Independent investigation: Lenny Leak, Gateshead (2001)

Strategies should be developed within inter agency working to improve the understanding of domestic violence, often a hidden problem in society, in the management of risk within the community. These strategies should also deal with the well established links between domestic violence and child protection issues.

Notwithstanding the history in this case of Mark Towell’s failure to engage with the many agencies with which he came into contact, it is important that all organisations provide every opportunity for engagement. Agencies should regularly review their procedures so as to maximise the potential for engagement with reluctant clients and to ensure that cases are not closed inappropriately.

The Northumbria Local Criminal Justice Board should establish liaison with the criminal courts to ensure the effective use of Community Penalties, in order to strengthen the assessment, management and supervision of offenders in the community who have proved otherwise difficult to engage.

Drug and alcohol misuse is a problem which presents itself to all agencies. The Panel recommends that the Drug Action Team reviews the policy and procedures of all agencies to ensure that there are pro-active and resilient services available for those with drug and alcohol problems. This review should include the strategy for the management of Drug Treatment and Testing Orders imposed by the Courts.

In the light of the recent introduction of the risk assessment tool OASys (Offender Assessment System Risk of Harm) the Probation Service should ensure that Offender Supervision Plans are adhered to so that ongoing risk assessment is fully integrated into the supervision process.

Inter agency information sharing can work effectively. This was exemplified by the Child in Need planning meeting held on 23rd March 2001. The Panel recommends that there is a system of continuing monitoring, to demonstrate that policies and procedures for information sharing are understood and acted upon by practitioners and managers within and across all agencies. It is important that this involves not only the Health, Social Care and Probation Services but also the Police.

Despite the limitations of any risk assessment system, it is essential that organisations work within an agreed framework. All agencies should audit the implementation of risk assessment policies so as to ensure their consistent and effective use by practitioners. This would be assisted by a programme of joint multi agency training.

The Panel recommends that the South of Tyne and Wearside Mental Health NHS Trust explores the most effective use of the electronic information system in relation to internal and external information sharing. This should include both clinical information and formal risk assessments. The effectiveness of systems depends upon the appropriate input and maintenance of information and protocols regarding access. These are a prerequisite for ensuring that all available data can be employed in the subsequent care of any individual.

The effective supervision of practitioners is of great importance, particularly in cases involving difficult and challenging individuals. The supervision must include the opportunity to constructively question and challenge staff in order to develop their practice. All agencies must be able to demonstrate that they have robust mechanisms to implement and monitor supervision systems for all practitioners.

Appendix B of the Gateshead NHS Trust Policy Practice Guidelines/MBC Guidelines for Clinical Risk Assessment (Interim Policy MH2) should be made more inclusive by incorporating the Child Protection Co-ordinator, the Police and Probation Service within the information sharing process. Protocols should be amended to ensure this happens. This information sharing process must be seen as a priority within practitioner’s implementation of the policy.

The importance of ensuring the clarity and accuracy of recording and dissemination of information is an essential part of any inter agency meeting. All agencies should ensure that policies and systems are in place to facilitate this. The recently amended Child Protection Guidelines provide a model of good practice.