“: A”

The coroner’s concerns

: A. Surrey and Borders Partnership NHS Foundation Trust Concern 1 The evidence at the inquest revealed that the staff responsible for the triage of referrals to child mental health services had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I have been told that the triaging process is now undertaken by an “Access and Advice Team” but I am concerned that there continues to be no requirement for the staff in that Team to undertake relevant Autism training on a mandatory basis. Concern 2 The evidence at the inquest revealed that, despite a series of referrals to child mental health services over many years, Oskar Nash never received the clinical assessment he needed. I have been told that the system now in place ought to result in a child such as Oskar being seen and assessed by a clinical team. I am satisfied that the introduction of the Access and Advice Team, in the context of the new Mindworks service, is intended to ensure that a referred child’s needs are properly identified and met. However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies. In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated). Concern 3 The evidence showed that a referral to the child mental health services is triaged initially as being crisis, urgent, priority or routine. The criteria for crisis, urgent and priority referrals are specific and narrow and, consequently, the great majority of referrals are categorised as routine. I have been told that the routine referrals are automatically categorised as “low risk”. I am concerned about this as it is clear from the evidence that a child may not meet the criteria crisis, urgent or priority but, like Oskar Nash, may nevertheless be at a high or medium risk of harm. The Trust is currently receiving a high volume of referrals and so there is a considerable waiting time for its “routine” cases to be addressed. It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged. Concern 4 I was told that the Standard Operating Procedure manual for the triage of referrals to children’s mental health services is to be updated to reflect the Trust’s new working practices but that this has not yet been done. I am concerned that important changes to the system of work (for example, the vital requirement that a referred child’s records are reviewed before any triaging decision is made and the child/family are spoken to) are not yet established in written guidance. Concern 5 The evidence at the inquest showed that the clinicians who were responsible for ensuring that Oskar Nash’s medical conditions, including his risk of self-harm and suicide, and his consequential needs, were properly and sufficiently recorded in his Education, Health and Care Plan, failed to do so; this was in part because they did not fully understand their role and obligations in this regard. On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process. I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities. B. Surrey County Council (and National) (i) Education and Special Educational Needs Department Concern 6 The evidence at the inquest revealed that the staff in the Education / SEN Department, including SEN caseworkers, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis. Concern 7 The evidence at the inquest showed that, in the months before his death, Oskar Nash was moved from a special needs school and placed into a mainstream school which did not have the facilities or expertise sufficiently to meet his complex needs. I found that the inappropriate placement, by SCC, of Oskar into the mainstream school contributed to his death. Prior to the placement, the mainstream school had been provided with Oskar’s Educational, Health and Care Plan, but this failed adequately to identify and record his mental and emotional health concerns, his risk of suicidal ideation, his consequential needs, and the provision required to meet those needs, and it had not been updated to reflect a series of subsequent reviews of the Plan and significant subsequent events. The mainstream school was not provided with any of the extensive and informative records from the special needs school from which he was being moved. I was told by the mainstream school that, had they seen the records held by his special needs school, they would have recognised their inability to meet his needs and informed the SEN Department accordingly. At the prevention of future deaths hearing, I was told that it continues to be the case that a prospective school will usually be provided by the SEN Departme

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2022-0031

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0