PFD report

Alex Kelly · Prevention of Future Deaths report

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Issued 28 Dec 2014•Mid Kent and Medway

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
28

Raised in this report

Recipients
5

Named on the report

Responses found
5

Of 5 recipients

Stated actions
45

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised28

  1. Failure to provide complete information and records for safer regimes meetings
  2. Failure to verify medication ingestion before recording administration
    Part of recurring concern: Unsafe medication administration
  3. Failure to transfer documentation and emails onto Framework
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.32

  1. Action

    Revise behaviour improvement plans and review them through the safer-regimes meeting to prevent conflicts with adjudication processes.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  2. Action

    Introduce a more rigorous ACCT quality-assurance process with individual feedback to case managers.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  3. Action

    Expand safer-regimes meeting participation, establish new terms of reference and ensure required information is available before minutes are published.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    The ACCT process is not inherently unfit for use with young people; identified implementation deficiencies have been addressed through guidance and quality assurance.

    Stated by HM Prison and Probation ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Unsafe medication administration.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Failure to recognise distress and increased risk communicated through behaviour.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Unreliable emergency cell-entry arrangements in prisons.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Unreliable forensic psychiatric assessment pathways for criminal-justice placement decisions.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Unreliable access to required social-worker support.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Ineffective prison suicide and self-harm prevention systems.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Failure to maintain effective safeguarding review and monitoring; Unreliable recording of significant incidents and disclosures.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in safety-critical care decisions; Inadequate multi-agency safeguarding coordination.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Unreliable inter-agency information sharing for coordinated care.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Unreliable ACCT suicide and self-harm prevention processes.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Failure to ensure safe prisoner transfers.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Unreliable recording of safeguarding information; Unreliable recording of significant incidents and disclosures.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

Yes — Unsafe interoperability between prison custody and healthcare procedures.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Revise behaviour improvement plans and review them through the safer-regimes meeting to prevent conflicts with adjudication processes.

Verbatim wording from the response

“The behaviour improvement plans in use at HMYOI Cookham Wood have been revised and are reviewed at the safer regimes meeting described above to ensure that there is no conflict between the plan developed to support a young person and the use of the adjudications process.”

Source location

2014-0555-Response-by-Ministry-of-Justice
Page 6 · response
Published 28 December 2014

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 more rigorous ACCT quality-assurance process with individual feedback to case managers.

Verbatim wording from the response

“As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.”

Source location

2014-0555-Response-by-Ministry-of-Justice
Page 5 · response
Published 28 December 2014

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

Expand safer-regimes meeting participation, establish new terms of reference and ensure required information is available before minutes are published.

Verbatim wording from the response

“In your report you also expressed your concern about information not being shared with the safer prisons meeting. New terms of reference have been developed for this meeting and a broader range of professionals now attend the safer regimes meeting, including practitioners from physical and mental healthcare providers, the psychology department, the substance misuse service, the education provider and the chaplaincy, as well as representatives from the residential, safeguarding and security functions within the establishment. The meetings are chaired by the Head of Residence who is responsible for ensuring that all members have all the information that they require, as well as agreeing the minutes of the meetings before they are published.”

Source location

2014-0555-Response-by-Ministry-of-Justice
Page 5 · response
Published 28 December 2014

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 ongoing ACCT refresher training to staff and train Supervising Officers as ACCT case managers.

Verbatim wording from the response

“All staff at HMYOI Cookham Wood who are in direct contact with young people receive the Introduction to Safer Custody training as part of prison officer entry level training or during their induction. This is an introductory course that gives a general introduction to safer custody, including suicide prevention, self-harm management and violence, and the different roles and processes related to it.”

Source location

2014-0555-Response-by-Ministry-of-Justice
Page 5 · response
Published 28 December 2014

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

Formulate an information-sharing protocol covering all relevant agencies providing services at HMYOI Cookham Wood.

Verbatim wording from the response

“The responses from Oxleas NHS Trust and the Central and North West London (CNWL) NHS Foundation Trust have responded in detail to the concerns that you addressed to healthcare at HMYOI Cookham Wood, but I would like to add one point with regard to the sharing of information.”

Source location

2014-0555-Response-by-Ministry-of-Justice
Page 6 · response
Published 28 December 2014

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

Publish guidance reminding staff to present ACCT plans at adjudications so self-harm risks inform adjudication decisions.

Verbatim wording from the response

“The third concern that you have addressed to the Governor of HMYOI Cookham Wood relates to what you describe as a conflict between regimes, in the sense that the ACCT process and behaviour improvement plan were not sufficiently joined up with the adjudications process.”

Source location

2014-0555-Response-by-Ministry-of-Justice
Page 5 · response
Published 28 December 2014

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 establishment’s information-sharing policy to ensure it reflects current legislation and best practice.

Verbatim wording from the response

“Prison Service Instruction (PSI) 08/2012 Care and Management of Young People sets out a requirement for each under 18 YOI to have an information sharing policy to ensure that relevant information is shared with professionals, parents or carers and others, at appropriate intervals. HMYOI Cookham Wood has such a policy, and the Governor is currently conducting the annual review that is undertaken to ensure that it always reflects current legislation and best practice. It mandates that information is shared with families and other appropriate bodies or persons (for example, the YOT), on each of the following occasions:”

Source location

2014-0555-Response-by-Ministry-of-Justice
Page 4 · response
Published 28 December 2014

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 a standardised multidisciplinary casework model across the Young People’s Estate, including coordinated resettlement and transition planning.

Verbatim wording from the response

“You will be aware that the death of Alex Kelly was one of three tragic deaths of young people that occurred in 2011-2012, and that in response to these deaths a range of actions were taken to improve the care and management of young people. This letter will focus on the actions that are relevant to your concerns, but before doing so it may be helpful to provide you with some information about a broader programme of reform currently being undertaken in the NOMS Young People’s Estate (YPE). This touches on a wide range of operational policies and practices, and will see fundamental changes made to the way in which the core day is structured in the YPE in order to support delivery of an enhanced regime that will provide young people with increased access to education and twice as much time in the open air each day.”

Source location

2014-0555-Response-by-Ministry-of-Justice
Page 1 · response
Published 28 December 2014

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

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
Page 1 · response
Published 28 December 2014

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
Page 2 · response
Published 28 December 2014

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
Page 3 · response
Published 28 December 2014

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
Page 2 · response
Published 28 December 2014

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
Page 3 · response
Published 28 December 2014

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
Page 2 · response
Published 28 December 2014

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
Page 4 · response
Published 28 December 2014

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
Page 2 · response
Published 28 December 2014

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

Dispense most medication under supervision, use liquid medication where risk assessment indicates, and verify ingestion before recording administration.

Verbatim wording from the response

“The majority of medications are now dispensed under supervised conditions and, where risk assessment deems it appropriate, in liquid form. Young people are asked to demonstrate the medication has been taken by opening their mouths. Staff will only then record that the medication has been administered using the electronic clinical record (SystmOne). If there are concerns about the possible diversion or failure to ingest medication, this is recorded and the relevant persons notified. This includes completing a security report and informing wing staff and other clinicians, such as CAMHS.”

Source location

2014-0555-Response-by-Oxleas-NHS-Trust
Page 2 · response
Published 28 December 2014

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

Record medication refusal, non-attendance, diversion or failed ingestion and notify relevant healthcare and custodial staff.

Verbatim wording from the response

“Healthcare staff are aware of the need to inform all those involved in the management of a young person about their compliance with medication and to record such issues within the medical record and other prison documentation – ACCT, NOMIS and wing observation book. All healthcare staff complete mandatory trust and HMPS Information Governance training, which also includes information sharing guidelines. The process is embedded in established clinical and safer custody forums.”

Source location

2014-0555-Response-by-Oxleas-NHS-Trust
Page 2 · response
Published 28 December 2014

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

Share young people’s medication compliance information with those involved in their management and record it in clinical and prison documentation.

Verbatim wording from the response

“Healthcare staff are aware of the need to inform all those involved in the management of a young person about their compliance with medication and to record such issues within the medical record and other prison documentation – ACCT, NOMIS and wing observation book. All healthcare staff complete mandatory trust and HMPS Information Governance training, which also includes information sharing guidelines. The process is embedded in established clinical and safer custody forums.”

Source location

2014-0555-Response-by-Oxleas-NHS-Trust
Page 2 · response
Published 28 December 2014

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 a YOT escalation policy for reporting shortcomings in other agencies to management, with annual management review and monitoring.

Verbatim wording from the response

“Point 1,a; this issue was identified within the IMR and SCR. As a result of these publications a YOT escalation policy was formulated and has operated successfully since March 2013. A copy of the escalation policy is attached at Annex 2. The policy will be reviewed and its implementation monitored by YOT management on an annual basis.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 3 · response
Published 28 December 2014

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 case workers to undertake annual ACCT and enhanced-review training, with attendance recorded and monitored by the YOT Manager.

Verbatim wording from the response

“All Case Workers are now obliged to attend annual training in relation to the ACCT process and the use of enhanced reviews. A record of this training is maintained and monitored by the YOT Manager at Cookham Wood.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 5 · response
Published 28 December 2014

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

Arrange ACCT training for the Resettlement Team.

Verbatim wording from the response

“ACCT training has been arranged, facilitated by Cookham Woods ACCT trainers for the Resettlement Team as a whole.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 5 · response
Published 28 December 2014

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 case workers with accommodation and transfer guidance and require placement suitability to be considered at remand and sentence-planning meetings and reviews.

Verbatim wording from the response

“The Case Workers have now received guidance from the YJB in relation to the types of accommodation available and new referral process to transfer a young person if needed. At all Remand and Sentence planning meetings/reviews attendees discuss whether Cookham Wood and/or the equivalent establishment is the appropriate placement for the young person as requested by the Placement Review and Transfer Protocol, YJB Placement Service (June 2013). This new policy lays down the process by which a transfer request may be made. However, the final decision sits with the YJB placements Team.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 5 · response
Published 28 December 2014

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop and present training for Cookham Wood case-holding staff on welfare responsibilities and available welfare options.

Verbatim wording from the response

“Point 3,b; Training is to be developed and presented to all case holding staff by the YOT Manager at Cookham Wood. This will establish the welfare responsibilities of Case Work Team staff and others in the establishment in respect of the welfare options and responsibilities towards young people in custody.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 5 · response
Published 28 December 2014

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 custody-transfer training to relevant staff and produce and cascade supporting flowcharts and guidance notes.

Verbatim wording from the response

“Point 2,c; In conjunction with 2,b, training will be delivered to all case holding practitioners and all other members of YOT staff who may have contact with a young person in custody to ensure they fully understand the arrangements in place to request a move from one custodial establishment to another. A flow chart and guidance notes will be produced and cascaded to all practitioners. This training and documentation will be completed by April 2015. Documentation will be available to the Coroner, if so required upon completion.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 3 · response
Published 28 December 2014

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 Cookham Wood case workers to facilitate regular community visits, significant-incident updates, and community and parental participation in ACCT reviews.

Verbatim wording from the response

“Point 3,a; The arrangements now in place, require Case Workers at Cookham Wood, to encourage the external YOT and Social Workers (where a Looked After Child (LAC)) to visit young persons in custody at least monthly, to meet with the young”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 3 · response
Published 28 December 2014

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 all case workers with current guidance on planning, intervention delivery and resettlement, and require them to work to it.

Verbatim wording from the response

“New guidance for National Standards for Youth Justice Services 2013 has been produced by the YJB in relation to Planning and Delivery of Interventions and resettlement. All case workers have received a copy and work to this new guidance.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 5 · response
Published 28 December 2014

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 on YOT welfare responsibilities for practitioners working with young people in custody or remand.

Verbatim wording from the response

“Point 2,b; Training is being arranged by one of the YOT Senior Practitioners to update case holders and/or other members of the YOT who may have contact with a young person in custody or remand, of their ongoing responsibility towards their clients when they pass into remand or custody. This will highlight the range of welfare responsibilities in addition to those outlined in the National Standards for Youth Justice. This training will be completed by April 2015.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 3 · response
Published 28 December 2014

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

Record all mental-health clinical contacts on Systm1 and use line-manager checks, staff training, and care documentation standards to support accurate records.

Verbatim wording from the response

“As described above, all clinical contact by the Health and Wellbeing (mental health) Team is recorded on Systm1. Office space and access to IT has improved. In August 2014, the new team relocated to a recently refurbished room which has four new computers. All staff members have a direct line manager with supervisory responsibility. Line managers are responsible for checking staff entries made on Systm1 so that accurate and timely entries are made, which demonstrate appropriate care planning, risk management and information sharing. All new team members have received training to use Systm1, and an annual record keeping audit will serve to monitor documentation standards.”

Source location

2014-0555-Response-by-Central-North-West-London-NHS-Trust
Page 3 · response
Published 28 December 2014

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

Conduct an annual record-keeping audit to monitor documentation standards.

Verbatim wording from the response

“As described above, all clinical contact by the Health and Wellbeing (mental health) Team is recorded on Systm1. Office space and access to IT has improved. In August 2014, the new team relocated to a recently refurbished room which has four new computers. All staff members have a direct line manager with supervisory responsibility. Line managers are responsible for checking staff entries made on Systm1 so that accurate and timely entries are made, which demonstrate appropriate care planning, risk management and information sharing. All new team members have received training to use Systm1, and an annual record keeping audit will serve to monitor documentation standards.”

Source location

2014-0555-Response-by-Central-North-West-London-NHS-Trust
Page 3 · response
Published 28 December 2014

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

Complete information-governance training for all staff to support appropriate sharing of healthcare information.

Verbatim wording from the response

“All of our staff have completed information governance training and have robust policies to refer to, and assist them to make the appropriate decision about when and how to share important healthcare information with other parties, both inside, and outside HMYOI Cookham Wood. All clinical information is documented on the IT program Systm1, which is shared with other healthcare providers working within the establishment – namely, Oxleas NHS Foundation Trust. Information that is shared with other parties on a ‘need to know’ basis is conveyed in person and recorded on P-NOMIS (the IT program used by HM Prison Service staff), Wing / Unit Officer’s observation books and in ACCT folders.”

Source location

2014-0555-Response-by-Central-North-West-London-NHS-Trust
Page 2 · response
Published 28 December 2014

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

Share medication non-compliance concerns through cross-agency handovers, electronic tasks, prison communication records, and relevant safeguarding processes.

Verbatim wording from the response

“Our healthcare staff are acutely aware that non-compliance with certain prescribed medications may indicate that a young person’s mental state has deteriorated, or that it may deteriorate in future. This can result in planned or impulsive self-harm or suicidal acts. Healthcare staff are therefore required to share this knowledge with other partners for patients receiving psychotropic and other potentially harmful medications.”

Source location

2014-0555-Response-by-Central-North-West-London-NHS-Trust
Page 2 · response
Published 28 December 2014

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 ACCT process is not inherently unfit for use with young people; identified implementation deficiencies have been addressed through guidance and quality assurance.

Verbatim wording from the response

“As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.”

Source location

2014-0555-Response-by-Ministry-of-Justice
Page 5 · response
Published 28 December 2014

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
Page 3 · response
Published 28 December 2014

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
Page 2 · response
Published 28 December 2014

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

CNWL, the current provider of child and adolescent mental health services, is assigned the relevant follow-up responsibility.

Verbatim wording from the response

“As you have identified within your report, Oxleas NHS Foundation Trust was not the provider of healthcare at the time of this young man’s death. We began to provide primary care services in HMPYOI Cookham Wood in April 2014. On the same date Central and North West London (CNWL) NHS Foundation Trust were awarded the contract to provide the Child and Adolescent Mental Health Service to Cookham Wood. I am therefore copying your report and this response to the chief executive of CNWL.”

Source location

2014-0555-Response-by-Oxleas-NHS-Trust
Page 1 · response
Published 28 December 2014

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 Youth Justice Board placements team has final authority to decide requests to transfer a young person between custodial establishments.

Verbatim wording from the response

“The Case Workers have now received guidance from the YJB in relation to the types of accommodation available and new referral process to transfer a young person if needed. At all Remand and Sentence planning meetings/reviews attendees discuss whether Cookham Wood and/or the equivalent establishment is the appropriate placement for the young person as requested by the Placement Review and Transfer Protocol, YJB Placement Service (June 2013). This new policy lays down the process by which a transfer request may be made. However, the final decision sits with the YJB placements Team.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 5 · response
Published 28 December 2014

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

Responsibility for administering prescribed medication rests with Oxleas NHS Foundation Trust, while CNWL provides urgent review when non-compliance is reported.

Verbatim wording from the response

“Oxleas NHS Foundation Trust have responded in detail on this point, as it is their staff who administered prescribed medications in HMYOI Cookham Wood. However, it is our responsibility to provide urgent medical and psychological review of young people who we are informed are non-compliant with prescribed medication, as they could be; a) ‘stockpiling’ medication with which to overdose, b) ‘trading’ it as an abusable commodity, c) they may feel that the medication is simply not helping them.”

Source location

2014-0555-Response-by-Central-North-West-London-NHS-Trust
Page 3 · response
Published 28 December 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.13

  1. 1

    Operate the Comprehensive Health Assessment Tool for new admissions, with trained staff, prompt screening, follow-up assessments and effectiveness standards.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  2. 2

    Train all staff to use the CHAT tool.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  3. 3

    Monitor CHAT assessment use through implemented standards.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  4. 4

    Assess every arriving child with the CHAT tool and allocate a key worker when indicated.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  5. 5

    Refer medication refusal or non-attendance to the initiating specialty for care-plan review, updating and further advice.

    Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  6. 6

    Require senior-manager approval and monitoring of all placement alerts and recommendations before submission to the Youth Justice Board.

    Stated by Medway Council (Youth Offending TeamStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  7. 7

    Produce an agency action plan addressing findings from the individual management and serious case reviews.

    Stated by Medway Council (Youth Offending TeamStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  8. 8

    Deliver gatekeeping-procedure training to YOT employees through regular team meetings.

    Stated by Medway Council (Youth Offending TeamStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  9. 9

    Submit eligible early-release paperwork to the Governor for consideration regardless of compliance with the sentence plan, and discuss progress at sentence-planning reviews.

    Stated by Medway Council (Youth Offending TeamStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  10. 10

    Review remand and custody applications and outcomes through quarterly quality-assurance reviews.

    Stated by Medway Council (Youth Offending TeamStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  11. 11

    Deliver an embedded multidisciplinary child and adolescent mental health service with increased staffing capacity at HMYOI Cookham Wood.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  12. 12

    Provide improved office space, IT access, and four computers for the mental-health team.

    Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2014.
  13. 13

    Provide urgent medical and psychological review for young people reported as non-compliant with prescribed medication.

    Stated by Central and North West London NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 28 December 2014.

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 the Comprehensive Health Assessment Tool for new admissions, with trained staff, prompt screening, follow-up assessments and effectiveness standards.

Verbatim wording from the response

“I am aware that in response to your report Oxleas NHS Foundation Trust (which, as you are aware, was not the provider of healthcare services at the time of Mr Kelly’s death) explained that the Comprehensive Health Assessment Tool (CHAT) is in use for all new admissions at HMYOI Cookham Wood.”

Source location

2014-0555-Response-by-Ministry-of-Justice
Page 2 · response
Published 28 December 2014

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

Train all staff to use the CHAT tool.

Verbatim wording from the response

“All staff have been trained in the use of CHAT and we have implemented a series of standards to ensure that we monitor its use and implementation. All new admissions to the prison are offered these assessments and the take up rate is over 98%. Those who initially refuse are approached to be assessed at a later date.”

Source location

2014-0555-Response-by-Oxleas-NHS-Trust
Page 1 · response
Published 28 December 2014

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 CHAT assessment use through implemented standards.

Verbatim wording from the response

“All staff have been trained in the use of CHAT and we have implemented a series of standards to ensure that we monitor its use and implementation. All new admissions to the prison are offered these assessments and the take up rate is over 98%. Those who initially refuse are approached to be assessed at a later date.”

Source location

2014-0555-Response-by-Oxleas-NHS-Trust
Page 1 · response
Published 28 December 2014

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

Assess every arriving child with the CHAT tool and allocate a key worker when indicated.

Verbatim wording from the response

“I would like to begin by confirming that every child who arrives at Cookham Wood is assessed by our staff using a Comprehensive Health Assessment Tool commonly known as the CHAT Tool. This is an evidence based assessment tool addressing physical health, substance misuse, and mental health issues. If indicated by this assessment, a key worker is allocated to the child with responsibility for care planning and ensuring the young person’s needs are met.”

Source location

2014-0555-Response-by-Oxleas-NHS-Trust
Page 1 · response
Published 28 December 2014

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

Refer medication refusal or non-attendance to the initiating specialty for care-plan review, updating and further advice.

Verbatim wording from the response

“Information is shared and recorded as detailed above. A young person’s failure to take medication due to refusal or non-attendance generates a referral to the specialty which initiated the treatment. They, in turn, review and update the individual’s care plan as well as providing further advice.”

Source location

2014-0555-Response-by-Oxleas-NHS-Trust
Page 2 · response
Published 28 December 2014

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 senior-manager approval and monitoring of all placement alerts and recommendations before submission to the Youth Justice Board.

Verbatim wording from the response

“Point 2,a; There is now a procedural requirement for all placement alerts to the Youth Justice Board to be monitored by a YOT Senior Manager, to approve the placement recommendation prior to submission. In practice, the Duty Manager undertakes this for that day. The Court Officer will contact the Duty Manager from court to inform him/her that there is a possibility of remand or custody. The draft placement alert is then viewed electronically for approval or amendment. Where there is a possibility of remand or custody identified in a Pre Sentence Report, then this is brought to the attention of the Duty Manager via the pre court planning meeting held weekly.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 3 · response
Published 28 December 2014

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

Produce an agency action plan addressing findings from the individual management and serious case reviews.

Verbatim wording from the response

“Following the death of Alex Kelly, Medway have produced an Agency action plan in response to the Individual Management Review (IMR) and the Serious Case Review (SCR). A copy of the latest version of the Agency action plan is attached to this response at Annex 1. Actions have been agreed with and compliance monitored by the Medway Safeguarding Children’s Board.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 2 · response
Published 28 December 2014

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 gatekeeping-procedure training to YOT employees through regular team meetings.

Verbatim wording from the response

“To support this change, training was provided to YOT employees in respect of gatekeeping procedures. This training was delivered during regular monthly team meetings by the YOT Operational Manager.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 3 · response
Published 28 December 2014

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

Submit eligible early-release paperwork to the Governor for consideration regardless of compliance with the sentence plan, and discuss progress at sentence-planning reviews.

Verbatim wording from the response

“Point 3,c; Early Release paperwork (if the sentence is appropriate) is submitted to the Governor for consideration regardless of whether the young person has engaged with the sentence plan. The progress of the young person, measured against agreed targets will be discussed at each of the sentence planning reviews.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 6 · response
Published 28 December 2014

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 remand and custody applications and outcomes through quarterly quality-assurance reviews.

Verbatim wording from the response

“The YOT Operational Manager is required to undertake reviews of all remand/custody applications and outcomes as part of the YOT quality assurance arrangements. These procedures have been in place since March 2013. The Duty Manager as outlined above receives all alerts of possible custody or remand. The Operations Manager on a quarterly basis carries out reviews of custody or remands. To date there have been no inappropriate cases identified.”

Source location

2014-0555-Response-by-Medway-Youth-Offending-Service
Page 3 · response
Published 28 December 2014

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 an embedded multidisciplinary child and adolescent mental health service with increased staffing capacity at HMYOI Cookham Wood.

Verbatim wording from the response

“Central and North West London NHS Foundation Trust (CNWL) commenced delivery of child and adolescent mental health services in HMYOI Cookham Wood in April 2014, yet the recommendations you have made are clearly relevant to our work and the work of our close partners – HM Prison Service, NHS England and Oxleas NHS Foundation Trust. Whilst your Regulation 28 report was not addressed to CNWL, as the incumbent provider of mental health services we feel duty-bound to provide you with a formal response to your health-related recommendations.”

Source location

2014-0555-Response-by-Central-North-West-London-NHS-Trust
Page 1 · response
Published 28 December 2014

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 improved office space, IT access, and four computers for the mental-health team.

Verbatim wording from the response

“As described above, all clinical contact by the Health and Wellbeing (mental health) Team is recorded on Systm1. Office space and access to IT has improved. In August 2014, the new team relocated to a recently refurbished room which has four new computers. All staff members have a direct line manager with supervisory responsibility. Line managers are responsible for checking staff entries made on Systm1 so that accurate and timely entries are made, which demonstrate appropriate care planning, risk management and information sharing. All new team members have received training to use Systm1, and an annual record keeping audit will serve to monitor documentation standards.”

Source location

2014-0555-Response-by-Central-North-West-London-NHS-Trust
Page 3 · response
Published 28 December 2014

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 urgent medical and psychological review for young people reported as non-compliant with prescribed medication.

Verbatim wording from the response

“Oxleas NHS Foundation Trust have responded in detail on this point, as it is their staff who administered prescribed medications in HMYOI Cookham Wood. However, it is our responsibility to provide urgent medical and psychological review of young people who we are informed are non-compliant with prescribed medication, as they could be; a) ‘stockpiling’ medication with which to overdose, b) ‘trading’ it as an abusable commodity, c) they may feel that the medication is simply not helping them.”

Source location

2014-0555-Response-by-Central-North-West-London-NHS-Trust
Page 3 · response
Published 28 December 2014

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026