Recipient

Cookham Wood Prison

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First report 28 Dec 2014•Latest report 4 Oct 2021

Recipient record

Reports, concerns and published responses

Justice · Prison or young offender institution. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
2

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Cookham Wood Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to “HMYOI Cookham Wood”, a former name of Cookham Wood Prison.

    Mid Kent and Medway

    AI-generated summary

    Caden Stewart · 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

    Caden Stewart, aged 16, became unwell after weightlifting in custody and was later found collapsed and unresponsive in his cell. He was diagnosed with a brain haemorrhage, underwent surgery, and died at King’s College Hospital. The principal concerns were inadequate reporting and recording procedures and insufficient communication between prison officers and healthcare staff, resulting in healthcare failing to attend his requests to be seen.

    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. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate healthcare waiting status during handover

    Wider context from the report

    “3. The wing officer in charge did not check whether Caden had been seen by healthcare at any stage over the following hours nor did he inform his successor on handover that Caden was waiting to see healthcare and had not been seen ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of awareness among Physical Education Instructors of PSI 58/2011 and its requirements

    Wider context from the report

    “1. Physical Education Instructors were unaware of the existence of PSI 58/2011 and the requirements within ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of officers to communicate healthcare needs and reported illness

    Wider context from the report

    “2. There was a lack of communication between officers such that the physical education instructors did not inform the escort that Caden needed to see healthcare, the escort did not inform the wing officer in charge that Caden felt unwell and needed to see healthcare, none of the officers responsible for checking Caden’s welfare during patrol state were aware that he had reported feeling unwell and was waiting to see healthcare ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to check whether a person awaiting healthcare has been seen

    Wider context from the report

    “3. The wing officer in charge did not check whether Caden had been seen by healthcare at any stage over the following hours nor did he inform his successor on handover that Caden was waiting to see healthcare and had not been seen ”
    Open source report

  2. Mid Kent and Medway

    AI-generated summary

    Alex Kelly · 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

    Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

    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. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide complete information and records for safer regimes meetings

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to verify medication ingestion before recording administration

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to transfer documentation and emails onto Framework

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise distress communicated through behaviour

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise conflict between behaviour plans and adjudications

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of YOT keyworkers to understand custodial welfare responsibilities

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to use holistic safe-management planning when interventions are ineffective

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inflexible cell-entry requirements during urgent safeguarding concerns

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of forensic psychiatric assessment before custodial placement

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Conflict between ACCT and disciplinary procedures

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in allocating a named social worker and escalating allocation difficulties

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Incomplete recording of mental-health in-reach contacts on System One

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share medication non-compliance and its potential effects

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a system for flagging or diverting urgent communications during staff absence

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to seek advice before disciplinary action indicated increased self-harm risk

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to understand available safe-management options

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to highlight significant events in ongoing safeguarding records

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to involve outside agencies and carers in safeguarding

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to reconcile inconsistent secure-placement recommendations

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to inform and involve agencies and carers in custodial welfare management

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of ACCT reviews to address reasons for behaviour

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to understand YOT authority to initiate secure-estate transfers

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate interagency shortcomings affecting YOT management

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to adopt a holistic approach to custodial support

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to understand corporate parenting responsibilities for children in custody

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inconsistent recording of significant events across safeguarding records

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to flag medication non-compliance for clinical and custodial action

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cookham Wood Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise or report significant incidents and disclosures

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026