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Serious Case Review

Posted by Chris A Brown at 09/10/2013 23:17:09

Bron Sanders, Independent Chair of the East Riding Safeguarding Children Board, has issued the following statement to accompany the publication of the Serious Case Review following the death of a young person who died aged 14 years.

“This has been a tragic case for everyone involved and as independent chair of East Riding Safeguarding Children Board, I would like to offer our sympathies to the family and friends of this young person.

“The purpose of a serious case review is to establish what happened and highlight any shortfalls in services.

“More importantly however, is to use this learning to improve services to minimise the risks for other children in the future.

“This review concluded that no-one failed this young person and no-one who was involved in this case could have reasonably foreseen the tragic outcome.

“We know that self-harm can be a symptom of underlying emotional or mental distress and the review highlighted how the school’s pastoral care team and the Child Adolescent Mental Health Service (CAMHS) tried to help this young person.

“But they found, as is quite common, that many young people who self-harm are unwilling to speak to parents or professionals about their problems.

“The review has highlighted a number of recommendations and areas of learning for all agencies involved.

“These include:

• improving professionals and volunteers knowledge and understanding about self-harm and suicidal behaviour;
• ensuring services for young people who self-harm are accessible and designed to engage them;
• improving the way agencies work together and share information when working with young people who are known or suspected to be self-harming and/or exhibiting suicidal behaviour.

“All the agencies involved in the review have taken on board, and acted upon, the recommendations.

“Improvements are being made in professional practice which will better help young people showing signs of self-harm.

“In recognition that self-harm and suicide in young people is a national issue, the review is also recommending the Government should acknowledge the risk of significant harm to this group of young people and issue explicit policy and guidance.

“The review has also highlighted the need for much better understanding and awareness, both locally and nationally, about why young people self-harm as well as for those working with young people to be alert to the way young people express their distress and the risks associated with it.”

Serious Case Review into the death of a young person aged 14

Serious Case Review (pdf 312kb opens in a new window)

Information about self-harm

Self-Harming and Suicidal Behaviour in Young People (pdf 115kb opens in a new window)

Action plan for all agencies

Action plan (pdf 191kb opens in new window)