Norfolk Serious Case Review published today

23rd September 2020

Norfolk Safeguarding Children Partnership has today published a serious case review into the death of a 16-year-old child who died in 2017, due to natural causes contributed to by a paracetamol overdose.
(scroll down to access the report)

The teenager had a range of complex physical and emotional needs and was receiving support from multiple agencies and professionals at the time of his death, including child and adolescent mental health services, children’s services and a range of other health agencies. He had not been attending school for more than three years and had a range of diagnoses, including non-epileptic seizures, autism and an eating disorder.

The review highlighted the complexity of AE’s needs and the difficulty in achieving consistent multi-agency collaboration. The key findings of this SCR focus on the need to: appreciate the particular challenges faced by adolescents; celebrate the importance of ordinary life; think family; recognise the impact of isolation and take action; and support family members and multi-agency staff in their attempts to provide the best possible care to vulnerable young people so that their potential can be fully realised.

Chris Robson, Chair of the Norfolk Safeguarding Children Partnership said: “The thoughts of everyone in the partnership continue to be with AE’s family. There is no question that AE was much loved and that his parents did their very best to give him the care and support that he needed.

“The professionals working with AE also wanted to do their very best for him and there was some good practice by staff from across agencies. However, the report makes it clear that the sheer number of people involved in AE’s care made collaboration extremely difficult and, although each part of the “system” was trying to address its area of responsibility, services were not joined up and were unable to step back and really understand who AE was. Instead he became defined by his challenges and his diagnoses and agencies responded to those in isolation.

“The findings of this review are not unique to Norfolk and there is no quick fix or solution. However, progress is being made in the county –children’s mental health services are being transformed so that there is a single system, where information and records are shared and young people’s needs are really understood. There is also significant investment being made in specialist education provision and professionals are increasingly focused on children’s strengths and needs, rather than their diagnosis. As a partnership we will continue to monitor and challenge this, so that services continue to improve for children and young people like AE.”

The full report is available here.

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