Death of a 15-year-old boy in March 2013, as the result of an overdose of drugs prescribed to his father. Andrew's family was well known to services including education, children's social care, health and child and adolescent mental health services (CAMHS). Andrew's parents were divorced and Andrew lived with his father, who was receiving services for long-standing mental health problems at the time of the incident. Issues identified include: risky sexual behaviour, self-harm, significantly poor record of school attendance and previous overdose of prescription drugs. Identifies four key themes from the review: challenges of working with hard-to-reach families; teenage neglect and the use of child protection procedures; teenage mental health and suicidal ideation; impact of adult mental health problems on parenting capacity. Presents learning in relation to the themes, including: a need to identify hard-to-reach families and understand why they are not engaging; and practitioners would value a tool to assist information gathering and analysis for assessing the parenting capacity of adults with a mental health problem. Review was undertaken using the Partnership Learning Review model, jointly commissioned by Dorset and Bournemouth and Poole Safeguarding Children Boards.
      
 Title:  Serious case review: overview report: in respect of Family S11. LSCB: Dorset Safeguarding Children Board Author: Karen Tudor Date 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.                          Dorset Serious Case Review S11 Page1                                                                SERIOUS CASE REVIEW OVERVIEW REPORT  in respect of Family S11             Independent Safeguarding Leads: Prity Patel – Independent Chair of Review Team Karen Tudor – Independent Overview Author  February 2014  Dorset Serious Case Review S11 Page2  CONTENTS   PAGE  1. INTRODUCTION 1 2.       FAMILY INVOLVEMENT 5 3. THE LEARNING THEMES  5 4. THE LEARNING PROCESS First Learning Event Second Learning Event 6   5.        DORSET SAFEGUARDING CHILDREN BOARD AND LEARNING 7 6. FACTUAL SUMMARY OF THE CASE  8 7. ANALYSIS OF THE THEMES  8. THE CHALLENGE OF WORKING WITH “HARD TO REACH “FAMILIES What do we mean by “hard to reach”? Closing the Case Learning from the Case Recognising the Problem Independent Review and Developing a Strategy for Engagement Impact of Closure What Needs to be Done 16      9.    TEENAGE NEGLECT AND THE RELEVANCE OF THE CHILD PROTECTION PROCEDURES Assessment and Care Planning Response to Referrals Management Oversight  Joint Consultation Use of Chronologies Andrew’s wishes and feelings Risky Behaviours Understanding of Child Protection If Child Protection Procedures had been implemented would this have made a difference? Practice Developments What Needs to be Done 22 10.    YOUTH MENTAL HEALTH AND SUICIDAL IDEATION Multi Agency Working  Mental Health and Education Suicidal Ideation What Needs to be Done 32 11.  ADULT MENTAL HEALTH AND IMPLICATIONS FOR PARENTING What Needs to be Done 37 12. CONCLUSION 39 13.  FINALLY 40    Dorset Serious Case Review S11 Page3   1. INTRODUCTION  1.1 This Serious Case Review concerns professional responses relating to a 15 year old boy, who died in Spring 2013, following abuse of drugs not prescribed for him but available in his home. The child, for the purposes of anonymity known as Andrew, had received services from a range of professional staff including education, Children’s Social Care, health and CAMHS1. Andrew’s father, known as Mr Walker, was also receiving services for long standing mental health problems.   1.2 When a child dies or is seriously hurt and the family are receiving services from child care agencies, the Local Safeguarding Children Board (LSCB) has to consider whether a Serious Case Review should be carried out.   1.3 In June 2013 the Dorset Safeguarding Children Board (DSCB)2  made this decision under Regulation 5 of the Local Safeguarding Children Boards Regulations, 2006. (See Appendix 1 for details)  1.4 The Review must be conducted in line with Government guidance, “Working Together to Safeguard Children, 2013” 3  which says the purpose of these reviews is “to identify improvements which are needed and to consolidate good practice.”     1.5 The guidance states that 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 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; � makes use of relevant research and case evidence to inform the findings  1.6  In order to protect the family’s privacy, names have been changed and some of the details  about their family life have been omitted or described in general terms however this has not  impacted on the overall findings or analysis.  1.7  The intention of the Government is that the findings will be relevant to all those involved in the  business of safeguarding children. For readers unfamiliar with the terminology, definitions and  additional information are referenced at the end of each section.    Method   1.8 In view of the move towards using systemic models and practitioner involvement to promote  learning, the Board decided to pilot a new review model known as a “Partnership Learning  Review” jointly commissioned by Dorset and Bournemouth and Poole LSCBs.4   1.9 The principles echo those prescribed in chapter 4 of Working Together 2013, that Reviews should be  proportionate, that professionals involved in the case should be engaged in the learning and that the  family have every opportunity to contribute to the Review.  1.10 An Independent Safeguarding Lead was appointed to manage the process and chair the meetings of  the Review Team and a second Independent Person was appointed to be the author of this report, Dorset Serious Case Review S11 Page4   known as the Overview Author. The process was overseen by a Review Team comprising  multi- agency partners, none of whom had involvement with the case.5   Information Gathering and Analysis  1.11 The Review Team agreed the period analysed would be from early 2010, when the family  moved to Dorset, up to Andrew’s death in the Spring of 2013.   1.12 Individual Agency Representatives, that is managers with appropriate seniority and who had not  been involved in any way with this case, each prepared a chronology of their agency’s  involvement with the family with comments and analysis. They were also asked to contact  their colleagues in the area where the family lived before they relocated to Dorset and add any  relevant historical information to their summaries.   1.13 They were asked by the Review Team to focus on: � Neglect and needs of older children and the relevance of the child protection framework. Common understanding of the term ‘neglect’ � What assessment was done with the child and his family, what, if any, models were used and how interventions were planned  � Any observations about the links between parental mental health and the impact on parenting � The experience and perception of inter and intra-agency communication. What was the effectiveness of communication between agencies? � The challenge of engaging young people/families and any strategies which were considered and/or were useful � Any observations about the prescription and monitoring of the use of strong medication � What was understood of “suicidal ideation”6, particularly in a young person? � Understanding of the impact of risky behaviour and the level of tolerance of the behaviour � Examples of good practice i.e. over and above expected practice � The use of supervision From Scoping the Partnership Learning Review, July 2013  1.14  The chronologies were combined into a document which provided a comprehensive overview of the  involvement of the various agencies with Andrew and his family.   1.15  Where further information or clarity was needed, members of the Review Team were asked to  provide additional information and some source documents. The Overview Author also interviewed  some of the key professionals who had worked directly with the family.    Parallel Processes  1.16  This Review began in May 2013. By this time the Crown Prosecution Service had decided there  were to be no criminal proceedings in connection with Andrew’s death, this meant practitioners  could meet at the Learning Events to discuss the case.   Dorset Serious Case Review S11 Page5  1.17  An inquest into the cause of Andrew’s death was held in the Autumn of 2013 and concluded  “there was insufficient evidence to record a verdict of suicide”, that Andrew had died “as a  consequence of abuse of drugs not prescribed to him.”          1. Child and Adolescent Mental Health (CAMHS) are NHS-provided services for children, they specialise in providing help and treatment for children and young people with emotional, behavioural and mental health difficulties.  2. Dorset Safeguarding Children Board (DSCB)  Section 13 of the Children Act 2004 requires each local authority to establish a Local Safeguarding Children Board (LSCB) for their area and specifies the organisations and individuals (other than the local authority) that should be represented on LSCB. In practice the Board is made up of senior representatives of the organisations who have contact with children including children’s social care, police, health and education.    3. Working Together to Safeguard Children – A guide to interagency working to safeguard and promote the welfare of children, HM Government 2013. http://www.workingtogetheronline.co.uk/chapters/chapter_four.html#scr  4. Partnership Learning Review, A Model for conducting Serious Case Reviews, 2013, Ron Lock, Independent Child Protection Consultant and former Chair of Bournemouth and Poole LSCB.   5. Working Together 2013, Chapter 4, states that “the LSCB must appoint one or more suitable individuals to lead the SCR who have demonstrated that they are qualified to conduct reviews using the approach set out in the guidance.”  It says “the lead reviewer should be independent of the LSCB and the organisations involved in the case. The LSCB should provide the national panel of independent experts with the name(s) of the individual(s) they appoint to conduct the SCR. The LSCB should consider carefully any advice from the independent expert.”  In this case an Independent Safeguarding Lead was appointed to manage the process and chair the Review and a second Independent Person was appointed to be the Author of this report. They are referred to as the Independent Chair and the Overview Author. The Review Team included managers with significant experience in all aspects of practice relevant to the case; these were the Strategic lead for Education Inclusion Services, Designated Nurse for Safeguarding, Acting Safeguarding Manager Children’s Social Care, Housing Services Manager, Dorset Police, Consultant Clinical Psychologist for Children and Consultant Clinical Psychologist for Adults.   6. “Suicidal ideation” is a medical term  described as thoughts about taking one’s own life with some degree of intent. Suicidal ideation is generally associated with depression however, it seems to have associations with many other psychiatric disorders, life events, and family events, all of which may increase the risk of suicidal ideation.  Dorset Serious Case Review S11 Page6  2.      FAMILY INVOLVEMENT  2.1 Andrew’s parents were divorced and Andrew lived in Dorset with his father, known as Mr  Walker.    2.2 Andrew’s younger sister known as Annabel, lived with them for part of the time, moving between her father and mother, Mrs Walker, who lived about 200 miles away.   2.3 Andrew’s paternal grandparents lived locally and provided intermittent support for both  children during times when Mr Walker agreed to them getting involved.  2.4 Members of Andrew’s family were invited to meet the Overview Author to tell their story and  express their views on the input they had received from the various professionals with whom they  had contact. The Overview Author met with Andrew’s mother and father, his sister and his  paternal grandparents.   2.5 In addition to their experience in Dorset, the family talked about the children’s early life and  some of the difficulties they had faced. Some information which emerged was:  � Andrew’s parents were relatively young when he was born � There were problems within his parents’ relationship � Early care of Andrew and his sister was shared among family and friends � There was  a serious house fire at the family home when the children  were very young � The fire led to Andrew’s father spending time in hospital and the  onset of chronic pain � Mr Walker’s mental health problems allegedly became worse after the fire  2.6 There was a difference of view between family members about Andrew’s alleged mental  health problems, with some believing that his environment was entirely to blame for his  difficulties.  2.7 Annabel was able to assist the Review by talking about the children’s life with their father,  what it was like for them and how they looked after each other.  2.8 The family’s contribution enabled Andrew’s voice to be heard throughout the Review.       3.      THE LEARNING THEMES  3.1 Discussion of the chronology with the Review Team, meetings with the family and with practitioners  at the Learning Events led to the identification of four key themes for analysis.   3.2 These were: � The challenges of working with “hard to reach” children and families  � Teenage neglect and the relevance of Child Protection Procedures  � Teenage mental health and suicidal ideation � Adult mental health and implications for parenting   Dorset Serious Case Review S11 Page7     4. THE LEARNING PROCESS  4.1 Two Learning Events were set up for the practitioners and their managers who had first hand  knowledge of the family.   4.2 In addition, chronology authors were invited to attend an event designed to enable them to  consider the themes, discuss the findings and contribute to learning.   First Learning Event  4.3 During the first event, detailed examination of the case enabled practitioners to discuss the  chronology, agree the facts and reflect on the themes. Working in small multi-agency groups,  they were asked to think about their practice, to identify what worked well and  what could have  been done better.   4.4 The Overview Author explored what happened to this child, why decisions had been made and why  actions had been taken or not taken with a view to understanding any gaps or inadequacies in the  multi-agency safeguarding system. Care was taken to avoid hindsight bias with exploration of why  decisions and actions were taken at the time including the impact of any organisational influences.  4.5 Practitioners were encouraged to consider the relevance of the themes to their general  safeguarding practice and what learning could be gained from this case. At the end of the day,  they were asked to read and research around the themes, to identify some facts and local and  national practice developments to share with the group at the next event. The purpose of this  exercise was to encourage the group to take responsibility for their own learning from this case.    Second Learning Event  4.6 Six weeks later, the second Learning Event focussed on the first draft of the Review, the  analysis and  initial findings.   4.7 Practitioners discussed the draft findings and in small groups were able to talk about whether  they agreed with the conclusions and whether the reasons for some of the deficits in practice  were accurate, proportional and properly explained. The group made suggestions about the  links between the themes.  4.8 Participants looked at learning from the case and described what changes in practice had  already occurred and what steps they were taking to improve, for example, communication  between adult mental health services and children’s social care, assessment and care  management in general and assessment of teenagers in particular. The Pupil Referral Unit  which provides an alternative education placement for children unable to attend mainstream  school, described improvements in communication with families.   4.9 Finally, each group shared their research findings on each theme. This produced some information  new to participants, for example about the incidence of self harming and risk of  suicide, and some  information which it was useful for practitioners to re-visit, for example  methods of engaging hard  to reach families.  Dorset Serious Case Review S11 Page8  5.        DORSET SAFEGUARDING CHILDREN BOARD AND LEARNING  5.1 At the end of the Review the report was shared with DSCB for their consideration of the  learning  from the case and what needed to be done to consolidate and improve practice in the future. The  Partnership Learning Model was evaluated at the end of the process.          Dorset Serious Case Review S11 Page9  6. FACTUAL SUMMARY OF THE CASE  6.1 Andrew died in the Spring of 2013 having taken a quantity of pills belonging to his father.    6.2 The Review period begins in 2010 when Andrew, aged 13, moved to Dorset with his father and  younger sister Annabel. His parents were separated and his mother lived about 200 miles away.   6.3 When the family arrived in Dorset, Annabel’s school received information indicating that  both children had a very poor record of school attendance.   6.4 By the Autumn of 2010 it was also known that Mr Walker had a long history of mental health  problems.     2010  6.5 When the family arrived in Dorset, the school attendance issue was quickly picked up and  Andrew was placed on a “fast track school attendance programme” to monitor his attendance and  provide support. Just before the end of the school year, Andrew was referred to the Education Social  Work and Attendance Service, ESWAS, later re-organised to become known as the Early  Intervention  Service. (EIS) Their role was to identify any problems preventing Andrew attending school and  provide advice and support.  6.6 On moving to the area, the family were housed in temporary accommodation. A complaint was  received from a neighbour about the use of the communal area and although a housing officer  visited in response, they were unable to gain access for a further 6 months. This was an early  indicator of the subsequent difficulties of all agencies in engaging with the family.  6.7 Andrew and Annabel were registered with a GP who noted their immunisations were not up  date. There was no response to a letter sent to Mr Walker following this up. Two further  letters were sent and the school nurse was enlisted to try and ensure some action was taken.   6.8 Mr Walker was referred by his GP to the adult mental health services. He was also noted, in  routine screening, to be drinking alcohol at a “hazardous” level. Mr Walker had also expressed  concerns to the GP that Annabel (aged 11) might have a mental health illness. She was assessed by  CAMHS 8 weeks later and her name placed on a waiting list. (Annabel moved back to her mother in Summer 2011 before being seen and there has been no evidence of her having any mental health problems.)    6.9 Towards the end of the year the children’s school attendance had not improved and Mr  Walker had  failed to attend a meeting to discuss this. The records indicate that he was to be given a fixed  penalty notice however this action wasn’t followed up.   6.10 A single agency assessment was carried out by the EIS. Following this assessment, the case was  discussed with their Safeguarding Advisor and a range of concerns were noted which they  considered needed further assessment. They passed these on to Children’s Social Care requesting a  visit. At the same time a similar referral was made by the school nurse.  6.11 In December 2010, Children’ Social Care visited to carry out an Initial Assessment and found  Andrew unconscious, having taken an overdose of his father’s medication.  Dorset Serious Case Review S11 Page10   6.12 As a result of the overdose, Andrew was admitted to hospital.   6.13 Also involved in the overdose incident was Andrew’s older girlfriend and it was alleged they  were experimenting with the drugs. Annabel was with them. It was noted that Andrew showed  evidence of self harm, including cuts and a burn. He gave various stories to hospital staff including  that he felt very low and wanted to kill himself but also that this was an impulsive act with  unexpected consequences. During his stay in hospital, assessments noted Andrew, just 13, as  being sexually active, drinking alcohol and smoking cannabis. His school  attendance by this time was  10% and his immunisations were still not up to date. For several hours during Andrew’s  admission  his father couldn’t be located, but when he did come to the hospital, staff were  satisfied with his  response to the concerns.    6.14 CAMHS carried out a “deliberate self harm” assessment and Andrew was discharged home for  follow up in the new year.   6.15 The Initial Assessment from Children’s Social Care concluded that further assessment was  required and a plan was put in place addressing the issues identified as needing action. Mr  Walker appeared responsive to concerns and to have taken note of the need to keep his  medication securely locked up.  6.16 There were varying accounts of the overdose and how Andrew had access to the medication but  insufficient evidence to prompt a criminal investigation.    Early 2011   6.17 Neither child returned to school in the New Year and EIS suggested that it might be appropriate to  implement Child Protection Procedures and begin a Section 47 investigation.8 They were under the  impression this would lead to a Child Protection Conference.   6.18 Children’s Social Care reported back that they didn’t consider child protection procedures to be  necessary at this stage although they did send a letter to Mr Walker indicating continued  “non engagement” might lead to this.   6.19 Children’s Social Care requested that EIS pursue an Education Supervision Order for both  children.  6.20 Andrew was referred to a sexual health worker who noted concerns about his personal care and  appearance and the CAMHS worker made attempts to contact the family to see Andrew to follow up  the December overdose incident.   6.21 Andrew continued to attend school very intermittently. He was observed to be having trouble with  some peer relationships and was excluded for a few days for fighting.    6.22 In March 2011 the children were discussed at a Multi-Agency Allocation meeting held at the  school, also known as “Team around the School “meetings.  The purpose of this was to discuss  children who were known to several agencies and for those agencies to share what they were doing  and keep colleagues up to date.   Dorset Serious Case Review S11 Page11  6.23 Support was offered and additional concerns about Andrew’s possible substance misuse  were noted. Questions were raised about the impact of Mr Walker’s mental health on his  parenting and Children’s Social Care asked his GP for advice regarding parenting capacity.     6.24 Housing visited to discuss allegations of anti social behaviour and agreed to monitor the  situation.    Spring 2011  6.25 Despite efforts to contact the family, except for Andrew seeing the GP, the children were not  seen by Children’s Social Care or CAMHS for almost three months.   6.26 In April 2011 a visit from the social worker found Annabel, aged 11, outside her home in the  pouring rain unable to find her father or gain access to their home. Mr Walker could not be located  and she was cared for by her grandparents until her father returned 6 hours later.   6.27 At this point concerns for Annabel eclipsed those for Andrew. Her school attendance continued to  be a problem and a multi-agency meeting at the school referred to the possibility of “neglect by  default.”   6.28 There were various communications between professionals about the family. EIS sent warning  letters to Mr Walker (penalty notices) setting out the need for the children’s school attendance to  improve. Mr Walker indicated Andrew had been ill and this was the reason he didn’t attend school.  6.29 After prolonged efforts to make an appointment, in March Andrew started seeing the CAMHS worker. He was offered weekly appointments although his engagement was intermittent (he was  seen 11 times over a year.) When he did see his CAMHS worker he reported feelings including low  mood and thoughts of self harm.     Summer 2011  6.30 Children’s Social Care completed a Core Assessment9 in June. The conclusion was that the  children should receive services within the Child in Need10 framework and a meeting was held  which reviewed the actions which had been identified in the Initial Assessment from January.  6.31 Discussions with staff during the Learning Event indicated they were more concerned about  Annabel than Andrew and arrangements were made for her to return to her mother. Her  name was removed from the CAMHS waiting list.   6.32 Andrew made it clear he would not consider moving back to his mother. He told some  practitioners he was very angry with his mother, who he perceived as having rejected him and  “replaced him” with a new baby in December 2010.   6.33 During the Summer of 2011 Andrew appeared to engage with the CAMHS worker who had  been persistent in efforts to contact the family.   6.34 Mr Walker told the CAMHS worker that Andrew’s mood was “dropping” that he was developing  feelings of paranoia and isolating himself in his bedroom. At his father’s request, Andrew was  referred to a psychiatrist. In addition, the social worker noted Andrew looking really unwell.   Dorset Serious Case Review S11 Page12  6.35 Andrew was attending school intermittently and staff noted his poor physical presentation and low  mood, evident from some creative writing he shared. The school discussed this with Children’s Social  Care and were advised to follow their own policy on “suspicions about drug use.”  Andrew  continued his work with CAMHS who noted his low feelings and his suggestion to them that he  might have difficulties similar to his father.   6.36 Around the same time it was observed that Mr Walker was “becoming nocturnal and hiding  from visitors.”     6.37 In view of his father’s difficulties, Andrew was referred to the Young Carers Scheme11. In an  Initial Assessment he described himself as “angry, stressed and fed up all the time.” They  invited Andrew to various activities although he never attended.    6.38 Towards the end of term Annabel returned to her mother. Mr Walker eventually agreed to the move  on the basis that it was not permanent.    Autumn 2011  6.39 The Autumn term found Andrew missing school again. Young Carers had been unable to make  contact (he never engaged with their services and they closed the case after 12 months) and  Andrew was missing some appointments with CAMHS.    6.40 He was however seen by the child psychiatrist who noted his “intermittent thoughts of self  harm” and levels of “self neglect.” Now aged 13, Andrew was prescribed medication which  appeared to improve his mood.     6.41 In November 2011 Andrew and his father participated in meetings at school and agreed to  Andrew’s phased return, however this wasn’t successful.    6.42 Attempts by Children’s Social Care to see Andrew were not very successful. He was seen at the  beginning of October and then again, 11 weeks later, towards the end of December.    6.43 Just after Christmas Andrew, now aged 14, was taken to hospital having been assaulted by an older  boy, allegedly “for a bet.” The police were informed as there were allegations that the incident  centred around the supply of drugs. No action was taken because there was insufficient  evidence to  support a prosecution.   6.44 During the hospital visit, Accident and Emergency staff noted marks of differing ages on Andrew  indicating self harm, they followed procedures, made a check with Children’s Social Care and  completed an interagency referral form. In response, the social worker telephoned Mr Walker and  booked a visit for early January.   2012   6.45 Two weeks after receiving the interagency referral form from the hospital, Children’s Social  Care visited the family with a housing officer. The focus of discussion was Mr Walker’s wish to move  to a larger property to accommodate his new girlfriend and her baby. With regard to the December  assault, Children’s Social Care were satisfied that Mr Walker’s and Andrew’s responses to the  incident were “appropriate”, there is no mention in the record of the reports of self harm. Home  conditions were noted as “clean and tidy.” Dorset Serious Case Review S11 Page13    6.46 Annabel was now living with her mother, Andrew appeared to be feeling better and following a  referral from the child psychiatrist, had started attending the Pupil Referral Unit  (PRU.)12 A student  social worker was assisting with the case, trying to work with Andrew on motivation and  sometimes giving him a lift to the PRU.   6.47 Andrew was still seeing the CAMHS worker intermittently and was spending some time doing  activities with his grandfather. During this period his demeanour was observed to be more  positive. The child psychiatrist noted Andrew had made progress and there was “no suicidal  ideation or intent.” In February 2012 the psychiatrist retired and handed the case over to his  successor. (Andrew never engaged with the new consultant)     6.48 In March, Andrew described a few difficult days associated with Mother’s Day when he said he had  considered suicide. He was also having problems with relationships with some students at the PRU  and arrangements were made for him to transfer to a different PRU. The CAMHS worker  noted Andrew’s bedroom was “dirty and smelly.”  6.49  In April Andrew was unwell with “self diagnosed” glandular fever, missed more time at the PRU  and  had disengaged with the CAMHS worker. CAMHS suggested involving the Crisis Intervention Home  Therapy Team (CIHT), a tier 4 service13, however Andrew did not meet the threshold for  intervention.  6.50 Mr Walker had not engaged with the adult Community Mental Health Team and was discharged.   6.51 In May the family moved house and there was some confusion among Children’s Social Care and  CAMHS about the new address. For about 2 weeks, appointment letters were sent to the  wrong address.    Summer 2012  6.52 In the Summer, a review of the Child in Need Plan took place and it was noted that there had  been little progress. Child Protection intervention was mentioned as a possible option if  “outcomes  were not met.”  6.53 A social work student continued to work with Andrew on motivation and a Community Resource  Worker 14 was allocated to the family. This led to an introduction and setting up of a series of 8  meetings for Andrew but, despite the efforts of the worker, he only attended two and they closed  the case. The worker commented Andrew was “isolated with few friends.”     6.54 In June, CAMHS were having similar problems of engagement. They had not seen Andrew since April. Based on his attendance history and length of time they had been involved they  closed the case with the option of re-opening if there was evidence of re-engagement with any  service.    6.55 At the same time (July) Children’s Social Care were considering “downgrading” the case and  handing over to the Early Intervention Service, they proposed a Team around the Child Meeting  (TAC)15  to hand the case over the locality team, (also known as EIS) This meeting took place in  November.   Dorset Serious Case Review S11 Page14  6.56 Andrew continued to be prescribed his anti-depression medication on a repeat prescription. The  new psychiatrist informed the GP that he intended to discharge Andrew as he hadn’t attended  appointments and queried whether the prescription should continue without his oversight as this  would contravene the NICE guidance.16 He suggested the GP use his discretion on this issue. The GP  considered the best option was to continue with the prescriptions.  6.57 Annabel, now aged 13, visited her father and refused to go back to her mother, having told  family members she was concerned for her father’s mental health. Mr Walker had a significant  disagreement with Children’s Social Care who he believed were encouraging Annabel to return to  her mother.   6.58 Andrew’s attendance at the Learning Centre was still poor and when he was at school he was having  problems with relationships with other students and getting into fights.    Autumn 2012  6.59 In the Autumn of 2012 Andrew hadn’t returned to school after the Summer break. Efforts by EIS  and  the staff at the PRU to contact the family using various methods were unsuccessful.   6.60 Children’s Social Care were concerned about Annabel and tried to arrange for her to go back to her  mother. This led to continued hostility from Mr Walker who accused them of trying to break up the  family.   6.61 In November 2012 Children’s Social Care received an anonymous letter expressing concerns  about Andrew’s and Annabel’s care alleging the children were being left alone for long periods, that  the home conditions were poor and shouting and swearing could be heard coming from inside the  property.    6.62 No action was taken in response to the referral and there is no record which explains why it  appeared to be overlooked.    6.63 In November 2012, with help from her grandparents and Children’s Social Care, Annabel  returned to her mother. Shortly after this Andrew was assaulted in the grounds of the PRU and  stopped attending. PRU staff reassured Andrew that the other student involved had left  but  continued efforts to contact Mr Walker and Andrew were unsuccessful.  6.64 A Transfer CAF17 was prepared and a Team Around the Child meeting was held in mid November,  the purpose of the meeting was to hand the case over to EIS but an administrative oversight meant  EIS were not invited to the meeting. Also, neither Mr Walker nor Andrew attended. Following the  meeting EIS attempted to contact the family but without success.   2013   6.65 In January Andrew was seen by the GP practice nurse for a “stop smoking” consultation.   6.66 Andrew had not returned to the PRU after the Christmas break and efforts to contact the  family were not successful. A home visit by staff from the PRU took place in early March but no-one  was at home.        6.67 Andrew died a few days after this visit.   Dorset Serious Case Review S11 Page15    8. Section 47 of The Children Act 1989 places a duty on all Local Authorities to investigate  and  decide what actions might be required to protect/safeguard the welfare of any children that are at risk of significant harm.   9. Initial Assessments, Core Assessments and Transfer CAFs (Common Assessment Framework) are all assessment models commonly used by Children’s Social Care when working with families to collect and analyse information about the family’s needs and parenting capacity.     10. Child in Need, Under Section 17.1(a) of the Children Act 1989, local authorities have a duty to safeguard and promote the welfare of children within their area who are assessed as “in need.” Local Authorities can provide a range of services intended to support and help families  11. Young carers are children and young people under 18 who provide regular and ongoing care and emotional support to a family member who is physically or mentally ill, disabled or misuses substances. Young Carers schemes provide advice, information and support for children in their area, often inviting them to group  activities to meet other young carers in their area.   12. Pupil Referral Units (PRUs) provide alternative education for those pupils who, for a number of reasons, are  unable to access mainstream school. Pupils may have been permanently excluded from school, be at risk of exclusion or be unable to attend school for medical reasons or be experiencing other difficulties.  13. At the time CAMHS services were referred to according to the level of complexity of a child’s problems. Andrew had been receiving a “tier 3” service and was not considered as meeting the threshold for a “tier4” service.   14. Community Resource Workers are employed by Dorset Children's Services to provide flexible support for children and families who are in need, the support may include one to one work and individual packages of positive activities. Community Resource Workers usually take young people out, this allows the opportunity to engage in appropriate activities outside the home.  15. Team around the Child Meeting (TAC) A TAC is a multi-disciplinary team of practitioners established on a case-by-case basis to support a child, young person or family. The TAC is intended to a model of service delivery that involves:  • a joined-up assessment, usually a Common Assessment Framework (CAF • a lead professional (LP) to coordinate the work the child / young person and family at the centre of the process  • virtual or flexible multi agency team that will change as needs change • coordination at the point of delivery • a TAC support plan to meet the needs of the child / young person • regular meetings to which the child / young person and families are invited to attend   16.  The National Institute for Health and Care Excellence (NICE) provide the NHS with authoritative and evidence based guidance on the diagnosis and treatment of disease and ill health, this includes guidance on the treatment of depression in children and young people and the prescription of drugs. The full guidance can be found at:   http://www.nice.org.uk/CG28  17.  Transfer CAF, see note 9     Dorset Serious Case Review S11 Page16    7.      ANALYSIS OF THE THEMES   7.1 To understand what work had been undertaken with Andrew and his family, to judge the  effectiveness of practice and to understand why decisions and actions had occurred, particularly if practice was considered to have been poor, four themes were identified.   These were: � The challenges of working with “hard to reach” children and families  � Teenage neglect and the relevance of Child Protection Procedures  � Teenage mental health and suicidal ideation � Adult mental health and implications for parenting    7.2 The Review Team, the Chronology Authors (IAR’s) and the practitioners worked with the  Overview Author to analyse practice. Andrew’s family also contributed to the discussion during  their interviews.  7.3 The outcome was a general agreement about what had been done and why and where there were  shortfalls in quality, the reasons for this. Understanding the reasons led to discussion about  what lessons could be learnt. Some of the lessons arose from previously unknown information and  some from the opportunity to reflect on practice in an environment which aimed to provide  both objective challenge and support.   7.4 Engaging with practitioners was essential to this understanding and meant that they were fully  engaged in the learning from the outset.   7.5 There have already been changes made as a result of the learning and this report refers to those  changes as well as what remains to be done. Each section begins with a summary of Findings and  Learning.   7.6 For the DSCB each theme raises questions to address in order to ensure the learning is not lost but is  consolidated within the context of ongoing practice development.    Dorset Serious Case Review S11 Page17  8. THE CHALLENGE OF WORKING WITH “HARD TO REACH “FAMILIES     What do we mean by hard to reach?  8.1 The terms “hard to reach” “service resistant” and “hard to help” are terms commonly used to  describe families who resist intervention and appear to go out of their way to avoid efforts to help  them. Families commonly fail to keep appointments, miss meetings and provide reasons why  they cannot do what is asked of them. They might be aggressive or challenging or live lives that are  too chaotic for any meaningful work.   8.2 Barrett (2008)18 suggests the term “service resistant” is a more helpful term and she indicates the  group may, for example, include families with long term complex problems, where domestic abuse  may be a feature or where parents are substance abusers.    8.3 In this case, the chronology details numerous efforts to engage with Andrew and his father  over the three year period of this Review. The family missed appointments, didn’t answer  letters or messages and presented reasons why suggestions about help wouldn’t work.   8.4 To complicate matters further, when the professional workers became concerned about lack of  progress and threatened to take action, Mr Walker appeared to accept some responsibility for  parenting and, for a short time, did just enough to prevent matters escalating into legal action  about non school attendance or implementation of the child protection procedures. During these  periods Andrew attended school more regularly and appeared to be better engaged with CAMHS.  8.5 The challenge of trying to engage with this family and the inconsistent progress affected  every area of work with them; it compromised the ability of the workers to carry out thorough  assessment, to plan and review progress or to provide any in depth therapeutic  services.     SUMMARY OF FINDINGS  • Difficulties in achieving consistent engagement with the family impacted on the practitioners ability to undertake planned and purposeful work • A variety of methods to engage the family were tried  but with little effect • There was no formal recognition of the family as “hard to reach” and therefore no effective strategy in place • Agencies closed the case around the same time with little consideration of the combined effect         SUMMARY OF LEARNING  There is a need:  • To identify relevant families and agree terminology • Introduce a protocol, for example a “stop and review” meeting • Understand why the family are not engaging and what the risks are • Support worker resilience • Be clear about outcomes • Consider the impact of closing a case and the need to inform partner agencies Dorset Serious Case Review S11 Page18  8.6 Overall, from when the family first came to Dorset to when Andrew died, there was little  progress in understanding the family dynamics, assessing the standard of care of the children,  planning or achieving any change in areas identified as necessary for Andrew.   8.7 The chronology shows that there was a great deal of activity during the period the family were  known.  Numerous meetings were held and there were many conversations between  professionals about what needed to be done. It is to their credit that workers were generally  persistent and tried a variety of methods to make contact including telephoning, texting, email,  letters, visits, hand delivering letters and driving Andrew to school; appointments with CAMHS  were offered in various  settings to make attendance as easy as possible for Andrew.   8.8 It was the health workers who were able break through some of the barriers, CAMHS, the  child psychiatrist and the GP probably knew the family best. This is an interesting reflection of Mr  Walker’s apparent pre-occupation with health matters.   8.9 The occasions when some improvement in engagement was noted, and Andrew became  more visible and was able to express his own opinions this appeared to be enough for  professionals to remain optimistic that change was within reach.   8.10 Even in the Team Around the Child meeting in late 2012, organised when everyone was withdrawing  because of non  engagement, the notes indicate a sense of optimism that Andrew might start  attending school more regularly even though it had been at least three years without any notable  change.    Closing the Case  8.11 By the Summer of 2012, about 6 months before Andrew died, the various agencies working with the  family had recognised their difficulties and had thought about who or which agency might be better  placed to work with the family. The chronology lists a number who tried, for example student  social workers, Young Carers, Community Support Services, and EIS all of whom tried to work with  this family with little or no success.   8.12 CAMHS, Children’s Social Care and the psychiatrist had been unable to reach the family for  several months and were at a loss about what else they could do. The family had made it  clear they didn’t want any further help.   8.13 The psychiatrist closed the case, handing medical oversight to the GP, CAMHS decided to  withdraw and Children’s Social Care decided to “downgrade” the case and hand it to EIS.  8.14 Interestingly, Barrett describes the concept of families being “over targeted” with often little effect  and that appears to be what happened in this case. At times, as efforts were made to see them,  the  family were overwhelmed with messages or appointments and on one occasion they had three  meetings with different agencies scheduled on the same day.   8.15 From the family’s point of view they acknowledged, to some extent, the challenge they presented  and identified some of the barriers encountered by those trying to help them, these are commonly  found in similar cases:   � They had negative attitudes and understanding of individual social workers  Dorset Serious Case Review S11 Page19  � They were overwhelmed by the introduction of new workers and the number of people involved in their case � They wanted health intervention but did not want any services from  Children’s Social Care � They associated child protection with removal of children and were deliberately resistant to intervention   Learning from the Case  8.16 Although well intentioned, efforts to engage with Andrew and his father were ineffective.  For  example when writing letters didn’t achieve a response, workers tried texting, when texting didn’t  succeed they hand delivered letters, when Mr Walker failed to get Andrew to school a student  social worker gave him a lift. When one agency was failing to engage, referral were made to  others and although efforts produced short bursts of improvement, given the history, it was  predictable that the family were unlikely to respond any differently to new and additional  agencies when they had such a well established  pattern of non engagement.   8.17 To assist practitioners who find themselves in this situation, The Pan Dorset Inter Agency  Safeguarding Procedures, Working Harder to Engage with Children, Young People or Their  Families More Effectively19 includes information:     “designed to support referring and receiving agencies in the preparation of     policy and the review of procedures and practices to ensure these issues are     addressed.”    8.18 The procedure was written in response to a recommendation from the Independent Case  Review W20, which although the outcome of that case was quite different, the theme of non-  engagement was similar to this case, the summary says:      “It was undoubtedly very difficult to make and encourage change when      dealing with limited information and complex, hard to reach families. It needs     to be acknowledged that the families themselves did not always want to     accept help. It would nevertheless appear that in this case agencies did not     work sufficiently robustly and proactively in a multi-agency arena to gain the     families engagement in order to help support them in their care of these      young people.”  8.19 The Report highlights learning as the need:  • to assess the causes  of behaviour in order to plan appropriate intervention  • to challenge parents who minimise issues within the family and  • for professionals to take an objective stance about the work carried out by other professionals and challenge them appropriately  8.20 The procedure is a start towards recognising the problem but, despite this guidance, discussion  with staff during the Learning Events indicated that they have no clear direction about what is  expected of them if they are having trouble engaging a family beyond trying harder.       Dorset Serious Case Review S11 Page20   Recognising the Problem  8.21 There are a number of strategies which have been identified as helpful in these circumstances, the  first step is to recognise the problem.   8.22 Although everyone tried hard with this family, with the exception of some of the health services  who  have a “missed appointment protocol”, there was no formal recognition of them as hard to  reach or “service resistant” and no shared language to describe families in this situation.     Independent Review and Developing a Strategy for Engagement  8.23 If the problem of lack of engagement is recognised, an independently chaired review might help  practitioners step back from a “more of the same” approach and focus on, for example, the  reasons for non engagement, assessing the risks and being clear about what changes need to be  made.   8.24 Honor Rhodes (2013)21 in her work on engagement suggests it is helpful for workers to be well  trained, well supervised and to be clear about the reasons for engaging with a family. This fits  with the need for robust assessment, planning and review which is discussed in detail in the next  theme.  8.25 A clear assessment will assist staff in identifying what changes need to be made and by when. The  rewards for positive change can be identified and if no change is achieved or behaviour worsens,  the consequences can be made clear. In this case staff understood their statutory responsibilities  and the possibility of using their powers, for example court action for non school attendance, but  were less clear about when the threshold for intervention was passed.  8.26 The Ofsted report, Ages of Concern22 describes findings from Serious Case Reviews concerning  babies and children over 14 years old. The report reiterates the tendency for practitioners to:     “focus on the young person’s challenging behaviour, seeing them as hard to reach or    rebellious rather than trying to understand the causes of behaviour and the need for    sustained  support”  8.27 Working with families who are resistant, with children who are protective of vulnerable  parents and  who may be fearful of being removed from home is not easy and this case shows that high  levels of activity don’t necessarily lead to good outcomes.   8.28 Improved guidance from the DSCB would assist with better recognition that a family is service  resistant, objective oversight of cases and greater understanding of the reasons for non  engagement.  The implications for children in these circumstances could be assessed and more  effective multi agency planning put in place.     Impact of Closure  8.29 When reflecting on their practice in this case it became clear to practitioners that each agency had  closed the case, around the same time, without giving sufficient consideration to the impact of  closure on the family or on the other agencies who were trying to work with the family. For example  the psychiatrist closed the case and handed responsibility for prescription of medication to the GP, Dorset Serious Case Review S11 Page21   the GP assumed CAMHS were involved but they closed the case unaware that Children’s Social Care  were planning to “downgrade” and hand the case on to EIS.  8.30 There have been some changes in practice since these events which would make this scenario less  likely now, all of which are discussed in more detail later in this report. These include new practice  guidance for GPs on prescription of medication to children and more robust arrangements for care  planning and review in Children’s Social Care which strengthens communication between agencies.   What Needs to be Done  8.31 Practitioners have suggested that when a case is to be closed, an “impact assessment” should be  carried out, although the format might vary, the purpose would be to consider the impact of closure  on the family, including an assessment of risk and consideration of who in the professional network  needs to know. Staff working in the field of adult mental health were especially conscious of the  need to inform Children’s Social Care if they were closing a case and the family were known to them.   8.32 Practitioners would welcome a protocol highlighting the need for effective communication in these  circumstances.       18. Barrett, H, Engaging Hard to Reach Families in the Voluntary and Community Sector. London: Family   and Parenting Institute, 2008  19.  Pan Dorset Inter Agency Safeguarding Procedures, 4.6 Working Harder To Engage With Children,  Young People or Their Families More Effectively    http://www.dorsetlscb.co.uk/site/wp-content/uploads/2009/12/Chapter-4.6-Working-Harder-to-  Engage-with-Families-New-Jan-12.pdf  20.  Bournemouth and Poole Safeguarding Children Board, Case Review W, Executive Summary, March  2011  http://www.bournemouthpoole.lscb.org.uk/serious_case_reviews/pictures/content203/final_exec_ summary_case_w_-_24_1_11.pdf  21.  Honor Rhodes, Effective Work with Hard to Reach Families, Parenting UK, 2013   22.  Ages of Concern: Learning Lessons from Serious Case Reviews, Ofsted 2011    Additional Resources    Working with Troubled Families, A Guide to Evidence and Good Practice, Department for    Communities and Local Government, December 2012.    Thoburn, J. (2009). Effective interventions for complex families where there are concerns    about, or evidence of, a child suffering significant harm     http://www.c4eo.org.uk/themes/safeguarding/files/safeguarding_briefing_1.pdf     Thoburn, J. (2010). Towards Knowledge-based Practice in Complex Child Protection Cases: a Research-  based Expert Briefing   http://pierprofessional.metapress.com/content/2564550m1u666574/fulltext.pd Dorset Serious Case Review S11 Page22  9. TEENAGE NEGLECT AND THE RELEVANCE OF THE CHILD PROTECTION PROCEDURES    SUMMARY OF FINDINGS  • Despite indicators, Andrew, was not seen as a child at risk of significant harm  • Therefore opportunities to implement the Child Protection procedures were missed • There was a perception that CP is the responsibility of Children’s Social Care  • The Initial and Core Assessments lacked detail and didn’t identify risk • Events were seen in isolation  • Planning lacked focus and clearly identified outcomes • Workers were de-sensitised to Andrew’s vulnerability   SUMMARY OF LEARNING  • Child Protection is relevant for teenagers • All agencies have a responsibility to use CP procedures  • Use of a graded care profile assists in objective assessment of neglect • Chronologies provide useful insight into young people’s experience • Use of Safeguarding Advisors  can provide useful objective oversight    9.1 In this case there were a number of indicators that Andrew and his sister’s needs were not  being met by their father. These include non school attendance, late registration with a GP and  immunisations not up to date, Andrew’s access to his father’s medication, his personal care and  the state of the family home, Andrew’s risky behaviour, sexual activity with an older girlfriend, being assaulted and his alleged drug misuse.   9.2 Some, or all of these factors, were noted by all the agencies involved and the chronology  notes at least nine references to the possibility of using the Child Protection Procedures  if no  progress was made. But at no point did assessment or referral lead to the implementation of the  Procedures.   9.3 In addition to the accumulating range concerns about Andrew, there were specific referrals to  Children’s Social Care from A&E in December 2011 and from an anonymous source in November  2012, and several incidents which raised questions about Andrew (and Annabel’s) safety which  might have triggered further investigation.   9.4 Despite the concerns about Andrew, from the outset the focus of attention for this family was on  getting Andrew and Annabel to attend school and a lot of effort was put into trying to support the  family  towards this aim and Andrew was not seen as a child meeting the threshold for child  protection intervention.   9.5 In discussion with staff it appears that several factors contributed to their view:    � Events in the children’s lives were seen in isolation, there was no assessment of the implications of multiple events   � There was a perception that child protection is the responsibility of Children’s Social Care and a reluctance to challenge their view Dorset Serious Case Review S11 Page23  � There were some misunderstandings about what was being done, some practitioners believed Child Protection procedures were to be implemented � A few practitioners do not consider the Child Protection framework to be relevant for older children. � The professional mindset did not allow room for consideration of the risk of neglect or sufficient thought to be given to what life was like for Andrew at home.   Assessment and Care Planning  9.6 Andrew was assessed on separate occasions by CAMHS, EIS and Young Carers, each with a  view to his suitability for service provision.   9.7 Children’s Social Care assessments included an Initial Assessment (December 2010), a Core   Assessment (June 2011) and a transfer CAF (October 2012). From these assessments a Child In  Need plan was put in place the emphasis of which was getting Andrew and his sister to attend  school.   9.8 The Initial Assessment was based on the events leading up to and including Andrew’s first  overdose. A task centred Child in Need plan was drawn up to try and address the most pressing  issues of Andrew’s school attendance (which was 10% at that time) and his safety following the  overdose. Mr Walker was to be supported in accessing mental health support services for  himself.  9.9 Further Assessment was identified as necessary based on the number and complexity of the  issues facing this family, but the Core Assessment was not completed for a further 6 months. The reason for the delay appears to be a combination of factors including difficulties in engaging with the  family, Children’s Social Care going through a major re-organisation and the social worker having  four successive managers during the six month period. The combination of these factors led to drift  in reaching acceptable timescales.     9.10 The information on which the Core Assessment was based is unclear from the document as there is  some discrepancy in the notes about the dates the family were seen and the evidence from  interviews. The assessment was also compromised because it describes both children with different  needs on the same document. Information gleaned directly from the children and from other  professionals is included.  9.11 Some of the information known about the family which indicated potentially very serious  concerns about the care Andrew (and Annabel) were receiving was not explored in detail. For  example Annabel “hadn’t attended school for about a year,” “Mr Walker does not set boundaries”  and concerns about “Mr Walker’s capacity to safeguard the children as he is affected by his  medication.”   9.12 There was also reference to 3 referrals about the family before they moved to Dorset but no  information indicating what these were about. There is a brief reference to the overdose in  December 2012 which led to the assessment but no exploration of the implications of this. There is  no mention of Andrew’s history of self harming, of the incident when Annabel, aged 11, was out in  the rain and couldn’t contact her father for several hours or of the implication of Mr Walker’s  suggestions Annabel might have a serious mental health problem.  Dorset Serious Case Review S11 Page24  9.13 Insufficient attention was given to Andrew’s early history, his early parenting and experiences of  loss and trauma which, along with the description of his relationship with his father, suggest he may  have had attachment difficulties. Inclusion of this in the assessment could have opened up  discussion about alternative methods of intervention.   9.14 There was also little mention of Mr Walker’s history. This problem was compounded by Mr  Walker’s lack of engagement with adult mental health services and although efforts were  made to enquire about Mr Walker’s diagnosis, medication and the impact this was having on his  parenting capacity, enquiries did not produce any information which was considered in the  assessment.   9.15  The Assessment records that child protection measures would be considered if the outcomes of  the plan were not met “within the timescale agreed” although it is not clear from the recording  what the timescale was.  9.16 Following the Core Assessment, the original Child in Need Plan was reviewed. Actual outcomes  were added to the plan, some tasks had been completed, for example concern from Mr Walker  about Annabel’s mental health had led to her name being on the waiting list for a service, but no  substantial change was recorded and the focus remained on improving the children’s school  attendance.  9.17 Although the Child in Need (CIN) plan should have been the focus for the multi-agency team to  agree objectives, clarify who was doing what and measure progress, discussion with the  practitioners suggested the meetings were not seen as central to practice. Other agencies  including school nurses and education staff, reported they are unlikely to know if a child has been  assessed as “in need” and has a plan and it was interesting that when staff spoke of a child having “a  plan” it was assumed this was a Child Protection plan.   9.18 Children’s Social Care raised issues of capacity and potential workloads as a factor influencing  arrangements for CIN, when meetings are held and who is informed or invited suggesting it would  be impossible to invite all those concerned to every meeting. This was hotly debated by senior  managers who considered that recent changes in boundaries had spread the work more evenly  between teams. Clearly this subject requires further debate and resolution.  9.19 The main forum for discussion of progress with this family were the “multi agency allocation”  meetings also known as the “Team around the School” held at the school every half term  until Andrew started at the PRU.   9.20 The purpose of these meetings was to discuss children who were known to several agencies and  for whom there were shared concerns. The meetings were attended by a range of  professionals and often discussed up to 15 children, minutes were taken and the expected  outcome was that each agency would share their concerns, agree an appropriate level of  intervention share their plans and feedback progress.    9.21 The advantage of these meetings was that they brought people together to talk about their  single agency plans but they were not intended to provide a robust platform for effective multi- agency  working. Also, the fact the meetings were convened by the school and were held there  perpetuated the view that school attendance was the key issue for the children.   Dorset Serious Case Review S11 Page25  9.22 Child in Need reviews were held in June 2011 and May 2012 but these appear to have been  given less of a priority because of the school meetings partly because Andrew and his family were  more likely to attend meetings at school.     Response to Referrals  9.23 There was no further assessment from Children’s Social Care after June 2011 although there  were a number of incidents which might have led to a Section 47 investigation.   9.24 The case recording does not mention a  specific referral, received from a member of the  public in  November 2012, which detailed concerns about the care of the children and their being left  alone for long periods, it appears to have been “lost” in the system.   9.25 Although Children’s Social Care managers have looked into this, it has been impossible to  determine exactly what happened to the referral and who saw it at the time. Several factors  were identified as relevant, these were that the referral arrived at the time the case was  being closed and also the IT system does not allow for information received to be classed as  a  ”referral” on an open case. This potentially means it isn’t given priority for a decision. Managers  assured the Overview Author that they have audited their systems and this failure appears to have  been an isolated incident.     9.26 Other missed opportunities included Children’s Social Care response to the referral from A&E,  to  Annabel being out in the rain and unable to contact her father and Andrew being assaulted.    9.27 These incidents were each dealt with in isolation. If they had been looked at together, for example  by using an up to date chronology, this might have led to identification of a pattern and prompted  thinking about risk. Each agency followed its own procedure with a mind to its own purpose, for  example the police investigated the allegations of drug activity, but on finding insufficient evidence  of criminal intent, failed to consider the incident as a possible indicator of parental neglect or in  terms of risk to a child; when the school raised concerns they were advised by Children’s Social Care  to follow their own procedure with regard to suspicions of drug abuse.  9.28 From interviews with staff it seems likely that the prevailing mindset about this family was that Andrew would be OK if he attended school. This was not in itself an unreasonable view as we know  that access to education can be a factor in promoting resilience in children. The difficulty was that  the mindset became fixed and did not allow for the underlying causes of his difficulties, the concept  of parental neglect or risk to Andrew to be properly explored.    9.29 A recent SCR published by Bath and North East Somerset, in respect of David A18 contributes to  learning in this case and provides a relevant analysis of services provided to a child who died by his  own hand, aged 14 years. The Review considers themes similar to those in this case including  describing a “single cause mentality” with each agency concentrating on their own single  issues and a lack of understanding of the “multi causal effect” reiterating the need for consideration  of the interplay of factors.    Management Oversight   9.30 Throughout the working of this case each agency had access to management oversight,  supervision  (Children’s Social Care) or access to a Specialist Safeguarding Advisor (Police, Health and Education  services)  Dorset Serious Case Review S11 Page26   9.31 During the time Children’s Social Care was working with this family the department was  going  through some change and the social worker had 4 different line managers. However supervision was  available and this case was discussed from time to time in line with policy. Time constrains do not  allow for every case to be discussed in every supervision session and because this case was not seen  as exceptional, it was not given any special priority. The report from the chronology author, who  looked at the social worker’s supervision notes, indicates the case was discussed but there was no  analysis of Andrew’s circumstances and no risk identified.  9.32 The Police Safeguarding Advisors were surprised they had not been consulted about the  case. The  reason appears to have been that the officers who investigated the individual incidents, Andrew’s  first drug overdose and his assaults, were solely concerned about whether a crime had been  committed and didn’t consider whether Andrew might be a child at risk of harm. Maintaining all  officers  awareness and knowledge of child protection is a constant challenge for the police  service and awareness raising and understanding of the Dorset Child Protection Procedures is  a  consistent feature of their training.   9.33 Only two practitioners from the various health services took advantage of safeguarding advice.  Other health workers didn’t see the need to access advice because  Children’s Social Care were  already involved and lines of communication were open and also because this case was not  seen as a “child protection case” workers didn’t see the need for additional  advice.   9.34 When other agencies raised the possibility of implementing the Child Protection Procedures  they were told by Children’s Social Care the case didn’t meet the threshold and they didn’t  challenge this view.   9.35 Supervision therefore, although available and providing support for the workers in difficult  circumstances, didn’t provide adequate objective oversight or challenge.     9.36 In discussion during the Learning Events, it became clear to participants that despite the  problems of differing thresholds, professional challenge is to be encouraged.    Dorset Health Care Trust‘s Safeguarding Policy24 supports this, it states:     “The lack of understanding about what to do when differences in professional opinion arise   has been a finding in both Local and National Serious Case Reviews. As a result of    multi-agency protocol was released in April 2011 to address this. If professionals have a    concern over the handling of identified risks they can contact the      Safeguarding Children Service to discuss their concerns and seek resolution.”   9.37 The multi-agency dispute resolution protocol25 can be found on the Dorset Safeguarding Children  Board’s web site and is  currently under review.      Joint Consultation  9.38 In considering learning from this case, all the practitioners were interested in developing the concept  of multi-agency consultations, particularly in complex cases when there are different views about  thresholds or when families are service resistant. How this would work in practice needs further  consideration from the DCSB.  Dorset Serious Case Review S11 Page27    Use of Chronologies  9.39 Social Care practitioners do use chronologies and there was one in this case although it wasn’t effective in informing assessment and planning.   9.40 As well as noting incidents in an easy to access format, the combined chronology prepared  for this  review highlights some interesting patterns for example Andrew’s first overdose took place just  after the birth of his half brother, he was seriously assaulted almost on the anniversary of his first  overdose, he became particularly depressed around mothers day, his fatal overdose occurred near  mothers day when his mother was pregnant with his second half sibling.    9.41 A Children’s Social Care Management circular26 provides some guidance on the use of chronologies  and states their purpose as:    “To record and organise factual information… to help the worker and/or manager to    analyse the impact of events on the child and identify any patterns.”   9.42 The document goes on to suggest examples of the type of activity to be included with an  emphasis on agency activities.   9.43 This case demonstrates that greater emphasis on significant events in a young person’s life  rather than on professional interventions adds insight into their life experience and is vital  element of an effective assessment. The guidance would be improved by being updated to  reflect current thinking.    Andrew’s wishes and feelings  9.44 Studies of interventions with teenagers show that young people often present in a way that  means we stop thinking about them as children in situations of neglect. It is interesting that in this  case, Annabel was seen as more vulnerable as a younger, female child being raised by a male lone  parent. This raises questions of how gender as well as age influences perception of risk.    9.45 Although Andrew was just 13 when he first came to the attention of Children’s Social Care, he has  consistently been described as big for his age and appearing to be a physically mature child. There  were references in the chronology to Andrew’s “self neglect” and an over-emphasis on Andrew as  responsible for his own care. There were also references in multi-agency meetings to “neglect by  default” an ambiguous term which detracted attention from the seriousness of the children’s  situation.  9.46 It is probable that Andrew’s ability to articulate his views and his determination to sort out his own  problems and not to be parted from his father also masked his vulnerability. In addition, when  Andrew was visible, attending school, engaged with CAMHS  or seen by health workers or the social  worker, he didn’t stand as out as being particularly different or more vulnerable than his peers.  9.47 Neglect of young people is a feature of Serious Case Reviews. In  2013, the NSPCC list 27 SCR’s of  which 11 feature children over 11 years of age27.   9.48 The Ofsted Report, Ages of Concern looked at Serious Case Reviews carried out between 1st April  2010 and 31 March 201128. It concludes that:  Dorset Serious Case Review S11 Page28     “Of the 150 children, 69 children died. The other 81 were involved in serious incidents   which resulted in a decision by the Local Safeguarding Children Board to carry out a   serious case review. The age profile of the children …shows that …the majority of the children   were five years old or younger at the time of the incident. Fifty-one children were under   one year old. A more detailed analysis of the older children shows that 28 young people were   14 years or older.”    9.49 It goes on to say:    “In the cases involving young people over the age of 14 there is a recurring message that, in   different ways, professionals had not treated the young person as a child in need. The failings   included those instances where:   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 children,    because of confusion about the young person’s age and legal status or a lack of age-  appropriate facilities.“  9.50 The Pan Dorset Neglect Guidelines address this issue and were drawn up in response to a  Serious Case Review (Family S3) 29  which involved the neglect of two children aged 8 and 16  years old. It draws attention to the risk of “drift” and “start again syndrome” and provides  some useful practice guidance.   It says:   “…serious neglect of older children and adolescents is often overlooked, on     the assumption that they have the ability to care for themselves. Make sure     your risk assessment focuses on the age of the child. Ask the question “what is     it like for this child to live in this family/environment?”  9.51 The Guidelines draw attention to the usefulness of graded scales to give an objective measure of the  care of children, for example the Salford Graded Care Profile30. In this case objective measurement  would have been helpful in identifying whether there were indications of neglect and in addressing  the subjective views of some practitioners about whether teenagers themselves can decide on an appropriate level of self care.     Risky Behaviours   9.52 Dorset Child Protection Procedures address what to do about concerns about sexual exploitation,  children missing from home or care and drug and alcohol misuse but contain no specific  guidance on  how to  address teenage risky behaviours such as self harming, suicidal ideation  and risky sexual  behaviours.  9.53 Practitioners identified that a high number of young people demonstrate these kinds of  behaviours  and that it isn’t easy to distinguish those who need additional help.   9.54 It’s debateable whether new guidance would help or confuse workers. However the DSCB  should satisfy itself that practitioners are clear about what constitutes risk, how to assess risk and Dorset Serious Case Review S11 Page29   protective factors, particularly in older children who may be a risk to themselves and guidance about  effective interventions is available.    Understanding of Child Protection   9.55 There were numerous occasions when Mr Walker was warned about the possibility of implementing the Child Protection framework but this appears to be have been seen by practitioners as a tool to  try and engage the family rather than an expression of concern. This had some short lived success as  staff report one of the reasons the procedure was not used was that the case hovered on the  threshold of intervention, with periods of improvement just adequate to prevent action.  9.56 The family perceived the possibility of child protection intervention as a threat and  synonymous with removal of the children. It is likely that this intermittent “threat” undermined any  likelihood of building an effective relationship with Andrew or Mr Walker.   If Child Protection Procedures had been implemented would this have made a difference?  9.57 This question was raised by some of the practitioners during the Learning Events.  9.58 Neglect Matters, A Multi agency-guide for Professionals Working Together on Behalf of Teenagers31,  provides useful information about potential consequences of neglect of older children, including  anxiety, depression and proneness to suicide, anti-social behaviour and violent conduct. It describes  effective interventions and a useful framework for working with teenagers and their families.      9.59 A study commissioned by the DSCB and carried out by Bournemouth University on the impact of  using the Child Protection procedures showed that “the majority of respondents to their surveys  agreed that the child protection process has made a positive difference to the family” this included  88% of parents and guardians surveyed. 32  9.60 Using the Child Protection process encourages a mindset which is open to thinking about a parent’s  capacity to meet a child’s needs and the impact on children if those needs are not met.    9.61 The Child Protection framework also encourages workers to think about the balance between  providing support and exercising authority, which is vital in working with families who are resistant  to intervention.   Practice Developments  9.62 Continuing professional development has been a priority for DCSB and in addition to the  planned work, publication of a local Domestic Homicide Review33 which looked at the history of a  teenager who went on to commit a serious crime, has prompted attention to be given to the  concept of teenage neglect.   9.63 A conference specifically on teenage neglect is planned for the Spring of 2014 which will contribute  to the consolidation of learning from this case.   9.64 Individual agencies have made a number of improvements in practice. In Children’s Social  Care, assessment and care planning has become more robust with improvements in the way  information is recorded and children are assessed individually and have separate plans.  Dorset Serious Case Review S11 Page30   9.65 Practice development is supported by “Developing Confident Practice in Child Safety in Dorset”34 a  DSCB initiative designed to assist in implementing the “Munro Agenda.” The document reiterates  Munro’s thinking and states:    “Local Authorities and their partners should start an ongoing process to review and    redesign the ways in which child and family social workers deliver services, drawing on    evidence of effectiveness of helping methods where appropriate and supporting practice  that   can implement evidence based ways of working with children and families.”  9.66 The concept is that Dorset will adopt a new model of risk assessment which is evidence  based and  outcome focussed.  Work has begun to implement the new thinking and will continue to roll out  through 2014.   9.67 Other practice changes are: � The Early Intervention Service have introduced a new protocol on non school attendance � CAMHS have a local link with Children’s Social Care to work together and provide services for care leavers, looked after children and children who are to be adopted.  Plans are being discussed to build on these practices. � Schools and PRUs are working together with parents of children on the Fast Track programmes to improve school attendance     What Needs to be Done  9.68 This case adds to the ongoing learning about the difficulties of assessing and working with teenagers  and their families, especially when they are resistant to intervention. In addition to the practice  developments which are in place, the DSCB should consider reviewing the relevant sections of the  Pan Dorset Procedures to ensure the practice guidance reflects current thinking and staff  have sufficient guidance on working with teenagers.  9.69 Monitoring the quality of assessment and planning for teenagers, particularly if within the  Child in Need Framework, will reassure the DSCB that learning is being integrated into day to day  practice.      23. Serious Case Review, Bath and North East Somerset LSCB, in respect of David A, Reconstruct, September 2013 http://www.bathnes.gov.uk  24. Dorset Health Care Trust‘s Safeguarding Policy  http://www.dorsethealthcare.nhs.uk      Dorset Serious Case Review S11 Page31   25. Dispute Resolution Protocol, Dorset DCSB http://www.dorsetlscb.co.uk/site/wp-content/uploads/2009/12/Dispute-Resolution-Protocol-April-2011-pdf  26. Dorset Children’s Services Management Circular, Children and Young Person Chronologies, 2010  27. NSPCC Serious Case reviews published 2013  http://www.nspcc.org.uk/Inform/resourcesforprofessionals/scrs/serious_case_reviews_2013_wda94557.html   28. Ages of concern: learning lessons from serious case reviews, A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to31 March 2011   http://www.ofsted.gov.uk/resources/ages-of-concern-learning-lessons-serious-case-reviews  29. Dorset Children Safeguarding Board, Pan-Dorset Multi-Agency Child Neglect Guidance on the recognition, assessment and management of neglect  https://www.dorsetlscb.co.uk/site/wp-content/uploads/2009/12/Chapter-3.16-Multi-Agency-Child-Neglect-Guidance.pdf  30. Salford Graded Care Profile The Graded Care Profile (GCP) was developed as a practical tool to give an objective measure of the care of children across all areas of need by Drs. Polnay and Srivastava. The profile was developed to provide an indication of care on a graded scale. It is a descriptive scale. The grades indicate quality of care and are recorded using the same 1 to 5 scale in all areas. Instead of giving a diagnosis of neglect it defines the care showing both strengths and weaknesses as the case may be. It provides a unique reference point. Changes after intervention can demonstrably be monitored in both positive and negative directions. It can be used to improve understanding about the level of concern and to target areas of work as it highlights areas of greater risk of poorer outcomes. It is useful in all cases where neglect is identified as an issue.   http://www.salford.gov.uk/graded-care-profile.htm  31. Neglect Matters, A Multi agency-guide for Professionals Working Together on Behalf of Teenagers Leslie Hicks and Mike Stein, University of York, published by the DCSF (now the DfE) 2010 http://www.york.ac.uk/inst/spru/research/pdf/NeglectMatters.pdf  32. The Heart of the Work, Review and Evaluation of Child protection Processes and Systems, Bournemouth University commissioned by Bournemouth and Poole and Dorset Safeguarding Children Boards, July 2013  33. Domestic Homicide Review, DCSB, to be published 2014  34. Developing Confident Practice in Child Safety in Dorset, Dorset Children’s Social Care, 2013  The Munro Review of child protection is part of a national drive to improve the quality of child protection services, it is based on the work of Professor Eileen Munro and has become known as the “Munro Agenda.”   Dorset Serious Case Review S11 Page32  10. YOUTH MENTAL HEALTH AND SUICIDAL IDEATION      SUMMARY OF FINDINGS  • Health assessments were not used by other agency in planning interventions • Insufficient weight was given to Andrew’s early history and environment  • The threshold for CP intervention was not clear or shared by all agencies  • Family based intervention was not considered as an option • The term “Suicidal Ideation” and the implications were not fully understood by staff    SUMMARY OF LEARNING  • Investigation into the underlying causes of a young person’s distress is likely to lead to more effective intervention • Seeking “formulation” will assist in effective multi-agency working • Self harming and suicidal ideation is an indication that a child is at risk of harm and consideration should be given to the relevance of a Section 47 investigation • Multi agency working and sharing of information is vital for effective assessment and intervention      10.1 Andrew first came to the attention of the health services when he was admitted to hospital  having taken an overdose of his father’s medication. He gave varying accounts of his intentions     telling some staff that he was fed up and suicidal and others that it was an impulsive act and he was  experimenting with the effects of the drugs.   10.2 A timely Deliberate Self Harm Assessment (DSHA)35 was carried out which concluded Andrew’s risk  of further harm was “low to medium.” He was discharged with a plan for follow up by CAMHS. The  assessment noted previous indications of self harming of different ages and that the overdose  took place a few weeks after Andrew’s mother had given birth to a new  baby.  10.3 Services at this point were relevant and timely.    10.4 A referral was made to Children’s Social Care although neither the hospital staff, CAMHS or the  police requested a strategy discussion and Section 47 Child Protection investigation.    10.5 In the New Year following Andrew’s overdose Children’s Social Care visited and completed  their Initial Assessment and Child in Need Plan, CAMHS made efforts to engage with Andrew and  begin some therapy.   10.6 It became clear to the CAMHS worker that this was going to be difficult and it took 3 months,  until March 2012, for Andrew to have his first appointment. The initial plan was  that he would be  seen fortnightly but he missed lots of appointments. He had 11 meetings with the CAMHS  worker in just over a year, his last appointment was April 2012. (Just over a year before Andrew  died)  10.7 The CAMHS team use a model of assessment which records information about the young  person’s history, mood and family circumstances. In this case however, CAMHS’ delay in starting Dorset Serious Case Review S11 Page33   work with Andrew meant they had little to contribute to the CIN plan which didn’t address the risk  of self harm beyond stating that as a result of the overdose incident, Andrew (and Annabel)  needed to be kept “safe from harm.”  10.8 The CAMHS worker tried various methods to persuade Andrew to keep his appointments,  including changing the appointment schedule and venue.  The intermittent nature of the  meetings made it difficult to delve deeply into Andrew’s history.   10.9 During contacts with CAMHS Andrew disclosed suicidal thoughts on several occasions including  around significant anniversaries. At other times, Andrew expressed the view he was fine, had  periods when he presented as sociable and popular and described himself as having lots of  friends. (This might have been a reflection of his interest in Facebook)  10.10 In January 2011, it is interesting to note that Mr Walker arranged a referral for Annabel to  CAMHS in a response to what seemed to be fairly typical teenage behaviour. Her name was  placed on a waiting list but she moved back with her mother before she began treatment.  Since she returned to her mother she has shown no indications of any mental health problems and  is attending school. It is possible that Mr Walker was projecting some of his own issues on to Andrew  and some family members remain convinced that Andrew didn’t have any mental issues at all but  that his problems were entirely due his environment.  10.11 However, in August 2011 Mr Walker requested Andrew (aged 13) be seen by a psychiatrist and an  appointment was arranged with Andrew’s agreement. The psychiatrist described Andrew’s low  mood and thoughts of self harm and “discernable levels of self neglect.”  This may have been part  of a medical diagnosis and the practitioner has since retired from practice preventing any  exploration of the term. It is also possible this was another example of placing inappropriate  responsibility on Andrew for his own care and a missed opportunity to explore whether there were  any concerns about parental neglect.   10.12 Andrew was prescribed medication and his mood appeared to improve. NICE Guidelines36  approve this form of therapy for young teenagers if accompanied by a “talking therapy” and  subject to proper medical oversight.   10.13 When the original psychiatrist retired in early 2012, his replacement failed to engage with  Andrew and Andrew didn’t attend any more appointments. This meant he continued to be  prescribed the medication by his GP without the supervision of the consultant psychiatrist who  subsequently discharged Andrew from his care.  10.14 The psychiatrist and the GP were both aware that continued prescription contravened the  guidelines. The GP weighed up the situation and, on balance, decided it was in Andrew’s interests to  continue with the medication. The GP was aware that Andrew was seeing CAMHS although he  didn’t know that appointments were irregular or that CAMHS decided to withdraw and close the  case in the Summer of 2012.  10.15 On the basis that it would not be helpful for Andrew to have too many people involved with  him, the GP kept a low profile. In practice Andrew only saw the GP four times, all during 2011. This  meant Andrew was prescribed anti-depressant medication for about 12 months  without any medical  oversight.   Dorset Serious Case Review S11 Page34  10.16 Although the reasons for this situation are understandable, those concerned with this case are  clear this practice is unacceptable and it has now changed. With regard to the prescription of anti- depressant drugs to children under 16, the Dorset Clinical Commissioning Group37 are clear that   these must be prescribed by a consultant psychiatrist and prescriptions are now subject to a  formal four monthly review.    Multi-Agency Working   10.17 In this case, Andrew’s mental health problems had a significant impact on all aspects of his  daily life, led to his self harming, depression, periods of isolation and withdrawal and spending  weeks in his room.  10.18 During the period of this Review there was evidence that agencies were talking about the  difficulties and what they could do to help. There is evidence of letters being sent between health  professionals and school, discussions about engaging the family and the possible need to  implement the Child Protection procedures. Information was shared but not analysed to any  effect.   10.19 Communication was less frequent in the Summer of 2012 when CAMHS and Children’s Social Care were both planning to close the case. There is no formal protocol which directs agencies to inform  each other when a case is to be closed. Had the CIN plan been robust and reviewed regularly this  would have provided a platform for more effective sharing of information.  10.20 Children’s Social Care followed their procedure and convened a Team Around the Child (TAC)  meeting prior to closing the case but neither CAMHS, nor EIS who were expected to pick up the  work, were invited. This was not a deliberate decision but partly an administrative error and also an  indication of so called “silo mentality” which occurs when agencies are preoccupied with their own  agenda and don’t share information effectively.    10.21 Effective multi-agency working was also hampered by a lack of understanding among, for example,  education and children’s social care of the implications of Andrew’s mental health difficulties.  Conversely, the practitioner Learning Event showed that mental heath staff were unclear  about risky behaviours and the links with Child Protection.   Mental Health and Education  10.22 Based on Andrew’s history, the psychiatrist wrote a letter to education indicating Andrew  couldn’t cope with main stream school and referring him for education at the PRU for a period of  three months.   10.23 Andrew was given a place at the PRU on the basis of this medical referral.  (Some children are placed  at the PRU because of emotional and behavioural difficulties and others on medical grounds.)   10.24 After Andrew started at the PRU, health issues were a commonly quoted reason by Andrew or Mr  Walker for Andrew’s not attending school. On several occasions education services threatened to  take legal action against Mr Walker for the persistent non attendance. Exploration of why legal  action was never taken indicated that staff at the PRU felt that prosecution was not an option if a  child had been referred on medical grounds. In Andrew’s case the problem was compounded by Mr  Walker’s own mental health problems.    Dorset Serious Case Review S11 Page35  10.25 Andrew’s medical referral for education covered a three month period, up to March 2012, after  which the psychiatrist recommended Andrew’s gradual reintegration into mainstream school.  It is  notable that there was no follow up or plan about what to do next and, a year later, efforts were still  being made to get Andrew to attend the PRU.  It seems that the difficulty in engaging with Andrew  and his father meant the focus of the PRU was making contact with the family and repeated  efforts at getting Andrew to attend without considering the complex underlying reasons for his  behaviour or seeking further medical advice.   Suicidal Ideation 10.26 Suicidal Ideation (SI) is described as thoughts about taking one’s own life with some degree of  intent. If a young person shows signs of SI this does not necessarily mean that they are at  imminent risk, but current practice would indicate that further assessment is needed. SI needs to  be taken seriously and an assessment made by a suitably qualified clinician who should assess the  plan, motivation, and level of intent to determine if any intervention is needed. 10.27 Although we don’t know if Andrew took his own life deliberately, there are several references to  suicidal ideation in the chronology. In the work which was done with Andrew and his family,  addressing the suicide risk appears to have been seen as solely the responsibility of the health  professionals.  10.28 The combined chronology describes a limited understanding of the term “suicidal ideation”  among other staff and a general use of the term “incident” to describe Andrew’s first overdose and  subsequent self harming behaviours which had the effect of minimising their importance. 10.29 All agencies commented that there are a significant number of young people who engage in risk  taking behaviours including self harming. The ward where Andrew was treated in December 2011  admits approximately 2 young people every week. This creates a difficulty, particularly for non  health staff, in identifying which young people are at risk of suicide or further harm. 10.30 Teenage suicide appears to have become an increasingly common theme in Serious Case  Reviews. In Dorset, since 2009, there have been 5 other deaths of young people age between 12  and 17 who have lost their lives as a result of their own actions. In the 3 which have been  reviewed, 1 featured poor school attendance and 1 was identified as “hard to reach.” The Dorset  Child Death Overview Panel (CDOP)38 continues to review these cases.  What Needs to be Done  10.31 It was clear from the practitioner Learning Event that some health staff had a good knowledge of  the risk factors and protective factors which influence the likelihood of suicide in young people.   10.32 However in this case, although CAMHS and the psychiatrist had been working with Andrew there  was no effective forum for their assessments to contribute to the overall planning. This meant that  individual agencies did not fully consider the implications of the mental health diagnosis and  whether or not Andrew was exhibiting suicidal ideation and the health staff did not have any  detailed information about contributing factors such as family relationships and parental mental  health.    Dorset Serious Case Review S11 Page36  10.33 Clinical case formulation39 aims to develop a shared understanding of a mental health diagnosis or   presentation which is collaborative, which draws on family history, social, cultural and biological  factors and uses language which is easily understood by everyone. A formulation summarises  assessment findings in a way that helps young people and the families to make sense of their  difficulties and can be useful in guiding therapy.  10.34 In Dorset, CAMHS are already working in some areas to promote the use of formulation in cases  where several practitioners from different agencies are working with a young person with mental  health difficulties and to encourage social workers and education staff to be proactive in asking for a  formulation.   10.35 Rolling out this work would assist  agencies working with young people who are self harming or  expressing suicidal thoughts and help them  to respond appropriately and be confident in their  abilities to assess the level of risk. This would then lead to more effective consideration of risk and  if it is appropriate to use the Child Protection procedures.       35. Deliberate Self Harm Assessment (DSHA) Deliberate self harm is a term used to describe episodes of intentional self injury that do not lead to death or may not have been motivated by a desire to die. Individuals can self-harm in many ways including taking too many tablets, cutting their body or burning themselves. Deliberate Self harm Assessments take into account social, emotional and medical information to determine the level of risk of suicide or further harm and to help plan future work.   36. NICE Guidelines   _ see reference 16  37. Dorset Clinical Commissioning Group29 is led by GP’s who have joined together to buy, change and ensure the quality of services available to their patients and the community. Its statutory duties are set out in Working Together 2013.  38. Child Death Overview Panel (CDOP)  The Child Death Overview Panel (CDOP) is a multi agency group responsible for reviewing all child deaths. The  Panel is a sub group of the Local Safeguarding Children Boards. The deaths of all live-born children 0-17  (excluding infants live born following planned, legal terminations of pregnancy), are reviewed by the             Child Death Overview Panel in line with statutory guidance.  39. A “formulation” normally includes a summary of the child’s (or adult’s) difficulties, how they relate to each  other, how they developed and what might be maintaining them. It is based on current psychological  knowledge and practice. Protective factors in the young person’s environment, family or personal  qualities are usually included in the formulation. The formulation may be revised in the course of the work (re-formulation) as new information emerges and further insight is gained into the young person’s circumstances and perceptions.     Additional resources   Talk to me, The National Action Plan to Reduce Suicide and Self Harm in Wales 2009-2014  http://www.publicmentalhealth.org/Documents/749/091102talktomeen.pdf    Dorset Serious Case Review S11 Page37  11.  ADULT MENTAL HEALTH AND IMPLICATIONS FOR PARENTING    SUMMARY OF FINDINGS  • There was insufficient information about Mr Walker’s diagnosis and the impact of his mental health on his parenting capacity • The impact of caring for a parent with health problems was not included in the assessments of the children   SUMMARY OF LEARNING  • When a parent has mental health problems it is vital to understand the impact that has on their parenting capacity • Practitioners would value a tool to assist in information gathering and analysis    11.1 The evidence indicates that Andrew’s father had long standing mental health issues and  everyone  working with the family was aware of this. Mr Walker had a number of diagnoses over the  years and had been prescribed a range of medication. He had also been  in possession of additional  medication not prescribed to him. Mr Walker has a good grasp of mental health symptoms and  treatments having, some years ago, studied the subject with a view to training as a practitioner.   11.2 For those working with the family, Mr Walker’s mental health was given a lot of consideration; in  particular it was seen as a major factor in his difficulties in engaging with services. This led to staff  accommodating his needs and persistently trying a range of methods of communication as he  expressed his anxieties and preferences for indirect methods such as texting and email.  11.3 Mr Walker’s requests for services for himself were noted and efforts were made to help him  engage with services, although in practice he never did.    11.4 The Pan Dorset Inter-agency Safeguarding Procedures, chapter 3, Joint Mental Health, Substance  Misuse and Childcare Protocol (Dec 2010)40 makes it clear that:      “For the purposes of safeguarding children, the mental health or mental illness of the     parent or carer should be considered in the context of the impact of the illness on the     care provided to the child. “  11.5 It goes on to say:      “If there are concerns relating to the parent’s needs and no other services are    involved, the parent’s GP should be contacted, by the Children’s Social Care     practitioner in the first instance , for his/her view of the family situation.”   11.6 In this case Children’s Social Care did seek the views of the GP about Mr Walker’s ability to  parent the children but this did not help as the GP was not in a position to comment on Mr  Walker’s parenting capacity.  A more effective enquiry would have been about Mr Walker’s  diagnosis and medication and the impact of this on his behaviour. This information could  then have been included in the Core Assessment along with analysis of the likely impact on Dorset Serious Case Review S11 Page38   parenting and risk. This would also have assisted in deciding how best to engage with Mr Walker and  how to accommodate his anxieties.   11.7 It is an accepted view among mental health workers that children generally cope better if they have  an understanding of their parent’s diagnosis. There was some discussion among practitioners in this  case about whether Mr  Walker was projecting his own symptoms on to  Andrew (and Annabel) and  evidence that Andrew was anxious about whether he was becoming like his father. If one of the  workers had been able to reach an understanding of Mr Walker’s diagnosis and share this with  Andrew, then this might have dispelled some of his anxieties.   What Needs to be Done   11.8 This case has already prompted developments in practice aimed at improving communication  between children’s social care and adult mental health services with a view to developing the social  workers knowledge and confidence to ask appropriate questions of adult mental health workers.    11.9 For this to be effective adult mental health workers must be prepared to share information.   11.10 Effective communication should be about diagnosis, the effects of medication, formulation and also  about the individual’s behaviour and prognosis for change. This information can then be used by the  children’s social worker to inform their assessment and care planning for the children and family.   11.11 Where there is any change or non compliance, the DNA policy should be enforced along with the  treatment plan or, if the case is to be closed, the worker should discuss this with Children’s Social  Care who will assess the impact of the information on their assessment.   11.12 During the Learning Events staff welcomed the prospect of closer working relationships between  adult’s and children’s services and meetings have been held at a local level to discuss some specific  cases.  It is planned to roll this initiative out county wide although further work is required to  develop a protocol and shared understanding of the purpose of the work.   11.13 The DSCB should consider reviewing the Safeguarding Procedures to ensure they provide  clear guidance about the need to share information when a parent is known to have mental health  difficulties.          40. The Pan Dorset Inter-agency Safeguarding Procedures, chapter 3, Joint Mental Health, Substance Misuse and  Childcare Protocol (Dec 2010)  http://www.bournemouth-poole- lscb.org.uk/interagency_safeguarding_procedures/pictures/content213/childcare_protocol_update    Additional Resources  SCIE eLearning: Parental Mental Health and Families, Published 2011  http://www.scie.org.uk  Dorset Serious Case Review S11 Page39  12. CONCLUSION  12.1 The predominant feature of this case is the challenge of working with a hard to reach young person  whose vulnerability and neglect was never fully acknowledged.   12.2 As the Pan Dorset Neglect Guidance states:      “…serious neglect of older children and adolescents is often overlooked, on     the assumption that they have the ability to care for themselves. Make sure     your risk assessment focuses on the age of the child. Ask the question “what is     it like for this child to live in this family/environment?”  12.3 There is a wealth of research and practice guidance available for practitioners which explores  effective methods of working with young people and how to achieve the best outcomes. In the  course of this Review all staff participated willingly in the opportunities for learning and there have  already been some developments in practice which will assist them in the future.   12.4 Significant developments include: � Children’s Social Care have strengthened their assessment and care management processes and are introducing reflective practice into their work � From April 2014 there will be a new structure in place which includes a practice improvement post, the purpose of this is to ensure quality standards are met and strategy and plans for practice improvement make a real difference to children’s lives � The Early Intervention Service is now established and has an improved protocol to address non school attendance,  � There have been some useful links made between CAMHS and children’s services and adult and children’s services  � Dorset Clinical Commissioning Group are working to ensure prescription practice regarding the prescription of anti-psychotic and ant-depressant drugs for children always follows the NICE guidelines and is closely monitored  12.5 Teenage neglect is already on the DSCB’s practice development agenda and a number of initiatives  to improve practice are in place or being considered. These include improving guidelines for  assessment of teenagers and reviewing the safeguarding procedures to ensure they are clear and  up to date and provide sufficient guidance for working with older children.   12.6 The guidance on use of chronologies and communication between children’s services and  adult mental health services also needs reviewing.   12.7 A key area for further development is how to manage service resistant families and although  practitioners shared ideas about how services can be improved, there is work to be done on how  outcomes can be achieved.  12.8 The Learning Events provided an opportunity to reflect on the benefits of effective multi-agency  working, particularly of information sharing in assessment and care planning. Innovative thinking  produced ideas about promoting the use of “formulation” to contribute to assessment and the  possibility of joint consultation on complex cases.   Dorset Serious Case Review S11 Page40  12.9 Findings from this review will contribute to the development agenda and the DCSB is key to  implementing and evaluating the practice developments.   12.10 Questions for the DSCB to consider are:  a)   The Pan Dorset Inter-agency Safeguarding Procedures provide useful practice guidance for  staff, can the DSCB satisfy itself that staff are aware of the Guidance, that there is a shared  understanding of the roles and responsibilities and it is used appropriately?  b)    Can the DCSB satisfy itself that member organisations have satisfactory arrangements in  place for supervision and access to specialist advice and that professional challenge is an  accepted part of child protection practice?    c)   Can the LSCB satisfy itself that staff are well equipped and well supported in identifying and  developing strategies for intervention with service resistant families? Should  consideration be given to adopting a “service resistant” or “hard to reach” protocol to  encourage early recognition of the problem and independent oversight of a strategy for  intervention?   d)   Is the incidence of self harming and teenage suicide significant enough for the DSCB to   consider work on a prevention strategy?   e)   Is further work required to ensure there is effective sharing of information between adult and  children’s services when parenting capacity is being assessed?    13. FINALLY   13.1 Andrew was much loved by his family and is sadly missed.  It is the intention of this Review that  services will continue to improve for other young people who may need help in the future.      Karen Tudor Overview Author February 2014          Dorset Serious Case Review S11 Page41  APPENDIX 1   The Local Safeguarding Children Boards Regulations 2006 Regulation 5, Functions of LSCBs  5.  (1) The functions of an LSCB in relation to its objective (as defined in section 14(1) of the Act(1)) are as follows—  (a) developing policies and procedures for safeguarding and promoting the welfare of children in the area of the authority, including policies and procedures in relation to— (i) the action to be taken where there are concerns about a child’s safety or welfare, including thresholds for intervention; (ii) training of persons who work with children or in services affecting the safety and welfare of children; (iii) recruitment and supervision of persons who work with children; (iv) investigation of allegations concerning persons who work with children; (v) safety and welfare of children who are privately fostered; (vi) co-operation with neighbouring Children’s Social Care authorities and their Board partners; (b) communicating to persons and bodies in the area of the authority the need to safeguard and promote the welfare of children, raising their awareness of how this can best be done, and encouraging them to do so; (c) monitoring and evaluating the effectiveness of what is done by the authority and their Board partners individually and collectively to safeguard and promote the welfare of children, and advising them on ways to improve; (d) participating in the planning of services for children in the area of the authority; (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1)(e) a serious case is one where—  (a) abuse or neglect of a child is known or suspected; and (b) either— (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. (3) An LSCB may also engage in any other activity that facilitates, or is conducive to, the achievement of its objective.    