From the beginning of Year 12 school became concerned about Darry whose behaviour began to deteriorate; there was evidence of increased anxiety, low mood, complete lack of interaction with peers and a need to be with only a few trusted adults. There were incidents of verbal abuse, leaving the class, absconding from the school site and generally being disruptive on an almost daily basis. There were meetings with the parents in October 2015 and a comprehensive school pastoral support programme was put in place. The school were particularly concerned regarding escalating incidents of self-harm. A referral to Child and Adolescent Mental Health Services (CAMHS)2 and the Community Team for people with Learning disabilities (CTLD) was suggested, but Mother refused this support. She said that Darry did not trust professionals and Mother also expressed distrust because she felt she had been asking for help for years without success. This contradiction, between mother requesting support, but refusing services and support for Darry was a theme across the review and is discussed in Finding 1.  2.2 The school completed the Education, Health and Care (EHC) plan 3 and developed an individual timetable with a few trusted adults to support Darry. There were regular school reviews, EHC4 reviews and meetings/contact with the parents, and in February 2016 as a result of the further escalation of concerns, mother agreed to a referral to Child and Adolescent Mental Health Services (CAMHS) to address Darry’s deteriorating mental health and self-harm, and a referral to the Adult Community Learning Disability Team (CLDT) for support; Darry was not known to the Children with Disability Team. School Referral for Support: February 2016                                                                  2 CAMHS stands for Child and Adolescent Mental Health Services. CAMHS are the NHS serv ices that assesses and treat young people with emotional, behavioural or mental health difficulties. There are local NHS CAMHS services around the UK, with teams made up of nurses, therapists, psychologists, support workers and social workers, as well as other professionals. 3 On 1 September 2014, the law for special educational needs (SEN) changed. The Children and Families Act (‘The Act’) introduced a more holistic approach to meeting the needs of a child or young person with SEN, with a mandate for councils to replace Statements of SEN with Education, Health and Care (EHC) plans. 4 On 1 September 2014, the law for special educational needs (SEN) changed. The Children and Families Act (‘The Act’) introduced a more holistic approach to meeting the needs of a child or young person with SEN, with a mandate for councils to replace Statements of SEN with Education, Health and Care (EHC) plans. 7  2.3 The CLDT referral was accepted, and Darry was placed on a waiting list for an assessment. This assessment would not take place for another 9 months, though other agencies were in contact with this team on a regular basis; there was general confusion, disagreement and debate about the role they might play and regular discussion about which team (adult or children’s) was responsible for providing Darry and family with an assessment and possible support. This is discussed further Finding 2. The issue of the uncertainty about which agencies, individually or collectively, could and should provide services to address the complex needs of Darry and family and how a multi-agency plan could be devised using the best of what all agencies could offer is discussed in Finding 2. 2.4 The referral to CAMHS by the school was comprehensive and focussed on Darry’s deteriorating mental state, low mood, depression, complete isolation in school, self-harm and suicidal ideation. The CAMHS Learning Disability Team started their assessment two weeks after the referral was received; this was a prompt response which demonstrated effective practice. This assessment included meeting with the school, mother and the extended family, time with Darry who felt unable to say very much and the completion by Darry and Mother of the Revised Children’s Anxiety and Depression Scale (RCADS5 ).  2.5 The assessment process was completed in May 2016 and was communicated to Darry and the family via letter; this highlighted that there were concerns about self-harm and suicidal ideation/family history of suicide, physical and emotional abuse by father and a history of unreported bullying at school. However, the assessment did not provide a formulation or holistic analysis of the possible causes of Darry’s current difficulties incorporating all the known information about the wider factors which were likely to be impacting on Darry’s wellbeing. Without these broader factors being directly linked to an understanding of any young persons’ difficulties, there is an unintended consequence that the focus of professional concern can become about the young person as the problem, potentially reinforcing feelings of low self-esteem. This is discussed further in Finding 2. Within the assessment there was no specific consideration of the concerns about                                                                   5 The Rev ised Children’s Anxiety and Depression Scale (RCADS) and the RCADS – Parent Version (RCADS-P) are 47-item questionnaires that measure the reported frequency of v arious symptoms of anxiety and low mood. They produce a total anxiety and low mood score and separate scores for each of the follow sub-scales: separation anxiety; social phobia; generalised anxiety; panic; obsessive compulsive; total anxiety; and, low mood.  8  self-harm, the possible cause, a risk assessment and a specific plan of action. It was unclear which was the agency that would lead on this issue. This is discussed in Finding 3. The CAMHS plan was to provide Darry with Dance Therapy for an exploration of feelings non-verbally and to build a therapeutic relationship over time; mother and the family were also offered regular support. This plan was regularly reviewed by the CAMHS team. 2.6 The Dance therapy started and would provide regular and predictable weekly support for Darry over the next six months. The CAMHS team met with mother, Darry and Maternal Grandmother (MGM) in June 2016 and they provided the team with more details about the physical and emotional abuse experienced by Darry at the hands of father in the past. Mother also reported being domestically abused. CAMHS professionals were appropriately concerned about Darry and the other sibling’s safety and they made a verbal referral to Children’s Social Care(CSC). This was in line with both QQQQQ Think Family approach and the Children’s safeguarding procedures. The CAMHS professional was informed by CSC that they needed to seek consent from Mother to discuss the referral6; this was in line with current procedures but it would have been expected that advice would have been given about what the next steps should be if consent was not given, such as convening an early help meeting and process or discussing whether the concerns were so serious that consent could be dispensed with. The issue of differences of professional opinion regarding the nature of concerns for a child or young person and ensuring that this does not lead to no multi-agency response is discussed in Finding 2. Mother said she did not wish to give consent because she was worried about the impact this might have on the family. The available information about significant physical abuse by father suggested that the threshold for a safeguarding response had been met and there should have been a strategy meeting/discussion. The lack of a written referral or written record of the conversation held meant that it is not clear what information was shared between the two agencies. The issue of the importance of providing written referrals, which are clear about concerns regarding likely significant harm to a child/young person is addressed in Finding 4.                                                                   6 The parents' permission should be sought before discussing a referral about them with other agencies unless permission-seeking may itself place a child at risk of significant harm. Where a professional decides not to seek parental permission before making a referral to Children's social care, the decision must be recorded in the child's file with reasons, dated and signed and confirmed in the referral to Children's social care. http://www.proceduresonline.com/swcpp/QQQQQ 9  2.7 CAMHS appropriately sought advice from the named nurse for safeguarding about next steps and it was suggested that a CAADA/DASH7 risk assessment be completed with mother to assess current risks. Mother initially refused, but the CAMHS professional persevered with engaging mother CAADA/DASH risk assessment was completed and the conclusion was that there were low level risks for mother and she was appropriately signposted to support services. The issue of the potential impact of domestic abuse on Darry and the siblings was not explicitly addressed by any agency. The issue of the importance of ensuring that the impact of domestic abuse on children and young people is considered as part of a wider analysis of needs is discussed in Finding 2.  2.8 At the beginning of September 2016 CAMHS met with mother and Darry for the regular review of progress of the CAMHS plan. Mother reported a difficult summer; father had left home and had been aggressive and violent, Paternal Grandmother (PGM) had died and the family dog (who Darry was very close to) had died. The Dance therapy sessions were discussed and it was agreed that the sessions would continue with the aim of building a therapeutic relationship and through this to work for Darry to begin trusting others and talking about feelings. This was an appropriate plan of action for individual work for Darry who continued not to feel able to talk to any professionals. Escalation of concerns about Darry  2.9 In the middle of September 2016, the school reported to CAMHS an escalation in Darry’s self-harming behaviour. The school were concerned about Mother’s negative attitude to the self-harm which indicated high levels of stress for the family and a lack of understanding or empathy for the distress that Darry was exhibiting; see Finding 4 regarding a discussion of the importance of enabling parents or family figures to be supportive and understanding in the context of self-harm. CAMHS advised ensuring that Darry did not have access to sharp objects and to contact children’ social care if the school remained concerned. There was insufficient discussion between the agencies of what needed to be done to address the escalating self-harm, whether a multi-agency meeting was required or who should take the lead role.  This is also discussed in Finding 3.                                                                    10  2.10 The school contacted children’s social care (CSC) who said they could not accept a referral without consent being sought from mother. Given the concerns shared this advice was consistent with the existing safeguarding thresholds; it would have been expected that advice would have been provided, about other steps to take, although this happened the next day. School continued to be worried and they contacted CSC again the next day and were advised to convene a Team around the Child meeting (TAC). The school felt this was a positive opportunity to bring all involved professionals together and it was organised for a week later and attended by school staff, and a CAMHS team member. The concerns about Darry self-harming, continuing to express ideas about wanting to die and mother’s negative and unempathetic attitude were discussed; there was concern that the family were not coping.  2.11 Mother joined the meeting late and was described as angry, emotional and expressing that she had been asking for help for years and remained unsupported. Mother talked about family losses and suicides. She asked that the school email her rather than telephone because she could no longer cope. There was no discussion about what needed to be put in place to support the family (for the benefit of Darry) and who would provide this. There was no multi-agency plan developed, no minutes and no Lead Professional nominated. Each agency continued with their own work and individual plans. The importance of clear early help processes and plan is discussed in Finding 2. 2.12 The school were tasked with contacting the Community Learning Disability team to clarify when the assessment of Darry would take place. The Community Learning Disability team said they would be undertaking an assessment but whilst Darry was still not 18 suggested a referral to the Children with Disability Team, despite being told that contact had already been made. Once again, each agency questioned who was responsible for providing a service to the family, ending in no further action and a lack of support. See Finding 2. Darry runs away overnight 2.13 At the beginning of October 2016 Darry ran away from home threatening to commit suicide. The police were informed and engaged in an extensive search in the early hours of the morning. Darry was found and taken to hospital. Darry had a number of injuries which were likely self-inflicted; bruising to the face, bumps to the head, cuts 11  to the hand and a possible sprained wrist. Darry was initially assessed by an adult psychiatrist who concluded that Darry lacked capacity, without a formal mental capacity assessment being conducted; this is discussed in Finding 5.   2.14 Darry was also assessed by the hospital on-call child and adolescent psychiatrist who concluded after advice from a more senior colleague (Consultant Child Psychiatrist) that inpatient psychiatric care would not meet Darry’s current needs and that support in the community should continue; this made good clinical sense, but the lack of a crisis/assertive outreach service meant there was a lack of appropriate community resources available8. Initially mother was unhappy with the decision to return home because she said the family felt unable to cope. The family were persuaded on the basis that there would be further discussion about increased support. They were advised verbally and by letter that Darry should stay with Maternal Grandmother (MGM), that the doors and windows should be locked, knives, scissors and tablets to be locked away and Darry to have close supervision. The family reported during this review process that they felt a responsibility to keep to this advice for the next few months. This was in fact a short-term plan and the intention was that a more robust multi-agency plan would be developed but this intention was not made explicit.  This raises issues regarding whether this advice amounted to a deprivation of Darry’s liberty; this was the least restrictive option in the short term, but a review of this plan was necessary in the longer term and a consideration of the requirements of the MCA 2005; something that was never sufficiently addressed for Darry. This is discussed in Finding 5.  2.15 The school were concerned about Darry’s safety after this recent incident and sought advice from CAMHS who reassured them that the school was a safe place. School contacted the Disabled Children’s Team and provided the first written referral. This outlined recent events but could have been clearer about the concerns and the risk of significant harm; this is discussed in Finding 4. The Disabled Children’s team (DCT) agreed a social worker would attend the next school review planned for the following week to see if support was required.  T                                                                  8 The CAMHS team had sought funding for a crisis/ assertiv e outreach team from the transformation funding held by the CCG but this was not granted despite this having been highlighted as a priority nationally. This meant that clinicians were having to manage the needs of children and young people with very complex needs without this community-based service. 12  2.16 The school meeting took place as planned the following week and was attended by school staff, DCT social worker and a CAMHS professional. Recent events were discussed, and it was agreed that the CAMHS review was to be expedited, there would be clarification of the progress of the Autism assessment and the educational psychologist assessment would also be brought forward. This was tagged as a school review but was actually more like a follow on to the multi-agency Team Around the Child Meeting (TAC) previously held. This lack of clarity meant that no formal TAC plan to address the needs of either Darry or the family was developed and no Lead Professional nominated. There were no TAC minutes and each agency recorded a slightly different version of the meeting and its outcomes. The importance of a robust early help response to address the needs of vulnerable adolescents is discussed in Finding 2. 2.17 The duty social worker from the disabled children’s team contacted the community learning disability team two weeks later who confirmed that they would be completing an assessment in the next month (this was 9 months after the original referral; this delay was caused by lack of resources in the team). It was agreed therefore that the disabled children’s team would not start an assessment or be involved in considering whether Darry or the family were in need of services or support because this would require Darry and the family to engage with too many new professionals. This was a considered discussion which did not take account of the purpose of the referral and the school were not informed of this decision and advised about next steps. 2.18 Darry was seen for review at CAMHS on the 18th October with Mother and MGM. It was agreed that the autism assessment would be started. Darry did not feel able to speak. It was suggested that anti-depressants might help Darry, but mother was not happy with this, reporting a history of family concerns about their use. It was agreed that the current approach to building a therapeutic relationship with Darry, using the non-verbal approach of dance therapy would continue and the use of medication would be discussed in the future if necessary. 2.19 A summary of this meeting was sent to the family and the community learning disability team; this noted that the current problems for Darry were mild to moderate learning disabilities, low mood and self-harm and possible communication difficulties. The wider concerns regarding school and home were not incorporated into a more holistic analysis. 13  Darry taken to hospital 2.20 At the beginning of November, after half term, school had considerable concerns about Darry, particularly self-harming and running away from school. On one occasion Darry would not return to the school and the maternal Grandparents came to collect Darry. Darry was observed to be expressing anger and aggression and refused to return to school or listen to the grandparents or school staff. Eventually the police were called and they were able to help get Darry into the grandparent’s car and they escorted the family home.  2.21 The police made a referral to children’s social care team and shared information with CAMHS because they were so concerned. The police concerns were passed to the disabled children’s team who contacted school and information was shared; once again it was proposed that contact be made with the adult community learning disability team. This team said they were planning an assessment but because Darry was not yet 18 it would be more appropriate for the disabled children’s team to be involved; contradicting the advice provided a week earlier. Once again, the debate about which team was responsible for the care of a vulnerable adolescent meant no action was taken.  This was the fifth referral (verbal and written) that the children’s social care had received regarding Darry and should have prompted a discussion about what would be an appropriate response. This lack of response did not fulfil the ambitions of the QQQQQ Think Family Approach with the emphasis on there should be no ‘wrong door’ to services9. 2.22 Aunt contacted the CAMHS team for help and support after this incident. It was agreed that medication (risperidone10 and diazepam11 PRN12) would be prescribed for Darry. This medication was reviewed three weeks later when Darry was seen in hospital. There should have been a formal Mental Capacity Assessment completed for Darry at this time to consider whether she had the capacity to consent to the prescription of the medication or, if she lacked capacity, whether it                                                                  9 file:///C:/QQQQ 10 Risperidone is antipsychotic medication. These medicines work on the balance of chemical substances in the brain. It is prescribed to reliev e the symptoms of schizophrenia, autism, learning disability or a similar mental health problem/psychosis. It is also giv en to treat aggressiv e behaviour problems in some people where these could become a danger to self or to others. 11 This drug is used in the short term to treat sev ere anxiety, it relaxes patients – mentally as well as physically – and prev ents anxiety.  12 Abbrev iation for pro re nata, a Latin phrase meaning "as needed." The administration times are determined by the patient's needs. 14  was in her best interests for this medication to be prescribed. This is discussed in Finding 5. 2.23 School were concerned about whether Darry could be in school safely and they organised a meeting. This was attended by CAMHS staff, Special Educational Needs service (SEN) representative, school staff and Mother and MGM. The meeting summarised the recent history of Darry’s deteriorating mental state and mother’s views regarding long term bullying, family losses and domestic abuse. More information was provided about the previous level of violence at home. There was still no multi-agency plan or a lead professional identified. Darry returned to school with the agreement that there would be further discussion about what setting Darry would attend in the future and school would progress this. Darry taken to hospital 2.24 On the morning of the 23rd November 2016 Mother contacted CAMHS to report that Darry had run away again and expressed suicidal thoughts. Mother was advised to call the police who found Darry in a distressed state with self-harm cuts to the hand. Darry refused to speak and would not go with the police. The police detained Darry under Section 136 of the Mental Health Act 13 and took Darry to hospital. Darry was assessed under the Mental Health Act by a child and adult Psychiatrist and a mental health social worker (AHMP14). Darry refused to speak and stayed curled up in a ball in the corridor of the Place of safety15. Darry was assessed as lacking capacity and it was agreed that Darry would be re-assessed the next day with mother present to see if this would help Darry feel more comfortable and able to talk. The mental health social worker spoke to mother on the phone who was described as low in mood and reported that the family could not cope                                                                  13 Section 136 is part of the 1983 Mental Health Act. The police can use Section 136 when they think an individual has a mental illness and needs care or control. They will take the individual to a place of safety which could someone’s home, a friend’s or relative’s home, a hospital or a police station. The individual will have a mental health assessment whilst on this section and can be kept on this section for up to 24 hours. This can be extended for 12 hours. 14 Approved Mental Health Professional (AMHP): an AMHP is a mental health professional who is trained to use the Mental Health Act. This can be a psychologist, nurse, social worker or occupational therapist. They be involved in bringing you to hospital under a section of the Mental Health Act. 15 The place of safety is a specialist four bedded unit designed specifically for people in extreme mental distress who are detained for their own safety and the safety of others under section 136 of the mental health act. 15  with Darry at home, but she was unsure of the best option available. She agreed to come to the meeting the next day.  2.25 Mother arrived for the meeting/assessment the next day, without knowing that it had been cancelled. There was confusion about next steps and the ward staff expressed concern about the lack of a plan given that it was Friday lunchtime. The hospital social worker did a lot of work to develop a short-term plan. She contacted children’s services duty team, the children with disability team and the adult community learning disability team. All said that they could not see what role they might play and the lack of a local crisis/assertive outreach team meant that it was agreed that support would be provided by the Intensive Support Team (IST) from the adult mental health services team, despite this not being within their remit. This was good practice to meet Darry and the family’s current needs.   2.26 Professionals from the IST visited the next day. Darry refused to speak but agreed to sit in the kitchen and listen whilst mother and maternal aunt shared the recent family history and that Darry had been physically and emotionally abused by father. The subsequent written record has a question mark next to a query about whether Darry had been sexually abused, but it is not clear whether this was discussed with the family or was a professional hypothesis of the team. It has not been possible to establish this. The intensive support team had no further contact with Darry or the family. The provided verbal feedback to the CAMHS team about their involvement, but it is unclear whether the issue of possible sexual abused was discussed. The IST sent over all the records of all the hospital’s recent involvement with Darry rather than a summary of their work. This full set of records provided minimal information about the query of sexual abuse (the records just say sexual abuse?). The IST did not take any action to address concerns about sexual abuse, and it is unclear whether this concern was understood by other agencies. It would have been expected that action would have been taken to explore this serious concern further. 2.27 The plan was for support to continue in the community. Darry was seen for a dance therapy appointment and was described as slightly chattier, talking about school and feeling worried about a potential new educational placement.  The family were seen by the CAMHS team at home but the current support was not reviewed in response to this further crisis. The community learning disability team undertook their assessment at the end of November (9 months after the original 16  referral) and further contact was planned for early January 2017. This assessment took place in isolation from all the other work.   2.28 School contacted CAMHS in the second week of December 2016 at the end of term as they remained significantly concerned about Darry. CAMHS confirmed that they were continuing their plan of support. 2.29 Immediately after Christmas Darry ran away from home again. Darry was found by the police in a distressed state and unwilling to speak and they brought Darry home. The police liaised with the hospital where Darry had recently been seen and the police reported that Darry was refusing to take medication. The hospital provided information about CAMHS involvement and the CAMHS team offered an appointment for the next day. Darry was brought to the appointment by mother, maternal grandmother and maternal aunt. During the interview Darry ran off and engaged in a serious self-injurious act/suicide attempt which Darry survived, but now has life changing physical injuries.  2.30 Darry was in hospital for some time. Members of The CAMHS team visited Darry in hospital, provided support and advocated for Darry with other professionals. Darry was assessed by the adult social care learning Disability Team and a full package of support put in place. Darry has now returned home with support from the family, hospital staff and the adult social worker. Independent advocacy has been put in place for Darry.   17  3. The Findings 3.1 The aim of any serious case review is to review the circumstances of one young person (Darry) and their family to explore the professional response to their needs and circumstances and to use this information as a ‘window on the system’; to uncover more general strengths and weaknesses in the safeguarding system. The aim is to establish learning or findings which can contribute to improving practice in the future.   3.2 At the heart of Darry’s story is a question about the most appropriate way of addressing, assessing and meeting the needs of young people who have experienced abuse, witnessed domestic violence who have deteriorating mental health, learning disabilities and for whom self-harm is a means of communication. The Findings that follow largely focus on these big issues. The Findings  1. Professionals need to evaluate the most appropriate action to take to address parents/carers reluctance to accept services designed to improve the circumstances of children and young people 2.  Young people with poor or deteriorating mental health require a holistic multi-agency response which takes account of all the factors that might have caused their difficulties, rather than a focus on the individual young person as the problem.  3. Self-harm is a serious issue which needs robust multi-professional action, management and clarity about who should be the Lead agency. 4. Referrals to Children’s Social Care (CSC) need to make clear the concerns to enable a decision to be made on the best available information. CSC need to provide feedback when concerns are not clear to help the multi-agency network improve. Where it is agreed that referrals do not meet the threshold for CSC services there should be a discussion about alternative courses of action such as an early help response to ensure that children and young people’s needs are met. 5. There is Professional confusion about the Mental Capacity Act (MCA) as it relates to 16-17 year, particularly in the context of parental decision making and professional advocacy.  18  Finding 1: Professionals need to evaluate the most appropriate action to take to address parents/carers reluctance to accept services designed to improve the circumstances of children and young people 3.3 This finding is about the discrepancy noted in this review that mother and family members often talked about feeling unsupported by professionals, and at the same time often refused to engage with services and support offered, both for Darry and the other siblings. This meant that services designed to improve Darry’s circumstances or ensure safety and wellbeing were not always implemented. This issue was not sufficiently discussed, assessed or analysed by professionals; there was a lack of clarity about why this discrepancy occurred and what was the best approach to address it.  3.4 It is not unusual for adults/family members to be reluctant or resistant to engage with specialist services. This has been a key theme of serious case reviews for the last 20 years and there have been a number of national research reviewsi commissioned by policy makers and the Children’s Commissionerii to try and make sense of this and consider how this can be addressed. What emerges is that a reluctance or resistance to engage with services is complex and requires careful analysis to ensure that children, young people and their family’s needs for support and safeguarding are met.  3.5 Poor engagement with services can be caused by parents own needs such as learning disabilities, poor mental health, previous negative experiences of services and lack of understanding of what is being offered.   It can also be caused by a poor professional response, which lacks empathy, poor clarity of role and responsibility and a lack of acknowledgement of power dynamics. Poor engagement can also be an important indicator of child and adolescent neglect. 3.6 Mother did share that she did not always trust professionals and worried about the impact of some services on the family. During discussions with her and the family during the serious case review process it emerged that mother felt that all the professionals that she had contact with were helpful and supportive but that she did not always understand professional language or what some services were or how they might help Darry or the family.  3.7 It is important that professionals work respectfully and in partnership with families, seek to understand resistance or reluctance and address concerns. They need to reflect whether they have been clear what services are, check that they are using appropriate language and 19  ensuring that adults and children understand the support being offered, or concerns being raised.   3.8 It is also important that professionals consider what lack of engagement might mean for the well-being and safety of children and young people. Professionals must feel equipped to be able to challenge adult family members about creating barriers for their children and young people to access appropriate services to children and young people. Finding 2: Young people with poor or deteriorating mental health require a coordinated multi-agency holistic response which takes account of all the factors that might have caused their difficulties, rather than a focus on the individual young person as the problem.  3.9 This Finding looks at the extent to which Darry’s deteriorating mental health was understood and addressed with a holistic and coordinated multi-agency approach.   3.10 Good mental health is the foundation of healthy development in the long term for children and adolescents. Mental health problems, whether these are subject of a formal diagnosis or not, have a significantly adverse impact on children and young peoples’ outcomesiii.  3.11 In order to address mental health difficulties in children and adolescents it is important to try and understand what causes those difficulties. These will vary for each individual, but researchiv suggest that the risk of developing a mental health problem is strongly influenced by social disadvantage, adverse childhood experiences such as abuse or neglect, severe bullying, experiencing and witnessing domestic abuse as well as individual factors such as learning disabilities or autism spectrum disorders.  3.12 This multiplicity of causal factors requires a holistic or ecological approach where risk factors at the societal level, community level, family and individual level are considered and the negative interaction of these factors and the cumulative impact of multiple disadvantage over time is understood.  Good holistic assessment lies at the heart of this, alongside a clear formulationv, a written understanding of causal factors which takes account of all these variables.  3.13 If the wider context or trauma and abuse in which poor mental health develops for young people is not explicitly assessed and does not become part of a holistic formulation leading to a plan of action and 20  understanding, then the focus can become on “what is wrong with you” as opposed to “what has happened to you” and moving towards “how are we going to make things better for you”. This individual problem focussed approach is inevitably self-reinforcing.  Young people can feel responsible for the abuse and harm they have experienced and this can contribute to feelings of low worth and self-esteem; if the assessment and intervention response focusses only on there being something wrong with the individual, rather than the abuse they have experienced this can exacerbate mental health difficulties. Young people’s self-esteem and depression can deepen.   3.14 The multiplicity of causal factors impacting on a young person’s mental health also requires a multi-agency response. Although there were a number of agencies involved with Darry and the family who communicated with each other, a pattern emerged over time of silo working. Each agency undertook its own assessment of Darry, the school, CAMHS, and on two occasions the hospital. These all considered Darry and the family, but these different assessment processes happened in isolation from each other, the assessments were not shared or asked for by other agencies. These assessments led to individual agency plans but at no point was a multi-agency plan developed. This was in part caused by the lack of clarity about an early help response. The school were advised to convene a Team around the Child meeting when they made a referral to children’s social care. This happened and was attended by mother and all agencies involved at that time with Darry. Key issues and future plans were discussed, but no lead professional was agreed and no holistic multi-agency plan formulated. The lack of a Lead Professional or agency also meant the family were often unclear who to contact when there was a crisis and they often had contact with a number of different professionals. There were several follow-on meetings, which were called school reviews, but were actually follow on team around the child meetings.   3.15 This lack of clarity was further exacerbated by those agencies involved with Darry seeking additional help and support from children’s social care and adult services as Darry’s mental health deteriorated. CAMHS made a safeguarding referral and were asked to seek consent, which was not agreed by mother. The school made three referrals to children’s social care and the hospital and police made one referral each. These often led to a link with the children with disability team, who would then ask the adult community learning disability to expedite 21  their involvement. Other agencies also tried to involve the adult community learning disability team. These discussions often focussed on age, or threshold criteria, but none focussed on the needs of Darry or the family. Far from fulfilling the first principle of the QQQQQ Think Family approach and guidance “There should be no ‘wrong door’ t o services”16 the constant discussion between agencies suggested there was no “right door” for Darry and the family.  3.16 There appears to have been a number of factors at play here. Agencies working in silos, carrying out their own assessments and constructing their own plans, without these being shared/coordinated or being asked for by others; confusion about an early help response in the context of a young person’s deteriorating mental health, agencies seeking the involvement of children and adult services, perhaps believing that this was the way that a coordinated approach could be achieved and children and adult services focussing on age eligibility as a way of limiting services rather than Thinking Family and thinking what was the “right door” for Darry and the family. This left Darry and the family without a coordinated and holistic multi-agency plan which addressed the many causal factors. This lack of a holistic assessment and plan meant that the issues of domestic abuse and its impact on Darry and the Sibling was not addressed nor the historic abuse Darry and the siblings were subjected to by father.  Finding 3: Self-harm is a serious issue which needs robust multi-professional action, management and clarity about who should be the Lead agency 3.17 There were considerable concerns about Darry self-harming over the period of this serious case review.  This Finding looks at the professional response to self-harm and the of the need for a specific response to address this very serious issue.  Over the period under review there was a lack of clarity regarding who should take the lead role in assessing and managing Darry’s self-harming behaviour, who should undertake a risk assessment, put an overarching risk plan in place and assess and treat causal factors. This confusion meant that the self-harm was not explicitly addressed. 3.18 Clarity regarding the multi-agency response to self-harm locally is essential because of the serious nature of the issue. One in twelve young people self-harmv i and there is a 50 – to 100 times greater likelihood that a young person who self-harms will attempt suicidev ii. Self-harm is defined as any behaviour that causes harm or injury to someway as a way to deal with difficult emotions caused by something                                                                  16 file:///C:/Users/QQQQQ 22  that is currently happening to the young person or has happened in the past. Self-harm can start as a way to relieve the build-up of pressure from distressing thoughts and feelings. This might give temporary relief from the emotional pain the person is feeling; however, this relief is only temporary because the underlying reasons still remain. Soon after young people might experience feelings of guilt and shame, which can continue the cycle. For this reason, a sensitive and non-stigmatising response to self-harm is required from family members and professionals.  3.19 It is essential that the underlying causes of self harm are addressed to create change for the young person. Self-harm in young people is largely caused by a range of issues such as physical, emotional or sexual abuse and neglect, domestic abuse, bereavement, significant bullying and is often accompanied by depression, anxiety and unresolved angerv iii. There is considerable guidance regarding the management of self-harm and advice about possible interventions. It is essential that a psycho-social assessment of needs is carried out ix and a careful risk assessment focused specifically on the self-harmx. This should lead to an integrated care and risk management plan with a joined-up multi-disciplinary approach.  3.20 This integrated approach did not happen for Darry. There was no risk assessment focussed on the self-harm, there was no multi-disciplinary care plan and no Lead agency or professional. All these were essential. Meetings were organised, but these did not focus on what needed to be in place to address Darry’s self-harming behaviour. This was despite reassurance to the family that support would be provided in the community when Darry returned after being in hospital.  3.21 There were concerns that mother and family members were very negative and dismissive about Darry’s self-harm behaviour indicating that they saw it as possibly attention seeking and linked to personal difficulties. The connections to the experience of abuse and trauma were not made for them or for Darry and they were not signposted to some of the written resources available or helplines.  3.22 The lack of a risk and care plan meant that when the police found Darry wandering in the community they were not clear what their response should be to Darry.  3.23 Children’s Social Care were made aware of these issues through referrals from the school, the police and the hospital but did not see that these concerns alongside allegations of abuse might indicate a 23  need for an assessment, despite the Safeguarding Children Board Procedures Manual highlighting that this should be considered. The child safeguarding procedures say that “any child or young person, who self -harms or expresses t houghts about  this or about  suicide, must  be t aken seriously and appropriate help and int ervention should be offered at  the earliest point 17.  3.24 The periods of hospitalisation and link back to the community were an opportunity to think about what was in place and whether this was helpful to Darry. This review did not happen clearly enough, and the links between crisis care and support in the community was insufficient, leaving the family and Darry feeling they were in constant crisis. The care and risk plan could have helped with this. 3.25 The NICE Guidelines on the management of self-harm in young people proposes that Tier 3 Mental health service should generally be responsible for the needs and risk assessments, overseeing the longer-term care plan and should fulfil the Lead Professionals role for the coordination of the required mulita-agency services18. Locally there is a need for clarity about the multi-agency response to self-harm who should lead this work and how it will be resourced. Finding 4: Referrals to Children’s Social Care (CSC) need to make clear the concerns and enable a decision to be made on the best available information. CSC need to provide feedback when concerns are not clear to help the multi-agency network improve and to ensure that children and young people are safeguarded It  is important not to conflate information sharing with communication. Communication is t he process by which information is t ransferred from one person t o anot her and is underst ood by bot h parties (Reder and Duncan, 2003xi;) 3.26 Serious case reviews have highlighted the importance of effective communication between agenciesxii to ensure that children and young people’s needs and well-being are assured. This is particularly important when agencies are making a referral to children’s social care about either a child or young person being in need or at risk of harm. Researchxiii suggest that there can be problems in the interface between those making a referral and those receiving a referral.                                                                   17 http://www.proceduresonline.com/QQQQQ 18 Mental health services (including community mental health teams and liaison psychiatry teams) should generally be responsible for the routine assessment and the longer-term treatment and management of self-harm. In children and young people this should be the responsibility of tier 2 and 3 CAMHS . https://www.nicQQQQQ  24  3.27 CAMHS were appropriately concerned about information that Darry was being physically and emotionally abused by father and decided to contact children’s social care. They did not discuss this with mother to make clear why they were concerned and why a referral to Children’s Social Care might help. Telephone contact was made and the absence of a written referral makes it hard to be clear what information was actually shared. The advice given was that consent needed to be sought and when this was done mother refused for the referral to be made. This required more discussion and gentle challenge to mother about the wellbeing of Darry and the other siblings. If this challenge had been unsuccessful the referral could still have been made if the belief was that the abuse had gone unaddressed. Given the level of concern about current physical abuse, mother described father dragging Darry across the floor by the hair, this referral should have led to a strategy discussion. It appears that the concern regarding possible significant harm got lost in the interface between the referrer and the receiver of the referral. This should have led to more challenge to children’s social care in the context of their stated and agreed multi-agency thresholds. 3.28 The school also made a written referral to children’s Social Care about their concerns for Darry. This was prompted by concerns regarding mother’s very negative and punitive attitude towards Darry’s self-harming. They were right to be concerned about the impact on Darry. This primary concern got lost in the detail of the referral. School had not sought consent because they were concerned about mother’s attitude, but they were asked to do so. At this stage mother had disengaged from communicating with the school because she reported feeling overwhelmed and unsupported.  This all needed untangling to establish whether the reasons for mother’s reluctance and how this could be addressed.  3.29 There should have been a discussion between the agencies about what next steps would be for Darry and the family if a referral was not accepted; this happened once and was helpful. The principles of the Think Family approach suggest that it is all agencies responsibility to think carefully about what services would help. 3.30 Good quality written referrals need to make clear the likelihood or reality of the harm being experienced by the child or young person giving a succinct, but clear summary and analysis making use of the QQQQQ Threshold Guidance and the descriptors of harm and abuse 25  contained in Working Together 2015. Information should be provided about the reason for the referral, why the child or young person is at risk or in need, what action has already been taken and why this has not addressed the concerns. It is important that an overall professional analysis and judgement of the concerns is provided to enable an appropriate decision to be made. This means moving beyond the provision of facts but making sense of the information in the context of what the agency knows about the child and what the current concerns mean for their well-being and safety.  3.31 If these concerns are not clear, there is a responsibility on children’s Social Care to provide appropriate feedback. It is then the responsibility of the referrer to appropriately question decisions that they believe do not meet the needs of the child or young person and to use the escalation policy where professional discussions are unsuccessful. 3.32 This finding serves as a reminder of getting this interface right for children and young people.  Finding 5: Professional understanding of the Mental Capacity Act (MCA) as it relates to 16- 17 year, particularly in the context of parental decision making and professional advocacy “The focus of t he Mental Capacity Act  2005 (MCA) is not  about  how t o make decisions for young people, but  it is about  developing a cult ure of care t hat serves t o maximise young people’s capacit y, support  t heir decision making and advocat e for t hem so t heir voice is heard” 3.33 This Finding looks at the application of the principles and practice of the Mental Capacity Act 2005 for Darry who was aged 17. The Mental Capacity Act 2005 came into force in 2007 and applies to anyone in England and Wales who is aged 16 or over. The MCA is primarily about people’s rights to make decisions and choices for themselves with the assumption that they have the capacity to do so; it is also about the right to have decisions and choices made in a person best interests if they lack the mental capacity to be able to make those decisions for themselves.   3.34 For young people aged 16/17 the underpinning assumption is the same; that they will have capacity to make decisions about their care and treatment and will be provided with all possible support to do so. It is the responsibility of professionals to determine whether a young person does not have capacity to make a decision or give consent to 26  treatment/interventions and to make an explicit assessment of this which is recorded on each occasion it is required. In regards to young people aged 16/17 those with Parental Responsibility (PR19) can make decisions on behalf of a young person as long as they are seen to sit within the zone of parental control (ZPC20). There is no statement about which decisions come into the ZPC but the Mental Health Act 1983 code of practice21 suggest that there are three key principles for professionals to bear in mind.  “Is t he decision one t hat a parent  could be expect ed t o make: are t here any indications that the parent might not act in the young person’s interests and t he nature/invasiveness of what is being proposed.” 3.35 When Darry came to the attention of CAMHS and hospital services Darry refused to speak or engage with professionals.  This was why non-verbal therapy was proposed. This lack of engagement meant that mother made many of the decisions about treatment choices and plans.  The first decision mother made regarding services for Darry was about a possible referral to children’s services regarding allegations of physical and emotional abuse by father. Mother refused consent; this should have prompted an assessment of Darry’s mental capacity, and if Darry was found to lack capacity a consideration of whether this referral was in Darry’s best interests. The point here is that professionals needed to explicitly note whether Darry could consent to the referral, whether it fell within the zone of parental control and what could be done to advocate for Darry.  3.36 In October 2016 Darry ran away from home and was found by the police in a dishevelled state. Darry was taken to hospital and refused to speak to professionals. Mental Capacity was not explicitly assessed and the decision was made that Darry should return home. Mother and family members were advised to lock the windows and doors and supervise closely. There was no timescale put on this and this plan was never discussed with those providing support in the community. Mother and family members believed that this was a permanent decision rather than a short-term crisis plan to keep Darry safe over the                                                                  19 Parental responsibility is defined in law as “all the rights, duties, powers, responsibilities and authority, which by law a parent has in relation to the child and the administration of his/her property.” 20 The 2007 amendments to the Mental Health Act 1983 and their accompanying Code of Practice produced new guidance  on the limits of parental influence over young people's ability to consent. The 2007 amendments to the 1983 Act has formalised what was previously left open to balanced professional interpretation of the implications of Parental responsibility and the Mental Capacity legislation. 21 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/435512/MHA_Code_of_Practice.PDF 27  weekend because in-patient care would not be appropriate for her needs. In the short term this plan was in legal terms the least restriction option to keep Darry safe. In the longer term this amounted to a possible Deprivation of Liberty for Darry which needed more discussion in the context of Darry’s Mental Capacity.  3.37 The Cheshire West ruling in 2014 provided the acid test for definition of Deprivation of Liberty, namely the need to ask the question “is the person under continuous supervision and control and not free to leave”; if this is so then it is a Deprivation of liberty. The Legal Framework in place at the time did not allow parents to deprive 16/17-year olds of their liberty through the zone of parental control, though this ruling has subsequently changed. In this context at the time this incident took place mother had no authority to carry out the instructions to prevent Darry from leaving the house or closely supervising Darry. (In June 2015 the High Court ruled in Re D1 that a person with parental responsibility may consent to the deprivation of their child’s liberty where it falls within the ‘zone of parental control’22). 3.38 The application of the principles and practice of the Mental Capacity Act 2005 to the world of 16/17 year olds is very important. Issues of autonomy and control over decision making and choices regarding care and intervention for this age group are essential, particularly where these young people have been abused and where by definition control and autonomy have been undermined. This Finding recognises the complexity of decision making for young people, but highlights the importance of routine Mental Capacity Assessments, an informed approach to what comes within the zone of parental control and when advocacy or a best interests meeting/discussion is required.                                                                     22 https://www.rlb-law.com/briefings/healthcare/the-zone-of-parental-control-deprivation-of-liberty/ 28  Appendix 1: Chronologies were sought from and received from:   Schools attended by Darry QQQQQ Council Children’s services QQQQQ Council Adult Services QQQQQ Health Trust  QQQQQ Police SEND QQQQQ Community Partnership GP  QQQQQ Partnership NHS Trust     29  Appendix 2: About the Independent Reviewer and overview author: QQQQQ, is accredited in systems learning and the SCIE “Learning Together” model and is an experienced independent investigator and safeguarding lead who has undertaken many Serious Case Reviews nationally over the last XXXXX years.  QQQQQ has a professional background in social work, training and policy development.  XXX has never worked for any agency in QQQQQ and is completely independent.   30  Appendix 3: Review Panel   Organisation Title  Independent Author QQQQQ Local Safeguarding Children’s Board Independent Chair  QQQQQ Assistant Director, Support and Safeguarding Children  QQQQQ Council Service Leader, Strategic Safeguarding and Quality Assurance  QQQQQ Council Prevention and Re-engagement Service Leader and Virtual School Head teacher   QQQQQ Council Safeguarding in Education Training Officer  QQQQQ Council Safeguarding Adults Manager  QQQQQ Designated Nurse for QQQQQ  QQQQQ Health Area Trust Designated Nurse QQQQQ Police Chief Inspector     31  References: i Fauth, R. et al (2010) Effective practice to protect children living in 'highly resistant' families: knowledge review 1. C4EO ii QQQQQ iii DOH (2015) Future in mind: promoting, protecting and improving our children and young people’s mental health and wellbeing file:///C:/Users/richa/Documents/QQQQQMental_Health.pdf iv Professor Dame Sally C Davies Chief Medical Officer annual report 2012: children and young people’s health; Chapter 10 Mental health problems in children and young people; Murphy and Peter Fonagy https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/252660/33571_2901304_CMO_Chapter_10.pdf vMacneil et al (2012) Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice Craig A BMC Medicine 2012, 10:111 file:///C:/Users/richa/Documents/QQQQQpdf v i Young Minds: Self Harm Your guide to self-harm and getting the help you needhttps://youngminds.org.uk/media/1519/youngminds-self-harm.pdf v ii Royal College of Psychiatry (2010) Self-harm, suicide and risk: a summary: https://www.rcpsych.ac.uk/pdf/PS03-2010x.pdf v iii https://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/parentscarers/self-harm.aspx ix https://www.nice.org.uk/guidance/CG133/chapter/1-Guidance#psychosocial-assessment-in-community-mental-health-services-and-other-specialist-mental-health x https://www.nice.org.uk/guidance/CG133/chapter/1-Guidance#psychosocial-assessment-in-community-mental-health-services-and-other-specialist-mental-health xi Reder, P and Duncan, S (2003) Understanding communication in child protection networks. Child Abuse Review. Volume12, Issue2 xii Sidebotham et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014; Department for Education  https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/53382 6/Triennial_Analysis_of_SCRs_2011-2014___Pathways_to_harm_and_protection.pdf    xiii Broadhurst, K et al (2010) Ten pitfalls and how to avoid them: What research tells us. NSPCC  https://www.nspcc.org.uk/globalassets/documents/research-reports/10-pitfalls-initial-assessments-report.pdf                                                                   