This document has been classified as: Not Protectively Marked
South Tyneside Safeguarding Children Board
South Tyneside Safeguarding Children Board
Serious Case Review
Into the Circumstances Concerning
Kevin (a pseudonym)
Independent Author: Professor Michael
Preston-Shoot
January 2016
This document has been classified as: Not Protectively Marked
Contents
Page
1.
Introduction to the Serious Case Review
3
2.
Introduction to the Case
3
3.
Family Composition
6
4.
Terms of Reference
6
5.
The Review Process
6
6.
Family Involvement
9
7.
Background to the Reviewed Period
9
8.
Key Practice Episodes
11
9.
Themed Analysis and Lessons Learned
25
10.
Examples of Good Practice
32
11.
Conclusions
33
12.
Recommendations
34
13.
References
37
Appendices
Terms of Reference
38
Questions for Reflective Conversations
42
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1.
INTRODUCTION
1.1
South Tyneside Safeguarding Children Board (STSCB) commissioned a serious
case review relating to Kevin (a pseudonym) in July 2015. The terms of reference
refer to the period June 2012 and February 2015.
1.2
Serious Case Reviews (SCRs) are commissioned where abuse or neglect is
known or suspected, including where a child is seriously harmed, and there are
concerns about how organisations or professionals worked together (HM
Government, 2015). Serious harm includes sustaining a potentially life
threatening injury and serious long-term impairment of physical health and
development, which is pertinent to this case.
1.3
The review should explore what happened and why, namely the underlying
reasons that led individuals and agencies to act as they did. It should seek to
understand practice from the viewpoint of those involved at the time rather than
use hindsight, recognising the complex circumstances in which professionals
work together to safeguard children. Reviews should draw on relevant research
to inform the findings and recommendations, and be transparent in the process of
collecting and analysing the data (HM Government, 2015). These principles were
followed in this review.
1.4
Agencies participating in the review were:
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South Tyneside NHS Foundation Trust
South Tyneside Clinical Commissioning Group
Children and Families Social Care
Northumbria Police
Services for Young People
Local Secondary School
Northumberland, Tyne and Wear NHS Trust
South Tyneside Homes
North East Ambulance Service
Northern Doctors Urgent Care Ltd.
2.
INTRODUCTION TO THE CASE – THE TRIGGER EVENT
2.1
This account is taken from the healthcare records shared at a subsequent multiagency safeguarding concern meeting. On 09/01/2015 Kevin’s grandfather
telephoned NHS 111 (non-emergency medical helpline) to report that Kevin had
lost a lot of weight and had been suffering from rectal bleeding for 5 days, with a
history of diarrhoea for 6-8 weeks. The nurse practitioner who eventually dealt
with the call, made contact with Kevin’s mother and finally advised her to take
him to see the GP. The nurse practitioner additionally referred her concerns to
Children and Families Social Care (CFSC).
2.2
From this, a Social Worker attempted a home visit on 09/01/2015 but there was
no answer when she called. She left a card to which Kevin’s mother responded.
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In response to this contact out of hours Social Workers visited on 10/01/2015.
During this visit the Social Worker contacted NHS 111 to seek advice, and the
same advice was given to make an appointment with the GP. The Social Worker
contacted the GP on the 10/01/2015 to request a home visit, which was declined.
This may be due to the family having moved home previously and not reregistered at a GP practice in their new local area.
2.3
A GP appointment was subsequently made by Kevin’s mother; at which, once
seen by the GP, a direct referral into an A&E department was completed. Kevin
was reportedly in a ‘collapsed state’ and was transferred to the A&E department
via an ambulance, arriving at 11.55hrs on the 14th January 2015, as a pre-alert
admission via North East Ambulance Service (NEAS). Kevin had been physically
carried into the GP’s surgery
2.4
The admission history recorded that Kevin had been to see his GP that morning
with a one year history of diarrhoea and some recent rectal bleeding. Kevin’s
blood pressure (BP) when in attendance at the GP practice was low and he also
had tachycardia (fast heart rate). On arrival to the A&E department Kevin
recounted a history of weakness, feeling unwell with rectal bleeding and a one
year history of loose stools. He was described as pale in colour.
2.5
Kevin advised medical staff that his diarrhoea had not been investigated. His
medical records showed he had a history of tremor exacerbated by anxiety. It
was suggested that Kevin had left school due to his embarrassment of having
diarrhoea. Medical documentation stated “bed ridden – and house bound – never
leaves his room”. Kevin had no history of vomiting and reported minimal
abdominal pain, with no problems passing urine. Kevin was alert and able to
speak in sentences. It was noted he had some swelling to his face, lips and oral
cavity. He was peripherally cold, with his BP remaining low. The medical
assessment determined no abdominal tenderness, with bowel sounds heard
(sounds would be expected). It is recorded that Kevin was malnourished, with
three pressure ulcers: one category 3 left hip and two category 2 to sacrum. His
blood haemoglobin (Hb) was low and on admission Kevin required a blood
transfusion of four units. Comment: category two pressure sores involve partial
thickness tissue loss, presenting as a reddish wound bed. Category three
pressure sores involve full thickness tissue loss where fat may be visible but not
bone, tendon or muscle.
2.6
Staff in the A&E department spoke with CFSC and were advised that Kevin had
been allocated a Social Worker. The Social Worker had been unable to gain
access to the house when she had called on the 9th January 2015. The Social
Worker was able to have some communication with a GP practice to discuss her
concerns regarding Kevin’s weight loss and planned to try again to gain access
to see Kevin. It was evident that the Social Worker had had concerns regarding
Kevin’s low mood and weight loss and that Kevin would not attend his planned
GP appointment on the 14th January 2015.
2.7
It was noted that Kevin’s grandmother also had concerns regarding Kevin’s rectal
bleeding which was getting worse, and she was advised that this was probable
inflammatory bowel disease and Kevin was to keep the planned appointment.
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2.8
During liaison with the Clinical Operations Manager when Kevin was admitted to
hospital on the 14th January 2015, Kevin’s mother had spoken to the unit
manager, who had asked her why Kevin had not been to the GP earlier. Kevin’s
mother had reported that they had moved house and the family were not
registered with a local GP. Kevin’s mother stated that approximately 6 weeks
prior to admission date Kevin had said that the channels on the TV downstairs
were not very good so he had taken himself off to stay in his room. Kevin
apparently had a fridge in his room and Kevin’s mother made food for him; she
was out at work and therefore was not sure exactly how much of his meals he
ate. Kevin’s mother reported that as he was not registered with a GP practice,
Kevin’s original GP agreed to see him and his grandparents had to support him
to get to the practice for the appointment as Kevin’s mother was at work.
2.9
Kevin underwent emergency surgery and further investigations determined the
likelihood of Crohn’s Disease (an inflammatory chronic disease of the bowel).
Medical records show that Kevin and his mother were advised that the surgery
and Kevin’s condition indicated a 31% risk of mortality and the surgery was
considered a lifesaving necessity. Kevin was initially nursed in the Intensive
Therapy Unit (ITU) and later was transferred to an Adult Surgical Ward. Kevin
initially did well and was reported to have chatted with staff on the ward. It was
reported that he appeared to have a good relationship with his family. Kevin’s
condition later deteriorated and due to problems in maintaining his blood
pressure he was transferred to the High Dependency Unit (HDU).
2.10 There was apparently concern by the clinicians that further surgery would be
required by way of a total colectomy (removal of the large intestine from the
lowest part of the small intestine to the rectum); however, this was not necessary.
2.11 Ward staff were unsure at that time how Kevin would cope with body image
issues and although Kevin was considered a relatively quiet person, he did talk
about his family but did not initially mention a father figure and it was unclear if he
had any relationship with his father. The allocated Social Worker had reported a
discussion with Kevin’s mother regarding his presentation of weakness,
malnourishment and history of rectal bleeding, pressure damage, with no medical
intervention sought; Kevin’s mother could not provide any explanation, reporting
only that Kevin had refused to attend health appointments with her.
3.
FAMILY STRUCTURE
3.1
Kevin lives with his mother and younger siblings. Kevin has contact with his
father and with his maternal grandparents. Concerns have not been expressed
about Kevin’s siblings and they were not included in the terms of reference for
this review.
4.
TERMS OF REFERENCE
4.1
The terms of reference for the review were agreed as follows:
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 Critically analyse and evaluate the events that occurred, the decisions made
and the actions taken or not. Were there missed opportunities or episodes
when there was sufficient information to have taken a different course of
action? Were assessments conducted effectively and appropriate conclusions
drawn?
 Where judgements were made or actions taken which indicate that practice or
management could be improved, try to get an understanding not only of what
happened, but why.
 Demonstrate whether organisations/services heard and responded to Kevin’s
voice and considered his ‘lived experience.’
 Identify good practice.
 Consider whether professionals were proactive in escalating concerns and
effecting challenge where appropriate.
 From an inter-agency perspective, consider whether processes, procedures
and communication were effective and how they impacted on the case.
 Analyse the impact of the Gillick Competency and Fraser guidelines in relation
to this case and the decision-making process by professionals.
 Identify how the LSCB could deal with similar issues of adolescent self-neglect
in the future.
5.
THE REVIEW PROCESS
5.1
The agencies involved initially produced independent management reports that
sought to capture the chronology of their involvement and describe their
involvement with Kevin and his family. From these reports the overview report
writer identified five key episodes and initial questions for consideration.
5.1.1 Key episode one: This episode covers the period from July 2012 to January
2013. The concerns related to Kevin’s poor school attendance and hygiene, and
poor home conditions (bare plaster walls, offensive odours). It was difficult to
make contact with the family. As a result of the CAF process, improvements were
noted in the referring problems and the case closed. This episode followed some
previous concerns about Kevin’s mental well-being. Questions arising about work
with the family at this time include:
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What assessments were undertaken of Kevin’s mental well-being?
How was his poor school attendance understood?
What stories were told about the home conditions?
How was the difficulty in engaging with Kevin and his family understood?
When it was difficult to engage with the family, what risk assessments were
undertaken?
5.1.2 Key episode two: This period runs from October 2013 to February 2014.
Once again, there were concerns about poor school attendance but also about
his health, especially his weight loss and swollen lips. Kevin’s mother apparently
agreed to seek GP advice and to report back to the school. Questions which
arise here include:
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 Did Kevin’s mother report back about conversations with the GP? If not, why
was this not followed up? If she did, how was this information checked out and
followed through?
 What risk assessments were undertaken at this point?
 Were those involved at this point aware of the history in this case, and what
impact did that have on decision-making?
5.1.3 Key episode three: The month is October 2014. Kevin has left school but is
proving difficult to engage by Services for Young People (SYP). He is reported by
his mother to be suffering from depression. One IMR writer for this SCR suggests
that more questions should have been asked of the mother. His case does not
appear to have been tracked and the family remain difficult to engage. Questions
which arise here include:
 How were the mother’s concerns about Kevin perhaps being depressed
followed up?
 How aware were those involved at this time of the history in this case?
 What risk assessments were done, especially but not just of his mental wellbeing, and with what conclusions?
 What attempts were made to engage with Kevin?
 What options in this case were perceived and what stories influenced practice
with Kevin?
5.1.4 Key episode four: The month is January 2015 and the crucial component of
this episode is Kevin’s hospital admission. He is said to have been unwell since
August 2014 and now to be underweight and malnourished. He has bed sores
and diarrhoea. He is refusing to see his GP. He does not keep a same day
appointment but is eventually taken to see a GP. He is said to refuse hospital but
is eventually admitted. A nurse suggests sectioning under the Mental Health Act
1983. There are also significant rent arrears. Questions which arise here include:
 Were any agencies in contact with Kevin and his family between October 2014
and January 2015 and what did they notice? Why does this case appear to
reach crisis unexpectedly?
 Why did Kevin’s mother wait so long before escalating her concerns?
 Why did 111 not send an ambulance and why did the GP not undertake an
urgent home visit?
 What risk, child protection, mental capacity and mental health assessments
did the social workers complete?
 How aware were those involved at this point of the historical background of
this case?
 What stories were influencing practice in this case about young people of
Kevin’s age and presentation?
5.1.5 Key episode five: The month is February 2015. Kevin is being discharged
from hospital following severe self-neglect and neglect. A priority mental health
appointment is offered but Kevin refuses to attend and is therefore discharged.
Key questions include:
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 How is his mental capacity assessed?
 How is his refusal understood in legal terms?
 What assessments have been done of his mental health and the family
situation?
 What is the plan to address and seek to mitigate the risks in this case?
 How are the family dynamics understood?
5.2
Underpinning this analysis of the apparent key episodes are several factors that
may have influenced how professionals approached the case. Once again,
framed as questions, they include:
 Was Kevin assumed or assessed as having mental capacity to take specific
decisions about his health care? How did the legal context and knowledge of
the law influence such an assessment?
 If Kevin did not understand the serious condition he was suffering from, did he
have capacity?
 What awareness was there that the Mental Capacity Act 2005 and the
Guardianship provisions in the Mental Health Act 1983 apply to young people
over the age of 16?
 Did professionals believe that Kevin could be experiencing significant harm? If
they did not, what factors influenced this belief? If they did, what assessments
were undertaken and what conclusions were reached?
 On what basis does it appear to have been concluded that there was no
evidence of neglect?
 When Kevin was in hospital, what psychiatric, psychological and medical tests
were done to assess him? What attempts were made to engage him and to
understand how he saw his situation?
 How did understanding of the Gillick judgement and Fraser guidelines impact
on professionals’ thinking and approach to this case?
5.3
This framework for the review was discussed by the STSCB Learning and
Improvement Sub Group at which it was agreed that the agencies involved would
conduct internally reflective conversations with those professionals involved in
the case, using the above framework with the addition of key lines of inquiry,
namely:
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5.4
Age
Gender and position in the family
Family dynamics (e.g. Kevin’s relationship with his mother)
Knowledge of the family’s involvement with local agencies
The attitude of the family towards engagement with local agencies
Educational attainment
Lines of inquiry were added that focus more on the agencies involved with the
family and what individuals and organisations brought to the work:
 Understanding of the law relating to parental responsibility in respect of young
people of Kevin’s age – what those involved understood regarding:
o whether Kevin could consent and refuse medical intervention
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o whether his mother could override his decisions
o under what circumstances professionals could/could not override the
decisions of both Kevin and his mother
Understanding of the law relating to whether Kevin had the mental capacity to
take decisions
Questioning based on concerned curiosity and assertiveness in respect of
confidence in exploring issues of Kevin’s:
o Mental Health
o Physical Health
o Presenting behaviour
Confidence in challenging Kevin’s mother regarding Kevin’s self-neglect, his
mental and physical health and possible neglect by the family
What assessments of mental health, mental capacity and risk were
undertaken
How the interviewees saw their role and responsibility when involved in the
case and how they saw the roles and responsibilities of other agencies
Impact of organisational policies, procedures and culture
5.5
The overview report has subsequently pulled together the learning from these
conversations, which has been further tested in two learning and service
development events.
6.
FAMILY INVOLVEMENT
6.1
Both Kevin and his mother were invited to participate in the review but both
declined, expressing the desire to move on from the events under consideration.
7.
BACKGROUND TO THE REVIEWED PERIOD - HISTORY
7.1
Kevin throughout the investigation has been referred to by staff as a “slight boy”.
Interestingly on review of child health records and health medical records it
appears that Kevin was a “stocky” child and young person. Child health records
from age 5 weeks to 14 years show his weight as always lying between the 75 th
and 91st centile. They provide a picture of a well-built young person throughout
his childhood who was also known to play rugby, suggesting that Kevin was a fit
and healthy young person.
7.2
In February and March 2008 Kevin failed to attend an out-patients appointment
with a Consultant Paediatrician. At the time there was no DNA policy in place.
Within NHS Foundation Trust records it is unclear who referred and the reason
for the referral. Comment: this underscores the importance of recording, which is
a key component of a person’s right to (knowledge about their) private and family
life.
7.3
Kevin was later seen in September 2009 by another Consultant Paediatrician
with familial tremors to his hands with a probable cause being due to anxiety. A
referral was made to a Clinical Psychologist. Correspondence within medical
records from the Clinical Psychologist to the Consultant Paediatrician reported on
a clinic appointment which suggested that the main issues were Kevin’s jealousy
of his siblings, in particular his brother, and that Kevin was quite a perfectionist
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and could get anxious in new situations. The Clinical Psychologist reported on
Kevin’s tremor increasing when in certain situations such as when doing
presentations and starting something new, but that Kevin genuinely seemed to
manage having the tremor and the issues were not impacting significantly on his
life. The Clinical Psychologist indicated that Kevin appeared as having a strong
relationship with his mother and valued the time they spent together especially
without his siblings. Kevin had informed the Clinical Psychologist that he did not
need any support from her. The plan at that time was to discharge him from clinic
with advice given to both Kevin and his mother that if he felt the tremor or other
factors were impacting on his mental health then they could request another
referral via the GP. The Clinical Psychologist’s overall viewpoint was that Kevin
appeared to enjoy the sessions although he had made it quite clear that he had
no need for the service.
7.4
At that time, although Kevin enjoyed the three sessions with the Clinical
Psychologist, he had indicated that he did not need to be there. This perception
may have possibly influenced his recent decision during/after his January 2015
hospital admission not to engage with Clinical Psychology or referrals to CYPS.
7.5
In December 2009 Kevin was seen by a third Consultant Paediatrician following a
referral from a GP, where Kevin’s tremors were reported to be worse at rest and
when anxious. Kevin was recognised as an “anxious individual and a
perfectionist but also somebody who achieves a great deal and will develop
further and may well find ways and get through his anxieties by whatever goals
he may set himself”. At the age of 11years old Kevin was demonstrating an ability
to achieve and possibly cause anxieties by setting his own high standards.
Comment: this history is the first account of mental health concerns and Kevin’s
reluctance to engage, which were to become a feature of this case. There is also
interesting reference to family relationships. This information does not appear to
have been known by all the professionals and agencies that subsequently came
into contact with Kevin and his family.
8.
KEY PRACTICE EPISODES
8.1
Key Episode One
8.1.1 This covers the period from July 2012 until January 2013. In summary, after
a period of initial difficulty, engagement of Kevin’s mother with the social
worker who completed the initial assessment and the family worker who
offered a period of intervention was good and the intervention appeared
successful. The home conditions improved. Kevin’s school attendance
was not being raised as an issue and in fact from this time neither the
home conditions nor his school attendance were raised as issues again
with children’s social care.
8.1.2 However from a CFSC perspective there are some issues of significance:
 There was a significant time lapse in attempts to contact Kevin’s mother
and see the home. At times these were weeks apart. This raises
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questions both about the urgency with which the agency felt they
needed to act and the message this gave to Kevin’s mother about the
level of concern, although it has been suggested that such gaps were
not unusual for the service at that time. Comment: the approach is
different now. CFSC confirm that, following service restructuring, such
gaps would now be unusual and would be seen as unacceptable.
 There was little focus in the thinking or action in both the initial
assessment and the subsequent Family Support Service period of
intervention of the whole family. It was very problem focussed. Kevin is
recalled as being anxious but no specific work was attempted with him.
His brother is described as challenging, with concerns also registered
concerning his difficulties in school, his food intake and his poor
sleeping pattern. Comment: this may have been a missed opportunity to
consider underlying issues within the family and regarding Kevin’s
mental well-being. However, CFSC confirm that, following service
restructuring, a family worker is attached to each social work team to
promote a more whole system approach. At the time, however, family
dynamics remained unexplored, for example the father’s departure from
the family and his subsequent contact, and the impact of this on
different family members. At the time family support workers may not
have been expected to develop skills in asking questions informed by
concerned curiosity.
 The support was thorough, timely and comprehensive and brought
about significant measurable change for the family, namely the home
conditions improved, changes were made to the physical condition of
the property and the family were able to move to a larger property that
was more conducive to their needs. Comment: however, an opportunity
to explore fully what underlay the home conditions was missed.
Opportunities were taken to explore what underlay the home conditions,
such as issues around pets and the number of hours Kevin’s mother
spent out of the house at work. However, a lack of a “Think Family”
approach restricted this work.
 There was very limited direct involvement with Kevin and the
intervention and support was very adult focused. Comment: the
intervention was arguably insufficiently child centred and focused on
family dynamics. There is now a reported different approach by CFSC,
acknowledging that this CAF episode was insufficiently child centred.
Those involved at this time found that Kevin’s mother was raising
concerns broader than the home conditions and that, therefore, her
interaction was not an example of disguised compliance. However, it is
unclear to what extent these concerns were followed through because
of the emphasis on resolving the home conditions. The views of Kevin
and his siblings remain unclear.
8.1.3 Recommendation One – given the changes to family support and early
intervention arrangements, an audit would be timely to evidence the
impact of the changes.
8.1.4 Neither the GP nor the school nurse appears to have been well sighted in
terms of any concerns about Kevin’s mental well-being. The school do not
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appear to have been aware of Kevin’s previous history and so accepted
assurances from Kevin and his mother regarding his well-being. Education
and SYP were unaware of Kevin’s involvement with paediatricians and
CAMHS in 2009 and did not routinely at that time check information held
by healthcare professionals as part of a CAF process. Had this previous
history been known, it is possible that the school would have questioned
further Kevin’s absences. Comment: the learning events concluded that
schools infrequently request medical records or information and that, on
this occasion, the school might have asked Kevin’s mother what the GP
said to her. It was recognised that schools cannot ask questions of GPs
without parental consent but they may not be sufficiently aware of how and
when to escalate concerns about a young person’s ill-health, although a
threshold protocol is in place.
8.1.5 Kevin’s mother engages well with all agencies eventually in resolving the
home conditions, although she is noted as having been aggressive when
the school informed her that it had initiated a CAF and referral to children’s
social care. When the school enquires about Kevin’s health, she reports
that he has been vomiting and says that she is following the advice of the
GP but the latter’s records suggest that she may not have been in contact
with the GP. The school follow up non-attendance with visits to the home
and Kevin is seen and noted as anxious about falling behind with his work.
Comment: this begins a pattern by Kevin’s mother of engagement
periodically. The learning events have questioned closely whether during
this and each subsequent episode there is evidence of disguised
compliance. Kevin’s health and well-being are of concern but those
agencies in contact with Kevin defer to his mother and there is no
assessment at this point. Indeed, checks of GP records for this review
failed to find evidence of any medical issues being highlighted for Kevin. If
the school was sufficiently concerned to urge the mother to speak to
Kevin’s GP, this should have been followed through subsequently.
8.1.6 Recommendation Two – STSCB consider the development of a
safeguarding in schools strategy that outlines expectations concerning
sharing information and concerns internally within each school about
young people’s well-being and escalation with external agencies.
8.2
Key Episode Two
8.2.1 This period runs from October 2013 to February 2014. The school followed
up Kevin’s absences when his mother did not make contact. In reflective
conversations school staff questioned whether they asked too few
questions about Kevin’s health and placed too much reliance on good
school attendance meaning that all was well. They did not doubt his
mother’s reassurance that she was seeking medical advice in relation to
Kevin’s health. Comment: too much reassurance was taken from the
mother’s apparent co-operation. Insufficient emphasis was given to
concerned curiosity and to following up with Kevin’s mother the outcomes
of what she had agreed to do. No-one at the time appears to have
wondered whether the ulcers identified on Kevin’s lips were an allergic
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reaction to possibly deteriorating home conditions, specifically the number
of animals in the house.
8.2.2 It appears that the secondary school did not know about his primary
school educational history and so did not make contact earlier with other
agencies. Had they have known, they might have requested a re-opening
of the CAF or referred Kevin to healthcare professionals. Comment: the
failure to share or request information about case chronology and history
means that agencies start again with each interaction with the family rather
than build on what has gone before. Knowledge of a young person’s
chronology can inform discussion within and between agencies about
accumulating concerns. In this case, at this point in time, the concerns
may have been experienced as low level but shared assessment, initially
within the school, might have co-ordinated an approach to Kevin.
8.2.3 The school did eventually refer Kevin to SYP, although this may have
been less a formal referral than a request to ‘pop in’, but their visit is
unsuccessful and is not followed up. Comment: this represents a missed
opportunity to engage with Kevin and his family. SYP did not know the
prior history at this stage and may have followed up the unsuccessful visit
if they had known. Comment: once again, an agency is starting again,
unaware of potentially significant historical information.
8.2.4 The GP at this time was unaware of the historic concerns and was not
contacted by any other agency with concerns about Kevin. The GP had no
engagement with Kevin’s mother. Comment: if the mother was not in
contact with the GP, this would only have come to light had an agency
made contact with the GP to relay concerns about Kevin’s health and to
ask whether his mother had been in contact. Agencies may feel
constrained from sharing such information unless there were child
protection concerns. Healthcare professionals do not appear to have been
made aware of any concerns about Kevin’s health at this time. For
example, neither Kevin nor his mother made any contact with the school
nurse although he may have been encouraged to access a school nurse
through drop-in sessions.
8.3
Key Episode Three
8.3.1 The month is October 2014. Kevin did not enrol at College. A worker from
SYP visited but did not see Kevin. Nor did the worker know the history of
the case to this point. For instance, Kevin had not been identified by his
previous school as a potential NEET. In reflective conversations, the
worker has suggested that had they known the background, they might
have requested to see Kevin instead of relying just on what his mother
said. Comment: it was a missed opportunity not seeing Kevin. Equally, this
highlights the “start again phenomenon” that other SCRs have also found,
meaning that the worker here had insufficient information to assess the
risk of harm. The case chronology or history is not known, resulting in
workers beginning their assessments afresh.
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8.3.2 Recommendation Three – The STSCB should resolve, when pupils leave
school for Sixth Form College or further education, what information might
be passed on so that individuals are not lost sight of.
8.3.3 Kevin’s mother tells the worker that he is unwell and will not enrol at
College until the New Year because of anxiety and depression. The
worker did not explore with Kevin’s mother what other agencies might
have been involved and if he was engaging with them, or apparently why
he might need up to three months to recover sufficiently to engage with
College. The worker did follow-up with further visits but these were
unsuccessful and neither Kevin nor his mother responded to the calling
cards that were left. In reflective conversation, the worker has
acknowledged that they should have requested to speak to Kevin but were
unclear if they could do this. They have acknowledged that they should
have followed up sooner and perhaps placed too much weight on what the
mother said. Comment: consideration should be given to training for staff
on the legal rules as the worker involved at this time appeared uncertain of
their authority. This might have been a missed opportunity to explore
relationships in this family. SYP report also that there is now a greater
focus on the young person’s welfare, with a result that information
regarding his ill-health would now be followed up. At the time, however,
that was not the focus required of the service.
8.3.4 Recommendation Four – SYP provide advice/support for staff and multiagency partners on guidance relating to 16 and 17 year olds missing from
education.
8.3.5 Neither the GP nor any other healthcare professionals were alerted to any
concerns about Kevin’s mental or physical well-being at this time. Indeed
this would have been difficult as no agency was in regular contact with
either Kevin or his family at this time.
8.4
Key Episode Four
8.4.1 This covers the month of January 2015. Records indicate that Kevin has
not seen a GP since 2009. Prior to this episode no concerns appear to
have been raised with the GP about Kevin. The GP does not appear to
have had information about what agencies were or had been involved,
which compromised any risk assessment that might have been
undertaken. It appears that Kevin’s mother had registered herself with a
new GP following the family’s move after the CAF process but that Kevin’s
GP registration had not changed because he had not been to the surgery
to register. This may have contributed to the subsequent difficulty in
securing a GP visit to the home because of catchment areas.
8.4.2 It appears to have been a grandmother who telephoned the GP with a
report of diarrhoea and weight loss. It is unclear from the records if Kevin
was offered a same-day appointment and failed to attend. It is not clear
what information about the extent and duration of Kevin’s symptoms was
communicated to the GP surgery; however, it is clear that the 111 service
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knew that Kevin was only 4 stone in weight, that he had had diarrhoea for
between 6 and 8 weeks, and rectal bleeding, as this information was given
by Kevin’s grandfather and mother. Comment: good record keeping is
essential to inform and keep track of decision-making.
8.4.3 It is important to consider the contact between the family and 111 in some
detail. Recordings of the conversations between the call handler and both
Kevin’s grandfather and mother have been retrieved and listened to. The
first call was made by the grandfather to 111, reporting his worry about his
grandson who had lost a lot of weight and had an episode of rectal
bleeding that morning. He stated that Kevin had not left home during the
preceding six/nine months and that he was threatening suicide. He was
not at the same location as his grandson so the call taker was not able to
continue the call as they have to carry out a clinical assessment following
the pathways assessment tool. This was explained to the grandfather who
understood this and gave his daughter’s mobile number so the call taker
could ring her direct. To ensure this was possible the grandfather’s contact
details were also confirmed just in case there was a problem.
8.4.3.1 The call taker tried the number provided which was not working.
The call taker rang the grandfather back who provided another
contact number. This new number was answered by Kevin’s
mother. She sounded distressed and provided a brief history of a
few months of Kevin being unwell, losing weight. He was refusing
to go to the GP or hospital. That morning he had experienced an
episode of diarrhoea and had passed blood rectally, to which he
had drawn his mother’s attention. The mother advised that he
would not speak to her today; however the call taker advised that
she needed to be beside him to carry out a clinical assessment.
Kevin’s mother knocked on his door and he allowed her to enter.
8.4.3.2 When Kevin spoke he sounded lethargic and was not able to
understand some of the questions his mother was asking
regarding his bowel movements. His mother described a history of
back pain and stomach cramps since Christmas and she had been
pleading with him to go to the doctors. She stated that she had
tried to persuade Kevin to see a doctor and that she could not take
it anymore. She said he possibly weighed less than 4 stones and
that all the bones in his body were visible; she reported that he
was not able to stand very well, that he had deteriorated rapidly,
and that he had dizzy spells and was without energy. There was
mention of Crohns disease and cancer and that he had threatened
to kill himself today if his mother contacted the doctor. The mother
said she knew that that was not possible. The family had moved
address and as Kevin was still registered with the GP at their old
address, his mother thought that meant he was not registered.
Comment: the call handler was very attentive, even when following
formulaic diagnostic questions, and clearly explained why she was
passing the call to a clinical nurse.
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8.4.3.3 This was a complex call for the call handler to manage, the
information was documented on the screen and the call was ‘warm
transferred’ to the nurse. A recording of the conversation between
the clinical nurse and Kevin’s mother has also been retrieved and
listened to. The nurse carried out a further clinical assessment to
establish the best treatment option, following formulaic diagnostic
questions known as the rectal bleeding pathway. The nurse asked
if she was able to speak directly to Kevin; his mother asked him
and he could be heard to say that he would talk to her through his
mother. Again an assessment of the bowel movement and rectal
bleeding was explored; no dizziness or collapse was described but
Kevin’s mother did refer to his suicide threats and his fear of
having cancer. A history of back pain and stomach cramps were
described for about 6 months whilst the rectal bleeding had just
happened today. Once again, there was reference to Crohns
disease and to being able to see his bones. In response to the
nurse’s questions, she reported that his skin temperature was
normal but that he had bumps near his back passage which were
not painful. His mother described the difficulty she and the rest of
the family had had in trying to get Kevin to seek medical attention
as he refused all help.
8.4.3.4 Kevin was severely unwell. The conclusion was that Kevin should
see a GP within 6 hours; however, his mother stated that she did
not know how she would get him there as he was so weak. There
was a slight misunderstanding that the child was not registered
with a GP after the house move; however, the system still showed
him registered with his old GP surgery. As he was still registered
with a GP but he was out of their area for a home visit, this was
apparently not possible to arrange. There was the option to go to a
Walk in Centre; the nurse also suggested the mother try to get an
appointment at his own GP or the mother to speak to the GP if he
would not attend, with the possibility of having him sectioned. The
nurse advised that it needed to be established whether the
problem was medical or psychological. She further advised that
Kevin clearly had a serious underlying problem. Kevin’s age (16)
was mentioned with the nurse advising his mother that she must
intervene and enforce some care for him, for example by
contacting her own GP for advice and assistance. The call ended
there with the mother being advised of the above options.
Comment: the nurse appears uncertain of the way forward
towards the end of the conversation with Kevin’s mother, with
advice about ensuring that he sees a doctor within six hours being
repeated. There is a sense of the conversation going round in
circles. The upshot appears to have been that a GP appointment
was made for the following Wednesday.
8.4.4 Comment: given the lack of information about the history available to the
GP this offer of an appointment might be understandable but arguably the
symptoms reported should have given rise to more serious concern both
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from the GP surgery and 111. Indeed, it is agreed that, whilst the
assessment conducted by the clinical nurse was appropriate and correct
for the symptoms described, the questions asked and the answers given,
the call needed upgrading to a contact sooner than the 6 hours as triaged.
In addition, the nurse concerned could have contacted the currentlyregistered GP directly to ensure urgent follow-up/contact/home visit.
Kevin’s mother should also have been advised what action to take if she
was unsuccessful in ensuring that Kevin saw a doctor within the
recommended timeframe. This case also invites consideration of what out
of hours’ arrangements are in place and, when parents of young people
are reporting serious healthcare concerns and difficulty in persuading them
to seek treatment, for example from A&E or a Walk-in Centre, what
options 111 staff have been trained to consider. For example, there is no
reference to Kevin’s mental capacity and the options available if he did not
have capacity regarding consent to, or refusal of medical treatment. There
is no discussion of whether an ambulance should be called or what should
happen if Kevin’s mother could not get him seen by a doctor within the
recommended six hours. If the assessment by the clinical nurse was that it
was not appropriate for an ambulance to be called immediately, as Kevin
was not actively rectally bleeding and had no abdominal pain, at what
point might that assessment have been reviewed? It should be noted that,
at the time of the call, the clinician involved did not feel that an ambulance
was appropriate clinically, although she did submit a safeguarding referral
following the call because of her concerns. Subsequently, having listened
again to the call and having participated in a reflective conversation using
the format agreed for this review, she accepts that it would have been
appropriate to have sent an ambulance given the risks that had been
identified during the call.
8.4.4.1 Recommendation Five – The 111 service should review the
training and protocols provided for assessing healthcare risks
when young people are seriously ill and refusing treatment,
including the legal options available within the Children Act 1989,
Mental Health Act 1983 and Mental Capacity Act 2005.
8.4.5 A safeguarding referral was appropriately made by the 111 service clinical
nurse. Comment: the safeguarding referral form records the nature of
abuse as being self-neglect and concern for Kevin’s general welfare and
mental health. His medical symptoms are outlined but the level of risk is
marked as non-urgent, even though the advice was that he needed to see
a doctor within six hours and his mother had stated her concerns about
whether she could ensure that this happened. The family do not appear to
have been aware that this referral was being made. The form states that
Kevin was not previously known to social care, when in fact there had
been prior involvement (episode one). Reflective conversations with the
Social Worker who subsequently completed the single assessment and
undertook the section 47 enquiry and her supervisor, and with the two Out
of Hours Social Workers who visited Kevin on 10/01/2015, highlight two
key issues from which a number of other issues flow. These appear to be:
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 How much did Kevin choose to neglect his health needs, was he aware
he was doing this and did he have that right?
 Should Kevin’s mother have done more and sooner and did her failure
to do this constitute neglect for her son on her part as a parent?
8.4.6 The similarity with which practitioners who have met the family describe
Kevin, his mother and their relationship has been noted. Comment: once
again we gain an insight into family dynamics but exploration at this point
in time has been difficult. Attempts have been made to engage with Kevin
and his family to explore relationships and how Kevin became so unwell.
However, he has placed clear limits around what he is willing to talk about.
Thus, it is unclear how Kevin saw his lived experience of his family, how
he pictured his emerging identity and what his father’s contact was with
him and the rest of the family.
8.4.7 There is an overriding view of Kevin as an articulate bright young man who
was anxious and frightened and this led to his self-neglect. It should be
noted, however, that to the 111 staff he appeared lethargic. Comment:
service users who participated in research on self-neglect (Braye et al.,
2014) said that shame and embarrassment often lay behind reluctance to
engage. Feelings of shame can also lie behind parental resistance to
engagement and change. He is felt strongly by professionals to have had
capacity. Comment: this case invites consideration of the question when to
overrule such capacity when someone is 16-17. It is known that resistance
is linked to individual and family dynamics, including feelings of shame,
ambivalence and lack of confidence in an ability or need to change
(Forrester et al., 2012). It is significant that both of the social workers who
visited Kevin out of hours are mental health trained and well aware of the
legislative and practice context in this area. Comment: Kevin’s capacity
may have been affected by his loss of body weight and dehydration. It is
not clear whether this was considered.
8.4.8 In relation to Kevin’s mother, whilst the descriptions of her are similar,
there are polarised views regarding what she could have done. Most
practitioners were clear that she should have done more; however, when
discussing what this would look like and how this would be have achieved,
the picture starts to look more complex. It is here that Kevin’s age and
stage of development starts to play a more significant role in the minds of
practitioners but also in the actions of his mother. Comment: the legal and
social status of 16-17 year old young people is a complicating feature of
this case.
8.4.9 From the collective view it is evident that Kevin would not acknowledge at
this point just how seriously ill he was. It was certainly the view of the
practitioners that his mother should have known as his parent. However,
when exploring what she did / did not do and how she could have done
things differently the situation starts to emerge differently.
8.4.10 Both out of hours’ practitioners spent 30-40 minutes with Kevin and he did
not present to them as in such pain or distress that they felt an ambulance
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was required. He is described as being lucid, bright and articulate. Both
knew the history of the case, which represents good practice. Kevin’s
mother was being told by medical professionals that given the symptoms
described a planned appointment was the best way forward. All
professionals spoken to agreed that Kevin’s mother was not downplaying
the concerns and was in fact extremely worried, perhaps feeling powerless
and desperate, overwhelmed and unable to act effectively. She was
distressed and tearful, and fearful that he was going to die. This then
raises the question as to whether it was reasonable to expect her to act
differently and ignore medical advice. Social workers have expressed the
view that she might have been more persistent in raising concerns, even in
the face of his apparent refusal to see the GP. Comment:. Kevin’s mother
was aware that he was refusing to leave the house to seek treatment at
this point. She may have found it difficult to act on advice that she should
dial 999 for an ambulance. As the 111 service and the OOH social workers
knew this, the question then arises as to what a reasonable professional
would have done in these circumstances, even knowing that he was not
completely refusing medical treatment but rather just the location of it,
unwilling to leave the house. Moreover, the 111 service had advised
previously that Kevin should be seen within six hours. Since this had not
happened by the time the OOH social workers were speaking with the 111
service, it is puzzling that the level of risk does not appear to have been
reassessed.
8.4.11 No recording of the conversation between the social workers and the 111
service is available. The out of hours’ social workers advised the 111
service that a home visit was required but this was apparently declined.
The OOH social workers were clear that they were visiting as a child-inneed referral. Had the request for assistance been made under section 27,
Children Act 1989, would NHS professionals have considered themselves
under a duty to respond? Comment: it is reasonable to expect that a social
worker assessment be acted upon, especially when the 111 service knew
the extent of Kevin’s ill-health. Equally, if the social workers thought that a
medical or healthcare assessment was required, and given that it proved
impossible to secure one, what escalation of their concerns might have
been expected and/or did they consider this therefore a sufficient
emergency to call for an ambulance?
8.4.11.1 Recommendation Six – NHS Commissioners, NHS Trusts and
the 111 Service should clarify how concerns may be escalated
by social care and other professionals out of hours.
8.4.12 At least one social worker contacted Kevin’s out of area GP to report
significant weight loss and to recommend a home visit and risk
assessment. The GP did not make a home visit in response to the social
worker’s assessment. Comment: the GP should have acted sooner on the
concerns raised by social workers. Again, this refusal to undertake a home
visit might have raised the level of risk, such that concerns should have
been escalated and/or ambulance called. However, in counterpoint, if
medical and healthcare professionals did not think that calling an
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ambulance was warranted, is it reasonable to expect a parent or social
care professional to override this assessment? Social workers were
appropriately questioning what might be underlying Kevin’s behaviour but
he would not engage with them in personal conversation. However, at
some point he apparently remarks that he has self-neglected and seemed
keen not to get his mother into trouble. He was not refusing treatment per
se but rather refusing to leave the house to see a doctor. The social
workers, who understand both mental capacity and mental health
legislation, believe that he has capacity. Comment: capacity for what? If to
determine his own treatment, consideration should be given to when a
decision to refuse might be overruled and by whom. If Kevin was known to
have anxieties and irrational fear about medical intervention, it is
questionable as to whether he had capacity to refuse. It might have been
appropriate to seek legal advice or guidance from on-call service
managers.
8.4.13 In the reflective conversations it was clear that:
 for many of the practitioners, notably practitioners who were mothers
themselves, they felt if it was their son they would just have made Kevin
go or phoned 999. With hindsight it would appear that Kevin’s mother
feels the same way. GP did not make a home visit in response to the
social worker’s assessment. Comment: in light of the information that
the social workers were passing on, the GP should have acted sooner.
 Kevin’s mother does not readily look outside the family for advice.
 there was a level of frustration and lack of understanding as to why the
GP would not home visit when the collective view was that this was
required.
 there was an acceptance to a point of Kevin’s rights – not to allow his
mother to see him naked, not to go to the walk in centre. However, the
practitioners were of the view that this had limits. Comment: but when
are the limits reached?
 there was evidence of persistence and an acceptance of the urgency in
taking action. It would appear this was heavily influenced by the
learning from the SCR in respect of Edward and a feeling that his age
could not get in the way. Comment: so could Edward happen now?
What has changed since Edward?
8.4.14 Kevin is accompanied by his grandparents to A&E on 14 th January 2015.
He was transported there by ambulance, having attended the GP surgery
for the booked appointment. He is diagnosed as having profound weight
loss and anaemia as a result of chronic diarrhoea persisting over several
months. He has rectal bleeding and severe colitis. He has grade 2 and 3
pressure sores. A safeguarding alert is appropriately made to children’s
social care. He has extensive surgery with an ileostomy and peritoneal
drain, with periods in intensive care. He is significantly underweight. He is
discharged on 12th February 2015.
8.4.15 Kevin reports to healthcare staff that he has “self-neglected himself” but
this does not appear to have been pursued with him. Comment: Kevin
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appears to have used this phrase with social workers also. Is this a missed
opportunity to explore what he means? Healthcare professionals conclude
that Kevin did not comprehend the seriousness of his condition but are
unsure whether this was denial and/or a lack of understanding. Kevin
admits to being frightened and anxious about whether he had cancer,
resulting in being afraid to seek medical advice for his weight loss.
Comment: the code of practice for the mental capacity Act 2005 (DCA,
2007) recognises that, in addition to young people lacking mental capacity
to decide about treatment, they may be unable to make the decision for
some other reason, for example if overwhelmed by the implications of the
decision. Here the Mental Capacity Act 2005 does not apply and the
legality of any treatment should be assessed under common law
principles. Those involved with this case should have been mindful of this
guidance throughout.
8.4.16 Kevin’s mother tells healthcare staff that he is stubborn and could not be
persuaded to see a GP. Healthcare professionals are unsure whether she
fully understood the seriousness of his condition.
8.4.17 The focus whilst Kevin was in hospital was on his physical health. The
conclusion is that he had suffered from untreated inflammatory bowel
disease for between six months and one year. He was assessed as
struggling to accept the implications of the surgery and his mood was
sometimes low. In the single assessment period which followed and
totalled 15 days due to the prescribed timescales, attempts were made to
engage both Kevin, his mother and father, and his extended family. Within
this period Kevin remained seriously ill in hospital and therefore interaction
was limited. In relation to his extended family and siblings the social
worker visited them together with the team manager, in order to explore
how the situation had deteriorated and what if any were the on-going risk
implications for them and Kevin. Attempts to understand Kevin’s lived
experience were limited by time and circumstance. Attempts were made to
understand the context and functioning for the family in order to
understand how the situation had escalated to such a serious degree.
There is clear evidence within the social care file and from speaking to
staff that attempts were made to engage at this level with Kevin and his
entire family. Practitioners accept that due to the 15 day timescale and the
willingness of the family to engage, particularly his father and to some
extent Kevin, this did not result in a complex or deep understanding of the
dynamics within tis family. It is this author’s view that, given the
circumstances and the timeframe within which the assessment needed
must be produced, it would be unrealistic to expect that the complex family
dynamics would be understood. However, continued attempts to engage
in this way should be made.
8.5
Key Episode Five
8.5.1 This covers the month of February 2015. Reflective conversation with the
current social worker and the student social worker who had undertaken
some direct work with Kevin highlight again the similarity of views
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regarding Kevin and the family. There almost appears to be a level of
incongruence with the recorded descriptions of the seriously ill young man
and his mother versus the family with whom these workers are working.
The view regarding his capacity and the level of engagement by his
mother was as described by staff in episode four. The learning from the
serious case review on Edward was significant in influencing thinking and
practice, for example ensuring that Kevin was seen as quickly as possible
after the 111 referral in episode four. Comment: it would be informative to
assess the impact that the Edward SCR has had on policy and practice.
8.5.2 Recommendation Seven – The STSCB should conduct an audit to review
the impact that the Edward SCR has had on policy and practice. A
learning event should be held to review the findings of the audit.
8.5.3 Healthcare staff have reported that since his hospital admission Kevin is
managing his stoma independently and appears bright, capable of making
decisions and understanding of his physical healthcare needs. The home
conditions have improved; Kevin is engaging with his social worker and is
attending physical health appointments.
8.5.4 However, he has declined mental health involvement and this aspect of his
case has been closed. This information has been shared with all other
agencies. His refusal to engage has been explored with Kevin and his
mother by mental health practitioners and supervisors and has not been
challenged as they have assessed that his mental capacity is not impaired
and that he does not appear to be significantly mentally distressed.
Kevin’s mother reassured mental health staff that she had discussed this
with Kevin’s social workers. Comment: information-sharing is good
practice but case closure might be a questionable decision in light of the
mental health concerns that there have been in this case and the pattern
of non-engagement. Persistence might prove useful in enabling Kevin to
engage. Kevin’s mother also has a history of saying that she has
discussed or will discuss one professional’s concerns with other
practitioners but this has not always been verified. Indeed, some
healthcare professionals have expressed concern that without
psychological intervention the current situation might not be sustainable.
Comment: the potential need for psychological intervention should be
monitored in an on-going way by those who remain involved with Kevin.
8.5.5 The benefits of persistence and consistency in professional relationships
with Kevin have been shown by the social worker’s experience in this
episode. Initially Kevin, as sometimes before, stated that he did not want
to talk. However, with persistence, over time he has engaged more easily
and that now he and his mother are co-operating with the children in need
plan (the child protection plan having been stood down). The social worker
confirms the assessment of others that Kevin is currently bright, mature
and articulate. He looks well. The social worker, and a student social
worker until recently involved, are conscious that for someone lacking in
confidence and having previously chosen to social isolate themselves,
there is a balance to be struck regarding the number of professionals now
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involved and intervening in his life. Indeed, Kevin’s engagement with the
student social worker was a very positive experience for him and contrasts
with his sometimes refusals to engage. Comment: this awareness is useful
but risk assessments should be done if and when Kevin declines to
engage with specific services, and his decisions challenged from a
position of concerned curiosity.
8.5.6 The student social worker also persisted and engaged with Kevin through
interests and activities that he found useful. His male gender may have
facilitated this. The student social worker did not push Kevin to talk about
what had happened, even when Kevin was expressing awareness of his
stoma and wanting to explore the possibility of a reversal operation.
Comment: it is difficult to strike a balance between expressing concerned
curiosity and going at the pace of the service user. The student social
worker’s involvement in the case has now ended. Is this a loss for Kevin?
9.
THEMED ANALYSIS AND LESSONS LEARNED
9.1
Reflecting on his hospital stay
9.1.1 On admission and during his hospital stay, the focus appeared to be
around possible exacerbation of colitis and Crohn’s Disease (an
inflammatory chronic disease of the bowel), which is also reflected in the
discussions held between the hospital and social care services staff. The
Dietician and the Paediatric Physiotherapist reported no concerns
regarding Kevin’s attitude towards food or gaining weight, with the
Dietician detailing the foods Kevin was reporting to eat, with evidential
weight gain. The Paediatric Physiotherapist considered that Kevin had a
healthy approach to his weight gain, seeking and voicing his pleasure and
gaining weight, and ‘bulk’.
9.1.2 Conversely, when reflecting with those staff exposed to and
knowledgeable of the needs of children and adolescents, the School
Nurses, the Stoma Nurse, and the District Nurse all reflected upon
possible Anorexia and Bulimia issues. Furthermore, they have all
considered that it is crucial to further explore these issues with Kevin. Both
the District Nurse and the Stoma Nurse have stipulated that, without
psychological intervention to determine the root cause of how Kevin
arrived at the point of collapse, they have some doubts that Kevin’s
outstanding progress to-date is not sustainable and that they do have
concerns that a relapse is possible. Comment: research on self-neglect
(Braye et al., 2014) found that interventions will be more effective if the
meaning of the behaviour is understood.
9.1.3 During reflective discussion with the Stoma Nurse and her line manager,
they made reference to documented evidence of the increase in
inflammatory bowel disease in teenagers brought on by increased stress,
particularly those in exam years. The Dietician considered Crohn’s
Disease (an inflammatory chronic disease of the bowel) and advised Kevin
and his mother during a clinic appointment the importance of eating well
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especially if there was an exacerbation of the disease and that advice
should be sought as soon as possible if any weight loss is worrying, which
both Kevin and his mother agreed to.
9.1.4 Kevin was already noted to increase his anxieties pre examinations and it
may have been helpful during this time to opt in the School Nursing
Service in order to support Kevin in the monitoring of his health and wellbeing needs. This would however have required a more pro-active
approach, as the option of a drop-in session within school was not
something accessed by Kevin.
9.1.5 Kevin is now attending a post 16 establishment and without support the
pressures of AS and A level studies may increase the risks of a relapse.
9.1.6 At the Child Protection Review Conference in April 2015 Kevin’s weight
was recorded as: 52.8 kg (which lies between the 2 nd and 9th centile). The
most recent weight recorded in July 2015 by the Dietician was 59.3 kg
(just under the 25th centile) providing evidence of Kevin working towards
achieving a healthy weight. Staff reported on Kevin’s healthy attitude with
his weight gain.
9.1.7 Comment: research on self-neglect (Braye et al., 2014) found that effective
intervention was based on continuity of relationships and, where there was
evidence of mental distress, sustained therapeutic involvement.
Experienced professionals are reporting their concerns that, without
framework of support, Kevin’s progress may not be sustained. In reflective
conversations at the first learning event, there was already some concern
that Kevin may once again be retreating to his bedroom rather than eating
with the family as has been advised. It has been noted that when Kevin’s
mother attempts to challenge him, he is not happy and glares at her. If the
family dynamics cannot be explored with the whole family, a focus could
be attempted on trying to understand Kevin’s mother’s perspective or the
grandparents’ views of what is happening in the family where Kevin
appears secretive and much less engaged in the extended family than his
siblings. However, at both learning events it was also reported that Kevin
is still going to the gym, interacting with peers and attending a post 16
establishment. In that sense things appear more settled and the progress
initiated by the student social worker maintained.
9.1.8 On occasion in the NHS Foundation Trust where he was treated, Kevin
was nursed on adult wards. This is in consequence of the paediatric unit
not having a long stay bed provision, with children up to the age of 16
years of age, being transferred to other regional hospitals following a short
stay period within the Paediatric Emergency Care Centre (ECC). This
does not apply however to young people of 16 and 17 year, who are
accepted into the adult service provision.
9.1.9 Whilst it is reported that each adolescent case is determined
independently, young people of this age are rarely cared for in paediatric
units, with the main care being provided by adult services which is not
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something unique to this secondary care setting, and is also known to be
the same regionally and possibly nationally, with young people of this
transitional age possibly falling between children and adult health services.
9.1.10 It is evident in Kevin’s case that he received mixed provision of both adult
and paediatric services. Had Kevin’s surgery been planned, he would
have received this care package at a regional children’s hospital which
would have incorporated both acute and post discharge services provided
by paediatric services.
9.1.11 Whilst there was no negative impact from Kevin being nursed between
adult and paediatric health services it is acknowledged within the Trust
that this is a grey area with young people of Kevin’s age not being
considered in the development of care pathways. Paediatric pathways end
at 16 years old and adult pathways commence at 18 years old. In the
event of young people of this age that do require acute services, there
must be a planned approach agreed between adult and paediatric
services There is evidence that this was achieved, during Kevin’s acute
and community care. Comment: this is one example of the challenges that
face healthcare and social work services when working with young people
aged 16 and 17. The District Nursing service (for over 18 year olds) was
not included in discharge planning and yet had some involvement because
of the ward on which Kevin was treated. There has been some concern
that information may not have been shared across all the healthcare
professions involved in his care.
9.1.12 Recommendation Eight – There is a clear paediatric pathway for children
below the age of 16. There is an adult healthcare pathway. The Clinical
Commissioning Group should consider a pathway for 16 and 17 year old
young people notwithstanding the excellent medical and healthcare which
Kevin received.
9.2
Age and Capacity
9.2.1 Professionals involved with Kevin, especially in episodes four and five,
believed that he had the right to make some choices. Kevin gave a clear
view that he needed and wanted things to be planned and was adamant
during the weekend prior to his hospital admission that he would not go to
A and E or the Walk-in Centre. OOH social workers were clear that they
would take Kevin and facilitate his attendance, but Kevin was equally clear
in his refusal to attend. Their view was that, given Kevin’s presentation,
namely lucid and not in pain, he was able to make this decision and that in
fact involving him in the process was likely to be more successful than any
forced action. Comment: the research on self-neglect (Braye et al., 2014)
identifies that effective work is most likely to be a combination of
negotiated and imposed interventions, a balance that has to be found
uniquely in each case. Those professionals who met Kevin found,
however, that he was anxious, with a fear of hospitals and a strong
concern that he might have cancer. Those who met him, most of whom
were experienced in dealing with cases where mental health and mental
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capacity legislation might be relevant and who felt that they understood
these legal rules and those related to Gillick competence, concluded that
Kevin’s personal anxiety was based on an informed analysis of his
physical presentation and not on any irrational or dysfunctional thought
process. However, some healthcare and social work staff commented that
neither Kevin nor his mother really appreciated the seriousness of his
condition, perhaps due to embarrassment, anxiety and fear, leading to
denial of the dangerous state of his physical health. Comment: the
unanimity with which Kevin is believed to have had capacity is striking.
Perhaps more weight, however, should have been placed on his reported
embarrassment at seeking medical help, his low mood, depression as
mentioned several times by his mother, his self-reported fear that he might
have cancer and was afraid of admission. In addition, greater
consideration might have been given as to whether Kevin had decisional
capacity in the sense of being able to understand all information relevant
to his condition and executive capacity in the sense of being able to
manage the consequences of his decisions?
9.2.2 During Kevin’s stay on an adult surgical ward, the Charge Nurse made
reference to him being treated as an adult, whilst on an adult ward. The
Charge Nurse was knowledgeable of Gillick Competency and Fraser
Guidelines but admitted to having limited knowledge that the Mental
Capacity Act 2005 included adolescents. As with some other healthcare
and social work professionals involved in the case, the Charge Nurse
suggested that if they had had any doubts, for example that Kevin did not
evidence understanding of information provided to him, then they would
have sought advice from the Safeguarding Team or referred to specialists
for a mental capacity assessment in order to determine how best to
manage this. Comment: when adolescents are, albeit rarely, nursed on
adult (surgical) wards, the knowledge of staff regarding mental capacity
and adolescents may be limited and training might focus here. Equally, for
all professionals involved with 16 and 17 year old young people, knowing
about Gillick competence does not resolve but merely brings forth the
dilemma of having to decide when to override a decision to refuse
treatment.
9.2.3 Several professionals expressed the view that Kevin’s mother should have
done more to ensure that his physical health needs were treated.
However, when asked what she might have done, other than being more
proactive in making contact with her GP or other professionals, it proved
somewhat challenging to define. Comment: this reflects the position of 16
and 17 year old young people in law. Case law on refusal to consent in
relation to young people predates the Mental Capacity Act 2005 within
which, of course, young people aged over 16 are presumed to have
capacity. Clarification of the legal position for parents and social workers in
this situation would be useful. Participants in the learning events noted
that Kevin was not refusing all medical intervention, just wanting to see the
GP on his own terms, in his own home. At some point Kevin gave
permission for his grandfather to pick him up and take him to the
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appointment if he changed his mind and refused to go. This may have
been Kevin exercising control in the only way he felt able to.
9.2.4 The Family Law Reform Act 1969 presumes that young people have the
capacity to agree to surgical, medical or dental treatment but allows a
person with parental responsibility or a court to authorise treatment where
a 16/17 year old young person refuses consent. Most of the Mental
Capacity Act 2005 applies to young people aged 16 and 17 years who
may lack capacity to make specific decisions. Assessing capacity is a
decision-specific test where a person lacks capacity if at a material time
they are unable to take a decision for themselves in relation to the matter
because of an impairment of, or a disturbance in the functioning of the
mind or brain. That impairment or disturbance may be temporary or
permanent. A person is unable to make a decision if they are unable to
understand information relevant to the decision, retain and use or weigh
that information as part of making the decision, and/or unable to
communicate their decision.
9.2.5 If a young person aged 16 or 17 lacks capacity to consent to care or
treatment, people may act in their best interests providing that they have
consulted with those involved or interested in the young person’s welfare,
where practical and appropriate to do so (DCA, 2007). Disagreements
about care, treatment or welfare of a young person who lacks capacity
should be referred to a court, as should cases where a young person has
capacity and refuses consent, especially when a person with parental
responsibility wishes to give consent. If however they are unable to make
the decision for some other reason, for example if overwhelmed by the
implications of the decision, the Mental Capacity Act 2005 does not apply
and the legality of any treatment should be assessed under common law
principles (DCA, 2007). There is an overlap with provisions available in the
Children Act 1989.
9.2.6 Recommendation Nine – The Department for Education should provide
guidance for professionals in respect to mental capacity of 16 and 17 year
olds to refuse consent to treatment.
9.2.7 Recommendation Ten – STSCB should commission multi-agency training
on mental capacity and 16/17 year old young people.
9.3
Family Dynamics
9.3.1 It is the view of practitioners that Kevin’s mother should or could have
sought help sooner. Comment: whether more can be done to attempt to
engage Kevin and his family to ensure future stability for him and his
siblings should be kept under review. On reflective discussions with the
practitioners involved there are contrasting accounts of the family
dynamics. The acute, community and outpatient clinic staff indicated that
Kevin wanted his mother fully involved in his care and to be informed in
the decisions of his care. The relationship between both Kevin and his
mother appeared to be a mother/child relationship with Kevin’s mother
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“fussing” over Kevin. However, when practitioners visited Kevin in the
home, they indicated that Kevin had a more dominant and assertive role,
with an element of protectiveness and the relationship between Kevin and
his mother was described more as a “friendship”.
9.3.2 Kevin’s mother had several jobs and was frequently out at work requiring
Kevin to be independent. Kevin’s mother however, was present at all
planned home visits and only at some opportunistic visits she may not
have been present. Reflective and learning event discussions have also
recognised that, within the first three episodes especially, concerns were
low level. Nonetheless, in the context of thinking family, where people
have given consent or where a legal mandate exists, sharing of
information about even low level concerns might enable consideration to
be given as to whether accumulation of concerns is indicative of
heightened risk.
9.3.3 Both the District Nurse and the Stoma Nurse also made reference to the
home conditions, reporting it was in a poor condition, sparse, unloved and
unkempt, and continuously being decorated (no wall-paper on walls). This
appears to be a throw-back to episode one. Neither of the practitioners
could access the kitchen as this was where the family dog was placed
during their visits.
9.3.4 Kevin always included his mother in the decision making regarding his
health care during and subsequent to his hospital admission; however, the
District Nurse reported that she was aware that Kevin had resumed
spending time in his bedroom and had provided clear advice to both Kevin
and his mother that he must spend time downstairs with the family,
particularly to be eating his meals with his family. The District Nurse
reminded them that there was a need to prevent the previous situation
reoccurring. Both Kevin and his mother acknowledged and agreed with
this. Comment: consideration should always be given to whether
compliance is superficial to ward off professional intrusion.
9.3.6 The Stoma Nurse reflected on her concern that Kevin had not
communicated any problems that he experienced with the size of the
ileostomy appliance over a four day period which was brought to the
Stoma Nurse’s attention by Kevin’s mother and not by Kevin himself. The
Stoma Nurse reflected that, due to the good rapport that she had with both
Kevin and his mother, she would have anticipated that it would have been
Kevin informing her of concerns especially when he was considered
independent in managing the appliance. It is unclear when Kevin shared
these issues with his mother and the time scale of Kevin’s mother seeking
advice, which is potentially reflective of his previous situation. Comment:
might the cycle of not engaging be reappearing and, if so, how will
agencies respond now? However, the stoma nurse remains involved with
Kevin’s care and will re-refer to other services where necessary.
9.3.7 Both the social worker and student social worker involved in episode five
thought Kevin’s attachment with his mother positive and that they were
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working out what level of oversight she should have of his stoma
management. They were both shocked and saddened at what had
happened, perhaps feeling guilty, but preferring to move on without
exploring it. Similarly, Kevin appeared to be spending more time with his
father but wanting to keep him separate from professional intervention and
not wanting to explore the situation. Comment: this appears to suggest
that Kevin splits and compartmentalises those involved in his life. If Kevin
is willing to engage in future regarding recent events in his life, using an
approach rooted in concerned curiosity he could be invited to explore key
family episodes and their impact on him.
9.4
Wider Knowledge-base
9.4.1 Research in relation to young people and self-neglect has located one
SCR (Dorset Safeguarding Children Board, 2014) that focuses on a young
boy aged 15 who died and where there were concerns about levels of selfneglect alongside vulnerability and neglect in what is described as a
service resistant family with parental mental health issues. This SCR
comments that engaging with practitioners from the outset is essential to
understanding what had been done and why, and what could be learned
from quality shortfall. The SCR also noted that communication between
children’s social care, adolescent mental health services and adult social
care services was important. The SCR recommends that agencies should:




Have a protocol for hard to reach families and young people
Consider the impact of case closure decisions on other agencies
Assess family dynamics
Assess causes and meaning of behaviour, see events not in isolation
but as multiples and use chronologies
 Support worker resilience
9.4.2 Research on adolescents and mental health has shown self-neglect,
especially amongst boys, to be a risk factor and may indicate a lack of
self-reflecting behaviour. It may be associated also to uncertainty about
parental love and maternal affiliation rather than self-negativity (Ybrandt
and Armelius, 2010). Depression may lead to social withdrawal and selfneglect, for example for young people with Asperger syndrome (Tantum,
2000).
9.4.3 A systematic research literature review on self-neglect (Braye et al., 2011)
found that young people who self-neglect show an increased likelihood of
mental distress but little attention has historically been paid to this
phenomenon. The review also found that mental capacity of young people
in the midst of transition was often not well understood and yet was a
central factor in determining care pathways for them. This research turns
the spotlight on the availability and adequacy of specialist mental health
care for young people.
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9.4.4 Two reviews of SCRs (OFSTED, 2011; Vincent and Petch, 2012) contain
useful material about cases involving young people. Key messages
emerging from these reviews include the following:









Seek to understand the causes of hard to reach behaviour
Parental lifestyles can play a part in young people’s risk-taking
behaviour
Young people are treated as adults and not children due to confusion
about their age and legal status
Professionals lack confidence in challenging young people and their
parents
Consideration should be given to use of statutory powers (Children Act
1989 is still relevant for young people aged between 16 and 18)
A good working knowledge of adolescent development and risk is
needed, including mental health ( we know, for example, that
depression can cause increased social withdrawal and self-neglect in
adolescence
A coordinated and assertive approach towards young people is often
lacking; a failure to work collaboratively
Adolescent mental health services are often criticised
Decision-making should include risk assessments
9.4.5 Recommendation Eleven – The Department for Education should
commission research on young people who self-neglect to build an
evidence-base for effective practice.
10.
EXAMPLES OF GOOD PRACTICE
10.1 There has been clear evidence of proactive working and positive engagement
with the family to assist the situation for Kevin to improve, most especially in
episode five. However, the focus of some intervention was more practical than
family oriented, with sometimes insufficient follow-up or concerned challenge.
10.2 Kevin’s voice and his lived experience has been heard, most especially in
episode five, though the understanding of this experience through his
deteriorating ill health is less well understood due to Kevin’s reluctance to discuss
this more fully.
10.3 Whilst it is clear that learning from the SCR regarding Edward was at the
forefront of some practitioners’ minds, was this always helpful and did it serve to
view the situation as more neglectful than the evidence suggests? Comment: a
recommendation has already been made that the impact of this SCR on
agencies, especially CFSC, should be evaluated.
10.4 The candid nature of the reflective conversations has been impressive, namely
practitioners’ ability and willingness to engage in a reflective process which is not
always easy. However, not all professionals have engaged in the reflective
conversations or learning events, most especially the GPs.
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10.5 Recommendation Twelve – STSCB and the Clinical Commissioning Group
should explore ways of seeking to engage GPs in SCRs given their limited
participation in reflective conversations and the learning events that comprised
the agreed methodology for this serious case review.
10.6 Healthcare professionals saved Kevin’s life once he was admitted to hospital and
there is good evidence of planning, information-sharing and working together to
ensure his future wellbeing. On-going support is in place for Kevin.
10.7 Professionals have raised concerns, for example through the CAF process in
episode one and have challenged each other’s responses, for example in
episode four.
10.8 Kevin has been engaged by both healthcare professionals and social workers,
who have shown persistence.
11.
CONCLUSIONS
11.1 Kevin was seriously ill and almost died. This was a case complicated by a key
episode occurring “out of hours” and by the interface between parental
responsibility, mental capacity, age and refusal to seek treatment. Those
professionals involved at the time, who have engaged in reflective conversations
and learning events, have been very conscious that the lenses through which
they see scenarios will impact on the options that they consider. They have been
acutely aware of the need to “think family” and to seek to understand the
meaning behind what is presented to them. They have been keen to apply the
learning and recommendations from the serious case review on Edward,
published by the STSCB, even though the circumstances of that case are not
identical.
11.2 Fortunately he appears to be making a good recovery and to be engaging both
socially and educationally. He is in regular contact with the healthcare
professionals who are responsible for his postoperative care. He maintained
contact with his social worker and the case is now closed. There is a risk of
subsequent disengagement and, possibly, of mental health or further physical
health concerns. Especially once Kevin turns 18 and the involvement of
children’s services concludes, on-going involvement will become the
responsibility of healthcare professionals. Any disengagement or relapse will
need full assessment.
11.3 Recommendation Thirteen - CFSC to continue to develop the skill base through
Core Skills Training in terms of support for staff in working with harder to reach
young people and their families, including when working with older young people
where the issue of choice and decision making competency exist.
11.4 Recommendation Fourteen - STSCB should seek reassurances from agencies,
especially mental health providers, that their policies on case closure when
young people decline to engage have been reviewed. Where several agencies
are involved with a young person, cases should only be closed following multiagency consultation.
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12.
RECOMMENDATIONS
12.1 Recommendation One - In relation to Key Episode One, significant changes have
been made to the arrangements within the CFSC Referral and Assessment
Service since 2012. These include significant changes to practice, management
oversight, recording and a radical re- design of the service to become the
Contact and Referral team. It would be pertinent to carry out some independent
audit work to bench mark the impact of these changes upon practice. A peer
review of the service by a neighbouring Local Authority was undertaken in
November 2015. CFSC should ensure that all practitioners involved in early help
interventions have sufficient skills to take a whole family approach and to express
concerned curiosity derived from the situations they observe.
12.2 Recommendation Two – STSCB should consider the development of a
safeguarding in schools strategy that outlines expectations concerning sharing
information and concerns internally within each school about young people’s
well-being and escalation with external agencies.
12.3 Recommendation Three – The STSCB should resolve, when pupils leave school
for Sixth Form College or further education, what information might be passed on
so that individuals are not lost sight of. The Board should also consider what
information is shared between educational establishments regarding young
people, not just those who might be at risk of NEET. The STSCB should review
its protocols for information-sharing and engage with partner agencies
concerning expectations around information-sharing between educational
establishments and GPs, between primary and secondary healthcare settings, for
example on discharge from hospital, between different educational
establishments when young people move, and surrounding early help
interventions. Any protocol should clarify when consent of parents and/or young
people is required. It should cover situations where there is a history of mental
health and other concerns, where young people are refusing to engage.
12.4 Recommendation Four – SYP should provide guidance for staff and multi-agency
partners on 16 and 17 year olds missing from education.
12.5 Recommendation Five – The 111 service should review the training and
protocols provided for assessing healthcare risks when young people are
seriously ill and refusing treatment, including the legal options available within the
Children Act 1989, Mental Health Act 1983 and Mental Capacity Act 2005. When
contact is made with 111 and GPs, general appearance should be quantified
where possible to ensure an accurate risk assessment.
12.6 Recommendation Six – NHS Commissioners, NHS Trusts and the 111 Service
should clarify how concerns may be escalated by social care and other
professionals out of hours. In relation to Key Episode Four, better understanding
of the 111 service and the criteria and issues that pertain to GP visiting out of
hours needs to be explored and disseminated across the whole service. This
would allow staff to appropriately challenge advice given in a consistent way.
Escalation processes within CFSC and across agencies should be re-enforced
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across the whole service to support staff to raise challenge and issues when they
believe that the response from any agency is not in the child’s best interest.
Given these processes already exist the STSCB should consider a range of ways
to engage staff and understand the challenges and barriers when facing the need
to escalate issues. STSCB should review the escalation of concerns policies that
agencies have, for example for the Out of Hours Service, and the access
different agencies have to senior management and specialist legal advice.
12.7 Recommendation Seven – The STSCB should conduct an audit to review the
impact that the Edward SCR has had on policy and practice. A learning event
should be held to review the findings of the audit.
12.8 Recommendation Eight – The Clinical Commissioning Group should review
healthcare pathways for 16 and 17 year old young people. NHS Trusts should
review the care and treatment of older young people, discharge planning and
subsequent healthcare treatment pathways.
12.9 Recommendation Nine – The Department for Education should provide guidance
for professionals in respect to mental capacity of 16 and 17 year olds to refuse
consent to treatment.
12.10 Recommendation Ten – STSCB should commission multi-agency training on
mental capacity and 16/17 year old young people. It should also arrange multiagency mental health awareness training with a focus on adolescence. One
learning outcome of such training should be a review of thresholds for overruling
treatment and service refusal by 16 and 17 year old young people.
12.11 Recommendation Eleven – The Department for Education should commission
research on young people who self-neglect to build an evidence-base for
effective practice.
12.12 Recommendation Twelve - STSCB and the Clinical Commissioning Group should
explore ways of seeking to engage GPs in SCRs given their limited participation
in reflective conversations and the learning events that comprised the agreed
methodology for this serious case review.
12.13 Recommendation Thirteen - CFSC should continue to develop the core skill base
of their staff in working with harder to reach young people and their families,
including when working with older young people where the issue of choice and
decision making competency exist.
12.14 Recommendation Fourteen - STSCB should seek assurances from agencies,
especially mental health providers, that their policies on case closure when
young people decline to engage have been reviewed. Where several agencies
are involved with a young person, cases should only be closed following multiagency consultation.
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References
Braye, S., Orr, D. and Preston-Shoot, M. (2011) Self-Neglect and Adult Safeguarding:
Findings from Research. London: Social Care Institute for Excellence.
Braye, S., Orr, D. and Preston-Shoot, M. (2014) Self-Neglect Policy and Practice:
Building an Evidence Base for Adult Social Care. London: Social Care Institute for
Excellence.
DCA (2007) Mental Capacity Act 2005: Code of Practice. London: The Stationery
Office.
Dorset Safeguarding Children Board (2014) Family S11. Serious Case Review
Overview Report.
Forrester, D., Westlake, D. and Glynn, G. (2012) ‘Parental resistance and social worker
skills: towards a theory of motivational social work.’ Child and Family Social Work, 17
(2), 118-129.
HM Government (2015) Working Together to Safeguard Children. A Guide to InterAgency Working to Safeguard and Promote the Welfare of Children. London: The
Stationery Office.
OFSTED (2011) Ages of Concern: Learning Lessons from Serious Case Reviews: A
Thematic Report of OFSTED’s Evaluation of Serious Case Reviews from 1 April 2007 to
31 March 2011. Manchester: Office for Standards, Children’s Services and Skills.
Tantum, D. (2000) ‘Psychological disorder in adolescents and adults with Asperger
syndrome.’ Autism, 4 (1), 47-62.
Vincent, S. and Petch, A. (2012) Audit and Analysis of Significant Case Reviews.
Edinburgh: Scottish Government.
Ybrandt, H. and Armelius, K. (2010) ‘Adolescents’ mental health and their images of self
and parents.’ European Journal of Mental Health, 5, 59-75.
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South Tyneside Safeguarding Children Board
SERIOUS CASE REVIEW
SUBJECT: Kevin (a pseudonym)
Terms of Reference and Project Plan
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1.
SCOPE OF THE REVIEW
1.1
This serious case review is in respect of Kevin (a pseudonym)
1.2
Time period: June 2012 until March 2015
2.
FRAMEWORK
2.1
The LSCB should aim for completion of an SCR within six months of initiating it. If
this is not possible (for example, because of potential prejudice to related court
proceedings), every effort should be made while the SCR is in progress to: (i)
capture points from the case about improvements needed; and (ii) take corrective
action.
2.2
Agreeing improvement action:
The STSCB should oversee the process of agreeing with partners what action
they need to take in light of the findings.
2.3
Publication of reports:
All reviews of cases meeting the SCR criteria should result in a report which is
published and readily accessible on the STSCB’s website for a minimum of 12
months. Thereafter the report should be made available on request. This is
important to support national sharing of lessons learnt and good practice in
writing and publishing SCRs. From the very start of the SCR the fact that the
report will be published should be taken into consideration. SCR overview reports
should be written in such a way that publication will not be likely to harm the
welfare of any children or vulnerable adults involved in the case.
2.4
This review will adhere to the guidance for SCRs included in Working Together,
which states that reports should:
•
•
•
3.
provide a sound analysis of what happened in the case, and why, and what
needs to happen in order to reduce the risk of recurrence;
be written in plain English and in a way that can be easily understood by
professionals and the public alike.
be suitable for publication without needing to be amended or redacted.
(Working Together 2015 p79)
AGENCIES PARTICIPATING IN THE REVIEW








South Tyneside NHS Foundation Trust
South Tyneside Clinical Commissioning Group (including GPs)
Children and Families Social Care
Northumbria Police
Services for Young People
Local Secondary School
Northumberland Tyne and Wear NHS Trust
South Tyneside Homes
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4.
METHODOLOGY TO BE ADOPTED
4.1
The methodology to be adopted is to be based on practitioner involvement – this
will include reflective conversations, practitioner learning events, recall events,
analysis and identified learning.
5.
TERMS OF REFERENCE
5.1
The Serious Case Review should consider the information held by agencies in
the time period from June 2012 to March 2015.
Any significant
incident/information from outside of the timeframe of the review should also be
considered and shared with the Reviewer, where appropriate. The Case Specific
Terms of Reference reflect the methodology to be adopted, i.e. Reflective
Conversations.
5.2
Case Specific Terms of Reference
6.
 Critically analyse and evaluate the events that occurred, the decisions made
and the actions taken or not. Were there missed opportunities or episodes
when there was sufficient information to have taken a different course of
action? Were assessments conducted effectively and appropriate conclusions
drawn?
 Where judgements were made or actions taken which indicate that practice or
management could be improved, try to get an understanding not only of what
happened, but why.
 Demonstrate whether organisation/service heard and responded to Kevin’s
voice and considered his ‘lived experience’
 Identify good practice
 Were professionals proactive in escalating concerns and effecting challenge
where appropriate?
 From an inter-agency perspective, were processes, procedures and
communication effective and how did they impact on the case?
 Analyse the impact of the Gillick Competency and Fraser guidelines in relation
to this case and the decision making process by professionals
 Identify how the LSCB could deal with similar issues of adolescent selfneglect in the future

TIMETABLE
24/07/2015
27/07/2015
21/09 /2015
24/09/2015
15/10/2015
26/10/2015
09/11/2015
19/11/2015
23/11/2015
Scoping / terms of reference
Initial review of organisations documents
Learning & Improvement sub group meeting
Letters to managers/practitioners and questions template to be sent
out
Submission of reflective conversation responses
Version 1 draft report and distribution
Learning Event / SCR Panel Meeting
Version 2 draft report and distribution
SCR Panel / Learning Event
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30/11/2015
03/12/2015
12/01/2016
11/02/2016
7.
Final draft report and distribution to SCR Panel
Deadline for amendments/sign off from SCR Panel
Learning and Improvement sub group meeting to sign off
Final report to STSCB Executive Board for sign off
MEETINGS WITH FAMILY/SIGNIFICANT OTHERS
7.1 Family have declined to participate in the SCR as they feel they have moved on
from this episode in their life.
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REFLECTIVE CONVERSATIONS – GUIDANCE
Serious Case Review – Kevin (a pseudonym)
All questions for the reflective conversations have 2 elements:
1. What do you think the impact was on you of …
2. What do you think the impact might have been on others of …
Alternatively both lines of enquiry could be phrased as:
1. What difference do you think … made to your approach to the case?
2. What difference do you think … made to how … approached this case?
The themes or lines of inquiry to be explored with regard to Kevin and his family are:






Age
Gender and position in the family
Family dynamics (e.g. Kevin’s relationship with his mother)
Knowledge of the family’s involvement with local agencies (it may be necessary to
prompt here, for example GP, school, Children and Families Social Care)
The attitude of the family towards engagement with local agencies (again it may be
necessary to prompt as above)
Educational attainment
There are themes and lines of inquiry that focus more on the agencies involved with the
family and what individuals and organisations brought to the work, for example:






Understanding of the law relating to parental responsibility in respect of young
people of Kevin’s age – here we are looking at what those involved understood
regarding whether Kevin could:
o consent and refuse medical intervention
o whether his mother could override his decisions
o under what circumstances professionals could/could not override the decisions of
both Kevin and his mother)
Understanding of the law relating to whether Kevin had the mental capacity to take
decisions
Questioning based on concerned curiosity and assertiveness in respect of
confidence in exploring issues of Kevin’s:
o Mental Health
o Physical Health
o Presenting behaviour
Confidence in challenging Kevin’s mother regarding Kevin’s self-neglect, his mental
and physical health and possible neglect by the family
How the interviewee saw their role and responsibility when involved in the case and
how they saw the roles and responsibilities of other agencies
Impact of organisational policies, procedures and culture (for example the role of
EDT, constraints due to resources/management, age of the young person)
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The template for questions in relation to the key episodes is provided below. Here the
reflective conversations should focus, not just on the interviewee but also on how they
understood the position of other agencies involved in the episode in terms of their roles
and responsibilities.
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South Tyneside Safeguarding Children Board
Reflective conversations in respect of Serious Case Review for Kevin (a
pseudonym)
Date:
Author:
Professionals
Present:
Key Episode 1: Covers the period from July 2012 to January 2013. This involves the
School, GP, CFSC, Family Support, School Nurse and South Tyneside Homes.
Concerns related to Kevin’s poor school attendance and hygiene, and poor home
conditions. It was difficult to make contact with the family. As a result of the CAF
process improvements were noted in the referring problems and the case closed. This
episode followed previous concerns about Kevin’s mental wellbeing.
1.1 What Assessments
were undertaken of
Kevin’s mental wellbeing?
1.2 How was Kevin’s poor
school attendance
understood?
1.3 What stories were told
about the home
conditions?
1.4 How was the difficulty in
engaging with Kevin and
his family understood?
1.5 When it was difficult to
engage with the family,
what risk assessments
were undertaken?
Key Episode 2: Covers the period from October 2013 to February 2014. This
involves the School, GP, CFSC, Family Support School Nurse, SYP and South
Tyneside Homes. Concerns are around poor school attendance but also about health,
especially weight loss and swollen lips. Kevin’s mother apparently agrees to seek GP
advice and to report back to the school.
2.1 Did Kevin’s mother
report back about
conversations with the
GP? If no, why was this
not followed up? If yes,
how was this
information checked out
and followed through?
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2.2 What Risk Assessments
were undertaken at this
point?
2.3 Were those involved at
this point aware of the
history in this case and
what impact did that
have on decision
making?
Key Episode 3: Covers the month of October 2014. Kevin has left school and is
proving difficult to engage by SYP. He is reported by his mother to be suffering from
depression. There is a suggestion that more questions should have been asked of
mother. Kevin’s case does not appear to have been tracked and the family remain
difficult to engage.
3.1 How were the mother’s
concerns in relation to
Kevin being depressed
followed up?
3.2 How aware were those
involved at this time of
the history in this case?
3.3 What risk assessments
were done, especially
but not just of Kevin’s
mental wellbeing, and
with what conclusions?
3.4 What attempts were
made to engage with
Kevin?
3.5 What options in this
case were perceived
and what stories
influenced practice with
Kevin?
Key Episode 4: Covers the month of January 2015. The crucial component of this
episode is Kevin’s hospital admission. Those agencies involved her appear to have
been EDT, GPs, 111, South Tyneside Homes, NTW, Police, A&E and CFSC. Kevin
is said to have been unwell since August 2014 and now to be underweight and
malnourished. He has bed sores and diarrhoea. He is refusing to see his GP. He
does not keep a same day appointment but is eventually taken to see a GP and is
admitted to hospital. A nurse suggests sectioning under the Mental Health Act. There
are significant rent arrears.
4.1 Were any agencies in
contact with Kevin and
his family between
October 2014 and
January 2015 and what
did they notice? Why
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does this case appear
to reach crisis
unexpectedly?
4.2 Why did Kevin’s mother
wait so long before
escalating her
concerns?
4.3 Why did 111 not send
an ambulance and why
did the GP not
undertake and urgent
home visit?
4.4 What risk, child
protection, mental
capacity and mental
health assessments did
the Social Workers
complete?
4.5 How aware were those
involved at this point of
the historical
background of this
case?
4.6 What stories were
influencing practice in
this case about young
people of Kevin’s age
and presentation?
Key Episode 5: Covers the month of February 2015. Kevin is being discharged from
hospital following severe self-neglect and neglect. A priority mental health
appointment is offered by Kevin refuses to attend and is therefore discharged.
5.1 How is Kevin’s mental
capacity assessed?
5.2 How is Kevin’s refusal
understood in legal
terms?
5.3 What Assessments
have been done of his
mental health and the
family situation?
5.4 What is the plan to
address and seek to
mitigate the risks in this
case?
5.5 How are the family
dynamics understood?
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Questions to underpin analysis of the key episodes: There are several factors that
may have influenced how professionals approached the case.
6.1 Was Kevin assumed or
assessed as having
mental capacity to take
specific decisions about
his health care? How
did the legal context
and knowledge of the
law influence such an
assessment?
6.2 If Kevin did not
understand the serious
condition he was
suffering from, did he
have capacity?
6.3 What awareness was
there that the Mental
Capacity Act 2005 and
the Guardianship
provisions in the Mental
Health Act 1983 apply
to young people over
the age of 16?
6.4 did professionals
believe that Kevin could
be experiencing
significant harm? If
they did not, what
factors influenced this
belief? If they did, what
assessments were
undertaken and what
conclusions were
reached?
6.5 On what basis does it
appear to have been
concluded that there
was no evidence of
neglect?
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6.6 When Kevin was in
hospital, what
psychiatric,
psychological and
medical tests were
done to assess him?
What attempts were
made to engage him
and to understand how
he saw his situation?
6.7 How did understanding
of the Gillick
Judgement and Fraser
Guidelines impact on
professionals’ thinking
and approach to this
case?
RECOMMENDATIONS:
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