Independent investigation: Simon Widger, Eastbourne, Sussex (2000)

The East Sussex Area Child Protection Committee (ACPC), and the Social Services Children and Families Division are recommended to review their working practice, training, support and supervision for staff in respect of the following areas of concern: a) Inclusion of parents/carers in child protection and statutory care planning meetings. The presumption of partnership and inclusion of parents in such meetings is properly at the heart of childcare practice in line with the spirit and guidance in the 1989 Children Act. However, when there are circumstances that cause professionals to question the benefits and non-benefits of parental involvement for the child whose welfare is the primary focus, it can be difficult and contrary to normal good practice to enforce an exclusion of the parent(s), it may, nonetheless, be the right action to take. The ACPC Procedures identify this issue; they should ensure that this is incorporated, and reviewed in the interagency training programme. Similarly, the Social Services Department should ensure such training for staff working with children in the care of the local authority, where the occasional exclusion of the child’s parent will require sensitive handling. b) Working with difficult and noncompliant parents/carers. The ACPC and Children and Families division must ensure that front line staff have training specifically geared to work with such people and deal with the implications of this in their decision-making. The Report of Newham ACPC into the death of Ainlee Labonte/Walker (December 2002) sets out detailed recommendations for working with dangerous families, which the local ACPC is urged to consider in formulating its training and in reviewing interagency procedures. c) Working with carers where induced/fabricated illness of children is suspected. The ACPC Procedures provide information and guidance reinforcing the requirement for strong interagency understanding, information gathering and planning. Effective training and the availability of expert advice is necessary to enable front line practitioners across the agencies to work effectively in this complex area. The Social Services Department has to ensure that the expertise and guidance contained in the ACPC procedures is properly applied in cases where they are reviewing work with children in their care, both those who are Accommodated and Looked After. d) Ensuring comprehensive and accurate record-keeping within A & E departments. To ensure that as part of the assessment of children presenting with unexplained medical symptoms, unexplained child deaths or injuries, there is effective cross referencing of those names with other children on the Child Protection Register to ascertain whether there are siblings in the household who may also be victims of suspected abuse. e) That where a child is presented in A&E the names of all siblings and other children who live in the household are recorded. f) If a child is discovered injured in any inpatient hospital setting or residential placement it must be treated as an Untoward Incident and fully investigated by people not directly involved in the child’s care. g) Reference is made to the local Multi-agency Public Protection Scheme under their local arrangements. Since June 1998 these procedures should have been effectively embedded in local services with greater clarity about the criteria for consideration and smoother process for accessing this forum. However, the ACPC and Sussex Public Protection Steering Group should review their working protocol to ensure there is effective understanding and implementation of referral mechanisms and any follow up actions.

The local authority should be more proactive in developing specific services under the umbrella of the Lansdowne Unit (or any equivalent centre,) working with its partners in the health and education services to disperse the costs associated with such provision. Such a development might also link with more specialist fostering resources where foster carers are prepared and supported to care for abused children and young people.

Young people should not be placed by Statutory Authorities to live in independent settings before the age of 16 and even when over 16 (up to the age of 18) only with an individually tailored care package.

That the Social Services Department ensures that all court reports are up to date and that a record of the judgement of the Court is maintained within the case files as a matter of course.

That the Children and Family Court Advisory Support Service (CAFCASS) is encouraged and enabled to: - a) arrest the decline in the number of Children’s Guardians; b) encourage suitably experienced people to continue in and take on this work; c) ensure that adequate funding is authorised for particularly complex cases; d) achieve effective monitoring, support and audit arrangements with independent contractors to ensure that these Guardians are supported and that their work is monitored and of good quality; e) resolve the classification of the status of independent contractors with the Inland Revenue in order that their work is better supported and monitored.

The panel recommends that all those involved in the Statutory provision of Child and Adolescent Mental Health (CAMH) services consider whether section 31 of the Health Act 1999 would help improve the services they offer, or whether some other form of formalised integration would be beneficial. Such integration should include Education as a core component of a CAMH service.

This recommendation covers a number of single points within the management and administration of mental health services that require change. To ensure effective implementation all the Statutory Agencies will need to work together, however in circumstances such as these, the lead is clearly with the NHS Trust. a) The details of all people detained within a Police Station under Section 136 of the 1983 Mental Health Act, who are seen in the Police Station and are assessed as not subject to further detention or voluntary admission must be communicated to the Mental Health Services to ensure that if they are or have been patients of such services, the event is duly recorded within their notes and the information is available to those who do, or may, provide care to them. b) There must be a protocol developed that clearly demonstrates how a child within the CAMH services makes the transition from being in receipt of care to full discharge or to Adult Services. This protocol should be multi-agency and show at each stage which service is responsible. c) All professionals working with people with mental health problems should be fully trained in Risk Assessment techniques and receive regular updates. d) Organisations must undertake random audits to ensure that Risk Assessment protocols and procedures are being adhered to. e) All individuals admitted to a general hospital following an attempt to take their own life must have a Psychiatric assessment. f) There should be clear minimum qualifications for Locum Psychiatrists established through the Trust’s Clinical Governance Procedures. g) Locum Consultant Psychiatrists must receive a comprehensive induction to ensure that they fully understand all the operational protocols required to enable them to assess and treat patients. This should include details of how referrals to other services should be made. h) There must be a clear understanding across organisations of what constitutes an Untoward Incident and what the response is to such an Incident. The organisations involved must hold multi-agency reviews of all internal and external inquiry reports within 6 weeks of the publication of the report. The review must include a systematic appraisal of all of the recommendations and identify a timescale for completion and a lead agency responsible for ensuring delivery. This must be recorded and continue to be monitored by the Commissioners of the services involved at twice yearly reviews until such time as all of the recommendations have been implemented.

When any defendant, having been identified by Multi-agency Public Protection Panels (MAPPP) as potentially dangerous, appears before the courts on any charge, then a system should be in place which ensures: - a) that the Court Assessment and Diversion Scheme is alerted to ensure an initial assessment is made with the assumption that a full forensic psychiatric report will be prepared in most cases. b) that the Court Assessment and Diversion Scheme liaise with probation report writers, and where appropriate Courts, to seek full forensic psychiatric reports. c) that the report writer has access to all the information held by MAPPP on the defendant and refers to this in the report. d) that there should be liaison through the local MAPPP, with the Prison Service, to ensure that all information held by the MAPPP is available to inform any rehabilitation/treatment programme and the release plans made to manage the offender in the community.

There is outstanding work from the Internal Review and the panel considers that the organisations involved in the internal review should complete the implementation of the following: (numbering corresponds to numbering within Internal Review Report dated December 2000.) a) 9.2. It is imperative that all Information Sharing Protocols include the processes to be followed when sharing information about a child. Information Protocols should be “age seamless”. b) 9.3. and 9.13. The Care Programme Approach (CPA) Policy should clearly identify the CPA responsibilities and arrangements for all 16 – 18 year olds regardless of whether they are under the care of CAMH or Adult services. It should also determine the mechanism and procedures to be followed when transferring the care responsibilities from CAMH to Adult services. c) 9.4 and 9.5. The Forensic Access criteria that have been established should be reviewed to include the following: - • Response times for acknowledgement of referral, referral to assessment, assessment to feedback to referrer. • The criteria that will determine when an individual is ready for transfer to Adult services. • Written protocols for how joint work between Forensic and Adult services will be co-ordinated. d) 9.6. The National Service Framework for Working Age Adults clearly identifies the introduction of electronic CPA as a target that should have been achieved in 2002. It should be multi-agency and easily accessible. It is imperative that this is progressed within all services and that the format includes a system of “flagging” high risk individuals to all agencies. e) 9.7. Probation Services should be involved in the Forensic/Adult Mental Health Liaison Forums. f) 9.8. Multi- agency training should continue on a regular basis. g) 9.9. It would be helpful if the Forensic Access Criteria document included “role outlines” of all staff involved within the service as an aid to referrers. h) 9.14. Joint training for CPA including Risk Assessment and Management must be introduced.