30 Jan 2025 Liam Stephen Allan · Prevention of Future Deaths report West London
View report summary
Concerns raised 2 Delays in police alerting of the LFB and subsequent emergency response View source Inadequate visibility of riverside buoyancy aids View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Liam Stephen Allan · 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
Liam Stephen Allan was arrested alongside the River Thames on the evening of 26 August 2022, entered the river, and drowned. The report identified concerns about inadequate lighting and visibility of riverside buoyancy aids, and about delays in alerting the London Fire Brigade because notification was made by telephone rather than through the faster CAD-mediated system.
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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Delays in police alerting of the LFB and subsequent emergency response
Wider context from the report “The process for alerting the LFB by the Metropolitan Police Service (MPS) uses a telephone to transmit information from the MPS to the LFB , rather than using a CAD-mediated system to transfer information electronically from the Police to the LFB which is faster than transmitting information by telephone . This delay means that there is a risk that future deaths could occur due to a delay in the LFB being alerted by the Police and a corresponding delay to the LFB's subsequent response to an emergency incident .
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility of riverside buoyancy aids
Wider context from the report “The lighting of buoyancy aids on the riverside is not adequate , meaning that they are not able to be identified rapidly and then deployed without delay in an emergency situation.
Buoyancy aids are more visible when painted with white stripes and/or reflective white stripes. However, not all buoyancy aids are so painted , meaning that they are not able to be identified rapidly and then deployed without delay in an emergency situation.
” Open source report
11 Aug 2020 Moses Victor Boardman · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to commence CPR when a reversible cause for collapse overrides a DNAR order View source Failure of a commissioned care provider to escalate inability to reach a patient for care visits View source Absence of a clear computerised record explaining a change of address in the departure lounge View source Lack of a clear safeguard ensuring vulnerable patients are discharged to the correct address View source Failure to properly monitor patients assessed as fed at risk View source Failure of transport staff to properly assess venue suitability View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Moses Victor Boardman · 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
Moses Victor Boardman, an elderly and frail man, was mistakenly discharged to his home instead of sheltered accommodation, where he was found without heating, light or food and subsequently readmitted to hospital after a further cerebrovascular accident. While assessed as being at risk of aspiration and requiring supervised feeding, he was later found eating a whole fruit unsupervised, suffered a choking incident, and died at 04.48. The substantive concerns included discharge and transport safeguards, failure to escalate missed care visits, monitoring of patients fed at risk, and the response to a potential reversible cause of collapse when a DNACPR order was in place.
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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to commence CPR when a reversible cause for collapse overrides a DNAR order
Wider context from the report “6. The RLH failure to commence CPR when a potential reversible cause for collapse existed that would override the effect of the DNAR order .
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure of a commissioned care provider to escalate inability to reach a patient for care visits
Wider context from the report “4. The responsiveness of the care provider commissioned by LBTH to escalate the fact that they had been unable to reach Mr Boardman for his first 3 care visits .
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear computerised record explaining a change of address in the departure lounge
Wider context from the report “1. The absence of a clear computerised record in the RLH departure lounge explaining the change of address.
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear safeguard ensuring vulnerable patients are discharged to the correct address
Wider context from the report “2. The lack of a clear safeguard to ensure that a vulnerable patient is discharged to the correct address .
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to properly monitor patients assessed as fed at risk
Wider context from the report “5. The proper monitoring of patients on RLH ward 14F who have been assessed as being “fed at risk” . Specifically, why was a vulnerable patient left with unsuitable foods within his reach .
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure of transport staff to properly assess venue suitability
Wider context from the report “3. The failure of RLH transport staff to properly assess the suitability of the venue that a patient is being taken to.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reiterate the Failed Visits policy and its reporting requirements to commissioned providers at the next provider forum.
Verbatim wording from the response “Three Sisters Care not informing the LA that they had been unable to provide care to MB as arranged.
The Failed Visits policy requires all commissioned domiciliary care providers to inform the local authority speedily of all occasions when the provider is unable to provide care as arranged because the provider does not seem to be at home or does not admit them. Commissioned providers are routinely reminded of the Failed Visits policy at quarterly providers meetings of the importance of adhering to the policy will be reiterated to them at the next forum. The quality of service provided by Three Sisters Care is currently under review with the lead commissioner requiring targets on an improvement plan to be met. Failure to achieve the standards required may result in the provider being de-commissioned.” Source location 2020-0160-Response-from-London-Borough-of-Tower-Hamlets.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the care provider’s service quality and require achievement of improvement-plan targets.
Verbatim wording from the response “Three Sisters Care not informing the LA that they had been unable to provide care to MB as arranged.
The Failed Visits policy requires all commissioned domiciliary care providers to inform the local authority speedily of all occasions when the provider is unable to provide care as arranged because the provider does not seem to be at home or does not admit them. Commissioned providers are routinely reminded of the Failed Visits policy at quarterly providers meetings of the importance of adhering to the policy will be reiterated to them at the next forum. The quality of service provided by Three Sisters Care is currently under review with the lead commissioner requiring targets on an improvement plan to be met. Failure to achieve the standards required may result in the provider being de-commissioned.” Source location 2020-0160-Response-from-London-Borough-of-Tower-Hamlets.pdf
Open published response
17 Feb 2020 Liam Floyd SEAGER · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Delays in implementing a traffic management order prohibiting pedestrian crossing on the A12 View source Unavailability of a pedestrian crossing on the A12 at Wick Lane View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Liam Floyd SEAGER · 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
Liam Floyd Seager was knocked over and killed by a transit van at approximately 3am on New Year’s Day 2019 while crossing the A12 southbound underpass. The concerns were the absence of a pedestrian crossing near the collision site, the delay before a traffic management order would prohibit pedestrians crossing there, and the need for preparatory work and a pedestrian crossing at Wick Lane.
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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Delays in implementing a traffic management order prohibiting pedestrian crossing on the A12
Wider context from the report “I heard at inquest that there is no pedestrian crossing on the A12 near the location of the collision.
1. Transport for London has indicated that it hopes to have a traffic management order in place by June 2020, which will prohibit pedestrians from crossing at this point. I am concerned that we are still four months away from this.
2. Once the traffic management order is in place, a pedestrian crossing is needed to make it easier for pedestrians to cross the top of the A12 at Wick Lane. Even before this, Tower Hamlets could undertake useful preparatory work to enable the build to proceed quickly following the TMO.
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a pedestrian crossing on the A12 at Wick Lane
Wider context from the report “I heard at inquest that there is no pedestrian crossing on the A12 near the location of the collision .
1. Transport for London has indicated that it hopes to have a traffic management order in place by June 2020, which will prohibit pedestrians from crossing at this point. I am concerned that we are still four months away from this.
2. Once the traffic management order is in place, a pedestrian crossing is needed to make it easier for pedestrians to cross the top of the A12 at Wick Lane . Even before this, Tower Hamlets could undertake useful preparatory work to enable the build to proceed quickly following the TMO.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce detailed plans for new pedestrian phases, protected crossing infrastructure, railings and additional pedestrian restriction signage at the A12/Wick Lane junction.
Verbatim wording from the response “Tower Hamlets Council has produced detailed plans for new pedestrian phases to be incorporated into the signalled junction of the A12 / Wick Lane to provide protected pedestrian crossing. These have been discussed with the Police and TfL and it is recognised that the railings around the crossing landing points at the top of the slip roads provide an additional deterrent to pedestrians seeking to cross the A12. The railings will also provide space for additional signage indicating that pedestrians are not permitted to walk along the A12.” Source location Response from Tower Hamlets Council
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Seek TfL approval to close the A12 slip roads for four days to enable necessary footway widening works.
Verbatim wording from the response “These works will commence once approval is secured from TfL to close the A12 slip roads for 4 days to facilitate the necessary footway widening work. Those approvals are being sought as a matter of urgency.” Source location Response from Tower Hamlets Council
Open published response
22 Nov 2019 Jonathan Jesutofumi Adebanjo · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Insufficiently conspicuous signs prohibiting swimming at the location View source Failure of swimming-prohibition signs to communicate the dangers of poor visibility, undercurrents and submerged rubbish View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Jonathan Jesutofumi Adebanjo · 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
Jonathan Jesutofumi Adebanjo drowned while swimming at Shadwell Basin after descending into the water by ladder. The concerns identified were that prohibition signs were too small and insufficiently obvious, and did not explain the dangers of poor underwater visibility, an undercurrent, and rubbish or discarded items below the surface.
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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Insufficiently conspicuous signs prohibiting swimming at the location
Wider context from the report “I am concerned that:
(a) The signs indicating that swimming is prohibited at the location should be larger and more obvious ;
(b) The content of the signs should indicate the reason why swimming is dangerous, namely the poor visibility, the presence of the undercurrent and the presence of rubbish and discarded items below the surface.
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure of swimming-prohibition signs to communicate the dangers of poor visibility, undercurrents and submerged rubbish
Wider context from the report “I am concerned that:
(a) The signs indicating that swimming is prohibited at the location should be larger and more obvious;
(b) The content of the signs should indicate the reason why swimming is dangerous , namely the poor visibility, the presence of the undercurrent and the presence of rubbish and discarded items below the surface .
” Open source report
25 Jun 2018 William Lugg · Prevention of Future Deaths report London Inner (North)
View report summary
Concerns raised 8 Failure to understand and follow the prescribed failed visits procedure View source Dissemination of inaccurate information about client welfare View source Failure of failed visits policies to give sufficient prominence to police involvement View source Absence of a clear system for assessing and deciding referral priority View source Failure to clearly record keyholder identity and contact details View source Failure of the provider’s failed visits procedure to reflect the prescribed procedure View source Failure to adequately record carer calls about failed visits View source Failure to record referral priority decision-making View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
William Lugg · 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
William Lugg lived alone and received daily care visits, but after an unwitnessed fall on or by the morning of 3 March 2018, carers received no answer and he was not found until 6 March 2018, when he was discovered deceased at his residence. The concerns included failures to follow and coordinate failed-visit procedures, inaccurate information about his welfare, inadequate recording of keyholder and call details, insufficient prominence given to contacting police, and the absence of a clear Monday-morning referral-prioritisation system.
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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to understand and follow the prescribed failed visits procedure
Wider context from the report “(1) Tower Hamlet’s Failed Visits Procedure was poorly understood and not followed by Careworld staff , in particular (though not limited to): (a) the appropriate means of alerting Tower Hamlets to failed care visits that occurred during a weekend ; and (b) use of the Tower Hamlet’s pro forma Failed Visit Record ;
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Dissemination of inaccurate information about client welfare
Wider context from the report “(4) No adequate record of calls from a carer to the Careworld Care Co-ordinator regarding failed visits was made, leading, in turn, to inaccurate information regarding the client’s welfare being disseminated to Tower Hamlets by another member of Careworld staff ;
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure of failed visits policies to give sufficient prominence to police involvement
Wider context from the report “(5) Neither Tower Hamlets or Careworld’s Failed Visits policy gives any / any sufficient prominence to the possibility of involving the police if other attempts to confirm the individual’s welfare following a failed visit have proved unsuccessful;
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear system for assessing and deciding referral priority
Wider context from the report “(6) The absence of a clear / clearly understood system for the Adult Social Care Team to use on a Monday morning for assessing and deciding the priority of referrals from the Out of hours service made over the weekend (and for recording this decision-making).
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to clearly record keyholder identity and contact details
Wider context from the report “(3) Vital information regarding the identity of and contact details for the only other keyholder to the premises in this instance was not clearly recorded by either Tower Hamlets or Careworld;
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure of the provider’s failed visits procedure to reflect the prescribed procedure
Wider context from the report “(2) Careworld’s own Failed Visits Procedure does not mirror or reflect aspects of Tower Hamlet’s prescribed procedure ;
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately record carer calls about failed visits
Wider context from the report “(4) No adequate record of calls from a carer to the Careworld Care Co-ordinator regarding failed visits was made , leading, in turn, to inaccurate information regarding the client’s welfare being disseminated to Tower Hamlets by another member of Careworld staff;
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to record referral priority decision-making
Wider context from the report “(6) The absence of a clear / clearly understood system for the Adult Social Care Team to use on a Monday morning for assessing and deciding the priority of referrals from the Out of hours service made over the weekend (and for recording this decision-making) .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add accessible emergency-contact, key-holder, mobility and related front-sheet information requirements to the Failed Visits Procedure.
Verbatim wording from the response “18. The revised policy addresses the above recommendation. It now includes a section on “being prepared” which highlights the importance of good record-keeping. This section in the procedure aims to ensure that services that may encounter a “failed visit” situation are equipped with the right information to enable them to act quickly and effectively. This includes, for example, the requirement to hold essential information such as the names, addresses and telephone numbers of emergency contacts, family and friends, the nearest key holder, any mobility issues and whether the person is known to leave their property or not. The procedure requires that this information be accessible to those who may need it, any time, day or night.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a referral-processing practice session addressing lessons from the case and implementation of the new procedure.
Verbatim wording from the response “23. The Referral Processing section in the Assessment & Intervention Team ran a practice session on 2 August 2018 where they looked at the lessons learned from Mr Lugg’s case and implementing the new procedure for their section.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Formally launch the revised Failed Visits Procedure to Adult Social Care staff and commissioned providers.
Verbatim wording from the response “17. The Council’s Failed Visits Procedure has been reviewed and following consultation, including with our provider services, it is being revised. The revised policy will be signed off and formally launched with the Adult Social Care and commissioned providers in August 2018.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a dedicated First Response Officer and updated referral-processing procedures for prioritising and escalating out-of-hours and failed-visit reports.
Verbatim wording from the response “22. The Assessment & Intervention Team (Adult Social Care) has reviewed its service delivery model and now has additional resources to cover the referral processing section. A First Response Officer is dedicated to managing the email referrals between the hours of 9am – 5pm, every day. This enables any urgent referrals to be picked up immediately. The officer prioritises the Emergency Duty Team (Out of Hours) reports and other failed visit reports each morning, including after a weekend. Any such” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a prominent emergency police-call checklist and clarify that any officer may call police when serious harm is suspected.
Verbatim wording from the response “20. The Council’s revised Failed Visits Procedure now includes a one-page checklist which makes more prominent the requirement to call the Police in an emergency situation, following some quick checks to locate the person:-” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ensure care providers are conversant with the Failed Visits Procedure.
Verbatim wording from the response “v) The care providers are required to follow a Failed Visit Procedure which requires them to check with various agencies such as the hospital, police, and next of kin while also alerting the local authority. As this does not appear to have been fully implemented in this case, the local authority now ensures care providers are conversant with the Failed Visit Procedure.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a single point of access for health and social care, including review of out-of-hours access and accessible case recording.
Verbatim wording from the response “• Developing a single point of access for health and social care which includes a review of the Out of Hours service. This will cover how the service is accessed as well as case recording which is accessible to those who need to see it.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Failed Visits Procedure following consultation with provider services.
Verbatim wording from the response “17. The Council’s Failed Visits Procedure has been reviewed and following consultation, including with our provider services, it is being revised. The revised policy will be signed off and formally launched with the Adult Social Care and commissioned providers in August 2018.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The failed visits procedure and staff competency requirements were clearly specified in commissioned home-care contracts.
Verbatim wording from the response “8. It is the Council’s view, that the requirement both to comply with the Council’s Failed Visits Procedure and to ensure that care staff are competent in complying with the said procedure is clearly specified.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
22 Jun 2018 Alexia Awenimi WALENKAKI · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to use appropriate wood in equipment View source Lack of clear accountability and continuity for annual inspections View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alexia Awenimi WALENKAKI · 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
Alexia Awenimi Walenkaki died after falling from a rope suspended from a wooden post that collapsed while she was playing in a children’s play area on 17 July 2015. The jury identified the use of inappropriate wood and organisational failure, including a lack of accountability for annual inspections, as causative factors. The coroner was concerned that unclear responsibility and continuity in management structures could lead to recurrence.
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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate wood in equipment
Wider context from the report “The jury identified two causative factors in the equipment failure that resulted in Alexia’s death:
- inadvertent use of inappropriate wood ;
- organisational failure and lack of accountability for annual inspections.
When one person was suspended and another went on maternity leave, there was no clear handover of responsibility for annual inspections. I fear that a lack clarity and continuity in terms of role demarcation and management structure may persist, particularly when staff move on.
Whilst I heard that there have been changes at Tower Hamlets since Alexia’s death, I am concerned that there is the potential for recurrence of the organisational failure identified by the jury.
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Lack of clear accountability and continuity for annual inspections
Wider context from the report “The jury identified two causative factors in the equipment failure that resulted in Alexia’s death:
- inadvertent use of inappropriate wood;
- organisational failure and lack of accountability for annual inspections .
When one person was suspended and another went on maternity leave, there was no clear handover of responsibility for annual inspections . I fear that a lack clarity and continuity in terms of role demarcation and management structure may persist, particularly when staff move on.
Whilst I heard that there have been changes at Tower Hamlets since Alexia’s death, I am concerned that there is the potential for recurrence of the organisational failure identified by the jury .
” Open source report
29 Dec 2015 Imran DOUGLAS · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Lack of social worker knowledge of Transition Plans View source Failure to ensure YOT and YJB knowledge and expertise are considered in placements before completion of the Transition Plan View source Lack of accessible universal records throughout the offender pathway View source Disconnection between Looked After Child pathway planning and Transition Planning View source Failure to propose clinical interventions View source Failure to record clinical history and examination View source Failure of social workers to communicate directly with secure estate staff View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Imran DOUGLAS · 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
Imran Douglas died by suicide on 13 November 2013, on the fifth day of his detention at HMP Belmarsh, after being sentenced to 18 years. The report identified concerns about transition and placement arrangements, communication and information-sharing between agencies, access to electronic records, and the adequacy of a medical assessment and response to suicide risk.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Lack of social worker knowledge of Transition Plans
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was . The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff. This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure YOT and YJB knowledge and expertise are considered in placements before completion of the Transition Plan
Wider context from the report “I consider that there is an outstanding risk that, when a rising 18 enters the criminal justice system with insufficient time for the normal Transition Plan, and especially when staff are under pressure, that even with the changes in placements from courts that have been made, and the Joint National Protocol, the knowledge and expertise of the YOT and YJB may not be properly considered in a placement if the legal duty for placement has passed to the PMU before the Plan is complete .
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Lack of accessible universal records throughout the offender pathway
Wider context from the report “The jury criticised the lack of access of HMP Belmarsh to the E Asset system and the fact that key documents from the Secure Training Centre were never accessed by the secure estate . The lack of a universal system of records throughout the offender’s pathway results in information on risk not being known to others and may contribute to future deaths.
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Disconnection between Looked After Child pathway planning and Transition Planning
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning . A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff. This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to propose clinical interventions
Wider context from the report “The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning form. The clinical review conducted as part of the Prison and Probation Ombudsman’s Report concluded that health care provision in HMP Belmarsh was below the standard expected.
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to record clinical history and examination
Wider context from the report “The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning form. The clinical review conducted as part of the Prison and Probation Ombudsman’s Report concluded that health care provision in HMP Belmarsh was below the standard expected.
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure of social workers to communicate directly with secure estate staff
Wider context from the report “Evidence pointed to a disconnection between Looked After Child pathway planning and Transition Planning. A social worker said that the LAC plan was “potentially informative” but did not matter if it was not completed, but that now it is regarded as key and should be shared. One social worker said she did not know what a Transition Plan was. The current Head of Children's Social Care at LB Tower Hamlets said that staff pressures at the time had eased somewhat, but that under her leadership the interface with the secure estate was through the YJB and so social workers do not directly talk to the secure estate staff . This was despite the requirement for the two to work together in the Youth to Adult Transitions Framework. Given the lack of documented communications of the risks and concerns between YOT and Feltham in 2013, this evidence throws doubt on the reported improvements in training and changes in interagency communication have been put into operation since.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update and recirculate guidance on transition planning, professional communication, information sharing, and detention placement plans by 31 March 2016.
Verbatim wording from the response “16. This is now being updated in light of the issues raised during the course of the request and will be recirculated by 31 March 2016 to all YOS and CSC teams, to specifically address the following issues:” Source location 2015-0446-Response-by-London-Borough-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the London Independent Reviewing Officer Managers Forum project to improve communication and partnership working with the secure estate.
Verbatim wording from the response “12. Additionally, Tower Hamlets is currently engaged in a project through the London Independent Reviewing Officer Managers Forum to improve communication and partnership working with the secure estate. ████████ Group Manager for the Independent Reviewing Officer (IRO) Service has visited Feltham Young Offenders Institute three times, and met with the Governor to discuss proposals to promote the welfare needs of young people in custody. Due to the success of this programme, similar meetings have now been scheduled with Cookham Wood YOI.” Source location 2015-0446-Response-by-London-Borough-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide training to managers and frontline staff to support implementation of the reviewed procedures and transition arrangements.
Verbatim wording from the response “10. The group has already reviewed the internal Risk Management Procedures, and has planned an agenda of work through to June 2016. This includes the consideration of the full range of procedures that impact on young people in secure placements, on remand and thus in the care of the Local Authority. It is also tasked with reviewing the transition process from the youth estate to the adult estate, in line with the Joint National Transitions Protocol for managing the cases of young people moving from Youth Offending Teams to Probation Services. Training will then be provided to managers and front line staff to support implementation.” Source location 2015-0446-Response-by-London-Borough-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver cross-service training for line managers, social workers and Youth Offending Service officers on remand, transition, risk management and secure-estate communication.
Verbatim wording from the response “17. A training session was provided on 8 February 2016 for line managers, social workers and YOS officers, which was well attended. In addition to giving an overview of the Legal Aid, Sentencing and Punishment of Offender Act 2012, the following topics were addressed:” Source location 2015-0446-Response-by-London-Borough-Tower-Hamlets
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The young person did not meet the threshold for an Adult Social Care Transition Plan and would not have received one in that context.
Verbatim wording from the response “with profound physical or learning disabilities transitioning to Adult Social Care provision. As ID’s care needs did not reach the threshold for Adult Social Care services because of the progress he had made since his car accident, he would not have been in receipt of a Transition Plan in this context. Further, because of the needs of the young people who ordinarily receive a service from the Children with Disabilities as such that they are extremely unlikely to be remanded or sentenced to custody, this team has never previously had a case where they have been involved with the secure estate. However, it is accepted that in these circumstances, greater care should have been taken by senior managers to ensure that the allocated team was supported to understand that additional requirements of meeting the needs of a young person on remand.” Source location 2015-0446-Response-by-London-Borough-Tower-Hamlets
Open published response
28 Dec 2014 Alex Kelly · Prevention of Future Deaths report Mid Kent and Medway
View report summary
Concerns raised 28 Failure to provide complete information and records for safer regimes meetings View source Failure to verify medication ingestion before recording administration View source Failure to transfer documentation and emails onto Framework View source Failure to recognise distress communicated through behaviour View source Failure to recognise conflict between behaviour plans and adjudications View source Failure of YOT keyworkers to understand custodial welfare responsibilities View source Failure to use holistic safe-management planning when interventions are ineffective View source Inflexible cell-entry requirements during urgent safeguarding concerns View source Lack of forensic psychiatric assessment before custodial placement View source Conflict between ACCT and disciplinary procedures View source Delays in allocating a named social worker and escalating allocation difficulties View source Incomplete recording of mental-health in-reach contacts on System One View source Failure to share medication non-compliance and its potential effects View source Lack of a system for flagging or diverting urgent communications during staff absence View source Failure to seek advice before disciplinary action indicated increased self-harm risk View source Failure to understand available safe-management options View source Failure to highlight significant events in ongoing safeguarding records View source Failure to involve outside agencies and carers in safeguarding View source Failure to reconcile inconsistent secure-placement recommendations View source Failure to inform and involve agencies and carers in custodial welfare management View source Failure of ACCT reviews to address reasons for behaviour View source Failure to understand YOT authority to initiate secure-estate transfers View source Failure to escalate interagency shortcomings affecting YOT management View source Failure to adopt a holistic approach to custodial support View source Failure to understand corporate parenting responsibilities for children in custody View source Inconsistent recording of significant events across safeguarding records View source Failure to flag medication non-compliance for clinical and custodial action View source Failure to recognise or report significant incidents and disclosures View source See 25 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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 London Borough of Tower Hamlets; 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
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain social-worker staffing levels and smaller caseloads to support allocation of a worker to every looked-after child.
Verbatim wording from the response “6. Children’s Social Care Services in Tower Hamlets has a clear expectation that all children and young people looked after by the council will have an allocated social worker. The number of social workers in the teams providing this service have been maintained despite a reduction in the number of looked after children and this has been reflected in smaller case loads. Managers within the service are clear that ensuring that all looked after children have an allocated social worker is one of their primary responsibilities.” Source location 2014-0555-Response-by-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Framework I process changes to improve recording usability and reinforce timely information uploading through guidance, briefings, case audits and management oversight.
Verbatim wording from the response “11. The case recording system used in Tower Hamlets, Framework I, is acknowledged to be one of the more user friendly software systems available. There is not an alternative available that would offer significant benefits to staff in terms of ease of use or the automation of routine tasks. Managers and staff have developed and implemented changes to the processes within Framework I to improve its ease of use.” Source location 2014-0555-Response-by-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require absent staff to provide return dates and emergency contacts in email messages, with reminders repeated every three months.
Verbatim wording from the response “15. Managers and Social Work Staff have been reminded of the need to ensure that if they are going to be absent from work, they must ensure that a message is placed on their email account to indicate when they will return to work and who to contact in the event of an emergency. Reminders will be repeated every three months.” Source location 2014-0555-Response-by-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor worker allocation through monthly management reports and require urgent investigation when vulnerable children appear unallocated.
Verbatim wording from the response “7. The Children’s Social Care Management Team receives a monthly report providing information about all children and young people receiving a service. This includes confirmation of the allocation of looked after children (and children subject to a protection plan); if the performance report shows that any of these vulnerable children appears to be without an allocated worker, then the responsible senior manager is required to investigate this as a matter of urgency. There have not been any unallocated looked after children over the course of the last 3 years, other than the brief period in which they are being transferred between social work staff / social work teams.” Source location 2014-0555-Response-by-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Instruct managers to request out-of-office messages for unexpectedly absent staff and audit absent staff email accounts.
Verbatim wording from the response “16. Unfortunately, it is more complicated to make similar arrangements for members of staff who are away from work unexpectedly, e.g. because of ill health. Some staff have access to their email accounts from home or via a mobile device and can add an “out of office” message from home in the event of unexpected absence from work. However, not all staff have this facility and because access to the council’s email system requires triple authentication together with a requirement to treat all passwords confidentially, they cannot arrange for somebody else to do this on their behalf. Managers have therefore been instructed that, in the event of the unexpected absence of a member of staff, they should request that an out of office message is added to the email account of the absent member of staff by the Council’s information technology provider.” Source location 2014-0555-Response-by-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind managers to complete case transfers efficiently and maintain an identified key worker for every case.
Verbatim wording from the response “8. Since the completion of the organisational restructure in January 2012, Service and Team Managers have been reminded of the need to ensure that case transfer is undertaken in an efficient and timely manner and that there is always an identified key worker for each case.” Source location 2014-0555-Response-by-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Devise, update and launch a joint social-care and Youth Offending Service protocol defining responsibilities for looked-after young people in custody.
Verbatim wording from the response “19. The Children’s Social Care Service and the local Youth Offending Service have devised a protocol setting out clearly the responsibilities of each service in the event that a young person receives a custodial sentence which has been updated to take account of changes in the legislative framework. The launch of the revised protocol provided an opportunity to remind Social Work staff that a custodial sentence does not remove their statutory responsibilities towards a looked after child although they may not be able to fully exercise those responsibilities.” Source location 2014-0555-Response-by-Tower-Hamlets
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate an escalation policy using management alerts for failures to implement looked-after children’s plans, including social-worker allocation.
Verbatim wording from the response “9. The Head of Service has written to all of the Independent Reviewing Officers to remind them of their responsibility to raise any concerns about case allocation and planning to Team and Service Managers and ultimately to the Head of Service via an escalation policy. This escalation policy is based upon the use of alerts to draw to the attention of first line, middle and senior managers the failure to implement any part of the plan for a looked after child, including allocation to a social worker. The escalation policy was reviewed and updated in 2013 and has been used to highlight concerns about the lack of progress in the implementation of plans for some looked after children.” Source location 2014-0555-Response-by-Tower-Hamlets
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Unexpected absence alerts cannot be activated immediately because authentication and password controls prevent others adding messages, causing delays of up to a week.
Verbatim wording from the response “16. Unfortunately, it is more complicated to make similar arrangements for members of staff who are away from work unexpectedly, e.g. because of ill health. Some staff have access to their email accounts from home or via a mobile device and can add an “out of office” message from home in the event of unexpected absence from work. However, not all staff have this facility and because access to the council’s email system requires triple authentication together with a requirement to treat all passwords confidentially, they cannot arrange for somebody else to do this on their behalf. Managers have therefore been instructed that, in the event of the unexpected absence of a member of staff, they should request that an out of office message is added to the email account of the absent member of staff by the Council’s information technology provider.” Source location 2014-0555-Response-by-Tower-Hamlets
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replacing Framework I is not pursued because no alternative system offers significant benefits in usability or routine-task automation.
Verbatim wording from the response “10. Children’s Social Care recording systems have become increasingly complex with the need to ensure that a wide range of guidance and regulation is adhered to, data captured and records maintained. There is a balance to be achieved between social work time spent in front of a computer recording this information and direct contact with the children, young people and families for whom a social worker is responsible, as was pointed out by Professor Eileen Munro in her review of child protection service published in 2010.” Source location 2014-0555-Response-by-Tower-Hamlets
Open published response
7 Jul 2014 Harold George de Mello · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 9 Lack of guidance on assessment conduct and recording View source Inaccurate and incomplete recording of carers and care arrangements View source Failure to assess suitability of a commode for the service user View source Inconsistent recording between assessments and correspondence View source Failure to reconcile assessments with referral and historical information View source Failure of senior review of assessments against referral information View source Failure to conduct comprehensive assessments addressing referral concerns View source Lack of good practice guidelines for assessments View source Failure to verify care arrangements and support needs View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Harold George de Mello · 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
Harold George de Mello, who had multiple co-morbidities, limited mobility and incontinence, died in hospital on 13 April 2014 after collapsing at home and being treated for bronchopneumonia. The principal concerns were that social-care assessments did not adequately investigate or record the reported incontinence, hygiene problems, care arrangements and differing information, and lacked sufficiently comprehensive guidance and senior review.
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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on assessment conduct and recording
Wider context from the report “(6) guidelines should, therefore, refer to both the manner and the recording of the assessments and senior colleagues should thoroughly check assessments against the referrals or reports made
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and incomplete recording of carers and care arrangements
Wider context from the report “(4) that no reference was made to any of the people to whom the service user referred as being carers , that information was wrongly recorded (a person wrongly described as a niece who was not a relative) and that there is a significant difference in the fact that the visit assessment suggests that the deceased had adequate social care whilst also noting that a ‘carer’ was not fit and able to undertake domestic tasks. That no investigation was properly made into the actual care available to Mr de Mello and no contact made with either the claimed carer or the relative with power of attorney to confirm the reality of his situation and the extent of his dependence or needs
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to assess suitability of a commode for the service user
Wider context from the report “(5) that there was a difference in the actions recorded in the assessment (apparently the ordering of urine bottles) and the letter written to Mr de Mello stating that a commode had been ordered and no consideration of whether he could use a commode
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Inconsistent recording between assessments and correspondence
Wider context from the report “(5) that there was a difference in the actions recorded in the assessment (apparently the ordering of urine bottles) and the letter written to Mr de Mello stating that a commode had been ordered and no consideration of whether he could use a commode
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to reconcile assessments with referral and historical information
Wider context from the report “(3) that, given that a conclusion was made that there would be no social care provided, the assessment was made (and signed off by a senior colleague) without any reference to the rather different reports from the referrer and in the deceased’s historical record . There is an incongruence between the claimed observations of the First Response Officer and the information that led to the assessment that was not explored
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure of senior review of assessments against referral information
Wider context from the report “(6) guidelines should, therefore, refer to both the manner and the recording of the assessments and senior colleagues should thoroughly check assessments against the referrals or reports made
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct comprehensive assessments addressing referral concerns
Wider context from the report “(2) a First Response Officer could go to a person’s home, could be told that it was OK to look in the occupant’s bedroom but feels it is ‘inappropriate’ to do so despite the fact that there have been concerns about the service user’s incontinence and personal hygiene from the referrer including a report as to the bedding being soiled with urine and faeces . Assessments should be made bearing in mind the referral and the actual concerns made and should be comprehensive , particularly when a service user has agreed to the assessment and examination proposed
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Lack of good practice guidelines for assessments
Wider context from the report “(1) that there are no good practice guidelines for assessments that are being carried out leading to the fact that:
” 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 London Borough of Tower Hamlets; that does not assign responsibility.
PFD Monitor interpretation Failure to verify care arrangements and support needs
Wider context from the report “(4) that no reference was made to any of the people to whom the service user referred as being carers, that information was wrongly recorded (a person wrongly described as a niece who was not a relative) and that there is a significant difference in the fact that the visit assessment suggests that the deceased had adequate social care whilst also noting that a ‘carer’ was not fit and able to undertake domestic tasks. That no investigation was properly made into the actual care available to Mr de Mello and no contact made with either the claimed carer or the relative with power of attorney to confirm the reality of his situation and the extent of his dependence or needs
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver targeted Critical/Cumulative Analysis training to staff.
Verbatim wording from the response “A programme of targeted Critical/Cumulative Analysis training with staff members has been scheduled for December 2014.” Source location 2014-0449-Response-by-Tower-Hamlets-Local-Authority
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an eco-mapping tool to identify support networks, gaps, risks and factors affecting informed decision-making.
Verbatim wording from the response “Introduction of an eco-mapping tool which facilitates identification of a person’s support network thereby ensuring quality, informed decision making and risks are appropriately identified and managed. The tool will support practitioners to consider: Who and what agencies are involved? What is helping? What is hindering? Where are the gaps in support?” Source location 2014-0449-Response-by-Tower-Hamlets-Local-Authority
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop multi-agency practice guidance for intervening with and supporting people at risk of self-neglect and poor environmental hygiene.
Verbatim wording from the response “With the implementation of the Care Act in April 2015 the London Borough of Tower Hamlets are in the formal process of developing:” Source location 2014-0449-Response-by-Tower-Hamlets-Local-Authority
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a mandatory electronic-record section documenting informal carers’ views and involvement in assessments.
Verbatim wording from the response “Introduction of a new mandatory Carers’ Views section in the electronic record (Framework) which records informal carer involvement thereby ensuring all supportive networks are considered as part of the assessment process. This will reduce risk of carers not being involved in the assessment process in the future. | Adult Social Care Dept. | Completed” Source location 2014-0449-Response-by-Tower-Hamlets-Local-Authority
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the internal management review, action plan and lessons learned to managers and relevant frontline staff for discussion and implementation.
Verbatim wording from the response “Immediate Practice Improvements | Disseminate internal management review and action plan to management team:” Source location 2014-0449-Response-by-Tower-Hamlets-Local-Authority
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a new assessment and eligibility framework informed by best-practice guidance under the Care Act implementation workstream.
Verbatim wording from the response “Care Act Implementation April 2015 - Development of new practice framework.” Source location 2014-0449-Response-by-Tower-Hamlets-Local-Authority
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations