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Serious case reviews published - 8th April 2016

The Islands Child Protection Committee has today published summaries of two independent serious case reviews that it commissioned last year following the deaths of two young people in the UK.

These reviews were commissioned by the ICPC to determine if any learning could be identified for Guernsey agencies involved in the care of the two young people. The ICPC has accepted the recommendations made by the independent reviews and will monitor progress to ensure they are implemented.  

The Executive Summaries of these review reports can be found here

Full press release

The Islands Child Protection Committee has today (8th April 2016) published summaries of two independent serious case reviews that it commissioned last year following the deaths of two young people in the UK.
These reviews were commissioned by the ICPC to determine if any learning could be identified for Guernsey agencies involved in the care of the two young people. The ICPC has accepted the recommendations made by the independent reviews and will monitor progress to ensure they are implemented. 
The ICPC is a multi-agency committee, given legal status in the Children (Guernsey and Alderney) Law 2008, which seeks to enhance the safety of children and young people in the islands by promoting effective co-ordination and co-operation between the various agencies that provide services to children and families. Its membership includes, but is not limited to, representatives from the Health and Social Services Department, Home, Education, Guernsey Police and the Children's Convenor.
These cases are subject to inquest proceedings in the UK and it is not appropriate for the ICPC to comment on matters that are the jurisdiction of the coroners.
Independent reviewer Hilary Corrick-Ranger authored the serious case review report relating to Child/Adult Y, a young woman who died having been hit by a car in the UK.
Child/Adult Y had been under Guernsey care since the age of six and had been placed off-island due to her complex needs. After turning 18 her placement continued to be funded and organised through services in Guernsey.
The review concluded that it was not possible to predict Child/Adult Y's death. It acknowledged that the decision to send young people off-island is not taken lightly, but stated such placements make it difficult to support the young person in care. The review also recognised the difficulty the island has in finding appropriately skilled fosterers locally who can cope with challenging behaviour.
Independent reviewer Amy Weir authored the serious case review report relating to Child X, a 17-year-old who died in the UK following suspected drug misuse.
Child X had been under the care of authorities in the north of England from the age of four. He was later adopted but as a teenager he began going missing, taking drugs and not attending school.
Child X was later discharged from care by the relevant UK authority and subsequently moved to Guernsey to live with his birth father. He later spent several months in prison.
The review concluded it was not possible to say that Child X's death was predictable or preventable. It found that Guernsey services were informed that Child X was in the island, but no written information about his care was provided by the relevant authority in England. Child X and his father had been visited when he arrived in Guernsey but the review stated there is a need to ensure formal assessments are completed for vulnerable children who move to the island.
Simon Westwood, Independent Chair of the ICPC, said the purpose of serious case reviews is to identify areas where improvements can be made to further reduce the risks to young people.
'These reviews are by definition, a retrospective look at practice and in these cases look back a number of years. Legislation, practice, and governance structures have changed during that time. The objective is to understand what more we need to do to reduce the risk of harm to children and young people, not to apportion blame; indeed to create that climate can create more risk for children if agencies become insular and do not work together effectively.
'The ICPC felt it was important to commission these reviews to see what if any lessons can be learned for agencies involved, including those in the UK. We will share this learning with UK authorities as they will want to consider any local practice issues.'
Mr Westwood said it was not possible to release the serious case reviews in full, due to data protection issues and the potential for family members to be identified by the content included.
'ICPC members wish to extend their deepest condolences to the families and anyone who knew these young people. The ICPC has ensured that these reports have been shared with close relatives prior to publication.
'While it is impossible to say that tragic events like this could never happen again, the actions that all agencies engaged with the ICPC have already taken, and the further action agreed in response to the recommendations, will go some way to making sure we keep our children and young people safer.'
Ruby Parry, Director of Communities at the Health and Social Services Department, said: 'Much of the learning identified has already been addressed and work to implement the remaining recommendations is ongoing.
'Regarding the report into Child/Adult Y, the independent reviewer acknowledged that the decision to send a young person off island is never taken lightly. HSSD and the ICPC will continue to stress the importance of providing sufficient care placement on island wherever possible. Work is ongoing to introduce a therapeutic fostering service; we are recruiting for this specialist foster carer scheme at the moment and would encourage anyone who thinks they could provide a home for children with complex needs to contact The Family Placement Service on 713230.
'Where placing a child off island is unavoidable, we are developing plans to engage UK-based social workers to support placements in the UK.
'Regarding the report into Child X, processes have now been put in place that will require relevant agencies to carry out assessments detailing the needs of all children who have been referred for support after moving to the island. This management information will be provided to the ICPC.
'The ICPC will also investigate whether there is an opportunity and willingness to agree a protocol for working, and sharing information, between small island jurisdictions and the UK. '
Alan Brown, Director of Education, said: 'We welcome the reports and will continue to work with all other departments and partner agencies to take forward the learning points from the reviews to ensure that we can deliver the best outcomes possible for our vulnerable children and young people.
'In particular, we are re-examining our transition processes for vulnerable learners to make sure they are appropriately supported for moving between education phases, especially from secondary to post-16 education.'
Mark Lempriere, Home Department Deputy Chief Officer, said: 'The Home Department and its services continue to work closely with all other agencies involved in the care of young people. These reviews have identified several areas of learning and the Department, through its work on the ICPC and other joint-working platforms such as the Multi Agency Safeguarding Hub and the Criminal Justice Working Group, will play an active role in taking them forward.
'Reviews such as these play an important role in assisting relevant agencies examine the way we can collectively improve the way we support and protect vulnerable young people.'
ENDS
Issued by Joel de Woolfson, telephone number 719451