Recurring concern

Unreliable Child in Need assessments for vulnerable young people

First to latest report 2 Sep 2014 — 19 Feb 2023

Reports that mention this concern
2
Times this concern has been raised
4
Stated actions linked to this concern
4

What this concern includes

Includes failures in the Child in Need process for vulnerable children and young people, including recognising entitlement during detention or homelessness, acting on referrals, completing required assessments, appointing responsible social workers and sharing relevant information needed for assessment and support.

What is not included
  • Excludes adult social-care assessments and general community-care needs assessments.
  • Excludes child-safeguarding or child-protection assessments that are not explicitly part of a Child in Need process.
  • Excludes generic mental-health assessment, detention, homelessness or information-sharing failures where the Child in Need process is not the deficient control.
  • Excludes failures to provide care or support after a Child in Need assessment has been completed appropriately, unless the asserted deficiency is part of the Child in Need process itself.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Essex

    AI-generated summary

    Molly Ann Sergeant · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Molly Ann Sergeant, aged 17, was found deceased on 16 October 2020 after hanging, having left a note. The report identifies concerns about delayed autism diagnosis, insufficient assessment and discharge planning, failures in social-care assessments and coordination, and a lack of understanding of her aftercare rights and chronic suicide risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of understanding of changing child-in-need assessment rights during detention

    Wider context from the report

    “(5) Essex County Council did not: a. act on appropriate referrals to social care by Essex Partnership NHS Trust b. conduct required assessments of Molly during her detention c. did not appoint a social worker until after Molly was discharged There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act. ”

    Source location

    Molly Ann Sergeant · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to conduct required assessments during detention

    Wider context from the report

    “(5) Essex County Council did not: a. act on appropriate referrals to social care by Essex Partnership NHS Trust b. conduct required assessments of Molly during her detention c. did not appoint a social worker until after Molly was discharged There was a lack of understanding of the impact of Molly’s detention on her right to assessment as a child in need and how this changed during her detention under the Mental Health Act. ”

    Source location

    Molly Ann Sergeant · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require Child and Family Assessments and continued Social Care involvement for every young person admitted to a Tier 4 inpatient bed.

    Verbatim wording from the response

    “There is now agreement that there will be a Child and Family Assessment for every young person admitted to an in-patient Tier 4 bed. This has been in place since January 2022 but has been re-emphasised to the Children and Families Hub and all operational social work teams since the Inquest. The initial communication stated that any young person admitted to a psychiatric in-patient unit is a child in need (by definition) and will receive a Child and Family Assessment. There is a specific audit being undertaken this Spring 2023 by our Professional Standards Unit to ensure that these are always taking place. The expectation is that the Young Person will have an allocated social worker throughout their stay as an in-patient.”

    Source location

    Response from Essex County Council
    Page 3 · response
    Published 10 March 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and publish internal Section 117 guidance covering duties, processes and the Section 117 Panel.

    Verbatim wording from the response

    “There is also an internal Section 117 guidance working group which has been developed by the Leads for Mental Health within ECC. This is due to be published in Spring 2023. This will cover Section 117 duties and responsibilities, the Section 117 process, the Section 117 Panel.”

    Source location

    Response from Essex County Council
    Page 4 · response
    Published 10 March 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Deliver Section 117, Section 85, mental health and autism awareness training and awareness-raising for Children and Families staff.

    Verbatim wording from the response

    “In relation to training and awareness-raising sessions across Children and Families in respect of Section 117, Section 85 and autism awareness, there has been extensive mental health training that has taken place throughout 2021 and 2022 and the dates of this training were previously submitted to the Coroner. Further Section 117 training sessions took place in January 2023 and further courses are due to take place in May and July 2023. The Essex Social Care Academy is currently working on additional commissioning options in relation to further mental health training and autism awareness”

    Source location

    Response from Essex County Council
    Page 4 · response
    Published 10 March 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Audit whether Child and Family Assessments are consistently completed for young people admitted to Tier 4 inpatient beds.

    Verbatim wording from the response

    “There is now agreement that there will be a Child and Family Assessment for every young person admitted to an in-patient Tier 4 bed. This has been in place since January 2022 but has been re-emphasised to the Children and Families Hub and all operational social work teams since the Inquest. The initial communication stated that any young person admitted to a psychiatric in-patient unit is a child in need (by definition) and will receive a Child and Family Assessment. There is a specific audit being undertaken this Spring 2023 by our Professional Standards Unit to ensure that these are always taking place. The expectation is that the Young Person will have an allocated social worker throughout their stay as an in-patient.”

    Source location

    Response from Essex County Council
    Page 3 · response
    Published 10 March 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The acknowledged shortcomings were not causation or contributory factors in Molly’s death.

    Verbatim wording from the response

    “It is not our view that these shortcomings, which we have fully acknowledged and have taken significant steps to ensure do not happen again, were causation factors or contributory factors which led to Molly’s very sad death.”

    Source location

    Response from Essex County Council
    Page 2 · response
    Published 10 March 2023

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Peter Stanley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use previous psychiatric services information in assessment and Child in Need planning

    Wider context from the report

    “(11) There is no system to ensure that where there has been previous psychiatric services involvement by a young person that such information will be used to inform assessment and the 'Child in Need' planning process. ”

    Source location

    Peter Stanley · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inconsistent use of the Child in Need process for homeless young people

    Wider context from the report

    “(6) Peter was classed as 'intentionally homeless' after his release from court on 15 July. ████████ gave the court compelling evidence that this was wrong and that Peter should have been treated as a 'Child in Need'. Emphasis on the 'Child in Need' process when a young person is homeless would ensure proper assessment and sharing of information. Failures in sharing Peter's mental health history/needs were significant issues in this case. This emphasis is now standard practice in Sheffield but I understand it is not likely to be the case everywhere. ”

    Source location

    Peter Stanley · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026