Agenda item

The purpose of this report is to advise the Health and Wellbeing Board (HWB) of the findings arising from two important thematic reviews carried out over the last 12 months by the Surrey Safeguarding Children Partnership (SSCP). The report seeks to gain the support of the Board to achieve a robust multi-agency response in addressing the specific findings, enable development of practiceand influence commissioning priorities.

Witnesses:

Simon Hart - Independent Chair of the Surrey Safeguarding Children Partnership (SSCP)

Amanda Boodhoo - Surrey Wide CCG Associate Director Safeguarding / Designated Nurse Safeguarding Children

Mrs Mary Lewis - Cabinet Member for Children, Young People and Families (SCC)

Key points raised in the discussion:

1.   The Independent Chair of the Surrey Safeguarding Children Partnership (SSCP) introduced the report, noting that thirteen case reviews were concluding concurrently and that SSCP had also taken the opportunity to consider twelve cases where young people in Surrey had taken their own lives. The SSCP saw it as a unique opportunity to review the substantial amount of information and to ensure the strongest possible partnership response to the findings.

2.   He noted that whilst usually abuse and neglect would be a trigger for a case review it was often not the characteristic for suicide. Nevertheless, SSCP considered it important to look at all the circumstances in which a young person may die to ensure a comprehensive review as presented through the two thematic reviews.

3.   The Surrey Wide CCG Associate Director for Safeguarding summarised the key headlines, noting that she had the privileged position of chairing the case review group. It was an invaluable opportunity to gather data pertinent to the deaths of young people in Surrey which benefited from family engagement.

·      Thematic Review - Deaths of Children and Young People through probable suicide 2014-2020: the key findings from the twelve deaths of children were presented to the Board.

-  Significant figures included 45% of children that were open to CAMHS (Child and Adolescent Mental Health Service) and only 50% of those children were known to social care, which meant that those other children were accessing wider universal services. 

-  Key themes from the review included the ‘impact of Adverse Childhood Experiences’ (ACE) which was high in Surrey in which 83% experienced four or more ACEs. Another theme was the ‘Autistic Spectrum Disorder’ in which 58% of children in the review were categorised under.

-  One interesting finding that had not been flagged up by national data was the theme of ‘Medication’ or the number of children that had a change in medication, one third had a change or increase four weeks prior to their death.

-  Other themes were: ‘Gender’, ‘Substance misuse – drug and alcohol’, ‘Management of self-harm’, ‘Schools and further education colleges’ - although a number of children were in school some found it difficult to access the lessons - ‘Multi-disciplinary working within healthcare’ and ‘Social care’.

·      Thematic Review - Serious Case Reviews (SCRs) 2016-2020 – Briefing Paper: there were thirteen Surrey Serious Case Reviews, Partnership Reviews and Rapid Reviews. The main finding was that were three key learning domains: the experience of the child, parental issues and practice issues.

-  Serious Case Reviews would be commissioned when a child who was known to the services in the county died or was seriously harmed.

4.    The Cabinet Member for Children, Young People and Families commented that the depth of the analysis of the two thematic reviews was important. She emphasised that all of the affected children were living, growing up and learning in Surrey at the time of their death and in accordance with the legislation - Section 17 of the Children Act 1989 - safeguarding was the collective responsibility of all in the county.

5.    She challenged Board Members on what could be and could have been done differently to make adolescent suicides less likely to occur; adding that it was World Suicide Prevention Day. Prevention and early intervention were key such as minimising the feeling of loneliness, isolation and hopelessness of young people. She asked the Board to reflect on how to ensure depth and consistency in Surrey’s responses to those affected children and to bolster the strength of partnership delivery.

6.    The Independent Chair (SSCP) was concerned with the recurring findings in the case reviews nationally, regionally and locally; as well as new risks to safeguarding faced by children such as social media and the internet. Out of the twenty-five cases across the two thematic reviews there were common messages which provided a transformative opportunity to reflect on what could be done differently to strengthen the outcomes for children, to better support their families and front-line practitioners.

7.    A Board Member thanked the SSCP for their work and highlighted that she sat on the Suicide Prevention Board, noting that Surrey had recently secured three mental health support teams from NHS England further strengthening early intervention and highlighted the Samaritans’ ‘Step by Step’ service which provided practical support to assist schools to repair and recover from a suicide attempt. The Suicide Prevention Board was also in discussions around suicide and young carers and as the carers champion she was looking to create a bespoke package for that cohort; the Board was also taking a deep dive into autism.

8.    A Board Member expressed gratitude to the SSCP for the comprehensive piece of work amalgamating the key themes. Evidence nationally showed that young people faced challenges to emotional and mental health exacerbated by Covid-19. All had a duty to think about the context and pressures in which young people were exposed to. As a result of the thematic reviews, the Surrey and Borders Partnership - NHS Foundation Trust (SABP) were looking at their own practices and how to better understand the impact of emotional distress, severe mental illness and neurological development disorders as a reaction to early childhood trauma.

9.    She noted that the work led by the late Dave Hill CBE in the last few years as the Executive Director for Children,Lifelong Learning and Culture towards a greater collective focus on early intervention was crucial and how the preventative measures could be accelerated. In response, the Independent Chair (SSCP),noted that a common understanding across agencies in relation to suicide was vital.

10.  Although there was national research into self-harm and social media, the Board Member was worried that there was still no answer and traction on social media locally. In response, the Independent Chair (SSCP) noted that in discussions with police colleagues they were being advised that there were clusters of young people sharing similar thoughts and experiences on social media. Understanding that network of peers in relation to suicide, self-harm or abuse provided a learningopportunity to understand the drivers which lead to some young people taking their own lives and what influences others to make different decisions.

11.  The Board Member asked whether suicide prevention training was mandatory in all statutory organisations. In response, the Independent Chair (SSCP) endorsed the comment on training but emphasised the importance of ensuring that partners spend time with front line practitioners to be assured that the training has had an impact and that positive changes in practice could be identified. Training should not be seen as a short-term measure. 

12.  A Board Member commented that he did not get the impression from the reports that the management and supervision of key workers who were the first points of contacts for those attempting suicide, was as stringent and proactive as it could have been in many cases. In response, the Independent Chair (SSCP) agreed that when things went wrong, management and supervision were common characteristics in those case reviews, emphasising the need to more consistently support front line practitioners in difficult situations.

13.  The Board Member noted that the reports showed a reactive mode in which action was taken after a young person self-harmed or attempted suicide or their families raised the alarm. Funding should be used proactively to identify those children at greater risk, although that was challenging.

14.  The Board member stressed that Surrey Police took suicide seriously, noting that there was a suicide prevention officer in post and that often the police where the first responders who witness traumatic incidents. That initiative on the part of Surrey Police was acknowledged by the Independent Chair (SSCP) as a very positive and helpful step forward.

15.  A Board Member highlighted that more work was needed in acute hospitals in terms of training for suicide prevention. He queried whether there was a piece of work looking at the wider system to ensure a collective response at an earlier stage and how different agencies worked together with children in hospitals when they were recovering from an attempted suicide or an acute illness.

16.  The Chairman noted that it was a complex area in which all had a collective responsibility to address, the Board would reflect on how to ensure consistent responses across agencies and he invited representatives from the SSCP back at a future meeting.

RESOLVED:

The Health and Wellbeing Board:

1.    Reflected and commented on the findings from the Thematic reports on Adolescent Suicide (Deaths of Children and Young People through probable suicide 2014-2020) and Serious Cases (Serious Case Reviews (SCRs) 2016-2020 – Briefing Paper).

2.    Committed to working with the SSCP to ensure a robust multi-agency response to findings.

3.    Ensured that commissioning arrangements for future service provision take full account of the findings.

4.    Supported the SSCP in reviewing practice development through training and multi-agency audits over the next 24 months.

Actions/further information to be provided:

1.    The Board would reflect on how to ensure consistent responses across agencies.

2.    Representatives from the Surrey Safeguarding Children Partnership (SSCP) are to be invited back at a future meeting in approximately six-month’s time.

3.    The additional points raised by Board Members in the Microsoft Teams chat will be captured and provided to the Board and officers.