Death of a 14-year-old boy in February 2016, initially thought to be due to suicide but, before the review was completed, an inquest determined the cause to be misadventure. Martin was an adolescent with mental health needs. His parents separated following domestic abuse by the father; the mother moved to London from a rural location to live with a new partner and two teenage daughters who had experienced a troubled childhood. Martin received special education provision, first from a home tutor and then in a special school outside the borough. Although there were worrying concerns about his emotional wellbeing at home and school in December 2015, a referral to children's social care was not made. Issues identified include: the challenge for professionals working with families where members have a range of complex needs; lack of coordination in provision of services across local authority boundaries; specific practice issues were found which highlight the dilemmas faced by front-line practitioners when exercising professional judgement in their safeguarding practice. Recommendations include: to strengthen the sharing of information to ensure a whole family approach when working with children in complex, blended families; to re-launch the CAMHS pathways within the borough; to review the effectiveness in which Education Health and Care plans are shared with health professionals; for the London Safeguarding Children Board to work with organisations across London to mitigate the risk to children where there is a lack of clarity associated with localised commissioning arrangements; and partner agencies should be asked that contracts with service providers include an expectation that they should fully participate in any serious case review process.
      
    Serious Case Review No:  2017/C6635  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.     A Local Safeguarding Children Board  in London    Serious Case Review  Martin   Report Author  Jane Wonnacott  MSc MPhil CQSW AASW Lead Reviewer      Page 2 of 19 Contents 1. INTRODUCTION 3 2. THE SERIOUS CASE REVIEW PROCESS 3 3. FAMILY BACKGROUND 5 4.    MARTIN 6 5. INVOLVEMENT WITH SERVICES BEFORE MOVING TO THE LONDON       BOROUGH 6 6. INVOLVEMENT WITH SERVICES IN THE LONDON BOROUGH                  7  7.   REVIEW FINDINGS                                                                                         13                      Page 3 of 19 1. INTRODUCTION 1.1 This serious case review was commissioned by a Local Safeguarding Children Board in London following the death of a 14 year old boy (known throughout this report as Martin) who was found dead at his home. Initial reports were that Martin’s death was due to suicide, he was known to have experienced family disruption and there were concerns that agencies had not worked effectively together to support the family. As a result, the chair of the Local Safeguarding Children Board decided that the case met the criteria for a serious case review1.    1.2 Before the review was completed an inquest determined that the cause of Martin’s death was misadventure.  1.3 Due to the particular circumstances of Martin’s death, the presence of surviving siblings in the family, and the expectation that review reports will become a public document, this document contains minimal details about specific family members from the case records. The main focus of the report is information relevant to improving services to children and their families. 1.4 In order to preserve confidentiality the names of other local authorities who have had contact with Martin are anonymised.  2. THE SERIOUS CASE REVIEW PROCESS 2.1 A lead reviewer was appointed, supported by a reference group of senior professionals from relevant agencies within the borough. As Martin had attended a special school in another London Borough, (Borough 2) the review was supported by an education representative from Borough 2. 2.2 Members of the reference group were:  Director Children and Families (chair)  Designated Doctor, NHS CCG  Designated Nurse, NHS CCG  Det. Sgt MPS Review Group  Director of Safeguarding Mental Health Trust  LSCB manager  Head of Early Intervention Service  Principal Education Psychologist   Safeguarding Children Service Manager, Children’s Services.                                                 1 The criteria for undertaking a serious case review are set out in Working Together to Safeguard Children (DfE 2015)    Page 4 of 19 2.3 All reference group meetings were attended by the lead reviewer Jane Wonnacott; an independent consultant with over twenty years’ experience of carrying out serious case reviews.  2.4 All agencies that had records of contact with Martin and his family provided a chronology of their involvement. Information was also obtained from the rural county where Martin and his family had lived before their move to London. 2.5 In order to understand professional practice from the perspective of practitioners involved with Martin and his family, the lead reviewer and a member of the reference group met with practitioners either individually or in small groups. Although much information cannot be included in a public document, all the detailed written and verbal information has been carefully considered and used to inform the final findings of this review. 2.6 Some delay was caused as a result of the need to establish expectations regarding involvement of a private education provider in the review. Martin had received home tuition from a private provider who queried whether the time involved in preparing review documents should be paid for by the Safeguarding Children Board. This was resolved without payment being made but does raise the issues about the need for clarity regarding contributions to serious case reviews in external contracts. 2.7 Family members were invited to contribute to the review and the lead reviewer met with one of the young people in the household. Although attempts were made to speak to other family members, their personal circumstances meant that it was not possible for them to contribute to the review. Some delay to the review process occurred whilst this was being established.  2.8 All information was considered by the lead reviewer and the reference group and a draft of the report was shared with all practitioners who had contributed to the review in order to check accuracy as well as hear suggestions for recommendations to be included in the final version.  2.9 The reference group provided constructive feedback and challenge to the lead reviewer during preparation of the report and were responsible for quality assuring the report before it was presented to the LSCB. 2.10 The final report was presented to LSCB in spring of 2017.        Page 5 of 19 3. FAMILY BACKGROUND 3.1 One of the issues in this case is the challenges associated with working with complex blended families. Although wishing to keep personal details to a minimum, the following table is included in order to help the reader make sense of the commentary later in the report.  Please note all names are pseudonyms.   Age in February 2016 Martin Subject of this review 14 yrs 11 months Emma Sister 7  Edward Brother 8  Mother Mother of Martin, Emma, Edward 34 David Mother’s current partner 42 Sophie David’s daughter who was living with the family in London at the time of Martin’s death 16 Hannah David’s daughter who was living with the family in London at the time of Martin’s death 15     Father The father of Martin, Emma and Edward who does not live in London.  Not known Phoebe David’s oldest daughter who does not live in London Not known  3.2 Martin was the oldest of three children and at the time of his death lived with his mother, sister, brother and the two daughters of his mother’s partner David. All members of this blended family lived in a rural county before moving to London when Martin was thirteen.  3.3 During the time that family members lived in the rural county, Martin was living with his birth mother and father and siblings. Immediately after his parents’ relationship broke up following alleged domestic violence by his father, the family, excluding Martin’s birth father, moved to London.  3.4 Also, during this period David was living in the same rural county with his daughters and their mother completely separately from Martin’s family. The two sets of siblings had no previous contact with each other and met for the first time after they moved to London.       Page 6 of 19 4. MARTIN 4.1 Martin was a young person with a number of challenges including disrupted family circumstances, a diagnosis of ADHD and other medical problems. These circumstances resulted in him attending special education provision.  4.2 There are very positive remarks about Martin in the information received for this review, which allowed the review group to see the individuality and personality of Martin as a young person, including a comment from a school that he was “soft natured and caring” and a “pleasure to have in class”. In common with many young people, when he felt comfortable with an adult he would open up and talk freely but when not comfortable could be perceived as uncommunicative. Information suggests that his relationships with peers fluctuated and at times these were positive and at other times confrontational. Relationships with the others in the family home also varied but the young person who contributed to this review has stressed that there are good memories as well as bad about life at home.  4.3 Martin experienced fluctuating moods and there were non-life threatening incidents of self-harm throughout his time in London.   5. INVOLVEMENT WITH SERVICES BEFORE MOVING TO THE LONDON BOROUGH Martin and his family 5.1 There were five occasions where Martin or his siblings were referred to children's social care and none of these referrals resulted in any ingoing involvement. 5.2 Following an education psychology assessment, Martin was in receipt of a statement of special education needs which recommended that his education needs could be best met in a specialist provision for pupils with Behavioural, Emotional and Social Difficulties. It had been noted that Martin had ADHD alongside other medical conditions and he was prescribed medication by the consultant paediatrician. 5.3 Martin started at a secondary special education college and was there for three months prior to his move to London. He appears to have settled well. 5.4 The trigger for Martin’s move to London was the breakdown in his parents’ relationship, including alleged domestic violence by his father.     Page 7 of 19 Sophie, Hannah and their family 5.5 Phoebe, Sophie and Hannah experienced a troubled childhood and were subject of child in need plans but the case was closed to children's social care after David and the girls’ mother separated. After a short time living with their mother, Sophie and then Hannah moved to London to be with their father.  6. INVOLVEMENT WITH SERVICES IN THE LONDON BOROUGH 6.1 Martin registered with a GP in the London Borough in March 2014 and the GP wrote to the paediatrician in his previous area requesting a summary of Martin’s health and medications. After receiving this information, a referral was made to the local hospital paediatric clinic in June 2014. Martin was seen in clinic in October, a family history was taken and he was referred to CAMHS. Prior to referral to CAMHS Martin’s medication continued to be prescribed by the GP as would be usual practice in these circumstances. After the CAMHS consultation the GP continued to prescribe as directed by the CAMHS psychiatrist. 6.2 The London borough adopted Martin’s statement of special education needs and whilst a suitable school could be found home tuition was arranged via a private tutoring service. Information from the service shows that Martin formed a good relationship with his tutor and made progress. When Martin alleged previous physical abuse from a family member this was appropriately referred to children's social care.  6.3 The previous local authority had alerted the London Borough’s children's social care to Martin’s move to London as well as the history of domestic abuse allegations. As a result, a London borough social worker had been in contact with Martin’s mother via telephone and was reassured that all future contact with the children’s father would be supervised. During 2014 there were further contacts with children's social care indicating Mother may need support. Concerns about the children were reduced as Mother presented as very concerned about her children and willing to take on board issues raised by any professionals she came in contact with. The question for this review is whether at any stage there could have been more attention paid to whether advice given was actually followed through2. 6.4 A place was found at a special school outside the London borough (in Borough 2) and Martin started there in July 2014. In view of the distance, the initial arrangement for travel to school was via taxi. Near the end of the school year Martin is described by the school as quickly assimilating into his peer group and was happy to talk to members of staff with whom he felt comfortable.                                                  2 “Disguised compliance” has been identified as a feature in many serious case reviews whereby parents appear to comply with plans agreed with professionals but in fact do not do so.      Page 8 of 19 6.5 Children's social care liaised with the school and also referred Martin and his siblings to a multi-disciplinary team providing early help and support to families. This referral did not result in any ongoing input at this time as although attempts were made to engage the family with domestic violence services, Mother did not engage and the case was closed.  6.6 Martin was discussed at CAMHS duty meeting at the end of October 2014 and it was agreed that the case was complex; the referral should be accepted and as he had been assessed elsewhere there was no need for an assessment appointment before offering an outpatient appointment at the ADHD clinic for a medication review. This decision was revised when Martin was not taken for his first appointment at the ADHD clinic in December and it was agreed that a full assessment should be completed as well as offering another appointment for the ADHD clinic. He was again not taken to the second ADHD appointment in February 2015 but was seen for a full assessment by CAMHS in March. The GP was unaware that Martin had not been taken to the ADHD clinic and (wrongly) assumed that CAMHS were seeing him regularly and that all was well in respect of his ADHD management. 6.7 Meanwhile, David had contacted local CAMHS regarding Sophie. This resulted in one appointment and a referral to the multi-disciplinary early help service for support. The family were unhappy about the appointment times available with the early help team and the case was eventually closed in July 2015.  6.8 Martin attended CAMHS for the full assessment in March 2015 accompanied his mother and David. This assessment was largely based on self-report. A full family history was taken and the plan was for Martin to pursue attendance at the ADHD clinic, a referral was made to the parenting service, and the ADHD parents group, (provided by the CAMHS service).  6.9 An invitation was sent for the parenting service and ADHD group but Mother and David did not attend. An issue at this stage was that the GP did not receive any information from CAMHS, was unaware of the plan and therefore could not contribute to any follow up with the family. This is particularly significant as records suggest that Martin was not taken to the ADHD medication clinic appointments in March and April.  6.10 Martin’s school were also not aware of the CAMHS referral and that there was an issue with Martin attending appointments. Consequently, during April when Mother spoke to the school’s designated safeguarding lead, regarding her concerns about Martin’s emotional wellbeing, they advised her to take Martin to the GP. If they had been aware of CAMHS involvement, information given by Mother could have been relayed directly to CAMHS with Mother’s consent.  6.11 By the end of April 2015, Martin’s school had completed ten “cause for concern” records ranging from a dirty appearance through to comments that he   Page 9 of 19 did not wish to see his father and marks on his arms. The child welfare assistant called the London borough’s children's services to request advice and from the perspective of the school they were making referral to children’s services. Within the London borough’s children’s services this discussion was treated, (in line with expected practice), as a request for advice rather than a referral since referrals, unless they are urgent, were expected to be in writing. The issue of ensuring there is a shared understanding of systems and processes across organisational and local authority boundaries is discussed further in finding two of this report. 6.12 After exploration of the concerns by the London borough social worker, including confirmation that Mother would respond positively when challenged, the advice given was that the situation did not reach the threshold for a statutory child and family assessment at that time. The school were advised to seek more clarity from Martin, speak to Mother and inform her if at any point they felt a referral needed to be made. They were also informed that they could get further support from the early help service or CAMHS.  6.13 From the school’s perspective they acted on the advice from children's social care by having some structured conversations with Martin about how safe he felt. During which he identified that his main concern was visiting his father and Mother reassured the school that this was being managed. From children's social care’s perspective there was no further contact from the school and therefore an assumption that no referral was needed.  6.14 In June 2015 Martin and his Mother did attend the ADHD medication clinic. One month’s supply of medication was prescribed with a request for the GP to continue prescribing when needed.  6.15 In July 2015 children's social care received a police notification about an incident during which Father (living in the rural county) had contacted Mother via Face Time and had made serious physical threats. The notification said that it seems the children were unaware of this incident although Mother later told CAMHS that this had been overheard by Martin.  6.16 After the summer holidays in 2015, the school describe Martin returning in September as “different”, and more streetwise. These emerging concerns were in relation to his mental health and wellbeing and consequently this was the focus of all subsequent actions by the school rather than a focus on safeguarding concerns.  6.17 In November 2015 CAMHS duty received a call from Mother with a number of worrying concerns about Martin’s emotional wellbeing at home and school. The CAMHS worker asked Mother to call the school and ask them to send the concerns to the treating psychiatrist. Mother called the school and they sent an   Page 10 of 19 e-mail to CAMHS the same day asking for Martin to be referred to a counsellor as they were not able to provide this within school.  6.18 Three days later, the CAMHS duty officer called Mother to request permission to contact Martin’s school and explained that “social services” would be contacted as well. There followed several attempts by both CAMHS and the school to speak to each other. The CAMHS worker discussed the case with the safeguarding lead nurse via e-mail who advised that a safeguarding referral should be made if the school had not already done so.   6.19 By this stage there was a sufficient level of concern for either the school or CAMHS to make a referral to children's social care. Neither did so.  6.20 During December 2015 the school continued to be concerned about Martin’s emotional wellbeing and he told a member of staff that “social services” were involved and this would cause him problems. This prompted a call from the school to Mother encouraging her to use social service support. School records note a conversation with CAMHS four days later, (again after failed attempts to speak by both parties) where they relayed their concerns. There is no record of this conversation in the CAMHS records and it is likely that it took place with a duty officer.   6.21 The London borough CAMHS called Mother offering an urgent appointment later in December 2015. An e-mail was sent to the school to inform them of the appointment and asking them to refer Martin to “social services”. The school replied via e-mail that they did not feel Martin reached the threshold for referral (based on their previous conversation with children's social care) and at this stage their main concern was for Martin’s mental health. In their view he needed targeted help through counselling and that the school could not provide this although they could provide daily mentoring. The school’s newly appointed family support worker had visited the family home at the start of December to try to source counselling via a voluntary organisation but had not been successful.   6.22 Even though the school were clearly not going to make a referral, staff in CAMHS did not follow the advice of the safeguarding lead nurse and do so themselves. There is no documented reason for this. With the benefit of hindsight CAMHS workers have suggested that one reason was that they believed the referral would not be accepted by children's social care without further information and/or the main concerns were coming from the school who did not now feel a referral should be made.   6.23 Martin and Mother were seen at the CAMHS ADHD clinic by the clinical psychologist. Martin reported that he had stopped self-harming, medication was reviewed and a further appointment was made for early February 2016 which Martin did not attend.   Page 11 of 19 6.24 Meanwhile Sophie had been referred to the children’s services multidisciplinary early help team. The content of her discussions with the clinical psychologist in that team raised concerns about tensions and potential violence in the family home. These disclosures and the family circumstances were discussed with the children's social care locality team who advised that there was “not enough risk at present to require their involvement from locality”. 6.25 By this stage it was clear that two sets of siblings had come together in the household having been previously unknown to each other and there were also concerns about possible violence and overcrowding in the family home. It was decided that family work would be a good way forward and Mother and David both agreed. As a result of this decision, the family was allocated to a family support worker in the early help team who arranged a home visit which took place early February 2016.  6.26 During January and February it came to the notice of Emma and Hannah’s school (on separate occasions) that they were experiencing emotional problems and after a referral by the GP to CAMHS Hannah was referred to the early help team who were already working with the family.  6.27 In February 2016 Martin’s school were very unhappy about the decision of the London borough’s school transport service to stop his taxi. It was their view that he was not used to public transport (this had not been the usual means of travel where he had lived previously), the journey was not an easy one and there had been no opportunity for independent travel training. They believe this had a direct impact on attendance as, three days before his death; he did not attend school as according to Mother it was too cold for him to ride his bike.  The school are clear that they vehemently opposed the withdrawal of the taxi and made their views known to the local authority.   6.28 The school transport service has a different view and there seems to have been a breakdown in communication and relationships between the school (which was out of Borough) and the London borough. Borough records show that they had assessed Martin’s journey as being within the guidelines and that he would benefit from travel training but the school had not been willing to engage with a travel training programme offered by Mencap.  The borough offered to fund public transport costs for a parent to accompany Martin as well as a breakfast club for his younger sibling but this had not been taken up. As the borough believed that the school did not wish to be involved in travel arrangements they did not inform them of this plan.   6.29 There are therefore two different perspectives on this issue. On the one hand the borough believe the school could have cooperated with travel training but in its absence did make reasonable efforts to ensure Martin could get safely to school. On the other hand the school were not aware of the transport   Page 12 of 19 arrangements and could not challenge Mother as to why she had not taken up the offer of funds to accompany Martin on his journey.  The end result was that Martin apparently decided to cycle to school and on at least one occasion did not attend due to the weather. 6.30 During February Mother spoke to Martin’s school and the early help team about issues between Martin and other children in the home. The school sent a letter to CAMHS and the issues were followed up via a home visit by the early help team’s family support worker. The concerns were discussed including access to inappropriate material on the internet.   6.31 There is a note that the concerns were to be discussed in supervision “tomorrow” and the practitioner told the review that this supervision discussion:  Identified the need to understand physical chastisement  Identified the need to understand whether Martin’s behaviour was putting other “siblings” at risk  Identified the need to see Mother and David separately and all children individually. 6.32 The case was also discussed in a meeting within the early help team between the family support worker, the clinical psychologist, and the family therapist (who was seeing Hannah individually). Concerns discussed included parental mental health, parenting styles and pornography and Martin’s behaviour. 6.33 The plan from the meeting was for the family support worker to see all children individually at school and speak with Mother regarding a GP appointment for her mental health issues. 6.34 Following the meeting (the same day) the psychologist within the early help team spoke to the psychiatrist in CAMHS regarding Martin’s behaviour and an agreed plan was for Martin to be followed up in the ADHD clinic. 6.35 In the days just prior to Martin’s death the early help team began seeing the children/young people individually at their schools. Mother called CAMHS to ask for a reassessment of Martin for autism, and called later to say that she would be attending the forthcoming ADHD parent’s group in April/May. 6.36 At the end of February 2016 Martin died.       Page 13 of 19 7. REVIEW FINDINGS  7.1 This review was commissioned at a time when evidence suggested that the cause of Martin’s death was suicide. Before this report was written, an inquest into Martin’s death concluded that he died as a result of misadventure3 a verdict which clarifies that Martin did not intend to kill himself, which was the original rationale for conducting a serious case review. The reference group liaised with the chair of the LSCB and it was agreed that in view of the lessons that had already emerged from the review and that information had already been shared under the statutory serious case review arrangements, it should continue as a serious case review with a view to sharing the findings more widely. These lessons relate to issues about the way our system works with adolescents who may be at risk of harm either accidentally or non-accidentally.  7.2 Adolescence itself presents a variety of risks but most young people manage the transition to adulthood in a “supportive environment which is conducive to building resilience.”4 For others, their life experience is more complex and although Martin’s death was unexpected, we do know that he was a young man with mental health needs living in challenging circumstances. It should be recognised that individual practitioners made considerable efforts to engage with Martin and his wider family but the system as a whole was not always successful in establishing a consistent multi-professional response to his particular circumstances.  The findings from this review therefore focus on areas where improvements could be made in the support provided to young people and their families in similar situations.  7.3 The overarching conclusion of this review is that complex blended families provide challenges for practitioners and the wider system, particularly where the family has moved between local authority areas. The findings below relate to three specific aspects of this issue, namely:  Working with situations that are “unusual” and do not easily fit day to day procedure and practice.  The impact of localised arrangements for the delivery of services.  Exercising professional judgement in complex networks.                                                    3 Current guidance clarifies that “Misadventure may be the right conclusion when a death arises from some deliberate human act which unexpectedly and unintentionally goes wrong”. (Guidance from the chief coroner no.17 Revised 14th January 2016) 4 Sidebotham et al (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014.Page 98   Page 14 of 19 Finding One Martin lived in a blended family whose members had a range of complex needs. This presents a challenge for the various systems working with families when managing the cluster of features which were present in this case.  7.4 Martin arrived in the London borough with a diagnosis of ADHD and medication prescribed via his local hospital. He did not therefore enter the London borough’s local CAMHS service in the usual way and was referred to the ADHD clinic for treatment without the need for an assessment. It was after he was not taken to clinic appointments that the decision was made to carry out a holistic assessment.  7.5 CAMHS usually ask for copies of Education, Health and Care Plans5 and information from other settings including schools but because Martin had not followed the usual referral pathway this had not been done. As a result the CAMHS assessment did not have the full range of information and the school were not initially aware of CAMHS involvement. An additional complicating factor was that the school was out of borough. 7.6 The GP practice involved with this review is a small practice where there is much informal communication between the partners. As a result, there is no “vulnerable children list” meeting, as would be more usual in large practices. This would have ensured that the regular locum GP was party to discussions and provided an opportunity to ensure that information across the family system was reviewed. GP practices are one key place where there is a possibility at an early stage to understand the family as a whole including situations where parental issues may be affecting parenting and where there are indications that a number of children in the household may be adversely affected. These factors were relevant in this case and all members of the household were registered with the same GP practice.     7.7 Shortly before Martin’s death, it became apparent to the early help team that there were concerns about several of the young people in the blended family and the team were taking steps to understand the family as a whole. Up until this point there had been limited understanding within any other team or organisation about the interrelationship between the issues relating to individual members of the household. Records in health organisations and in children’s services would not necessarily have been cross referenced and it would also not have been appropriate to disclose confidential information about one young person to others in the network unless there were identified safeguarding concerns. Schools working with individual children may not have been aware that they were part of a complex recently blended family and that apparently                                                 5 These replaced Special Education Needs statements and are plans for young people up to the age of 25 who need more support than can be provided within school.    Page 15 of 19 minor issues relating to one child may have had a greater significance. There is no easy solution in these circumstances but all organisations do need to consider how effectively they gather and collate information where children are in blended families and how this information is shared across the network. 7.8 In this case, there was little evidence of a mind-set which started from a presumption that individual children are best served by understanding the family as a whole and that permission could automatically be sought to share information about one individual with professionals working with other members of the family.    Recommendation One  The LSCB should work with partner agencies to consider how to develop an information sharing mind-set which, within the legislative framework, maximises the use of intelligence across the system in order to ensure a whole family approach to work with children within complex, blended families.   Finding Two There was a lack of coordination in the provision of services to Martin exacerbated by differences in arrangements across local authority boundaries.   7.9 Localised commissioning arrangements are now an established feature of public sector service provision. Whilst contributing to efficiency savings, there are also risks associated with the variation in arrangements within and across organisational boundaries and an increasingly complex network of relationships between services and individual professionals. Whilst not all the problems with coordination were as a result of variations in commissioning arrangements, there was evidence that assumptions were too readily made about the way in which services were delivered and a lack of appreciation of variations within the system. This resulted in those making referrals to other services referrers not asking pertinent questions about what they should expect as a result of their referral. Similarly those providing services did not always communicate clearly with others in the system particularly in relation to the boundaries and limitations of their service.   7.10 The fact that Martin was placed at a school outside the Borough contributed to some degree of miscommunication with the school apparently unaware of CAMHS arrangements in the other borough. Discussions with the GP also revealed some misunderstanding despite a document that has been in existence for some years setting out the process and which needs to be updated and reissued. The expectation of clinicians in the child and adult mental health service (CAMHS) is that referrals would be made into their clinic,   Page 16 of 19 a full assessment undertaken and a decision made as to whether the child/young person could be managed solely via the ADHD medication clinic or whether additional CAMHS services were required. This system does not appear to be well understood as the GP told this review that they understood the ADHD clinic to be separate from CAMHS.  From the GP’s perspective, when a child or young person is thought to have ADHD, it would be usual practice to refer to the community paediatrician who would then refer on to CAMHS if necessary. Referral directly to a hospital paediatrician would not be expected practice in the London borough but in this case the referral from the GP was (quite reasonably) to the hospital, as in the rural county, Martin had been under the care of a hospital.  7.11 In this case communication between the GP and CAMHS did not work well with the GP assuming Martin was attending regularly when in fact he was missing a number of appointments. GP’s should be informed when a child is not taken to the CAMHS appointment if they are the referrer or aware that a colleague has referred. They will not be informed if they do not know of CAMHS involvement and the family do not give permission for the GP to be informed. In this case the GP was copied into the referral letter sent by the paediatrician and therefore should have been informed that Martin had not been taken to appointments. There was therefore a lost opportunity for follow up by the GP and less consideration of the impact of other family factors including parental issues than would have been the case if non-attendance was identified as a concern.  7.12 Special schools frequently take children from a number of local authority areas meaning that there may not be a close working relationship with individuals when they wish to discuss concerns. Increasingly systems for managing referrals within local authorities vary from area to area and it is important for schools to have an understanding of the different arrangements and equally children’s services need to consider that schools will not necessarily be familiar with their systems. In this case the London borough expected that the school would come back to them to discuss actions following the referral with 10 causes of concern whereas the school interpreted the borough’s response as meaning their threshold was not met and from that point focused on Martin’s emotional and mental health needs.  7.13 From the school’s perspective the issue relating to the decision to stop Martin’s taxi was particularly significant. As discussed in paragraphs 6.27-6.29 above neither party communicated effectively with the other, resulting in an apparent breakdown in communication between local authority school transport and the school.    7.14 Education Health and Care plans should be one means of coordinating arrangements for young people. In this case, for reasons outlined above,   Page 17 of 19 CAMHS did not request a copy of the plan and equally the plan was not shared with any health professional including CAMHS. This review has been told that this is not specific to this case and health services are not routinely receiving copies of the plans reducing the likelihood of a good overall understanding of the interrelationship between services working with the young person.  Recommendation Two In order to maximise the possibility that the professional community understands CAMHS pathways within the borough, the pathway document should be revisited and relaunched to all organisations working with children, including GPs.  Recommendation Three Children’s Services and Health organisations should review the effectiveness of the way in which Education Heath and Care plans are shared with Health professionals.  Recommendation Four The London Safeguarding Children Board should be asked to work with organisations across London to mitigate the risk to children where there is a lack of clarity about roles, responsibilities and information sharing associated with localised commissioning arrangements.      Finding Three This review found a number of specific practice issues which highlight the dilemmas faced by front line practitioners when exercising professional judgement in their safeguarding practice.   7.15 This was a set of circumstances where there were emerging issues which from time to time could have been considered to indicate safeguarding concerns for Martin and other young people in the family. Factors that were present in this case and have been well rehearsed in other serious case reviews are:  alleged or known domestic abuse and the need to fully consider the impact on parenting and children in the family,  verbal compliance by parents but actions indicating lack of engagement with agreed care plans,  parental mental health potentially having a negative impact on parenting capacity.    Page 18 of 19 7.16 In this case, Martin’s mother always appeared to be very concerned about his wellbeing and, as a result, professionals had insufficient curiosity about lack of engagement with suggested services and Martin not being brought to appointments. It now seems that it may have been prudent to consider Mother’s own well-being and any impact this may have had on her parenting including young people in the family taking a caring role. The reasons why this was not considered would appear to mainly relate to the issues in finding one and two of this report. It would be helpful for any dissemination of learning by the LSCB to reiterate the importance of these factors in safeguarding practice. 7.17 One specific practice issue relates to professional actions at the interface with children's services. When the school contacted children's services with ten causes for concern, neither party followed up the outcome of the school’s additional information gathering exercise. Concerns raised by special schools should be scrutinised particularly carefully given evidence which suggests that children with impairments (physical, cognitive and behavioural) are more likely to be abused.6 In this case children's social care took the lack of further contact from the school to mean that concerns had reduced and the school believed that the concerns outlined had not reached the boroughs threshold. When similar issues continued, the school focused on understanding Martin’s behaviour as a result of emotional and mental health issues rather than safeguarding concerns. This seems to explain the lack of safeguarding referral following discussions with CAMHS although there was accumulating evidence at this stage that all was not well in the family home and it would have been best practice to make a referral.  7.18 The lack of referral to children's services by CAMHS is less easy to understand when the safeguarding lead nurse had advised that this should be done. Staff members involved suggest that they are uncertain as to whether situations such as Martin’s would reach a threshold for intervention and this can inhibit their actions.  7.19  The role of the children’s services multidisciplinary early help team is particularly important in this case. They were able to engage with Sophie and just prior to Martin’s death were beginning to understand the family as a whole system. Their service appears to have been viewed positively by family members but the team were holding a high level of complexity without the foundation of a thorough holistic assessment. Risks were becoming clearer but the team did not have the whole picture in relation to family history and previous involvement by statutory agencies in the rural county. The recent Ofsted inspection of children’s services in the borough noted the high quality of work within this team, confirmed they are dealing with a high level of complexity                                                 6 Sullivan, P.M. and Knutson, J.F (1988) The Association Between Child Maltreatment and Disabilities in a Hospital-Based Epidemiological Study. NY: Pergamon Press   Page 19 of 19 and that the local authority is seeking additional resources to enhance the support offered. In this case the issue does not appear to be one of resource but a need for greater clarity as to when an early help assessment is needed and/or when case should be “stepped up” to the locality team for a statutory assessment to be carried out.   Recommendation Five The LSCB should ask Children’s Services for evidence that:  development work with the multidisciplinary early help team has strengthened their capacity and capability to undertake holistic early help assessments to underpin the help they are providing to families  the threshold at the interface between the early help team and locality team regarding when cases should be “stepped up” for a statutory assessment is working effectively.  Recommendation Six Discussions with practitioners for this review have identified perceived barriers to making a safeguarding referral to children's social care. The LSCB should agree and implement a plan aimed at ensuring that children’s services are receiving appropriate information and referrals where there are concerns about the safety and wellbeing of a child.  Finding Four The serious case review process highlighted the need to be clear about expectations regarding contributions to the process when commissioning services 7.20 Commissioning arrangements had an impact on the serious case review process with the private home tutoring service querying whether the time associated with preparing papers for the serious case review was within the terms of their contract. This could potentially be an issue for other external providers in the future and it would be sensible for contracts to be clear in relation to this point.  7.21   Recommendation Seven The LSCB should ask partner agencies to ensure that contracts with service providers include an expectation that they should fully participate as required in any serious case review process.  