Death of a 16-year-old boy by suicide. Case review covers the period from January 2012 to December 2017. There were no services involved with Child K at the time of his death apart from school. An initial child protection conference was triggered due to Child K's plans to run away to his family's country of origin and his threats to teachers and other pupils. School made a referral to the Channel Panel and he was made the subject of a child protection plan. After this, his engagement with professionals declined. Concerns about the effects of domestic abuse in the household. Father was controlling and there were sporadic acts of violence. Child K was diagnosed with an autistic spectrum disorder. Shortly before his death, Child K made a report to the police which suggested his actions may result in risk to himself. Ethnicity/nationality not stated. Findings include: Child K was seen differently by different people; Child K's needs in relation to his autism rarely featured in multi-agency meetings; and Child K felt that the involvement of professionals in his family's life was a significant disruption. Recommendations include: consider a trauma-informed relational approach; consider whether practice and service provision is sensitive to the cultural, historic and gender context of families, including those outside of the main Black and Minority Ethnic groups; and review cases of domestic abuse before closure to confirm that couples and children have been signposted to counselling or meditation services.
      
 Title:  Serious case review Child K. LSCB: Hertfordshire Safeguarding Children Partnership Author: Bridget Griffin Date of publication: 2020  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.                             1                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA                                                                                                                       Hertfordshire Safeguarding Children Partnership  Serious Case Review Child K  March 2020                                                          2                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA Contents   Section 1   Introduction  P.3   Background and summary of case  P.3  Terms of Reference P.3  Purpose  P.3  Section 2 Summary of Service involvement and Key Learning P.4 – P.11  Finding 1  Understanding Child K as an individual - a relational approach.  P. 4 - 5  Finding 2 Identifying and responding to Child K’s emotional/mental health needs and his needs arising from his autism.  P. 5 - 6  Finding 3 Responding to families  P. 6 - 8  Finding 4  Family Safeguarding P. 8 - 10  Finding 5 Working with adolescents at risk  P. 10 - 11 Section 3  Conclusion  P. 11 Appendices  Appendix 1 Methodology  P. 12  Appendix 2 References  P. 13                                                   3                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA 1. Introduction   Background to the review and summary of the case  This Serious Case Review (SCR) concerns a 16-year-old child (Child K) who sadly died after taking his own life. There was multi-agency involvement with Child K and his family during Child K’s teenage years.  Child K was the subject of a child protection plan for a relatively short period as a result of concerns about the damaging effects of domestic abuse on all members of the household. During this time, Child K was diagnosed as having an autistic spectrum disorder. Apart from school, there were no other services involved with Child K at the time of his death.    Hertfordshire Safeguarding Children Board (now Partnership) decided that circumstances of his death met the criteria for a Serious Case Review (SCR). This SCR has involved the agencies and professionals who worked with Child K and family members. Child K wrote a detailed letter before his death, this letter has been used to inform a number of the findings with the intention of representing his voice in this SCR. It is recognised that this letter provides information and insights that were not available to practitioners during his life. Whilst recognising the value of taking them into account, the review is aware of introducing bias due to hindsight and has sought to avoid this.  Terms of Reference  Full details of the review process are included in appendix 1. In summary, the author of this report (an independent lead reviewer) worked alongside members of a panel, made up of senior professional advisers and managers representing the agencies and services who had been involved in providing services to Child K and his family, none of the panel members had any direct involvement in service provision to the family.   Purpose  The purpose of an SCR is to seek to understand what happened and why it happened in the context of local safeguarding systems, rather than solely the actions of individuals, and to ensure that agencies are held accountable for their services, systems and processes in safeguarding children and how they work together as a multi-disciplinary system. A SCR also aims to enable Local Safeguarding Children Boards, through the detailed review of a single case, to test the effectiveness of local and national safeguarding children procedures, protocols and working arrangements and to inform future service improvements.  This SCR considered the work of:   • School  • Health agencies/services (including community health, GP services and the community paediatric team)  • Police  • Local authority Children’s Service - The Safeguarding Families Service  • An outreach counselling service provided in the school – provided by the local Education Support Centre  The timeframe for this SCR is from January 2012 to December 2017. Detailed individual meetings and a telephone conversation took place with all family members except Child K’s father who decided he did not want to be involved. During these conversations’ family members were candid when speaking about service provision and it is acknowledged that this kind of conversation may not have been possible to achieve when professionals were involved.       4                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA 2. Summary of service involvement and key learning   The following is a summary of the key learning in this case. Where it has not been possible to fully evidence the systemic nature of the issues on a local level, relevant national research is referenced.    Taken as a whole it was clear that professionals followed policy and procedure and utilised available practice models and tools. Professionals were committed to providing a good service and there were many occasions when there was evidence of excellent practice. The overarching learning from this case is to highlight limitations in the extent to which practice models and approaches, put into operation within a framework of child protection procedures, can be flexible enough to offer a personalised approach to children and families who have unusual or unique features.   FINDING 1:  Understanding Child K as an individual – a relational approach   It was difficult to gain a sense of Child K from agency assessments/reports or from the range of professional contacts/recordings. In the words of a practitioner (who had reviewed the case files in preparation for meeting the Lead Reviewer): Nothing fits with him, there is nothing linking him across professionals, there is no sense of who he was, he could be 5 different people you are reading about.   When he was described, he was clearly seen differently by different people (for example: for some he had good relationships with peers, for others he had difficult relationships with peers and felt he did not belong). Child K expressed himself fully when writing emails and letters, leaving no doubt about who he found difficult to relate to and why. His relationship with adults varied and it seemed that those assigned to work most closely with him did not have (through no fault of their own) the best knowledge of him, or the best possibility of making a meaningful connection.    In the words of his mother: ‘He was a perfectionist. Nobody knew what he was thinking, he didn’t talk to anyone. Maybe someone with the same interests as him could have spoken to him – could have understood.  The Lead Reviewer learnt about Child K from the conversations with family members, the Domestic Violence Officer and the Deputy Head at Child K’s school. These professionals were not assigned to work with Child K, their knowledge of Child K came from (sometimes only brief) interactions with Child K in the course of their work. Their own personalities, knowledge and interests meant that, to a degree, they were able to form a relationship with Child K and understand his world and it seems that Child K responded.     From the perspective of a family member: When I met professionals or teachers he liked or disliked I completely understood it – you should look at people and match them.   No adolescent can possibly get on with every adult he comes into contact with. It is not unusual for young people of Child K’s age to experience varied relationships with adults, and for adults to have different perceptions of, and relationships with, young people. Research suggests that a relational-based practice model should be used with young people within the framework of a trauma informed approach.1 A trauma informed approach understands, recognises and responds to the effects of all types of trauma and central to this approach is relationship centred practice which provides an opportunity to support children and adults in forming and sustaining quality relationships.   1 Trauma-informed responses in relationship-based practice D. Taggart Research in Practice 2018   5                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA  The components of this approach, and how this might be enacted, suggests that relationships with key practitioners should take account of the cultural, historical and gender context of the relationship and be sensitive in the selection of key workers, where the young person’s specific identity is fully considered. To the young person this can mean: They thought about me as a unique person. Me as a whole person.2     Practitioners discussing the case during the review were asked whether it was possible for a relational approach to be implemented within the Family Safeguarding Teams or within the wider professional network. Potentially this would mean someone in the professional network, who represents the child’s preferred relationship, is mandated to ask and broach issues directly with the child that might normally fall outside their ascribed role in the case, or outside the strict definition of their professional role with the child. In other words:  Is it possible to give the role to the right person for the right child at the right time?    During the period under review it was apparent that this was not a concept that had been widely thought about or debated, it seemed that established practice to ascribe traditional roles defined by professional background and agency (particularly when a child is the subject of safeguarding concerns) seemed to inhibit the flexibility that is needed when working with adolescents.   From the child’s perspective, being flexible enough to consider the child’s established network and open to respond to the child’s preferred relationship has the added benefit of nurturing a sense of empowerment, choice and control to enable the development of agency through access to resources, engendering a feeling of taking control of their life.      For professionals working in a trauma-informed way – listening to young people carefully, helping them recognise how past experiences influence their ways of relating to the world today and offering a trustworthy relationship where they can try to build a safer life for themselves – might be the most important service we can offer them (Knight, 2015). It is through this re-forging of social bonds and the development of different types of relationships that young people can learn to live with the legacy that trauma leaves and where the hope for a different type of life can be fostered. 3  Since the period under review Hertfordshire have provided training to the workforce on trauma informed practice, the following recommendation focuses on a particular aspect of this practice.    Recommendation 1:  Hertfordshire Safeguarding Children Partnership (HSCP) to consider the recent evidence on the value of a trauma-informed relational approach (including Research in Practice) suggesting that greater flexibility is needed so that the child’s preferred relationship influences decisions about the allocation of professional roles and responsibilities.  FINDING 2:  Identifying and responding to Child K’s emotional/mental health needs and his needs arising from his autism  Child K had received a diagnosis of autism shortly after an Initial Child Protection Case Conference (ICPCC) and scored well above the threshold for autism due to his unusual pre-occupations and poor sociability. Family members said that Child K was not happy to have  2 Trauma-informed responses in relationship-based practice D. Taggart Research in Practice   June 2018 https://www.rip.org.uk/news-and-views/blog/trauma-informed-responses-in-relationship-based-practice  3 D. Taggart, Trauma-informed responses in relationship-based practice. Research in Practice  2018   6                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA this diagnosis but that he needed services to make suitable adaptions to support him, especially in his social communication which, in the view of his brother, was a significant factor in his increasing isolation during the last few months of his life.  He could not live this life, he shut himself away – he had no future – he could not communicate with the world.    However, Child K’s needs relating to his autism rarely featured in multi-agency meetings, assessments or service provision. The reasons for this lack of focus on Child K’s autism were complex; Child K was performing well at school, his behaviour did not pose any day to day management difficulties at school, parents did not actively promote the need for adjustments to be made to services and there was confusion about his diagnosis (in some records he was thought to have a diagnosis of ADHD, in others Asperger’s, and in others he was thought to show only small signs of autism).   Formal diagnostic terms applied to children’s needs are significant only in so far as they can provide a framework in which a child’s needs can be better understood. Of most importance is what this diagnosis means for the child and how it can inform services and care givers so that suitable adjustments can be made to enable a child’s needs to be met. This is particularly important when considering how best to achieve meaningful communication and to understand a child’s emotional needs.   Evidence from our two-year project highlighted that people with Autistic Spectrum Disorders (ASD) are particularly vulnerable to developing mental health problems. We also found out that existing services tend to treat people either for their ASD or for their mental health problems, failing to recognise the complex dynamic between the two.4   Throughout planning forums (Child in Need and Child Protection) it was recognised that Child K needed services that could promote his emotional wellbeing. Despite recognising Child K’s emotional needs, there seemed very limited options available to support his emotional wellbeing in the context of his autism. Relevant NICE guidance5 states that where there is a diagnosis of autism, the co-existence of mental health difficulties should be considered.  Professionals were clear that he would not have met the criteria for a service from CAMHS and spoke about how the lack of a joint pathway in Hertfordshire (with CAMHS and the community paediatrician’s) for children with a neuro-developmental disability inhibits the provision of a joined-up approach. This view was endorsed by experienced review panel members.  Since this SCR, a new pathway has been agreed that includes CAMHS/mental health involvement in the diagnostic stage of autism. Addressing a child’s needs in the longer term requires practitioners/clinicians to identify any mental health needs and take action. It is expected that implementation of this pathway will happen in 2020 and this will be overseen by the Clinical Commissioning Groups and the Health and Wellbeing Board.  Recommendation 2:  HSCP to receive a progress report about implementation of this pathway from either the Clinical Commissioning Groups or the Health and Wellbeing Board and provide support and challenge.        4 https://www.mind.org.uk/about-us/our-policy-work/equality-human-rights/wellbeing-of-people-on-the-autistic-spectrum 5 National Institute for Health and Care Excellence. Autistic spectrum disorder in under 19’s: recognition, referral and diagnosis. Published 2011, updated 2017.    7                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA FINDING 3: Responding to Families      i. Responding to Domestic Abuse (DA)  Once the primary concern in the family was identified as domestic abuse, service intervention was prompt and followed a model that was well-established, supported by research and at the time considered to be best practice.   Child K was removed from a Child Protection (CP) Plan largely because there had been a period of over a year with no reported incident of domestic abuse. At this point, the DA workers withdrew. The family remained together, Child in Need (CiN) services were provided and Child K’s case was closed to Children’s Services. Family members were clear that once the police became involved there had been no further physical assaults but that relationships at home continued to be difficult and caused emotional turmoil and distress. This is likely to have been the result of the control exercised by the father over a substantial number of years, in addition to the sporadic acts of violence.  The work that had been completed within the family focussed on 1:1 work with Child K and 1:1 work with his parents (separately). Whilst both the CiN and CP plans recommended family work/mediation, this had not taken place. As a result, there had been no work to address the ongoing emotional turmoil resulting from these very difficult family relationships. In this case, the recommendation for family work had been accepted by the family. However, it is important to acknowledge that consent for this kind of work is not always forthcoming and this poses particular challenges for practitioners who are left in a difficult position of balancing the child’s needs with the lack of consent and making decisions about what action to take.    Despite consistent and creative efforts, the Domestic Abuse Officer tried (without success) to engage father so a risk assessment could be completed. Consequently, it was not possible to be clear about the nature of the domestic abuse in the home or the nature of the risks. As the risks were unknown, no work could be completed with the couple and this is the standard approach in these circumstances.   No services were offered to the children to address the trauma they had suffered as a result of living in a household where DA had been a feature of their childhoods. Child K’s sister was an adult at the time the case was closed but it was clearly something that remained unresolved for her and, in her view, for her brother. During the course of this SCR, this was recognised as an important issue and concerns were expressed about the lack of specific emotional wellbeing services available for children to address the impact of DA. This is recognised as being an issue that is not specific to Hertfordshire.    ii. Understanding and responding to families and their needs  Review of the documentation revealed little information about the couple’s background; their childhood experiences, their life together, their inter-related and changing needs as a couple and as a family. Little appeared to be known about the culture and belief systems, their possible experiences of discrimination and isolation (in the words of one family member: a minority within a minority) and their culturally specific view about the impact of professional/state involvement in family life.  When speaking to family members it was clear to the reviewer that cultural, historic and gender factors were important influences in the family and that these needed to inform professional intervention.  From mother’s perspective, the involvement of professionals in their lives was an invasion of privacy. Within the family’s culture of origin maintaining the privacy of family life was critical and the involvement of professionals felt to be stigmatising. She said her husband felt put down by professionals and that the influence of his culture and childhood significantly shaped his behaviour and perspective. Family members said whilst they did not excuse his behaviour they: ‘understood him’, meaning they understood his childhood and the impact this had and   8                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA felt that his childhood experiences (and how these shaped his behaviour in adulthood and his relationship to authority) was important to understand.6   It was understood from the DA officers that there are no emotional wellbeing services available to men in Hertfordshire, although men are encouraged to access national organisations.7 Whilst it seems unlikely that Child K’s father would have accessed emotional wellbeing services, even if they were available, it is important to acknowledge that our childhood experiences/wounding has an important impact on our adult behaviour and this is as important to address for DA perpetrators as it is for all men.    Recommendation 3:  Children’s Services, in association with multi-agency partners, to review cases of DA before closure to confirm that couples and children have been signposted to counselling/mediation services.  Recommendation 4:  The Domestic Abuse Executive Board to consider whether current work streams (Needs Assessment & DA Strategy Review) are paying sufficient attention to the availability of emotional wellbeing services for men, and for children who have suffered harm as a result of living in households where DA has featured.   Recommendation 5:  HSCP to consider whether current practice and service provision is sufficiently sensitive to the cultural, historic and gender context when providing multi-agency services across the partnership, including to families from a background outside of the main Black and Minority Ethnic groups in Hertfordshire.   FINDING 4:  Family Safeguarding    In 2015, Hertfordshire was awarded a Department for Education (DfE) grant to develop the Family Safeguarding approach and this became operational across the County in November 2015. Some aspects of this approach, as it was practiced at the time (described later in this section), impacted on the service provided to the family. At this point, it was very early days in its application. Nevertheless, the panel’s view was that it was useful to highlight some relevant issues in this SCR.   Family Safeguarding brought children’s social workers together with specialists in adult mental health, domestic abuse and substance misuse under a unified management structure. Multi-disciplinary teams share motivational interviewing8 as the core practice tool and the approach aspires to improve information sharing at strategic and operational level. This model of integrated support was positively evaluated on behalf of the Government and data suggests that it has helped to reduce the numbers of children coming into care and costs across public services.   In June 2015, the DfE commissioned an evaluation of the Family Safeguarding approach in Hertfordshire.  The evaluation (completed in July 2016) published in July 2017 was positive and a number of recommendations for policy and practice were made: 9  6 Whilst this section is focussed on understanding and responding to gender cultural and historic factors it is important to be clear that DA is not acceptable in any circumstances regardless of cultural considerations  7 Such as: The Mankind Project https://mankindprojectuki.org/ 8 Motivational interviewing is a counselling method that helps people resolve ambivalent feelings and insecurities to find the internal motivation they need to change their behaviour. It is a practical, empathetic, and short-term process that takes into consideration how difficult it is to make life changes. 9 Family Safeguarding Hertfordshire: Evaluation Report July 2017 Children’s Social Care Innovation Programme Evaluation Report 55. Forrester, Lynch, Bostock, Newlands, Preston, Cary (P.67)    9                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA • further development of the adult worker role is required. There could now be an increased focus on developing and harnessing the expertise of adult workers to support multi-disciplinary working • further work is needed in developing the conceptual framework  • there is a need to develop the theoretical approach to group case discussion and provide training and supervision for those leading such discussions • further work is needed to support the understanding and application amongst workers of the principles and skills of the practice model being developed by Hertfordshire  At the time of multi-agency intervention in this case, the model of intervention did not appear to be flexible enough to enable team members to depart from their ascribed roles and responsibilities and interpretation of the model appeared to be prescriptive (See Finding 1 above).  No group supervision took place and as a result there was insufficient opportunity for professionals to reflect together on the work, this was said to be commonplace at the time. Had there been effective group supervision, these forums may have provided an opportunity to reflect, in a more challenging way, on the problems faced by staff when working with the family.   Cultural considerations and additional needs, such as autism, were not considered when using motivational interviewing and there was no review of whether its use was effective. When asked, during the SCR, practitioners were unable to identify an alternative tool/approach they could have used.  On many occasions throughout the review, practitioners were asked to describe the theoretical framework and values of the Family Safeguarding approach.  Practitioners cited the integration of workers from adult and children’s services and the use of motivational interviewing, but no one was able to provide an understanding of the values or the theoretical framework underpinning the approach. If practitioners and managers are unable to articulate the reason behind a particular action within a professional value base/theoretical model, there is a danger that any approach may be experienced and understood only as a range of tools and practical interventions. This means that workers may be less able to adapt and apply the approach in unusual or difficult circumstances and to evaluate the effectiveness of what is being done. This risks practitioners taking a view that families are not engaging rather than taking a view that the particular tool in use (or approach) does not meet the needs in the family.  The evaluation completed by the DfE was accepted and since this time Hertfordshire have made some important changes in many areas. At the time of service provision, it had not been possible to fully train staff in motivational interviewing, this has now been addressed.10 In addition, significant developments have led to some considerable changes in the way the model is implemented. Changes relevant to this review includes; an improved understanding of the model, strengthened group supervision and training in practice methodologies which complement the Family Safeguarding approach. 11  In a recent case study by Public Health England, the Family Safeguarding approach was rightly commended for the improvements evidenced in the quality of practice and outcomes for children and families. This case study notes areas for continued improvement and the following statement from the report has relevance to the findings of this SCR:  It was a  10 Since this time, there have been significant improvements in the quality and quantity of staff training in motivational interviewing  11 Such as training in the use of Appreciative Inquiry     10                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA challenge to create changes in practice across the service. Although some important shifts were achieved, more were required. Apart from effective training (some of which was of mixed quality), there was a need for more time and ongoing input so that workers could implement new ways of discussing and working with families in a more collaborative and effective way.12  It is recognised that since this case, and since the commissioning of this SCR, there have been a range of interventions that have made a considerable difference to service provision and Hertfordshire Children’s Services continue to evaluate and improve the Family Safeguarding approach. In the view of the panel, it was felt important to include the issues raised in this SCR to provide a further opportunity to reflect on the changes that have been made and to support multi-agency partners in their desire to provide the best possible services to children and families.  In addition, there was a request to include a recommendation regarding the use of motivational interviewing with adolescents to support the continued development of this area of practice. Therefore, two recommendations are made:   Recommendation 6:  Hertfordshire Children’s Services to update HSCP on how the specific issues identified in this SCR have been addressed, HSCP to provide support and challenge.   Recommendation 7:  Further development of the motivational interviewing approach to be linked to other service developments currently taking place in Hertfordshire’s multi-disciplinary adolescent teams.      FINDING 5: Working with adolescents at risk   The primary risks that triggered a strategy meeting and an Initial Child Protection Conference was Child K’s plan to run away to his family’s country of origin (a hazardous and unrealistic endeavour)13 and serious threats made to teachers and pupils. The referral made to the Channel Panel14 by his school suggested a genuine belief that Child K was potentially at risk to others and to himself. Professionals agreed that Child K was at significant risk and he was made the subject of a child protection plan.       From Child K’s perspective, the involvement of professionals in the life of his family at this time was a significant disruption and when he was made the subject of a child protection plan his engagement with professionals declined. In the letter he wrote before his death, he spoke with passion about the involvement of services in family life and how: They ruined the perfect semi-clockwork order of the household.   The recent Research in Practice evidence scope That Difficult Age15 has highlighted the importance of seeking an approach which takes account of and works positively with what is known about ordinary adolescent development. This is particularly necessary in considering engagement with services where adolescents can be perceived as ‘difficult to engage’ per se. The responsibility is often placed with them, and there can be a perception that they are  12 Case Study: Family Safeguarding in Hertfordshire. Public Health England May 2019 https://www.gov.uk/government/case-studies/family-safeguarding-in-hertfordshire 13 Child K had bought a plane ticket and had made careful plans to achieve this endeavour 14 Channel Panel : ‘Channel’ is a programme which focuses on providing support at an early stage to people who are identified as being vulnerable to being drawn into terrorism. The programme uses a multi-agency approach to protect vulnerable people’ https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/425189/Channel_Duty_Guidance_April_2015.pdf 15 RIP(2014) That Difficult Age: Developing a more effective response to risks in adolescence: https://www.rip.org.uk/news-and-views/latest-news/evidence-scope-risks-in-adolescence   11                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA making a free and informed choice. However, research makes it clear that adolescents’ struggles with services are often connected with their past experiences, the point they have reached in their intellectual, physical and emotional development and the growing importance of their social relationships outside the family. The need to find new ways of living and adapting through this transitional phase may make adolescents more cautious about services which they perceive will destabilise their established strategies for coping with their problems.   The revised statutory guidance:  Working Together to Safeguard Children (2018) and Keeping Children Safe in Education (2018) refers to Contextual Safeguarding. This is a conceptual framework for understanding, assessing, and reducing the risk of harm originating beyond the family home. This new approach recognises the importance of the transitional phase and the growing importance of social relationships outside the family. It has a specific focus on risks to young people who may be at risk of harm in the community from sexual and/or criminal exploitation, radicalisation, serious youth violence and gang membership/affiliation.  At first, Child K might not have seemed vulnerable to such concerns. However, a family member told the review that if the family had lived in an area where there were high levels of delinquency his brother would have been drawn into this behaviour – he was drawn to violence and he would have fitted in. The Channel Panel referral cited the risks Child K may pose to others and a report Child K made to the police shortly before his death suggested that his actions may result in risk to himself.   However, the contextual safeguarding approach is not an approach that neatly fits Child K’s needs and even if this was in place at the time of service involvement, it is unlikely that Child K would have been regarded as meeting the risks as defined in this guidance. The Research in Practice evidence scope16 challenges services to take a holistic approach in understanding the needs of adolescents and the risks they face, advocating an approach that considers the multifaceted dimensions of context relating to individual, family, psychological and cultural domains.   It is understood that this approach is used in Hertfordshire within the multi-disciplinary Targeted Youth Support teams. However, Child K’s circumstances would not have met the criteria for this service. Once again, the question of how far the system can apply a flexible approach arises - there are no easy answers - there is no neat fit.  3. Conclusion   It is not always possible to predict or prevent the suicide or attempted suicide of a young person.  Practitioners tried hard to make a difference with what was available, but little fitted well for Child K and his family. Fundamentally, the question posed by this case is: How can we retain the structures and processes necessary to bring consistency to activity where risks can be high and unpredictable (such as the safeguarding of children) while at the same time make services sufficiently personalised to meet specific cultural and family needs?   The need for procedures and consistent approaches when children are at identified risk can leave little room for flexibility. Hertfordshire’s Safeguarding Families approach is innovative and seeks to address many of the inherent difficulties in established ways of working. This SCR encourages Hertfordshire to continue to nurture their spirit of innovation and ask difficult but essential questions about how services can be flexible enough to personalise what can become rules-based and therefore potentially bureaucratic safeguarding so it can properly respect and respond to the uniqueness of individuals and families.     16  RIP(2014) That Difficult Age: Developing a more effective response to risks in adolescence: https://www.rip.org.uk/news-and-views/latest-news/evidence-scope-risks-in-adolescence    12                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA Appendix 1: Methodology   Review process The review was conducted in accordance with Working Together 2015 guidance that:   • recognises the complex circumstances in which professionals work together to safeguard children;  • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  • is transparent about the way data is collected and analysed; and  • makes use of relevant research and case evidence to inform the findings. (HM Government, 2015 p74)   At the start of this review the panel agreed the following lines of enquiry:  Areas of enquiry • Family members’ views on the services provided by agencies over safeguarding concerns.   How agencies addressed:   - The level of engagement of the family (individually and as a group) with agencies over safeguarding concerns and the response of agencies - Professional understanding of Child K’s pattern of behaviour and the diagnosis of autistic spectrum disorder  The effectiveness of:  • Agency responses to safeguarding concerns arising from domestic abuse • The child protection plan • The child in need plan • The response of agencies to the re-referral on the family in late 2017  This report was completed based on information provided by staff and managers directly working with the family, who were interviewed by the author. The author had access to assessments, reports and CiN meetings, Child Protection Case Conference minutes and plans, and core group meetings that were shared by the Local Authority Children’s Service.  Frontline practitioners were also involved in a learning event where the Lead Reviewer shared the initial findings from the review. There were helpful discussions between the lead reviewer and practitioners about whether the practice identified in the review was usual and how any problems could best be addressed.   Methodological comment and limitations  The process of the review was smooth, all relevant staff met with the Lead Reviewer and the majority attended the Learning Event. Panel members engaged in active debate and analysis of the data and were open to challenge and debate about the analysis and the findings of this SCR.          13                                 Lead Reviewer & Author: Bridget Griffin BA (Hons) CQSW, MA Appendix 2:  References    National Institute for Health & Care Excellence: Autistic spectrum disorder in under 19s: recognition, referral and diagnosis Published 2011, updated 2017.    Hertfordshire Safeguarding Children Board Child Protection Procedures (2015).   Pringle, Whitehead, Milne, Scott & McAteer : The relationship between a trusted adult and adolescent outcomes: a protocol of a scoping review Systematic Reviews 20187:207 https://doi.org/10.1186/s13643-018-0873-8  National Autistic Society: Communication https://www.autism.org.uk/about/communication/communicating.aspx  RIP(2014) That Difficult Age: Developing a more effective response to risks in adolescence: https://www.rip.org.uk/news-and-views/latest-news/evidence-scope-risks-in-adolescence  Michael P. Johnson, Conflict and Control: Gender Symmetry and Asymmetry in Domestic Violence, available at http://www.personal.psu.edu/faculty/m/p/mpj/02VAW.html [hereinafter Johnson, Symmetry].  Michael P. Johnson & Kathleen J. Ferraro, Research on Domestic Violence in the 1990s: Making Distinctions, 62 Journal of Marriage and Family 948 (2000).  The Tavistock and Portman NHS Foundation Trust; Tavistock Policy – Tavistock relationships, Situational Violence.   Doncaster Domestic Abuse Strategy 2017-2021 (Doncaster Safeguarding Partnership).  Suicide by children and young people in England. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Manchester: University of Manchester (2016).  Royal College of Psychiatrists: Autism and Asperger’s : For parents and carers and anyone working with Young People 2018  https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/autism-and-asperger's-syndrome-information-for-parents-carers.  American Academy of Child & Adolescent Psychiatry:  Suicide in Children and Teens (2017).   https://www.autistica.org.uk/what-is-autism/signs-and-symptoms/suicide-and-autism   Spirito, L. Brown, J. Overholser, G. Fritz : Attempted suicide in adolescence: A review and critique of the literature.     Family Safeguarding Hertfordshire: Evaluation Report July 2017 Children’s Social Care Innovation Programme Evaluation Report 55. Forrester, Lynch, Bostock, Newlands, Preston, Cary.    Case Study: Family Safeguarding in Hertfordshire. Public Health England May 2019 https://www.gov.uk/government/case-studies/family-safeguarding-in-hertfordshire 