london borough of islington safeguarding …...• independent nightingale hospital / capio unit...

LONDON BOROUGH OF ISLINGTON SAFEGUARDING CHILDREN BOARD

SERIOUS CASE REVIEW

‘EML’

26.11.19

Contents

1 INTRODUCTION 1

1.1 Trigger event & need for a serious case review 1

1.2 Purpose, scope & conduct of the review 3

2 PERSONAL DEVELOPMENT & KEY EVENTS 8

2.1 Pre-school experiences 8

2.2 Primary schooling 8

2.3 Secondary school 8

2.4 Life-threatening episode 1 10




2.8 Suicide 36

3 RESPONSE TO TERMS OF REFERENCE & OVERALL FINDINGS 37

3.1 Introduction 37

3.2 Application of statutory & non-statutory thresholds in agencies’ assessment, planning & intervention 37

3.3 Co-ordination of care, support & risk assessment & level of clarity with respect to roles & responsibilities 39

3.4 Sufficiency of information sharing between (& within) organisations, & with the family 40

3.5 Scope for more informed appreciation of the experiences, wishes & feelings of EML in planning services including transition to ‘Adult Services’ e.g. use of advocacy 41

3.6 Recognition & responses to early concerns and levels of understanding of EML’s family (siblings, parenting capacity etc) 42

3.7 Impact of sourcing & funding local tier 4 provision & extent to which its use was clinically-driven by EML’s needs rather than as a means of containing professional risk 42

3.8 Overall findings 42

4 RECOMMENDATIONS 46

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1 INTRODUCTION

1.1 TRIGGER EVENT & NEED FOR A SERIOUS CASE REVIEW

1.1.1 EML was a 17.5 year old White British female who lived in Islington, and had an extensive history of sometimes life-threatening self-harm. On 21.04.18, having been granted s.17 ‘leave of absence’ from the Beacon Centre (a ‘tier 4’1 specialist mental health hospital where she had been compulsorily detained under s.3 Mental Health Act 1983), EML was hit by a train and killed.

1.1.2 An Inquest was completed in September 2018 with the Coroner’s conclusion that EML had died by suicide.

1.1.3 Following consideration by the borough’s ‘Child Death Overview Panel’ (CDOP) on 25.04.18, Islington’s Case Review sub-group on 05.06.18 considered whether the circumstances of EML’s death satisfied the criteria for a serious case review (SCR) within relevant statutory guidance (Working Together to Safeguard Children 2015)2. It was determined that, insofar as EML was detained under the Mental Health Act 1983 at the time of her death, the criteria were satisfied and a recommendation that a SCR should be completed was made to the independent chairperson of Islington’s Safeguarding Children Board.

1.1.4 The above recommendation was ratified on 06.06.18 by the chairperson of the Board who duly notified the Department for Education (DfE), regulatory body Ofsted and central government-appointed ‘National Panel of Independent Experts’ (NPIE).

1.1.5 This SCR was completed between July 2018 and July 2019 in accordance with terms of reference summarised in section 3. Its author was also latterly provided with a copy of a ‘serious incident’ (SI) report’ completed by the Barnet Enfield & Haringey (BEH) Mental Health NHS Trust in 2018. The author of that internal report, in consultation with EML’s parents, had evaluated the services provided by the Beacon Centre. The BEH Health Trust has re-affirmed its willingness to consider any further comments or suggestions that the bereaved parents may wish to make when they have

1 NHS England commissions ‘tier 4’ Child and Adolescent Mental Health (CAMHS) services provided by Specialist Child and Adolescent Mental Health Centres including associated non-admitted care (crisis intervention, home treatment, step-down care and other alternatives to admission when delivered as part of a provider network); Clinical Commissioning Groups (CCGs) commission CAMHS for children and young people requiring care in tier 1, tier 2 or tier 3 services. 2 Regulation 5 Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with Working Together to Safeguard Children HM Government 2015. A ‘serious case’ is one in which, with respect to a child in its area, ‘abuse or neglect is known or suspected and the child has died’ or been ‘seriously harmed and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard her/him’. In addition, even if one of the criteria is not met, an SCR should always be carried out when a child dies in custody, in police custody, on remand or following sentencing, in a Young Offender Institution, in a secure training centre or a secure children’s home. The same applies where a child dies who was detained under the Mental Health Act 1983 or where a child aged 16 or 17 was the subject of a deprivation of liberty order under the Mental Capacity Act 2005.

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read this SCR.

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1.2 PURPOSE, SCOPE & CONDUCT OF THE REVIEW

PURPOSE & SCOPE

1.2.1 The purpose of a SCR is to identify required improvements in service design, policy or practice amongst local, or if relevant, national services. SCRs are not concerned with attribution of culpability (a matter, when of relevance, for a court to determine), nor cause of death (the role of a Coroner).

1.2.2 In an attempt to examine every possible line of enquiry with respect to EML’s recurrent self-harming and her death, the period of review was determined to be from birth. An independent report was commissioned from CAE Ltd www.caeuk.org and it was agreed that upon receipt of material, lead reviewer Fergus Smith would:

• Collate and evaluate it • Seek to arrange and facilitate meetings with family and

professionals • Draft for consideration by the SCR panel a narrative of

agencies’ involvement, an evaluation of its quality and conclusions and recommendations for Islington’s Safeguarding Children Board and member agencies

1.2.3 Lines of enquiry may be summarised as the:

• Application of statutory and non-statutory thresholds in agencies’ assessment, planning and intervention

• Co-ordination of care, support and risk assessment and level of clarity with respect to roles and responsibilities of agencies and individual professionals

• Sufficiency of information sharing between (and within) organisations, and with the family

• Scope for more informed appreciation of the experiences, wishes and feelings of EML in planning services including transition to ‘Adult Services’

• Recognition & responses to early concerns and levels of understanding of EML’s family (siblings, parenting capacity etc)

• Impact of sourcing and funding local tier 4 provision and extent to which its use was clinically-driven

1.2.4 Rooted in the narrative in section 2, responses to the above issues are provided in section 3 and recommendations for improving specified services listed in section 4.

CONDUCT

Agencies contributing information & involvement of professionals

1.2.5 The following were asked to supply a chronology and a proportionate

http://www.caeuk.org/

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evaluative report of respective involvement:

• ‘School 2’ (Secondary) and ‘School 1’ (Primary) (mainstream education providers)

• Haringey and Islington Clinical Commissioning Groups (GP Services)

• Whittington Health NHS Trust (Community Child & Adolescent Mental Health Services – CAMHS and Emergency Department Care)

• Independent Nightingale Hospital / Capio Unit (Eating Disorder Service)

• Barnet Enfield & Haringey (BEH) Mental Health NHS Trust (provider of Beacon Adolescent Unit in Edgware)

• Camden & Islington NHS Foundation Trust (medical assessment at North Middlesex University Hospital NMUH and detention at Beacon Centre Acute Adolescent Unit)

• Islington Employment, Education & Skills (Children’s Social Care assessments of need)

• Islington Pupil Services (completion of Education, Health & Care EHCP assessment & its resourcing)

• Oxford Health NHS Foundation Trust (in-patient provider of care and mental health treatment at Highfield Unit)

• East London (NHS) Foundation Trust ELFT (provision of Psychiatric Intensive Care Unit PICU)

• Barts Health NHS Trust (emergency medical / psychiatric treatment at Royal London Hospital)

• NHS England (commissioner of ‘tier 4’ services and management of the Care, Education, Treatment Review - CETR process)

• Metropolitan Police Service MPS (responding to incidents of self-harm)

• North Middlesex University Hospital NHS Trust (Emergency Department care)

• Barts Health NHS Trust (emergency medical / psychiatric treatment at Royal London Hospital)

• Royal Free London NHS Foundation Trust (Eating Disorder Service at Royal Free Hospital site and Emergency Department at Barnet Hospital)

In July 2019 a consultation event for involved professionals was convened. The majority of relevant agencies were well represented and the views of those attending consistent with the findings of the panel.

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SCR Panel

1.2.6 The following representatives made up the panel:

• (Chairperson) Specialist Children’s Quality Assurance Manager, LB of Camden

• Consultant Psychiatrist & Named Safeguarding Doctor Oxford Health NHS Trust

• Safeguarding Manager and Prevent Lead, Camden & Islington NHS Trust

• Head of Pupil Services, LB of Islington • Child Psychiatrist, BEH Mental Health Trust • Safeguarding Children, Lead BEH Mental Health Trust • Head of Safeguarding & Mental Capacity Act Adults • Director of Safeguarding and family Support, LB of Islington • Lead Safeguarding & Children’s Centres, LB of Islington • Lead Nurse Safeguarding Children, Oxford Health NHS

Trust • Service Director Housing Operations, LB of Islington • Lead Named Nurse for Safeguarding Children, Barts Health • Head of Safeguarding, Whittington Health NHS Trust • Designated Doctor, Islington CCG • Head of Safeguarding & Quality Assurance Islington,

Safeguarding and family Support • Metropolitan Police Service • Designated Nurse for Safeguarding Children and Looked

After Children, Islington CCG • Head of Service, Children in Need, LB of Islington • Principal Officer Safeguarding in Education, LB of Islington • Regional Safeguarding Nurse, NHS England • Head of Early Years & Childcare, LB of Islington • Head of Safeguarding & Named Nurse for Safeguarding

Children, Royal Free London NHS Trust • Named GP Child & Adult Safeguarding, Islington CCG. • Named Nurse for Safeguarding Children, Whittington

Health • Adult Psychiatrist, Camden & Islington Mental Health Trust • Islington Safeguarding Children Board Manager • Lead reviewer

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FAMILY

1.2.7 The parents were informed in writing that a SCR was being completed and invited in a subsequent letter sent by the author to contribute. At an initial meeting in May 2019 they shared their experiences and views of the services provided to their daughter and offered invaluable insights.

1.2.8 Further meetings with the parents provided an opportunity to discuss proposed findings and identified some further lines of enquiry. Having subsequently been given sight of a near final version of this full report, the parents provided a detailed critique of what had been reviewed and reported upon. In addition, they commented upon what else might usefully have been addressed e.g. a clinical review of medical / therapeutic approaches to mental health and eating disorder-related treatment and collaboration of relevant consultants.

1.2.9 The efforts of the SCR panel were inevitably focused on the safeguarding-related terms of reference provided in Summer 2018, though the author is confident from his contacts with relevant service providers that there has been a great deal of intra-agency thought and debate amongst those who worked intensively with and for EML and that this SCR and responses to its recommendations will prompt more.

1.2.10 The need to publish and share learning without adding to the distress of family or vulnerable others was also discussed with parents and informed many amendments introduced to this final draft. The panel and the author are very grateful for the thoughtful, thorough and constructive approach adopted by EML’s parents faced with the loss of a much loved and gifted child. The challenge of reading and re-reading this report will have required them to re-live many distressing events

1.2.11 Toward the end of the panel’s deliberations, the question of the relevance of the Mental Capacity Act 2005 and its associated Code of Practice was

Father

Mother

EML

Sib 1

Sib. 2

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debated and the conclusions of that discussion are summarised within the findings in section 3.

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2 PERSONAL DEVELOPMENT & KEY EVENTS

2.1 PRE-SCHOOL EXPERIENCES

2.1.1 A retrospective parental account provided to the first of the ‘tier 4’ units in which EML received treatment indicates that her birth and early developmental years (achievement of ‘milestones’ etc) were unremarkable. A single reference to a preference (aged 4), for solitary play and possible concerns about fine motor skills was found, but nothing that did or should have prompted concern.

2.1.2 EML had, according to her parents, been shy and watchful before joining in with peers, though always very articulate. Some repetitive / stereotyped conduct was recalled by them, as were characteristic and ongoing signs of anxiety e.g. thumb-sucking, especially in social situations. Her parents thought that their daughter found it hard to discern ‘social cues’ and felt left out by her peers. They later passed on to clinical staff (though school staff were probably unaware of it – see below) EML’s account of psychological bullying at both schools she attended.

2.2 PRIMARY SCHOOLING

2.2.1 EML attended ‘School 1’ from 2004-2011. Those staff who remain employed there remember with fondness, a bright quiet child, about whom there had been no concerns.

2.2.2 Any pastoral records would have been transferred when EML moved up to her Secondary ‘School 2’. For that reason, it remains uncertain whether the staff working with EML had known of some reported anxiety at the age of 10, thought to be related to a serious depressive episode experienced by her father at about that time.

2.2.3 As referred to above, EML in later years referred to some bullying at this school. She had not raised the issue at the time and neither staff or records indicate any awareness of that source of pressure.

2.3 SECONDARY SCHOOL

2.3.1 EML began attending School 2 in September 2011. She remained on roll there when the family moved to live at ‘address 2’ in Islington in February 2014 and throughout periods of authorised absences or in-patient care as described below. Sources of stress for the teenage EML and later identified by the family were the:

• Death (by suicide) of a paternal aunt in 2003 and death from natural causes, of the maternal grandfather in 2013

• Diagnosis of the maternal grandmother’s dementia and her joining the family in September 2013 (EML was then 13

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and is understood to have chosen to take an active role in the emotional support of her grandmother)

2.3.2 Police involvement prior to their responses to some self-harm incidents was limited to a number of occasions when officers assisted in tracing and returning the confused maternal grandmother.

2.3.3 An early reference to EML’s difficulties emerges from the material provided by her school. It reveals that in June 2014 apparently self-inflicted marks had been noticed. EML referred to being unhappy at home and eating alone in her bedroom. This was followed up internally and resolved when EML subsequently denied any difficulties. No further information about this incident is available.

Comment: EML’s parents remained unaware of the above incident (which pre-dated by several months, recognition of eating difficulties) and consider it a missed opportunity to recognise and respond to the distress implied.

EMERGING EATING DISORDER

2.3.4 Concerns about EML’s eating were identified by her parents in February / March 2015 (she was then 14). By September 2015 a GP record of a consultation, notes that EML had stopped having periods since April 2014 and had an abnormal weight loss. Examination showed that she was on the 1st centile for her ‘body mass index’ (BMI) at just under 163 i.e. ‘underweight’. A referral was made for a paediatric consultation at the Whittington Hospital.

2.3.5 Less than a month later, mother’s concern that EML might have anorexia nervosa4 prompted a private consultation with a consultant psychiatrist at the Capio Unit. Mother reported EML had been eating less since Christmas 2014, lost 2 stone in 6 or 7 months and been presented to the GP in May and August 2015. Mother referred to the pressure on family members since her own mother had joined them.

Comment: parental feedback (as opposed to formal records supplied to the SCR) describes insufficient awareness amongst GPs e.g. of the meaning and distinction between anorexia and bulimia and in their view, a preoccupation (unsurprising to the author and panel) with testing and eliminating physical explanations for the described symptoms; the parents report their sense of ‘having to make the running on a life-threatening condition’ and cite several occasions on which the local Royal Free Hospital Eating Disorder Outpatient Service could have played a more proactive and supportive role’.

2.3.6 On examination by the Capio psychiatrist, EML appeared pale and emaciated (at 42 Kgs). She reported a low mood, wanted to receive help

3 Body Mass Index is defined as the body mass in Kg divided by the square of the body height in metres i.e. Kg/m2. 4 Anorexia Nervosa is an eating disorder and serious mental health condition. People who have anorexia try to keep their weight as low as possible by not eating enough food or exercising too much, or both. This can make them very ill because they start to starve. They often have a distorted image of their bodies, thinking they are fat even when they are underweight. Men and women of any age can get anorexia, but it is most common in young women and typically starts in the mid-teens www.nhs.uk

http://www.nhs.uk/

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for eating-related anxiety, and was afraid of being seen eating as it appeared greedy. She denied suicidal thoughts. A diagnosis of anorexia nervosa was made and the treatment plan included a referral to a dietician, blood tests, supervision of all meals, no exercise and follow up in 1 week.

2.3.7 Records supplied by School 2 refer to a meeting with parents on 19.10.15 and their confirmation of the diagnosis of anorexia nervosa. There were further meetings and contacts focused on EML’s support needs. By 13.11.15 EML had gained some weight, was ‘back at school’ (absences having been authorised by the school) and ‘meeting a dietician weekly’. The then plan was to complete blood tests with the GP, initiate use of vitamin B and refer for one-to one therapy with a follow up in 3 months. GP records also indicate a communication received from a Hospital Eating Disorder Clinic, raising the possibility that the family was exploring alternative sources of help.

Comment: feedback from parents indicates dissatisfaction with the approach taken to EML’s eating disorder and a summary of their concerns has been added to section 3.

2.3.8 The parents have reported that at this time EML’s full-time school attendance was enabled by mother attending on 3 days per week to ensure consumption of lunch and school staff fulfilling the same role on the remaining days. Reflecting hospitalisation in early 2016, no further records have been seen until plans for rehabilitation were being formulated and School 2 re-involved later that year.

2.3.9 The author of the report supplied to this SCR by School 2 is critical of a failure to ensure an effective multi-agency partnership in EML’s planned return to school in late 2016 / early 2017. Opportunities for multi-agency communication, information exchange and co-operation are commented upon in the remainder of section 2.

2.4 LIFE-THREATENING EPISODE 1

2.4.1 Toward midnight on 06.01.16 EML (15.5 years old) attended Whittington Hospital Emergency Department and reported the ingestion of 30 ‘500 mg’ Paracetamol tablets 46 hours earlier. She said she had wanted to die and was admitted for observation. Her discharge summary reported she wanted ‘to stop feeling’ and felt she was ‘letting everybody down’, especially parents. EML had only disclosed her overdose when her parents noticed her vomiting. The trigger was, she said, a family argument. Notes refer to anorexia nervosa and private consultations at the West London Unit since 2015. EML remained an in-patient until her transfer to a tier 4 unit described overleaf

Comment: no referral was made (as it should have been according to the relevant hospital protocol) to the local Children’s Social Care.

ADMISSION TO ‘TIER 4’ UNIT IN LATE JANUARY 2016

2.4.2 On 18.01.16 EML was assessed and had lost a further 1.5kg over the weekend. She was thought to need an admission to address her eating

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disorder because it was clear she could not be managed with outpatient treatment and supervision. The plan was ‘to access a tier 4 bed’.

2.4.3 The above event triggered a later informal admission on 27.01.16 to the ‘tier 4’ Highfield Unit5 in Oxfordshire. Some uncertainty is apparent in email exchanges between professionals about who would manage the case at the point of discharge and the chronology supplied to this SCR indicates that the ‘Adolescent Outreach Team (AOT) will not manage the case in the community’ (its view apparently being that the primary issue was an eating disorder). The Royal Free Hospital Eating Disorder (ED) Team was planned to be involved ‘from the ED aspect’ (the Eating Disorder Team at the Royal Free Hospital is commissioned to offer a service to relevant patients from Barnet, Camden, Islington and Haringey).

2.4.4 The author has been advised that the Highfield Unit in Oxford was the closest available and had an established expertise in eating disorders. Following admission and amongst other routine matters, it was determined that:

• EML required 15 minute interval observations and sleep monitoring and would be nursed on the eating disorders programme

• A formal ‘meal assessment’ would be arranged and that feedback from her school was required

Comment: no confirmation that School 2 was contacted has been provided; the parents have articulated clearly and convincingly that the distance from home rendered it hard to maintain the level of contact and support that EML required from family and friends and also made it impractical to put in place an incremental rehabilitation programme.

2.4.5 A care co-ordinator (it is thought from the Royal Free Hospital, though parents believe Islington CAMHS) was identified by the Unit. Records confirm that staff were aware that EML had been unknown to CAMHS prior to admission and had been treated privately since October 2015 by a psychiatrist who had diagnosed anorexia nervosa. Weight was noted to be 41kg. On 11.03.16 after she tried to run from the Unit, s.5 (2) of the Mental Health Act 1983 was applied6.

2.4.6 On 14.03.16 following a mental health assessment, EML was detained under s.2 of the Mental Health Act 1983 and on 08.04.16 this was converted to s.3 (Treatment). On 11.04.18 EML received precautionary medical treatment at the John Radcliffe Hospital in Oxford having swallowed 2 AA batteries.

2.4.7 On 15.04.16 the (Oxford-based) care co-ordinator confirmed to the GP Practice that a telephone ‘care planning approach’ (CPA) meeting had

5 The Highfield Unit is a specialised inpatient unit for those age 11-18 and provides crisis management, treatment and preparation for long-term psychological and family-based intervention in the community. 6 S.5(2) is a temporary hold of an informal or voluntary service user on a mental health ward in order for an assessment to be arranged under the Mental Health Act 1983; it seeks to ensure immediate safety whilst the assessment is arranged.

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been completed (on 11.03.16). On 13.05.16 when a further CPA meeting was convened, an email thread reflects an exchange between the London-based AOT which opened the case on 18.05.16 and the ‘Primary Mental Health Team 3’. EML was considered to remain at very high risk, though Unit staff (in the view of Community-based peers), ‘seemed to be pushing for leave home’. The main issues continued to be significant suicidality, self-harm, anxiety and possible autistic spectrum disorder (ASD).

Comment: this entry was the first occasion on which ASD was cited.

2.4.8 The meeting was informed there had been a number (minimum 5) of incidents of attempted and deliberate self-harm since her last CPA:

• Attempts to take scissors with the intention of self-harming, requiring physical restraint as a preventative measure

• Tying 4 un-suspended ligatures, which at times EML was able to, and were otherwise removed by staff

2.4.9 Feedback from staff indicated that EML sometimes presented in an apparent dissociative state (holding a fixed stare and verbally unresponsive to others) and had reported believing she needed to end her life to stop her ‘doing evil things’ as well as on-going thoughts that she was ‘evil’. EML had also reported some paranoia around some staff believing they could ‘read her mind’ and ‘change her thoughts’. She had also reported, on waking in the night frequently seeing men standing in front of her. By late May, some staff were querying whether EML might be on the autistic spectrum. Her mother was recorded as resisting a formal assessment of that possibility.


2.5.1 On 17.06.16 whilst on home leave, EML jumped from a 3rd storey window and incurred 4 fractured vertebrae. She offered a consistent explanation to her mother and professionals that she had not planned to jump and kill herself; she had heard a noise on the roof and thought her sister was under threat in her bedroom; she had gone out onto the roof and felt compelled by a voice to jump. The report submitted to the SCR by Oxford Health NHS Foundation Trust indicates that a CPA meeting (reportedly the 3rd though possibly 4th) was held on the day of her fall.

INTER-AGENCY LIAISON

Royal London Hospital – Highfield Unit

2.5.2 When seen by the ‘Rapid Assessment, Interface & Discharge’ (RAID) team at the Royal London Hospital a mental health nurse was allocated to supervise EML and there was a commendably high level of clinical liaison between staff and the Highfield Unit (as well as the formalities required for detention under the Mental Health Act to be temporarily transferred to the hospital). Recognising the safeguarding implications, the hospital alerted Islington Children’s Social Care.

2.5.3 Following an efficiently managed transfer to the ‘Paediatric, Surgical &

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Rehabilitation’ ward (she was by then calm and settled though low in mood), EML was reviewed by the consultant psychiatrist. At that point 3 days after her fall, she was alert, oriented, co-operative and engaging appropriately. One or other parent stayed day and night.

Comment: the chronology of events / liaison, and report supplied by Barts Health NHS Trust evidences a high standard of service within the hospital and in its communications and information exchange with the Highfield Unit.

Metropolitan Police – Islington Children’s Social Care

2.5.4 The first episode of involvement by the local Children in Need (CIN) team of Islington’s Children’s Social Care was on 20.06.16 when it was notified (by means of a ‘Merlin’ from Police) of EML’s fall. A ‘child and family assessment’ was initiated immediately though a strategy discussion with Police (ordinarily preceding that action) was not convened until 18.07.16, a month later. The delay has been explained as a result of the dominance of mental health issues coupled with the need to establish whether EML was known to Social Care in Haringey (where the family used to live) or Oxfordshire (location of Highfield).

Comment: in the author’s view, the decision that s.47 enquiries were not required was justified in the then known circumstances.

2.5.5 In an exchange between Whittington Paediatric Mental Health Team and the Royal London Hospital (it is unclear who initiated it), it was noted that EML’s parents were angry because they had not appreciated that they ‘should not let EML out of their sight’. Their stance suggests insufficient briefing by Highfield staff and/or insufficient awareness of the inherent risk.

2.5.6 Following an initial review of the incident by Highfield, it arranged an independent ‘serious investigation’ (SI) which included the parents (it is unclear whether EML’s views were sought). Recommendations for improving the effectiveness of ‘absence of leave’ for patients were made and have since been introduced.

Comment: the need to minimise ambiguity or uncertainty becomes apparent again when EML was on her final ‘home leave’ from the Beacon Centre in April 2018 (see paras. 2.8.2 - 2.8.3).

Community CAMHS – Royal London Hospital

2.5.7 Islington Community CAMHS sought an update from the Royal London Hospital (RLH) at this time and made it clear to the allocated mental health nurse that she must not leave EML on her own without a staff member being present.

2.5.8 During the remainder of her time as an in-patient at the RLH, liaison between CAMHS and the local Clinical Commissioning Group (CCG) highlighted some concerns about clinical decision-making i.e. the high level of suicidal risk EML presented and an absence (in part a consequence of distance from home) of trials of shorter, independent leave in the local area

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(during her last leave over 2 weeks previously, she had absconded).

2.5.9 The level of concern amongst professionals at this time prompted an email exchange between NHS England (which commissions ‘tier 4’ provision), mental health lead for NECL and the CCG’s children’s commissioner. Liaison between CAMHS and the RLH suggested EML’s eating disorder was not the chief concern and the Adolescent Outreach Team (AOT) might be best positioned to assume clinical responsibility when she was discharged from the Highfield Unit (to which EML had returned on 24.06.16).

2.5.10 Later in July, a diagnosis of ‘Autistic Spectrum Disorder’ (ASD) was confirmed at Highfield by a consultant and a plan agreed for an AOT member to visit her to get to know her once home leave began.

Comment: that diagnosis was later questioned by some at the Beacon Centre partly because EML was considered too psychotic to provide reliable results from the application of the diagnostic tool employed.

Care Planning Approach (CPA) meetings 5 -7

2.5.11 On 21.07.16 at a 5th CPA, participants heard that EML’s mood state and level of engagement (as well as weight) had been variable. She had had suicidal thoughts and manifested paranoid thinking ‘a lot of the time’.

2.5.12 At a further meeting a month later (20.08.16) occasional improvements were noted in EML’s mood state and less (though still some) paranoid thinking. Weight had increased. Subject to confirmation at a further scheduled CPA, Community CAMHS in Islington was expected to offer treatment and support following discharge. One or other parent was reportedly staying in Oxford between Sunday and Friday night ensuring ongoing support and availability for agreed leave of absence with them (conditional upon their supervision of her ‘at all times’). The parents have corrected this account and report that they visited every Saturday and Sunday and at least once during the week. In addition, they spent a week on holiday in Oxford at the end of August during which time they took EML out daily on supervised leave.

2.5.13 During the first assessment by Children’s Social Care, the needs of EML and her younger sibling had been addressed (a further re-assessment focused solely on EML) and it was:

• Concluded that a strong family bond existed • Agreed there was no need for further Social Care

involvement (mental health was regarded as the main issue and being addressed by relevant other agencies)

Comment: the conclusions were justifiable on the basis of observations made, though no direct contact was made with EML and there remained scope for more extensive exploration of earlier childhood; the potential value of a co-ordinating role does not seem to have been considered.

2.5.14 It was agreed that should there be a plan for EML to be discharged or have

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further leave of absence, Children’s Social Care was to be informed. Prompted by the wish to identify a more local unit, EML’s advocate initiated a challenge soon after case closure in late August 2016 and sought a further assessment of need from Children’s Social Care and the Whittington NHS Trust.

SELF-HARM INCIDENT 6

2.5.15 The next recorded self-harm episode was on 14.09.16 when ward staff had to forcibly remove a ligature from EML. No detail of this incident has been provided.

Care Planning Approach Meeting 6

2.5.16 A further CPA meeting was held on 29.09.16 and attended by an AOT representative. EML was reported to be continuing to present with low mood, suicidal ideation, psychosis and remained on the eating disorders programme. The possibility of a transfer to Priory Southgate or Simmons House was raised, the latter rejected because it was not secure and the former for un-recorded reasons. The required ‘ASD care and treatment review (NHS England) process’ was being followed

Comment: a meeting with NHS England during the course of this SCR clarified that is has what may be encapsulated as an oversight function to ensure that clinical services are safe and appropriate for certain pre-defined patients.

2.5.17 On 07.10.16 a meeting was held at school with mother to discuss the Education, Health and Care Plan (EHCP) process for EML. There followed phone liaison between school and Highfield Education Unit about any need for additional educational information or material. A final (7th) Highfield CPA meeting was held on 20.10.16 by which time s.3 detention had expired on 08.10.16 and EML had become an informal patient. Records supplied refer to ‘unsuccessful attempts’ from 04.10.16 to seek advice from NHS England about units closer to home.

Comment: the NHS England report supplied to this SCR omits any such reference which seems likely to refer to the acute shortage of tier 4 provision.

2.5.18 What was still then referred to as a ‘Care and Treatment Review (CTR) (terminology changed in April 2017) was reportedly planned by NHS England after transfer to a London Unit had been achieved. The report provided by the Oxford Health Trust reports that ‘the findings from the neuro-developmental assessment helped to inform ongoing assessment, management of her suicide risk and her care plan. This resulted in improved engagement evidenced by a reduction in the amount of self-harming and suicidal behaviours’.

Comment: the reported improvements are not obvious to the author.

SELF-HARM INCIDENTS 8 & 9

2.5.19 During the 7th CPA meeting of 20.10.16, 2 further incidents of self-harm were noted. It was acknowledged that the risk EML posed could be hard to

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assess because she remained impulsive. Home leave was deferred and arrangements for staff to escort her home for day leave and to assess her in the home environment initiated.

2.5.20 The parents were reported to be frustrated at delays in the response of the Priory Unit (the preferred option at that time). Also on 20.10.16 the matron of the Highfield Unit met EML’s parents and discussed the possibility of a transfer to the Beacon Centre at Edgware Community Hospital (a tier 4 Adolescent Inpatient Service for 14-18 year olds). The material provided to the SCR indicates that the parents had read poor reviews of that facility and were not keen on its use. The parents recall being advised against its use by CAMHS which referred to its poor reputation. Highfield anyway facilitated further direct and indirect contact with a view to offering sufficient reassurance.

Comment: staff provided careful and sensitive support ahead of EML’s transfer.

Brief Home Leave & Transfer to Beacon Centre

2.5.21 Whilst awaiting confirmation of when a bed might become available at the Priory, a place at the Beacon Centre was offered and accepted. EML and her parents supported the move and remained committed to the proposal of further family therapy.

2.5.22 A 2 hour home leave was completed on 27.10.16 and was adjudged to have gone well. EML was transferred to the Beacon Centre on 01.11.16. Information and advice passed on, included the warning that the risk of self-harm was high and that impulsivity made early warning signs not easy to identify. School 2 was notified of transfer to the more local Unit next day and a discharge report received a week later.

2.5.23 A nurse from the Highfield Unit had accompanied EML and the report provided to the Beacon Centre was a very comprehensive account of relevant health and social information including the need to be sensitive to facial and body language indicators of mood and/or distress.

2.5.24 A week after transfer, on the basis of the tier 4 status and ASD diagnosis, NHS England advised that CTRs should be co-ordinated centrally by the CCG’s children’s commissioner and that CAMHS would be notified. By 11.11.16 a further (more in-depth) Children’s Social Care assessment (triggered by the family’s representations) had confirmed with parents, that upon transfer to the more local Beacon Centre, all relevant services were being provided and that there existed no role for Children’s Social Care. The case was closed.

Comment: the first having been completed only a month earlier; the conclusion of the further assessment (this one informed by a meeting with EML), was justified; section 3 does include some thoughts (debated with the parents) about the potential value of more extensive Children’s Social Care involvement.

Uncertainty about diagnosis & a proposed CTR visit

2.5.25 Later in November, records indicate that its psychologist (for unstated

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reasons) expressed the Centre’s concern about the planned CTR visit. The diagnosis of ASD was being questioned because:

• The parents had expressed some surprise at it • Clinicians at the Beacon had not noted any significant or

obvious difficulties in social functioning, communication and imagination (other than what might be explained by shyness, settling in and experiencing psychotic symptoms)

• Of uncertainty about the previous assessment e.g. whether EML had been experiencing psychotic symptoms

• Of a delay in receipt of reports from the Highfield Unit

First CPA meeting at Beacon Centre (CPA1)

2.5.26 On 23.11.16, records supplied by Islington CAMHS confirm concern about the diagnosis and work undertaken to that point. On 02.12.16 a meeting at School 2 discussed a phased return to mainstream education. A conversation with an Islington educational psychologist reflected doubts within the Centre as to EML’s readiness. Further debate centred around potential use of individual independent tutors. The special educational needs (SEN) process was still being followed.

2.5.27 By early December, Beacon staff were concerned (a view later reinforced by the Islington consultant) about weight loss and asked the AOT to refer to the RFH Eating Disorder Outpatient Service. EML’s notes include a wish to slit her throat or jump in front of a train and feelings of hopelessness, helplessness and worthlessness. Apparently linked to the discontinuation of Clozapine7 a deterioration in mental state was observed by 13.12.16. Parental feedback suggests that many of the prescribed anti-psychotics had the side-effect of increasing appetite and feel that the ongoing involvement of eating disorder experts might have helped.

Self-harming incidents 9 -13

2.5.28 A letter to the GP from the Beacon Centre listed self-harming episodes

7 EML is reported to have had an adverse reaction to Clozapine previously prescribed at the Highfield Unit. On the advice of the ‘National Monitoring System’, the Beacon was advised to and did prescribe Olanzapine instead; EML took a long time to stabilise on the alternative medication.

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during December 2016:

• An attempt to hide a tin lid with an intention of self-harm (02.12.16)

• Ligature-tying using string from a hooded jacket (07.12.16) • Being found in a toilet after self-harming and attempting to

grab medical equipment whilst a dressing applied (08.12.16)

• Putting tissue in mouth and ‘sellotape’ over mouth and nose (12.12.16)

• An attempt to run off the Unit, with sufficient subsequent distress to require intramuscular injection (13.12.16)

SELF-HARM INCIDENT NUMBER 14

2.5.29 On 17.12.16 EML accessed a tin lid and lacerated her left arm to the extent that a check at Barnet Hospital’s Emergency Department was needed. The medical team there was provided with a comprehensive transfer letter from the Beacon Centre duty doctor including a need for EML to be on 2:1 supervision at all times because of the risk of further self-harm or absconding. There is no evidence the case was discussed with paediatric medical staff at the time of attendance as would be expected. It was though discussed at the weekly departmental multi-disciplinary meeting and a discharge summary later sent to the GP. Whilst all relevant medical information was shared with the hospital, there was confusion about legal status and a record made that the Beacon Centre held parental responsibility.

Comment: without regard to the previous use of s.2 and s.3 of the Mental Health Act 1983, ‘parental responsibility’ remained exclusively with her parents.

SELF-HARM INCIDENT NUMBER 15

2.5.30 Overnight leave between Christmas Eve and Boxing Day had been uneventful, but 11 days after her last self-harm attempt, EML was in a local supermarket with 3 members of staff when she picked up a can and tried to break it and cut her wrists. She said she wanted to die, was restrained by staff and ambulance and police officers helped escort her back to the Beacon Centre. EML was held for 72 hours under s.5(2) Mental Health Act 19838 for an assessment by the Mental Health team. She reported that ‘birds in her head’ were telling her to do things to herself. Police appropriately provided a ‘Merlin’ notification to Islington Children’s Social Care which again concluded that it could add nothing of value to the mental-health services already being provided.

SELF-HARM INCIDENTS 16 -19

2.5.31 4 further self-harm attempts (all within days of one another) were included

8 Under s.5(2) MHA 1983 a doctor can hold a patient in hospital for up to 72 hours, if s/he writes a report explaining why the individual need to be detained, and sends the report to hospital managers.

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in the Beacon Centre’s GP notification:

• An attempt to jump downstairs with an intention to injure herself (03.01.17)

• Tying a jumper around her neck (05.01.17) • Trying to walk in front of a car during a group outing

(06.01.17) • Using head phones as a ligature and blocking a key hole

with ‘Blu-Tack’ to stop staff from helping her (08.01.17)

Care & Treatment Review CTR 2 / CPA 2 & planning return to school

2.5.32 Prompted by NHS England, a CTR meeting was convened at the Beacon Centre on 18.01.17. It involved AOT and the Eating Disorder Service from the Royal Free Hospital. Minutes of this and all other meetings were circulated to GP, community mental health colleagues and parents. Though an ongoing issue, EML’s eating disorder was not thought to have prompted ill-health; rather her habit of cutting and watching the pooling of blood had prompted sufficient loss to trigger anaemia and a need for iron supplementation.

2.5.33 Minutes of a CPA meeting also completed on 18.01.17 (mistakenly labelled 18.01.16) reflect EML’s fluctuating moods and numerous self-harm incidents. School 2 had not received a response to its earlier offer to the education unit at the Beacon Centre and on 07.02.17, re-iterated its ability to provide additional and exam-related material.

Comment: it remains uncertain whether the non-response was just an oversight or reflected a clinically-driven reluctance to work co-operatively as would later appear to be the case in exchanges between medical staff and School 2.

2.5.34 The report provided by the school refers to ‘working with the parents on the EHCP application and transition’ back to school. Mother expressed a hope that EML might be able to attend for some lessons. The school received a very belated background report from the Highfield Unit on 09.02.17 and, on 19.02.17 the outputs of January’s CTR meeting.

2.5.35 During February 2017, an AOT clinician initiated visits to EML at the Beacon Centre. According to records provided, a CPA meeting was held on 02.03.17 and a potential discharge date (dependent on risk), was set for 04.04.17. The former date is inaccurate. The focus of work was planned to shift from psychosis (symptoms of which were considered more stabilised) to more trauma-focused, regulating emotions and attachment issues. Following that CPA meeting, a ‘school safety plan’ was received on 27.02.17 and prompted an exchange of emails between school and

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Centre.

Assessment under s.85 Children Act 1989 9

2.5.36 On 27.02.17 in compliance with s.85 Children Act 1989 (welfare of children in long-term health and education institutions) Islington Children’s Social Care was notified of EML’s continuing presence at the Beacon Centre. The relevant assessment was completed in accordance with the borough’s procedures. It concluded that all appropriate services were in place and that her parents had a ‘good’ relationship with the involved professionals.

Comment: this assessment was thorough and well-informed by all parties e.g. the assessor attended a CPA meeting and met both parents and EML; the ‘good’ relationship between parents and agencies was not entirely sustained; tense exchanges between School 2 and the Beacon Centre are described below and inevitably impacted upon parent-school rapport and probably EML.

DISAGREEMENT ABOUT EDUCATIONAL RE-INTEGRATION

2.5.37 Records supplied to the SCR confirm that the school had on 02.03.17 sought the advice of the Children’s Social Care ‘safeguarding lead’ in Haringey (where the school is located) who supported the cautious approach being contemplated by its staff. School 2 subsequently communicated to the Beacon Centre its concern that re-integration needed to be more structured and would require a completion of a risk assessment before it commenced. The Beacon consultant child and adolescent child psychiatrist indicated that her Centre would take responsibility for any consequence of EML’s return and a member of Centre staff was promised to provide on-site support at school.

Comment: the tension between the Centre and School 2 peaked at this point, leaving all parties in a difficult position; there is though, no way that an individual in one agency can ‘import’ the professional and lawful responsibilities that exist for an institution such as a school for its pupils and staff.

2.5.38 With the support of the SENCO, a meeting was planned for 13.03.17 to discuss the postponed transition to school. Before then, the school sought to visit the Centre so as to inform and develop its risk assessment (an intention initially thwarted by a coincidental receipt of notice of an Ofsted inspection). The school subsequently sought further advice from Haringey Children’s Social Care and was supported in its re-stated wish that all eventualities had been addressed before transition began.

Education, Health & Care Assessment

2.5.39 Arising from the CRT of January 2017, a request for an ‘Education, Health & Care Assessment’ was submitted on 21.03.17 to Islington’s multi-agency ‘Education, Health & Care Management Board’. An Education, Health and Care Plan (EHCP) was completed in October 2017 and termly funding of £30K made available for provision of full-time support when EML eventually re-joined school. School 2 feedback indicates that the Beacon

9 S.85 Children Act 1989 places a duty on local authorities to check on the safety and welfare of children living in residential education or hospital provision for any continuous period exceeding or likely to exceed 12 weeks.

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(actually the consultant psychiatrist) voiced the view that the school’s apparent reluctance to accept EML back, had delayed her recovery. That view, apparently relayed to the parents, understandably upset them and impacted on their view of School 2.

Comment: the author has studied numerous emails about the planned transition; in contrast to the mutually respectful relationship between a caring and attentive school and Highfield, the attitude of some medical staff at the Beacon toward School 2 was at best insensitive and lacked appreciation for the commitment, skill and lawful responsibility toward all its pupils and colleagues.

2.5.40 The commendably reflective report supplied to the SCR by ‘Pupil Services’ (the source of educational psychology input and funding) posed the question of whether it may have been too keen to resolve the polarised views formed during 2017 between School 2 and the Beacon Centre. How these views played out and some proposals for improving the prospects for more collaborative responses in any comparable situations are explored and spelled out in sections 3 and 4 respectively.

2.5.41 School 2 has confirmed its delivery of training to relevant staff to prepare them for EML’s return. A ‘transition timetable’ was devised and a learning support assistant (LSA) provided. School 2 is clear in its allegation that in the period preceding and following EML’s return, relevant information was deliberately held back e.g. references were made by Beacon staff to ‘incidents’ but no details provided. No rationale for that has been provided though Community CAMHS has very latterly reported that ‘there were clinical discussions at the Beacon Unit meetings to discuss EML and her ongoing needs, which Education were not allowed to be part of at the request of the parents and EML. They joined the planning component of the meeting.’

Comment: the position reported by School 2 suggests a failure of multi-agency collaboration; it also raises an uncomfortable question about whether School 2 (ultimately) accepted a situation regarded as insufficiently informed or safe.

Indication of possible organic problem

2.5.42 An Electroencephalogram (EEG) on 20.03.17 showed signs of ‘sub-cortical frontal dysfunction’ to be further explored including a MRI. EML was considered a moderate risk to self-harm with high levels of impulsivity and suicidality but denying any specific plans. The date may be mistaken because a ‘consultant neuro-psychologist’ had on 14.03.17 reported an EEG as abnormal possibly caused by anti-psychotic medication or underlying pathology and recommended an MRI. Records supplied provide no further explanation.

FURTHER SELF-HARM INCIDENTS 20 & 21

2.5.43 There was an (unspecified) suspected self-harm episode (incident 20) whilst on weekend leave. Staff noted that mother was ‘minimising the event’ and reluctant to share details. Mother has informed the author that because feedback about the weekend was sought whilst EML was present, she had felt constrained with respect to what she could make explicit, lest it

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add to the stress EML was already feeling.

2.5.44 On 22.03.17 EML ran impulsively from staff on her return to the Unit from school with a thought (she said later) of ‘jumping in front of a train’. This event was acknowledged by the psychiatrist in an email to School 2 though she remained of the view a planned time-limited visit to school could proceed next day. School 2 sought further advice from Haringey’s Safeguarding Service which served to reinforce its wish for the latest ‘risk assessment’ from the consultant and ‘a clearer safety plan’.


2.6.1 Though not seen in material provided by the Beacon Centre, a record of an AOT clinician who visited the day afterwards referred to an incident ‘last night’ i.e. 27.03.17 when EML had made what was described as a ‘severe suicide attempt’ using a ligature causing petechial haemorrhages (tiny pinpoint red marks suggesting asphyxia caused by an external means of obstructing the airways) whilst on 15 minutes observation level. A special educational needs and disability (SEND) planning meeting scheduled at the school on 28.03.17 was postponed.

CPA 3 meeting

2.6.2 At the 3rd CPA meeting held on 04.04.17, the hospital team view was that discharge should proceed. Staff felt the level of risk and impulsivity in terms or suicidal ideation and impulsivity was chronic, and not something long term hospital admissions were addressing viz: experiences at both tier 4 establishments. The risk of institutionalisation was debated. The provisional discharge date was moved to 16.05.17 dependent on risk. Information provided in early July 2019 indicates this date was challenged by the community team who felt the risk of suicide remained too high and consequently met with the CCG’s children’s commissioner to support their concerns.

Comment: the dilemma facing professionals was very real, though to reduce risk outside of institutional care the involvement of the school was of critical importance; (this meeting took place during school holidays; it appears that School 2 was not invited to, and may have been unaware of the event).

2.6.3 Later that week Islington CAMHS Clinical Nurse Specialist sought the name of the Royal Free Eating Disorder Service Consultant with whom the Beacon Centre could liaise. Her/his services were anticipated to be necessary after the discharge planned for 16.05.17. In advance of the next CPA meeting scheduled for 13.05.17 the advice of the ‘safeguarding lead’ was sought and contact made with the Islington Children’s Social Care officer who had completed the s.85 assessment.


2.6.4 EML, accompanied by her mother and 2 nurses, was taken by ambulance to Barnet Hospital Emergency Department (ED) via ambulance on the evening of 30.04.17. She had been found in a bathroom at the Centre having sustained self-harm injuries to neck, both forearms and right lower

CAE 23

leg with a razor blade. Following medical treatment, she was discharged back to the Centre. The relevant paediatric documentation (focused on safeguarding) was not used by hospital staff though the GP Practice did receive notification and it was also discussed at the weekly psycho-social meeting maintained by the ED. During April / May emails suggests that CAMHS was hopeful Children’s Social Care might be able to contribute to the support package once EML was discharged.

Comment: the failure to complete the standard paediatric documentation would be repeated at a further presentation (incident 24) in July.

2.6.5 A CETR10 was planned for 19.06.17 and intended to obtain parental consent for a continuing health care referral and placing EML on ‘a risk register’ of the CCG’s children’s commissioner.

Further CPA (4 & 5) & SEND meetings

2.6.6 A 4th CPA meeting was held on 16.05.17 (no minutes) and a 5th on 06.06.17. No representative from the Eating Disorder Outpatient Service attended the former because after discussion with the team, it was felt that there was no current role for the RFH ED Service. The case was though, to be discussed at its internal team meeting at the end of May. EML was present though it is unclear who else was involved. At the latter meeting, some improvement in mental state was recorded.

Comment: in those instances where minutes have been traced, they do not make it clear which professionals were present.


2.6.7 Though not referred to in the Centre’s chronology (the 2nd example), Children’s Social Care has reported that it was informed by the Beacon EML had ingested an (unspecified) number of Benzodiazepine (a sedative). No further action was taken by Children’s Services. By mid-June, EML was on extended s.17 leave and negotiations about arrangements for school continued e.g. the issue of adult supervision as/when Beacon staff accompanying EML to school needed a break.

Comment: school records imply though no conclusive evidence exists to confirm, a perception reflected in its report to the SCR that Beacon staff avoided phone contact.

CETR 3

2.6.8 A CETR was held at the Beacon Centre on 19.06.17. At a home visit on 23.06.17 by CAMHS psychologist 1, EML appeared relaxed. S/he noticed a scarf tied onto the metal bed frame and electrical leads on the floor. Given the historical ligature risk, s/he wondered why they hadn't been put away, and how EML experienced the potential to access them if feeling

10 In April 2017 the NHS England policy for Care, Education and Treatment Reviews for Children and Young People was revised - CTRs became CETRs.

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impulsive. This was not discussed with the parents.

Comment: this should have been followed up; however, the numerous incidents that occurred whilst in tier 4 units (with specialist staff and design) illustrate how difficult it is to eliminate all opportunities for impulsive self-harm.

2.6.9 NHS England’s ‘Project Lead, Transforming Care, Specialised Commissioning’ indicated in an email to CAMHS of 26.06.17 that it was ‘reviewing EML weekly within its ‘Transforming Care Assurance Meeting’ in Specialised Commissioning’, would monitor the discharge pathway, and any barriers involved to the process being implemented, and weigh that against risk management of the discharge.’

Comment: there is no evidence to suggest that the oversight function provided by NHS England impacted on clinical planning.

2.6.10 In the remainder of the Summer term, EML remained an in-patient at the Beacon Centre and with parental support, returned each evening after attendance at her mainstream school.


2.6.11 On the evening of 11.07.17, whilst on day release EML had become anxious, bought razor blades and inflicted superficial cuts to legs and arms. She was brought to Barnet Hospital by her mother, treated and discharged with a view to her returning to the Centre. A briefing letter had been provided by the Beacon. For the second time, standard paediatric documentation was not used so mandatory safeguarding risk questions undocumented. The attendance was discussed at the weekly multi-disciplinary psychosocial meeting and the GP duly notified.

Final CPA meeting & discharge

2.6.12 Less than week later (on 16.07.17) a meeting intended to discuss post-discharge arrangements with EML and her parents had to be postponed when she again self-harmed by cutting (the 25th such episode). Some of cuts were serious enough to require suturing. When the meeting was held 2 days later, it was attended by EML and both parents. Records indicate completion of 30 family therapy sessions, and in the view of the consultant psychiatrist, a need to continue use of the same medication.

Comment: though the learning emerging from the extensive family therapy sessions is understood to have informed agency responses e.g. at ward rounds and other internal / external events; the notes of those sessions are brief, not easily reconciled with the psychiatric / medical / nursing records and potentially offered the parents inconsistent messages.

2.6.13 A CPA meeting was completed on 18.07.17 and records of it suggest that a plan to discharge EML on 03.08.17 and for delivery of ongoing support from the Centre and community sources was agreed. This interpretation has (in July 2019) been challenged by Islington’s AOT which has recently submitted its claim that ‘in all meetings that we attended we proposed that she was still too risky to return home with the support of the AOT team.

CAE 25

The Beacon Centre and the parents both wanted her to be discharged. This caused tremendous tension, between the consultant at the Beacon Centre, the community consultant and the parents. In the light of the responsible medical officer (consultant at the Beacon Centre) discharging into the community, the AOT in conjunction with NHS England attempted to provide the most robust package possible’.

Comment: material submitted to this SCR during its 12 months duration provided no indication of the magnitude of differences of professional view.

2.6.14 At the daily home visit by the AOT on 28.07.17, EML’s response to the re-iterated proposal of family therapy, individual work and daily AOT check-ins was - she saw no point in daily AOT checks because ‘if I wanted to self-harm I'd just do it’ and …’you couldn't stop it’. The immediate risk to self was evaluated as low though unpredictable.

SELF-HARM 26

2.6.15 On 01.08.17 a joint medical review by an unnamed AOT and Centre clinician concluded that EML was managing relatively well at home, attending appointments and taking medication. There had been no self-harm since home-leave from the Centre began – and no current hallucinations or overt mood symptoms. After 18 months of in-patient care, EML was discharged on 04.08.17. A week later, for reasons she did or could not explain, EML self-harmed by minor cutting to her legs whilst unsupervised (26th episode). AOT staff provided reassurance and confirmed that mother was able to provide support the rest of the day.

Comment: mother had reportedly been away from home dealing with her own mother’s needs – an example of the impracticability of ensuring 24/7 monitoring.

2.6.16 Contacts with AOT and family therapist over the following week indicated continuing fluctuations of mood. The GP Practice received a very comprehensive discharge summary from the Beacon Centre.EML’s diagnosis / circumstances at this time were captured as follows:

• History of anorexia nervosa

• Non-organic psychosis

• Previous severe depression

• Autism Spectrum Condition [sic] (a term often preferred by non medical professionals to the term ‘disorder’)

• Severe emotional regulation difficulties

• Microcytic anaemia (which parents report was not followed up whilst CAMHS was providing community support)

• Vitamin D insufficiency

• Prolonged inpatient admission

2.6.17 Discussions between school, parents and Education Service continued over the Summer. At a further AOT contact on 21.08.17, the risk of harm was again evaluated as low though difficult to predict. At an AOT session

CAE 26

with mother on 31.08.17 the next stages of re-integration were discussed. The practitioner (unnamed in reports provided), believed the next few weeks ‘have the potential to be slightly tentative’. The possibility of Dialectical Behaviour Therapy (DBT)11 from the Maudsley Hospital was explored though in agreement with family, potential providers and involved others, did not trigger a referral. At an AOT session on 07.09.17 EML’s mood was ‘elevated’. This was discussed with mother because experience suggested it could be a ‘warning sign’. Risk was re-evaluated as ‘moderate’ and continued to be so for the next 2 sessions. After reduced self-harming over August / September, frequent episodes were to resume from October.

Comment: in the first 6 weeks post-discharge daily CAMHS contact (in person or by phone) was maintained; the parental perspective is that the various individuals making contact formed no meaningful or effective relationships; in their view EML needed more direct commitment by the consultant psychiatrist.

SELF-HARM INCIDENT NUMBER 27 & 28

2.6.18 At an AOT session with a new psychologist on 29.09.17 EML reported self-harming but refused to show her injury and declined to share what the trigger/s may have been. A further incident occurred on 02.10.17 and EML accompanied by mother presented to the Whittington Hospital. A referral to Islington Children’s Social Care was completed because mother said (contrary to medical advice) that she wanted to discharge EML. The agency’s response to the referral was that threshold criteria were not met but that ‘Early Help’ would be offered.

Comment: EML’s view is not recorded and it is unclear to the author and probably the parent, what ‘Early Help’ would have looked like.

Self-harm incidents 29 - 31

2.6.19 Early October 2017 saw further self-harming including an occasion that occurred whilst AOT staff were conversing by phone with mother (detail unknown, but it was the 29th incident). In response to what was regarded as a deterioration in EML’s stability, School 2 saw the need to stick with the current plan and for all parties (including school staff) to keep EML in sight at all times, which was confirmed. An early review by the CAMHS consultant psychiatrist was also brought forward to 13.10.17.

2.6.20 On 10.10.17 EML self-harmed for what was (at a minimum the 30th time, there were additional self-limiting under-recorded events). At a psychiatric review on 13.10.17 and in AOT discussion in the following days, the risk of EML acting impulsively was deemed ‘high’ and the need to explore why there had been a deterioration recognised. A further need to think about transition to Adult Services was recorded.

2.6.21 In a phone call to AOT on 27.10.17 mother raised the possibility that her daughter was concealing anti-psychotic medication. At the next AOT contact, EML offered a reassurance she was not avoiding medication e.g.

11 Dialectical behaviour therapy (DBT) is a type of talking treatment based on cognitive behavioural therapy (CBT) but adapted to help people who experience emotions very intensely.

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purging after its ingestion. She was observed to be ‘vacant and non-engaged’ at times but did not report feeling as suicidal as 2 weeks ago. The perceived risk remained ‘variable’. On 04.11.17 she again cut herself sufficiently seriously to require hospitalisation though denied suicidal intent (episode 31).

Psychiatric review by Consultant 2

2.6.22 By 07.11.17 on review by a CAMHS psychiatrist the plan was:

• EML would be discharged from hospital once her stitches were reviewed by the Paediatric Team

• AOT would phone at 4pm to check she still felt safe • EML would return to hospital or let her parents / AOT know

if she was not able to guarantee her safety • AOT would meet EML next day at 9am prior to her family

therapy session at 9.20am

2.6.23 In mid-November, re-emerging eating problems (binging and self-harming in response to consequent guilt) prompted involved professionals to think an Eating Disorder Service referral was required. EML resisted and this was not progressed. Through into December EML continued to have suicidal ideation. Aside from one recorded occasion, she denied that she would act on those thoughts and commented to the consultant that ‘the day that we should worry is the day that she does not go to school which would be the only way that she would communicate being actively suicidal’. During December the school responded to a suggestion from parents that EML receive examination results separately to reduce associated stress.


2.7.1 In the early evening of 14.12.17, EML was brought to the Emergency Department of NMUH. She had self-harmed by cutting her right forearm and taken an intentional overdose of 32 Ibuprofen and 72 Paracetamol hours earlier (Whittington Health Trust reported this as 30 Ibuprofen and 42 Paracetamol). EML was admitted to an adult ward for medical treatment. Her father had reported her as missing to Police and the AOT. The involvement of the London Ambulance Service rendered unnecessary, any direct Police involvement.

Comment: whilst such a response would have made no practical difference, a Merlin notification to Children’s Social Care would have been best practice.

2.7.2 This incident triggered a referral to Islington’s Children’s Social Care Service. It later determined the threshold for an assessment was not met but that ‘targeted support’ would be offered, in particular to support EML’s younger sibling. The parents agreed to consider that option. Insofar as she had been discovered only by chance in a shopping mall toilet, EML’s conduct was regarded as an attempt to kill herself and she was subsequently detained under s.2 Mental Health Act 1983 with a view to re-

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admission to the Beacon Centre.

Comment: EML had kept her CAMHS appointment that day and not referred to any suicidal intention, suggesting an inclination to kill herself was becoming more dominant than impulsivity and possibly outweighing the substantive services in place intended to minimise that risk; she also disclosed 4 historic overdoses though the team was aware of only 1 significant one in 2016. It is unclear what ‘targeted support’ might have constituted.

2.7.3 EML was seen by Adult Mental Health Services liaison team and it was agreed with the care co-ordinator that she would be offered medical treatment and remain in hospital over the weekend pending transfer to the most suitable setting.

RE-ADMISSION TO BEACON CENTRE

2.7.4 EML was deemed to be ‘high risk’ and on 18.12.17 was transferred back to the Beacon Centre under s.2 Mental Health Act 1983 having been assessed by the community consultant and another s.12 ‘approved doctor’. The consultant noted that both parents were naturally upset and neither wanted re-hospitalisation under section. They have explained that they feared re-admission might be (as indeed it was) accompanied by an increase in self-harming. The school was informed next day of the event and agencies’ responses to it. EML was seen by her consultant psychiatrist at the Beacon Centre on 19.12.17 when her request to remain as an informal patient was heard and a positive response postponed until her further responses were seen.

2.7.5 EML was considered to lack the mental capacity to make a decision about admission and remained on 15 minute observations. Plans were drawn up with mother for planned Christmas leave. EML was allowed to leave with mother and a friend (who had previously been an in-patient).

2.7.6 At this point, NHS England proposed that a Care, Education & Treatment Review meeting (CETR)12 should be convened on 10.01.18 though it is thought that the first such meeting was actually March 2018.

Comment: on each relevant occasion, EML’s view had, as required, been sought; the caution being exercised by the psychiatrist on this occasion was wholly justified; there is scope for clarifying and reconciling expectations of what is to be addressed and recorded in CETR and CPA meetings.

2.7.7 Just before Christmas, AOT’s clinical nurse specialist completed a re-referral to the Royal Free Hospital Eating Disorder Outpatient Service which was accepted (though later closed because of the events described

12 CETR: is a ‘care and education treatment review and is intended to be a person and family-centred process that supports transition into and out of Mental Health or Learning Disability services; reviews should address the questions: is the person safe? is s/he getting good care; what are the plans for the future? does the person need to be in hospital for care and treatment?

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below).

SELF-HARM INCIDENTS 32-36

2.7.8 EML acknowledged an urge to self-harm and used a red crayon to draw cuts on her arm. In the course of the next couple of days before Cristmas, she made 4 attempts to self-harm by means of:

• Holding a shoelace around her neck • A ligature using a payphone cord • A bin bag stuffed in the mouth to prevent air entry • A ligature using a sleeve

2.7.9 The level of distress associated with the first 3 incidents was such that sedatives were administered and her parents informed. Whilst a 2:1 observation level was maintained, the view was formed that EML required a place in a ‘Psychiatric Intensive Care Unit’ (PICU). EML again tried (on 27.12.17 - episode 36) to tie a ligature around her neck. It took 3 staff to restrain and ensure her safety. Parents were informed. EML indicated that she would kill herself before the end of the year and spoke in comparable terms to her consultant next day stating she would ‘be dead before she was 18’ (her fears were understood to be becoming an Adult Mental Health Services - AMHS user).

Admission to PICU at Coborn Unit

2.7.10 The assessed risk level remained ‘high’ and attempts were made to expedite the planned transfer to a PICU (no such facility existed at the Beacon). At the Beacon’s ‘admission conference’ on 28.12.17 (10 days after admission) insufficiency of understanding about what was precipitating the repeated attempts on her life, confirmed a need to transfer her to a PICU (EML had made it clear to the AOT that she could not face the transition to Adult Services).

2.7.11 EML was transferred later that day under s.3 Mental Health Act 1983 (a Treatment Order) to the East London Foundation Trust (ELFT) Coborn Unit. EML’s mother was disappointed with the secure van deployed (which she said ‘felt like a cage’) and some delay upon arrival. The Beacon Centre’s consultant psychiatrist acknowledged those concerns and reassured her EML’s bed would be left open to enable a transfer back when she was stable enough.


2.7.12 Whilst at the PICU, there were 2 more self-harm attempts on 08.01.18 (not acknowledged in the report submitted to the SCR – a further example of incomplete records). There followed multi-disciplinary discussions and wider conversations with senior management, CCG’s children's commissioner and the Whittington safeguarding team that highlighted the

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need for:

• The Coborn team to be aware that a CETR review of the community package of care would need to be held prior to any discharge plans being made.

• An initial review to confirm whether a ‘Serious Incident / Never Event’ had occurred with respect to EML’s overdose in the community which could impact on planning

Comment: valid in their own right, those possibilities focused on ‘process’ rather than individual need.

2.7.13 The CAMHS team expressed concern about its capacity to manage the level of need EML represented were her s.3 Treatment Order to be rescinded. EML was re-admitted as an informal patient to the Beacon Centre on 14.01.18 and was nursed on a ‘1:1 with privacy’ basis. In the first few days and following a consultant-led review, she was allowed limited leave in the grounds with one or other parent.

2.7.14 EML continued to report suicidal thoughts, though with no current plans or intent. She spoke of her concern about the transition to Adult Services when 18. The Unit confirmed the re-admission with the school. Mood and mental state continued to fluctuate.


2.7.15 On 19.01.18, a CPA review meeting (the 5th) agreed the approach to be taken for ongoing treatment and home leave. Next day, peers alerted staff they could hear EML head-banging and when staff attended she was found in the bathroom lying on the floor, her jumper cord tight around her neck and pulling with both hands. Staff freed her hands and cut the ligature off. Following medical review, 1:1 observations were reinstated and the room searched for any other possible ligatures. EML later reported that this had been an attempt to kill herself.

2.7.16 At a ward round on 23.01.18 it was determined there should be no ‘leave’ in the 2 hours following a session or clinical encounter (which had proved to be associated with raised emotional responses).

Comment: that conclusion suggests a sensitive appreciation of EML’s very particular needs.

2.7.17 Observations were stepped down to 15 minute frequency with 3 x daily 1:1 support, medication was reviewed and cognitive behavioural therapy (CBT) considered as means of addressing EML’s anxiety. In addition to a managed return to mainstream school, the need to consider a transition to Adult Services was again recorded. An email dated 25.01.18 from Camden and Islington NHS Foundation Trust offers the first recorded move toward negotiating a transition to Adult Mental Health Services. In consequence of the ASD diagnosis, NHS England was noted to be taking the lead with respect to the provision required for that condition.

2.7.18 By 25.01.18 EML was attending (with staff support), Northgate Education

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Unit. Following discussions with EML’s mother, a risk assessment for home was planned (5-6 hours day-leave on Saturday and, subject to a review and risk assessment that evening, a repeat on Sunday). Parents were advised that if EML’s mood became elated they should give a 2.5mg daily dose of Olanzapine as required.

SELF-HARM INCIDENT 40 (& 41- 44)

2.7.19 On 30.01.18, EML whilst in the dining room, jumped through a hatch to the kitchen, grabbed and opened a tin and used the lid to self-harm. She was restrained by staff and taken into the ‘low stimulus room’ where staff continued with verbal de-escalation and medication was administered. Parents were informed and an ‘incident report’ completed. 4 further self-harming incidents occurred (all impulsive and some with potentially life-threatening risks) next day.

2.7.20 At a ‘core team meeting’ on 31.01.18 EML was concluded to be at ‘chronic high risk’. Parents were contacted and informed of escalating concern and a plan to undertake a ‘Mental Health Act assessment’ with a view to use of s.3 Mental Health Act 1983, rather than remaining as an informal patient. EML was refusing all medication at this time.

Further use of s.3 Mental Health Act 1983

2.7.21 On 01.02.18 a referral was made to Camden and Islington NHS Foundation Trust (Approved Mental Health Practitioner duty) for the required s.3 assessment. It laid out her history of s.2 status since 19.12.17, repeated use of ligatures, transfer to the PICU where she recovered a little and the s.2 was discharged. Recently, EML had again being tying ligatures and was on 2:1 observations. Self-harming by cutting and food restriction was also cited. The Beacon Centre wanted to refer her to a low secure ward because its staff could not manage the high risk of suicide. EML was continuing to refuse medication.

2.7.22 The required mental health assessment was completed on 02.02.18. EML offered little by way of explanation of the triggers for self-harm / suicide attempts and no convincing reassurances. The team agreed a need to detain under s.3 and a recommendation was accordingly made and agreed in compliance with the Mental Health Act 2003.

2.7.23 EML’s mother was informed by phone and accepted the result of the completed assessment. She was already aware, though reminded of her rights as the ‘nearest relative’. The assessing psychiatrist and approved mental health practitioner also informed EML of the outcome of the assessment and her rights to a tribunal and an ‘independent mental health advocate’ (IMHA).

2.7.24 By 04.02.18 EML indicated her wish to appeal the s.3 decision and was advised about how she could do so. Because her mood state seemed improved, her supervision was on 05.02.18, relaxed from ‘2:1’ to ‘1:1 and no privacy’. A later reference to staff about killing herself before she reached her 18th birthday seems to have been linked to EML’s continuing

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anxiety about transitioning to Adult Services.

2.7.25 Limited home leave was arranged at this time and feedback indicated that EML had during her time at home, appeared ‘vacant, staring blankly and volatile’. In the Centre, she continued to present with high levels of anxiety and helplessness about her future, self-hatred and with active suicidality. She also continued to experience high levels of dissociation and de-realisation13 / de-personalisation14 further complicating the management of risk. A 6th CPA meeting on 13.02.18 captured what appears to have been a little-changed situation.


2.7.26 On 16.02.18 EML cut her arm with a glass sufficiently to require dressing by staff. She could offer no explanation of a specific trigger. Her parents were informed. The perceived level of risk remained ‘chronically high’. A week later, the consultant met with EML’s mother and clear and comprehensive arrangements were agreed for weekend leave with close supervision by parents. Support from the Beacon staff was offered if needed and risk assessments were to be completed prior to and following, leave. An Islington CAMHS care co-ordinator was scheduled to visit on 27.01.18 [sic] to start planning community support.

2.7.27 Several periods of home leave were reported to have gone well and EML argued to be ‘off section’ and allowed home to recover. Records indicate ongoing episodic food-related problems e.g. binging / purging.


2.7.28 After several uneventful periods of home leave, on 07.03.18, EML was found in a toilet self-harming with a piece of broken crockery. She explained that a friend had passed away which had upset her. Home-leave was suspended and she remained on 15 minute observations. Her risk assessment was updated and parents informed. Home-leave was resumed the following weekend and was said to have gone well.

Care Treatment Review (CETR 4?)

2.7.29 A CETR meeting was held on 13.03.18 though no records are accessible from the Centre’s ‘Rio’ database (the Trust has latterly confirmed that minutes and an action plan were sent later that month by NHS England). EML and her parents thought that she did not need to remain ‘on section’. As on other occasions, parents were regarded by staff as unduly optimistic in their (wholly understandable) wish that their daughter would recover, avoid becoming a mentally unwell adult and instead, fulfil her considerable potential. The parents’ alternative description of their position is that long-

13 De-realisation = feeling as though the world around is unreal, seeing objects changing in shape, size or colour, seeing the world as 'lifeless' or 'foggy' and feeling as if other people are robots (even though the individual knows they are not 14 De-personalisation = feeling as though one is watching oneself in a film or looking at oneself from the outside, feeling as if one is just observing one’s emotions, feeling disconnected from parts of the body or emotions, feeling as if one is floating away, feeling unsure of the boundaries between self and other people SOURCE www.mind.org.uk

http://www.mind.org.uk/

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term hospitalisation whilst keeping EML safe, was not necessarily helping her get better and was eroding her sense of hope.

Exploration of future options

2.7.30 On 14.03.18 AOT nurse emailed Islington’s children’s commissioner about transfer to Adult Services indicating that the multi-disciplinary team recommendation to the CETR is that they require support with joint commissioning for EML. it is understood that the community consultant psychiatrist wanted to transfer EML directly into an adult residential therapeutic in-patient setting. A reference has been seen in the report provided by the Beacon Centre to an exploratory referral to an unnamed low-secure Adolescent Unit which rejected it because EML was approaching her 18th birthday. CAMHS has recently indicated that it believes that this action was due to the Beacon Centre feeling that they no longer had the capacity and resources to keep EML safe.

2.7.31 On 15.03.18 an email from the CAMHS consultant stated …’I want to be very clear that we are not supporting her return to the community as we believe she is too high risk for the AOT to keep her safe’. I do not support the plan for her to visit her school at this moment in time, as there is currently no possibility of AOT being able to support this due to her high level of risk’. The CETR panel on the basis of reports from professionals, parents and EML had recommended that she remained in the Beacon Centre until 18 and transition directly into Adult Services.

2.7.32 CAMHS has latterly reported that the inpatient consultant was in agreement with the community consultant and AOT in contrast to the first admission when there had been opposing psychiatric views.

Mental Health Tribunal, CPA meeting & transition planning

2.7.33 On 19.03.18 the Tribunal upheld the use of s.3 detention. EML was disappointed but was supported by her mother and appeared to accept the decision. Next day a CPA meeting was held (for some individuals, by means of a conference call and erroneously dated 22.03.18 by NHS England). The account provided the SCR indicated that ‘the parents were not initially present’. Enquiries have established that the parents and EML’s advocate were actually kept waiting outside of the meeting of professionals for some 2 hours (possibly because the NHS England chairperson deemed their presence unhelpful). At the end of the meeting, the parents were understandably angry with the CPA process and met with the ward manager for over 40 minutes.

2.7.34 In their detailed contribution to this SCR, EML’s parents make the point that for nearly all young people in tier 4 provision, the shared aspiration will be a return to their family. Hence they argue for a ‘close working relationship’ rather than ‘keeping the family at a distance’. In their recollection, the meeting described above was the worst example of a failure of partnership which served to erode trust and reduce certainty about the risks associated with EML’s condition.

Comment: the School 2 SENCO was also denied a contribution because (in

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consequence of the meeting’s late start) she was kept waiting by a phone for over an hour; records do not offer clarity about those present or that the meeting was held (for some), by means of telephonic contact.

2.7.35 Discussions were held at this time with School 2 and AOT community mental health team regarding transitioning back to school whilst still an inpatient. School and community team were keen for EML to remain at the Northgate Education unit until more stable in her mental health.

2.7.36 At this time a letter was drafted (no confirmation that it was sent has been provided) by AOT that sought to inform Adult Services about what would be required once EML reached her 18th birthday. It summarised difficult early experiences at school and ‘at home’ (it is not clear to what this referred), including repeated experiences of bullying, as well as her grandmother becoming demented and the impact this had on her and family life. Such experiences had led her to develop negative beliefs about herself, others and the world. It appears also that the persistent anxiety which had come during (unspecified) ‘difficult social situations’ in childhood contributed to an ongoing to a constant anxious state.

2.7.37 The referral noted that EML’s difficulties were chronic and severe and that ‘she continues to present with high urges to self-harm and suicidal thoughts, requiring intensive support to manage her safety. She has had long-term mood difficulties with regulating emotions and high levels of generalised anxiety in the context of early relational trauma through bullying and social communication difficulties, poor self-esteem and low self-image. Her difficulties have been further influenced by her diagnosis of ASD and subsequently started to present with strange worries and beliefs and perception abnormalities developing into an acute psychotic episode unspecified’.

2.7.38 For the remainder of March and into April, EML’s routine of Unit, home leave and schooling was uneventful. Her individual sessions and the family therapy continued. A visit by Islington CAMHS ‘care co-ordinator’ addressed the need for ongoing community support and acknowledged EML’s continuing anxiety about the transition.


2.7.39 On successive days (03.04.18 and 04.04.18), EML cut herself. The first incident occurred whilst on home leave and the second whilst back in the Unit. Neither injury required medical intervention. On 09.04.18 the following CETR ‘community action points’ are noted:

• 1.The panel felt that CCG commissioners need to start working with the transition team to explore options for future care and management

• 2. The panel felt that EML would benefit from the support and help of an advocate

• 3. Consider a DBT(Dialectical Behaviour Therapy) group post 18; the panel felt that consultant psychiatrists from

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Islington’s Adult Mental Health Service need to work jointly with the Beacon consultant to help facilitate the process

2.7.40 Medication levels were reduced in mid-April 2018 with no apparent impact of EML’s mood or behaviours.

Transitions meeting: Referral to Adult Services & Care Planning

2.7.41 On 12.04.18 AOT initiated a referral to the ‘Adult Services Personality Disorder Service’. EML’s psychosis was apparently less prominent at this time. The AOT’s associated report provided a good deal of medical detail and confirmed the following more recent biographical information. The report offered some insight into early childhood. She was always considered very shy, ‘watchful before joining in, but very articulate’, possibly presenting with increasing feeling of anxiety and sensitivity of surroundings.

2.7.42 The report refers to the fact that EML had disclosed significant bullying from school years 3-6, saying she was taunted and verbally bullied throughout this time and had still not managed to fully talk about it. She described her peers convincing her that they were her friends, getting her to follow them and then leaving her so that she became lost. In ‘year 7’ she reported having a good friend initially who then ‘ditched’ her. In ‘year 8’, there were a couple of difficult relationships and in ‘year 9’ she began to develop some closer friendships which continued into ‘year 10’. EML reported they did not have that much in common as she had begun to self-isolate. In ‘year 11’ EML continued to have these friendships and was more stable in her relationships with a few others.

Transition Panel & association with a peer’s potential self-harm

2.7.43 On 12.04.18 EML’s case was re-presented to the Transition Panel by the CAMHS Care Co-ordinator with the inpatient consultant and clinical psychologist at the Centre contributing via a conference call. AOT also initiated a referral to the ‘Transitions Team’ who felt that her needs would best be met by a referral to the ‘Adult Services Personality Disorder Service’. EML’s psychosis was apparently less prominent at this time and a diagnosis of Emerging Personality Disorder (EPD) had been made at the Coburn Unit.

2.7.44 On 15.04.18 EML (who had been phoned by an ex-patient at the Beacon) was driven to a bridge by her parents and sought to offer support to her friend who was contemplating jumping. There was concern within the Unit that the younger sibling had been exposed to the incident and Children’s Social Care was alerted.

2.7.45 The next few days were relatively uneventful (though on 17.04.18 she had attempted to climb the Unit wall with no indication of a rise in risk). EML returned to school on 18.04.18 for 1 lesson when she completed a maths test. On this and a further occasion next day, she appeared to have coped well though later emailed to say she felt tired. At the time of her death, there had been a scheduled ‘CPA meeting at the Beacon Centre on 08.05.18 to which a senior clinician with ‘decision-making authority’ from

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Camden and Islington NHS Foundation Trust (potential providers of 18+ psychiatric services) had been invited.

2.8 SUICIDE

2.8.1 On 21.04.18 EML was on leave from the Beacon Centre and left home to walk a friend to a local train station. When she failed to return as quickly as anticipated, her mother alerted Police and informed them of EML’s vulnerability. Before she was able to complete a ‘missing person’ report, British Transport Police alerted the Metropolitan Police Service that a pedestrian subsequently identified as EML, had been hit by a train.

2.8.2 The Coroner’s conclusion upon completion of the Inquest on 05.09.18 was that EML had died by suicide whilst suffering severe mental ill-health. At the Inquest, the responsible clinician indicated that the care plan for home leave had included an agreement that EML would ‘always be escorted by a family member’.

2.8.3 The parents have recalled that the final family therapy session had addressed the issue of ‘independence’ and that the therapist’s support for offering ELM more ‘space’ had influenced their decision to allow ELM to walk her friend to the station.

Comment: the need for clarity and consistency amongst the range of therapeutic interventions was identified in para.2.6.12; though sufficiently captured in the Beacon Centre records - the central pre-condition of home leave was not reflected in any written document which the family could refer to if EML were to challenge her parents’ level of monitoring; a recommended improvement to practice is provided in section 4.

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3 RESPONSE TO TERMS OF REFERENCE & OVERALL FINDINGS

3.1 INTRODUCTION

3.1.1 Evaluating the services offered to or used by EML and her family has been rendered more difficult by the following systemic and/or individual agency weaknesses:

• Uncertainty about minutes with respect to many of the CETRs and some CPAs (a proportion anyway completed by phone involving an unknown number of un-identified contributors)

• Inaccuracies with respect to dates in several sets of records and (of greater significance) an underestimate in material submitted of the number of self-harm incidents by the Beacon Centre (and whilst EML was in the PICU)

• Anonymity with respect to professionals referred to within documents supplied to the SCR panel, rendering it difficult to distinguish one role / individual e.g. a care co-ordinator from another [the author has latterly been informed that regrettably, the terms of reference supplied to contributing agencies contained an ambiguous instruction that prompted premature anonymisation]

3.1.2 Some appreciation of the magnitude of challenge faced by the professional network is gained by considering a statement that EML made on 29.11.16 - 'I never want to fail at suicide again as that hurts, it is that that stops me. If I knew that it will definitely work, then I would'. She also declared on more than one occasion that she would be dead before she was 18. Though (understandably) the parents were and needed to remain hopeful of ‘recovery’, many involved professionals recognised that the risk of EML killing herself would at times be high.

3.2 APPLICATION OF STATUTORY & NON-STATUTORY THRESHOLDS IN AGENCIES’ ASSESSMENT, PLANNING & INTERVENTION

Islington Children’s Social Care

3.2.1 The response of Islington Children’s Social Care on each of the 3 occasions on which it undertook some form of needs assessment were justifiable. The first such assessment should have involved EML directly though that is unlikely to have led to any difference in its conclusion. The second re-assessment was triggered only by the parents’ wish (articulated by EML’s solicitor) to source a closer tier 4 unit and, although it appropriately involved EML directly, it reasonably enough identified no additional role for that agency. The s.85–related contact was completed to an unusually high standard.

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3.2.2 The author has given thought to the notion that there might have been a useful role for the local authority to fulfil e.g. as a co-ordinator / facilitator of the services provided or a source of advocacy. It might be argued that EML satisfied the s.17 Children Act 1989 definition of a child in need15. However, her needs were primarily psychological and medical and there existed a sufficiency of agencies and expertise. To the extent that a very articulate individual such as EML required an advocate, one was identified at the points where ‘sectioning’ was being planned. In concert with her intelligent and articulate parents, EML was more than capable of voicing an opinion. Islington staff were therefore justified in accepting the family’s disinclination to accept any additional service from Children’s Social Care.

CAMHS

3.2.3 Though not as clear as one might have expected from the report supplied to this SCR, Community CAMHS appeared to have recognised and articulated as early as the point of EML’s admission to the Highfield Unit that it might be unable to offer sufficient support at the point of discharge to ensure her safety.

3.2.4 An insufficiency of explanation has rendered it very difficult to evaluate the extent to which Community CAMHS contributed to the planning for EML either during or between her periods in either tier 4 location. The relative opacity of what was provided may in part explain the parents’ comments which compared and contrasted generally positive experiences of the Highfield Unit and Beacon Centre with a sense of limited priority being awarded EML by CAMHS e.g. they feel that they were less informed about EML than they had been whilst an in-patient.

Highfield Centre

3.2.5 In broad terms, the admission, case management and discharge from the Highfield Unit appear to have complied with policy and professional expectations. The Unit demonstrated a welcome level of self-criticism in completing an SI after the ‘life-threatening episode 3’ incident.

15 S.17 indicates that for the purposes of this Part (Part 3 Family Support) a child shall be taken to be in need if— (a) he is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority under this Part; (b) his health or development is likely to be significantly impaired, or further impaired, without the provision for him of such services; or (c) he is ‘disabled’. ‘Family’, in relation to such a child, includes any person who has parental responsibility for the child and any other person with whom he has been living. For the purposes of this Part (3), a child is disabled if he is blind, deaf or dumb or suffers from mental disorder of any kind or is substantially and permanently handicapped by illness, injury or congenital deformity or such other disability as may be prescribed; and in this Part ‘development’ means physical, intellectual, emotional, social or behavioural development; and ‘health’ means physical or mental health.

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Beacon Centre

3.2.6 Recognition within the Beacon Centre of the need in December 2017 to relocate EML to the PICU was a positive example of a recognition of the limitations of its offering and was well-informed and timely.

3.2.7 It seems possible that the (justifiable) recognition of the risk of EML’s institutionalisation if she were to remain too long at the Beacon Centre was allowed to carry more weight than the parallel need to diminish the risk levels back in the community by strengthening its sources of support (of which School 2 was an important example).

School 2

3.2.8 The governors and senior leadership team of School 2 had a general duty of care to all pupils and staff and were obliged to balance that with its ability to put in place measures that would minimise the clear and present risk of self-harm when EML was in school. Staff were clearly very committed to ensuring a successful transition for EML and took all reasonable steps available to them to reduce risk levels to EML as well as others (who would be impacted upon by their involvement in or witnessing of what might have been distressing behaviours).

NHS England

3.2.9 The involvement of (unnamed) individuals from NHS England appears to have been triggered by the (anyway questioned) diagnosis of ASD and reflect ‘process’ rather than ‘patient need’. As commented upon below, an insufficiency of records of its support and oversight of EML’s treatment rendered it difficult to evaluate the usefulness of the service to her or her family.

3.2.10 A meeting with representatives of NHS England provided some clarity as to its function though reinforced the need for improved transparency with respect to the interfacing processes of CPAs and CERTs.

3.3 CO-ORDINATION OF CARE, SUPPORT & RISK ASSESSMENT & LEVEL OF CLARITY WITH RESPECT TO ROLES & RESPONSIBILITIES

Co-ordination

3.3.1 At times of crisis, there were examples of effective co-ordination between

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psychiatric and medical service providers and others e.g. the:

• Presentation of EML to the Royal London Hospital and close liaison with the Highfield Unit in June 2016

• A further comprehensive briefing supplied by the Beacon duty doctor to the Emergency Department of Barnet Hospital in December 2016

• Schools 2’s consultation with its borough’s Safeguarding Unit.

3.3.2 There were also examples of parental perceptions of poorer co-ordination:

• The Beacon Centre noted in November 2016 (though did not evidence) a difficulty in contacting Community CAMHS

• The potential for an effective partnership between the Beacon Centre and School 2 was largely lost

• In the parents’ view there was (given the ongoing eating disorder) insufficient interaction between involved agencies and the Eating Disorder Service at the Royal Free Hospital

Clarity of roles

3.3.3 Within the anyway complicated relationships between health commissioners and providers, the particular contribution of NHS England was not apparent (and rendered more opaque by some insufficiency of record-keeping). The vast majority of records supplied are those of the tier 4 providers and it proved difficult to establish the extent to which views within the community-based CAMHS accorded with those dealing with the in-patient EML.

3.3.4 The tension between School 2 and the Beacon Centre is clear in the material supplied by the school but CAMHS (as far back as the admission to Highfield) had also anticipated the risk of returning EML to home and school subject to a level of chronic risk exceeding the resource-limited ability of local community services (working essentially office-hours) to contain it.

3.3.5 At its simplest a failure to share information, a more fundamental interpretation of the attitude adopted by some Beacon Centre medical staff in early 2017 is that it indicated insufficient awareness of and respect for the primary role and lawful responsibilities of school managers and expectations of contemporary multi-agency working that (taking full account of patient and parents’ wishes) award paramountcy to the safeguarding of a child.

3.4 SUFFICIENCY OF INFORMATION SHARING BETWEEN (& WITHIN) ORGANISATIONS, & WITH THE FAMILY

3.4.1 Across all involved agencies, it seems as though there was a clear recognition of EML’s intelligence and (though views varied as to its extent or reliability) insight. Whilst her involvement was inevitably and appropriately constrained at times when she was deemed a risk to herself,

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EML was otherwise offered engagement that recognised her cognitive ability and maturity.

3.4.2 There is ample evidence that due consideration was awarded by all parties, to the lawful application of the provisions of the Mental Health Act 1983 and Mental Capacity Act 2005.

3.4.3 The parents were consistently involved in both therapeutic contacts and in discussions about their daughter’s best interests. The possibility of EML having an appointed advocate who could assist in the articulation of her (rather than her parents’ views) was raised whilst she was an in-patient at the Highfield Unit in 2016 and again by the Beacon Centre in March 2018. Though hospital records are insufficiently clear to confirm this, the parents confirmed that a mental health advocate had been engaged in February 2018 and that there were occasions when she was denied (contrary to EML’s expressed wish) entry to some meetings.

3.4.4 EML’s needs were extensive and subject to rapid change. As referred to above, information exchange worked well with respect to both tier 4 units and those hospitals to which EML was presented for emergency medical attention.

3.4.5 The single and serious failure to share relevant information is evident in the exchanges between the Beacon Centre and School 2 (though Pupil Services also report that ‘the frequency / extent of self-harming was not fully apparent’ [to it]). Rooted in their beliefs about professional responsibilities and boundaries, senior medical staff unjustifiably denied School 2 information that would have informed and enabled a more confident risk assessment.

3.4.6 The report provided by the Trust accountable for the Beacon Centre is largely silent with respect to the issue though the report (and a large amount of supplementary information) supplied by School 2 suggests that a very particular perception of ‘medical confidentiality’ and/or ‘patient’ and ‘parental’ preference over-rode child protection considerations and determined the position adopted by medical staff.

3.4.7 School 2 had appropriately sought advice about the cautious stance it adopted and although in hindsight, a formal complaint could have been justified, the larger proportion of responsibility rests with the individuals and systems within the Beacon Centre.

3.5 SCOPE FOR MORE INFORMED APPRECIATION OF THE EXPERIENCES, WISHES & FEELINGS OF EML IN PLANNING SERVICES INCLUDING TRANSITION TO ‘ADULT SERVICES’ E.G. USE OF ADVOCACY

3.5.1 In common with most adolescents, EML sometimes expressed frustration about her parents and sought or implied a wish to articulate her own views. Subject always to the legitimate need to evaluate her ‘capacity’ to make informed choices, staff at both ‘tier 4’ units demonstrated great sensitivity

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to her wishes and feelings.

3.5.2 There exists an expectation that any young person who is on section should be offered the opportunity of having a mental health advocate. EML was offered this possibility on at least one recorded occasion and declined it. Records do not indicate on what basis she felt such an arrangement to be unnecessary. It may be that her exceptional ability to articulate what she wished to, felt sufficient.

3.5.3 It is not clear whether the offer of an advocate was raised at each CPA meeting since of course, EML’s views might well have evolved over time. The need to plan for transition to Adult Services represented a very real source of anxiety for EML who perhaps understood that her mental health issues were unlikely to resolve in the foreseeable future.

3.6 RECOGNITION & RESPONSES TO EARLY CONCERNS AND LEVELS OF UNDERSTANDING OF EML’S FAMILY (SIBLINGS, PARENTING CAPACITY ETC)

3.6.1 Though memories have been referred to, by EML (being alone and anxious when very young) and by parents (some social difficulties pre-school and significant levels of bullying at School 1) those records that have been retrieved cannot confirm them. For all practical purposes, agencies offering universal services e.g. schools, GPs etc would have had no reason to be concerned about an exceptionally intelligent child from a high achieving professional 2 parent family presenting no problems or symptoms until she was at least 10 years of age.

3.7 IMPACT OF SOURCING & FUNDING LOCAL TIER 4 PROVISION & EXTENT TO WHICH ITS USE WAS CLINICALLY-DRIVEN BY EML’S NEEDS RATHER THAN AS A MEANS OF CONTAINING PROFESSIONAL RISK

3.7.1 The NHS England report acknowledges that at the point of it first becoming involved (January 2016) the nearest ‘tier 4’ provision was 60 miles from home. Staff at the Highfield Unit and in the Islington-based AOT were sensitive to the additional strain imposed on the family of having to support EML at some distance, a problem compounded by the absence of a local out of hours / weekend service. The NHS England report also acknowledges that the November 2016 transfer was to the more local and convenient North London Beacon Centre.

3.8 OVERALL FINDINGS

3.8.1 In the knowledge that any retrospective evaluation of events is heavily influenced by professional records, the author and panel was keen to hear and reflect upon the experience of EML’s family. The following sub-section offers a summary of their views / lived experiences.

PARENTAL VIEWS

3.8.2 Having seen a near final draft of this report, EML’s parents believe that it

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understates the poor responses across agencies to their daughter’s eating disorder and cite the following examples:

• Early appointments with GPs revealed one who was unaware of the difference between anorexia and bulimia and in their minds, an excessive focus on 'ruling out' physical causes e.g. through blood tests rather than engaging with the possibility of an eating disorder

• The Royal Free Hospital Eating Disorder Service- an expert outpatient service 15 minutes' drive from home - could have played a much more proactive and supportive role in treatment whilst EML was in the Whittington Hospital, in discussions about a potential community-based alternative to referral to the Highfield Unit, whilst in the Beacon Centre and when at home and being treated in the community

• The parents report their experience as being of unhelpful ‘compartmentalisation’ i.e. the Beacon Centre was a secure unit, focused on suicidality and was not equipped to deal with eating disorders; the Royal Free Hospital had expertise in eating disorders, but was not willing or able to look after a suicidal patient, as they did not have the security available. In the parents’ view, this insufficiency of service provision justifies action by NHS England.

3.8.3 The parents identify a further point of potential learning when they contrast exemplary liaison between the integrated Education Unit within the Highfield Centre with its equivalent at the Beacon Centre. They believe a better academic link between the latter education provision and School 2 would have developed trust, a better co-ordinated approach and potentially reduced the significance and consequently tension associated with attending mainstream school on any given day.

3.8.4 On a more general level, they argue for more open and honest communication with parents and those representing children and recommend that clinicians in both tier 4 units and community CAMHS should create an opportunity to review their respective approaches to psychiatric treatment and co-operation across agencies.

POTENTIAL RELEVANCE OF MENTAL CAPACITY ACT 2005

3.8.5 Though not explicitly spelled out in material submitted to this SCR, on the occasions when EML lacked capacity to consent to recommended treatment, it had been provided either by virtue of action authorised by the Mental Health Act 2003 or (reluctantly at times) by one or other parent agreeing or tacitly accepting it.

3.8.6 A High Court Judgement in 201716 (which overturned an earlier Judgment) had reinforced the ability of a parent to provide lawful consent. On 04.10.19 the Supreme Court overturned that Judgement, potentially rendering the obtention of lawful consent for treatment of those aged 16/17

16 Sir James Munby (President of the Court of Protection), , Lord Justice David Richards and Lord Justice Irwin in the matter of D (A Child).

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more complex. The impact of this change of interpretation of relevant law will be limited because the ‘Liberty Protection Safeguards (LPS) – a new system for authorising deprivation of liberty – is scheduled to come into force on 01.10.20.

3.8.7 The panel considered whether at any point during hospital or community-based treatment, EML’s rights under the Mental Capacity Act had been breached and identified none. Because of the intrinsic complexity of interfacing laws and the obvious vulnerability of a young person lacking the capacity to provide her/his own consent, a recommendation has been added that the local network of agencies constituting the Safeguarding Children Board, should address the implications for staff training and development in advance of LPS.

EML’S NEEDS

3.8.8 All professionals with whom EML had contact throughout childhood and adolescence recognised her to be exceptional in terms of intelligence, kindness, humour, articulacy and (obviously in her later years) vulnerability in consequence of mental health. A great deal of effort and very significant levels of skill and practical resources were dedicated across all agencies over time to keep EML alive, deal with her troubling thoughts and feelings and assist her to exploit her enormous potential.

3.8.9 There is evidence across all agencies of (for the most part) effective partnership with parents and (to the extent that her condition allowed it) careful attention to EML’s expressed and implied wishes and feelings. Parents remain of the view that the support between EML’s admissions to the Beacon Centre required more expertise than could be provided by the involved staff. They refer specifically to the need for their daughter to have been seen more often by a consultant psychiatrist.

3.8.10 The parents’ understandable need to hope for improved mental health, coupled with their commitment to EML may have rendered it more difficult for some professionals to communicate sufficiently what was times an acute, and later a chronic high risk of suicide. In addition to examples provided above, there were other commendable examples of effective inter-agency communication and co-ordination:

• The thorough s.85 Children Act 1989 assessment completed by Islington Children’s Social Care in April 2017 whilst EML was detained at the Beacon Centre

• (Notwithstanding whether an alternative process might have been preferable) the completion of the EHCP,

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provision of a learning support assistant and conscientious school-based support of EML

• School 2’s consultation with its borough’s ‘safeguarding lead’ so as to better respond to the perceived pressure from Beacon medical staff to accept EML at short notice

3.8.11 There were also examples of less effective professional practice:

• The re-involvement of NHS England after EML’s fall appears to have been convoluted and ill-understood

• Though it may have been sufficiently clear to those involved, it is not obvious from material supplied who, at any one time, was the ‘lead clinician’

• An apparent refusal by the consultant psychiatrist and some medical colleagues at the Beacon Centre to share all relevant information with the assessing ‘Pupil Services’ psychologist or to establish a mutually respectful partnership with School 2

3.8.12 A number of systemic issues reflecting nationally-determined policy and resourcing decisions are apparent (and not peculiar to this case):

• The unhelpful 60 mile distance from EML’s home to the nearest ‘tier 4’ with suitable expertise (rendering visiting by family / friends and the potential for an incremental return to home more difficult)

• The intrinsically complex and insufficiently transparent lines of accountability between commissioners, providers and the superimposed NHS England role (rendered more opaque by an insufficiency of recording) – this issue would not have been obvious to the family

• The imminent discontinuity (a source of great fear for EML) implied by discussion of a transfer to Adult Mental Health Services

3.8.13 Preparations for the inevitable transition to involvement with Adult Services had commenced and were impacted upon by the parents’ natural need to keep hoping for an eventual recovery as well as EML’s fear and resistance to ongoing dependence upon psychiatric treatment.

3.8.14 Properly acknowledged to be a source of anxiety for the family, the CPA meeting scheduled for May 2018 was to focus on the transition and choice of an Adult Therapeutic Unit. It was overtaken by EML’s death.

3.8.15 In summary, EML’s premature and tragic death by suicide was predictable, but occurred in spite of enormous efforts expended by dozens of skilled and conscientious professionals working in a predominantly though not entirely, effective partnership, with a loving and committed family.

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4 RECOMMENDATIONS

ISLINGTON SAFEGUARDING CHILDREN BOARD (ISCB)

4.1.1 ISCB should seek from member agencies which provide services to children or families, confirmation that each has:

• A written policy indicating their requirements for production, content, timeliness, intra/inter-agency sharing and retention of records

• An effective procedure for evaluating compliance • Evidence of such periodic evaluations

4.1.2 ISCB should alert NHS England (the commissioners of tier 4 services) to the negative consequences of admissions to units at a distance from home (reduced frequency / greater costs associated with family visits; disruption of friendship groups and less opportunity for incremental rehabilitation to home, school and community) and (in the light of growing demand) increase and develop more local provision.

4.1.3 ISCB should alert member agencies to the need to ensure workforce development / training opportunities so that the complex interface of the Children Act 1989, Mental Health Act 2003, Mental Capacity Act 2005 (and its May 2019 amendments) as well as the anticipated ‘Liberty Protection Safeguards (LPS) are better understood and compliance ensured with respect to:

• Consent with respect to assessment or treatment of an under 18 year old as an exercise of parental responsibility

• ‘After care service obligations’ under s.117 Mental Health Act 2003 and

• Lawful deprivation of liberty in any setting following implementation of the LPS provisions in October 2020

ISLINGTON CLINCIAL COMMISSIONING GROUP (CCG)

4.1.4 In response to the demonstrable impact on EML of the anticipated transfer to Adult Mental Health Services, likely national ‘direction of travel17, current local aspirations, (and informed by research such as that cited at 18 & 19) the CCG should recognise the existence of the following gaps in provision

17 ‘Transforming Children and Young People's Mental Health' Government Green Paper December 2017 18 The ‘Headspace Centre Model – Rickwood D, Paraskakis M, Quin D et al – Australia’s Innovation in Youth Mental Health Care Early Intervention in Psychiatry 2019 13:159-166 http://doi.org/10.1111/eip.12740 19 Designing Youth Mental Health services for the 21st Century: examples from Australia, Ireland and the UK. Patrick McGorry, Tony Bates and Max Birchwood British Journal of Psychiatry 202,s30-s35, doi: 10.1192/bjp.bpo.112.119214

http://doi.org/10.1111/eip.12740

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and develop and commission services to offer:

• CAMHS-support out of office hours • A more gradual transition process that extends the current

remit of CAMHS beyond an individual’s 18th birthday

WHITTINGTON HEALTH TRUST

4.1.5 In circumstances where it is anticipated that a young person will need to transition into Adult Mental Health Services (AMHS), clear and co-ordinated planning should be initiated 6 months before her/his 18th birthday and include a member of AMHS attending Care Planning Approach meetings and engaging with the young person prior to discharge.

ISLINGTON PUPIL SERVICES

4.1.6 Given parallel CETR and EHCP processes, Pupil Services should:

• Develop a local assessment and treatment pathway for young people stepping down from ‘tier 4’ provision

• Take all reasonable steps to ensure that ECHP assessments are as full and detailed as they need to be and that any lack of parental consent should be challenged in circumstances where proven or potential safeguarding risks exist

OXFORD HEALTH NHS FOUNDATION TRUST (HIGHFIELD UNIT)

4.1.7 Therapists engaging in therapeutic work should produce summaries of their work with explanatory models or hypotheses and such summaries should be an integral part of any overall in-patient unit assessment or advice to family.

4.1.8 The inpatient unit should document communication with CAMHS in relation to planning ‘leave’ from the unit ensuring:

• Completion of carefully co-ordinated arrangements • In complex, risky cases or where disagreements remain,

that leave is postponed until support from the local CAMHS can be made available

BARTS HEALTH NHS TRUST

4.1.9 With a view to strengthening a current drive to improve information sharing, action planning and accountability across the Trust, when a child is admitted with complex mental health needs and is known to other agencies, the findings of the report of the Royal London Hospital involvement should be shared as an example of best practice

NHS ENGLAND

4.1.10 NHS England should complete a rapid review with the respective service

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providers of what value its involvement added (beyond nomination and funding of the two centres) and:

• Develop and disseminate clear procedures (in particular addressing the interface of CETRs with the CPA process)

• Establish some key performance indicators e.g. timeliness and minuting of CETR meetings

BARNET, ENFIELD & HARINGEY MENTAL HEALTH TRUST

4.1.11 The Trust should seek an assurance from the Beacon Centre that all relevant events such as self-harm are recorded in a timely manner and remain available for purposes of audit or review.

4.1.12 For child-patients on s.17 home leave, the net results of completed risk assessments and verbal briefings should be captured in a brief and explicit document (a ‘pass’ given patient and parent/s) spelling out limits of time and distance to optimise supervision and minimise risk.

4.1.13 The accounts of the exchanges between the Beacon Centre and School 2 raise concerns about the understanding of lawful and effective multi-agency work with respect to information-sharing and justify:

• An event involving senior staff from the Beacon and representatives of community agencies with which they routinely engage to debate and clarify ‘best practice’, and

• (If considered necessary) development of an agreed protocol to encapsulate best practice

EML SCR 26.11.19

london borough of islington safeguarding …...• independent nightingale hospital / capio unit...

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