Tameside
Safeguarding Children Board
A Serious Case Review
‘Child M’
The Overview Report
April 2015
Page 1 of 65
Index
Introduction and context to the serious case review .................................... 4
1.1
Rationale for conducting the serious case review.................................. 7
1.2
The methodology of the serious case review ....................................... 8
1.3
The scope of the serious case review ................................................ 10
1.4
Particular issues identified by the SCR review team for further investigation
by the key lines of enquiry: ....................................................................... 11
1.5
Membership of the case review team and access to expert advice ......... 11
1.6
Independent lead reviewers ........................................................... 12
1.7
Parental and family contribution to the serious case review ................. 13
1.8
Time scale for completing the serious case review .............................. 15
1.9
Status and ownership of the overview report..................................... 15
1.10 Cultural, ethnic, linguistic and religious identity of the family ................ 16
2 Summary of contact and significant events ............................................... 17
2.1
Exclusion from school .................................................................... 18
2.2
Escalation of self-harm and admission to in-patient CAMHS .................. 20
2.3
Overdose and admission to hospital emergency service ........................ 25
2.4
Further threat of self-harm ............................................................. 25
2.5
First mental health assessment following arrest .................................. 26
2.6
Lancashire police referral to Tameside children’s services ..................... 27
2.7
Child M’s first appearance in court and allocation to youth offending
services................................................................................................. 28
2.8
First contact from Lancashire YOT with Tameside YOT .......................... 29
2.9
Child M’s arrest and detention by Greater Manchester Police ................ 30
3 Appraisal of professional practice in this case ........................................... 32
3.1
The admission and care provided at the T4 unit in June and July 2013 .... 35
3.2
The arrangements for discharge from the T4 service and follow up support
36
3.3
The overdose and admission to hospital in October 2013 ..................... 37
3.4
The police detention and mental health assessments in October 2013 ... 37
3.5
The referral to Lancashire MASH in October 2013 and assessment ........ 40
3.6
Assessment and allocation to Youth Offending Services in Lancashire and
Tameside .............................................................................................. 41
3.7
Child M’s mental health assessment whilst in police custody in Tameside
and attendance in court ........................................................................... 43
3.8
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 ........................................................................................... 49
4.2
Family and professional contact and interaction ................................. 51
4.3
Responses to information and incidents............................................ 53
4.4
Tools to support professional judgment and decision making ............... 53
4.5
Management and agency to agency systems ..................................... 54
1
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4.6
Issues for the Tameside Safeguarding Children Board to consider in regard
to learning and improvement ................................................................... 56
4.7
Recommendations ........................................................................ 58
4.8
Issues for national policy ................................................................ 58
5 APPENDICES ....................................................................................... 59
Appendix 1 - Procedures and guidance relevant to this serious case review ....... 61
Legislation ............................................................................................. 61
The Children Act 1989 .......................................................................... 61
The Children Act 2004 .......................................................................... 61
Police and Criminal Evidence Act 1984 (PACE) .......................................... 62
Mental Capacity Act 2005 (MCA) ............................................................ 62
Safeguarding Procedures ...................................................................... 63
The local safeguarding children procedures .............................................. 63
Other local procedures relevant to this serious case review ............................ 64
National guidance ................................................................................... 64
Working Together to Safeguard Children (2010) and (2013) ........................ 64
Framework for the Assessment of Children in Need and their Families 2001 .. 64
Common Assessment Framework (CAF)................................................... 65
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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
1
Cognitive ability scores (CAT).
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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
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
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.
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.
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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.
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
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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
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
5
6
The Mental Capacity Act 2005 is described in the appendix to this report.
The IPCC report describes in detail the various codes that apply to refusal to bail and detention.
Page 7 of 65
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
(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 3rd
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 coordinated 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
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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.
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:
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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;
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:
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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)
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 coordinate 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
Head of Service
Head of children’s social work
Principal social worker
Organisation
Children’s Safeguarding Tameside Metropolitan Borough
(TMBC)
TMBC
Lancashire County Council (LCC)
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Detective sergeant
Review officer
Service manager youth offending
service (YOS)
Head of youth offending service
Assistant head of service
Named nurse safeguarding
children
Head of clinical services
Business manager
Business manager
Business support officer
Designated nurse
Service manager
Greater Manchester Police
Lancashire Constabulary
Lancashire YOS
Tameside YOS
Young People’s Service (YPS) in Lancashire
Lancashire Care NHS Foundation Trust
MEDACS (from July 2014)
Lancashire Safeguarding Children Board (LSCB)
Tameside Safeguarding Children Board (moved to another
local authority in June 2014 to take up a new post)
LSCB
Chorley and South Ribble Clinical Commissioning Group (CCG)
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.
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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
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.
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.
Page 13 of 65
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.
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.
Page 14 of 65
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.
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.
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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
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.
Page 16 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.
Page 17 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 midDecember 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.
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.
Page 18 of 65
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
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
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.
Page 19 of 65
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
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 selfimage 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
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for a mental health assessment by the Crisis Resolution Home Treatment
Team (CRHTT) who undertook a same day assessment12; the practitioner had
‘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
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
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.
Page 21 of 65
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.
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
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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
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
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.
Page 23 of 65
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.
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
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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).
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
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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
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
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.
Page 26 of 65
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.
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
Page 27 of 65
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.
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 5 th 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 6th 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 8th
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 9 th 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
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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.
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.
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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.
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 1 st 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.
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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
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.
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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.
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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
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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.
16
The Mental Capacity Act 2005 provides a framework to empower and protect people who may lack
capacity to make some decisions for themselves.
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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
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.
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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
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.
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.
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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 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 22 nd 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
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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
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 25th 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.
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.
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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.
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
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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
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.
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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.
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 selfharm 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.
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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.
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 28th 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
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Adult 1’s background or establishing what the relationship was between Child
M and Adult 1.
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
19
Greater Manchester Police dealt with an incident in the 11th 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.
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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.
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 reprioritising 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
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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
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
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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.
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.
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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
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.
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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.
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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
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vulnerable child referral to Tameside via the CSC was also processed. It had
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.
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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
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
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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.
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.
Issues for the Tameside Safeguarding Children Board to consider in regard to
learning and improvement
1) Refer to section 4.6.
21
Information Sharing: Guidance for practitioners and managers; Department for Children, Schools
and Families, and Communities and Local Government; 2008
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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
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.
Issues for the Tameside Safeguarding Children Board to consider in regard to
learning and improvement
1. Refer to section 4.6.
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.
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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
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.
Issues for the Tameside Safeguarding Children Board to consider in regard to
learning and improvement
1. Refer to section 4.6.
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
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(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.
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.
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.
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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
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.
Issues for the Tameside Safeguarding Children Board to consider in regard to
learning and improvement
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?
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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
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?
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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
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 Maddocks
March 2014
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5
APPENDICES
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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
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
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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.
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.
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.
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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.
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
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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
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.
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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 –
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.
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