An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust: Published November 2022

Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) must ensure that young people in Child and Adolescent Mental Health Services (CAMHS) have a clear plan of care incorporating evidence-based practice.

TEWV must ensure that risk assessments for young people in CAMHS are based on a psychological formulation and are developed by a multidisciplinary team (MDT) in conjunction with the young person and their family.

TEWV must ensure that the management of restrictive interventions (including contraband items) is part of an agreed philosophy and approach, with clear protocols embedded to guide practice.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) must ensure that where risk items are found in a patient’s possession, there is clear recording and appropriate care planning to address the risk identified.

Durham County Council must ensure that social workers are directly involved in planning for a young person’s discharge from an inpatient environment.

Durham County Council must ensure that responses to referrals are completed within expected time frames, and subsequent assessments always incorporate the views of the family and young person.

Durham County Council must respond formally to serious concerns raised about the care and treatment of a young person under their care and explore those concerns with the family and young person.

CNTW must provide assurance that there are protocols in place for Local Authority Designated Officer (LADO) referrals and ensure that these are understood and followed by all staff on Ferndene.

NHS England Specialised Commissioning and the North East region Integrated Care Systems (ICSs), as system leaders, should work with the Directors of Children’s Services in the North East region to commission services that will meet the needs of the small but growing number of young people with complex needs and challenging behaviours that have both health and social care needs. Durham County Council and CNTW/TEWV must work together to secure effective joint Section 117 aftercare packages. Where children are looked after by the Local Authority, Durham County Council and the North East & North Cumbria Integrated Care System must provide suitable placement options to support discharge arrangements.

TEWV must provide assurance that clinical records are kept to expected standards.

TEWV, CNTW, NHS England and Durham County Council must provide assurance that all transitions between services for children and young people are completed in line with NICE guidance on the Transition of Children and Young people.

TEWV must provide assurance that all ligature risks identified in Tunstall Ward in 2019 have been addressed.

TEWV must ensure that the Supportive Observation and Engagement Procedure requires that care plans specify whether to enter the individual’s room if they cannot be observed from the doorway.