Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000)

It is recommended that the Deliberate Self Harm (DSH) assessment protocol is revised to give greater weight to issues of substance misuse and of potential risk to others and from others as well as the risk to self, ensuring that these points are documented.

CAMHS should consider using formal risk screening on all cases, as would be required in adult mental health services.

Each agency (CAMHS, Social Services, Community Health, Primary Care, Education, Judiciary) must ensure that the other agencies involved in a high-risk case (not subject to the Child Protection Review system) are informed of risky incidents. The development of the use of chronologies to assist in identifying high risk behaviours is strongly recommended. A computerised chronology system such as advised by “The Bridge” may be appropriate. An adaptation of the Care Programme Approach might also be suitable.

CAMHS should have clear serious incident reporting and investigating policies in place which are both part of their Trust’s procedures and in line with the clinical governance arrangements of the local adult mental health service.

A serious incident involving a minor in receipt of specialist health and social care should be the subject of formal communication between professionals and managers of both services. a) To co-ordinate follow-up with the young person and his/her family and the victim/victim’s family and b) To establish whether any lessons might be learned c) The importance of establishing sympathetic contact with the victim’s family is stressed, subject to appropriate legal advice.

The agencies should decide whether referral to the Area Child Protection Committee (ACPC) is appropriate to consider whether any follow-up action is necessary.

National guidelines on Homicide Inquiries should be clarified as to the necessity and nature of such inquiries especially when a minor is the subject.

It is recommended that systematic audit of CAMHS files takes place (if it does not already) to help ensure maintenance of high standards.

It is recommended that Social Services should review their file policy to ensure that fieldwork records and statutory review forms are complete and clearly identified.

CAMHS should send copies of correspondence to residential staff as well as the field social worker as the personnel are different and there is a separate file.

Social Services formal systems for circulating review or conference minutes should include the GP as the primary health care giver, as well as the community paediatric service and CAMHS, if involved.

Appropriate mental health services need to be in place for 16 and 17 year olds. Transition or contingency arrangements should be made for the use of adult mental health services well before the need arises and in consultation with all relevant parties. CAMHS should develop a policy on transfer arrangements in general with Adult Mental Health Services.

Access to appropriate mental health services, including access to services for adults, should be integrated into Social Services’ leaving care policies and procedures.

Young people “looked after”, in the transition phase, and receiving mental health care should have their needs reviewed jointly between agencies. This should include primary health care and education. The outcome should be a care plan available to all including the young person.

Where, as in this case, adult and child mental health services are not managed by the same organisation, CAMHS should ensure there is good liaison with adult mental health services between both professionals and managers to promote knowledge of good practice and appropriate patient care.

Opportunities to promote good understanding between CAMHS and social services as to their respective priorities, philosophies and resources should be developed at both strategic and operational levels.

Mental health services for 16 and 17 year olds should be specifically commissioned. Sufficient in-patient adolescent psychiatric beds need to be available so that the dilemma of either risky care in the community or inappropriate care in adult units can be avoided.

Resources linked to the Department of Health’s Quality Protects initiatives and to recent Care Leavers’ legislation should be used to ensure that appropriate educational opportunities and specialist mental health and drug and alcohol services are available for accommodated young people when planning for independence is underway.

There should be further development of jointly commissioned services helping to ensure good quality services for “looked after children” as they have high mental health needs.

The Youth Offending Team (YOT) system could be developed to promote multi-agency appraisal and intervention for young people involved in offending and anti-social behaviour who are at high general risk.

There should be further training for all CAMHS staff in risk assessment which should include child protection/vulnerability issues, deliberate self-harm and suicidality, violence assessment and substance misuse assessment and management.

There should be further training for all Social Services staff especially those dealing with looked-after adolescents in risk assessment which should include child protection/vulnerability issues, deliberate self-harm and suicidality, violence assessment and substance misuse assessment and management.

Joint training opportunities between agencies should be offered, especially on risk assessment and management issues.

At the point in the future when return to the community is being planned for X, there should be consultation between all agencies including the current health provision, social services and the police, to review what has emerged about psychosocial risks and needs at the various stages of X’s life; and to plan how X can best be supported to minimise risk to herself and others.