Serious Case Review in Respect of Child M   01.02.10

1.0   INTRODUCTION

A Safeguarding Children Board is required to carry out a Serious Case Review when a child/young person dies, and abuse or neglect is known or suspected to be a factor in the death. The purpose of a Serious Case Review is to: establish whether there are lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children and young people; identify what those lessons are; how they will be acted on and what is expected to change as a result.

1.1 The circumstances that led to the Review being undertaken

The young person ‘M’ died in 2008. The post-mortem has concluded that the cause of death was as a result of hanging and the Coroner’s Inquest subsequently returned a verdict of ‘death by misadventure.’ There was considerable background information available in respect of this case. This related to an investigation concerning sexual abuse of young vulnerable children by ‘M’s father which led to him being imprisoned. Later, ’M’ disclosed her father had sexually abused her and an investigation took place, with the conclusion was that no action would be taken. ‘M’ had no further contact with her father following the investigation. There was considerable involvement of agencies at the time of the investigation and further involvement by some agencies subsequently.

The Leeds Safeguarding Children Board Serious Case Review Panel met in April 2008 and recommended that the criteria for undertaking a serious case review was met. On 20th April 2008, the Independent Chair of the Safeguarding Children Board agreed that there should be a Serious Case Review relating to the death of the young person ’M’.

The completed Review was received by Leeds Safeguarding Children Board on 27 January 2009. An evaluation of ‘adequate’ was received from Ofsted in April 2009.

1.2 Terms of Reference

The Serious Case Review followed the general guidelines for the preparation of a Review set out in Chapter 8 of ‘Working Together to Safeguard Children’ (2006). The time frame for the Serious Case Review was agreed from ‘M’s birth in April 1991, up to the point of her death in March 2008. The specific terms of reference were:

1.2.1 To summarise the circumstances that led to the Review being undertaken.

1.2.2 To prepare an overview that summarises what relevant information was known to the agencies and professionals involved about the parents and home circumstances of ‘M’. This should include family/background history.

1.2.3 To undertake an analysis that considers the views of the immediate family; how and why events occurred and decisions were made; examples of good practice; opportunities that were taken or not taken to identify risk and protective factors in respect of the young person; whether with the benefit of hindsight different decisions or action may have led to an alternative course of action; and whether the death of ‘M’ was predictable and/or preventable.

1.2.4 To inquire into any specific issues identified in relation to this case which would indicate the extent to which ’M’ received adequate support

1.2.5 To identify any issues that have been highlighted in the individual management reviews, and which may impact on interagency working

1.2.6 To identify recommendations contained within individual agency reviews, and provide a summary of the lessons to be drawn from the case.

1.2.7 To provide a comment on the adequacy of the individual management reviews provided by participating agencies.

1.3 Agencies providing reports

1.3.1 West Yorkshire Police

1.3.2 West Yorkshire Probation Service

1.3.3 NHS Leeds Trust (a combined report was provided for Leeds Teaching Hospital Trust, Leeds Partnership Foundation Trust and NHS Leeds)

1.3.4 Leeds Children and Young People’s Social Care

1.3.5 Education Leeds

1.3.6 Independent School

1.4 Overview Report Writer

The Overview Report was written by Roger Thompson, who also attended the Serious Case Review Panel. He has a background in Social Services and the NSPCC. He is now self-employed, and among other work, is the Independent Chair of the City of York Safeguarding Children Board. He has never been employed by any agency in Leeds.

1.5 Family Involvement

The young person ‘M’s mother has been visited by the author of the Overview Report, and her views are included in the full report.

1.6 Family Circumstances

The young person ‘M’ was the only child of her mother and father, although each had a child from previous partners. The parents and ‘M’ are all White British. ‘M’s racial and cultural needs were met appropriately.

2.0   PRACTICE ISSUES AND LESSONS LEARNED: KEY FINDINGS AND CONCLUSIONS

2.1 The Overview Report has not apportioned any blame to any agency or professional for the death of the young person ’M’. There was no advanced information that could conceivably have led to the suspicion that ‘M’ would have died as a result of hanging and there is no suggestion that her death was predictable or preventable.

2.2 The death of ‘M’ has however given the opportunity for an examination of agency practice and actions in relation to their work with her and her family.

2.3 The Overview Report has identified factors in agency practice which would improve safeguarding arrangements for children and young people in Leeds. However, there is no evidence of any systemic or institutional failings in respect of the agencies who were or had been involved with ‘M’.

2.4 It is important in an Overview Report, which may be critical of practice, to acknowledge that there were aspects of work with the family that were positive and of a good standard. Examples of these are the approach and actions of the General Practitioner and the formal investigations arising from ‘M’s father’s serious offences.

2.5 The Report has addressed the issue of a seven weeks lapse in time recorded in the GP records before the GP received notification of an overdose by ‘M’. It is important that this lapse in communication is investigated as to whether this was an isolated example of a failure to inform, or if there were wider concerns about information sharing with the GP Practice.

2.6 The Report has addressed the matter of the lack of a school nursing service at independent schools. The school nurses in NHS Leeds Trust, and in the state education sector, when in receipt of Accident and Emergency attendance notifications, would follow up attempted suicide cases or overdoses, although the follow up would be dependent on the wishes of the young person concerned and would be complementary to other service provision. This did not happen in ‘M’s case, because there was no school nurse provision in Independent Schools. This has highlighted a potential gap in communication to the independent sector, although in this case, ‘M’s mother herself stated she informed the independent school of the overdose attempt. The formal process for communicating such important information to independent schools is uncertain, and it is important that an acceptable and robust system should be in place. It seems important to find a solution to this gap, by either consideration of a school nursing service within Independent Schools, or some other means of health provision.

2.7 The Report has addressed the matter of how Leeds Children and Young People’s Social Care provides training on communicating with children and young people. This should be reviewed to assess the effectiveness of the training. Also it is recommended that Social Care should monitor how their staff are communicating with children and young people with a view to increasing skills in this area of work and more clearly identifying the needs of children and young people who have experienced abuse.

2.8 The Report has addressed the issue that the schools attended by ‘M’, state that they were neither aware nor had any record of the circumstances of her father’s offences, or of the child protection investigations that subsequently took place. ‘M’ ’s mother has stated that she herself informed them about this. It is essential that where significant child protection information is identified all meeting chairs should ensure that any disclosure matters are considered, any specific recommendations minuted and formal notification made to the appropriate school and agency.

2.9 The Overview Report has addressed the terms of reference given by the Serious Case Review Panel and the conclusions, lessons to be learned and recommendations contained in the report follow on from these terms of reference and the analysis from the agency management reports.

3.0   RECOMMENDATIONS

In considering recommendations arising from this Serious Case Review, the intention is to focus on the key issues arising from the terms of reference. They require early implementation, and should be monitored by the Safeguarding Children Board. Agencies have drawn up action plans to ensure that focussed implementation of the recommendations takes place.

In making recommendations, it is important to emphasise that action may well already have been taken to put in hand changes to practice matters identified in the Overview Report.

1 Recommendation to the Chair of the Leeds Safeguarding Children Board

The Chair of the Leeds Safeguarding Children Board should write to independent education sector Head Teachers in Leeds advising them of the required standards, presentation format of individual management reviews and their duty to co-operate with Education Leeds in contributing to serious case reviews.

2 Recommendation to the Chief Executive of Leeds NHS Trust

The Chief Executive of NHS Leeds Trust should investigate the lapse in time recorded in GP records before the GP received notification of Child M’s overdose, to ascertain if this was an isolated instance of failure to inform, or whether there are more systemic issues involved which need to be addressed.

3 Recommendation to the Chief Executive of NHS Leeds Trust

The Chief Executive of NHS Leeds Trust should review the need for a school nursing service within Independent Schools in Leeds, and review whether there is a gap in the communication of relevant health information as a consequence of the absence of this service, and if so what action should be taken to remedy this position.

4 Recommendation to the Chief Executive of NHS Leeds Trust

The Chief Executive of Leeds NHS Trust should review the current arrangements for health care provision in independent schools in Leeds to ensure that there is adherence to the required standards of health care in these schools.

5 Recommendation to the Chief Officer, Children and Young People’s Social Care

The Chief Officer of Children and Young People’s Social Care should (with a view to identifying deficiencies and implementing improvements) review the effectiveness of

1 The current training provided to staff on communicating with children and young people and direct work skills

2 The way that their staff are communicating with children and young people, and how much direct work is being undertaken, with a view to increasing confidence in this area of work.

6 Recommendation to the Chief Officer, Children and Young People’s Social Care

The Chief Officer of Children & Young People’s Social Care should ensure that any disclosure issues which are discussed at Strategy meetings are minuted and that specific recommendations are notified in writing to the child’s school and other appropriate agencies. The minutes of Strategy Meetings should include a record of any decision (and the rationale) not to notify other agencies.

4.0   ACTION BY LEEDS SAFEGUARDING CHILDREN BOARD

On 27th January 2009, at a meeting of the Leeds Safeguarding Children Board, the Overview Report in respect of the young person ’M’ was received and approved.

The Board and constituent agencies accepted the recommendations in the report and the agency action plans to implement these, so that the lessons to be learned form this Serious Case Review would be included in local safeguarding practice and procedures. The Leeds Safeguarding Children Board will monitor and ensure the ongoing implementation of the recommendations and agency action plans.