introduction and context to the serious case review … · web viewintroduction and context to the...

TamesideSafeguarding Children Board

A Serious Case Review

‘Child M’

The Overview Report

April 2015

of 65

http://www.tamesidesafeguardingchildren.org.uk/

Index

1 Introduction and context to the serious case review..................................41.1 Rationale for conducting the serious case review................................71.2 The methodology of the serious case review.....................................81.3 The scope of the serious case review.............................................101.4 Particular issues identified by the SCR review team for further investigation by the key lines of enquiry:...................................................................111.5 Membership of the case review team and access to expert advice........111.6 Independent lead reviewers........................................................121.7 Parental and family contribution to the serious case review................131.8 Time scale for completing the serious case review............................151.9 Status and ownership of the overview report...................................151.10 Cultural, ethnic, linguistic and religious identity of the family...............16

2 Summary of contact and significant events..............................172.1 Exclusion from school..........................................................182.2 Escalation of self-harm and admission to in-patient CAMHS

202.3 Overdose and admission to hospital emergency service....252.4 Further threat of self-harm..................................................252.5 First mental health assessment following arrest.................262.6 Lancashire police referral to Tameside children’s services.272.7 Child M’s first appearance in court and allocation to youth offending services.........................................................................282.8 First contact from Lancashire YOT with Tameside YOT.......292.9 Child M’s arrest and detention by Greater Manchester Police

303 Appraisal of professional practice in this case.........................................32

3.1 The admission and care provided at the T4 unit in June and July 2013....353.2 The arrangements for discharge from the T4 service and follow up support

363.3 The overdose and admission to hospital in October 2013....................373.4 The police detention and mental health assessments in October 2013. . .373.5 The referral to Lancashire MASH in October 2013 and assessment........403.6 Assessment and allocation to Youth Offending Services in Lancashire and Tameside.........................................................................................413.7 Child M’s mental health assessment whilst in police custody in Tameside and attendance in court.......................................................................433.8 In what way does the case provide a view into the local systems for safeguarding children?........................................................................46

4 Analysis of key themes from the case and description of findings for learning and improvement..................................................................................48

4.1 Cognitive influence and human bias in processing information and observation......................................................................................494.2 Family and professional contact and interaction...............................514.3 Responses to information and incidents.........................................534.4 Tools to support professional judgment and decision making...............53

of 65

4.5 Management and agency to agency systems...................................544.6 Issues for the Tameside Safeguarding Children Board to consider in regard to learning and improvement................................................................564.7 Recommendations....................................................................584.8 Issues for national policy.....................................................58

5 APPENDICES..................................................................................59Appendix 1 - Procedures and guidance relevant to this serious case review......61Legislation........................................................................................61

The Children Act 1989......................................................................61The Children Act 2004......................................................................61Police and Criminal Evidence Act 1984 (PACE)........................................62Mental Capacity Act 2005 (MCA).........................................................62Safeguarding Procedures..................................................................63The local safeguarding children procedures...........................................63

Other local procedures relevant to this serious case review..........................64National guidance..............................................................................64

Working Together to Safeguard Children (2010) and (2013).......................64Framework for the Assessment of Children in Need and their Families 2001. .64Common Assessment Framework (CAF)................................................65

of 65

1 Introduction and context to the serious case review

1. The death of any child, whatever the circumstances, is tragic and profoundly distressing for those who knew and loved them. It has a devastating impact on their families, friends and communities whenever and wherever it occurs. It also has a profound effect upon the professionals who worked with them.

2. A draft report was presented to a meeting of the Tameside Safeguarding Children Board and Lancashire Safeguarding Children Board on the 25 th

November 2014. This was at a time when the Independent Police Complaints Commission (IPCC) had not finalised their report and the coroner’s inquest had yet to be completed. It is clear that additional evidence and information in regard to professional learning may be produced as evidence in these parallel processes and that the Boards may need to consider all evidence before publishing a final version of this report.

3. This review concerns the death of Child M. For the purpose of clarity, the use of acronyms for the various people involved is kept as simple as possible. Members of the family are referred to in terms of their relationship with Child M (mother, stepfather, father, grandparent, etc.). Professionals are referred to in respect of their professional role such as police officer, doctor, YOT worker, etc.). There are two adults who are referred to as Adult 1 and Adult 2. Adult 1 was a 30 year old male who was having a relationship with Child M just before the death. Adult 2 is the ex-partner of Adult 1.

4. Child M was a bright child with above average intelligence scores with cognitive ability test (CAT) scores of 123-125 and played a musical instrument at grade 7 or 8 and had a national award for accomplishment1. Child M has been described as free spirited with a sense of humour. People have commented that Child M was a delight to talk with when in the right mood but could also be very argumentative and verbally aggressive. Child M could be quirky and several of the professionals who knew and worked with Child M described a young person who for the most part dressed with an individual and artistic style.

5. In early December 2013 the body of 17 year old Child M was found in the garden of a domestic property in Tameside with a ligature around their neck. There was no evidence of any third party being involved in the death which is the subject of a coroner’s inquest.

6. Child M had a distressing history of self-harming behaviour. Child M was an inpatient at a Tier 4 (T4) adolescent mental health facility in the northwest of England for a month in the summer of 20132. At no time before, during or after that episode of treatment and care was there a diagnosis of a mental

1 Cognitive ability scores (CAT).2 Tier 4 encompasses inpatient treatment in contrast to the lower three tiers of community based CAMHS that provide a framework of support and treatment.

of 65

illness or of a personality disorder3. Child M continued to receive support via an outreach service for a period of several weeks after leaving the T4 unit. Child M had continued to self-harm and there had been an admission to a general hospital emergency service following an overdose in October 2013. Child M had a history of using alcohol and cannabis and had more recently also been using amphetamines.

7. Child M moved to Tameside in November 2013 from Lancashire after relationships had broken down with their mother and stepfather. At the time of that move the police in Lancashire had made a referral to children’s social care services (CSC) in Tameside describing their concerns about Child M’s behaviour and vulnerability particularly in relation to the history of self-harm. Child M died before the local CAMHS or YOT (youth offending team) in Tameside had become involved.

8. Child M was the subject of a referral order that had been made in Lancashire in November 2013 which required statutory supervision through the youth offending services. Administrative errors in the allocation of the referral order caused delay in the YOT services beginning any work with Child M. This was the only statutory involvement with Child M4. Child M was never assessed as a child in need or a child at risk of harm in Lancashire or Tameside.

9. It is because Child M had a history of significant self-harm that the review acknowledges that future incidents of self-harm were highly probable although this does not mean that Child M’s death could have been predicted. Although Child M had made threats to take their life on at least two occasions the episodes of previous self-harm had not been immediately life threatening. Some of this is because of the action of services such as the police as well as the intervention of family members. Some of it is attributable to other factors; for example the overdose in October 2013 was a non-toxic combination although whether this was intentional or not is not confirmed.

3 There was a differential diagnosis at T4 when a locum consultant psychiatrist diagnosed an emotionally unstable personality disorder; this was subject of disagreement with other clinicians. It was not discussed with mother and step-father.4 The referral order is a unique sentence directly involving the local community, by means of the volunteer youth offender panel members, in holding the young offender to account for their actions. Where a young person is before a court charged with a criminal offence for the first time and pleads guilty, the Court must pass (in most cases) a referral order. The young offender if aged under 16 years old is required to attend a youth offender panel with their parents/guardian or local authority representative if under the care of the local authority and may be required to make restitution or reparation to their victim based on a restorative justice approach. The youth offender panel is headed by two volunteers from the local community and a member of the youth offending team. Under the order the young offender agrees a contract with the panel which can include reparation or restitution to their victim, for example, repairing any damage caused or making financial recompense, as well as undertaking a programme of interventions and activities to address their offending behaviour.

of 65

10. Several people and services worked very hard to help Child M and in particular when there was concern about Child M harming themselves. This was why the GP and mental health services organised the admission to the T4 unit and was also a significant factor in the decision making by the police in their use of custody to prevent Child M harming them self.

11. The review identifies weaknesses in how aspects of risk assessment with Child M was approached and undertaken. There were opportunities to have tried alternative strategies to help Child M when they presented with some very challenging and distressing behaviour; this occurred at home, in the community, at school and when in the custody of the police. There was insufficient understanding about how to best organise help that in reality went back to Child M’s early adolescence. With hindsight, it is not clear that anybody had really tried to address why Child M behaved and interacted with peers and adults in the manner that they did. The IPCC (Independent Police Complaints Commission) are likely to identify contraventions of police procedure whilst Child M was in custody in Greater Manchester.

12. The SCR and the IPCC do not identify a significant contravention or action by any professional that was a critical factor. The learning identified does invite and require a better understanding by professionals in criminal justice, education, health and social care in the application of processes; this includes the use of the common assessment framework (CAF) for children showing indicators of need or vulnerability but have not reached thresholds for statutory safeguarding, navigating consent in regard to accessing specialist help in regard to mental health and substance misuse, the managing of referrals especially between different areas and recognition of vulnerability when dealing with older teenagers whose life style, circumstances and mental capacity maybe factors that require a more assertive and inquiring approach.

13. The review cannot say with any degree of confidence that if any alternative approaches had been taken it would have prevented the tragic death of Child M. It would have improved the opportunity for more effective co-ordination of effort across different services and improved communication between professionals and with Child M and with the family.

14. The review identifies lessons in regard to the way schools can access support for pupils with additional needs, the role of the local authority in advising and supporting behaviour management strategies, the application of safeguarding arrangements for older children displaying risk of significant self-harm and the circumstances under which services such as the appropriate adult are not sufficient to meet complex need. There are specific lessons in regard to how the police manage the care and safety of young people in police custody. The review also draws attention to the distinction

of 65

between mental health and mental capacity and the implications for assessment and decision making5.

15. The review acknowledges that some professionals were very concerned for Child M’s safety and felt at a loss as to what to do to protect them. This is an important point of learning. Professionals such as the police, social workers, youth offending and health care staff will be confronted with situations that fall outside the scope of their previous experience and knowledge.

16. In this case, the level and duration of some of Child M’s verbal and physical distress and violence was confusing and baffling even to very experienced police officers who have dealt with a diverse range of attitude and behaviour. At least one of the police officers was sufficiently worried about Child M’s safety to lead them to recommend that Child M should be remanded in custody as a court outcome for a minor offence. This was not appropriate and was done without consultation with specialist safeguarding officers or with services such as health and social workers. It remains unknown why none of the Greater Manchester Police officers who supervised Child M’s detention in custody thought to consult safeguarding specialist police officers or social care services about concerns for Child M’s safety and welfare. None of those police officers were available for interview by the SCR due to the IPCC investigation.

17. The recognition of risk during that period of custody was tragically prescient although the suggested safety plan was wholly inappropriate and was not in any event an option. Child M’s detention in police custody far in excess of the usual legislative timescales just prior to the tragic death was an effort to keep Child M safe in the absence of an alternative and more legally compliant strategy6. It also remains the case that neither of Child M’s parents were contacted to discuss concerns.

1.1 Rationale for conducting the serious case review

18. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with the procedures that are set out in chapter four of Working Together to Safeguard Children (2013).

19. An LSCB should always undertake a serious case review when a child dies or has been seriously harmed and abuse or neglect is either known or is suspected and there is cause for concern as to the way the authority, the Board or other relevant persons have worked together.

20. The reason for undertaking this review is that Child M was a vulnerable young person with a history of self-harm and some previous suicidal ideation

5 The Mental Capacity Act 2005 is described in the appendix to this report.6 The IPCC report describes in detail the various codes that apply to refusal to bail and detention.

of 65

(having thoughts but not necessarily plans or intent to take their own life). The death was reported to the Tameside Safeguarding Children Board and was initially discussed by the Tameside serious significant case panel (SSCP) on the 23rd December 2013.

21. At that meeting it was decided that there was insufficient information about the extent or nature of agency involvement in Lancashire with Child M prior to moving to Tameside to inform a decision regarding the criteria for commissioning a SCR. It was therefore agreed to re-schedule an extraordinary meeting of the SSCP on the 21st January 2014 who with the additional information provided to that panel recommended to the independent chair of the Tameside Safeguarding Children Board that the circumstances of Child M’s death met the criteria for a mandatory serious case review.

22. The review was commissioned by Mike Tarver, the independent chair of the Tameside Safeguarding Children Board on the 31st January 2014.

23. The commissioning meeting for the serious case review was not until the 3 rd

March 2014 when the scope and methodology for the SCR was confirmed and along with arrangements for the independent reviewers.

24. The purpose of the review is to establish what lessons are learned from the case for improving safeguarding services, to improve inter-agency working and to better safeguard and promote the welfare of children in Tameside and to also share learning and improvement with Lancashire.

1.2 The methodology of the serious case review

25. A serious case review team was convened of senior and specialist agency representatives from Lancashire as well Tameside to oversee the collation and analysis of information and outcomes of the review. The review was co-ordinated and managed by two independent lead reviewers with appropriate experience and training. Further information is provided in section 1.6.

26. This review uses a systems based approach to analysing information and presenting the findings in the final chapter using recommended best practice in identifying improvement and learning.

27. The review has used investigatory methodology where appropriate to establish the facts of the narrative and commissioned a report from the Greater Manchester Police when it became apparent that there would not be an opportunity to conduct discussions with those officers in regard to key events primarily in connection with the detention of Child M in police custody for the weekend before they died.

of 65

28. Although it is Tameside LSCB who commissioned and are responsible for this SCR an acknowledgement is required for the significant work done to facilitate and support the review through the LSCB in Lancashire. The review had significant complexity arising from the involvement of several services in two local authority areas and there were parallel investigations also being conducted. The review coincided with another SCR being conducted by the Tameside Safeguarding Children Board which placed considerable demands on the Tameside Safeguarding Children Board’s team which also saw the Tameside Safeguarding Children Board manager move to a post with another area and changes to business support arrangements.

29. The Independent Police Complaints Commission (IPCC) agreed to grant interested party status to the SCR and this facilitated direct contact and liaison between the two processes. The focus of the two investigations are different; the IPCC role is to investigate and decide if there are issues of misconduct for individual officers or for the police corporately; the task of the SCR is to identify lessons to be applied as a result of the events that are examined.

30. The death of Child M is the subject of a coroner’s inquest. The coroner has undertaken detailed pre-inquest enquiries that have included requiring written information being submitted by relevant services and practitioners. The chair of the Tameside Safeguarding Children Board attended one of the hearings before the coroner and reports were provided in regard to the process and progress of the review.

31. Work began on compiling a multi-agency chronology in March 2014. From the collated chronology the initial meeting of the review team identified the initial key lines of enquiry.

32. The review team also identified information for individual agencies to provide to the review. This included all relevant documents and reports from services working with the family in regard to assessments, agreements and plans.

33. The review team identified the services and individual practitioners that would provide information and participate in the review. A briefing was held in early May 2014 which was followed by a programme of individual conversations with practitioners from Tameside and Lancashire which were facilitated by members of the review team and lead reviewers.

34. The review team used the information from the conversations and other evidence to identify the following as key practice episodes for particular learning in this SCR:

a) The permanent exclusion from school in November 2011;b) The admission and assessment at a T4 CAMHS (child and

adolescent mental health services) in June 2013;

of 65

c) The multi-agency professionals meeting and discharge plan from T4 in July 2013;

d) The DASH (domestic abuse, stalking and harassment) assessment in October 2013;

e) The overdose and admission to hospital in October 2013;f) Referral to Lancashire’s MASH (multi agency safeguarding hub)

in October 2013 and assessment g) Assessment and transfer of information from Lancashire YOS

to Tameside YOS (youth offending service) in November 2013;h) Referral to the Lancashire referral order panel in November

2013;i) Police referral to the Lancashire MASH and DASH assessment

in November 2013;j) Information provided to the magistrates court in December

2013 and response to Child M’s behaviour in front of the bench.

35. The findings in the final chapter of this report use an adaptation of the framework developed by SCIE to present the key learning within the context of the local arrangements.

36. The work of the review is exempt from the Freedom of Information requirements that apply to public bodies. There is case law in regard to the information that can and should be disclosed to coronial and police criminal proceedings.

37. The review was conducted on the basis that the overview report would be published in full.

1.3 The scope of the serious case review

38. The period under most detailed review is from the beginning of 2013 when Child M had withdrawn from involvement by the young people’s service (YPS) and MIND in Lancashire up to the death of Child M in December 2013.

39. The following agencies have provided information and contributed to the SCR in accordance with Working Together to Safeguard Children (2013), Chapter 4 and the associated LSCB guidance and relevant learning and improvement frameworks.

Health services in Lancashire and Tameside that include:

o Lancashire Care NHS Foundation Trust (provision of mental health assessment and services)

o NHS England Clinical Commissioning Group (GP)o North West Ambulance Service (transported Child M to hospital

following an overdose in October 2013)

of 65

o Young Addaction (specialist substance abuse service for young people in Lancashire)

Tameside children’s social care services (CSC) (received a referral from Lancashire MASH in late October 2013)

Lancashire education services Lancashire Young People’s Service (YPS) (this included making a referral

to the MIND service in Lancashire) Lancashire Constabulary and Greater Manchester Police (dealt with

incidents of self-harm and both police areas detained Child M in custody) Lancashire and Tameside Youth Offending Services (YOS) (following the

referral order in November 2013)

40. Contact with and information from the family is described in section 1.7.

1.4 Particular issues identified by the SCR review team for further investigation by the key lines of enquiry:

41. In addition to analysing individual and organisational practice the review considered

a) The quality of the assessment of risk to Child M;

b) The quality of information provided at the point of transfer from Lancashire to Tameside;

c) The extent to appropriate frameworks and pathways were used to co-ordinate action to identify and address Child M’s needs;

d) The extent to which the views, wishes and feelings of Child M were considered.

1.5 Membership of the case review team and access to expert advice

42. The case review team that oversaw this review comprised the following people and organisations;

Position OrganisationHead of Service Children’s Safeguarding Tameside Metropolitan Borough

(TMBC)Head of children’s social work TMBCPrincipal social worker Lancashire County Council (LCC)Detective sergeant Greater Manchester PoliceReview officer Lancashire ConstabularyService manager youth offending service (YOS)

Lancashire YOS

Head of youth offending service Tameside YOS

of 65

Assistant head of service Young People’s Service (YPS) in LancashireNamed nurse safeguarding children

Lancashire Care NHS Foundation Trust

Head of clinical services MEDACS (from July 2014)Business manager Lancashire Safeguarding Children Board (LSCB)Business manager Tameside Safeguarding Children Board (moved to another

local authority in June 2014 to take up a new post)Business support officer LSCBDesignated nurse Chorley and South Ribble Clinical Commissioning Group (CCG)Service manager Young Addaction

43. The independent lead reviewers attended every meeting of the review team and case group meetings. One of the reviewers took lead responsibility for facilitating meetings and overseeing documentation and liaison in regard to family contact. The other lead reviewer took the principle responsibility for drafting the report. Both of the independent reviewers participated in conversations and meetings with case group members and collating evidence and information.

44. The review team had access to legal advice from a solicitor in the council’s legal service. The team also had access to other specialist advice if it had been required.

45. Written minutes of the review team meeting discussions and decisions were recorded by a member of the business support team in Tameside.

1.6 Independent lead reviewers

46. The Tameside Safeguarding Children Board commissioned two independent lead reviewers for the review. Maureen Noble works as an independent consultant who has over thirty years’ experience in a range of senior roles in public sector agencies. Maureen has a background in public protection and community safety and has managed and commissioned services for vulnerable young people. Maureen is a member of the NICE national working group on domestic abuse and acts a volunteer strategic advisor to a national charity. Maureen has previously worked as an author and chair of numerous serious case reviews for Local Safeguarding Children and Adults Boards. She has also chaired and authored several domestic homicide reviews. Maureen has worked as an author on a previous serious case review in Tameside. She has not worked for any of the agencies involved in this review.

47. Peter Maddocks is the author of this report and has over thirty-five years’ experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local authority services and of working in

of 65

national inspection services and the voluntary sector. He has a professional social work qualification and MA and is registered with the HCPC. He undertakes work throughout the United Kingdom as an independent consultant and trainer and has led or contributed to several service reviews and statutory inspections in relation to safeguarding children. He has undertaken independent agency reviews and has provided independent overview reports to several LSCBs in England and Wales as well as work on domestic homicide reviews. He has undertaken work as an overview author on previous serious case reviews in Tameside and in Lancashire. He has not worked for any of the services contributing to this serious case review. He has also participated in training for overview authors and independent reviewers including the application of systems learning.

1.7 Parental and family contribution to the serious case review

48. Child M’s parents have been separated for several years. After mother and father separated mother and Child M had moved to the London area where mother completed a degree course. Father says that the relationship with Child M’s mother was generally amicable after their separation and he continued to have contact with Child M when they returned to Tameside for weekends and holidays although there was 22 month period when the parents were not in contact with each other during which time he did not have contact with Child M.

49. Child M lived with mother and stepfather until the autumn of 2013 when Child M first of all stayed with grandparents and then more recently had moved to Tameside to initially live with father.

50. The parents and Child M’s stepfather were made aware of the serious case review when it was commissioned, in a letter sent to them by the independent chair of the Tameside Safeguarding Children Board. The mother and stepfather of Child M agreed to a meeting that involved one of the independent lead reviewers and the business manager from Tameside Safeguarding Children Board7 in April 2014. Father and paternal grandfather met with one of the lead reviewers and the head of service for children’s safeguarding in Tameside in October 2014.

51. The meeting with Child M’s mother and stepfather provided an opportunity for them to describe a history of increasingly challenging and difficult interaction and behaviour with Child M from about 2011 onwards who was then in Year 9 at school and the onset of adolescence.

52. They are very distressed by the death of Child M and felt angry and let down by services generally in trying to respond to an escalating level of emotional distress and conflict over several months before Child M died.

7 The business manager moved to a post with another authority in June 2014 and subsequent meetings with family members involved the head of service for safeguarding in Tameside thereafter.

of 65

53. They feel that Child M had undiagnosed mental health needs. Mother and step-father felt that Child M was displaying manic behaviour and other symptoms of mental ill-health (although mental health professionals did not diagnose any symptoms). Mother and step-father felt that their views were not given sufficient significance and that they did not have appropriate support. This is explored in later sections of the report.

54. They feel that because of the level and type of behaviour and distress that Child M exhibited the general response by services was either to not get involved enough or to deal with Child M as an anti-social young offender.

55. They felt that they did not get the level and type of support that was necessary at the time to help them respond to an escalating pattern of difficult behaviour at home and at school. There were six episodes of school exclusion culminating in Child M being placed at a pupil referral unit (PRU) in late 2011; there were problems with eating and outbursts of fairly unrestrained physical and verbal confrontation some of which necessitated calls for police assistance. Child M began a relationship with a young adult several years older which was a source of further concern. Child M spent increasing amounts of time at this boyfriend’s house.

56. There was a very clear sense from Child M’s mother and stepfather of feeling out of their depth in regard to the reasons and circumstances for Child M’s difficulties and self-harm. They were very frustrated that they were unable to secure the professional services they felt were required to help Child M. Later sections of the report include the perspective from professionals involved in key events.

57. Child M’s maternal grandparents have also provided information to the review. They told the review that Child M has travelled extensively around Europe and described a gifted and very intelligent child. The maternal grandparents feel that Child M was very motivated to achieve but was mentally fragile and could be frustrated when her mental agility was not harnessed. The grandparents feel that in general people responded to Child M as a ‘naughty child’ rather than doing more to understand what was underlying the behaviour and interaction.

58. The grandparents felt that processes such as assessments appeared to be a tick box exercise rather than going into enough detail. The grandparents had a lot of contact with Child M including when Child M was staying at the T4 unit. The grandparents say that they felt the stay was too short but they were unable to express a view other than to a receptionist at the unit.

59. Child M’s birth father and paternal grandfather described Child M as being very bright and had been able to recite the periodic tables at the age of four years and was an accomplished musician and diver.

of 65

60. Father described Child M as become very ‘up and down’. He felt things had ‘imploded’ with Child M becoming tired of education, breaking up with a significant friend and loss of their job. Father had not been aware that Child M was in a T4 unit having thought that Child M was in hospital for two weeks. When Child M came to Tameside in late 2013 to live with father he had tried to agree boundaries in regard to coming in times and knowing where Child M. Child M was unwilling to comply. Father was not aware of the extent of difficulties that Child had prior to moving to Tameside.

61. Father was upset that he was not contacted instead of the appropriate adult when Child M was arrested and kept in police custody in Tameside. He feels he was not kept informed.

62. Father explained that Child M had met Adult 1 when he was out walking his dogs.

1.8 Time scale for completing the serious case review

63. The case review team met on seven occasions between April 2014 and November 2014. The review findings was presented to a joint meeting of the Tameside Safeguarding Children Board and Lancashire Safeguarding Children Board in November 2014.

64. National guidance expects SCRs to be completed within six months and the majority of reviews involve a single LSCB. This SCR was unusual regarding the complexity of emerging issues and the fact that most of the information required was held by agencies outside Tameside. This resulted in the screening panel having to meet twice hence the short delay in the initial decision, made on 6th February 2014, to commission a SCR. The involvement of professionals and several services across two areas and coordinating the logistics of discussions with them and with members of the respective families required an extension to be agreed for completing the SCR.

1.9 Status and ownership of the overview report

65. The overview report is the property of the Tameside Safeguarding Children Board as the commissioning board.

66. Since June 2010, it has been an expectation that all overview reports provided to LSCBs in England should be published. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Child M and the family.

67. An executive summary is not required by the revised national guidance set out in Working Together to safeguard Children 2013. The Tameside

of 65

Safeguarding Children Board in consultation with the LSCB will determine how and what further information is provided to the family at the conclusion of the review and following the submission of the overview report to the Department for Education.

1.10 Cultural, ethnic, linguistic and religious identity of the family

68. Child M’s cultural and ethnic heritage is White British. No information about any other cultural or religious affiliation has been recorded in the documentation examined by the SCR although it is apparent that some of Child M’s family have strong religious faith.

69. The relationship between Child M’s parents before they separated had included incidents of domestic abuse which it is believed that Child M witnessed as a young child.

70. Child M’s mother is a qualified teacher who is employed as a head of science at a secondary school.

71. Child M had no siblings and lived with mother and stepfather in a village in Lancashire until late 2013. Stepfather is a qualified teacher and is an assistant head teacher. The stepfather is also white British.

72. The maternal grandparents to Child M also live in Tameside and had regular contact with Child M including on occasion providing care for Child M who went missing from home on more than one occasion.

73. Child M’s father lives in Tameside.

of 65

2 Summary of contact and significant events

74. Child M’s arrival in Lancashire had apparently coincided with the start of secondary education as a year 7 pupil. Very little is known by professionals in Lancashire or Tameside about Child M’s early childhood and primary school years. Information collated during the review indicates that Child M experienced several moves during her early years within Greater Manchester and Lancashire and lived in London for almost four years between the summer of 2000 and the summer of 2007.

75. Child M initially appeared to settle into secondary education although as the year progressed there were some disciplinary issues emerging in regard to matters such as playing with a mobile phone in class. By year nine Child M was presenting with increasingly difficult behaviour which appeared to be ‘out of character’ according to the school; Child M began to be aggressive which escalated rapidly when challenged.

76. Child M was first excluded from school in January 2010 whilst in year nine. It was for flicking a lighter in class which did not result in any damage or injury. The exclusion was challenged unsuccessfully by mother and stepfather.

77. In May 2010 the police in Lancashire had their first contact with Child M when mother reported that Child M was missing from home (MFH) following an argument about Child M going camping with friends. The MFH assessment recorded that Child M was at medium risk; Child M returned home the same day that the police had received the initial report.

78. A second three day exclusion from school in June 2010 was followed up by the first pupil support plan. In November 2010 a third two day exclusion was imposed for a verbal assault which was followed in January 2011 by a further two day exclusion for verbal abuse. A second pupil support plan was agreed and the third was agreed in May 2011 when Child M was given a ‘time out card’ as well as being placed on report. In June 2011 there were two exclusions (of five and four days) and it was agreed to attempt a managed move to another school8. According to step-father, the attempt at a managed move was instigated by him and mother and not by the school although it is evident that there was discussion with the school.

8 Managed moves between schools first appeared in DfES Circular 10/99 as an intervention to be used as part of a child’s Pastoral Support Programme, if appropriate, to reduce the risk of the child being permanently excluded. Current government guidance Exclusion from Maintained Schools, Academies and Pupil Referral Units 2012 advises school leaders that: ‘A pupil can transfer to another school as part of a ‘managed move’ where this occurs with the consent of the parties involved, including the parents.’ Sir Alan Steer in his report Learning Behaviour: Lessons Learned. A review of behaviour standards and practices in our schools (DCSF 2009) described Managed Moves as an appropriate strategy to promote the reduction in numbers of pupils being excluded in mainstream schools. This should be seen as a piece of preventative work to support pupils at risk of exclusion. Schools are not required by the Department for Education to use managed moves.

of 65

79. The plan for a managed move was disrupted by Child M effectively sabotaging a meeting with the head teacher of the proposed alternative school. With hindsight this was Child M making clear that they wanted to continue at the same school.

80. In September 2011 the sixth exclusion (two days) was imposed for further verbal abuse. A fourth pupil support plan was agreed that also included the head of year being assigned as a mentor.

81. According to the school, mother had declined a suggestion to make a referral to CAMHS although do not have a contemporaneous record of that conversation; mother and stepfather dispute this and told the review that they would have supported more involvement from services such as CAMHS and that it was mother who initially made contact with CAMHS. School and mother and stepfather had agreed that a referral to Young Addaction (the young people’s substance misuse service in Lancashire) would be helpful although Child M declined to give their consent and no referral was made; Young Addaction only became involved in 2013 after Child M was admitted to the T4 CAMHS unit.

2.1 Exclusion from school

82. In November 2011 Child M was permanently excluded from school after being found in possession of cannabis (in contravention of the school’s zero tolerance of drugs) and was placed at a pupil referral unit (PRU)9.

83. Up until this permanent exclusion in November 2011 Child M had regularly attended the same secondary school. The decision to exclude had a very significant and immediate impact on Child M as well as upon mother and stepfather. Mother wrote an email to the school pleading with them to stop short of the permanent exclusion.

84. Mother and stepfather did not formally challenge the decision to permanently exclude Child M either by any other written submission or by attending the meeting of the school’s pupil discipline committee in mid-December 2011; they say that they did not want to be put in front of people to be told how awful Child M’s behaviour was. They did not make any appeal after the committee confirmed the decision to exclude Child M.

85. School say that Child M was allowed to sit their GCSE exams at the school after their permanent exclusion because the PRU was not an accredited centre for the qualification authority although in the event did not attend for all of the scheduled examinations. Mother and stepfather say that Child M

9 Operated by a local authority a PRU has to be registered with the DfE and Ofsted and is subject to the inspection and regulation that applies to other schools. The PRU provides education for children and young people from a variety of backgrounds and circumstances and not all teaching takes place within the unit.

of 65

was only entered for science exams10. In contrast to the pattern of regular attendance at school Child M regularly truanted from the PRU.

86. Around this time Child M had begun a relationship with another young person who was significantly older and was still living with their family and was in employment and was not angry or aggressive. Child M was continuing to display aggression when at home but was spending increasing amount of time at the friend’s home playing on computers. Mother was in regular contact and helped with food and washing although would have preferred to have had Child M return to their home. Mother and stepfather felt more reassured at least knowing where Child M was living.

87. The young people’s service in Lancashire received their first referral about Child M in November 2011 as part of the routine support arrangements when Child M had been transferred to the PRU although it was April 2012 before they had their first direct contact.

88. Child M had already been referred to a local training provider working with young people at risk of becoming NEET (not in education, employment or training). The YPS took Child M to see the provider and arrangements were made for Child M to start the following week but Child M did not attend. Mother sourced the apprenticeship in business administration.

89. According to mother and stepfather they did a lot of the work in helping develop Child M’s CV and helping to broker arrangements at this time. They were not aware of the involvement of the YPS. Part of the reason was that Child M was staying with a friend when YPS were involved and any child over the age of 12 years can access YPS in their own right subject to an assessment under the Gillick competency11. Child M came to the attention of YPS when Child M turned up at a regular 'Drop In ' for young people seeking advice about accommodation and homelessness. YPS are not required to inform parents and the confidential nature of the service enables young people to seek the support they need (not withstanding any safeguarding or risk factors should this be disclosed).

90. In November 2012 Child M attended at a local housing drop-in service where an YPS worker happened to be on duty alongside housing staff. The YPS

10 Child M secured the following GCSE grades; PE – grade C (taken in year 10), chemistry - grade C, biology – grade C, physics – grade F (Child M did not hand in some course work so this reflects the grade) and Maths – grade C.

11 Gillick competency and Fraser guidelines refer to a legal case which looked specifically at whether doctors should be able to give contraceptive advice or treatment to under 16-year-olds without parental consent. But since then, they have been more widely used to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions. In 1982 Mrs Victoria Gillick took her local health authority (West Norfolk and Wisbech Area Health Authority) and the Department of Health and Social Security to court in an attempt to stop doctors from giving contraceptive advice or treatment to under 16-year-olds without parental consent.

of 65

worker knew Child M and therefore sought her out to speak with her. Child M reported that they had become homeless after an argument with mother and stepfather; Child M also said that a physical confrontation had taken place.

91. Child M agreed to a referral being made by the YPS worker to the local MIND service and for help from a local mediation service. One meeting took place with the MIND service in November 2012 during which there was a discussion as to whether counselling would be more appropriate for Child M with the PMHCT (Primary Mental Health Care Team).

92. According to information recorded by the young person’s service Child M returned home in November 2012. The young people’s service closed the case in January 2013 after Child M had repeatedly not kept to pre-arranged appointments; the case was allocated to a holding caseload.

93. Matters had reached a point by January 2013 of Child M not being willing to accept help from the young people’s or mental health services in Lancashire. Mental health services had also closed their involvement.

94. By March 2013 Child M was working as an apprentice in business administration.

95. Between May and June 2013 Child M participated in five sessions of counselling with the primary mental health team in Lancashire. The focus of the sessions were on Child M’s feelings of low self-esteem and poor self-image exhibited in feelings of guilt, shame and a high level of self-criticism. Child M also disclosed some distress about father’s use of alcohol and violent behaviour; the inference is that this relates to early childhood before the separation of Child M’s parents.

2.2 Escalation of self-harm and admission to in-patient CAMHS

96. From the beginning of 2013 Child M had been losing a lot of weight and there was increasing evidence of Child M self-harming again including cutting with a knife. In June 2013 Child M and mother were both becoming concerned about Child M’s increasing low mood and feelings of helplessness.

97. In the last session of the counselling Child M expressed thoughts of self-harm and of feeling unable to carry on. A referral was made to the local crisis team for a mental health assessment by the Crisis Resolution Home Treatment Team (CRHTT) who undertook a same day assessment12; the practitioner had

12 CRHTT provide a service to the people who are experiencing mental health problems that are in crisis or would perhaps require hospital admission. The service definition of 'crisis' is presentation of an individual whose normal coping mechanisms and resources have become overwhelmed by the

of 65

‘an impression of a substance induced disorder compounded by a background of childhood adversity’. As a result of that GP consultation a same day referral was made to the local mental health service and a place was found at the T4 CAMHS unit. With the agreement of Child M, mother and stepfather an admission was made to the unit the same day.

98. Mother took six weeks away from work during Child M’s stay at the unit and visited three times a day. Child M quickly began regaining lost weight. It was a ‘lovely time’ according to mother and stepfather; a ‘period of normality’.

99. A detailed history was taken during which Child M disclosed a long history of substance misuse including heavy use of cannabis, amphetamine and ‘bubble’ (mephedrone)13.

100.Child M self-reported a reduction in alcohol consumption since February 2013 as had the consumption of drugs but was using cannabis up to the admission to the unit. Whilst Child M was in the unit they did not use alcohol or drugs.

101.The four weeks that Child M was living at the unit provided an opportunity for Child M to be free from substances and engaged in a range of interventions that included psychological and dietary support, talking therapy and treatment with the anti-depressant medication. Child M’s mood and general health improved. During the stay Child M made a disclosure of inappropriate touching.

102.The Post Incident Review completed by the unit and was subsequently included in the papers submitted to the coroner stated that child M informed the ward dietician and nurse that they had gone to buy cannabis from a friend’s house in the company of another ‘friend’. The friend had inappropriately touched Child M and it was indicated that this was of a sexual nature. In the electronic records for Child M it is recorded that the “friend" was over 18 and at the time of the incident child M was 16 years old. Child M was 17 years old when an inpatient in June 2013. Child M did not want their parents or the police to be informed of the disclosure. A referral was made to children’s social care in Lancashire as per procedures.

onset or relapse of a severe mental illness, or through experiencing significant situational change and the crisis renders the individual and carer unable to manage their changed circumstances, presenting a risk to themselves or others, thus requiring an urgent specialist assessment of their mental health needs. The crisis needs to be sufficiently serious to require in-patient treatment if home treatment interventions were not available. CRHTT aim to provide a safe and effective alternative to in-patient care by helping people through times of mental health crisis in their own home environment and operate a 24/7 service.

13 Mephedrone (sometimes called ‘meow meow’) is a powerful stimulant and is part of a group of drugs that are closely related to the amphetamines, like speed and ecstasy. There isn't much evidence about mephedrone and its long term effects as it's quite a new drug but because it is similar to speed and ecstasy the long term effects may well be similar. There have reports of people hospitalised due to the short-term effects.

of 65

103.Child M had requested that mother and stepfather were not to be made aware of the information or referral which resulted in no further action. Practitioners made a judgement that Child M was competent and had the requisite mental capacity to withhold information from mother and stepfather. Advice had been sought in compliance with the Trust’s procedures and Child M was encouraged to share information with mother and stepfather.

104.Child M’s mother and step-father believe that there was an unauthorised absence from the Tier 4 unit. There is no record of any unauthorised absences and the safety profile does not indicate any unauthorised absences.

105.Mother and step-father made representations to the care trust in this regard and received a response. The response did not specifically clarify that the incident of touching was historical and therefore predated admission to the unit. Mother and stepfather remain convinced that Child M had an unauthorised absence although there is no other evidence of this being the case. Mother and stepfather are dissatisfied about this particular issue.

106. A pre-discharge planning meeting on the 9th July 2013 concluded that Child M did not have any signs or symptoms of a mental illness or disorder. It was felt by some at the meeting that the crisis that had precipitated the admission to the unit was an emotional response to the content of the counselling sessions. The episodes of emotional instability and ‘impulsive self-harm’ were thought to have been exacerbated by the substance abuse and adolescence.

107. The negative emotions shown in the counselling session were regarded as being positive evidence of developing emotional maturity and Child M was apparently not unduly troubled by her experiences. There was a concern to ensure Child M was not ‘pathologised’. It was thought that Child M might require psychological therapy in the future when able to cope with it. The decision was taken to discharge Child M with outreach support continuing for six weeks.

108. This decision and plan was supported by the majority of professionals who all believed that Child M along with mother and step-father were also in agreement. Child M’s mother felt that Child M had experienced a breakdown and was now making a good recovery. Mother expressed some understandable anxiety about Child M becoming involved with mental health services for the rest of their life. There was a general consensus that discharge was appropriate. The adolescent mental health consultant advocated that continuing involvement was required to prevent a further relapse as this was Child M’s first presentation and requested support by the complex care and treatment team (CCTT) service but CCTT did not feel child

of 65

M met their criteria14. Child M left the unit on the 12th July 2013. CRHTT continued their contact for a few weeks alongside Young Addaction and CAMHS.

109. Mother and stepfather have told the review that they felt that Child M was discharged too quickly although this is not the recollection or record of the professionals at the time. Although mother and stepfather felt that Child M and the other young people were nurtured and well cared for mother and stepfather felt that more work should have been done with them while Child M was at the unit.

110. Child M began a phased return to their apprenticeship with the support of their employer as well from the professionals and family. Initially things appeared to be greatly improved. Child M appeared to be abstaining from drugs and alcohol and contact with professionals was being maintained.

111.Within three or four weeks of leaving the unit mother and stepfather began to get a sense of things not being right although this does not appear to have been evident to professionals and in some of the contact described in later paragraphs the reports were positive from the family. Child M was coming home with angry stories about work and falling out with people and things rapidly went downhill. A week’s foreign holiday saw a number of angry confrontations that do not appear to have been discussed outside of the family.

112.On the 2nd August 2013 during a home visit by the CAMHS worker Child M disclosed using cannabis since the first home leave from the T4 unit (before discharge in other words) and had also since returning to live at home significantly increased their consumption. The worker stressed the potential risk and the negative impact on Child M’s mental health. These concerns were played down by Child M.

113.Four days later on the 6th August 2013 the CRHTT worker made a home visit. Child M was slow to open the door and said that they had not gone to work because of feeling too tired. Child M was distant and guarded and mono syllabic and was reluctant to engage in any conversation. Child M admitted smoking cannabis the previous day. Child M had not contacted their substance misuse nurse.

114.On the 13th August 2013 the Young Addaction worker made a home visit and discussed the relapse back into using cannabis. Child M attributed the relapse to a break up from a boyfriend.

14 The CCTT service is primarily for adults with moderate to severe enduring mental health problems/conditions. It is a multi-disciplinary team, operating five days a week 09.00 – 17.00. There is a section of the team that provides high intensive support/treatment known as assertive outreach targeting the harder to reach/engage patients. There is an overlap with the 16 – 18 years old and the CAMHS service.

of 65

115.During a home visit by the CRHTT on the 16th August 2013 Child M admitted continuing to smoke cannabis. Child M was asked if they wanted to continue with the support from the service. Child M confirmed they did although was not able to articulate their reasons. Child M was not willing to discuss or consider the risks associated with using cannabis. Mother (and stepfather) was not at home and was said to be away on holiday.

116.On the 19th August 2013 the CRHTT referred Child M back into the care of the Primary mental health care trust and discussions between CRHTT and CAMHS Outreach resulted in Child M being discharged from the T4 service. There was no diagnosable mental health problem and substance misuse was the primary concern. The continued involvement by the substance misuse services was considered to be the most appropriate response.

117.A joint home visit on the 28th August 2013 by CAMHS and CRHTT involved a meeting with mother and Child M. Mother was happy about the progress and was positive about the future (and contrasts to what they say they were dealing with at the time). They were both advised to continue with the support from the Young Addaction service.

118.Two appointments were cancelled in September 2013. A home visit by the Young Addaction worker on the 19th September 2013 that included seeing mother and stepfather identified no risks to Child M who reported having no problems and was working and appeared to have good relations. This did not reflect the real position at the time.

119.On the 3rd October 2013 the CAMHS wrote to the GP to advise them that Child M was being discharged from the service following non-attendance at appointments.

120.A home visit by the Young Addaction service on the 9th October 2013 discussed how much longer that service would be required. It was agreed that ‘a few more sessions’ were required to ‘ensure stability and reviewing the situation’.

121.Child M missed follow up appointment with the Young Addaction service and did not respond to the follow up telephone or text messages.

122.On the 21st October 2013 Child M contacted the police to report an assault by three people at the home of their boyfriend and that they were dealing in cannabis. The police went to the property by which time Child M had left. The police officers found no evidence of cannabis or of a disturbance. They were summoned to another unrelated and serious incident during which Child M appeared and again repeated the allegations. A DASH (domestic abuse, stalking and harassment) assessment was completed and a referral was made to the MASH (multi-agency safeguarding hub).

of 65

2.3 Overdose and admission to hospital emergency service

123.The following day on the 22nd October 2013 at 06.15 Child M contacted the T4 unit to report that they had self-harmed to their arms and legs and had taken an overdose. An ambulance was summoned and transported Child M to the local hospital emergency department. Child M had taken an overdose of antidepressants, antibiotics and codeine phosphate. According to the T4 unit staff they anticipated that they would be asked to readmit Child M to the unit. No referral was made by the hospital and in the event Child M did not return to the unit.

124.Not knowing that Child M was known to the Young Addaction service and it did not appear to be understood that a referral should have been made in any event to that service, no onward referral was made to Young Addaction. A referral was made to the Mental Health Liaison Team (MHLT) and LTHT records indicate that the school nursing service were also notified of the presentation; it would appear that this notification was never received.

125.Child M was admitted to a hospital ward and Child M was assessed by the mental health liaison service at 14.35. Child M declined a mental health assessment, was tired and wanted to go home. Child M agreed to see the crisis team the following day and agreed that they would keep themselves safe until seen by the specialist practitioner.

2.4 Further threat of self-harm

126.On the 25th October 2013 Child M contacted their ex-boyfriend to say they were going to kill themselves. The phone call was reported to the police who had begun the efforts to locate Child M when they were contacted by a member of the public to report that Child M was in a local road and was in possession of a razor blade. The police located Child M who was sober and calm initially but quickly became aggressive and assaulted the two police officers and damaged their police vehicle. Child M continued to be violent whilst in the custody of the police and it was not possible to conduct an interview.

127.A nurse employed by MEDACS was called to the police station. The nurse found Child M to be very agitated and the nurse felt that Child M might be under the influence of a substance although the physical examination did not identify any alcohol or opiate (legislation does not permit drug testing of a child under 18 years when arrested). Child M had a number of superficial cuts to the arms. The nurse assessed that Child M was fit to detain although was not in a condition to be interviewed, processed, transferred or released. Child M therefore remained in police custody. The nurse had concerns about Child M’s mental health and that Child M was possibly under the influence of

of 65

substances. The nurse wanted Child M to be reassessed within six hours of the initial arrest if Child M had not calmed down. A care plan was completed.

2.5 First mental health assessment following arrest

128.A second MEDACS assessment later the same evening was undertaken by a forensic medical examiner who coincidentally happened to be a doctor with psychiatric experience15. The forensic medical examiner had been asked to attend in order to assess Child M for fitness to detain (FTD) to establish whether Child M had any urgent medical condition (physical or mental) which meant that they could not remain in police custody.

129.The forensic medical examiner assessed Child M as being aggressive, abusive, uncooperative and condescending’ but was not displaying any disorder or affective abnormalities. There was no evidence of psychosis and Child M denied any thoughts about self – harm. Child M refused to engage when it was clear that the forensic medical examiner was unable to meet their demands (to be released or allowed to smoke).

130.The forensic medical examiner did not consider Child M to be mentally or physically unwell and was not in need of an admission to a hospital. The forensic medical examiner described Child M as displaying ‘controlled aggression’; a term used to describe the behaviour of somebody being angry or unpleasant but backing off and talking calmly before becoming abusive again. It is behaviour that the forensic medical examiner believed would not become physically abusive. The forensic medical examiner recommended observations every 30 minutes.

131.A vulnerable person’s referral was made by the police to the MASH and Child M was assessed by the mental health team who deemed Child M to be fit for release.

132. During the day stepfather made several phone calls to the CRHTT service, the crisis team and the T4 unit asking for help and expressing his concern about what would happen when Child M was released from the police station. He felt that Child M needed to go to hospital. There was also contact with the criminal liaison nurse who had seen Child M at the police station and confirmed that Child M was not suffering a diagnosable mental health condition. The review was told that stepfather had confirmed that he was going to try to persuade Child M to seek help from the drug and alcohol services. Stepfather has disputed this and has continued to express his view that it was Child M’s mental health that was his concern.

15 MEDACS is an international company providing a range of recruitment, staffing and managed health services in the public and private sectors. They provide managed outsourced healthcare services to police and prison services. The health care professionals have a range of experience and not all have the level of psychiatric experience of the forensic medical examiner who saw Child M.

of 65

133.Child M was released to the care of the family at 14.00. The stepfather was concerned about Child M but agreed to take Child M home. Mother was described as not coping well. The CRHTT offered to provide advice and support if it was needed.

134.At 16.20 the same day Child M texted the ex-boyfriend threatening to jump from a motorway bridge. Child M was located by the police and maternal grandmother. The police sought advice from the mental health crisis team who felt that Child M might have a personality disorder but was not mentally ill; Child M was never diagnosed with a personality disorder according to the information given to the review.

135.A vulnerable person (VP) referral was made to the Lancashire MASH and CSC. The risk assessment concluded that there was a high risk of harm. It was thought to be highly likely that Child M would self-harm again. The history of admission to the T4 CAMHS unit, of overdosing and threats to self-harm and threats of suicide was recorded. The VP referral was sent through to MASH. Child M went to the home of the maternal grandparent.

136.Co-incidentally, on the 28th October 2013 the Young Addaction service wrote to Child M to advise that because of the lack of response to phone and text contacts they wanted to confirm whether Child M wanted to continue to have contact and support from the service otherwise they would begin the discharge procedure to close their involvement. Child M subsequently made contact with Young Addaction on the 1st November 2103 apologising for their lack of contact but stated that ‘everything was OK’. Child M said they were busy at work and an appointment was made for the 7th November 2013.

2.6 Lancashire police referral to Tameside children’s services

137.The police through CSC in Lancashire made a referral to CSC in Tameside on the 28th October 2013. The referral informed Tameside that Child M had moved into their area to live with father and/or grandfather. The referral included information about Child M having recently lost their job and the breakdown in relationship with their partner and the history of visiting their home and incidents of self-harm. Information about the admission to the T4 unit was also included. Child M’s difficulties in accepting help from services and the impulsive pattern of risk taking and self-harming behaviour were also explained. The referral described Child M as being at high risk with little or no agency support and that Child M was at immediate risk without access to a service.

138.The referral from Lancashire was triaged by the duty manager and allocated to the work tray of a support worker to pick up the following week. The support worker referred the information to the 16-19 service in Tameside.

of 65

2.7 Child M’s first appearance in court and allocation to youth offending services

139.Child M appeared before the youth court on the 5th November 2013 for the assault on the police officers and was sentenced to a three month referral order. The court was advised that Child M had moved to a Tameside address. A youth justice specialist worker was on duty and in court for Child M’s (and other young people’s) attendance before the magistrates to answer charges for different offences. It was a busy day. It was Child M’s first appearance in court and appeared one of the more straightforward of the several cases that were in court that day.

140.The report of the court outcome was sent to the YOS in Lancashire. The case was allocated to a part – time worker on the 6 th November 2013. A letter was sent to Child M’s family home address arranging an initial appointment for a home visit on the 13th November 2013 on the wrong assumption that Child M was living there when in fact Child M had already moved to live with birth father in Tameside.

141.The case was reallocated to another YOS support worker on the 8 th

November 2013 because of workload issues. The planned home visit for the 13th November 2013 was cancelled. An attempt to make an alternative appointment using the mobile numbers provided on the court outcome information was unsuccessful. The manager spoke to Child M’s father in Tameside and made an appointment for the 15th November 2013. The manager assumed the parents lived together at the same address in Lancashire.

142.On the 11th November 2013 the birth father contacted the police to report that Child M had not been seen since the evening of the 9th November 2013. Father informed the police that Child M had a history of self-harming and contact with mental health services. A missing from home (MFH) risk assessment was recorded at medium level. The following day (12th

November) birth father informed the police that he had seen Child M who had told him that they were staying with Adult 1. Child M was judged to be safe and well and capable of making decisions according to the police.

143.On the 12th November 2013 Child M had the last contact with Addaction when visiting a drop in session at a local college. Child M reported feeling well and stable and had made a box of chocolates for the worker. Child M said that work and home circumstances were positive and stable and that personal relationships were also good. It was agreed that no further appointments would be required.

144.On the 14th November 2013 Child M contacted the police to report that they had been assaulted by Adult 2.

of 65

145.On the 15th November 2013 the YOS manager went to mother’s address in Lancashire for the appointment that had been made by mobile telephone with father and found nobody at home. The manager sent a further letter to mother’s address arranging a further appointment on the 22nd November 2013.

146.On the 18th November 2013 a letter was sent to Child M at mother’s address inviting Child M to attend a referral order panel on the 25 th November 2013. Child M’s mother phoned the following day to inform the YOT manager that Child M had not lived at the address since the offence was committed. Mother stated that Child M was living with father but that she might also be living at another address (Adult 1’s home) in Tameside; details were provided by Child M’s mother.

147.An unsuccessful attempt was made to contact Child M at the father’s address. A decision was taken to initiate breach procedures because of a mistaken belief that Child M had moved without informing the YOT in Lancashire.

148.On the 20th November 2013 Child M contacted the police to report an assault by Adult 1 that had occurred at Adult 1’s’ property. Police attended but neither Child M nor Adult 1 wanted to make a complaint.

2.8 First contact from Lancashire YOT with Tameside YOT

149.On the 25th November 2013 the first contact was made with Tameside YOT when the practice manager in Lancashire contacted the Tameside YOT manager. On the same day Young Addaction spoke to Child M by phone to confirm that there were no problems or concerns and closed their involvement. Child M had been in contact with Greater Manchester Police at 06.46 that day to report an assault by Adult 1. Child M alleged that Adult 2 had threatened to kill Child M if they did not leave Adult 1’s’ property.

150.On the 27th November 2013 the Tameside YOT telephoned Lancashire YOT to inform them that they had been unable to establish contact with Child M.

151.On the 28th November 2013 Tameside YOT informed Lancashire that they had made contact with Child M and requested a transfer form to be completed.

2.9 Child M’s arrest and detention by Greater Manchester Police

152.On Saturday the 30th November 2013 the police were alerted to a broken window at a community property in Tameside. Child M had broken in and had been sleeping at the property.

of 65

153.The police had previous contact with Child M earlier in November. On one occasion father had reported Child M as missing from his home. The police also responded to a report of a domestic argument involving Child M and Adult 1. They had also received information on another occasion about Child M being in a relationship with another adult male. In all of those contacts, Child M’s age and vulnerability in regard to use of drugs and the age difference between the males and Child M were not recognised and therefore reported to the specialist officers in PPIU.

154.Child M was arrested for criminal damage and was also found in possession of cannabis. Initially Child M was compliant and was placed in a police van without handcuffs being applied. Child M became very agitated while the police vehicle was stationary when the police called at the local police station where the police officers needed to collect documentation regarding the criminal damage. Handcuffs were applied to Child M for the remainder of the journey to the main police station at Ashton. On arrival at the police station Child M required further restraint.

155.A registered nurse from MEDACS was requested by the police to attend the police station to complete a FTD assessment. The nurse who was very experienced visited Child M in the cell at about 22.25 and observed that Child M was very drunk and under the influence of drugs and incoherent in speech. Child M had also removed their clothing. Child M was thrashing about and waving their arms around which made it difficult to take a blood pressure reading. The nurse began talking to Child M and taking a history. Although Child M continued to be erratic in their speech and movement the nurse was told something of Child M’s recent circumstances and that Child M was living with father in Tameside. Child M was very disparaging about father and made allegations of being hit by him and alleged that he was a drug user.

156.The condition of Child M meant that the nurse was unable to complete a full assessment but advised the police that Child M was not fit to be released because of the current condition, history of self-harm and having no fixed address. The nurse thought that Child M would need at least six hours before being fit to interview and possibly longer. A care plan was agreed for Child M’s stay in custody.

157.Child M remained in police custody overnight and on the 1st December 2013 another two nurses from MEDACS were asked to assess Child M at approximately 15.50. One of the nurses was shadowing the other as part of their induction.

158.The nurses were told that Child M’s behaviour had not calmed down. The nurses began taking a medical history and were told by Child M that they were on medication for depression. Child M said that they were taking sertraline and had been on 250 mg. The nurses immediately realised that this was an unusually large dose. Child M said that the GP had stopped

of 65

prescribing because Child M did not have a fixed address. The nurse asked about history of self-harm and thoughts of suicide; Child M acknowledged this earlier in the year. The nurse was unable to complete the examination or conversation; Child M became very angry about wanting a cigarette and being told that it was impossible because of the no smoking policy. Both nurses left the cell feeling intimidated by the level of verbal abuse and anger.

159.Once outside the cell and in discussion with the custody sergeant it was agreed that further enquiries should be made with the crisis team. Neither of the nurses were aware that Child M had been an inpatient in Lancashire rather than in Greater Manchester and the name of the unit had meant nothing to either of them. They drew a blank on getting any further information.

160.The second nurse went back into the cell with the purpose of trying to get further information and to complete the assessment. Child M gave the name of the local town in Lancashire although this still did not help either nurse with the identity of the T4 unit. The nurses advised that Child M should be subject of observation at 30 minute intervals and was fit to detain and could be interviewed with an appropriate adult. The nurses may not have been told that Child M had expressed any intent to self-harm which had included a threat to jump from a bridge when released. The information was not passed on to the court officer or YOT worker when Child M subsequently appeared in court.

161.An appropriate adult was requested through the out of hour’s social work service in Tameside and attended at the police station. The interview and the period in police custody was the subject of the IPCC investigation and the review team have not had opportunity to speak to the police officers who had contact or interviewed Child M.

162.Child M appeared in court exhibiting ‘bizarre behaviour’ which included waving arms around for example. Child M was bailed to father’s address. There was an older male (Adult 1) waiting outside the court for Child M.

163.Checks made by Tameside YOT on the 3rd December 2013 had identified that Adult 1 was on bail for a domestic abuse offence and had previous history of assaults including on police officers. That address was not suitable for Child M. It was later the same day that Child M died having apparently taken their own life.

of 65

3 Appraisal of professional practice in this case

164. Information about Child M’s history and circumstances was incomplete and contact and interaction between professionals took place within agency and professional silos. This occurred at school as well as with health and specialist substance services and was evident in how the police managed two significant episodes of arrest and custody.

165. This hampered people who clearly wanted to help and keep Child M safe from having a good enough understanding about the underlying factors contributing to their distress and disconnection. Matters were not helped when there was a fundamental divergence between mother and stepfather’s increasing conviction that Child M was mentally ill and the view of professionals that Child M was not suffering from any diagnosable mental illness.

166. Initially it seems there was a divergence between school and the family about Child M’s early misdemeanours. As time went on and the level of sanctions intensified there appeared to be more acceptance for both parties to address issues of behaviour although this never went beyond the school and the application of behaviour management strategies designed to achieve an improved compliance.

167. Child M was never identified as a child in need or requiring protection or a child with additional educational or social needs. This meant that Child M was never the subject of any statutory or multi-agency child assessment. None of the organisations or professionals had a comprehensive family and social history. Frameworks such as the CAF were never considered and referrals to specialist services such as CAMHS were delayed; mother and stepfather say they wanted referrals and contact to be made but this does not seem to have been understood by school who thought here had been a reluctance on the part of Child M and the family to agree.

168. It is now known that during Child M’s early childhood there was domestic abuse and substance misuse although there is no further detailed history recorded. Child M’s parents separated although the exact date is not known to any service or professional. Similarly there was no information available to professionals about when Child M moved to Lancashire and where else Child M and mother had lived.

169. It is apparent that very soon after beginning secondary education Child M began to display increasingly challenging behaviour at home and at school. Child M smoked cigarettes and cannabis and used alcohol although there is no information about when this began. Some studies have linked the use of alcohol to increased levels of aggression and cannabis to damage in the development of the adolescent brain.

of 65

170. There is evidence that Child M was using amphetamines in the latter months of life. Child M’s changing drug use is thought to have had implications for how Child M presented and behaved. Amphetamine use in adolescence can cause neurobiological imbalances and increase risk-taking behaviour, and these effects can persist into adulthood, even when subjects are drug free. Although substance misuse was a significant factor in Child M’s life and was a contributory factor in episodes of very aggressive or risk taking behaviour it was probably symptomatic of other factors that nobody is in a position to fully understand.

171. When Child M began to display disruptive and challenging behaviour the initial response was to approach it as an issue for behaviour management or anti-social behaviour. Child M’s behaviour was at times offensive and confusing and it remains unexplained.

172. The pastoral support plan developed at school involved a great deal of contact between the school and Child M’s mother and stepfather. The response to Child M’s anger and aggression appeared to be a continued focus on behaviour management. This persisted throughout the succession of exclusions until Child M was permanently excluded from mainstream education in November 2011. Government and professional guidance acknowledges that although disruptive behaviour has to be tackled and managed, it is important that strategies in respect of individual pupils and school policy generally pay attention to the identification of any underlying needs or problems.

173. Although it is apparent that there were senior school staff who were very aware of Child M’s behaviour and wanted to avoid a permanent exclusion and deployed a number of strategies such as the time out plan when Child M felt they were losing control, it is clear that there was never a consideration of using a CAF or trying to access specialist counselling or psychological support. The reason for this was that Child M was not seen as a child requiring specialist or social care support; some of this probably relates to the fact that Child M was articulate, highly intelligent and came from a professional family.

174. The local authority pupil access team that provided written comment and advice in regard to the permanent exclusion focussed on whether the decision complied with relevant national guidance and law and concluded that it did. The team provided limited input in regard to the extent to which Child M’s needs were being adequately assessed and taken account of. A system that was more focussed on the needs of children would be giving better account of how the needs of a distressed and challenging child need to be taken account.

175. Although there are several examples of individuals trying to help Child M the overall pattern to the intervention was to focus too much on immediate

of 65

signs and symptoms and not enough on exploring background and context and without enough awareness of what other people and services might be doing.

176. It is also apparent that for some professionals, there was a concern about not wanting to have Child M diagnosed as having a pathology of psychological or psychiatric problems although this was not a reason for not diagnosing a mental health condition. There were no recognisable symptoms as indicated in other sections of the report.

177. There was a fundamental dichotomy or disagreement between mother and stepfather who believed that Child M was suffering some form of mental health crisis and the resistance came from professionals not wanting to label or categorise especially when they were observing Child M in a much calmer mood. Although an account has been given about the absence of symptoms of mental illness there is no evidence that any of the people or services in contact with Child M during these critical contacts gave consideration as to whether there was evidence of Child M lacking any mental capacity; this is different to mental health or mental illness16.

178. There was also some evidence that some professionals (such as the forensic medical examiner) felt that aspects of the extreme behaviour was in fact controlled and with intent; a strategy of learned behaviour that had worked until it was deployed in a very controlled and secure setting such as a police custody suite.

179. Other factors were the way that Child M’s behaviour was defined. Without doubt, there was behaviour that was very challenging and at times broke the rules (at school for example) or the law (for example in regard to assaults and breach of peace and damage to property). A defining characteristic of the intervention was to focus on the behaviour and for the last weeks of Child M’s life the response became largely framed around youth justice services that did not identify Child M as a child who required safeguarding. This does not mean that professionals such as police officers who were called when Child M’s behaviour was out of control were not focused on the immediate protection of Child M. In Lancashire the police made a referral through the MASH which was forwarded to CSC in Tameside although this did not get followed up as a high risk referral in either area. Greater Manchester Police had Child M in a police station for weekend and although health professionals were consulted at no stage was there contact or discussion with specialist officers.

180. The problems of focussing on behaviour in isolation from looking at the history and circumstances of the child is that very limited opportunity was available to explore the reasons for Child M’s behaviour and interaction with

16 The Mental Capacity Act 2005 provides a framework to empower and protect people who may lack capacity to make some decisions for themselves.

of 65

other people. There are many reasons why children will present with distress and challenging behaviour. It is a fact that emotional and psychological health is affected by the consumption of substances such as cannabis and that early child hood trauma or difficulties can have significance for a child as they grow older. Self-harm and psychological crisis can be associated with children who have experienced abuse but have felt unable to disclose or talk about it.

181. Allied to this was the convergence of Child M’s age and the transition between child and adult services. This had some profound implications especially in regard to accessing child based mental health services. A defining ethos discussed in some of the practitioner groups centred on the distinction between an ethos in child based services that aims to be child centred in approach and acknowledges a need for a child to be nurtured and protected; the contrasting approach in an adult based service that a young adult that has to take responsibility for themselves unless there is some diagnosable condition that renders them incapable of doing this.

182. The use of a police station on two separate occasions to detain Child M is of concern. Although on each occasion it is apparent that police officers were focussed on keeping Child M safe the use of a police station for such purposes is inappropriate unless no other option is available. On neither occasion was there any consultation with the respective local authority social care service on a safeguarding strategy for a vulnerable child or exploring alternative accommodation to a police station.

183. There are key episodes or incidents where professional practice is commented upon in further detail.

3.1 The admission and care provided at the T4 unit in June and July 2013

184. The GP referral to the mental health service was prompt and resulted in an admission to the T4 unit the same day and was a clear recognition about the risk of Child M’s self-harm. It was successful in helping Child M and there is consensus from mother and stepfather and professionals that it was beneficial. It brought stability after what had been weeks if not months of very difficult relationships and behaviour.

185. There is some dissonance between the recollection of professionals and their records and the account that is provided by mother and stepfather regarding the timing of Child M’s discharge; they say that the discharge happened too quickly although this does not appear to have been articulated at the time in meetings with professionals.

186. However, on the basis that Child M was admitted and cared for on a voluntary basis there were no grounds in any event for any professional to override the wishes of Child M to be discharged from the unit or to seek any

of 65

court imposed orders through either the mental health or child care legislation.

187. The duration of the stay at the unit was short when compared to the average length of stay in a T4 unit (116 days) although there is no such thing as a recommended minimum or maximum stay; each episode of care has to be determined by the team working with the individual child17. It did not involve community services from other organisations largely because there had not been much involvement. Although there were initial disclosure and discussions where Child M was giving some account of their life and circumstances it is not apparent that this was a significant aspect of ongoing work. The focus was upon working on the substance misuse which all practitioners were led to believe had been addressed largely by Child M choosing to abstain. This was subsequently shown to not be the case.

188. Child M’s emotional, mental and physical health was assessed and Child M was not diagnosed with either a mental health or personality disorder. The working hypotheses appeared to be that Child M’s use of substances had been the significant factor.

3.2 The arrangements for discharge from the T4 service and follow up support

189. Child M had shown no signs of a mental illness or personality disorder during the four weeks as an in-patient and no incidents of self-harm. The previous incidents of self-harm were generally regarded as having been impulsive and could have been exacerbated by the substance misuse.

190. There was a difference of opinion as to whether Child M required support from the complex care and treatment team (CCTT); the majority felt this was not necessary and in the absence of any more formal psychological or psychiatric symptoms the service was deemed inappropriate. There was concern about not wanting to pathologise the symptoms and behaviour. Child M was seen to be a child who had a supportive family and the discharge plan was effectively a loosely structured schedule of visits for up to six weeks without any detailed further plan.

191. The home visits were undertaken by the CAMHS outreach service. Although Child M disclosed using cannabis there was no direct discussion between the CAMHS and the Young Addaction service.

192. After a series of failed appointments in September 2013 the CAMHS outreach service closed their involvement and notified the GP by letter on the 3rd October 2013 without any formal review. An assumption was made that if

17 The average length of stay across all T4 units did not differ significantly between 2012 and 2013 (123 days compared with 116). Child and Adolescent Mental Health Services (CAMHS) Tier 4 Report; NHS England, July 2014.

of 65

there was a re-emergence of problems that contact would be made with the service.

193. At the point of closure Child M’s circumstances were apparently much improved; Child M had responded to the help that had been provided, there were no reports of further thoughts of self-harm and had secured employment and training and was living with a supportive family. Although there had been at least one home visit when mother had been present the majority of contact appeared to be with Child M.

194. The team were not consulted when the criminal justice team liaison worker became involved in an assessment of Child M during the first episode of detention in police custody in October 2013.

3.3 The overdose and admission to hospital in October 2013

195. Child M’s phone call to the T4 unit just after 06.00 on the 22nd October 2013 in a distressed state alerted staff to a significant episode of self-harming behaviour; Child M was distressed and had cut their arms and legs and taken an overdose.

196. Although the T4 unit anticipated that they would be asked to take Child M back into the unit and had a bed available no request came through. No referral was made; the unit had notified the CRHTT. Child M was discharged from the hospital ward as medically fit and had been seen by the Mental Health Liaison Team and a plan of care formulated. There was no further assessment undertaken as Child M declined a mental health assessment.

197. The Young Addaction service was not made aware of the incident until the information was made available during this review.

198. The overriding impression is that nobody took a lead between the different parts of the health service. Given the recent serious concern about self-harm that had required support from the T4 service a review of the new information and a risk assessment would have been merited. Less than 72 hours after this incident Child M made threats to self-harm again which resulted in the police becoming involved.

3.4 The police detention and mental health assessments in October 2013

199. The escalation of risk from self–harm triggered the extended detention of Child M in police custody on two separate occasions. The focus of the police on both occasions was the safety of Child M although on both occasions it involved Child M remaining in a police station for extended periods of time. The police would acknowledge along with every other service involved in this review that a police station is not an ideal environment within which to be

of 65

providing care to a vulnerable child. There are also statutory limits on how long the police are able to keep a child (or adult) in custody18.

200. The first episode in Lancashire on Friday the 25 th October 2013 after they had been called by Child M’s mother and stepfather following a confrontation; Child M’s behaviour had become more confrontational with the police and with mother. The police officers were concerned that Child M might attempt to self-harm and believed (correctly) that a razor blade was secreted in the hand.

201. Child M was taken to the local police station where the behaviour continued to be very confrontational and out of control. The MEDACS nurse who attended the police station undertook an assessment of whether Child M was fit to detain. The conclusion of that visit was that Child M was under the influence of substances and should be reassessed later in the evening.

202. At 23.30 a doctor with a background in psychiatry began an extended assessment of Child M. As part of that assessment the doctor took a history from Child M and also spoke with the stepfather. Although the police officers and stepfather were concerned about Child M’s mental health the doctor found no recognised symptoms that would have supported a diagnosis of any mental illness. The assessment took place over more than four hours.

203. The written information from the doctor describes Child M as being aggressive, abusive, un-cooperative and condescending. The doctor described Child M as displaying ‘controlled aggression’. Child M showed no speech or thought disorder, displayed no sign of hallucinations or obsessive compulsive disorder. Her cognitive functioning was intact and knew where they were and what time it was. No evidence of psychosis was present. Child M was angry but not low in mood. There was no hyper mania and no sense of grandiosity. Child M did not want to see the Crisis Team or anybody from the T4 unit. Child M denied having any thoughts of self – harm.

204. The doctor commented about Child M responding to some boundary setting by police officers and noted that when Child M realised that their demands to be released were not in the control of the doctor they withdrew their cooperation with the forensic medical examiner’s assessment.

205. The account of the assessment provides a compelling account of very disruptive behaviour but not of a mental health crisis. The account also suggests a level of rationality and a query as to whether Child M still represented a risk to themselves at this stage.

18 The police can hold in custody for up to 24 hours (although can apply to have this extended; the police also have powers of protection that allow them to keep a child in a place of safety for up to 72 hours.

of 65

206. Child M remained in police custody overnight. At around 10.00 Saturday 26th October 2013 a further assessment was made by the criminal justice liaison worker who is a mental health nurse. According to the information provided to the nurse, the police had spoken with stepfather who had made them aware of the involvement of mental health services. The nurse was able to access records held by the Lancashire Community Foundation NHS Trust and identified the history of contact with the T4 and Crisis Team. The records also showed the overdose on the 22 October 2013. The nurse spoke with stepfather who explained that he felt that mental health services were trying to ‘shut the door’.

207. Although the nurse initially found Child M uncooperative and reluctant to engage Child M agreed to talk eventually. Child M made clear they wanted to go home and wanted to smoke a cigarette. They discussed what support that Child M might want to have. They discussed the self-harm and Child M explained that it helped her at times of distress (coping with difficult emotions).

208. Self–harm is very distressing to witness and can represent significant risk to the child and can be very difficult to understand; the act of self-harm helps some children with dealing with difficult life experiences or thoughts. It is for this reason that any action to address the risk of self-harm has to take account of how to help deal with the underlying distress and causes which may extend back into early childhood as much as reflecting the child’s current circumstances.

209. The nurse completed a care plan. This is not a comprehensive or very detailed document but is a record of the advice given to Child M and gave Child M information about sources of advice and help. In truth, the purpose of the care plan is to leave documentary evidence of what advice has been provided and action whilst in custody. The nurse notified the Crisis Team of the assessment and also spoke with stepfather. He was said to be not happy with the outcome but according to the nurse appeared to accept the assessment.

210. When the nurse returned at 14.00 the same day it was because the custody sergeant had requested a mental health assessment. The assessment concluded that there was no evidence of mental illness. Child M was distressed, shouting and upset but had no delusional thoughts, and had no current thoughts to harm them self or others. Child M had no hallucinations and was orientated in time and place. Stepfather and maternal grandmother came to the police station and it was agreed that Child M would be released from police custody; this was over 20 hours after the original arrest.

211. Within two hours of being released Child M made threats to jump from a motorway bridge following an argument with a boyfriend. The police and

of 65

grandmother had located Child M and grandmother was able to persuade Child M to go with her to her home.

212. The information submitted by the police to the multi-agency safeguarding hub (MASH) in Lancashire as well as to health and mental health services provided an account of the contact with Child M and records the concerns of the police regarding Child M’s vulnerability. A social worker followed up the information in a telephone call with mother on the 28 th October 2013 who was told that Child M had moved to live with their grandparent and was living in Manchester. A referral was made to Tameside CSC the same day although this appears to have been done without any direct discussion from Lancashire with CSC in Tameside.

3.5 The referral to Lancashire MASH in October 2013 and assessment

213. The written referral made by Lancashire on the 29th October 2013 to Tameside CSC described the incidents of self-harm and contact with mental health services in Lancashire. The referral noted the recent hospital admission following an overdose and that Child M had lost their job and a relationship had broken down. The referral described Child M’s feelings of depression and thoughts of suicide. It included information about the contact and custody with Lancashire police and confirmed that the current risk grading was high with Child M being ‘highly likely’ to self-harm again.

214. The referral was put into a holding tray at Tameside CSC and was allocated to a family intervention worker to complete further checks. The FIW is not a registered and qualified social worker but a professional who works alongside social workers and can be allocated tasks in regard to making enquiries. These were not started until a week later on the 5th November 2013 when the FIW spoke with the paternal grandfather and contacted the 16-19 CAMHS team to refer Child M to them. CSC ended their involvement. The CAMHS had noted the history of self-harm and made a couple of phone calls to the team in Lancashire who explained that assessments had not been completed in Lancashire because Child M had left the area.

215. Child M was not regarded as an urgent CAMHS referral and a provisional date of the 23rd December 2013 was scheduled for a first appointment with Child M. The letter had not gone out by the time that Child M died. The service has experience of working with young people with similar profiles as a dis-regulated group who are generally young girls who when faced with an interpersonal crisis respond in extreme ways sometimes involving self-harm.

216. No social work assessment was completed by CSC. The referral from Lancashire was processed as an information report; the fact that Lancashire CSC were not involved through a child in need (CIN) or child protection plan was influential in the triaging of the referral by Tameside.

of 65

217. The triaging which had been done by a duty social worker and manager did not involve any direct discussion with anybody in Lancashire, gave insufficient attention to the indicators of high risk of self-harm and vulnerability confirmed by the delay in making any enquiries at all regarding Child M’s circumstances. The manner in which the information was transferred between the two areas and how it was processed did not reflect the serious concerns that professionals in Lancashire had about Child M. There was no discussion with Child M’s mother or stepfather.

218. The final chapter of the report that describes findings and action required makes reference to the workload of the duty service, the prevalence of self-harm referrals and the apparent mind-set that were all factors in how the referral process was handled.

3.6 Assessment and allocation to Youth Offending Services in Lancashire and Tameside

219. Child M’s first appearance at court on the 5th November 2013 occurred after leaving mother and stepfather’s home and moving to Greater Manchester. There is little detail recorded by any of the agencies about the exact sequence and location of where Child M was living for several weeks. Initially Child M had been taken to maternal grandmother’s home, had spent some time at paternal grandfather’s before moving to Child M’s father’s home in Tameside. What was clear by the time that Child M appeared in the magistrates’ court on the 5th November 2013 was that Child M was living at father’s address and this was the information provided to the court and processed by the youth justice specialist social worker who was on court duty that day. Father was in court with Child M; mother and stepfather did not attend (and were not required to).

220. Given this was Child M’s first appearance in court it was anticipated that a referral order would be the decision of the court; as expected the magistrates made a three month order and the address provided to the court was father’s in Tameside.

221. The administration of a referral order is usually quite routine. A file that contains details of the young person together with the crime for which they are being brought before the court which is set out on a green sheet. Once the court has made a decision the youth justice specialist worker completes an outcome ‘blue’ sheet that records details of the decision together with other information such as address.

222. The court was busy that day and the specialist worker did not finish until 18.00 before leaving the paper work from the court appearances for the YOT office to process the following day.

of 65

223. Child M’s case was initially allocated to a part time YOT worker who began the process of setting up the initial visit with Child M and arranging a date with the local referral order panel. Critically, the worker used the address of mother and stepfather rather than noting the different address recorded on the court outcome sheet. This proved to be a fundamental error that led to the referral order not being properly processed and ultimately contributed to neither of the YOT services undertaking an adequate follow up and implementation of the referral order.

224. After the case was re-allocated on the 8th November 2013 to a second YOT worker in Lancashire because of workload of the first the second worker also failed to note the error in the address being used.

225. The error was eventually identified when Child M’s mother contacted the YOT service on the 19th November 2013 to say that Child M was no longer living with her. This phone contact was prompted by the receipt of the second letter from YOT re-arranging a scheduled home visit after the case had been re-allocated; mother had not made contact after the first letter. Mother explained that Child M was supposed to be living with father in Tameside but also provided a second address that Child M might be using (which was the address of Adult 1 not father).

226. Contact was not made with Tameside for almost a week. When a phone call was made on the 25th November 2013 there was further confusion in as far as Tameside were led to believe that they were making a visit on behalf of Lancashire rather than the fact that the original order had been made to a Tameside address but Lancashire had not notified the Tameside YOT. Tameside were asked to check an address (father’s) in Tameside to enquire if Child M had relocated to the area as Lancashire were having difficulty in locating them. The details about the second address were not supplied until an email was sent from Lancashire the following day. Initial information provided to Tameside included reference to the threats of self-harm, a history of depression and Child M being NEET (not in education, employment or training).

227. The confusion about which area had the referral order persisted; both areas initiated a transfer process from Lancashire to Tameside.

228. A visit by the Tameside YOT on the afternoon of the 28 th November 2013 to Adult 1’s address located Child M who was ‘cagey’ about living arrangements and how long they were staying there; the YOT worker reported no safeguarding concerns. This judgment appears to have been made based on Child M’s presentation and assertions and without any checks being made on Adult 1’s background or establishing what the relationship was between Child M and Adult 1.

of 65

229. It was apparent that Tameside were assuming that Child M was going to be resident in Tameside and there was enough information to indicate vulnerability. Good practice would have made more thorough checks at this stage but because Tameside were operating on an assumption that this was a Lancashire order no further work was done until the transfer had been completed. Child M was arrested and appeared before Tameside magistrates before the transfer had been completed.

230. The basic error in what should have been a routine procedure contributed to a lost opportunity in using the referral order to address the chaos and difficulties that Child M had. It does not mean that the referral order would have provided a solution but if it had been correctly processed it would have allowed an opportunity to talk with Child M and relevant members of the family about the difficulties leading up to the offences and afterwards.

231. It is concerning that in addition to the errors in regard to the address, there was no effort made to make any enquiries about Child M over and above the processing of format letters setting up appointments that were sent to the wrong address. There had been contact with services back to 2010 and if contact had been made with the MASH the YOT would have been alerted to the detail of risk. Given the vulnerability of many of the young people who will come to the notice of a YOT this appears to reveal a systemic weakness in both the mind-sets and procedures that were applied with Child M.

232. There were problems in being able to process all relevant checks when the YOT was informed that Child M was in court on the 2nd December 2013.

3.7 Child M’s mental health assessment whilst in police custody in Tameside and attendance in court

233. Child M’s second episode of significant contact and custody after moving to Tameside involved the Greater Manchester Police19. As described in the previous chapter the initial arrest was in relation to a relatively minor offence of criminal damage. However, as on the previous occasion in Lancashire, Child M’s verbal and physical aggression quickly escalated during the journey to the police station and was sustained over the entire period that Child M was in custody over a whole weekend. The reason that Child M was kept in police custody was because of concern about Child M’s safety; there would have been no other reason or circumstances that would have required the police to have detained Child M after taking a statement about the criminal damage.

19 Greater Manchester Police dealt with an incident in the 11 th November when Adult 1’s previous partner ejected Child M from his property; the police dealt with a MFH the same day when father contacted them. On the 14th November 2013 Child M told the police of being assaulted by Adult 2. On the 25th November 2013 Child M reported an assault by Adult 1. None of those contacts triggered a safeguarding referral either in regard to domestic abuse from an intimate partner or in regard to a child aged 17.

of 65

234. The custody sergeant recorded that on arrival Child M had been drinking alcohol and smelt strongly of cannabis and had old self-harm marks to their arms and legs. Within half an hour (21.49) the police requested a MEDACS assessment as to whether Child M was fit to interview. Checks on the PNC revealed information about a history of ‘attempted suicide’ and the fact that Child M suffered from depression.

235. The MEDACS nurse arrived at just before 23.00. Child M was still intoxicated, had removed their clothes and was ‘erratic’ in their behaviour. The nurse advised that Child M should be reassessed in six hours. Child M was the subject of half hourly checks.

236. There was no apparent consideration as to whether a parent should be contacted; the police were aware that Child M was living with father. A factor that appeared to influence decision making was the fact that it had been a row between father and Child M the previous day that had been significant in the original arrest along with other factors relating to substances. This would not have precluded an effort to locate mother (or stepfather). In the event the decision eventually was to request an appropriate adult to attend although this was not decided until after 10.00 the following morning and this was after Child M had been arrested again for causing criminal damage to the cell door.

237. The decision to request an appropriate adult (AA) appeared to be more influenced by complying with the PACE protocols and requirements. The AA attended along with a duty solicitor although an interview was cut short because of the escalating threat to them from Child M.

238. The police requested a further medical assessment which was conducted by two nurses who were unable to complete their interview with Child M due to the escalating aggression. Although these nurses checked with two local mental health trusts neither of them had any record of involvement with Child M. The system checks do not appear to have identified that the 16-19 service had received a referral (although had yet to make contact with Child M); the presentation of Child M with the police may have allowed a re-prioritising by the CAMHS if they had been made aware. The nurses were provided with the name of the T4 unit but were unable to locate any details (although the review team were able to identify it through using a standard internet search engine).

239. The police kept Child M in custody until the 2nd December 2013 when Child M was taken to court. The police recommendation for Child M to be remanded into custody was inappropriate and in any event Child M was bailed by the magistrates. Specific information about Child M’s threat to jump from a bridge when they were released from custody was not shared with other professionals. The reason for this is not known to the review. The

of 65

police officers were not available for interview because of the IPCC investigation. It was highlighted as a significant issue during the coroner’s inquest.

240. The detention in custody is the subject of the IPCC investigation. This has prevented both the review team and the Greater Manchester Police being able to interview any of the police officers involved to help develop an understanding about why Child M was managed in the manner that they were. The specialist officers employed by Greater Manchester Police who deal with vulnerable children were not consulted about Child M.

241. A report by the Greater Manchester Police for the review acknowledges that the vulnerability of Child M was not sufficiently recognised and understood beyond keeping Child M detained in a controlled and supervised environment of a police station. Although well intentioned, a police station is not designed to afford a therapeutic environment and must have been a very alien environment for a child who had very little previous contact with the police and had also shown an ability to overwhelm boundary setting in other places. In other words, faced with being locked up and physically contained and a propensity to very unregulated and unrestrained verbal and physical confrontations and being under the influence of substances the escalation took on a heightened intensity.

242. The contact with Greater Manchester Police prior to the arrest had been in relation to reports of domestic assaults; these were recorded and processed as involving adults rather than an adult male who was far older than a child and who had previous significant history in relation to domestic abuse.

243. The Greater Manchester Police report describes a disconnection between the requirements of law enforcement and of safeguarding vulnerable people (children or adults). The police were observing and receiving information in regard to Child M’s habitual contact and involvement with adults whose lifestyles posed a degree of risk and of questionable suitability for a vulnerable young person. They were in possession of information and intelligence for example in regard to the use of drugs and other substances. There is no evidence that the information was being processed through the specialist officers dealing with public protection or being shared with other services such as CSC, health or YOT.

244. If there had been a better recognition of the vulnerability and risk, if there had been a clearer understanding about the role of other services, if there had been less pre-occupation with complying with one aspect of law there would have been a better opportunity to offer far more appropriate safeguarding to Child M. In the absence of discussion with the officers the review has little insight as to why this should have been the case.

of 65

245. The assistant chief constable has already instigated revised risk assessment and management between Greater Manchester Police custody officers and the medical service.

3.8 In what way does the case provide a view into the local systems for safeguarding children?

246. The inability of all services to see Child M as a vulnerable child rather than a troubled or troublesome young adult was a common and recurring theme. People made assumptions that Child M was adult and because of their greater intelligence and verbal ability had greater resilience than a child who had come from more disadvantaged or compromised circumstances.

247. People were concerned about Child M’s safety although this was not translated into more effective multi-agency working and achieved little in exploring the underlying reasons and circumstances for Child M’s evident distress.

248. Child M benefitted from very prompt and appropriate care at points of crisis; examples included the referral to the T4 unit, the action of individual police officers to keep Child M physically safe when most out of control. There were individual examples of good practice which included the intervention of the YPS worker when Child M attended a drop in session in November 2012 and sought Child M to provide advice and help and the extended mental health assessment completed by the doctor when Child M was in police custody in Lancashire.

249. At no point during the years of involvement by different services beginning in 2010 was there an attempt to develop a more strategic plan. People generally worked within the silos of their individual services and nobody had a clear and enduring responsibility to co-ordinate work. The care plan following the discharge from the T4 unit did not extend beyond health professionals and none of them was designated as the lead person.

250. The pathways such as CAF, CIN and child safeguarding were not apparently regarded as relevant and applicable to a child who was bright, articulate and came from a professional and economically secure background. Child M had a different profile to the ‘norm’ of many other troubled children who have experienced greater levels of material or social deprivation. Child M was seen as a child whose behaviour was a problem more than a child who appeared to have problems that were in part manifested through behaviour that became increasingly complex and challenging.

251. Child M’s behaviour was very distressing for the family as well as for individual professionals who were subjected to it. A preoccupation developed as to whether it was symptomatic of mental illness. When professional assessments did not make that diagnosis it caused conflict between the

of 65

family and professionals. There was never an explicit discussion about mental capacity. Regrettably, the referral to the CAMHS in Tameside that might have provided some insight regarding the underlying factors contributing to Child M’s distress came too late.

252. The issue of self – harm is a significant issue for all services. The absence of curiosity and rigour in how the YOT and CSC received information appears to reflect an institutionalised or normalised response to behaviour that is not seen to be extreme or unusual. This may reflect the volume of young people with significant problems associated with self-harm and substance misuse as much as the complexity of need presented by Child M.

253. The initial contact with the police in Greater Manchester Police when Child M was reported missing from father’s home and the subsequent contacts involving much older adult males should have been an opportunity to recognise Child M’s vulnerability and to make referrals to specialist police officers and for further enquiries to be made.

254. The police records contain a reference to ‘attempted suicide’. Self-harm is not necessarily an attempt to take life or an intent to take life. Self-harm is a signifier of different factors that can have an impact on the emotional and psychological health of a child or young person.

255. The ‘appropriate adult’ service is a trained volunteer service and has limited ability to make a meaningful contribution to helping deal with the level of complex behaviour that was presented by Child M. The police and emergency duty service were unaware of the Protocols of Practice that apply in determining whether a volunteer or an employed and qualified registered social worker is deployed. This is discussed in the final chapter.

of 65

4 Analysis of key themes from the case and description of findings for learning and improvement

256. Meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable children needs to understand why things happen and the extent to which the local systems (people, work processes, organisational arrangements) help or hinder effective work locally within ‘the tunnel’20.

257. This chapter sets out the key findings designed to offer challenge and reflection for the Tameside Safeguarding Children Board and partners. The emphasis is not on the more traditional formulation of SMART recommendations that tend to call for ever more procedure or protocol.

258. The key findings are framed using a systems based typology developed by SCIE to identify some of the underlying patterns that appear to be significant for local practice in Tameside or Lancashire:

a) Cognitive influence and human bias in processing information and observation;

b) Family and professional contact and interaction;c) Responses to significant incidents and information;d) Tools and frameworks to support professional judgment and

practice;e) Management and agency to agency systems.

259. The remainder of this report aims to use this particular case to reflect on what this reveals about gaps or areas for further development in the local safeguarding system.

260. In providing the reflections and challenges to the Tameside Safeguarding Children Board there is an expectation that there will be a response to the key findings in regard to the following:

a) An indication as to whether the Tameside Safeguarding Children Board accepts the findings;

b) Information as to how the Tameside Safeguarding Children Board will take any particular findings forward;

c) Information about who is best placed to lead on any particular activity;

d) An indication of the timescales for responding to the findings;e) Information about how and when it will be reported.

20 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight.

of 65

261. The Tameside Safeguarding Children Board will determine how this information is managed and communicated to relevant stakeholders including the LSCB in Lancashire. The formal response should form part of the publication of the SCR.

4.1 Cognitive influence and human bias in processing information and observation

Safeguarding children is more than recognising and preventing harm up to 18 years of age; recognising vulnerability and acute distress; pervasiveness of substance misuse; cognitive impact of being placed in custody and the environmental factors that contribute to escalation in violent interaction.

262. The way that people think about the behaviour of another person and how they interact has an influence on how information is processed and their judgments are formed.

263.The way that professionals saw Child M had an influence on how they responded. It was a factor at school where staff viewed Child M as a very able and talented student who was articulate and came from a professional and supportive family.

264.Although there was some disagreement in the initial stages between the school and family about the significance of Child M’s behaviour it is apparent that in the latter months just prior to the permanent exclusion that there was a greater level of common concern.

265.The school’s deployment of behaviour management strategies never involved discussion with external specialist advisors or services and CAF was not seen as relevant to Child M’s circumstances.

266.The school did not see CAF as having relevance to Child M because they regarded the CAF as a framework for helping children who are more disadvantaged. This seemed to reflect a view that Child M had the capacity to change their attitude and behaviour because they were intelligent and because of their social background that placed value on education and achievement.

267.The role of the pupil access service is discussed in a later section that deals with management and agency to agency systems.

268.When the police particularly in Greater Manchester became involved along with YOT the pervasive mind-set that applied to Child M was that they were a young adult rather than a vulnerable child (the Lancashire police acknowledged Child M was vulnerable and submitted the vulnerable child referral which was forwarded although did not involve any direct contact or discussion); it was a similar mind-set that was also applied in how the vulnerable child referral to Tameside via the CSC was also processed. It had

of 65

implications for how referral information was read and processed, it had implications for how the episodes of custody particularly in Tameside was managed and it had implication for how information about Child M’s domestic circumstances with Adult 1 were processed.

269. The MEDACS nurses in Tameside were aware that Child M lived with her father. Child M made allegations of being hit by him and that she was a drug user. This information should have triggered concerns for the safeguarding and welfare of Child M and the need for a referral to CSC.

270. If all the services had first and foremost brought a mind-set that emphasised that Child M was not a ‘little adult’ but rather a vulnerable child it is more likely that greater inference and curiosity would have been displayed in regard to the indicators of risk.

271. It is acknowledged that Child M was very aggressive, rude and condescending in their interaction with some professionals and without a doubt this would have provoked some emotional responses in those being subjected to the behaviour. It may also have had an influence in being able to see past the behaviour and recognise the vulnerability; this was achieved with several of the professionals who came into contact with Child M from health and police services.

272. The third significant area of cognitive influence in this case relates to the way in which custody was the trigger for the most extreme displays of aggression and harmful behaviour from Child M.

273. The review is not in a position to provide a definitive analysis about why the behaviour displayed was so far out of the usual norm of the professionals who were involved. It is both the intensity as well as the duration of the behaviour that was and remains very distressing.

274. Placing children in custody has an impact on them emotionally, psychologically and behaviourally. Child M displayed an unusual level of confidence in situations such as the magistrates court hearing; Child M had very little experience of contact with the police or the justice system but had displayed a confidence in their interaction admittedly some of it being under the influence of different substances or in highly emotional circumstances.

275. The trigger for violence can arise from a variety of sources; a child being frightened, a child seeking to regain control, a child not wanting to lose face or perceived status, a child having problems with authority or structure, a child under the influence of alcohol or drugs, emotional or psychological trauma or distress.

276. The use of a police station to detain a child is subject of statutory codes designed to limit the length of time a child remains in police custody. In this

of 65

case, Child M was kept in custody because of concern about their safety. The police officers had clear cause to be worried about Child M.

277. Child M was never the subject of a discussion with specialist officers within the Greater Manchester Police as a vulnerable child and there was no contact with social care over and above the request for an appropriate adult.

278. This is not to suggest that the discussions would have prevented the death of Child M but it would have required a much clearer discussion about a vulnerable child that may also have involved more comprehensive enquiries with the family and with other services.

Issues for the Tameside Safeguarding Children Board to consider in regard to learning and improvement

1. Refer to section 4.6.

4.2 Family and professional contact and interaction

The role and rights of parents or people with parental responsibility to be consulted and kept informed; maintaining a clarity about the circumstances under which professionals may need to override a reluctance to give consent to referral or involvement of specialist services; promoting engagement and involvement of family at points of crisis.

279. All parents (or a person with parental responsibility) should have an expectation of being kept informed if their child has been arrested and placed in police custody.

280. If a child is arrested for committing a criminal offence and they are under 17, the police must inform the parents as soon as possible. Children who are arrested should be made aware of their rights when they are first brought to the police station. One of these rights will be that a parent or guardian can be informed of the arrest straight away.

281. A child may exercise their right in not wanting to see a parent or to have direct contact with them but there is nothing in law that prevents a parent being told what has happened to their child up to and arguably beyond their 18th birthday especially when there are concerns about the welfare of the child (unless there is cause to believe that there are concerns about the parent or guardian).

282. A parent may choose to have nothing to do with the child or with the incident but that does not preclude them from knowing unless there is reason to believe that it would represent a risk to the child or compromises enquiries or investigation by the police and or social care for example.

of 65

283. The arrest and detention of children and young people is the subject of detailed codes relating to PACE. In addition to those codes, there are other legal frameworks that apply in regard to the welfare of children.

284. The police had information about Child M’s father and knew that Child M was supposed to be living with him. They could have asked for details about the mother and any other family members. There was no reason not to do this other than the prevailing mind-set of treating Child M as a young adult who was not asking for contact with either of the parents.

285. The case has also highlighted apparent misunderstanding about the extent to which a parent (or child) can prevent a professional from making contact with other services or professionals.

286. Although the overriding principle as described in the ‘golden rules of information sharing’ is that consent is sought the law and professional guidance allows professionals to take action in circumstances where there are concerns about the child’s welfare21.

287. In determining whether a child’s welfare is at risk professionals are empowered to interpret this holistically. When a professional is in possession of information about a child’s chronic abuse of substances, risk of exclusion and apparent emotional difficulties they should feel confident about first speaking with the child and the family but having the capacity and motivation to go further if the family or child are unable to acknowledge or accept the need to involve another service.

288. The role of designated or lead professionals in places such as schools have a critical role in providing advice and guidance to colleagues in dealing with complex issues of consent and co-operation.

289. Child M’s mother, stepfather and maternal grandparents described feeling unable to express a view about critical interventions such as the decision to discharge Child M from the T4 service, challenge the permanent exclusion or how assessments were undertaken. All of these people have experience of working as education professionals and yet appeared to feel disempowered.


1) Refer to section 4.6.

4.3 Responses to information and incidents

Importance of schools having the capacity and commitment to accessing help through frameworks such as CAF; importance and value of direct person to person 21 Information Sharing: Guidance for practitioners and managers; Department for Children, Schools and Families, and Communities and Local Government; 2008

of 65

discussion between professionals when making a referral; behaviour management strategies and protocols that ensure emotional, psychological and mental health needs of a child are sufficiently explored and understood.

290. The CAF is designed to provide a framework for professionals such as education and health workers to identify children who appear to have additional needs but are unlikely to meet the thresholds for help and intervention from specialist services such as CSC and higher level CAMHS.

291. An effective CAF system should aim to strike a balance between not imposing too much bureaucracy and procedure that deters professionals from using the CAF but still manages to have sufficient information with which to make informed judgements and decisions. CAF was not considered for Child M because it is seen as being for the most disadvantaged of children and may or may not reflect the workload of different services. The value of CAF is bringing together information ideally with the involvement of the young person and family and using it as a basis for developing services based on the needs of that child. What is striking in this case is how little was known by any individual professional or service about Child M and their history.

292. The referral to Tameside from Lancashire did not involve any direct discussion between the services. It is apparent that there was a high level of concern especially from the police officers who had come into contact with Child M and although that was summarised in the referral information by the time it was being read and processed in Tameside it had lost that immediacy and level of concern.

293. Child M had a good attendance record at school until they were excluded. Although attendance and achievement data is monitored routinely, for a child such as Child M their profile would have aroused no significant interest in those arrangements. When Child M was excluded there was no additional oversight or contact with external services such as pupil access services.



4.4 Tools to support professional judgment and decision making

The triaging of referrals; assessment of children’s emotional and psychological capacity and well-being; systems for allowing children and family views, wishes and feelings to be taken into account.

294. The initial triaging of the referral in Tameside CSC relied on reading the information contained in the referral from Lancashire and then placing it in a holding tray. The referral was not followed up for almost week. It was unclear in discussion with the professionals what frameworks were being used to

of 65

prioritise over and above the information that Child M was not open to CSC in Lancashire.

295. The significance of Child M’s consumption of cannabis and evidence of using amphetamines and self-harm does not appear to have figured in this or other assessments of the information for example in YOT. The Crisis Team and Young Addaction service in Lancashire were also misled by Child M about their substance abuse.

296. The permanent exclusion of Child M was not challenged formally by Child M or mother and step-father although mother had written an email to the school when the exclusion decision was originally made. It was a significant event and was a watershed in Child M withdrawing from services.



4.5 Management and agency to agency systems

Availability and access to appropriate accommodation that minimises the use of police custody facilities for children; influence of workload on individuals and services; integration of CAMHS with other children’s services; availability and access to specialist police officers and designated child custody facilities; capacity and use of the appropriate adult service when dealing with very vulnerable and distressed children; the role of pupil access services when children are subject of behaviour management sanctions such as exclusion; knowledge and application of relevant protocols and codes of practice for responding to vulnerable children.

297. Up until March 2013 Lancashire was one of the few police services in the country that had a specific policy covering the detention of young people in police custody. After this date Lancashire Constabulary implemented the Authorised Professional Practice (APP) from the College of Policing. This is the standard policy for all police forces. The PPU Compliance Manager for Young Persons has recently written a new specific policy for Young People in Detention/Custody. The policy is in line with APP and is expected to be introduced within the next few months.

298. Police officers and police staff are trained in those procedures. There is a

detention room in each of the custody suites across the county. There is no access to specialist trained officers in the custody suite but between 08.00 and 20.00 there are specialist officers on duty in the public protection unit (PPU). There is a risk assessment (which was completed in regard to Child M). An electronic custody record introduced in March 2014 incorporates a risk assessment; work is underway to develop a discrete risk assessment for young people.

of 65

299. Greater Manchester Police has specialist officers and systems designed to respond to the needs of vulnerable children. These were bypassed in this case. The review has not been able to take evidence from the officers involved in order to understand why the system did not work in this case.

300. The IPCC give detailed attention to the specific requirements of PACE and in particular Code C as it relates to appropriate adults. The assistant chief constable in Greater Manchester Police had already issued instructions that all 17 year olds in custody should be offered access to an appropriate adult as a result of a judicial ruling in April 201322. A seventeen year old has the right to decline the access to the appropriate adult. The appropriate adult scheme in Greater Manchester in the only service organised directly by the Police and Crime Commissioner’s Office (PCSO) and provides extensive vetting and training to the appropriate adults many of whom have experience in related fields such health, social care and teaching. The appropriate adult can help identify other sources of advice and help for vulnerable children.

301. The availability of alternative accommodation when Child M was in police custody or for the purposes of bail was not inquired into. The review has not received information about access and availability particularly out of hours at weekends for example.

302. The pupil access service in Lancashire provided professional advice regarding the exclusion of Child M. The focus of the advice was on whether the exclusion was compliant with legislation and procedural guidance. A more child centred approach would have explored the underlying circumstances and reasons and created opportunity for the views of Child M and family being included.

303. The Lancashire Teaching Hospitals are now going to look at referral pathways to the Young Addaction service to ensure the hospital address all presenting cases of overdoses (whether prescribed or non-prescribed medications). Young Addaction accept all referrals for any overdoses if they are made.

304. The current core offer from the School nursing services in Central Lancashire is the Healthy Child Programme though the historic pattern of service delivery has not included 16-19 year olds once they move to sixth form or higher education. A limited service is provided for 16-19 years and this is currently the subject of a commissioning review.

305. The referral that was made by the Greater Manchester Police to Tameside social care emergency duty team requested an appropriate adult. A written

22 The Judicial Ruling on the 29th April 2013 was in relation to the treatment of 17 year olds in custody. In its judgement the Court found that in failing to revise PACE Codes C to distinguish between 17 year olds and adults, the government was in breach of obligations under the Human Rights Act 1998 and was therefore acting unlawfully. The subsequent PACE Order, explanatory memorandum and transposition note were laid before Parliament on 21st October 2013 that incorporated the ruling.

of 65

protocol of practice agreed between the Greater Manchester Police and the local authority describes the circumstances when an appropriate adult may not be suitable and an employed, qualified and registered social worker is allocated to respond. Neither the police nor the EDT duty officer was aware of this protocol of practice. The circumstances for allocating a social worker rather than volunteer appropriate adult include the seriousness of the offence, whether the person is known to social care or the complexities of the person such as mental health or learning difficulties for example.

306. The review has not seen the referral form or the summary record of the appropriate adult. The review has been told that the referral from the Greater Manchester Police did not include relevant information about threats to self-harm, the significant extent of Child M’s intoxication or the fact that MEDACS had been called to conduct assessments. In evidence to the coroner the EDT duty worker acknowledged that the on call social worker on the evening was also a qualified mental health social worker.


1) Refer to section 4.6.

4.6 Issues for the Tameside Safeguarding Children Board to consider in regard to learning and improvement

307. Although some of the specific points of learning revealed by this review are linked to analysis across two different local authority areas, the review panel recommend that both LSCB’s should give consideration to the following challenges and reflections. The challenges and reflections do not excluded individual services using the review as an opportunity to examine other aspects of policy, practice or processes in responding to vulnerable children at risk from self-harm. It is for each of the Boards to provide evidence in regard to implementing any learning and improvement arising from the review and in response to the following challenges and reflections.

1. Are the arrangements for recording a child’s journey through early year’s and education adequate?

2. Are arrangements for the external oversight of exclusions sufficiently rigorous in regard to identifying need, risk or vulnerability of a pupil?

3. Are the arrangements for identifying, accessing and if necessary purchasing specialist support services for children in education adequate?

4. Is there a good enough level of understanding about information sharing and referral protocols on the part of all organisations when in contact with a child whose behaviour or circumstances are raising concerns about their general

of 65

safety and well-being?; e.g. accessing CAMHS and substance misuse services in spite of resistance from child or family, notifying parents when a child is in custody (or admitted to hospital)

5. Is the leadership of care plans for children in T3 and T4 services sufficiently robust in identifying a lead professional and ensuring coordination across different services and organisations?

6. Are the notification arrangements for children admitted for T4 in patient care sufficiently clear in ensuring relevant services are aware of children receiving in-patient care of 28 days or more? (Notifying the LA and what would we expect to happen?)

7. Are the referral and transfer arrangements sufficiently clear and robust when children identified as being at risk of harm move out of authority? Should we be expecting telephone contact as well as an electronic or fax communication when level of risk is high?

8. Is significant substance misuse regarded as a safeguarding issue for children under 18 in all services?

9. Is significant self-harm regarded as a safeguarding issue for children under 18 in all services?

10. Do police services have adequate policy and procedure guidance for the management and detention of children including access to appropriate facilities and services?

11. Is role of appropriate adult sufficiently clear and is training and support adequate for that purpose?

12. Are YOT staff sufficiently trained in the use of tools and assessment processes in order to identify indicators of vulnerability and risk?

13. Do the police and MEDACS have sufficient access to appropriately qualified people with experience of childhood and adolescent emotional and psychological difficulties and are they appropriately deployed to respond to individual cases?

4.7 Recommendations

1. The Tameside Safeguarding Children Board should receive a report from the Greater Manchester Police and Tameside Metropolitan Borough Council

of 65

confirming what arrangements are in place to ensure that relevant protocols including the use of appropriate adults are known and used by both services.

2. The Tameside Safeguarding Children Board should ensure that copies of any statutory notices issued to any of the services as a result of the coroner’s inquest and their response are reported to the relevant sub-committee and that the Tameside Safeguarding Children Board formally consider whether any further learning or improvement work is required. This should include particular attention to any further information regarding the sharing of information about self-harm.

4.8 Issues for national policy

308. Guidance and availability of separate arrangements for detention of children in police custody from adults; quality and transfer arrangements for school records; guidance on involving family and parents in regard to vulnerable 17 year olds subject of arrest; case management and transition of children and young people between residential and Tier 4 CAMHS with community and lower tier CAMHS.

Peter MaddocksMarch 2014

of 65

CONFIDENTIAL

5 APPENDICES

of 65

CONFIDENTIAL

Appendix 1 - Procedures and guidance relevant to this serious case review

Legislation

The Children Act 1989

Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act23 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.

Section 17 imposes a duty upon local authorities to safeguard and promote the welfare of children in need.

Section 47 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm. These enquiries should start within 48 hours.

Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm.

The Children Act 2004

Section 10 requires each local authority to make arrangements to promote co-operation between it, each of its relevant partners and such other persons or bodies, working with children in the authority’s area, as the authority consider appropriate. The arrangements are to be made with a view to improving the wellbeing of children in the authority’s area – which includes protection from harm or neglect alongside other outcomes. This section is the legislative basis for children’s trusts arrangements.

23 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training

Page 61 of 65

CONFIDENTIAL

Section 11 of the Children Act 2004 places a duty on the key people and bodies described in the Act 24 to make arrangements to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The application of this duty varies according to the nature of each agency and its particular functions. The Section 11 duty means that these key people and bodies must make arrangements to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children and this includes any services that they contract out to others.

Police and Criminal Evidence Act 1984 (PACE)

The Police and Criminal Evidence Act 1984 (PACE) and the accompanying PACE codes of practice, which establish the powers of the police to combat crimes while protecting the rights of the public.

PACE Code C sets out the requirements for the detention, treatment and questioning of suspects not related to terrorism in police custody.

Mental Capacity Act 2005 (MCA)

The Mental Capacity Act 2005, covering England and Wales, provides a statutory framework for people aged 16 or older who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they may lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. The Act received Royal Assent on 7 April 2005 and came into force from 2007.

The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice provides guidance to anyone who is working with and/ or caring for adults who may lack capacity to make particular decisions. It describes their responsibilities when acting or making decisions on behalf of individuals who lack the capacity to act or make these decisions for themselves. In particular, the Code of Practice focuses on those who have a duty of care to someone who lacks the capacity to agree to the care that is being provided.

24 Local Authorities, including District Councils, the Police, National Offender Management Service, NHS bodies, Youth Offending Teams, Governors/Directors of Prisons and Young Offenders Institution, Directors of Secure Training Centres.

Page 62 of 65

CONFIDENTIAL

One of the most important terms in the Code is ‘a person who lacks capacity’.

Whenever the term ‘a person who lacks capacity’ is used, it means a person who lacks capacity to make a particular decision or take a particular action for themselves at the time the decision or action needs to be taken.

This reflects the fact that people may lack capacity to make some decisions for themselves, but will have capacity to make other decisions. For example, they may have capacity to make small decisions about everyday issues such as what to wear or what to eat, but lack capacity to make more complex decisions about financial matters.

It also reflects the fact that a person who lacks capacity to make a decision for themselves at a certain time may be able to make that decision at a later date. This may be because they have an illness or condition that means their capacity changes. Alternatively, it may be because at the time the decision needs to be made, they are unconscious or barely conscious whether due to an accident or being under anaesthetic or their ability to make a decision may be affected by the influence of alcohol or drugs.

Safeguarding Procedures

The local safeguarding children procedures

The procedures provide advice and guidance on the recognition and referral arrangements for children suffering abuse. This includes emotional abuse that involves causing children to feel frightened or in danger. The procedures also cover physical abuse of children. The procedures also describe abuse involving the neglect of children that includes failing to protect children from physical harm or danger or the failure to ensure access to appropriate medical care or treatment. This includes describing distinct action to be taken when professionals have concerns about a child, arrangements for making a referral, and the action to be taken. The procedures cover arrangements for the ACPC (now superseded by LSCB) to ensure there are effective arrangements that promote good interagency working and sharing of information and training. The procedures describe specific responsibilities for all agencies contributing to this serious case review. Other local procedures relevant to this serious case review

Page 63 of 65

CONFIDENTIAL

National guidance

Working Together to Safeguard Children (2010) and (2013)

The national guidance to interagency working to protect children is set out in Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. The guidance includes safeguarding and promoting the welfare of children who may be particularly vulnerable. This guidance was extensively revised and republished in March 2013. The revised guidance placed greater responsibility on local areas to develop their own frameworks and standards. It abolished the national framework for assessment and instead no required local areas to have in place their own assessment arrangements.

Framework for the Assessment of Children in Need and their Families 2001

The guidance in respect of the Framework for the Assessment of Children in Need and their Families was issued under section 7 of the Local Authority Social Services Act 1970 and was therefore mandatory until it was abolished with the publication of Working Together in 2013.

The framework set out the framework for ensuring a timely response and effective provision of services to children in need. It makes clear the importance of achieving improved outcomes for children through effective collaboration between practitioners and agencies. The framework set out clear timescales for key activities. This included making decisions on referrals within one working day, completing initial assessments within seven working days and core assessments within 35 working days. As part of an initial assessment children should have been seen and spoken with to ensure their feelings and wishes contributed to understanding about how they were affected. If concerns regarding significant harm were identified they had to be the subject of a strategy discussion to co-ordinate information and plan enquiries. Child protection procedures had to be followed.

Assessments should be centred on the child, be rooted in child development that requires children being assessed within the context of their environment and surroundings. It should be a continuing process and not a single or administrative event or task. They should involve other relevant professionals. The outcome of the assessment should have been a clear analysis of the needs of the child and their parents or carers capacity to meet their needs and keep them safe. The assessment should identify whether intervention was required to secure the well –

Page 64 of 65

CONFIDENTIAL

being of the child. Such intervention should have be described in clear plans that included the services being provided, the people responsible for specific action and describe a process for review.

Common Assessment Framework (CAF)

The CAF is a key part of delivering direct services to children that are integrated and focused around the needs of children and young people. The CAF is a standardised approach to conducting assessments of children’s additional needs and deciding how these should be met. It can be used by practitioners across children's services in England. The CAF remains in place.

The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Practitioners are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions.

All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008.

All areas were expected to implement the CAF, along with the lead professional role and information sharing, between April 2006 and March 2008.

Page 65 of 65

introduction and context to the serious case review … · web viewintroduction and context to the...

Documents