Nottinghamshire County Council (16 002 691)

Category : Adult care services > Transition from childrens services

Decision : Not upheld

Decision date : 30 Nov 2016

The Ombudsman's final decision:

Summary: The Ombudsmen have found that reasonable steps have been taken by a number of agencies to implement recommendations made in a serious case review carried out by the local adult safeguarding board.

The complaint

  1. The complainants, whom I shall refer to as Mr and Mrs B, complain that work has not been done to improve health and social care services following recommendations from an independent case review into Nottinghamshire Children’s Services and a serious case review carried out by the Nottinghamshire Adult Safeguarding Board relating to the care of their late daughter, whom I shall refer to as K.
  2. Mr and Mrs B wish to see evidence that steps have been taken to implement the recommendations, in order to reduce the chances of a recurrence of the events which led to K taking her life.

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The Ombudsmen’s role and powers

  1. The Ombudsmen have the power to conduct joint investigations and to report jointly on complaints that cross the boundaries of their jurisdictions. From April 2015 the Ombudsmen introduced a new process for investigating complaints about both health and social care services. These complaints are now investigated by single team acting on behalf of both Ombudsmen. (The Regulatory Reform (Collaboration etc. between Ombudsmen) Order 2007)
  2. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1)).
  3. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.

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How I considered this complaint

  1. In considering this complaint I had a telephone discussion with Mr and Mrs B and considered the written materials they sent me. I made enquiries of the Council and the Adult Safeguarding Board and considered their comments and supporting evidence they sent me.
  2. I took account of relevant law, statutory guidance, and local policy.
  3. I shared a draft version of this statement with all parties and took account of the comments received in response.

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The issues investigated

  1. This investigation considered the actions of Nottinghamshire County Council’s adult social care and children’s services, and Nottinghamshire Healthcare NHS Foundation Trust. The Ombudsmen did not consider the actions of Partnership in Care, the reasons for which are contained at the end of this statement.

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What I found

  1. K was known to Nottinghamshire County Council’s children’s social care department from the age of twelve years due to concerns about self-harming behaviours and unhappiness at home. K had periods of being cared for by Nottinghamshire County Council, and was made subject to a secure order following increasing concerns regarding self‑harm and absconding from care facilities.
  2. Professional concern regarding K’s mental health increased during her time at the secure children’s home. This led to her being detained under the Mental Health Act and being placed within mental health settings for treatment. Although K was seen to make progress within subsequent placements, attempts at rehabilitation were unsuccessful and professionals became concerned at the risk of her taking her life if she were to live in the community. As a result of this, K was detained in mental health settings for much of her adolescent years.
  3. In 2013 K transferred from children’s mental health services to adult mental health services, moving to a low-secure unit the day after her eighteenth birthday. Mr and Mrs B challenged the decision by way of appeal to the First Tier Tribunal, and asked that K’s treatment to be provided in a community setting. However, the appeal was unsuccessful.
  4. Following K’s admission to the adult unit, a number of concerns were raised regarding the safety of patients within the unit. The Adult Safeguarding team investigated two incidents, along with the Care Quality Commission (the regulator) and NHS England (the commissioning body).
  5. K’s self-harming behaviour escalated following her admission to the adult low‑secure unit, and on 24 June 2013 she sadly took her life through the use of a ligature. A coroner’s inquiry and serious case review carried out following K’s death found that staff at the low-secure unit did not fully realise the risk of suicide or understand that this was escalating in the days before her death. They found that K had been subject to five minute observations but these had been insufficient as she was able to self-harm and tie ligatures within these intervals, ultimately culminating in her death.
  6. The inquiry and review also acknowledged that the risk assessment and care plan to manage K’s self harming behaviours was not robust and was not reviewed appropriately given the increase in suicide ideation, and was compounded by the staff team on the ward not functioning effectively and internal poor communication. In particular the Coroner highlighted that the immediate transfer of K to an adult unit the day after her 18th birthday was not in her best interests and was detrimental to her mental health.
  7. The serious case review contained a number of recommendations to improve practice among the health and social care providers who had been involved with K.

Statutory context

  1. Safeguarding Reviews are a process for statutory and commissioned agencies to identify lessons which can be learned from particularly complex or serious safeguarding adults and children’s cases, usually where an adult or child in vulnerable circumstances has died or been seriously injured, and abuse or neglect has been suspected.
  2. As a result of a safeguarding review, the Panel recommends changes to improve practice and services. The aim of the process is to learn lessons and make improvements, rather than blaming individual people or organisations.
  3. The Serious Case Review process in Nottinghamshire requires each individual agency to conduct an independent management review, the outcome of which is fed-back to the adult safeguarding board to inform procedural improvement in the locality.


Nottinghamshire County Council’s Adult Social Care

  1. The Adult Social Care department of the Council was responsible for overseeing the safeguarding investigations relating to K following her eighteenth birthday.

Independent Management Review recommendations:

  1. The independent management review into the Council’s Adult Social Care department recommended that the Council develops operational guidance for its multi agency safeguarding hub. It recommended the guidance contains clear protocols for sharing information between agencies, which should be reviewed on an annual basis, along with contributions from partner agencies.
  2. In addition to this, Adult Social Care, Health and Public Protection (ASCHPP) staff acting in the role of safeguarding officer or safeguarding manager should have attained the level of competence as required in the National Safeguarding Capability Framework, and should establish a method of reporting which identifies safeguarding incidents by provider units and organisations.

Changes in practice at the time of the serious case review’s publication

  1. At the time the serious case reviews was published, the Nottinghamshire Safeguarding Adults Multi-Agency procedures were being reissued in line with the national best practice guidance, ‘Making Safeguarding Personal’ agenda, which provides a greater emphasis on outcome focused assessment and planning. The revised Nottinghamshire Procedures make specific reference to ensuring the separation of role between safeguarding manager and safeguarding investigation officer.

Response to the Ombudsmen’s enquiries

  1. In response to the Ombudsmen’s enquiries, the Council has shown it has implemented a local capability framework for safeguarding officers, and has devised a training programme for relevant staff. In addition to this, the Council has taken steps to improve its systems with respect to capturing and reporting on data relating to safeguarding incidents.

NHS England

  1. NHS England was the body responsible for commissioning the specialist mental health services for K.

Independent Management Review recommendations:

  1. The independent management review into NHS England recommended that the findings and outcomes of a national review into CAMHS availability is embedded into local its commissioning arrangements.
  2. In addition, it recommended the specialised commissioning team ensures that appropriate scrutiny and challenge is given to assessments and care planning carried out by partner agencies.
  3. Finally, it recommended that NHS England monitors its record keeping standards to ensure that case managers and other relevant staff adhere to the required standards.

Changes in place at the time of SCR publication

  1. At the time the serious case review was published, NHS England had introduced routine service visits for all specialised services in the East Midlands region, along with surveillance logs of visits to providers, with a view to facilitate the monitoring of standards and patient experiences.
  2. A Quality and Nursing Directorate of Leicestershire and Lincolnshire Area Team had joined the Mental Health Team to undertake routine and reactive service visits to explore quality and safety in services. In addition, safeguarding training had been undertaken by all members of the Mental Health Team, and a regional Safety and Quality Group had been established to share good practice and learning from serious incidents.
  3. Finally, a national database had been established which standardised clinical record keeping for all case managers, and information governance is training had become mandatory for staff.

Response to the Ombudsmen’s enquiries

  1. In response to the Ombudsmen’s enquiries, NHS England says that all its staff are up‑to‑date with safeguarding training, and annual completion of online safeguarding training is now mandatory. In addition, case managers now undertake ward rounds and gather feedback from patients on their care and treatment, and NHS England has introduced regular quality monitoring meetings to help identify and resolve any issues with local providers.
  2. NHS England has also incorporated recommendations contained in a national review of CAMHS, which has led to the standardisation of referrals and assessment documentation. It has developed a regional policy on transition arrangements for young people moving from CAMHS to adult mental health services, and has merged the databases for adults and children’s mental health services, to improve the capture and analysis of data.

Nottinghamshire Healthcare NHS Foundation Trust

  1. Nottinghamshire Healthcare NHS Trust (the Healthcare Trust) arranged community healthcare services for K, including child and adolescent mental health services and school nursing services.

Serious case review recommendations:

  1. The serious case review recommended the School Nursing Service considers how it might develop systems to identify children who are not on a school roll, and influence a Public Health led review of the school nursing service, and improve support systems for children and young people who present with self-harming behaviour in the school setting, and improve self-harm awareness training programmes for school nurses.
  2. With respect to CAMHS, the review recommended it improve supervision of child safeguarding professionals, and review its electronic case management system with a view to improve the sharing of information across partner agencies. It was also recommended that CAMHS review it out-of-hours services and access to nursing consultants.
  3. The review also recommended that all services in the Healthcare Trust review their record keeping procedures to ensure that all case records include evidence of assessment, case planning, roles and responsibilities of staff, and a clear record of the child’s views.

Response to the Ombudsmen’s enquiries

  1. In response to the Ombudsmen, the Healthcare Trust notes it has completed all the actions recommended in the serious case review. It says Nottinghamshire County Council shares data with it relating to children not accessing education, and it has developed training for school nurses in respect of issues surrounding child and adolescent mental illness and self-harm.
  2. The Healthcare Trust has also produced evidence of an audit in which it found positive evidence that the voices and views of children were being captured in case records. It notes that such audits are now carried out on a three monthly intervals. It also notes that CAMHS is involved in a national review of pathways for its clients.
  3. Finally, the Healthcare Trust notes it has employed a safeguarding expert to support supervision sessions in the CAMHS and looked-after-children team.

Nottinghamshire County Council’s Children’s Services

  1. Nottinghamshire Children’s Service care was responsible for the children’s social care services provided to K.

Independent Management Review recommendations:

  1. The Independent Management Review recommended that Children’s Social Care Service Director develops a Risk Management Framework which meets the needs, and manages the risks, of children and young people who self‑harm and/or express suicidal ideation.
  2. In addition, it recommended the Children’s Social Care Service Director be assured within two months of the management review that the Emergency Duty Service responds in an effective and timely manner to incidents of adolescent self-harming and suicide attempts.
  3. The review also recommended the Children’s Social Care Service Director ensure there is good practice guidance available to practitioners and managers regarding children and young people who are subject to treatment under the Mental Health Act and ensure that processes are regularly reviewed regarding quality of placement and continuity of funding.

Response to the Ombudsmen’s enquiries

  1. In response to the Ombudsmen, the Council says it has incorporated a model of best practice for escalating concerns about children and adults at risk of harm, which includes the ability to refer individual cases to a risk management panel, which comprises members of the key agencies who sit on the safeguarding boards for children’s and adults services. The Council explains this allows for the involvement of senior managers who are able to commit resources immediately to a particular case. The Council notes that a recent regulatory inspection reported no concerns with how the risk management of vulnerable children is administered at the Council.
  2. The Council notes that in 2011 it introduced a quality management framework which requires it to audit 5% of all children’s social care cases, a process which includes consideration of any involvement by the emergency duty team. The council says that any cases rated as inadequate are subject to an action plan and reviewed by senior managers. It notes that a regulatory inspection in 2015 revealed no concerns regarding the quality of the work completed by the emergency duty team.
  3. Finally, the Council notes it obtained legal advice regarding the relationship between its duties under the Mental Health Act 1983 and Children Act 1989 with respect to children detained in psychiatric units. The Council says that all children subject to detention under the Mental Health Act are now treated in the same way as any other looked after child, and team managers are advised to seek legal advice on individual cases as necessary.

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Final decision

  1. The evidence I have seen satisfies me that the above agencies have in place clear processes for overseeing the implementation of the recommendations which followed the serious case review. I have found that each agency has appointed individuals to oversee the agreed actions, with clear time frames for completion. In turn, I am satisfied their actions have been duly overseen by a sub‑committee of the safeguarding board, which reports back to the main board. In addition, the safeguarding board has explained that following a meeting with Mr and Mrs B, it has changed the process of future serious case reviews to place a greater emphasis on the views of affected family members.
  2. Overall, I am satisfied that the agencies complained have taken, or are taking, the necessary steps to fulfil the recommended actions following the safeguarding review. I have therefore closed the investigation into the complaint.

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Issues I did not investigate

  1. The Ombudsmen did consider the actions of Partnerships in Care. This is because Mr and Mrs B accepted an out-of-court settlement from the organisation with respect to actions surrounding K. In such circumstances, it is not therefore appropriate for the Ombudsman to initiate an investigation into the organisation.

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Investigator's decision on behalf of the Ombudsman

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