In respect of Child A.

Family Profile

 

Subject :       Child A   

Father   :       Mr X

Mother  :       Mrs X

Sibling  :      Child B

 

Establishment profile

The Establishment described itself as a clinic for eating disorders and was situated in Bath, using a number of sites to provide a range of services (residential and non-residential) to young people and adults. The establishment had been used by young people and adults from within Bath and North East Somerset and beyond.  The establishment was not registered with either the Healthcare Commission or the Commission for Social Care Inspection.

• Executive Summary approved and signed off by Bath and North East Somerset LSCB 5th June 2007.
• Extracted from the Overview Report approved by Bath and North East Somerset LSCB 9th November 2006 and the Addendum Report approved on 24th April 2007.

1.         Introduction.

1. 1      Child A was admitted to the Royal United Hospital, Bath on 25th March 2006 (aged 14 yrs 10 mths).Child A’s physical condition was described as extremely poor; had been assessed by a Community Paediatrician as dangerously underweight and at high risk of cardiac arrest. Child A, who suffered from anorexia nervosa, had been resident at the establishment since January 2006, having previously received services on a non-residential basis since November 2005. Child A’s parents had made direct contact with the establishment and were funding the services provided.

1.2       Child A had been seen at the establishment by  officers from the  Healthcare Commission on 22nd March 2006, during the course of a  planned visit following concerns expressed to the Commission on 16th March 2006.  At this visit, child A was found alone, housed on the fourth floor of the establishment. Patients notes examined did not contain evidence of medical supervision, care or discharge planning. No child protection procedures were in place and Social Services had not been informed that there was a child in the establishment.

1.3       The establishment was not registered with any regulatory authority.

1.4       Subsequent to its visit, the Healthcare Commission made contact with Social Services on 22nd March 2006 and again on 23rd March 2006 when a referral was accepted.  A strategy discussion’ took place on 24th March 2006 as a result of which Child A was medically examined by a community paediatrician on 25th March 2006 and admitted to the Royal United Hospital.

1.5       Subsequent strategy discussions were held in respect of child A, and to plan investigations into the operation of the establishment in respect of both child protection procedures and vulnerable adults procedures.

Footnote

1.         Strategy discussion.

            Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm, there should be a strategy discussion involving the Social Services and the Police, and other agencies as appropriate (eg education and health), in particular any referring agency.                Where a medical examination may be needed, a senior doctor from the providing service should be included in the strategy discussion.

2.         Criteria for undertaking a Serious Case Review.

2.1       Working Together to Safeguard Children 2006 and Bath and North East Somerset’s multi-agency child protection procedures identify a number of factors which should be taken into account when deciding whether a serious case review should be undertaken. The Local Safeguarding Children Board (LSCB) should undertake such a review  when a child dies or where a child sustains a potentially life threatening injury or serious and permanent impairment of health and development through abuse or neglect, and/or the case gives rise to concerns about the inter-agency working to protect children from harm.  Further, where there was clear evidence of a risk of significant harm for a child which  was:

• not recognized by organisations or individuals in contact with the child or
• not shared with others, or
• not acted upon appropriately.

2.2       Bath and North East Somerset LSCB established a Serious Case Review Panel to consider whether a serious case review should take place.  That panel recommended that such a review should be conducted, and this decision was made on 24th May 2006.   The NSPCC, as an organisation independent of all the agencies/professionals involved, were commissioned to provide an Overview Report.

3.         The Purpose of the Serious Case Review.

3.1       To establish whether there were lessons to be learned from the case about the way in which local professionals and organisations worked   together to safeguard and promote Child A’s welfare.

3.2       To identify what the issues were : how they should be acted upon ; and what is expected to change as a result.

3.3       As a consequence to improve inter agency working and better safeguard and promote the welfare of children.

4.         Terms of Reference.

4.1       To review Child A’s own circumstances and care prior to and during his/her residence at the establishment.

4.2       To review how the establishment operated and the services it provided  to Child A.

5.         Scope of the Serious Case Review.

            Within the above terms of reference, the Review focused upon:-

5.1       The services provided to Child A by local agencies and individuals

            prior to residence at the establishment and during the time spent there.

5.2       Whether there was clear evidence of a risk of significant harm to

            Child A which was not recognized by organisations or individuals in contact with him/her : or, not shared with others : or, not acted upon appropriately.

5.3       Whether appropriate actions were taken when Child A’s circumstances were reported to the relevant agencies.

5.4       Why there was such an apparent lack of clarity about the ‘status’ of the establishment and Child A’s ‘placement’ which resulted in an establishment providing services to vulnerable young people operating in an unregistered manner.

5.5       How and why did this establishment achieve spurious legitimacy, and why was this legitimacy accepted?

6.         Process of the Review.

6.1       The Review was undertaken by a Serious Case Review Overview  Panel, chaired by the NSPCC and comprising representatives from Bath and North East Somerset Council’s Children and Families Service and Education Service : Avon and Somerset Police : Bath and North East Somerset Primary Care Trust (Consultant Paediatrician and Lead Nurse and Clinical Quality Lead) all of whom had not been directly involved in the case or its management.

6.2       Individual Agency Management Reports, and secured case records,  were provided by:

• Bath and North East Somerset Children and Families Service.
• Bath and North East Somerset Education Service.
• Bath and North East Somerset Primary Care Trust. (PCT).
• Avon and Somerset Police.
• The Healthcare Commission.
• The Commission for Social Care Inspection.

6.3       The Overview Panel also requested, and received, a management report through the Primary Care Trust to detail the involvement of the GP in Child A’s care.

6.4       The Overview Panel questioned whether a report should have been requested from the establishment. This was not requested as a Section 47 investigation regarding the establishment was still in progress.

6.5.      The Overview Report was authored by the Chair and presented to an extraordinary meeting of the LSCB on 9th November 2006. After considering the Report, the LSCB requested an Addendum Overview Report with a more detailed focus upon the second term of reference – ‘How the establishment operated and the Services it provided to Child A.’

6.6       The Addendum Overview Report built upon the work already completed by the Overview Panel and was based upon an examination of the management reviews and records detailed above (para 6.2). The Addendum Overview Report was presented to the LSCB on 24th April 2007.

7.         Key issues arising from the Serious Case Review.

7.1       There was evidence that Child A was at risk of significant harm but this was not recognized nor acted upon by those caring for him/her or in contact with him/her.

7.2       No one involved in the operation of the establishment appears to have regarded themselves as having responsibility either for Child A’s medical supervision or treatment or for ensuring that appropriate medical services were provided to Child A by others.

7.3       Those individuals and agencies who had early contact with Child A did not recognize Child A as ‘in need’ : as a child with medical needs : or as a child at risk.  If links have been made between eating disorders and children at risk then an immediate referral to Social Services would have prompted speedier action to protect Child A.

7.4       Prior to 22nd March 2006, it appears that the risks to Child A and the   registrability of the establishment became confused and prevented earlier action to protect Child A.

7.5       The speed at which child protection procedures were enacted in this case did not reflect the extreme concern and pressing need to protect  Child A.  Whilst it is good practice to gain parents’ consent to see a child, this consent could and should have been over-ridden.

7.6       The establishment was able to achieve spurious legitimacy.  Assumptions were made about the legitimacy of the establishment  which meant that serious questions that should have been asked  about Child A’s welfare and safety, were not asked.

7.7       The establishment’s promotional literature stated that it provided services and expertise which it failed to deliver and did not have the professionally qualified staff to provide.

7.8       The lack of clarity about whether the establishment should have been  registered with either the Healthcare Commission or the Commission for Social Care Inspection (CSCI) meant that there was not a protective regulatory framework in place for young people, or adults, who used the establishment’s services.

7.9       The fact that the establishment was not registered with any regulatory body at the time of the investigations meant that a robust response to the circumstances disclosed could not be taken – as neither the Healthcare Commission nor the CSCI had the authority to close it. Guidance has subsequently been provided but the LSCB remains concerned that the fact that if an establishment does not provide the services it purports to provide appears to be a potential loophole in registration requirements.

7.10    The difficulties local agencies will experience in gathering information  about unregistered services for eating disorders, and monitoring these to ensure that no children or young people are at risk of significant harm. 

7.11    Actions are required to ensure that this establishment does not continue to offer or provide unregulated services to children and young people : and that prompt action is taken if it is discovered that such services are provided.

7.12    There are lessons for local and national practice which should be widely shared.

8.         Summary and Conclusions

8.1       The facts indicate that Child A was at risk of significant harm by the very nature of the eating disorder from which he/she suffered and the fact that he/she was not receiving the care and treatment needed.  In March 2006 it was clear that Child A had suffered significant harm whilst being cared for at the establishment. Harm is defined in the Children Act 1989 as “the impairment of health and development’.

8.2       There is evidence that the risk of significant harm and/or the actual  significant harm suffered by Child A was not recognized, shared or appropriately acted upon by the agencies involved with Child A.              Individual agencies appeared to focus upon what they perceived to be their own remit so that shared responsibility to protect Child A and  safeguard and promote his/her welfare was missed  Once the concerns were passed to the relevant agencies responses should have been quicker, assessments more thorough and follow up more secure in order to protect Child A.

8.3       The lack of awareness by all agencies of the potential life threatening nature of anorexia nervosa was highlighted and links with child protection were not made.  Child A’s needs became muddled with issues of clinic registrability.  Where procedures were in place to provide a robust framework for protecting children, these were not always carried out with sufficient urgency.

8.4       Child A’s wishes and feelings were not consistently sought by agencies.

8.5       The establishment achieved spurious legitimacy in this case partly because of a discussion with a GP : partly because of the association of a further GP as described as ‘Medical Director’ of the   clinic : and finally because the proprietor was believed and trusted by  Child A’s parents. Therefore an unregulated service was provided to Child A.

9.         Recommendations of the Overview Panel.

9.1    Training to be provided to all agencies to raise awareness that children and young people with eating disorders are children in need and may be children at risk.  A network of professionals to be established so that a working knowledge of the NICE (National Institute for Clinical Excellence) guide lines inform practice (LSCB).

9.2    Training be provided to all agencies working with children and young   people to highlight the shared responsibility to protect children.  This should include training to ensure that the key focus of all professionals should be the child even when there are other concerns.(LSCB)          

9.3    Training to be provided to ensure that all agencies know how to implement child protection procedures.(LSCB)

9.4    Training be provided to ensure that all agencies know how toimplement procedures relating to assessment. (LSCB)

9.5    Training to be provided so that all agencies working with children and young people understand how to ascertain the wishes and feelings of  children and young people and the importance of this.(LSCB)

9.6    The LSCB ensures that child protection supervision policies and procedures be reviewed by all agencies working with children and young people so that appropriate supervision occurs and is recorded on case files to ensure the protection of children and young people.   (LSCB)

9.7    The LSCB to bring to the attention  of the DfES and DOH the regulatory gap that exists and the consequent implication for children and young people. (LSCB)

9.8    The LSCB satisfied itself that an in-depth assessment of Child A’s needs has been carried out to ensure his/her future protection and that of his/her sibling. (LSCB)

9.9    The LSCB formulates its own procedures for carrying out Serious Case Reviews in Bath and North East Somerset so that these are understood by all the agencies likely to be involved.  (LSCB)

9.10  The LSCB explores the gap in the provision of services to children and young people with eating disorders and seeks to develop these locally. (LSCB)

9.11. The LSCB seeks clarity from the Commission for Social Care Inspection about its final position in relation to the registrability of the Individual Clinic for Eating Disorders and other similar establishments.  (LSCB)

9.12  Clear mechanisms be put in place to highlight the importance of  education staff ascertaining children’s wishes and feelings and to ensure the accurate recording of conversations (both telephone  and face to face) with children and their parents relating to concerns about a child’s welfare. (Education)

9.13  Training be accessed and implemented so that all education providers understand the indicators of risk to a child and comply with child protection policies and procedures. (Education)

9.14  An objective multi agency assessment process be established and followed when there are repeated concerns about a child’s welfare. This to include consideration of information given in respect of  absences and any alternative education provision.  (Education)

9.15  Guidance be given to all Schools in order that they know how to ensure  the authenticity of private tutors and alternative education providers.    (Education)

9.16  Guidance, supported by training be provided to all schools to ensure full implementation of new DfES guidance (September 2006) on absence coding to ensure consistency of decision making and record  keeping.  (Education)

9.17  Guidance, supported by training be provided to all schools to support full implementation of the DfES guidance on Access to Education through ill health.  (Education)

9.18  Advice about the management of eating disorders based on the NICE guidelines.  (NHS, National Institute for Clinical Excellence, 2004) be provided to all health, social care and education professionals including those in independent schools.  (PCT)

9.19  Training be provided to highlight the possibility that in life threatening conditions such as anorexia nervosa there may be issues of child protection that need to be explored.  (PCT)

9.20  Training and guidance on seeking and recording the wishes and feelings of children and young people be provided, accessed and acted upon by all relevant health staff.  (PCT)

9.21  Guidance be issued to GP’s about how they are to carry out their responsibilities for the monitoring of patient care in unregistered establishments.  (PCT)

9.22  Guidance be provided to all health staff relating to unregistered establishments.  This should include:

• Clarification of the difference between a ‘referral’ and a ‘discussion’ so that parents do not assume the suitability of a provider following discussion with a professional.
• Clarification about not entering into discussions with patients about independent providers unless they are satisfied that the provision is reliable and safe.  If this is impossible, it should be made clear to the patient that no recommendation is being made and the patient should be given advice about how to ensure that the service will be satisfactory.  (PCT)

9.23  Training be accessed and implemented by all healthcare professionals to clarify that it is their primary responsibility to act in accordance with child protection procedures.

9.24  Discussion and review of reporting procedures takes place to ensure:

• Clear mechanisms for collecting and recording the content of cases referred to the Duty Desk.
• Written records are made of all calls to the Duty Desk which inform timely and appropriate decision making.
• The onus of responsibility to collect key information relating to the content/intent of the call lies with the duty desk.  (Children and Families Service)

9.25  Training be provided to all social work staff to support effective and sensitive questioning techniques so that young people are safeguarded. (Children and Families Service)

9.26  An operational review of the staffing of the duty desk takes place. (Children and Families Service)

9.27  Ongoing training be provided to social work staff to ensure that child protection concerns are recognised and acted upon at the point of referral. (Children and Families Service)

9.28  Social work staff be reminded of their duties to follow Bath and North East Somerset Children in Need procedures. (Children and Families Service)

9.29  Child protection training specifically related to Section 47 Investigations and Core Assessments be developed in line with LSCB procedures and made available to relevant social work staff.  (Children and Families Service)

9.30  All social work staff be involved in discussions to ensure that lessons learned from this case, specifically relating to appropriate and timely actions to safeguard children at risk are widely shared and  implemented. (Children and Families Service)

9.31  Training and guidance on seeking and recording the wishes and feelings of children and young people be accessed and acted upon by social work teams. (Children and Families Service)

9.32  Working Together (2006) guidance be reinforced with social work staff  to inform good practice in multi-agency working. (Children and Families Service)

9.33  Police Officers are made aware of how to access and implement the ‘Working Together to Safeguard Children’ (2006) guidance.  (Police)

9.34  Training to be accessed and acted upon to ensure that child protection  concerns are recognized and responded to.  (Police)

9.35  Training be accessed and implemented to ensure that children and young people’s wishes and feelings are sought and acted upon. (Police)

9.36  Discussion and review of reporting procedures takes place within the Healthcare Commission to ensure:

• Written records of all calls made to Enquiry desk.
• The onus of responsibility to collect key information relating to the content intent of the call lies with the Enquiry desk.  (Healthcare Commission)

9.37  Training be accessed and implemented by all Healthcare Commission staff to support a working knowledge of the links between services provided and vulnerable children. This training to include guidance on the indicators of risk and the implementation of child protection procedures. (Healthcare Commission)

9.38  Guidance be published so that unregistered establishments cannot  provide impatient care for children and young people. (Healthcare Commission)

 

Maurice Lindsay

Chair

Bath and North East Somerset

Local Safeguarding Children Board

17th May 2007.

ML/jc.SCR.ExS.R.15.5.07.