Source · Prevention of Future Deaths

Jake Cahill

Ref: 2022-0032 Date: 1 Feb 2022 Coroner: Guy Davies Area: Cornwall & the Isles of Scilly Responses identified: 1 / 1 View PDF

Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.

Date 1 Feb 2022
56-day deadline 29 Mar 2022 est.
Responses identified 1 of 1
Child Death (from 2015) Other related deaths Suicide (from 2015)

Coroner's concerns

AI summary
Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.
View full coroner's concerns
(1) that there was no evidence of any consideration being given to the need for sensitive issues raised in the self-assessment form to be discussed with Jake by a professional before Jake completed the form.

(2) that the guidance to the self-assessment form issued by the Youth Justice Board makes no express reference to the need for consideration to be given and documented as to whether the form should be discussed with a vulnerable young person before completion.

Responses

1 respondent
Youth Justice Board for England and Wales Other
29 Mar 2022 PDF
Action Taken

The Youth Justice Board has updated national guidance to support practitioners in using self-assessment tools appropriately when engaging with children. The updated guidance covers topics such as bail, custody, family and health. (AI summary)

View full response
Dear Mr Davies Regulation 28 Prevention of Future Deaths letter Re: Jake Adam Cahill, deceased Thank you for your letter of 1 February outlining your decision to issue a report to prevent future deaths following the inquest into the death of Jake Cahill. As a mother of young teenage boys, I read your report with profound sadness at the tragedy of Jake’s death and wish to extend my most sincere condolences to Jake’s family and friends for their unimaginable loss. We accept your recommendation that the Youth Justice Board (YJB); ‘reviews the guidance and procedures relating to the distribution and completion of the self-assessment form [AssetPlus] given to young persons’ In addition, I wish to assure you that the Youth Justice Board (YJB) has reviewed your conclusions fully and is committed always to engage with findings of investigations such as yours to ensure that where there is direct or indirect learning for the youth justice system, we can act upon this to promote continuous learning and support the prevention of harm. As an independent public body appointed by the Secretary of State, we have a statutory responsibility to oversee the whole of the youth justice system. Through the consolidation of our statutory functions, we support youth justice services to coordinate and deliver the provision of youth justice services. The YJB’s leadership of the system also places us in a unique position of being able to triangulate learning from the investigations of others with our own assessments and understanding of the system we lead. We fully recognise the importance of considered and appropriate engagement with children throughout the youth justice system. With this in mind we have to find the balance between issuing central direction and guidance, and supporting practitioners to exercise professional judgement in order to encourage the skills and knowledge that support direct work with children. AssetPlus itself is an assessment and interventions framework that focuses on the professional judgement of practitioners with the aim of enabling better-focused, holistic end-to-end assessment and intervention plans to improve outcomes for children. In the early days of the Covid 19

pandemic when public services were having to find new ways of working remotely, the robustness and appropriateness of interventions and tools were tested. The self- assessment tool is key for engaging the child and their parent/carer but not envisaged for children to complete independently, however the AssetPlus user guidance did not explicitly prohibit this, and it is not unreasonable to conclude that unsupported engagement with questions about suicide and self-harm could have a significant impact on a child. For the YJB, accordingly, my priority has been to ensure that all youth justice services are aware that AssetPlus should not be used for unsupported self-assessment, and to instruct any that were doing so to cease immediately.

Acting upon your findings, we have written to all youth justice services asking them to consider their approaches to undertaking AssetPlus self-assessments and to remind them of the key principles in conducting self-assessments with children. This correspondence has been shared with you at Annex A.

I accept the need to review the AssetPlus guidance and we are already committed to reviewing this in the coming business year. In responding to your findings, this work will include within its scope, guidance that is specific to conducting self-assessments with children; particularly where they are more challenging to engage or where circumstances beyond the control of practitioners or the service dictates that these may have to be undertaken at a distance.

We are also in the process of revising our case management guidance to the sector, please see case management guidance extract on assessment process at Annex B, which provides youth justice service practitioners and managers with practical advice on how to work with children in the youth justice system. We are planning on publishing a revised set of guidance later this year and will include additional text on how best to conduct self-assessments.

My colleagues and I are absolutely committed to providing youth justice services with the guidance and support they need to deliver to the best of their ability. I believe the measures set out above strengthen the safety and wellbeing of children in the youth justice system and, I hope, offer you assurance that the lessons learned from Jake’s death will be effective in preventing any such tragedy from happening in the future.

Report sections

Investigation and inquest
On 14 September 2020 an investigation commenced into the death of 16-year-old Jake Adam Cahill. The investigation concluded at the end of the inquest on 13 January 2022. The conclusion of the inquest was as follows Medical cause of death: 1(a) Hanging The four questions - who, when, where and how – were answered as follows: Jake Adam CAHILL died on 14 September 2020 at

Cornwall by being an impulsive act in a moment of crisis, that was wholly unexpected and could not have been anticipated. Short form conclusion: Suicide
Circumstances of the death
Jake had been subject to police investigations for a minor criminal offence committed in March 2020. The police issued a conditional caution which was administered on 4 September 2020. Jake was clearly upset at being issued with a police caution and having conditions imposed. Subsequently the local youth Information Classification: CONTROLLED offender service (YOS) sent Jake’s mother, , some documents for completion. This included a self-assessment form, being a document produced by the Youth Justice Board for England and Wales. The letter from the YOS instructed to pass that self-assessment form to Jake for completion.

handed this form to Jake late in the evening of 13 September. The form was written in the first person and three questions were highlighted at Inquest, with a yes/no box for completion

• I have thought about hurting myself
• I have tried to hurt myself
• I have thought about killing myself

Jake ticked ‘no’ for each of these questions. The following day Jake took his own life.

In connection with the self-assessment form there was no evidence of any consideration being given to the need for sensitive questions raised in the form to be discussed with Jake by a professional before Jake completed the form.

Evidence was taken from police on the subject of the risk assessment forms used by police. These forms do include questions whether an individual intends to harm or kill themselves. This form is never sent to individuals but is always completed by the individual with an officer present, that officer being required to explain and if necessary, contextualise the questions.

The court heard that the guidance to the self-assessment form issued by the Youth Justice Board makes no express reference to the need for consideration to be given and documented as to whether the self-assessment form needs to be discussed with a vulnerable young person before completion of the form. The guidance examined at the Inquest was a document entitled ‘AssetPlus guidance v2.0’.

Jake had no history of any mental health conditions, or any history of self-harm or suicidal ideation. There was no evidence from friends and family of any warning sign as to Jake’s state of mind.

Toxicological examination was negative, in other words no drugs or alcohol were found in samples of blood taken from Jake after death.

The police investigation had searched through Jake’s browsing history. That enquiry revealed nothing of concern until the day of Jake’s death 14 September 2020, by way of image caches captured on his browsing history as follows

• 0650 I’m so done with everything
• 0713 Do you just deep how alone u truly are sometimes
• 1027 I want to die by hanging myself. How do I make sure that it works? Will it hurt? Information Classification: CONTROLLED

I made a finding of fact that the completion of that self-assessment form late on 13 September contributed to a moment of crisis for Jake the following day 14 September during which he took his life.
Action should be taken
• I recommend that the Youth Justice Board reviews the guidance and procedures relating to the distribution and completion of the self-assessment form given to young persons.
Copies sent to
Youth Offender Service for CornwallLocal Safeguarding Board
Inquest conclusion
Jake Adam CAHILL died on 14 September 2020 at

Cornwall by being an impulsive act in a moment of crisis, that was wholly unexpected and could not have been anticipated. Short form conclusion: Suicide

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Report details

Reference
2022-0032
Date of report
1 February 2022
Coroner
Guy Davies
Coroner area
Cornwall & the Isles of Scilly

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 29 Mar 2022 (estimated).

Sent to

Youth Justice Board for England and Wales

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