Death of 17-year-old boy after his arrest for illegal entry into the UK and subsequent placement in foster care a day earlier. YT was found in the back of a cargo lorry in Enfield on 8th July and was taken into police custody. Once it was established YT was a child a foster placement was sought and he was taken to a foster family the same day. The foster family struggled to communicate with YT but were planning to introduce him to another Eritrean the next day. Late the next evening YT was found dead in his room hanging from the curtain rail. None of YTs family are in the UK and it is unclear how he was travelling to the UK. As YT had only been in the country for one day, and there was a language barrier there is very little known about him and his situation. Recommendations include reviewing out of hours emergency child protection to record all aspects of vulnerability, ensure the voice of the child is heard and facilitate effective communication.
      
 Title:  Serious case review: ‘YT’. LSCB: Enfield Safeguarding Children Board Author: Richard Henson Date of publication: 2017  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.                           Enfield Safeguarding Children Board       SERIOUS CASE REVIEW:  ‘YT’            INDEPENDENT AUTHOR: RICHARD HENSON BA (HONS)    Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 2 of 28   Table of Contents: Chapter  Page No’s 1 Introduction 3 2 Scope of the SCR 3 3 Family composition 4   4 Arrangements for the SCR 4 - 5 5 Methodology for this SCR 6 6 Key events 7 - 10 7 An examination of any issues, in communication, information sharing or points of contact between: • YT and any agency • YT and the foster carers • Within or between services, to include those with responsibility for working out of hours, as well as those working in normal office hours and with particular reference to their knowledge of the processes (both national and local) for supporting an unaccompanied asylum seeking child? 10 - 14 8 Was the work in this case consistent with each organisation’s policy and procedures for safeguarding and promoting the welfare of an unaccompanied asylum seeking child and with wider professional standards? 15 - 18 9 What were the key relevant points / opportunities for; assessment, decision-making and effective intervention in this case in relation to YT?  What was the quality and timeliness of interventions and decision-making? Was there more that could have been done? 18 - 20 10 Were professionals aware of ‘what it was like to actually be that child’, sensitive to the needs of an unaccompanied asylum seeking child, knowledgeable both about potential indicators of abuse and mental health and about what to do if they had concerns about a child’s welfare? 20 - 22 11 Was practice sensitive to an / or influenced by the racial, cultural, gender, sexuality, linguistic and religious identity and any issues of disability of YT and were these explored, taken on board and recorded? 23 - 24 12 Conclusions 24 - 26 13 Recommendations 27 Appendix 1 Section 46 Children Act 1989 (Police Protection) 28 - 29  Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 3 of 28     1.  Introduction 1.1 YT, an Unaccompanied Asylum Seeking Child (UASC) presenting as a 17-year-old male from Eritrea first came to the notice following his arrest in Enfield, London on the 8th July 2016. After initial assessment and investigation of his situation he was placed under ‘Police Protection’ and looked after in emergency foster care commissioned by Enfield Children’s Social Care Emergency Duty Team (EDT). The following evening (9th July 2016), at approximately 9pm YT was found by his foster carers hanging in his bedroom. He was dead. The circumstances indicated that the death was a suicide.  1.2 This death of a ‘child in care’ therefore met statutory requirements for a Serious Case Review (SCR). An extraordinary meeting of the Enfield Safeguarding Children Board (ESCB), Serious Case Review Sub-Committee consisting of senior representatives from relevant agencies was held on 5th August. After discussion and consideration, the ESCB Independent Chair; Geraldine Gavin formally confirmed the decision to commission this review.  1.3 The SCR purpose is; • To establish what lessons are to 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; • To 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 • To improve intra and inter-agency working and better safeguard and promote the welfare of children. 2.   Scope of the SCR 2.1 This SCR is focused on events between the dates of 8th July 2016 – 9th July 2016. This timeframe was agreed to reflect the period from YT being known to services in the United Kingdom (UK) up until the date of his death. 2.2 This SCR does not have within its own terms of reference latitude to comment on national or global drivers that are behind the international migration / asylum seeking of young people from Eritrea to European and other developed countries. However, a recent UK Home Office report is available. 1 Global human migration patterns and causes fall outside the published guidance on reasons for conducting SCRs2.                                                            1Report of a Home Office Fact Finding Mission Eritrea: illegal exit and national service Conducted 7–20 February 2016 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/543863/Report_of_UK_FFM_to_Eritrea__7-20_February_2016.pdf  2 Working Together to Safeguard Children (2015), referred to in this report as “Working Together”.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419595/Working_Together_to_Safeguard_Children.pdf  Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 4 of 28   3. Family Composition 3.1 Name of Child: YT, assumed to be aged 17 (Working DoB: 01/01/1999) 3.2 Family members:  Little information of substance has been established in respect of family members. It is believed that his parents are Eritreans and remain resident in Mende Fera, Southern Region, Eritrea. No family members are believed to be present in the UK however following YT’s death the Metropolitan Police have contacted a brother who is residing in Oklahoma in the United States of America (USA) and a cousin who lives in Milan, Italy. These individuals are also understood to be asylum seekers. Father:  MT  Mother: EA A family friend, Mr. FM and his daughter LM who are resident in the UK have been spoken to by the police. At this stage a formal identification of YT’s body remains to be made.      4. Arrangements for the SCR 4.1 The ESCB convened an SCR Panel (the Panel), consisting of senior representatives from relevant agencies, to inform the Review. Panel meetings were chaired by Geraldine Gavin the Independent ESCB Chair.  This is the Overview report of this SCR and has been completed by an Independent author – Richard Henson BA (Hons). 4.2  A background note: Information obtained by HM Inspector, Nexus Custody Immigration Enforcement suggests that YT had been amongst a larger group of Eritreans who had concealed themselves in a Hungarian registered lorry that was transporting a cargo of wheelie bins. Prior to being stopped and searched at Calais the vehicle had stopped in St Hiliare des Cottes, Northern France. No personal identity details of persons in that group are known by UK authorities. It is possible that YT was overlooked in the search by the French officials and remained concealed in his hiding place until arrival in Enfield. The lorry did not stop in Dover. In any event, it is highly unlikely that any asylum seeker would have joined a lorry once in the UK as they could make an asylum claim immediately on arrival.   4.3 All relevant agencies were required to submit an Individual Management Review (IMR), on a template containing the following headings; 1. A summary of their agency involvement (what was the agencies’ involvement with his child and family? Include dates).  2. Response to specific questions as identified in the Terms of Reference (including reference to the general questions at 4.1 of the terms of reference and the agency specific questions at 4.2 of the TOR.  3. Summary and Analysis (what do we learn from this case?). 4. Recommendations.   Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 5 of 28   Table of agencies contributing to the SCR: AGENCY NATURE OF INVOLVEMENT London Borough of Enfield Children’s Social Care Services (CSC) Emergency Duty Team attended police station and arranged for young person to be accommodated in foster care Metropolitan Police Service (MPS) Territorial Police covering London Boroughs of Enfield, Haringey and Barking & Dagenham deal with custody, child protection, transport and rapid response to unexpected death of the young person  Future Fostering: - an Independent Fostering Agency Provision of care and accommodation services for the young person and support training to foster carer family  United Kingdom Border and Immigration Agency (UKBA) Nexus Custody Policy and approach for unaccompanied child asylum seekers / migrants London Ambulance Service Trust  Response to 999 call and attendance at death scene of sudden unexpected death of a child (SUDC) The East London Coroner, Waltham Forest Coroners Court* Post death arrangements and information ongoing family liaison / communication * There was no individual report submitted by the Coroner but relevant information was supplied through the MPS representative to the SCR panel   4.4 The Terms of reference for this SCR are outlined as; • What was the agencies’ involvement with this child and family? • Analysis of agency involvement • What do we learn from this case? • Recommendations for action  4.5  Five specific questions are to be covered in the scope of the SCR: Q1. An examination of any issues, in communication, information sharing or points of contact between: • YT and any agency • YT and the Foster Carers • Within or between services, to include those with responsibility for working out of hours, as well as those working in normal office hours and with particular reference to their knowledge of the processes (both national and local) for supporting an unaccompanied asylum seeking child? Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 6 of 28   Q2. Was the work in this case consistent with each organisation’s policy and procedures for safeguarding and promoting the welfare of an unaccompanied asylum seeking child and with wider professional standards?  Q3.  What were the key relevant points / opportunities for; assessment, decision-making and effective intervention in this case in relation to YT?  What was the quality and timeliness of interventions and decision-making? Was there more that could have been done? Q4. Were professionals aware of ‘what it was like to actually be that child’, sensitive to the needs of an unaccompanied asylum seeking child, knowledgeable both about potential indicators of abuse and mental health and about what to do if they had concerns about a child’s welfare? Q5. Was practice sensitive to and / or influenced by the racial, cultural, gender, sexuality, linguistic and religious identity and any issues of disability of YT and were these explored, taken on board and recorded? 5. Methodology for this SCR   5.1 This report is based principally on the response to the questionnaire from participating agencies, background information gathered to assist the Rapid Response to SUDC and Child Death Overview Panel (CDOP) and subsequent Panel discussions with the concerned agencies representatives. 5.2 This overview consists of; •  A factual context of key events within a brief chronological narrative; •  Commentary on the family situation and their input to the SCR; •  Analysis of the part played by each agency and of their submissions to the SCR; •  Closer analysis of key issues arising from the review; and •  Conclusions and recommendations.  5.3  The conduct of the SCR has not been determined by any single theoretical model but it has been carried out in accordance with the underlying principles of the statutory guidance, set out in Working Together and in accordance with the ‘Wood’ recommendations providing LSCBs with greater flexibility in how to approach SCRs on a case by case basis.  5.4 The review, recognises the complex circumstances in which professionals work together to safeguard children. It seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did. It seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than relying upon hindsight, except where hindsight promotes a fuller understanding of the events and causation. It is transparent about the way data is collected and analysed; and will reference relevant research and case evidence to inform the findings  5.5 The government has introduced arrangements for the publication of Overview Reports from SCRs, unless there are reasons why this would not be appropriate. This report has been written in the anticipation that it will be published. 6. Key events Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 7 of 28   6.1 On Friday 8th July 2016 a Hungarian lorry driver who had driven a heavy goods vehicle (HGV) via Calais, France – Dover UK, discovered YT amongst the cargo in the back of the trailer. The HGV had arrived at its destination, a freight company depot located at Duck lees Lane, Enfield. This location is a short distance from the M25 motorway and inside the local authority area of the London Borough of Enfield. The Metropolitan Police (MPS) were called and uniformed response officers arrived around about 4pm. 6.2 The police officers from Edmonton Police Station believing YT to have entered the UK illegally, arrested him, placed him in handcuffs and escorted him in a police vehicle to the custody suite at Wood Green Police Station where his detention was authorised by the custody officer at 5.10pm 6.3 Custody procedure is a statutory process and the police must comply with procedures outlined within the Codes of Practice for The Police and Criminal Evidence Act 19843. During the custody procedure, a written electronic custody record is completed containing all relevant information. As YT did not communicate in spoken English the police used a translation service provided on the telephone by ‘LanguageLine. Using this interpretation service YT could communicate with the police. By using this service the police established that YT was Eritrean and spoke the Tigrinya language4. The custody record includes information provided by YT that he was a 17-year-old Eritrean national and that he was seeking asylum in the UK. There was no other opportunity for police to verify this information as YT had no identification papers or other records with him. Police officers are trained to be professionally skeptical and to collaborate information from all available sources including professional judgement. YT’s’ demeanor and his physical appearance meant that the police retained some doubts as to his actual age.  6.4  Other personal information was also gathered and recorded by the police including several questions relating to his vulnerability, health and wellbeing. Police are required to establish contact details for parents or responsible adults when children (persons under the age of 18) are in custody situations. YT claimed that he was alone with no relatives in the UK. There are some countries where it is compulsory for police to notify respective Embassy’s or Consulates of the detention of their nationals. There is no such requirement in place for Eritrean citizens and YT had answered that he did not wish to communicate with his Embassy.   During the detention process the police contacted staff from the Home Office Immigration Enforcement Service – Nexus Custody. 6.5 An Immigration Officer was not present at Wood Green Police Station (which is often the case as they may be deployed to deal with immigration cases at other police stations in the area). However, advice was given to the police that YT should be referred to the local authority Children’s Social Care (CSC) team. This was for promoting welfare / safeguarding and for an age assessment to be considered if there was continuing doubt                                                            3 The Police and Criminal Evidence Act 1984 (PACE) is an Act of Parliament which instituted a legislative framework for the powers of police officers in England and Wales to combat crime, and provided codes of practice for the exercise of those powers Part V1 of PACE required the Home Secretary to issue Codes of Practice governing police powers. The aim of PACE is to establish a balance between the powers of the police in and the rights and freedoms of the public 4 Tigrinya, the correct spelling of which is Tigrigna is spoken by the Tigrayans and Tigrinyas of the Horn of Africa. Most Tigrigna speakers, close to 6 million, inhabit the northern region of Ethiopia known as Tigray. The remaining 3 million of the total 9 million Tigrigna speakers primarily inhabit Eritrea. This group is specifically known as the Tigrinyas in Eritrea. Tigrigna is also spoken by groups of emigrants from these regions.  Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 8 of 28   about YT’s actual age. This is known as a ‘Merton compliant age assessment’5 No papers relating to immigration enforcement were served on YT. These would have been served if an Immigration officer was present prior to YT’s departure from Wood Green Police Station.  6.6 Consequently, YT was released from arrest by the police and the custody record closed as ‘No further action’. He was instead regarded as a vulnerable child likely to suffer significant harm if not assisted by the authorities and placed under ‘Police Protection S. 46 Children Act 1989 (Appendix 1). The Designated Officer was a police Inspector who instructed that Enfield CSC be informed of the situation including the uncertainty that remained for the police over YT’s actual age. It was noted that if CSC also felt there was doubt then a police Forensic Medical Examiner (FME) should be called to assist with an age assessment. The police officers then returned to the Borough of Enfield (Edmonton Police Station) with YT to liaise with Enfield CSC.  6.7 YT was accommodated in an interview room where he remained under escort of the police officers. He was not in detention but remained in a situation where police were being vigilant and mindful of the need to transfer responsibility to CSC. His physical presence was needed so that a social worker could complete an assessment and decision from CSC. During this period YT was seen to act in an agitated way and at one stage he stood up and punched a wall in the interview room causing a small dent. The police officers attempted to calm YT but communication due to the language barrier was difficult. The officers decided it was necessary to place handcuffs on to YT’s wrists and they did so in the ‘front stack position’. This meant that YT could sit down but that his arms were in front of him, slightly crossed at the wrists with one above the other. This can be considered as the officers applying force but using a restraint position that offers the least discomfort to the individual.  The police officer’s stated intention was to prevent YT injuring himself (There was no visible injury to either of his hands from the punch to the wall) and to calm him down whilst awaiting the social worker. The police officers recorded their actions and rationale in their notes. There were no further aggressive outbursts with the potential to cause physical injury to YT while at the police station.     6.8 A social worker from the Enfield CSC Emergency Duty Team (EDT) attended at Edmonton Police Station at 7.50pm CSC having been contacted at 6.49pm and provided with some outline information on the circumstances. The police had also used Language Line to gain additional background information from YT and heard that he had no one to look after him or provide any form of shelter in the UK. They were told that he may have a brother in Milan, Italy. The social worker sought advice from the Enfield CSC Head of Service (for Assessment) on the matter of conducting an age assessment. They were advised that if at all in doubt then to err on the side of caution towards childhood and to accept responsibility for treating YT as an Unaccompanied Asylum Seeking Child (UASC).  6.9 The police officers dealing with YT had changed over (shift rotation) by the time of arrival of the EDT social worker. The social worker noted that YT did not look to be angry but appeared to be somewhat frustrated. At the arrival of the social worker YT was released from the handcuffs. In the opinion of the social worker, YT’s age was around 17 / 18 years and not significantly older than this. Communication in Italian was attempted by the social worker (as the information from the LanguageLine translator was that he had spent some time in Italy with his brother) but this was unsuccessful as YT did not understand Italian. The priority at this stage for CSC was to identify an appropriate care placement for YT so                                                            5 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/257462/assessing-age.pdf Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 9 of 28   that they could place him safely before undertaking assessment work and processes associated with registration as an UASC.  6.10  The social worker left YT with the police officers while colleagues contacted various foster care agencies for a placement. This was achieved at approximately 10.30pm with an Independent Agency - Future Fostering. A social worker using the brief details available to them spoke to the Foster Parents and it was agreed that they would be able to look after YT initially to Monday 11th July 2016. The location of the Foster Carers home was in the London Borough of Barking and Dagenham. The details of the address were telephoned to the police officers who were still looking after YT and they agreed responsibility for driving him to the foster carers home. 6.11 Shortly before midnight on Friday 8th July 2016 police arrived at the house with YT. He had very few personal belongings but did possess a mobile phone. Before they left the premises the police officers again utilised LanguageLine so that the Foster Carers could communicate with YT to let him know that he was going to be staying with them and to also gather some additional information on his needs.  This included information that he had no special dietary requirements apart from not eating pork, that he was not ill or on any medication. He indicated that he was of Christian faith and he was not allergic to anything. After this the police officers departed leaving YT with the foster carers.  The foster carers told YT that they knew of another Eritrean boy who was also being looked after in foster care and that they would attempt to introduce them to each other the following day.  6.12 The carers contacted their agency at 12.45 am informing them that they had YT with them.  YT was shown to a single bedroom on the 1st floor of the four-bedroomed dwelling house This room was for his sole use. Before going to bed he took a shower and was provided with some clean clothes by the carers. 6.13 Also living with the foster carers were their own birth son (aged 14) and another young person (aged 18) who was in a placement as part of ‘The Staying Put Scheme’6. Neither of these young people ever met YT.  6.14 On Saturday 9th July YT awoke and ate breakfast in the kitchen / dining room.  He managed to communicate to his carers that he needed a charger with a UK electric plug for his mobile phone. The carer agreed to provide a compatible one later that day. Although communication was limited YT indicated that he would like to speak to the Eritrean boy they knew. However, they had yet to get in touch with this person and were still trying to arrange this. YT returned to his room and went back to bed. He re-emerged about 3.30pm for a short while before once again returning to his room. The foster carer sensed some frustration in YT and believed that this was caused by communication issues. They had attempted to use the internet to download a translation service for English / Eritrean but this was unsuccessful. 6.15 Around 6.30pm the foster carer tried to call YT downstairs for supper. He responded verbally but didn’t leave his room. At 8.30pm the foster carers husband returned home and she asked him to go to YT’s bedroom to bring him down stairs for something to eat.  6.16 On entering the bedroom the carers found YT hanging from a curtain rail by his own shoe laces tied around his neck. He was lifeless but the foster carers cut down his body and lay it on the bed while called the emergency services via 999 at 9.05pm                                                            6 https://www.gov.uk/government/publications/staying-put-arrangements-for-care-leavers-aged-18-years-and-above Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 10 of 28   6.17 The carers attempted to revive YT and on arrival of the London Ambulance Service (LAS) the carer was performing cardio pulmonary resuscitation (CPR) on the body.  6.18 The assessment by the LAS paramedics of YT found his jaw was rigid, his tongue swollen and a deep ligature mark to his neck, there was evidence of rigor mortis and a low body temperature. Verification of the Fact of Death was recorded as 9.16pm on Saturday 9th July 2016. 6.19 The police had also been called to the foster carers address and a rapid response to the sudden and unexpected death of a child commenced. The Coroner’s office was contacted and other concerned parties including Social Care and the Fostering Agency notified. At about 01.30am on Sunday 10th July YT’s body was removed to the mortuary.  6.20 A post mortem examination was undertaken on the instructions of the Coroner for East London. No signs of abuse or issues arousing suspicion of unlawful activity were noted by the examination. The cause of death was recorded as ‘Suspension’.     7. An examination of any issues, in communication, information sharing or points of contact between: • YT and any agency • YT and the foster carers • Within or between services, to include those with responsibility for working out of hours, as well as those working in normal office hours and with particular reference to their knowledge of the processes (both national and local) for supporting an unaccompanied asylum seeking child? 7.1 YT came into direct contact with officers from two agencies, the Metropolitan Police Service and London Borough of Enfield Emergency Duty Team. He was also subject to decisions made by managers from the Home Office Immigration Enforcement (Nexus Custody) and London Borough of Enfield Children’s Social Care Department. 7.2 YT could not communicate effectively by using the English language. The circumstances of his discovery in the back of a HGV that had just arrived at its destination after travelling through France were sufficient grounds for police officers to suspect that he was committing immigration offences. These circumstances also provide justification for his arrest and for initial detention in the custody suite at Wood Green Police Station pending investigation by immigration officers from the Nexus Custody team. 7.3 The police appear to have fully followed the custody procedure and used the telephone translation service ‘LanguageLine’ to facilitate communication with him. LanguageLine is an independent company and provides the MPS commissions its service on a 24hrs basis to facilitate communication for all kinds of policing purposes.     Extract taken from LanguageLine website: LanguageLine Solutions (LLS) has over twenty years’ experience of providing high quality language services to the Criminal Justice sector.  LLS carries a proud history of association with the police sector and currently provides legal translation for all police forces across England, Scotland, Wales and the Republic of Ireland. LLS aims to provide a solution for all situations where a language barrier may exist. From assisting emergency services in life threatening situations to Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 11 of 28   supporting the local policing teams as they engage with an increasingly diverse community. To achieve this, the organisation offers a wide range of legal translation services that are continually developed according to the needs of its client base.  Over the last two decades, many of LanguageLine Solutions services and systems have been developed to meet the specific requirements of the Criminal Justice sector. 7.4 The custody process requires a police sergeant to record substantial details of the detained person including place and date of birth. There is also a series of questions that must be answered in relation to the arrested persons’ health and wellbeing including fitness to be detained.  7.5 YT had no identification documents to confirm his age and the police remained sceptical that the age of 17 years and date of birth (12/01/1999) were true. Age is an important factor in investigating immigration offences as there are significant differences in how the authorities must respond to asylum claiming children and adults.  7.6 Additionally, children in custody situations must be treated differently to adults as they are vulnerable by virtue of age. Parents or other ‘Appropriate Adults’ are called into the custody situation when children are detained to facilitate communication and ensure the welfare of the child is safeguarded.  7.7 The role of any appropriate adult is distinct and a separate function to that of a lawyer or legal advisor. A lawyer cannot assume the role of appropriate adult for a young person in police detention.  7.8 YT’s age was communicated to the Immigration officer and the police were advised that as he appeared to be making a claim for asylum as a minor (a child) a referral to social services should be made. 7.9 In this situation, the advice from the immigration officer to police was followed and by releasing YT from arrest and placing him into ‘police protection’ the requirement for an appropriate adult and the potential introduction of a lawyer were negated. The police officers in line with their responsibilities under S46 Children Act 1989 contacted Enfield Social Services.  The immigration officer was advised that YT had been taken into police protection and would be placed into the care of Enfield CSC. 7.10 The EDT Social workers sought advice from senior managers as to approach and making an age assessment and they followed this. A social worker personally visited YT and made an initial assessment relying on his own professional judgement. As there was some information indicating that YT had Italian connections there were attempts to speak with him in Italian.  7.11 The police officers had decided it was necessary to restrain YT with handcuffs following an outburst in which he had punched the wall in the interview room where he was being kept while awaiting the social worker. The officers interpreted YT’s actions as a sign of his frustration with the situation he was in. The handcuffs were removed following the arrival of the social worker. 7.12 Enfield EDT found an emergency foster placement for YT. Identifying suitable placements for children placed into police protection is a challenging matter for Local Authorities (It is outside this SCRs’ terms of reference to examine that issue in a greater depth).  7.13 The information used by Enfield EDT in seeking a suitable placement appears to have been very limited. The information made available was recorded by a manager at ‘Future Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 12 of 28   Fostering’ agency at 10.42 pm on a Friday evening. Essentially this was; ‘Enfield CSC were seeking a short-term placement (a weekend) for a 17-year-old Unaccompanied Eritrean Asylum seeking child of whom there was some doubt as to his actual age’. Little other information was provided, including to the fostering agency’s question of whether clothing provision was required.  7.14 The Future Fostering manager contacted the foster carers by telephone and they agreed to accept the placement based on the scarce details made available to them. Future Fostering asked the foster carers to gather additional information, including his name and date of birth once YT had arrival at their home and to telephone it through to them. This communication did not take place until 00.45 on Saturday morning. 7.15 The police had initially contacted Enfield EDT at 6.49 pm on Friday evening from Edmonton Police Station providing brief details of the circumstances leading to Police Protection being taken and including YT’s date of birth. This information was also that he had no family or friends present in the UK and would need accommodation but that police retained some doubts as to his actual age. On arrival at Edmonton Police Station at 7.50pm the social worker commenced an assessment.  7.16 Once the placement had been identified a telephone call between the Enfield EDT and the foster carers was held. This was an opportunity for additional information to have been requested or to be passed between agency professionals. It could also have been used to identify any important information gaps, including the current risk assessment.  7.17 The police officers were provided with the foster carers address and drove YT to the house arriving before midnight. Once again, the police utilised the LanguageLine service to facilitate communication between all parties and allow the foster carers to ask YT questions and to explain their role. There is evidence that the foster carers attempted to reassure YT and to make him feel less isolated e.g. They knew another Eritrean boy and explained to YT that they would take steps to bring them together the following day. 7.18 However, there does seem to have been some miscommunication as the foster carers attempted to facilitate communication in Italian language on an internet translation service when the police and social workers had previously established from YT that he did not speak Italian. 7.19 CSC was aware of its responsibility to support YT in respect of his UASC status and the need to initially prioritise his safety and promote his welfare through a suitable placement in foster care.  7.20 There are established procedures for dealing with UASC. The physical absence of an officer from Home Office Immigration Enforcement (Nexus Custody) at Wood Green Custody suite to serve papers on YT does not appear to have altered the timeline in which he was quickly released from police custody and care arrangements being implemented.  7.21 Accepting that it will not always be possible (due to other demands and out of hours times) to have an Immigration Officer present when a UASC is bought into a police station it would nevertheless be of great assistance to those with responsibility for safeguarding children could be provided with a reference and a priority pathway to assist in reducing the uncertainty for the child in these initial stages of contact.          Analysis.  The early interactions between the police and immigration officers were largely about primacy of responsibility and this depended upon the legal status of YT. Age was a Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 13 of 28   determining factor in which pathway should have been followed. UK law reflects the reality that children are vulnerable by age and should be dealt with differently to adults so that child welfare is promoted as the priority. This clearly did not mean that professionals should for a child ignore immigration requirements but that these were secondary to any safeguarding concerns.  In establishing information from YT, the police relied upon the LanguageLine service to acquire some vital personal information from him. Even though, the police officers retained some doubt as to his actual age, their actions were consistent with giving him the benefit of doubt until assessments could be completed and with treating him with the legal status of being a child. This meant that he was released from arrest without delay and removed from the custody area at Wood Green Police Station. YT was escorted to Edmonton in the Borough of Enfield to be closer to the local Children’s Social Care team who were now responsible for finding suitable safe accommodation, promoting his welfare and assisting him in the asylum-seeking process.  A question arises as to how much additional questioning or information gathering should have been progressed. Was it necessary or beneficial for the agencies to seek additional information from or about YT? The information that was available to agencies at this stage was very limited and almost entirely from a single source as it originated from YT’s’ answers to questions from the police while he was in detention and later in police protection.  Due to the time of day there was very little other opportunity to gather additional information; e.g. from a trusted member of the Eritrean community or a Tigrigna speaker. For the police to have done so, may also be considered as a potentially abusive or threating experience for a child in YT’s situation, as police officers in many countries fled by asylum seekers are linked with Government oppression. The reliability of any additional information gathered in such circumstances is likely to have been questionable. In the event, and until the time of the arrival of the social worker further questioning was avoided. Instead, YT was treated as being vulnerable and measures were put in place to protect him.  The use of restraint by the police and the reassessment of the need for continued handcuffing following the arrival of the social worker and the additional information exchange indicates that the situation was being dynamically assessed.  This provides some evidence of information being shared between agencies and proportionality being applied in the officer’s approach to safeguarding.  Record keeping is an essential activity for professionals involved in multi-agency safeguarding. Records should as far as possible be made in a timely way and contain sufficient information to support the rationale behind any decisions and allocation of resources. Not every decision made during dynamic operational settings will prove in the long term to be the best choice. So, where a child is found in a situation where they have suffered or are considered likely to suffer from significant harm a record should be made of what that harm is thought to be. The description should be detailed so that those who are required to take actions have sufficient information to progress actions that reduce the impact of the harm and remove the child from continued exposure to sources of harm. This can be described as ‘risk assessment’.  Professionals must use the information they have at hand for risk assessments and to support decisions based upon ‘what is actually known at the time’. It is also reasonable Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 14 of 28   to expect that these professionals will identify information gaps and take steps to gather additional material to fill such gaps.  This should be about being proactive and on the front foot in assisting other service providers who are also currently involved, or will be involved in any future safeguarding activity for the child. Therefore, strategy decisions should be recorded with a supporting rationale and passed on in a timely way so that risk can be effectively managed. Where children are older young people as in this case, it is vital to gather as much information as possible in relation to their perception of risk, their wishes and their needs. We know from many years of experience with child protection processes that effective communication with young people is necessary for improving chances of successful safeguarding outcomes. In other words; professionals need to hear the voice of the child.  There is a deficiency in record keeping in this case of useable information (including identifying information gaps) for continuing risk assessment. This is particularly evident in the provision of information between CSC, the fostering agency and the foster carers. This situation may have arisen partly because of changes to the officers dealing with the case (shift changes). The police officers handed over when shifts changed, several members of the EDT were involved and the Foster carers received information from their agency, a telephone call from EDT and then from the escorting police officers. If we project professional contact forward over the next few days, it is highly likely that several other professionals and those involved as carers will be involved and required to make decisions and provide safeguarding services. The absence of any form of log / decision sheet that also contains accurate personal information and a current assessment of risk and the safeguarding strategy means that important information may be missed or overlooked. Indeed, if we look towards the taking of history in medical settings and then the notes kept on patient’s progress following operations we can understand the benefits from updating and maintaining chronological records.          Improvements to rectify this deficiency are clearly possible and need not be onerous or bureaucratic.      8. Was the work in this case consistent with each organisation’s policy and procedures for safeguarding and promoting the welfare of an unaccompanied asylum seeking child and with wider professional standards? 8.1 The HOIE (Nexus Custody) policy and procedures were applied by its staff. Albeit that the immigration Officer was elsewhere the advice was consistent with safeguarding and promoting the welfare of a UASC. In effect the police were advised that a person under the age of 18 was to be treated as a child and referred to the relevant CSC department.  8.2 The concern raised by police that YT may be 18 years or older was met with advice that CSC should follow a Merton compliant age assessment while at the same time ensuring welfare and safety.  8.3 The initial police officers who called to the lorry depot decided to arrest YT on suspicion of committing Immigration offences. The circumstances of his presence in that place and his inability to provide any explanation justified their actions. They complied with legislation and took him directly to an authorised custody centre at Wood Green Police Station.  Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 15 of 28   8.4 During the custody procedure the police complied with procedure and utilised a translation service to communicate with YT. Questions gathering personal information and others concerned with his wellbeing and suitability for detention were asked and answered. This information led to contact with HOIE (Nexus Custody) who have jurisdiction in immigration offence investigation. The HOIE advised, based on the information and date of birth given, that police should release YT from arrest and contact CSC. 8.5 The police followed this advice and reviewed the status of YT. The promotion of his welfare was now the priority and he was placed under police protection. This is a statutory power and should only be used where its use is considered necessary to protect a child from significant harm.  8.6 When a child is placed under police protection an officer of the rank of Inspector is required to perform the role of ‘Designated Officer’ and ensure that communication of the child’s situation is expedited with various concerned parties (including the child itself). This ensures that the child is safeguarded and steps are in place to maintain this situation for up to 72 hrs. The contacting of the relevant CSC department is an essential part of this process. The designated Officer must create a record of actions when a child is taken into police protection and this record is subsequently brought to the attention of specially trained child protection officers for oversight. These actions and activities were completed.  The Inspector gave instructions to ensure the referral was passed to CSC and that if doubt continued in relation to age then a police forensic medical examiner should be consulted. The actions of the Inspector and officers were in accordance with the Operation Nexus Toolkit that is available to operational officers on the MPS Intranet system. However, the report dealing with the use of Police Protection was not closed in accordance with MPS standard operating procedures (This does not appear to have any bearing on the case outcome but meant that YT was still under Police Protection at the time of his death).              8.7 While in police protection at Edmonton Police Station YT exhibited some anger and agitation in which he punched the wall of the interview room in which he was placed. The wall was slightly indented but YT received no physical injury from this incident. The officers decided to handcuff YT to prevent any similar outbursts of frustration that may cause injury to him or any other person. The handcuffing of an individual is an application of force and police officers are lawfully permitted to apply force and restraint if this is only such as is necessary and proportional to prevent injury or damage. The officers recorded their actions and rationale in notes at the time. Following the death, the MPS referred the actions of the officers in restraining YT for scrutiny by investigators from the MPS Department for Professional Standards. No untoward behaviour has been identified. 8.8 The police utilised LanguageLine on at least three occasions to facilitate communication between themselves and YT and for the benefit of the social workers and foster carers. This was consistent and good practice.  8.9 There was a good initial repose to the referral from police and particularly in seeking advice from the ‘Head of Service’ in relation to how best to approach the issue of age assessment. This was followed up by a timely visit to Edmonton Police Station and attempts to garner additional information from YT himself. 8.10 Social workers and staff on Emergency Duty Teams have a complex task and finding the most appropriate service provision for high risk child protection cases takes considerable amounts of resources and skills. Finding a suitable placement for YT as a UASC and getting him there from the police station within 5 hours was an achievement particularly as other high risk safeguarding situations were being responded to simultaneously. Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 16 of 28   8.11 Although the social worker had visited YT at the police station there does not appear to have been any emphasis placed upon ensuring YT understood what was happening to him. Social care records are absent of information on his emotional, physical health and his well-being. This information could have been obtained from the police records and supplemented by material from additional questions using LanguageLine. The social worker was qualified to comment on either the presence or absence of mental health concerns but does not appear to have recorded this. Neither was anything recorded in regards to YT’s motivation and aspiration or whether he was hiding from any specific threat(s).  8.12 Future Fostering were contacted by CSC and indicated that they were likely to have a suitable temporary placement available based upon the information provided.  The actual information was very scant but it was shared with the prospective foster carers who agreed to offer their services for YT.  8.13 In the agency report template for this SCR, Future Fostering state; “Future fostering expects that Local authority undertakes a careful assessment of the young person’s needs and wishes irrespective of the young person’s immigration status and shares the same with the Independent Fostering Agency at the time of seeking a placement, even if it falls under the Out of Hours service of the Local Authority.” They go on to state; “It is a requirement that foster carers will need to be carefully and accurately briefed about the young person’s cultural, religious and ethnic needs and any particular dietary needs.” Both statements appear to be reasonable requirements for initial assessment as to the suitability of the placement being considered.  8.14 In the event a decision to accommodate was made before a careful assessment was made and then there was no careful or accurate local authority briefing available for the Foster Carers. Instead, the escorting police officers were relied upon to facilitate communication and gain some additional details (using LanguageLine) on arrival at the placement. Analysis. Agencies have followed the letter of organisational policy and procedures for safeguarding and promoting the welfare of UASC. The use of statutory power was proportionate and records show largely good recording of process and timely communication between agencies. Application of process and procedures by all the professionals in this case was good and there is no evidence to suggest that any changes are required.  The use of handcuffs to retrain YT when he became agitated and was violent was not excessive and was only maintained for as long as was needed for him to calm down. His later demeanor and cooperation with the professionals he met and the foster carers did not raise any additional concerns in relation to a repeat of any similar aggression.    All the agencies involved have substantial experience of dealing with asylum seekers and for the most part these families or individuals will be adults. There are different pathways in place for processing asylum claims by adults or family groups containing children. A solitary child / young person in this situation is clearly very vulnerable. There is in place an agreed procedure for dealing with UASC and despite the police retaining some doubts as to whether or not they were dealing with an under 18-year-old (child) the correct process was followed and he was treated as a child.  This meant he was placed under police protection and CSC were informed of the circumstances without delay. There being no family or friends who it would have been Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 17 of 28   safe to place the child with CSC immediately began to search their contacts for a suitable short-term placement. This is a routine task for social workers attached to Emergency Duty Teams and may be necessary for all forms of child protection.  There was a weakness in the process of gathering information from YT. S 46 Children Act expresses that when a child is in police protection officers should ‘take such steps as are reasonably practicable to discover the wishes and feelings of the child’. This equally applies to CSC staff dealing with the situation. There are no records outside those at the time of the custody procedure that show that questions were systematically asked which would form the basis of either a risk assessment or an assessment of needs. Where there is a concern of a child suffering significant harm a strategy discussion between professionals who will make decisions and take actions to protect that child should always occur. Even if the outcome is not to initiate S47 enquiries it is good practice to record the issues and decision with rationale. This approach not only supports the professionals at the time by ensuring the decisions are based on comprehensive considerations but will be highly useful for those who take on responsibility for further service provision.     Refugees may have significant health issues, that either motivate their migration or appear during the journey because of the physical environment or interaction with others.  Neither the police or social workers adopted a systematic approach to gathering comprehensive information to support either safety or welfare decisions and in a suitable format for handover to other colleagues. The absence of such information was compounded by the Fostering Agency approach when they did not demand sufficient information from the EDT contact.  Instead, the professionals and foster carers relied on LanguageLine to assist in providing information on a demand basis. This is poor practice as without any records of information already gathered it is difficult to identify any changes in response, conflicting information or areas where vital information has not yet been gathered. When viewed with hindsight, the information gaps appear to be largely; YT’s mental health situation (were there unrecognised issues?), Was the wall punching incident a signal of instability that may cause risk to him or others and what were the implications to him from being alone and isolated from any of the support he may previously relied upon?    The question; ‘How do we know it is safe and appropriate to place this child in this home?’ should have been considered and addressed by those responsible for the emergency placement. Wider professional standards include ‘evidence supported decision making.’ This is required operationally and should also include a proactive approach to review decisions periodically and when additional information is received. There is insufficient evidence that this approach was at the forefront of practice when arranging the placement for YT.    9. What were the key relevant points / opportunities for; assessment, decision-making and effective intervention in this case in relation to YT?  What was the quality and timeliness of interventions and decision-making? Was there more that could have been done? Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 18 of 28   9.1 Decision making and assessment commenced in this case when the police officers were called to the freight depot in Enfield. There initial investigations provided reasonable grounds to believe that YT had committed immigration offences and they made an arrest to secure his presence at a police station so that the matter could be properly investigated.  9.2 During custody procedure at Wood Green Police Station, the police used a translation service LanguageLine to gather personal information including questions relating to his vulnerability and wellbeing. This was an assessment process and used to support decisions as to whether any specialist assistance was required such as an interpreter, a doctor, a lawyer or an appropriate adult. It also included consideration as to whether as a foreign national there was a requirement to inform the relevant embassy or consulate.   9.3 The police contacted the Immigration Service by telephone as the on-duty immigration officer was working at another police station. The circumstances were outlined including the fact that YT was claiming to be aged 17 and seeking asylum. The Immigration officer advised the police on the protocol for UASC and instructed them to contact the relevant Local Authority Children Social Care department.  9.4 This advice was followed by the police who released YT from detention but assessing him and his circumstances as a child requiring safeguarding they placed him into ‘Police Protection’ S46 Children Act 1989. As Enfield was the relevant local authority the officers escorted YT to a police station in that Borough and telephoned a referral to the CSC Emergency Duty Team.  9.5      A social worker who spoke Italian and was also an approved mental health practitioners attended the police station and was introduced to YT. This was an appropriate and timely response. This was the first opportunity for a trained social worker to commence any assessment of needs and as an initial priority to ensure a suitable placement for the child’s safety. 9.6 During this meeting between the social worker and YT some information was gained and an assessment was made using personal judgement that he was likely to be a child. This clarified that CSC would assume responsibility for finding a suitable short-term placement and for assisting him with UASC matters. This decision and the information obtained were passed by the social worker to a colleague who began to seek a short-term foster placement. The meeting appears to have focused upon issues around age assessment and UASC protocol which were immediate and pressing matters due to the time of day on a Friday evening.  9.7 A child centered approach that focused on understanding YT’s wishes and feelings was possible and this would have benefitted assessment and provided additional information for better safeguarding provision.   9.8 The information provided verbally by EDT to the Future Fostering Agency was scant. Nevertheless, it was sufficient for the agency to offer a potential placement from what little was known.  The chances of finding an identical match at short notice between foster families and unaccompanied young people are remote. But, the Foster agency judged that the proposed Foster carers could provide • a safe and supportive living space; Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 19 of 28   • a place where experiences are recognised but the young person would not be placed under pressure to talk about them; • somewhere that is appropriate in terms of language, culture and religion. The first two criteria above were certainly provided by the foster care setting and based upon what information was available the placement had a good potential to achieve the remaining requirements. 9.9 The Foster Carers also needed to make decisions following the arrival of the police and YT at their home. Once again, the police made available the LanguageLine translation service to facilitate communication between the parties. At this point, there were attempts to made to support YT and make him feel less isolated with the possibility of introducing a young person from Eritrea to him the following day. Other information regarding his dietary needs was also established. Analysis. Throughout the period of contact between YT and officers from the safeguarding agencies there was ongoing assessment. This was not a single agency assessment but forms of assessment took place at several decision points e.g. To treat YT as a child rather than an adult. These assessments relied almost entirely on two sources of information. The first being the agencies’ policy and procedures (including statutory legislation), the second being information gathered from YT himself by questioning with the aid of translation services.  Apart from Future Fostering offering a placement on information that was insufficient to fully meet its own requirements for suitable placements the decisions made were based upon sufficient assessment of the available information to support the case progression.  In terms of timeliness of the decisions these were made expeditiously. EDT officers must often juggle several emergency matters that arise at the same time and a major feature of their role is to respond to the presenting emergency and make situations safe until the normal social care office resumes services including undertaking in-depth and holistic assessments.    In this situation, there was a weakness in the quality of assessing the actual needs and wishes of the child. There was a strong indication that he had been agitated and the fact that police officers judged it necessary at one point to restrain him using handcuffs should have prompted questions as to his intentions, wishes and feelings. Ideally, the information gathered from such questions should have been recorded and assessed and any issues communicated to the Foster Carers. This would have provided significant benefits in assisting their decision as to the suitability of their offer of a placement and in meeting the presenting needs of the placed child. In any event, EDT knew that this was to be a short-term emergency placement and any information as to the child’s risk or vulnerabilities would be needed in the near future as the case progressed.    10. Were professionals aware of ‘what it was like to actually be that child’, sensitive to the needs of an unaccompanied asylum seeking child, Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 20 of 28   knowledgeable both about potential indicators of abuse and mental health and about what to do if they had concerns about a child’s welfare? 10.1 There is some evidence of professionals taking a sensitive approach to YT as an UASC. This occurred immediately following the Immigration Officers advice to the police and the decision to place him into ‘Police Protection’, release him from detention and remove him to a suitable place to wait for social workers to progress his case.  10.2  Police officers are required for both law enforcement and to protect vulnerable people. Police stations are not ‘places of safety’ for accommodating children subject to child protection concerns but as a temporary measure to provide time for other agencies to deploy resources they may be used to retain a vulnerable child. An interview room was used for this purpose.  10.3 YT did become agitated and punched a wall. The police officers thought that this was a sign of frustration associated with being in his situation, not being able to communicate very well with the officers due to the language barrier and waiting around for unknown persons (a social worker). The use of handcuffs has been addressed previously (above) in this SCR. There is a duty on police when using police protection to ‘take such steps as are reasonably practicable to discover the wishes and feelings of the child.’ Unfortunately, this does not appear to have been a priority area for the police. Instead the major focus was in provision of a temporary place of safety and retaining his physical presence until CSC could take responsibility for assessment and case progression. This approach to YT stems directly from the age uncertainty issue but a consequence was that the police made no or little effort to gather information about his feelings that would assist a wider assessment of need such as, motivation, intentions and whether he was a victim of neglect or abuse.  10.4 The arrival of the EDT social worker was an opportunity for these issues to be raised and for a child centred assessment to commence. Instead, the priority once the social worker had decided that YT should be treated as a child was to find a suitable placement for him. This is understandable in terms of the pressing workload of EDT but from the perspective of establishing if a sufficiently child focused approach was in place it is deficient.  10.5 Professionals had opportunity during the ‘assessment meeting’ in the interview room at Edmonton Police Station to ask wider questions via the LanguageLine translator service. This opportunity was missed and therefore EDT had very little to pass on to Future Fostering when seeking the emergency placement. A more significant issue was that YT himself remained in an information vacuum as opportunities for him to express his needs and feelings were bypassed.  10.6 On arrival at the foster home the prospective foster carers needed to establish communication with YT to satisfy themselves they could provide a suitable environment for him. EDT were not present at this introductory meeting and the Foster Carers could not speak to YT in any common language. Again, the police facilitated communication using LanguageLine interpretation services on the telephone. This was helpful and allowed the carers to gather information on language, diet and clothing. They recognised YT’s need to speak to someone in his own tongue and let him know that they were in touch Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 21 of 28   with another Eritrean boy and that they would attempt to bring them together the following day.  10.7 The foster carers were sensitive to YT’s needs and they provided him with food after asking of his dietary requirements, facilities to wash, sleep and fresh clothes. The time of day was also relevant to the questioning and the depth of detail that were appropriate. The Future Fostering Agency does offer specific training to its carers in relation to looking after UASC but these particular carers had not completed that training and were expected to rely on previous general training and experience. Indeed, the Agency has noted that one of the Carers has a Master’s Degree in Counselling.         Analysis. YT came to the attention of the agencies on a Friday evening. This tends to be a period of high demand and when mainstream (9am to 5pm Monday-Friday) capability is not usually available to provide services. Instead, agencies rely upon emergency response and short term service provision to deal with acute and arising operational demands. There is nothing untoward or new in this situation and these arrangements are monitored and resourced commensurate with the levels of demand and/or projected demand experienced by the services responsible for providing emergency support.  The provision of short notice foster care for children taken into police protection or from other incidents arising is a regular demand for EDT. The actual causational incident type is a significant factor when arranging suitable placements but this is only one of several highly relevant issues that should be considered in deciding suitability of placements. Information about the needs and vulnerability of each child should be gathered so that the best possible placement for that child is commissioned. Decisions on safety and promotion of welfare should be supported with evidence to quantify aligned behind any decisions. This evidence may be; information received from others or existing records, it may be gathered from observation and dynamic assessment and it may be obtained by speaking to the child themselves.  Indeed, for older children it should be vital for professionals to gather their point of view and in so doing assess their levels of perception to vulnerability and risk of harm. This includes identifying specific welfare issues or any underlying illness in the child.  In this situation, the professionals and carers involved have acted in line with existing expectations to the presenting demand at hand. It would have been possible at several points; on taking YT into police protection, while waiting for the arrival of a social worker, during the assessment on arrival of the EDT social worker and on arrival at the foster home to ask additional questions aimed at and enriching the professional understanding of YT’s situation. But there was no guarantee for the professionals that additional probing of what was an already tired and unsettled young person would add much to their understanding of his needs. Indeed, his willingness to respond to communication via LanguageLine would have provided some reassurance to professionals that there were not acute emotional or mental health issues requiring an immediate response. There were no obvious indications to any of those who met and assisted YT that he was a suicide risk. Indeed, when considering what was known (information given by YT) about the purpose of his presence in the UK (Asylum seeker), his being released from Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 22 of 28   detention by the police and provided with care and accommodation it could be thought that he was in a positive situation.  What is not known is the detail of his journey from Eritrea to arrival in the UK. Was he travelling in a family or friendship group that had become separated? Had he previously been following the leadership of another and was now isolated or feeling abandoned?  He possessed a mobile phone that was connected to the French network and analysis of calls made on that device show a few contacts in France and Italy. When police contacted people, including a person who claimed to be YT’s cousin, on these telephone numbers the information provided was limited but in essence it was that a larger family group had left Eritrea with the intention of migrating to the West. There was no fixed plan but individuals intended to meet up in the future. YT phone was not used in the UK and he requested the foster carers to provide him with a charger as the one he had was not suitable for the UK and his phone battery was depleted.  There was therefore an indication for professionals and carers that YT was feeling isolated and wanted to speak with others who he could contact on his telephone. As he was being treated as an UASC a first step in assessing his situation would have been to ask questions as to how to contact his family or any adult family friends by using stored numbers from within the phone.  It is speculative to assume whether such actions would have provided any useful information or assistance in assessing vulnerability or need as they were not pursued. But agencies and carers alike should be aware of the importance of mobile devices in everyday life especially to the young. Mobile Phones and other devices hold a wealth of information and matters such as patterns of use, contact details and messages can be highly useful for analysis and assessment.             11. Was practice sensitive to and / or influenced by the racial, cultural, gender, sexuality, linguistic and religious identity and any issues of disability of YT and were these explored, taken on board and recorded? 11.1 The use of the translation service LanguageLine by the police at three separate stages assisted interaction with YT. Each time either the police were attempting to gain information about his status, welfare and any significant needs or requirements that needed to be taken into consideration in service delivery.  11.2 Apart from a questionnaire which is a standard part of the police custody process there was no standard format or process for gathering and recording personal information to assist in supporting service delivery that is appropriate to; race, culture, gender, sexuality, linguistic, religious identity and to any form of disability.  11.3 The foster carers asked questions about; diet, illness, medication, allergies and religious persuasion to help them assess their ability to provide a suitable accommodation for this child. The answers given using LanguageLine together with verbal information from the police and their observation of YT’s initial presentation allowed them to agree to the placement.  Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 23 of 28   11.4 In fact, the foster carers had only limited information available to them. They knew nothing substantial of YT’s background or personal experience beyond the period he was found by police. They were not informed that he had become agitated and police had found the need to handcuff him for a period. They also had no provision for translation services beyond the internet once the police departed. This was an emergency short-term placement at a weekend and the Carers were given no definite timeline for either an assessment process or for the UASC process with the immigration authorities. 11.5 Despite this and based largely upon the availability of a suitable bedroom, their training with support from the Future Fostering Agency and the polite presentation of YT himself the foster carers felt that they would be able to meet his immediate needs.   Analysis. The timescale relating to this incident is short. The statutory agencies used the available time to focus on the main presenting issues and these were firstly the immigration status and secondly the requirement to find suitable short-notice accommodation for a child who had been placed under police protection.  During this activity, there is evidence to confirm that the police, CSC and the foster carers were sensitive to significant intrinsic factors such as gender, cultural identity, diet and language. There was no obvious or presenting disability and sexuality does not appear to have arisen as an issue in this short period for assessment or response. Aside from the custody questionnaire, that was not in any event shared with other agencies, there was not any systematic record keeping or process for risk assessment that incorporated consideration of sympathetic practice to best support the child’s needs. Time was a factor in this case, but a child was taken into care and it is reasonable to expect that at the very least a rudimentary care plan that documented known or likely risks including consideration of cultural and personal factors would be drawn up and its information available to all those with responsibility for safeguarding and promoting the welfare of the child. Such a plan would also benefit from the inclusion of a communication strategy.  As an individual YT was isolated from friends and his community. His ability to communicate even simple needs was limited due to the language barrier and being in a new country for a very short time. He was therefore vulnerable. The availability of interpretation services on demand for foster carers in cases such as this where there is no common language between the child and the carers would greatly assist communication, reassurance and understanding any pressing needs the child may have.          12. Conclusions 12.1 In most SCRs the views of family members are sought and encouraged whatever their personal involvement with the situation leading to the incident prompting the LSCB to hold a review. In this case, there is no suggestion that any family members are present or have been present in the UK.  Police officers have spoken to family friends in the UK and have also spoken on the telephone to other relatives who are overseas. The little information Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 24 of 28   from these sources that has been forthcoming to this review is that YT was amongst others from his family who had decided to migrate from Eritrea to the West. There is no corroboration for this information and it is very sparse. Indeed, it is not certain if the UK was intended as the final destination for YT or other members of his family. There is no solid information on his actual motivations and the circumstances of his life prior to leaving Eritrea or while travelling from Africa, into Europe.   12.2 There are several reasons why family members of asylum seekers would not wish to provide information to ‘the authorities’. One may be their negative experiences with authority in home countries. While other reasons may be due to the current circumstances they find themselves in such as attempting passage themselves. So, there is no blame to be laid at the door of the family or any agency for this situation but rather it is pertinent to acknowledge the situation and that it may weaken the analysis and conclusions.    12.3 Consequently, this review has virtually no information on YT’s state of mind, his pre-existing vulnerabilities and any needs beyond that which was gathered by police officers, social workers and the foster carers who interacted with him during the very short time he was with them. This period was insufficient for anyone to complete an in-depth assessment of need or a comprehensive risk assessment. The assessment that was undertaken was largely focused upon ascertaining his status and particularly his age. This was critical to the police, the immigration officers and to social workers as age determined which agency should have primacy and responsibility for his safety and welfare.  12.4 In the reception of asylum seekers, age is relevant to the approach and pathways in place for processing applicants. The Children Act is applicable to the Immigration Service and officers in this case have given and advice which is consistent with that legislation and Home Office policy. The police followed the advice from the immigration officer releasing YT from arrest and criminal investigation, and taking him into ‘police protection’ with the status of a child likely to be at risk of significant harm. This meant a referral to CSC was made. A social worker travelled to see YT and decided to treat YT as a child in need of service provision. In effect this was an assessment decision.      12.5 Although YT had become quite agitated while waiting with a police escort in the interview room for the arrival of a social worker all the agencies had acted diligently and were progressing the assessment expeditiously. A discussion between the social worker and police that saw the removal of the restraining handcuffs provides evidence that consideration was given to his welfare and demeanour. If it was considered that he would continue to use aggression, harm himself or others the police would have been unlikely to remove the restraints. In fact, YT was compliant and cooperative as he answered questions and provided information to the social worker via an interpreter service. This information was used by EDT to find a short-notice foster care placement to accommodate YT for at least the weekend. 12.6 The role of EDT is to respond to immediate matters in a ‘task centred approach’. In this case a priority was to find suitable accommodation and they did this without undue delay. Where the EDT response was less effective was in commencing and recording an assessment that considered wider aspects of vulnerability and risk in the context of the wishes and feelings of the child. There is nothing to suggest that time was not available for these purposes. Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 25 of 28   12.7 A fully comprehensive and holistic assessment would not be possible or even appropriate but there was opportunity to initiate and record a dynamic initial assessment that would assist others in managing risk and meeting the individual needs of that child. This type of activity too, can be considered as a vital and a ‘task centred approach’. The absence of such a record to pass on and build upon means that the future carers and the professionals who deal with the case are deficient of some important information. Consequently, they must either ‘start again’ with assessment and / or they may need to operate in a generic way that is not centred on the known needs of the child. Both situations are inefficient and can add to the stresses for the child and safeguarders alike.  12.8    There is an understandable reluctance to add to the bureaucracy of the EDT workers but the absence of records containing; rationale for decisions, risk management strategies and how the wishes / needs of the child are being supported creates uncertainty in the short term and additional work in handovers and case progression for all stakeholders.  12.9 There is almost nothing to suggest to any professional or carer that YT was a suicide risk. He was undoubtedly in a situation where he was isolated from his family and friends and in a place where verbal communication with professionals and the carers was difficult. A full assessment of his mental health situation was not possible or appropriate to the initial meeting with the EDT social worker. However, the social worker was an approved mental health practitioner and he made no assessment of pressing mental health concern.  12.10 There was no formal risk assessment for the handover to the carers. This meant that the foster carers were not in possession of all known relevant information. The fact that YT had become agitated and punched a wall inside the police station and had been handcuffed was relevant and should have been recorded and passed to others who had responsibility for his welfare. This may have prompted increased levels of vigilance including observation of his demeanour for new signs of agitation and allowed the foster carers to respond to needs more effectively or seek assistance from other professionals.  12.11 Although a weakness in the professional approach to this UASC the absence of such a risk assessment does not provide any direct causational factors that contributed to YT’s own actions and death.  12.12 In considering the policy, processes and actions of professionals and the foster agency carers there is no evidence of any changes that could be made that would have specifically acted to deter YT from taking his own life. His death was not reasonably predictable to those who dealt with him. It would not have been appropriate to intrusively monitor him in his bedroom based upon what was known at the time.   Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 26 of 28   13.  Recommendation 13.1  The analysis of agency submissions to this SCR permits evaluation on the quality of practice and analysis of the circumstances and allows recommendations for improvements to be made. This recommendation has arisen out of a case where the presenting vulnerability of the child was as an unaccompanied asylum seeker who needed to be accommodated out of hours. The recommendation will also apply to other situations where children at risk of significant harm require emergency care provision. 13.2 The single recommendation is intended to support safer and more efficient operational practice by introducing changes to support communication in respect of risk management and ensuring the focus of emergency activity is centred on the child’s needs.  13.3 Timescales for delivering the changes needed for this recommendation are short / as soon as possible.   Recommendation 1.    Enfield Safeguarding Children Board (ESCB) should review and improve the ways in which professionals who are responsible for out-of-hours emergency child protection complete and record assessments and decisions; • to record all aspects of vulnerability, • to ensure the voice of the child is heard,  • to detail necessary actions to reduce the risk of harm and promote welfare, • to facilitate effective communication,  • to assist other / subsequent service providers.                  Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 27 of 28    Appendix 1  Section 46 Children Act 1989: Removal and accommodation of children by police in cases of emergency. (1)       Where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm, he may—  (a)remove the child to suitable accommodation and keep him there; or  (b)take such steps as are reasonable to ensure that the child’s removal from any hospital, or other place, in which he is then being accommodated is prevented.  (2) For the purposes of this Act, a child with respect to whom a constable has exercised his powers under this section is referred to as having been taken into police protection.  (3) As soon as is reasonably practicable after taking a child into police protection, the constable concerned shall—  (a)inform the local authority within whose area the child was found of the steps that have been, and are proposed to be, taken with respect to the child under this section and the reasons for taking them;  (b)give details to the authority within whose area the child is ordinarily resident (“the appropriate authority”) of the place at which the child is being accommodated;  (c)inform the child (if he appears capable of understanding)—  (i)of the steps that have been taken with respect to him under this section and of the reasons for taking them; and  (ii)of the further steps that may be taken with respect to him under this section;  (d)take such steps as are reasonably practicable to discover the wishes and feelings of the child;  (e)secure that the case is inquired into by an officer designated for the purposes of this section by the chief officer of the police area concerned; and  (f)where the child was taken into police protection by being removed to accommodation which is not provided—  (i)by or on behalf of a local authority; or  (ii)as a refuge, in compliance with the requirements of section 51, secure that he   is moved to accommodation which is so provided.  (4) As soon as is reasonably practicable after taking a child into police protection, the constable concerned shall take such steps as are reasonably practicable to inform—  (a)the child’s parents;  (b)every person who is not a parent of his but who has parental responsibility for him; and  (c)any other person with whom the child was living immediately before being taken into police protection,  of the steps that he has taken under this section with respect to the child, the reasons for taking them and the further steps that may be taken with respect to him under this section.  Enfield Safeguarding Children Board  ESCB SCR YT Final version     Page 28 of 28   (5) On completing any inquiry under subsection (3)(e), the officer conducting it shall release the child from police protection unless he considers that there is still reasonable cause for believing that the child would be likely to suffer significant harm if released.  (6) No child may be kept in police protection for more than 72 hours.  (7) While a child is being kept in police protection, the designated officer may apply on behalf of the appropriate authority for an emergency protection order to be made under section 44 with respect to the child.  (8) An application may be made under subsection (7) whether or not the authority know of it or agree to its being made.  (9) While a child is being kept in police protection—  (a)neither the constable concerned nor the designated officer shall have parental responsibility for him; but  (b)the designated officer shall do what is reasonable in all the circumstances of the case for the purpose of safeguarding or promoting the child’s welfare (having regard in particular to the length of the period during which the child will be so protected).  (10) Where a child has been taken into police protection, the designated officer shall allow—  (a)the child’s parents;  (b)any person who is not a parent of the child but who has parental responsibility for him;  (c)any person with whom the child was living immediately before he was taken into police protection;  (d)any person named in a child arrangements order as a person with whom the child is to spend time or otherwise have contact;  (e)any person who is allowed to have contact with the child by virtue of an order under section 34; and  (f)any person acting on behalf of any of those persons,  to have such contact (if any) with the child as, in the opinion of the designated officer, is both reasonable and in the child’s best interests.  (11) Where a child who has been taken into police protection is in accommodation provided by, or on behalf of, the appropriate authority, subsection (10) shall have effect as if it referred to the authority rather than to the designated officer.    