Death of a 17-year-old boy in May 2013, as a result of diabetic ketoacidosis. HH and his family were known to children's services and HH became a looked after child three months before his death. Issues identified include: parental neglect of HH's health needs not adequately acknowledged by health professionals, due to him being treated as an adult; HH's disguised compliance in relation to the management of his diabetes; and lack of awareness of the need for HH to test his blood sugar regularly among non-health professionals. Identifies learning from the review, including: non-medical staff need to ensure they receive advice and support from health colleagues when working with children with significant health issues; multi-agency training on neglect must provide a section on the specific issues for young people aged 14 and older; agencies must recognise 16 and 17-year-olds as children; and re-assessments must be undertaken following any significant changes of circumstances. Makes various interagency and single agency recommendations. Review was undertaken using the Significant Learning Incident Process (SILP).
      
Title: Subject of this serious case review: HH: overview report. LSCB: Herefordshire Safeguarding Children Board Author: Nicki PettittDate of publication: 2014 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 Final version 09.01.14    Herefordshire Safeguarding Children Board           Subject of this serious case review:  HH    OVERVIEW REPORT         2 Final version 09.01.14 CONTENTS   1. Introduction to SILP        Page 3  2. Introduction to the case       Page 4  3. Family Structure        Page 4  4. Terms of Reference        Page 5  5. The Process         Page 5  6. A brief background prior to the scoped period    Page 7  7. Key practice episodes       Page 8  8. Analysis by theme        Page 20  9. Conclusions and lessons learned      Page 38  10. Recommendations        Page 43  11. Bibliography         Page 47    Appendices 1. Terms of Reference and Project Plan 2. Agency Report pro-forma 3. Genogram  3 Final version 09.01.14 1       Introduction to the Significant Learning Incident Process (SILP)  1.1 SILP is a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted in a certain way at the time. This way of reviewing is encouraged and supported in the new Working Together to Safeguard Children published in March 2013.  1.2 The SILP model of review adheres to the principles of;  proportionality  learning from good practice  the active engagement of practitioners  engaging with families, and   systems methodology.  1.3 It has been generally accepted that over recent years the Serious Case Review agenda had become over-bureaucratic and driven by Ofsted ratings. The practitioners in the case have often been marginalised and their potentially valuable contribution to the learning has often been under-valued and under-utilised.  1.4 SILPs are characterised by a large number of practitioners, managers and Safeguarding Leads coming together for a learning event. All agency reports are shared in advance and the perspectives and opinions of all those involved are discussed and valued. The same group then come together again to study and debate the first draft of the Overview Report.  1.5  Herefordshire Safeguarding Children Board have requested that the SILP model of review be used to consider the circumstances surrounding the death of a child known as HH, in order to learn lessons about the way that agencies in Herefordshire work together to safeguard children.  1.6 Working Together 2013 states that SCRs and other case reviews should be conducted in a way which;  recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did   4 Final version 09.01.14 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.   1.7 This serious case review has been undertaken in a way that ensures these principles have been followed.   2  Introduction to the Case  2.1 The subject of this review is child HH, a 17-year-old male who was found dead in May 2013. He had three siblings, two older and one younger. The family is originally from Poland and Mother speaks little English. His Father lives in another European country. There has been no contact with Father since the family moved to the UK.   HH was a vulnerable young person due to his diagnosis with Type 1 diabetes, and because he was not living with his family at the time of his death.  HH became known to Children’s Social Care (CSC) in October 2012. He was an open case to the 16 plus team, who work with looked after children. Toxicology evidence suggests HH died of diabetic ketoacidosis.   3      Family Structure  3.1 The subject child is to be referred to as HH, he was aged 17 at the time of his death. HH has two older sisters, one of whom lives locally. She is an adult with a family of her own. HH has a younger brother. The two siblings in the UK will be referred to as Sister and Brother.   3.2 The parents of the subject children are referred to in this report as Mother and Father. They are separated. Mother had two partners during the scope of this report, both of whom had contact with HH. Only one is relevant to this review report however and will be referred to as ‘Mother’s partner’.     3.3 A genogram is attached at appendix 3    5 Final version 09.01.14 4 Terms of Reference  4.1 The detailed Terms of Reference and Project Plan appear at Appendix 1. The purpose, framework, agency reports to be commissioned and the particular areas for consideration are all described there.  What the agency authors were asked to analyse and the format of the agency report appears at Appendix 2.  4.2 It was agreed that the scope of this review would be from January 2012 when HH was diagnosed with Type 1 Diabetes Mellitus to 17th May 2013 the date HH was found dead. These dates were agreed as there was little information held by agencies about HH prior to January 2012, other than what is ordinarily held on children, such as school records.   5      Process  5.1 The mother of HH was contacted in order to ensure her views were considered and heard as part of the review. A letter was translated and sent, and was followed up by a phone call with a Polish interpreter. She was clear that she was not willing to meet with or to have a telephone conversation with the reviewer.  We had to accept that she did not want to be part of this review. It is important, while carrying out this review, to be mindful of the loss experienced by this family and that families do not always feel able to discuss their child in detail.  She has been written to prior to publication and it was hoped she would agree to a visit so that she is aware of the findings of this review and the content of the published report. Again she has refused this contact.   5.2 Before publication Sister was visited by the reviewer. The purpose of the visit was to gain information and to explain the findings of the review and to outline the plan for publication. It had not been clear prior to the learning event and recall day how significant HH’s sister had been in his care, so they had not been visited prior to the review taking place. Sister and her husband were keen to be engaged and were very helpful in explaining the family background. The information provided by them and their views has been included throughout this report.     6 Final version 09.01.14 5.3 The younger brother will receive a copy of the report prior to publication, which will be explained by a professional whom he knows and trusts. It was hoped that he would contribute to the review, but circumstances in his own life have made this difficult for him, and he has clearly stated that he did not wish to be spoken to. The HSCB are aware of the possible impact of the report and its publication on Brother and have a plan in place to ensure he receives appropriate support.  5.4 The Department for Education expects full publication of Serious Case Review overview reports, unless there are particular reasons why this would not be appropriate.  Working to that requirement, some confidential family information will not be disclosed in this report. It is however written in the anticipation that it will be published, and contains all of the information that is relevant to the professional responses to HH and his family.  The decision to disclose information has been taken with reasonable caution to prevent the identification of the child concerned and other family members, and to protect the right to an appropriate degree of privacy for the family.  5.5 A meeting for authors of individual agency reports was held on 12 September 2013, where the SILP process and expectations of the agency reports was discussed. A full day Learning Event took place on 24 October 2013. Most of the agencies involved were represented by both the report author and staff, including managers, who had been involved during the scope period. Absences were accounted for, and reasons included staff that were no longer employed and one on maternity leave. All the agency reports had been circulated in advance, to ensure all staff attending were able to fully understand the multi-agency information and focus of the review.   5.6 At a recall session on Monday 25 November 2013 participants who had attended the Learning Event considered the first draft of this report. They were able to feedback on the contents and clarify their role and perspective. All those involved contributed to the conclusions about the learning from this review. The final version of this Overview Report was presented to the Herefordshire Safeguarding Children Board (HSCB) on 9 December 2013. A small number of final changes were then made to the report to ensure issues raised by the Board were clarified by the Author.     7 Final version 09.01.14 5.7 The reviewer in this case and report author is Nicki Pettitt, an independent child protection social work manager and consultant, who is an experienced chair and author of serious case reviews, and a SILP associate reviewer. She is entirely independent of HSCB and its partner agencies.    5.8 The Coroner is investigating the death of HH and has adjourned the matter until the serious case review is completed. The Coroner has agreed to the publication of this report before the inquest is held.   5.9 The Police investigation has been concluded and no criminal prosecution will be undertaken in respect of HH’s death.  5.10 The Polish authorities have been informed of HH’s death and that a serious case review is being undertaken.   5.11 Working Together 2013 does not require the completion of a health overview report which considers the commissioning of health services and to pull together the related health information. It was reflected on at the learning event and recall day that a health overview report may have been helpful in this case. A recommendation has therefore been included to ensure that the learning from a health wide review is established in relation to HH. Feedback has been given to the Board and to the SILP organisation that this issue should be considered at the start of all reviews in future.   5.9 This process has been effectively administered by Lisa Beavan of HSCB.   6 The background prior to the scoped period  6.1 Agency authors were asked to consider all of the records held on the subject child, and relevant records on other family members. While they were asked to provide detail and analysis on the period of the scope of this review, they were asked to provide information from before the period in question in order to ensure that relevant and pertinent background information was available to the review.   6.2 It is believed that Mother and her family arrived in the UK in 2006. They came directly to Herefordshire.  HH was 10 years old at the time. Mother got a job on arrival and spent long hours in unskilled and low paid work to support the   8 Final version 09.01.14 family. Further details about her employment were shared during the review, but are not included in this report due to the wish to keep the family details anonymous. The younger children attended school near to the family home.   6.3 HH was known to a number of agencies. Education due to him attending school then college, and to a number of health agencies for unremarkable issues prior to his diagnosis with type 1 diabetes.  6.4 HH had attended hospital with a foot injury after an accident when he was 14 years old. He attended the first time with Mothers partner, when he returned for a check up he attended alone, which was felt to be unusual for a child of his age. The doctor contacted the school nurse (SN) as he was concerned that HH’s parent had not attended with him.  6.5 The SN discussed HH with the school and attempted to see HH in school a number of times. This was not possible for a number of months and the SN recorded that this was due to poor school attendance.  It was also recorded that the school reported that HH’s behaviour was often erratic and that he did not appear well-nourished.  SN requested that she be invited to a meeting that the school were planning to have with ‘the parents’. There is no record that such a meeting took place.  It should be noted however that while undertaking a later assessment, the duty social worker contacted HH’s previous school for background information and they stated that he was friendly and engaged at school and that there were no concerns about him. He was said to have left with a number of GCSEs and had very good attendance. This review did not receive a report from the school as it was outside of the scope of the review.  It has been reflected on at the conclusion of this review that a report from the school may have been helpful, and the HSCB has agreed to make contact with the school to see if there is any additional learning which may be gained from them.    6.6 The SN contacted the GP to discuss the school concerns and HH’s outstanding immunisations. The GP agreed to contact the family. The agency author for the GP notes that HH was the only member of his family to be registered at the GP surgery, which is unusual. HH filled out the forms to register at the surgery himself, when he was 12 years old, and on occasion he attended the surgery alone.    9 Final version 09.01.14  6.7 It is not clear if Mother was contacted, as stated above. It is noted that the GP surgery did not have any contact with HH’s family regarding his diabetes care, despite him being just 16 when diagnosed with this serious condition. He was assessed by the GPs who saw him as competent to make decisions for himself.  The GP who attended the recall event stated that on a regular basis GPs have to make decision about whether they can treat a child without the parent being present or possibly even aware. This is an issue for the HSCB to consider, in regards to the circumstances where lack of parental engagement in a child’s treatment is acceptable and where it is not.  This is a complex area which requires further consideration by, and guidance from, the HSCB.   6.8 The college that HH attended had no specific concerns about him, however his attendance was not adequate and this led to him leaving before completing either of the courses he had enrolled in, in 2011 and again in 2012.  The College did attempt to speak to HH in regards to his lack of attendance, but as they were unaware of the later involvement of CSC and the CiN plan (as covered below) they did not raise these issues with other professionals. This potentially valuable liaison was a missed opportunity for underlying issues to be explored and to find out more about HH’s world.   6.9 HH was known briefly to the Police prior to the scope of this review. In 2008 he was arrested on suspicion of an assault on a child in his class at school. No charge was made, but it was noted by the Police that Mother did not attend the Police station with HH, a teacher from his school acted as appropriate adult.    7      Key Practice Episodes       7.1 This review will now focus on the key practice issues during the period that this review will concentrate on. There were 4 key practice episodes before HH died. They were: I. January – May 2012, initial response to HH’s diagnosis with type 1 diabetes. II. The referral to Children’s Social Care (CSC) in October 2012 until an Initial Child Protection Conference (ICPC) was held in January 2013.   10 Final version 09.01.14 III. The period of the Child in Need (CiN) plan January 2013 – February 2013.  IV. February 2013 when HH became a Looked After Child (LAC) until he died in May 2013.   Key practice episode I : January – May  2012 Diagnosis.   7.2 HH was diagnosed as a type-1 diabetic after he presented at the GP out of hours service in the early hours of the morning on 28.1.12. He was promptly diagnosed with diabetic ketoacidosis (DKA.)1   7.3 Type 1 diabetes starts most commonly when people are young, between the age of 2 and 20. With Type 1 diabetes, also called insulin-dependent or juvenile diabetes - the pancreas is no longer able to produce insulin because the body's immune system destroys, or attempts to destroy, the cells in the pancreas that produce insulin. Insulin is the hormone that allows glucose to enter the cells of the body to provide fuel. When glucose cannot enter the cells, it builds up in the blood and the body's cells literally starve to death. Everyone with Type 1 diabetes must take daily insulin injections and regularly monitor their blood glucose levels. The cause of diabetes type 1 is unknown, but it is believed that people inherit a tendency to develop diabetes2.   7.4 Although they recorded an attempt to get HH admitted by the paediatric team, it was noted that the GP out of hours service were told that as HH was a college student he was not eligible for paediatric care. At this stage he became a patient of adult medical professionals. This was a significant decision which influenced his future care, as will be discussed below. The policy of Wye Valley Trust is that young people are admitted to the children’s ward up to age 17, and as HH was 16 years and 6 months old, he was eligible to receive paediatric services.   7.5 It is not clear if HH initially attended with any adult, or if any adult was informed of his diagnosis by the GP out of hour’s service. However the                                                             1 Diabetic ketoacidosis is an emergency condition caused by untreated hyperglycaemia. Ketoacidosis can be a life-threatening situation for those with diabetes. A person with type 1 diabetes has the greatest chance of developing ketoacidosis.   2 from www.healthtalkonline.org    11 Final version 09.01.14 hospital notes state that he attended with family, but that they left when it was agreed he would be admitted. The names or status of those who attended with him was not noted. HH was admitted to hospital for four days where his condition was stabilised and he received both support and advice on his diabetes and how to manage it after discharge. He was referred to the diabetes specialist nurse team, who taught him how to check his blood glucose, administer his insulin injections and how to manage both hypoglycaemia (low blood glucose) and ketoacidosis.    7.6 The adult diabetic nurse specialist (ADNS) did refer HH to her equivalent in paediatric services, due to HH’s age and concerns that no parents had been seen on the ward.   7.7 It was noted in the hospital notes on a number of occasions that HH appeared to understand the instructions given and his condition. However the diabetic nurse noted on the day before his discharge that HH was not fully competent regarding the management, and that she was not sure that he understood some of the educational information. Another visit was therefore arranged to see him before discharge, and it was then felt that he was confident about the treatment and understood the issues. Mother did not appear to receive any education on the condition or its treatment, and the discharge summary sent to the GP did not record the lack of involvement of any family in the treatment thus far.  7.8 The adult and paediatric diabetic nurses discussed HH and agreed to undertake a joint home visit on the day of discharge. It is not clear which family members where there at the visit, but the paediatric diabetic nurse specialist (PDNS) arranged a visit the next day with the dietician. This was good practice, and it should be noted that the dietician does not have a community role, but agreed with the PDNS that it was an important visit to make. Over the next week three further visits were undertaken by the PDNS, along with an appropriate interpreter.  During the visits Sister and Mothers partner were noted as being present. They were included in the education programme, as people to help HH to care for himself.   7.9 The PDNS also visited the college and met with HH tutor to ensure they were aware of the condition and a care plan was developed and left with the tutor.     12 Final version 09.01.14 7.10 At the end of February 2012 the case transferred back to the adult team. This is despite HH still being aged just 16. A handover letter was written outlining the case history. It was noted that: - Mother works long hours and has little interest in HH condition, as she had not attended any of the appointments.  - Sister, brother in law and Mothers partner understood the condition.  - HH had not attended college since before being diagnosed. - HH did not appear motivated to improve the current poor control of his blood glucose.   7.11 At the end of February HH attended an outpatient appointment with the adult diabetic consultant and nurse. His weight had improved and he looked healthier, but concerns still remained about management of the condition. They assessed that while HH clearly understood what he had to do, and why, he did not appear to be acting on the advice/treatment plan.   7.12 Further appointments were made in both May and June, but HH did not attend either and did not respond to a letter asking him to make contact. No further letters were sent and he was not seen by the diabetic team until he was readmitted in January 2013.   7.13 HH did attend a full diabetic screening at his GP surgery in April 2012. He also discussed some unrelated health issues, and it is thought that this was the real reason for his attendance rather than him taking advantage of assistance with his diabetes. Over the next few months he saw medical staff at the GP surgery in relation to the unrelated issue and it is noted that none of the staff seeing him evidenced in his notes that they took the opportunity to speak to him about his compliance with diabetes management or his missed appointments at the hospital. HH’s non attendance at the hospital appointments wasn’t addressed with HH until 18 November 12 when a GP contacted him by telephone and HH responded that he was unaware of the missed appointments.  7.14 This period was a key practice episode because it sets the scene for the management of HHs medical condition. It also presents this review with interesting and important information on both HH and his family, which is   13 Final version 09.01.14 significant for understanding the on-going management of his care, both medically and generally.   Key practice episode II : October 2012 – January 2013. The involvement of CSC.  7.15 The only contact with services between these key practice episodes was in July 2012 when HH called the Police saying that his mother and brother were arguing. The Police visited and no further action was taken.   7.16 HH had applied to attend a new vocational course at college to start in September 2012. His attendance was very poor however and he stopped attending after only a few weeks.   7.17 In these months HH was increasingly isolated. He was not in education employment or training and he had limited contact with medical professionals. Mother’s partner is believed to have left the family home in April 2012. This may be significant as he appears to have been involved in the care and management of HH’s diabetes. This leads to a marked deterioration in life at home for HH which results in the intervention of CSC from October 2012.   7.18 On 3 October 2012 HH went to housing and presented as homeless. They contacted CSC as their enquiries had led to concerns about Mother’s mental health and questions about how the family were coping. CSC undertook an initial assessment and concerns were identified in regards to the care of HH and his younger sibling.  The main concerns were lack of adequate food and heating and the school attendance of Brother. The particular vulnerability of HH was noted due to his insulin dependency and the importance of him receiving good care and diet. Checks were made with other professionals, including the GP. The GP records do not evidence that information was shared with the social worker regarding the lack of engagement by HH with the management of his diabetes. The GP agency author states that ‘if put together the concerns regarding possible parental neglect and the lack of concern regarding HH’s medical condition may have prompted Children’s Social Care to become more involved in his life’.  At the Recall Day the GP was clear that she had shared the concerns that HH was not engaging with services. The Social Worker confirmed this, and said that the GP had told her that there was a risk of coma, renal failure and death. This still did not lead to   14 Final version 09.01.14 information sharing with the hospital diabetic team about the involvement of CSC however.    7.19 At the learning event the social worker shared her frustration at finding out who was actually involved with HH at the time, in regards to his diabetes. She described leaving messages for health professionals but not being confident she was even trying to talk to the right people. CSC records show that a number of telephone calls were made by the social worker. As GP’s tend to be the one professional who all other medical professionals write to in regards to a patients treatment, an enquiry could have been made of the GP, by the social worker, to gain information on HH’s wider medical allocations.    7.20 On 10 October 2012 HH called the Police via ‘999’ and stated his mother was not feeding him or his brother. He said that CSC was aware and that they had visited. Checks revealed that HH’s brother was known to the police for anti-social behaviour issues. The family were visited and HH was spoken to. Mother was recorded as not being able to speak English. The officers checked the cupboards and confirmed that there was no food or electricity. HH stated he often went to his sisters for food. Police believed Mother was punishing the boys because they continually invited friends to the house and ate all the food. The officers noted that HH seemed in a healthy condition and they had no concern for his wellbeing. During this visit the neighbours were questioned, and they reported that the boys were often at home while Mother was away and there were regular anti-social behaviour violations.  Sister informed the review that her mother had been preoccupied at this time with her own relationship and had effectively moved out and left the boys at home.  7.21 As part of the initial assessment the social worker interviewed Mother using an interpreter, and spoke alone to both HH and his younger sibling. Mother was thought to be intimidated by her sons, with them dominating their mother. She had distanced herself from them and from the home, which they used to entertain their friends. Mother was clear that she was unable to attend appointments with HH as she could not take time off from work. She was confident that her daughter and son-in-law were willing and able to support HH. At the conclusion of the initial assessment a strategy discussion was held, and an agreement was made to complete a core assessment under S47 and child protection procedures.    15 Final version 09.01.14  7.22 HH was seen by a nurse practitioner at the GP surgery on 12 December 2012 for a review of his diabetic management, and bloods were taken. The GP review of the results led to it being recorded that there was ‘very poor control’ of his diabetes and that he needed a review. However HH missed an appointment with the nurse practitioner on 3 January 2013, resulting in a letter being sent. The agency author and the learning event agreed that this response was inadequate, and that the surgery should have been ‘more proactive’ in encouraging HH to attend.   7.23 This is a key practice episode because it resulted in the concerns about both children being assessed by CSC, and a number being acknowledged and accepted as of concern. HH was seen by the social worker and by a police officer, and was able to describe the situation at home. There was a degree of understanding about the vulnerability HH due to his medical condition, but difficulties in communicating with relevant health personnel led to no apparent link being made between the neglect concerns and the poor management of HH’s diabetes.   Key Practice episode III. From January – February 2013. Child in Need Plan.  7.24 The concerns further identified by the child protection investigation and core assessment led to an Initial Child Protection Conference (ICPC) being arranged for 2 January 2013. This did not go ahead because it was not quorate and HH had gone away to Poland for Christmas. It was eventually held on 11 January 2013. There was no representation from diabetes medical professionals at this meeting. CSC has a record of invitations being sent, but the diabetes team have no records on file of the invitation. It appears the invitation was sent to the children diabetic team, when the case was held by the adult’s team. The GP did not attend but sent a report stating that HH needed to show greater control over his diabetes. There was no analysis included from the GP of the impact on HH if he did not improve his management however.  The School Nurse was invited to the conference, and did comment on HH, but was not part of the on-going plan for him as he was no longer in education. There was no coordinated health input to the conference in regards to HH and his diabetes.     16 Final version 09.01.14 7.25 The decision of the conference was that HH should be subject to a Child in Need (CiN) plan rather than a Child Protection Plan.  The decision was recorded in the CP conference minutes which show that it was made after a discussion about the threshold criteria, which is whether HH was likely to be subjected to on-going significant harm, and which considered his age and his apparent willingness to cooperate and work in partnership with CSC. However HH did not attend the conference and the Chair did not ascertain his wishes and feelings prior to the meeting, as he was away. His level of commitment to the CiN plan was therefore not confirmed with him, and he did not hear firsthand the concerns (and the fact that people cared and worried about him) that were shared at the meeting. There were also a number of concerns about the sibling that would have impacted on HH, such as the deteriorating relationships in the home, lack of adequate food and utilities and the siblings behaviour being out of Mother’s control.   7.26 It was clarified at the Recall Day that the SW had tried a number of times to speak to HH about the conference and to get him to attend. However he was abroad seeing family over this period for around 6 weeks. There had been a lot of discussion about how to engage both boys with a plan, as it was accepted that they were keen to be better cared for at home, but that they were not motivated beyond that to cooperate with professionals. This was not felt to be unusual with young people of their age, and it was agreed that any engagement with them would need to be creative.  The review was reassured from the statements made during the learning event and recall day, and from the information shared by them, that professionals had considered the views of HH when considering him at the ICPC and when deciding on how to engage him in the plan.  7.27 The agency author for CSC stated that had there not been a younger sibling it is likely that HH would not have been the subject of a CP conference, but that the core assessment, which the agency author has stated was a good piece of work, would probably have lead to a CiN plan without the conference. The result of the conference was therefore felt to be an appropriate response to the issues in respect of HH. There is a wider issue that HSCB may wish to consider in light of this case, which is in regards to the consideration of 16 and 17 year olds at child protection conferences as a way of managing any risks they may face.  This is considered below in the analysis section.    17 Final version 09.01.14  7.28 Although it was not in the minutes of the conference, the resulting CiN plan for HH suggests that those involved had awareness that he was not engaging with the diabetes service, and states that the Social Worker would contact the diabetes team. An invitation to the conference was sent to the Paediatric diabetes team, they sent apologies but did not inform the SW or conference that it was in fact the adult diabetes service who was involved with HH. This means that the adult diabetes service were not aware of the child protection concerns or the level of anxiety about HH’s home circumstances. The case transferred from the FAST (duty) team to the Child in Need (CiN) team, as is the transfer protocol for CSC.     7.29 A CiN plan was subsequently made for HH, which stated that the aim of the plan was to ensure that his health and educational need were met. However no CiN plan meetings were held in order for the appropriate professionals, HH himself and significant family members to meet to share information and confirm any progress. An ADNS was identified as being involved at that stage, but was not told about the plan or consulted on any involvement that might be required. The ADNS told the review that she was not aware there was a CiN plan.   7.30 This is a key practice episode, as there was an acknowledgement that HH required more support than he was receiving at home, and that professionals needed to intervene in his case. Particularly health professionals in regards to his diabetes management. The making of a CiN plan appears to be appropriate on balance, but the quality of that plan was not as robust as it could have been, as it was not effective in involving key family and professionals, or in planning for clearly stated and outcome focused improvements in the required areas.   Key Practice Episode IV: Looked after child.   7.31 On 4 February 2013 CSC were informed that HH had been homeless since his mother made him leave the family home the previous week. He had initially been staying with a friend and then had a short time in a night shelter. He was placed into emergency B&B accommodation by CSC, in an establishment which often provided rooms to young people, and is described   18 Final version 09.01.14 as more supportive than the average B&B setting. They were made aware of the need for HH to take his insulin and have food available.   7.32 Responsibility for HH transferred to the 16+ Team, as is the process for all homeless 16 and 17 year olds.  He was allocated to the Family Support Worker (FSW) a member of CSC staff whose role it was to support young people when they initially become homeless. FSW is an experienced worker with skills and expertise in housing issues.  HH’s case was taken to the Placement Panel on 20 February 2013, 3 weeks after he was made homeless. The panel are a group of managers and practitioner who decide if a young person should become a Looked After Child (LAC) and agree funding for placements. Agreement was given for HH to be placed in supportive accommodation. It was made clear at this meeting, and recorded that support was to be given under S20 of the Children Act 1989, which would make HH a LAC. This is as expected under the Southwark Judgement (since May 2009) and because of HHs vulnerability due to his diabetes.   7.33 Responsibility for HH now moved to a Social Worker in the team, as a qualified member of staff needs to be allocated to children and young people who are looked after. However the newly allocated worker did not trigger the LAC episode on the computer system or arrange key LAC tasks before a period of sickness, and therefore HH did not receive the correct level of services that a looked after child should expect.  He did however continue to receive practical support from the FSW. At this time the interim manager in the team was dismissed and there was a vacancy until a new manager was appointed. This would have had an impact as there was no manager to identify that HH’s LAC status and workflow had not been generated on the electronic data base / recording system.    7.34 On the 8 March 2013 the diabetic service wrote to HH at the B&B accommodation, to offer him an appointment, they also wrote to the GP to inform them that HH was at risk of DKA as he was missing insulin doses. They reported being unable to contact him on his mobile phone, and requested any other contact details that they could try. It is not clear if any response was received. As the key individual service with responsibility for HHs health care, this was also not an adequate response.     19 Final version 09.01.14 7.35 HH had applied for a place at a supported independent housing unit at this stage, but it was agreed that it was more appropriate for him to spend some time in supported lodgings. It is clear that the 16+ team listened to HH’s views, but persuaded him that it was in his best interests to have a staged process to reach independence. He therefore moved into a supported lodgings placement on 19 March 2013. This is a placement in the home of a carer who is assessed and trained to work with 16 and 17 year olds. A placement planning meeting was held and a placement agreement was completed.   7.36 It is clear that good information sharing occurred, with the supported lodgings carer seemingly clear about HHs condition, the insulin regime, and dietary issues. The CSC agency report author states ‘An awareness of the risks associated with his insulin dependency continues to be evident in the case records, and appropriate attention given to this, through regular discussion between HH and his support worker as to the importance of this, his diet, and the need to keep his appointments with his GP and diabetic nurse’. What has become evident however is that none of the professionals involved from non-health backgrounds were aware of the need for HH to test his blood sugar levels with his Blood Glucose Meter (BGM) a number of times a day. It was only at the recall event that information was shared that HH had not been using the BGM very much at all. On most days he did not test even once. During April the BGM was not used.  The medical professionals in attendance shared that they would expect good compliance to involve at least three tests per day.    7.37 While he was placed with the supported lodgings carer the FSW, rather than a SW, undertook regular visits to HH, and a duty social worker covering for the allocated SW who was sick, undertook a statutory visit, as is expected with any LAC. HH received the level of visits expected with any LAC, and he received a number of additional visits from the FSW. However he did not have a LAC care plan, any LAC reviews chaired by an Independent Reviewing Officer or a referral to independent advocacy support. The LAC nurse would have become involved and would have had the responsibility for assessing and then overseeing and coordinating HH’s medical needs.  No LAC papers were signed by HH or his mother and a LAC medical was not arranged. It is acknowledged that staffing issues in the team at this time had   20 Final version 09.01.14 an impact on the oversight of the case, and the review has been informed that significant improvements in management and staffing have been put into place in the last 6 months.   7.38 Around this time HH enrolled in a youth employment project in the area, which he was encouraged to attend. Information was requested for this review from the project, however it is now closed, so finding out the information has not been possible.   7.39 In March 2013 HH came to the attention of the Youth Offending Service  (YOS) as he had been arrested in January 2013 for theft of food and for driving matters. The Police agency report informed the review that HH had attended the police station on four occasions in order for him to be formally interviewed about these issues. On two of these occasions a medical assessment had to be undertaken as HH was complaining of feeling unwell. On each occasion the nurse who undertook the assessment stated that HH was not fit to be interviewed and needed to go to the hospital. He was escorted to the hospital on both occasions by police officers.   7.40 This is further evidence that HH was not managing his condition well, as his blood glucose levels were very high and he did not have his insulin with him at the Police Station. No questions were asked about him stealing food, and whether this was due to his diabetes. Checks were not undertaken to see if HH was known to CSC. HH was dealt with in a busy custody department, and the police officers involved in this review were clear that it is not realistic to expect the custody staff to access the police intelligence system to find out if all under 18’s coming to their notice to see if they are known to CSC, other than checking if they are subject to a CP plan. Those involved in this review did believe that consideration should have been given to referring HH to CSC due to the on-going issues with his health and the lack of parental support at the police station and hospital. As a 17 year old, HH was seen as an adult rather than a child.   7.41 The involvement of the YOS led to a final warning assessment by the YOS police officer being imposed on HH. This final warning process is part of the Crime and Disorder Act 1998 and is often used for young people with minimal previous offences. The assessment was attended by HH, accompanied by his   21 Final version 09.01.14 worker from the 16+ team. As HH was receiving professional support from CSC, YOS had no further contact.   7.42 On 21 March 2013 the FSW rang the GP surgery for information on HH diabetes management. They requested support for the carer, and voiced concerns that HH was drinking fizzy sugary drinks. The GP sent some information leaflets to the carer. The GP told the review that this particular surgery has good expertise in diabetes, but acknowledged that they do not have any formal links outside of standard communications with the hospital based diabetes service. An ADNS informed the GP at the review that they can offer a liaison service to GPs and can contribute to more holistic assessments alongside GPs. This offer was positively received by the GP surgery.   7.43 Health concerns for HH continued in April, when the carer informed the FSW that HH was urinating and eating excessively. When the FSW saw HH on 19 April 2013 there was a discussion about his diet, as the FSW noted that HH seemed quite sleepy.   7.44 On 7 May 2013 HH moved to a supported semi-independent housing provider in a town some distance from the home address and the medical services used by HH. HH is said to have been confident using public transport and regularly travelled to see friends some distance from his home however, so he was not concerned about moving to a new town. The move was to the unit chosen by HH and he was said to be pleased with the choice. The move was however slightly premature and was precipitated by personal issues for the supported lodgings carer, which resulted in the involvement of the Local Authority Designated Officer for Child Protection (LADO).  The concerns were in regards to anti-social behaviour at the property, with issues including a group of young people drinking alcohol at a party. There were no concerns that HH had been involved, but the subsequent investigation led to the decision to end the placement. It has been reflected on during this review that this decision may not have been the right one for HH. It was seemingly made without consideration being given to undertaking a risk assessment and consideration of him remaining in the placement until arrangements could be made for him to move in a planned way.    22 Final version 09.01.14 7.45 Before he was given a room, HH and the lead worker at the unit completed a risk assessment and devised a support plan. HH confirmed he was able to manage his illness and said that he kept his insulin and some sweets in his backpack when away from his room. There was no social work team involvement with HH when he moved, as those who knew him were either off sick or on annual leave at the time.  He was assisted by a housing worker on the day of the move, and most of the information shared with the housing provider was self-reported by HH.   7.46 HH had left a number of his belongings at his previous placement, and these had been delivered to the social work office. This included his mobile phone, which had been purchased for him by CSC. The plan was for the allocated worker to deliver his things to HH when she returned from her period of annual leave the week of the 20 May 2013. HH not having access to the mobile phone at the time of his death may have been significant.   7.47 Appointments had been arranged for HH to attend the GP surgery to see both the GP and the diabetic nurse based at the GP surgery (he remained registered at his previous surgery) on 15 May 2013. He did not attend. Staff at the unit were not aware of this appointment and in fact accompanied him to a new GP to register when he arrived at the unit.   7.48 HH appeared to have settled into the accommodation well, and engaged with a number of activities over the first few days, with staff and other residents. These included cooking classes, which he was said to enjoy. The housing unit has provided information to the review that suggests that HH had been taking more interest in his general health and fitness in these weeks, speaking of wanting to eat healthily, exercise more, and he was seen reading men’s health magazines.   7.49 HH was not seen by staff for around 6 days and other residents for around 3 days before he was found dead in his room.  The cause of death was diabetic ketoacidosis (DKA). There has been an investigation into HH’s death by a number of medical experts. They have concluded that HH had the opportunity to stop himself from developing DKA by using his insulin treatment, giving the necessary extra doses he would need, and consulting his doctor or diabetes nurse. It is clear that HH was aware of ‘sick day rules’ and as he has DKA a number of times before was aware of both the symptoms and the treatment.   23 Final version 09.01.14 However it should be noted that it is the opinion of those involved that anyone seeing him in the 2 – 3 days before his death would have been aware that HH was sick and that he required medical treatment.     7.50 This is a key practice episode, as HH’s relationship with his mother broke down, he became a Looked After Child, and he had an urgent need for stable and suitable accommodation in order to ensure he kept healthy. He should have been offered a LAC medical and should have had a LAC review within 20 days of coming into care, which would have considered his health needs as part of his care plan. The LAC nurse is said to be particularly skilled at engaging 16 and 17 year olds and is flexible in meeting with young people to gain information about their health. It was a missed opportunity that she was not made aware of HH and did not attempt to assess his health needs. Due to processes not being followed in relation to HH status, key tasks did not happen. The impact of this practice episode on the outcome for HH will be further considered in the analysis below.   8 Themed Analysis  8.1 The analysis section of the review will consider the information above, which was gained from the Agency Reports and the staff who had worked with HH and his family who attended the Learning Event.  The key themes can be highlighted and covered in sections. These will lead to the lessons that need to be learned from this review, and any required recommendations and findings.    8.2 The main issues that have been identified by this review are as follows: A. The impact of HH’s age.  B. The vulnerability of HH as a young person with a serious health issue who was not receiving adequate parenting.  C. HH’s homelessness.  D. The status and suitability of HH’s plan. E. Lack of preparation and planning for HH’s move from supported lodgings to the semi-independent unit in another town.  F. Lack of consideration of the psychological impact of his diagnosis and treatment on HH. G. Culture and language issues.   24 Final version 09.01.14   A. The impact of HH being 16/17 years old.  8.3 The age that HH was when he was diagnosed with type 1 diabetes is significant, as it led to confusion about his place in the medical system he entered when diagnosed. He became a patient of the diabetes service through an ‘out of hours’ diagnosis, and was put into an adult bed when he should have had a paediatric bed. This exacerbated the confusion.    8.4 HH’s age led to him being treated as an adult by professionals, which meant that his mother’s lack of engagement in his care and treatment was accepted and not sufficiently challenged. HH was assessed as competent to make his own health decisions, and Mother’s lack of involvement was not seen by health professionals as a sign of neglect. As HH was receiving services from the adult diabetic services for most of his care, the impact of parental neglect was not adequately considered. There were no plans for transition from paediatric to adult services, which would have clarified HH’s health situation and may have highlighted the risk from his non-compliance.   8.5 It is clear that being 16 years and 6 months old at diagnosis, HH should have been referred immediately to paediatric services for his care. The local policy states that young people are admitted to the children’s wards up to their 17th birthdays. As he came into the system via out of hours services there appears to have been some confusion as to what bed should be offered and therefore which consultant should take on responsibility for his care. It is interesting to note that there were no adult medical beds available for HH on the night he was first admitted. There were however children’s beds available, and the care that followed might have been different had those on duty that evening pursued one of these empty beds for him.  8.6 An ADNS did recognise the need for the PDNS to be involved however, and they undertook some joint work when HH was discharged from hospital. The agency author told the review that the care provided by the PDNS was good, and it is acknowledged that this was in line with the NICE guidance. There were a number of home visits undertaken by the PDNS and a visit to HH’s college, which is good practice.     25 Final version 09.01.14 8.7 The PDNS passed responsibility of HH back to adult diabetic services in February, copying his transfer letter to the GP. Information included in the letter was that HH had not attended college for some months and that he ‘appeared to have little motivation or interest to improve the current poor control of his blood sugars’. It is the view of the agency author for the Wye Valley Trust that this was an inappropriate transfer back to the adult service, as HH was 16 years old and it had been acknowledged that Mother had shown little interest in supporting HH. No safeguarding supervision was sought to discuss this concerning issue.    8.8 HH was seen by the diabetic consultant and an ADNS a month later and they recorded that he was aware how to manage the condition, however they remained concerned that he was not acting on the advice given and was not following his treatment plan. HH did not attend any more hospital appointments until he was admitted in January of the following year, over 9 months later.   8.9 Had HH been under children’s paediatric services at this stage, the DNA (Did Not Attend or Was Not Brought) policy would have been triggered. The fact that he was being treated as an adult rather than a child therefore had an impact on the expectation of him to manage his own appointments and treatment. As the agency report for the Wye Valley Trust states ‘during the author’s meeting with the adult diabetic team, it was clear that the team had not considered HH to be a child in terms of safeguarding. This appears to have arisen due to the practice that, within health, young people generally receive services from adult teams from the age of 17 years. Safeguarding Children policies were therefore not considered to be relevant by the adult diabetic team, essentially because HH was within an adult service he was seen as an adult and not as a child’.    8.10 In ‘Factors affecting therapeutic compliance: A review from the patient’s perspective’ (Jin, Sklar and Li 2008) the issue of lack of compliance of teenagers with medication for long term health problems, ranging from asthma, to diabetes, to cancer, is considered.  By compliance they mean the patients cooperation in terms of taking medication, following dietary advice, or executing life style changes. In regards to HH maximum compliance was essential to ensure his condition was managed long term. The report states   26 Final version 09.01.14 that adolescents are less likely to comply with medication and condition management than younger children or older people, due to their wish to be like their peers, forgetfulness and lack of acknowledgement of the impact of not complying.   8.11 The GP agency reports states that HH was seen to understand the implications of his diagnosis. He was able to attend appointments when motivated. However, he (like many other young males of his age) found the rigid routine that diabetes involves (e.g. regular injecting and medical appointments) difficult to maintain.  8.12 There is no evidence that the diabetic service at the hospital were aware of any of the difficult family and safeguarding issues for HH over the course of the next year. They have not record of being invited to the Child Protection Conference (which was likely to be to the confusion about whether the children or adults diabetic service were involved) and there was no involvement in the CiN plan. There does not appear to have been any clarity among CSC about who was involved with HH’s medical care, other than the GP. The GP was not as effective as would be expected in ensuring that CSC were aware of those involved with HH, or at informing staff from the hospital that CSC were involved. As stated by the GP agency author ‘following the death of Peter Connelly in 2008 the CQC clarified that GP’s are seen as the central medical record holder and should be able to identify trends in patient’s care. I don’t believe that in this case the GP practice saw itself as the service that was pulling all the information regarding HH together in order to consider what extra support this young man needed to manage his diabetes’. The reviewer agrees that the GP was essential in this case in ensuring that HH received the health care he needed, but they were not adequately aware of, and therefore were not undertaking, this important role.   8.13 The period that HH spent in the custody unit at the Police station was also considered as part of the review. At the time, as a 17 year old, HH was not treated as a child. Following a recent ruling in the High Court, the Home Office has circulated an interim edict (effective 27 October 2013) to clarify that all 17 year olds in custody will be treated as children. This means they will be offered the assistance of an appropriate adult. West Mercia Police have pre-empted the ruling and have implemented the required changes immediately.    27 Final version 09.01.14  B. The vulnerability of HH as a young person with a serious health issue who was not receiving adequate parenting.   8.14 The review heard that the approach taken by health professionals to HH as an adult was different to the approach that would have been taken if he had been a child. Most importantly the use of the DNA policy and the likelihood that Mothers lack of attendance and support might have been acknowledged and concerns raised.    8.15 It was acknowledged that HH was often neglected at home, with his parent leaving him and his brother to fend for themselves, with limited home comforts.  His Sister told the reviewer that, in her opinion, Mother was not sufficiently ‘maternal’ towards the boys and that she only provided them with the minimum of practical and emotional care and support. In Working Together 2013 the stated definition of neglect is the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:   provide adequate food, clothing and shelter (including exclusion from home or abandonment);   protect a child from physical and emotional harm or danger;   ensure adequate supervision (including the use of inadequate care-givers); or   ensure access to appropriate medical care or treatment.  It may also include neglect of, or unresponsiveness to, a child's basic emotional needs. 8.16 The report Neglect Matters (Hicks and Stein 2010 DfE) sets out to establish a definition of neglect that is specific to adolescents. Included in the report are issues pertinent to HH and his neglect by his mother. It states that, for adolescents in particular, ‘some acts of commission may be seen as neglect, or contribute to young people being neglected e.g. being abandoned by parents or being forced to leave home’.  8.17 Neglect Matters states that all agencies should be aware that neglect is a significant issue for teenagers as well as younger and children, and that they   28 Final version 09.01.14 should have both a definition of neglect which includes the particular issues for adolescents, and an awareness of what neglect of older children is and the need to acknowledge it and refer it to safeguarding services.  8.18 The report goes on to describe what might lead to neglect of older children. It includes parental problems, and indeed in this case Mother’s isolation, predominating difficulties with her own needs and her partners, potential poverty and the need to earn money by working long hours, led to the children being left alone and Mother being both literally and emotionally unavailable. ‘Neglectful parenting can be seen as being evidenced by a combination of; a low level of parental control of young people (this dimension is often taken to include parental knowledge and monitoring of young people’s activities and whereabouts, and establishment of boundaries), and a low level of warmth and acceptance by parents towards young people’. Both were evident in Mother’s parenting of HH.  8.19 In 2013 Hicks and Stein published ‘Understanding and working with adolescent neglect: perspectives from research, young people and professionals’ Their key findings indicate that there is a need for both a re-examination of current definitions of neglect in the light of age-related distinctions and perspectives, and a fuller understanding of the particular needs of adolescents who are experiencing neglect.  This review will make a recommendation that the HSCB reviews its procedures and safeguarding training to ensure that teenage neglect is acknowledged and that the training pays attention to this issue.     8.20 The neglect of HH’s health needs was the most concerning aspect of this case, but was one that was not adequately acknowledged by health professionals, mainly due to him not being seen as a child. As the Hospital agency author states ‘The Safeguarding Children policy has clear guidance about actions to be taken when staff fail to access a child or young person or those who do not attend appointments. This includes undertaking a risk assessment, forwarded onto the social worker and the Trust’s safeguarding children team as appropriate. This led to missed opportunities to highlight HH unmet health needs to children’s social care,  at the time of the January 2013 admission when HH was a child in need’. The PDNS did not seek safeguarding supervision, although they clearly identified concerns about lack   29 Final version 09.01.14 of involvement by Mother with her son’s care. This supervision is also available to adult health professionals in regards to 17 year olds being seen in adult services. The review was informed that a letter has recently been sent out to all adult physicians to remind them of their responsibilities to vulnerable 16 and 17 year olds.   8.21 In this case the neglect of HH and his sibling was acknowledged to an extent, with a CP conference held due to concerns about Mother’s parenting and control of the children. The Core Assessment completed prior to the conference clearly stated that there is a risk to HH’s life due to his diabetes being neglected. However this message appears to have become diluted as responsibility for his case moved to other teams, who did not recognise and therefore adequately acknowledge the potentially serious impact on HH of the neglect of his diabetes.   8.22 The Child Protection Conference did not actually hear the voice of HH, as he was in Poland at the time of the conference, and it was agreed that the conference should not be delayed to await his return. This is an understandable decision. The social worker who had met him alone on a number of occasions did include information in her report and information sharing at the conference regarding his wishes and feelings. However no direct information in regards to his understanding of his condition or of the need to comply with his medication and dietary advice was explored with HH at the conference as he did not attend.   8.23 The recall meeting considered the debatable issue of whether 16 and 17 year olds should be the subject of a CP conference. Herefordshire has had feedback on a recent Peer Review which recommended the Northumberland risk management model. (Published by OFSTED 9 May 2013.)  In Northumberland they have developed a strategic response to the challenge that safeguarding adolescents brings, that is based on the premise that adolescents are still children and that they are entitled to the same protections as younger children under the Children Act 1989.  CSC in Herefordshire are taking steps to implement the use of a model based on the Northumberland one, and this review supports the intention of the HSCB to extend the use of this model across partner agencies to ensure good practice in the risk assessment of, and support offered to vulnerable young people.    30 Final version 09.01.14  8.24 When HH was no longer living at home and became a looked after child, he should have received all the services available to him with this status. One of the things that this should have been triggered was a looked after medical with the designated doctor and the involvement of the nurse for looked after children. Within 4 weeks of a child or young person coming into care, it is the statutory responsibility of the Local Authority to ensure that the child has a medical. This did not happen for HH and this was a missed opportunity to review his treatment and to alert those involved to his new status and to ensure their involvement in his care plan. It is possible that HH would not have cooperated with the looked after medical, but we cannot know. What is clear, is that the LAC nurse would have attempted to follow up any lack of cooperation swiftly and would have been persistent in pursing HH.   C. HH’s homelessness.   8.25 There is no evidence that when HH left home on 28 January 2013 CSC attempted to address the issues at home or the breakdown in the relationship between HH and Mother.  There was also a lack of further assessment after this change of circumstances, and the CiN plan very recently made was not updated. After an initial delay in CSC being informed of HH being homeless, efforts were put into finding HH suitable accommodation. The case transferred again from the CiN team to the 16+ team on 6 February 2013. HH therefore had 3 different allocated social workers in as many months.    8.26 In Herefordshire between 40 and 50 young people aged 16 and 17 present as homeless each year.  A large proportion become LAC due to their homeless status. The panel which considered HH’s case on 20 February 2013 gave agreement from him to receive accommodation under S20 of the Children Act 1989. This was the right decision both legally and due to HHs particular vulnerabilities. His CiN plan should then have been replaced by a LAC care plan, following a comprehensively updated assessment.   8.27 The decision for HH to become a Looked After Child was the right one legally. The May 2009 Southwark Judgement set the law, making it clear that if homelessness cannot be prevented, local authority children’s services should provide accommodation and support to homeless 16 and 17 year olds. The   31 Final version 09.01.14 judgment clarified that the specific duty of section 20 of the Children Act 1989 takes precedence over the general duty to children in need and their families under section 17. If a young person is accommodated under section 20 they become a ‘looked after child’, and with this they are ‘afforded further protection and rights with a range of support and services, including a named qualified social worker and a care plan. Young people who are ‘looked after’ will also then qualify for leaving care support and services up to the age of 21 or in some cases, up to the age of 25’. (No Excuses – preventing homelessness for the next generation. Homeless Link UK (2013)    8.28 The above organisation completed a project in 2013 that had requested information from local authorities about homelessness amongst young people. The freedom of information request responses they received led them to conclude that ‘in the seven months to October 2012, 8,153 young people across 161 local authorities faced not having a stable, secure place to call home and approached their council for help. On an annual basis, this is equivalent to around 14,000 approaches for the last financial year.  Of the children represented in the No Excuses report, 10% were said to have physical health problems, and 515 were NEET.   8.29 As Section 20 (3) of the Children Act requires that: ‘Every local authority shall provide accommodation for any child in need within their area who has reached the age of 16 and whose welfare the authority consider is likely to be seriously prejudiced if they do not provide them with accommodation.’ The legal obligation to HH was as a looked after child. It is not clear if HH was ever told he was in the care of the local authority, or if his family were aware of this.   8.30 Despite the lack of clarity about the status of the support, HH was supported by the provision of accommodation from the date that CSC were aware of his homelessness. While the initial B&B accommodation was not suitable accommodation for a 17 year old, good support was provided by the 16+ team to ensure that HH was provided with appropriate food and medication. HH then moved into an appropriate placement with a supported lodgings carer where his needs appear to have been met well, with the carer ensuring that concerns about his illness and lack of compliance with a healthy diet were reported, and who asked the social worker for information on the   32 Final version 09.01.14 condition and who wanted to learn how to assist HH. The lack of a comprehensive core assessment involving other agencies when HH’s circumstances changed was however a missed opportunity to fully consider his health needs and ensure that all professionals involved with HH shared the responsibility for his on-going care.   D. The status and suitability of HH’s plans, and information sharing.  8.31 As outlined above, the ICPC held in January 2013 was appropriate in its decision to make HH subject of a CiN rather than a CP plan, and in its application of the threshold criteria. The social worker that took the matter to conference made it clear that the resulting CiN plan needed to address HH’s diabetes. However it is the quality of the plan and the effectiveness of the agencies involved in the work they are doing and the communication with each other and the child and family that makes a plan work, not necessarily its status. The CiN plan for HH did not actively involve health staff, despite HH’s management of his diabetes being a major vulnerability. They were listed on the CiN plan but not told of its existence or the role they needed to play. Not having a health professional actively involved in the plan led to staff who were not medically qualified giving HH advice.  This continued when HH became a Looked After Child, with the FSW who saw HH on 19 April 2013 discussing about his diet with him as they noted that he seemed quite sleepy. This was a missed opportunity to ensure that a medical professional assessed HH and his compliance with his treatment.    8.32 The role of Sister and her family was known to a number of professionals, and it is clear that both HH and his brother received a lot of support from Sister and her husband. There does not appear to have been any consideration given to involving sister in the CP or CiN meetings and planning.  8.33 The college were not invited to the ICPC and were not aware that HH was the subject of a child protection investigation, conference and subsequent CiN plan.   8.34 In regards to the lack of a formal LAC status being registered for HH however, this did have an impact on him.  There was no clarity about the status of HH   33 Final version 09.01.14 when he was initially given B&B accommodation, and on moving into supported lodgings, then to the young people’s housing unit. Although officially a child in need on the Herefordshire CSC systems, his CiN plan was not updated to reflect the change in circumstances. A LAC care episode was not ‘opened’ and the systems that are in place to agree, achieve and monitor the LAC care plan were not provided. This includes regular visits from a qualified social worker, a LAC medical, involvement of the LAC nurse, placement planning meetings, a LAC review and the involvement of an independent reviewing officer.  8.35 Whatever the plan, it is clear that there were weak communications and information sharing, particularly between health and the other agencies involved. This contributed to the lack of effectiveness in the overall response to HH’s needs.  Examples of agencies not being aware of the situation for HH include the police dealing with the criminal matters who were not aware of the CiN status or placement being funded and supported by CSC, the college being unaware of the involvement of CSC, and the hospital diabetes team not being aware of the CiN /LAC status or CSC support.   8.36 At the learning event one of the ADNS’s clarified that she was aware that HH was in B&B accommodation and that she wrote to the GP on 8 March 2013 to share her concerns about the repeat DKA admissions, HH not attending appointments and lack of compliance. She also requested contact numbers and the latest address for HH. There is no evidence that the GP replied. Two weeks later, when the social worker contacted the GP for advice for the supported lodgings carer, this concerning information was not shared. The GP was aware that HH was now in supported lodgings, placed by CSC, but did not inform the ADNS service. These were missed opportunities.   8.37 It is clear that the multi-agency responses required to provide good quality packages of care to children and young people with complex backgrounds and needs require active teams around the child and clearly stated time-bound tasks. The involvement of all relevant agencies, working together to meet the child’s needs, provides the required checks and balances to ensure the best possible outcomes for children. These checks and balances were not actively in place this case, and hence HH’s needs were not adequately met.    34 Final version 09.01.14 8.38 Some issues were highlighted during this review regarding the management and supervision of HH’s case. Supervision was evident on the case records of CSC, including the decision to hold an ICPC. However there was a delay in decision making pending the consideration of the ICPC, the core assessment was concluded on 24th December, and the CiN Plan not completed until 23rd January. Issues have also been identified with the record of the ICPC which is the responsibility of the CP Conference Chair, where a good quality and reasoned analysis for the decision making is not adequately recorded.    8.39 Some management decisions were recorded when HH was initially the responsibility of the 16+ team, however they were predominantly about financial arrangements for HH after he was living independently. The Learning Event was informed that an agency team manager was in post at the time and that there were issues emerging at this time about the manager’s lack of knowledge of the responsibilities of the local authority to young people in care.  When the new manager was appointed supervision of the FSW was implemented and HH was discussed. However it was not identified that he was not a LAC on the I.T. system until after he died.  E. Issues with the preparation and planning for HH’s move from supported lodgings to the semi-independent unit in another town.   8.40 The move from the supported lodgings placement to the unit in another town was not managed as well as it should have been. This was for a number of reasons. Firstly the move was an ‘emergency’ and had to happen earlier than had been planned. The placement broke down because the supported lodgings carer had a number of personal issues which meant HH could not stay. This meant there was no handover meeting between the previous carer and the unit, as would have been expected practice. This meant that the useful information held by the carer, in regards to HH diabetes, was not passed on.  8.41 The involvement of the LADO in the decision to remove HH from the care of the supported lodgings carer requires some consideration. While it is usual practice to remove children from placements where there is a possible safeguarding concern, in the case of HH it is not clear that consideration was given to his needs. It may have been the case that his need for some stability   35 Final version 09.01.14 and on-going support was more important than the concerns being addressed with the carer. This is an example of the complexity of decision making required when planning for young people.      8.42 The leave and sickness of key professionals in the 16+ team meant that the move was managed without their support and without the passing on of the information they held.  The information made available to staff at the new unit was largely self-reported by HH. This is rightly criticised in the CSC agency report, with the author stating that ‘there were no arrangements made to ensure that in the absence of HH’s FSW on annual leave that his transition and follow up as he moved to the unit was given due consideration and action’. The Laming Enquiry into the death of Victoria Climbié (2001) was clear that local authorities need to ensure that when there are staff vacancies and absence, including due to sickness, plans need to be put in place to ensure that all children who are allocated receive the timely services of a qualified social worker. Since the death of HH additional resources have been put into the 16+ team and the resources available to cover for absent staff are more robust.    8.43 Despite the issues with the move HH was described as happy to be in the new placement and the Learning Event was told that he settled in well. The staff who attended stated that there were no concerns about HH, he appeared to be managing well and he was embracing this new opportunity.    8.44 The unit do not have staff present at all times. Staff are usually in the unit during office hours Monday – Friday. However this does not include bank holidays or days where there is staff training or whole team meetings. During the week that HH died staff were engaged in two consecutive training days, which were held off site. At the time of HH’s death being discovered he had not been seen by staff for 6 days. He had been seen by other residents 3 days before he was found in his room. The agency report stated that HH had missed a resident meeting and a cooking session the day before his death was discovered, but that this was not unusual for residents, and that they were not concerned. Through their input to this review, the organisation have stated a commitment to moving staff meeting and training days to ensure they are not held consecutively to a weekend and to ensure that a block of days   36 Final version 09.01.14 does not pass without staff being in the building. They have also stated their commitment to ensuring that any young person with a health issue is seen at a frequency agreed after consultation with health professionals. In HH’s case it would have been appropriate for him to have been seen daily, although the reviewer acknowledges this might not have been possible when he was placed in this particular unit. The CSC author has considered the contract with the housing provider which tasks them with providing services for Herefordshire’s young people. He concluded that ‘the contractual arrangements between Herefordshire Council and the (housing provider) are not sufficiently robust to ensure that there is clarity as to information sharing arrangements, and there is no evidence to suggest that any audit or performance reporting outcomes are shared with CSC, as the commissioning arrangements rest with the Housing and Communities Directorate.’ This is clearly a concern and the CSC agency report makes a recommendation in regards to this issue.   F. The psychological impact of diagnosis and treatment.  8.45 What is not clear is the impact emotionally on HH of his being diagnosed with this serious condition. Research shows that being an adolescent at the time of diagnosis can prove problematic.  ‘Many physical, psychological, social and cognitive changes take place in adolescence. Emerging personal values and beliefs, an acute awareness of body image and a desire for peer conformity and increasing independence can make the transition to adulthood troublesome. For teenagers with diabetes, usual adolescent needs and concerns are complicated by the demands of a complex treatment regimen. This can result in non-adherence to the recommended programme of care and, consequently, poor glycaemic control, which increases the risks for diabetes-related complications in later life. This situation poses a major problem for healthcare professionals. Teenagers, however, are frequently preoccupied with the present, and are unable to perceive, or will ignore, their vulnerability to long-term health problems.’ (Autonomy or non-compliance in adolescent diabetes. 1999. Timms and Lowes, Department of Child Health, University Hospital of Wales)     37 Final version 09.01.14 8.46 The agency author for the Wye Valley Trust points out that the NICE guidance Clinical Guideline 15 “Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults” highlights that children and young people may develop anxiety and depression and recommends that, particularly where there is evidence of poor control, screening for these conditions should take place with referral to CAMHS services as necessary.  This was not considered in HH’s case’.  It was pointed out to the review that there is no psychology input to the diabetes clinic, which had previously been available. HH was, in the view of the doctor attending the recall day, in denial about his illness.   8.47 The social worker who undertook the initial assessments of HH confirmed that he was embarrassed about his condition and did not like to speak about it. His sister confirmed this, stating that he was in denial about both the seriousness of the condition and his own responsibility to ensure he managed his testing, medication and diet. He would often visit them and not bring his testing kit, and they would have to drive him home to collect it so that he could test his blood sugars after he had eaten with them.    8.48 Also considered as part of this review was the potential impact on HHs diabetes and insulin management of his teenage hormones. ‘The same hormones that cause growth spurts can also wreak havoc on efforts to keep blood sugar under control. As growth hormone increases during the early and middle teen years, the body becomes less sensitive to insulin. As a result, high glucose levels are common in teens’. (http://type1diabetes.about.com)  The issue with HH however, was that he was not testing his blood sugars and taking his insulin consistently, so there was no baseline which would potentially have been affected by any hormonal change.   G. Culture and language issues.  8.49 An understanding of the meaning and consequences of the family’s specific culture and language is limited. There is little sense of what exploration was undertaken by agencies regarding the community supports that may be   38 Final version 09.01.14 available or of how far the family was part of any community. What was established was that Mother was very hard working and that she did not want to be dependent on benefits. It is also clear that the older sister and her partner were the main support used by Mother and the boys.   8.50 Also highlighted in this review is that on occasion the children were used as interpreters when professionals needed to speak to Mother. This was identified by health staff as well as the Police. On a number of occasions however interpreters were used by health and CSC staff, and this helped in the understanding of the issues for the children in this family.  West Mercia Police reported that when they were involved with the family they have used Polish speaking police community support officers. Mother was also aware that she could telephone the police and speak to a person who was fluent in Polish.   8.51 HH himself was assessed a number of times as being competent enough in spoken and written English to understand explanations of his condition and the treatment.  It was agreed by all those involved that HH was competent and had sufficient capacity to make decisions about his health. What was also clear however was that he showed a degree of disguised compliance, as is common with teenagers in respect of their health needs and treatments. This means he agreed to cooperate with his testing and insulin regime, but in reality did not comply.   8.52 There is some evidence that the children in this family behaved like adults on occasion, but it is not clear if this was due to the culture of this specific family, with the young people being expected to care for themselves. Examples of this are HH putting his school aged brother as his emergency contact on the college application, HH attending hospital appointments on his own at age 14, and HH registering himself at a GP practice that was not used by the rest of the family. His sister described him as fiercely independent and that he hated being seen as and treated like a child. She believes he perceived himself to be an adult. The review was clear however that this was not reflective of the wider culture of the country of origin, and is not regularly seen in other Polish families.  It was also clear, having met with the sister, that it is not reflective of the behaviour and expectations of the wider family.      39 Final version 09.01.14 8.53 The report Neglect Matters states that ‘for teenagers, parental monitoring and supervision has to be balanced alongside factors which assist in a young person’s emerging adulthood, such as the opportunity to exercise autonomy and independence. A young person’s journey to adulthood may also be shaped by factors including cultural background, levels of impairment, economic circumstances and contextual changes over time. As discussed earlier, expectations about what constitutes adequate parental supervision of adolescents will vary according to many differing factors’. For this family the family’s cultural background does not appear to have had an impact on the parenting that the children received from their mother. Other members of the family did not approve of Mothers lack of supervision of her sons. The social Worker who undertook the initial and core assessments reported that the sister’s mother-in-law was critical of HH mothers parenting of her younger children. This was confirmed by the sister and her husband. They explained their concern for both boys and their frustration at Mother’s neglect of her sons.   9 Conclusions and lessons learned  9.1 This report will conclude with consideration of the lessons learned, a statement of the key messages from this case, a list of the good practice identified and consideration of whether the death of HH was predictable and/or preventable.   9.2 When analysing this case from the point of view of Every Child Matters (Government initiative 2003) the prognosis for a good outcome for HH was poor on the five key outcomes:  Being healthy – poor management of his diabetes.  Staying safe – effectively living alone both at home and when he moved into the independence unit.  Enjoy and Achieve – reported poor school and college attendance.   Positive contribution – getting into trouble with the Police and issues with anti-social behaviour.  Economic well being – HH had left college and was a NEET for a time (not in education, employment or training) with poor employment prospects.     40 Final version 09.01.14 9.3 It is clear that while a number of the professionals involved with HH were aware that his diabetes could threaten his life, many were not.  With hindsight we have established that HH was not managing his condition and it should have been acknowledged widely among those working with him that he was at risk of death without more attention being paid to the condition and its treatment. HH’s mother did not help him to manage his condition when he was at home, and as his corporate parents key agencies did not recognise the importance of him testing his blood glucose levels and taking his medication to remain well.   9.4 After extensive discussion with those involved, it has been concluded that it would have been difficult for professionals to predict HH’s death. No young person of his age has died in Herefordshire, due to their diabetes, in the memory of the professionals involved, some of whom have been working locally in diabetes care for over 20 years.  This is despite a number of young people having very similar issues regarding a lack of management and care of their condition. What could have been predicted however is that without either HH or another person getting him medical help at the onset of diabetic ketoacidosis, death was the likely outcome. As this review has highlighted a number of missed opportunities that may have led to a different outcome for HH, this also leads to the possibility that HH’s death may have been prevented.  If he had received medical help in the days immediately before he died, had he managed his condition better, and had he received more support, help, encouragement and persistent reminding of the need to test his blood sugars and take his insulin appropriately, he may still be alive.    9.5 The report Ages of Concern: Learning Lessons from Serious Case Reviews, (OFSTED 2011) looked at the learning from serious case reviews being undertaken on children and young people aged 14 and above. None of the serious case reviews considered in this report was in regards to a child with serious health needs, but it is clear that a number of the conclusions were pertinent to HH.  The report found that:     Agencies had focused on the young person’s challenging behaviour, seeing them as hard to reach or rebellious, rather than trying to understand the causes of the behaviour and the need for sustained support  Young people were treated as adults rather than being considered as   41 Final version 09.01.14 children, because of confusion about the young person’s age and legal status or a lack of age-appropriate facilities  There was no coordinated approach to the young people’s needs   Young people aged between 16 and 18 are a vulnerable group who can miss out on receiving appropriate services because they fall between adult and children’s services  9.6 The agency reports have highlighted the learning for their specific agency, and have made recommendations. This overview report will highlight the learning across and between agencies. The learning from this review can therefore be stated as follows: I. All agencies need to recognise young people’s vulnerabilities as well as their rights and responsibilities as young adults.  II. Professionals need to be open-minded about what makes a young person vulnerable, and be clear that lack of compliance with medication for health conditions is potentially risky. III. Non-medical staff need to ensure they receive advice and support from health colleagues when working with children with significant health issues. IV. When a young person attends a college or training course, any assessment or information sharing about the young person needs to include the college. V. A comprehensive risk assessment should be carried out by any placement before a child with diabetes or other serious health condition is admitted, that includes input from health colleagues and any previous placements if applicable.  VI. Staff across all agencies must evidence that they have recognised 16 and 17 year old service users as children. They need to ensure that all decisions balance the needs of the young person for independence and self-determination with any need for protection.  VII. That staff are reminded that, after every significant change of circumstance, assessments and plans need reviewing to ensure that the impact of any changes have been thoroughly considered.  VIII. That any multi-agency training input on neglect provides a section on the specific issues for young people aged 14 plus, this should include lack of compliance with medication for health conditions.    42 Final version 09.01.14 IX. Non-health professionals need to be informed that type 1 diabetes is a potentially fatal condition. X. There needs to be clear transition planning for 16 and 17 year olds with additional health needs, which considers issues with lack of engagement.  XI. Professionals need to be creative when supporting and monitoring teenagers.  XII. That children and young people assessed as being Children in Need, and who are the subject of a CiN plan are not currently identifiable and flagged to all agencies checking systems in respect of vulnerable children.   9.7 It is important to emphasise the key messages from the many lessons listed in the agency reports and in the paragraph above. The HSCB and the SCR reviewer have therefore agreed that the following messages from this review need to be highlighted:  1. 16 and 17 year olds are children.  2. Diabetes type 1 is a life-threatening condition if not managed sufficiently well. All staff working with children with this condition need to be aware of the risks involved.  3. Re-assessments need to be undertaken following any significant changes of circumstances, which involved the child.  4. Clear roles and responsibilities need to be determined when providing support to children with long term and serious health conditions, particularly for health professionals.   9.8 HH died because he was not adequately supported in his diabetes treatment by either his biological or his corporate parents, and because professionals did not work together sufficiently well to ensure his complex health and social needs were adequately and consistently met. The processes and expectations of single and multi-agency working in place at the time of his death were not always followed, and while this did not directly cause his death it meant that this child with complex health needs did not receive the   43 Final version 09.01.14 focus and persistent oversight he required to avoid the crisis in his health which led to his death.    9.9 As well as concentrating on the deficits in practice and systems and the learning from this review, it is also important to highlight good practice and systems that worked well for HH and his family. They include the following:   A good core assessment was undertaken in this case, which consulted with a number of other agencies, involved Mother with the use of interpreters and spoke alone to HH. (Highlighted in the CSC agency report.)  CSC professionals developed good working relationships with HH, and regular support was provided to him from the time he presented as homeless until he moved to his final placement. (Highlighted in the CSC agency report)  The support provided to other young people in the unit where HH died, after his death, was described by those involved as ‘excellent’.   The CSC FSW provided good quality practical care to HH, seeing him almost daily while he was in B&B and ensuring he had food, taking him to the supermarket, and checking he had his medication.   The diabetes education provided to HH was reported to have been well done.   The Police responded to concerns about HH’s health by undertaking a medical assessment and ensuring he received hospital treatment without prioritising the need to interview him on outstanding criminal matters.    An interpreter was used extensively in this case, when communicating with members of HH’s family. However it is noted that written communications, like those set by the Youth Offending Service to Mother, were sent in English.   The supported housing provider has implemented changes to its procedures regarding the need to see residents on a more regular basis. This includes a change in their staff meeting day so that the unit is covered on a Monday (staff are not on site at weekends.)   The supported housing provider now ensures that all young people with a health condition have a full risk assessment, involving the relevant health professionals, before they are admitted.   44 Final version 09.01.14  The supported housing provider has changed its recording policy to ensure that information is handed over between staff in a more effective way.   10 Recommendations   10.1 A number of recommendations have been included in the agency reports, and a number of changes have already been made. This review report endorses these recommendations, which have addressed some of the learning highlighted above.     10.2 The following changes have been already been made following HH’s death:  Staffing improvements in CSC 16+ service, including improved management capacity.  Project management approach has been taken to drive forward improvements in CSC 16+ team.  Management and supervision training has been provided to managers in the 16+ team.  A management directive has been shared with CSC 16+ team regarding expectations of supervision and the evidencing of management decision making. Compliance with the standard will be checked and audited regularly by managers.   CSC 16+ team have received group supervision sessions on homeless young people.  The CSC 16+ team have undertaken an audit of all 16 and 17 year old young people who have presented as homeless to ensure that their placements are legally compliant with the Southwark Judgement. A further audit is planned to ensure compliance with Care Planning regulations.   Training has been offered to all staff in the CSC 16+ team on both the Care Planning regulations and on potentially life limiting illnesses, to include the risks associated with diabetes and epilepsy.  The adult and children’s diabetic services have started a review of practice in accordance with the Dept of health 2013 – 14 Best Practice Tariff Guidance and the West Midlands Quality Review ‘Care of Children and Young People with Diabetes’ with the intention of developing a   45 Final version 09.01.14 transitional care pathway for all young people up to age 19 with type 1 diabetes. This will ensure there is clarity of responsibility of consultant and between both services. It was agreed at the review meetings that this review must be health-economy wide, and should go on to develop a full care pathway for type 1 diabetes.   The GP surgery has made a number of changes, including a new protocol for acting on failures to attend/be brought to surgery.   The GP surgery will now aim for the GP to attend child protection conferences when a child or young person with significant health needs is being considered. Where they are unable to attend, a detailed report will be produced which will include details of missed appointments as well as hospital attendances.    The diabetic leads at the GP surgery are contacting their "high risk" and young male diabetic patients to encourage engagement.   The GP surgery plans to try and improve transition (from childhood to adult care) between hospital and community diabetic care.   10.3 The Local Authority Designated Officer for child protection (LADO) has been involved with an investigation into concerns voiced about the supported lodgings placement which is unrelated to HH and his care, as explained above. Links between that investigation and HH led to a meeting being held in October 2013 where the circumstances around HH’s death were considered. That meeting made a number of recommendations which are to be included in those made for this review to ensure that they are given the appropriate oversight from the HSCB. The recommendations made at this meeting were: I. There should be a multi-agency review of the commissioning process for placements for children and young people with long term medical conditions.  II. The housing provider to complete a review of their safeguarding procedures for young people.  III. The 16+ Team, as part of their review of the commissioning of placements, to also consider how they communicate support packages for young people with all 16+ providers. IV. Children’s Wellbeing to request that training is delivered to the appropriate staff on long term medical conditions in young people and how they should be managed.    46 Final version 09.01.14 V. Agencies to ensure that there is effective sharing of information when young people transfer placements, and in particular where young people have specific identified needs.   Recommendation 1:  The recommendations made at the meeting held in October 2013 (as listed above) to be implemented in full, and an update to be provided to HSCB on progress.  10.4 As well as the above LADO meeting recommendations, and those included in the agency reports, this overview report makes the following recommendations to ensure that the learning from this review has a positive impact on practice and systems in Herefordshire.  Recommendation 2:  That HSCB makes it clear to all agencies that young people are children until the age of 18, and that all services need to ensure their policies, procedures and practices acknowledge this. Before making this statement however, the HSCB must consider and take legal advice regarding the proposal to ensure that the confidential nature of advice and services being given in respect of sexual health to children of this age are not compromised.   Recommendation 3:  That HSCB carry out a multi-agency audit of young people with serious long-term and life-threatening conditions to identify where agencies are working well together and where improvements can be made. The audit should ensure that any safeguarding concerns have been identified and that responses follow procedures. This learning should be disseminated to all managers and staff across agencies working with this age and client group.   Recommendation 4: HSCB to review its information sharing arrangements in regards to children who are assessed as being Children in Need. This should include taking advice in regards to data protection, and a consideration of the feasibility of alerts being available to key agencies regarding children who are the subject of CiN plans.    Recommendation 5: That HSCB reviews its procedures and multi-agency safeguarding training to ensure that the specific risks of teenage neglect are acknowledged and that procedures and training emphasises this issue. This should   47 Final version 09.01.14 include the addition to HSCB procedures of the CSC model based on the Northumberland model of risk assessments of 16 and 17 year olds.   Recommendation 6:  That the agency authors for the WVT and the GP services to meet to consider the health commissioning issues raised by this review, and to consider if there are any additional recommendations required in relation to the health response to HH’s case. Any such recommendations must be monitored by the HSCB along with all the recommendations of this review.   Recommendation 7:  HSCB to share the learning from this review with staff across all partner agencies. This should include the clear message that diabetes type 1 is a life-threatening condition. Consideration to be given to using publicity generated by the publication of this serious case review to provide a public health message.   Recommendation 8: The organisations that have completed an agency report in this case are required to provide evidence to the HSCB that action has been taken to address individual and management practice which has fallen below expected professional standards.     ……………………..   48 Final version 09.01.14 Bibliography  Factors affecting therapeutic compliance: A review from the patient’s perspective. Jin, Sklar and Li  2008  Neglect Matters. Hicks and Stein  2010  DfE  No Excuses – preventing homelessness for the next generation.  Homeless Link UK  2013  Autonomy or non-compliance in adolescent diabetes.  Timms and Lowes 1999 Department of Child Health, University Hospital of Wales  Ages of Concern: Learning Lessons from Serious Case Reviews. OFSTED  2011  Working Together to Safeguard Children DfE 2013     1   HEREFORDSHIRE SAFEGUARDING CHILDREN BOARD   TERMS OF REFERENCE & PROJECT PLAN  SIGNIFICANT INCIDENT LEARNING PROCESS  SUBJECT: HH                              Appendix 12  SCOPE: The subject of this review is child HH, a 17‐year‐old male who was found dead on 17th May 2013. His mother is Polish and speaks little English. He has three siblings, two older and one younger. His father lives in Poland. He was a vulnerable young person due to his diagnosis with Type 1 diabetes and it was known he neglected his treatment needs. HH became known to Children’s Social Care in July 2012 and was an open case to the 16 plus team at the time of his death. Toxicology evidence suggests HH died of diabetic ketoacidosis.  Time period: 1st January 2012 (when diagnosed with diabetes) To 17th May 2013 (date HH was found dead in his room)  FRAMEWORK Serious Case Reviews and other case reviews should be conducted in a way in which:  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 (Working Together para 10, March 2013) AGENCY REPORTS TO BE COMMISSIONED 1. Childrens Social Care  2. Wye Valley NHS Trust 3. CCG ‐ GP 4. Supported independent housing provision 5. YOS/YISP 6. Police 7. FE College   3  TERMS OF REFERENCE While the focus of the review is child HH, relevant information concerning the assessment of other children and family dynamics should be included at the author’s discretion Generic Terms of Reference Agency report authors are asked to address the following issues in their reports 1)  The blurring of HH’s status as a Looked After Child. 2)  Thresholds applied in relation to child protection. 3) Communication with family and any impact of language / interpretation including what agencies understood to be HH’s mother’s level of understanding of his condition. 4) The decision to move HH to a placement several miles away. 5) What was the understanding of professionals of his capacity under the Mental Capacity Act? 6) Issues relating to the contract between the local authority and the supported independent housing unit i.e whether breaches occurred and whether there were commissioning issues. 7) Did the case conference consider the adequacy of HH’s mother’s parenting, the relationship between HH and his brother and the impact of his condition on his physical and emotional health? 8) How well did services understand their corporate parenting responsibility and safeguarding issues.   Agency report authors are asked to produce a summary of key episodes within a chronology.  A TEMPLATE FOR AGENCY REPORTS Attached: Meetings with Family/Significant Others The following members of child HH’s family have been identified to ask to contribute to this review: both parents and the adult male who once collected HH from hospital. The review will seek advice about incorporating the views of HH’s siblings where appropriate into this review process. Explanation of Process                                               Early September Feedback re: experience of services                         30th October Discussion of final report                                           (9th December)  4  DRAFT TIMETABLE  Scoping / terms of reference     31st July  Commissioning letters     15th August Authors Briefing     12th  September  Distribution of material to all attendees  14th October  Learning Event                                                     24th  October Drafting 1st report and distribution                    18th November Recall Day                                                              25th November Revising Report                                                     2nd December Presentation to LSCB/SCR Sub group              9th December           HEREFORDSHIRE SAFEGUARDING CHILDREN BOARD  AGENCY REPORT (Name of agency)  SIGNIFICANT INCIDENT LEARNING PROCESS  SUBJECT :   Case HH                                         Appendix 2 1  1. Please see Terms of Reference and Project Plan document for:  Purpose  Framework  Scope  2. Summarise  in  succinct  narrative  form  the  key  information  on  the  child  and  the parent. In particular identify the information which could have a bearing on the case from 1.1.12 onwards, including if there were any significant safeguarding concerns.  While the focus of the review is child HH, relevant information concerning the parent and the assessment of other children and family dynamics should be included at the author’s discretion.  3. Within the scoping period 1.1.2012 ‐ 17.5.2013 3.1. Summarise in narrative form the key information on the child (and family as relevant) from your agency/service. 3.2. Summarise the services offered and/or provided to the child and family and the decisions reached. 4. Generic Analysis 4.1. Critically analyse and evaluate the events that occurred, the decisions made and the actions taken or not. 4.2. Where judgements were made or actions taken which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. 4.3. Demonstrate  whether  your  agency/service  heard  and  responded  to  the children’s views, wishes and feelings. 4.4. Identify and explain if your agency/service believes that other agencies/services should have been sought and/or provided. 4.5. Identify good practice. (You  may  find  the  12  trigger  questions  after  paragraph  8.39  of  Working Together 2010 helpful in framing your response. However, it is not expected that you slavishly answer every question. Use it as a guide.) 5. Particular Areas For Consideration 5.1 What  impact  did  HH’s  status  as  a  Looked  After  Child  have  on  the  services provided?  2  5.2 Were appropriate thresholds applied in relation to child protection?  Please comment on how HH was viewed between the child/adolescent services as a 17 year old. 5.3 What  issues  were  there  regarding  the  communication  with  the  family  and significant  others?  Comment  on  the  impact  of  language/interpretation including  what  agencies  understood  to  be  HH’s  mother’s  level  of understanding  of  his  condition.    Also  comment  on  the  significance  of  the family’s culture. 5.4 What was the impact of the decision to move HH to an independent housing unit in another town. What was the understanding of professionals of HH’s capacity under the Mental Capacity Act?  What was HH’s understanding of his medical condition and how did he manage this? 5.5 Outline  if  there  were  issues  relating  to  the  contract  between  the  local authority and the independent housing unit.  To include whether breaches occurred and whether there were commissioning issues. 5.6 Comment on whether the case conference considered the adequacy of HH’s mother’s parenting, the relationship between HH and his brother, significant others and the impact of his condition on his physical and emotional health?  5.7 How well was the corporate parenting responsibility and safeguarding issues understood?  5.8 What impact did the fact that services were being provided by both adults and children’s services have on the care provided to HH? Consider if there were any particular transition issues?  6. Key Learning Points 6.1. What did we do well which we need to keep doing? 6.2. What didn’t we do so well that needs to stop? 6.3. What things need to be done differently to lead to improvements and how should this be done? 6.4. What is to be learnt about improving multi‐agency working? 7. Recommendations Please make them SMART (Specific  Measurable  Achievable  Realistic  Timely)  3  8. Sign‐Off This confirms that neither the reviewer nor senior person signing‐off this report has had any direct involvement with this case prior to the abuse of the children. Individual Management Reviewer: Date: The reports of all reviews must be signed by the relevant senior officer, indicating that the review has been:  carried out to the required standard and  the learning points are accepted by the organisation  the recommendations/action plan will be implemented The Senior Officer accepts that:  The review has been carried out to the required standard.  The learning points reached in the review are accurate.  The recommendations/action plan will be implemented. Senior Officer: Job Title: Date: On completion, please send or deliver the completed report securely and confidentially to Lisa Beavan by 11th October 2013 at the latest.  Genogram  HH                                                      Appendix 3 