Cumbria LSCB commissioned a Serious Case Review (SCR) into the death of Child O in 2011 – the SCR focusses specifically on services that were provided to Child O and his family and how agencies worked together and individually prior to his death.
Child O died tragically at 17 years old after hanging himself. The Coroner report concluded that he took his own life whilst suffering from mental health problems and after consuming a substantial amount of alcohol. Child O was a very vulnerable young person with complex and poorly understood needs and risk factors: he had an extremely complex history of contact with services in Cumbria and the North East. Child O was home educated from the age of ten; coupled with the parent’s withdrawal of Child O and his identical twin from the community and their disengagement from services this left them very isolated in their remote home.
Practitioners and supervisors should understand and respond to the needs of ‘twin families’ and to children and young people who are twins.
Practitioners should recognise, assess and respond appropriately to the possible safeguarding implications for children and young people who are isolated and/or home educated.
Practitioners who visit children when they are home educated should see and speak to children and young people regularly and this should be specified and agreed as part of a child or young person’s plan.
Practitioners and supervisors need to recognise, understand and respond to neglect, disguised compliance and fabricated or induced illness.
Practitioners and supervisors should proactively seek to discuss cases, share information, and give and receive support to and from multi-agency colleagues in their work with families or individuals.
Practitioners must ensure that children and young people who do not neatly fit service criteria do not ‘bounce’ between services and/or geographical areas.
The LSCB will conduct a number of workshops and a conference to raise the profile of the lessons in this and the other SCR being published.
Sharing learning from serious case reviews in order to improve safeguarding practice is vital. We use the recommendations from case reviews to improve safeguarding of children & young people.
If you would like to discuss SCR or any of its contents then please speak to your line manager, your representative on the LSCB or contact the LSCB Office. Cumbria House, 3rd Floor, 107-117 Botchergate, Carlisle, Cumbria, CA1 1RZ. Email LSCB@cumbria.gov.uk