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Haringey publishes Serious Case Review on Child O

Monday 19 October 2015

Independent Chair’s Summary Statement, on behalf of Haringey Safeguarding Children Board (HSCB)

In January 2014 the girl referred to in this report as “Child O” took her own life, shortly before her 17th birthday. Haringey Safeguarding Children Board deeply regrets her death, and expresses our sympathies to her family. Child O was a very troubled girl, and very many staff from a wide range of agencies sincerely did their best to help her.

The Local Safeguarding Children’s Board (LSCB) is the partnership within Haringey of agencies who seek to keep children safe. Our collective role is to promote effective joint working, and to hold each agency to account. Following Child O’s death, the Board commissioned an independent author to lead the process of reviewing the work of all agencies and seeking to identify learning. The review identified episodes where agencies could have responded differently at some key periods in her young life. It does not identify a causal link between these episodes and her death in January 2014, which it concludes could not have been anticipated. But some significant issues have been raised for the agencies who had sought to help her.

Through this review process, the agencies have carefully examined their practice since 2010, and have acted upon areas where they have identified the need for improvements. Collectively, we sincerely regret that there were a number of areas where we should have done better. We have accepted all the recommendations of the independent review, and have already acted upon many of them. I summarise the key issues below.

Child O presented severe challenges to agencies working with her and her family. As she entered adolescence her behaviour changed significantly, and she developed eating disorders. In the summer of 2010 she first reported having tried to kill herself several times. She attended various in-patient psychiatric placements for much of the following 3 years, whilst also spending frequent home leave and long holiday periods with her family. In June 2013 she moved to her final placement; a residential therapeutic school in Wiltshire, from where she took her own life in January 2014. Over the years she harmed herself frequently and severely, and professionals who sought to establish close relationships with her encountered significant barriers. She did not normally find herself able to trust people, and perhaps the greatest sadness that staff from all agencies express is that, despite so many people working with her closely over several years, nobody can feel sure that they truly understand what was at the heart of her unhappiness.

Many times Child O said that she had been subject to sexual abuse from outside the family. At no point were any of the agencies able to substantiate this, or persuade her to share any details with them, although most professionals came to believe that something of this nature had probably occurred. In today’s climate of greater understanding of the nature of child sexual exploitation, all agencies have developed more effective ways of responding to allegations of sexual abuse, and it is likely that her allegations would have been responded to differently today.

There is learning for all agencies in Haringey in the way in which they did not adequately use formal child protection arrangements. Child O was a challenging young woman to work with, but it is noticeable how few staff succeeded in gaining her confidence, and assessments of her needs rarely seemed to capture her voice. The quality of assessments by Haringey agencies has been a regular concern of the HSCB, and this case underlines the importance of many of the improvements in process that we have been seeking to introduce in recent years, in response to previous reviews. Police did not consider the possibilities of sexual exploitation sufficiently rigorously; health agencies did not always use the Care Programme Approach effectively; and social care assessments were lacking in suitable risk assessment and thoroughness. Opportunities were missed to consider whether she met the threshold for compulsory detention in hospital under the Mental Health Act.

The process of agreeing Child O’s placement at the private therapeutic school in June 2013 could have been much improved and expedited. The placement was very expensive – costing £124,800 over the 16 or so weeks she spent there – and no public agencies can agree such sums without very careful consideration that the placement fully meets the identified needs. But the quality of joint working between the council and the relevant health commissioning group, who were sharing in the costs of the placement, was poor, particularly from the local authority that provided two thirds of the funding. There has been clear learning for the local authority and its partners from this episode, and improvements have been introduced to the systems for jointly commissioning any future very highintensity placements.

There was also learning from August 2013 when Ofsted judged Child O’s independent school to be inadequate, as a result of significant safeguarding failings. Child O was with her family for 6 weeks at this time, initially in the USA. Whilst it was appropriate for the authority to review the placement in these circumstances, they did not engage properly with their funding partners, and did not engage successfully with the family, in this review process.

Child O’s period away from the school was extended from 6 weeks to 9 weeks as a result of this review, and unhelpful uncertainty was introduced to the placement. Improved processes have been introduced to cover the review of placements in such circumstances in the future.

All the agencies in Haringey involved with Child O have reviewed their own practice and are acting on lessons learnt. HSCB will monitor the delivery of those actions.

Sir Paul Ennals
Independent Chair
Haringey Safeguarding Children Board

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