Serious Case Review in Respect of Child L  01.02.10

1.00 CASE REVIEW

1.01 Serious Case Reviews are carried out by the Safeguarding Children Board, (formerly the Area Child Protection Committee) when a child dies or is seriously injured as result of abuse or neglect. This procedure is in accordance with the expectations set out in the DCSF guidance, “Working Together to Safeguard Children 2006”

1.02 This report summarises the findings from a Serious Case Review that was established to consider the professional interventions in respect of a family of a child, (who will be referred to as child L), and in particular to critically evaluate the circumstances that led to this serious incident which was suspected of arising from neglect or abuse. Child L was sixteen years old at the time of this incident.

1.03 As part of the LSCB’s commitment to manage and develop inter agency child protection practice within the City, this Serious Case Review was undertaken in order to establish the facts of the handling of the case and to analyse the professional involvement with this family. The purpose of the Review was to identify and recommend any relevant changes to professional practice, and about the ways in which the different agencies in Leeds work together to safeguard children and young people.

2.00 CASE REVIEW PROCESS

2.01 Each agency that had some direct involvement with the family was required to undertake an Individual Management Review, to look openly and critically at individual and organisational practice as it related to their involvement with this family. In undertaking this, each agency was required to produce a chronology of its contact with the family. Those managers conducting the Individual Management Reviews were not directly concerned with the services provided for the young person or family, or the immediate line manager of the practitioners involved.

2.02 Selected representatives of the LSCB and of key agencies within Leeds were brought together to form a Serious Case Review Panel to collate the information provided from the Individual Management Reviews and then to analyse the professional practice and inter agency working as it related to this family.

2.03 Members of this Serious Case Review Panel included senior experienced professionals from the LSCB, Leeds Children and Young Person’s (CYP) Social Care, West Yorkshire Police, Integrated Youth Services, Education Leeds, Leeds Health Authority, Yorkshire Ambulance Service, Carr Gomm and Leeds Youth Offending Service. The report was undertaken by an independent author with expertise in child protection.

2.04 Members of the Review Panel acknowledge the sensitivity of this report and in an effort to protect the identity of the family and respect their privacy, individuals within this Review have been anonymised and specific times and dates and locations are not referred to. To assist the reader of this Executive Summary the subject will be referred to as Child L. Other individuals referred to within this report have also been anonymised.

2.06 The Review was initiated on 29 February 2008 and received by Leeds Safeguarding Children Board on 4 November 2008. An evaluation of ‘good’ was received from Ofsted in July 2009.

3.00 TERMS OF REFERENCE

The terms of reference of the Review were as follows:

• construct a comprehensive chronology of involvement by the organisation and/or professionals in contact with the child and family from 30.07.1991 to 28.12.2007;

• briefly summarise decisions reached, the services offered and/or provided to the child or children and family and any other action taken;

• consider the events that occurred, the decisions made, and the actions taken or not taken. Where judgements were made, or actions taken, which indicate that practice or management could improve, try to get an understanding not only of what happened but why.

• were practitioners sensitive to the needs of the children in their work, knowledgeable about potential indicators of abuse or neglect, and about what to do if they had concerns about the child?

• did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?

• what were the key relevant points/opportunities for assessment and decision-making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way?

• did actions accord with assessments and decisions made? Were appropriate services offered/provided or relevant enquiries made, in the light of assessments?

• where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with?

• when, and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making revisions about children’s services. Was this information recorded?

• was practice sensitive to the racial, cultural, linguistic and religious identity of the child and family?

• were more senior managers or other organisations and professionals involved at points where they should have been?

• was the work in this case consistent with each organisation’s and the LSCB policy and procedures for safeguarding and promoting the welfare of children, and with the wider professional standards?

• were there any preventable factors that may have contributed to the death of child L?
  

3.01 In accordance with the LSCB Procedures each agency and organisation was required to secure their records in relation to the subject. Arrangements were made for Individual Management Reviews (IMR) to be undertaken in relation to each agencies or organisation’s specific involvement with the subject. Where it was identified that no member of the family were or have been known to the agency or organisation, a report was requested to confirm this.

4.00 SUMMARY OF THE CASE

4.01 Child L led a short but troubled life. He was the third and youngest child to be born into the family and the only child to be born out of his mother’s relationship with child L’s father. Child L had two older half siblings with whom he enjoyed a good relationship.

4.02 During his formative years it is alleged that Child L was sexually abused by his birth father but despite a Police investigation and a file being submitted to the Crown Prosecution Service, criminal proceedings were never instigated.

4.03 Child L’s mother had been subjected to incidents of domestic abuse by her former partners and Child L’s father had attempted suicide on at least four occasions. Both Child L and his mother had mental health issues.

4.04 Child L had a difficult time during his education, his behaviour being challenging and at times bizarre. Child L’s relationship with his mother was extremely close with Child L believing that he was the only person who was capable of protecting her.

4.05 Throughout the scoping period the common themes for Child L were poor school attendance and numerous missed health appointments. The mother of Child L mirrored this pattern as she would regularly engage Health services for herself and then fail to attend pre arranged follow up appointments.

4.06 Children and Young People’s Social Care had intense input with the family at times with Child L’s mother being uncooperative on occasions but demanding services from them in times of crisis.

4.07 Despite concerted efforts by the agencies concerned the family were difficult to engage and commitment from Child L and his mother was minimal.

4.08 On Friday 28th December 2007 after a relationship with his latest girlfriend had come to an end, Child L held an emotional conversation with his mother during which he threatened to commit suicide. Similar threats had been made by him before.

4.09 On the day of his death Child L, aged16 years of age, made a telephone call to his ex girlfriend, again indicating to her that he intended to end his life. Child L picked up a large bladed knife which he held to his chest and it is thought that he ran at a bedroom wall forcing the blade of the knife into his chest cavity.

4.10 Child L was found later the same day in his bedroom by his half brother in a state of collapse. An ambulance was summoned but despite attempts to resuscitate him he was pronounced dead on arrival at the hospital. A post mortem examination identified that Child L had died from a single knife wound to the heart. A coroner later delivered a verdict of death by misadventure.

5.00 CONCLUSIONS

5.01 Agency involvement in this particular case (single agency or multi agency), has in the main offered appropriate interventions in a timely and correct manner and with some elements of good practice for the time in question. The author doubts that anything done differently would have altered the outcome for Child L. There are however some areas of learning highlighted by the Review, some of which have already been identified by the respective agencies prior to this Review taking place and addressed.

5.02 The fact that early CYP Social Care records of Child L and his family have been destroyed in line with the file retention and destruction policy of 1998 has not assisted the Review process. Subsequently the analysis of early work undertaken with the family has been limited.

5.03 Agency practice of recording details of interactions is of vital importance for a variety of reasons. Informed decision making, managerial oversight and particularly any review of past involvement are just three examples. The case for keeping separate child protection files within Education was also an issue at that time. There have been some good and bad examples of record keeping throughout this Review.

5.04 The Review highlighted the need for a more structured mechanism to identify specific needs of individuals and families. This issue was evident during the “Professionals Meetings” that were held when important agency partners were excluded resulting in lack of clarity around the purpose and status of the meeting. The issue was also identified within the CYP Social Care Individual Management Review (IMR). Opportunities for inter agency Child In Need meetings which would have afforded a better platform for joint assessments to be made were missed. The need for all agencies to recognise the importance and value of a coordinated multi agency approach to the provision of services regardless of the status of their involvement is therefore a matter worthy of comment.

5.05 Issues around adult mental health have also been a major part of this Review, specifically the issues around the capacity of Child L’s mother to effectively protect and parent her children. There is little doubt that Child L’s mother’s mental health had a negative impact upon him.

5.06 The wider safeguarding aspects were highlighted on a number of occasions, two examples being when the Police attended an incident of assault by Child L’s eldest brother upon his other sibling and do not appear to have recognised the incident as a crime or investigated it appropriately. Secondly, when the causation of a serious eye injury to Child L was not investigated fully or referred to CYP Social Care or the Police by Health after he attended the Accident and Emergency Department with the injury.

5.07 One of the key points highlighted by the Review is the amount of work undertaken by Education during the school life of Child L. The input is noteworthy and the determination and tenacity of individuals within this organisation is creditable.

5.08 Despite the efforts of individuals within Education there was clearly a resistance by Child L to mainstream education. Alternative provision was considered but discounted due to Child L’s poor attendance and engagement.

5.09 A significant issue arising from this Review was the considerable amount of times that Child L’s mother and Child L failed to attend appointments with Health professionals. The family’s chaotic lifestyle and Child L’s mother’s mental health were clearly contributory to this.

5.10 Child L’s mother was at times struggling to take care of her own medical issues and her diminished ability and capacity to meet the needs of her children during these times was evident. It is worthy of consideration therefore as to whether or not earlier recognition of this lack of coping capacity would have resulted in any different outcome for this family’s level of functioning.

5.11 It is also recognised that medical records did not inform around social factors and stressors within the family. Current day practice has improved to some degree and from 2003 it is now more common for GP’s to incorporate appropriate detail around family circumstances.

5.12 The cheerless fact of this case is that this chaotic and dysfunctional family have had a considerable amount of time and effort expended upon them by all the key agencies. Although efforts were not always as coordinated as one would expect by today’s standards, work undertaken with Child L and his family was thorough and professional. Even with the benefit of hindsight, it is doubtful whether any agency could have done anything further which would have prevented the outcome of this tragic case.

6.00 RECOMMENDATIONS

6.01 LSCB

6.02 That within six months of the publication of this Review the LSCB Chair should ensure that all information sharing protocols between agencies and adult mental health professionals, where parental mental health issues could have a direct and significant impact on children and young people, are reviewed.

6.03 That within three months of the publication of this Review consideration is given by the LSCB to the circulation of the model of suicide prevention in children and young people documented in the publication “Analysing child deaths and serious injury through abuse and neglect: what can we learn? (DCSF publication.)

6.04 HEALTH

6.05 The Associate Director for Safeguarding Children should convene a joint Trust (LPCT, LTHT) review to scope the issues of children’s non attendance at health appointments within six months of the publication of this Review.

6.06 That the Director of Service Delivery and Chief Nurse within Leeds PFT review current training for Mental Health Staff within six months of the publication of this Review to ensure that training includes an awareness of the impact of parental health conditions upon children and young people.

6.07 CYP SOCIAL CARE

6.08 Within six months of the publication of this Review the Chief Officer should remind CYP Social Care Team Managers of the need for Social Workers to initiate contact with appropriate Mental Health professionals in all relevant cases. This should be monitored and documented during supervision.

6.09 Within six months of the publication of this Review the Chief Officer should ensure that the current file retention policy in cases where Child Protection Conferences have taken place but where no Child Protection Plan has been made is reviewed.

6.10 EDUCATION

6.11 Within three months of the publication of this Review, the Education Leeds Child Protection Coordinator should ensure that Designated Persons for Child Protection in schools and other areas of the Service are reminded of their responsibilities and the guidance relating to child protection files as detailed in ‘Safeguarding Children and Safer Recruitment in Education 2007’.

A.J.BAILEY Independent Author