Aleysha McLoughlin

The report

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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. The Rt Hon Jeremy Hunt, Minister for Health

2. The Rt Hon Nicky Morgan, Minister for Education
3. The Rt Hon Eric Pickles, Minister for Local Government

1 | CORONER

Tam M Jennifer Leeming, Senior Coroner, for the Coroner Area of Manchester
West

2 | CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations
2013.

INVESTIGATION and INQUEST

On 4" April 2014 I commenced an investigation into the death of Aleysha
Martine Karla McLoughlin, Aged 16. The investigation concluded at the end of
the inquest on 20 March 2015. The conclusion of the inquest was that Aleysha
Martine Karla McLoughlin had committed Suicide. The medical cause of her
death was 1a Hanging.

CIRCUMSTANCES OF THE DEATH

On the 15th of July 2003 a Care Order relating to Aleysha McLoughlin was made
at Manchester County Court upon the application of Bolton Council.

Aleysha was then placed with a family member, where she remained settled
until the 9th of September 2012 when she went to stay with her mother and
refused to return. On the 8th of October Aleysha left her mother's address and
although there was a short period thereafter when Aleysha returned to live with
her family member the placement broke down. Accordingly on the 26th of
November 2012 Aleysha was placed with a foster carer where she remained
until her death in April 2014. As the foster carer lived in a different area Aleysha
also changed schools, and at first she appeared to make a positive start at her
new school. However from in or about March 2013 her schoolwork and
behaviour began to deteriorate.

Likewise Aleysha appeared to settle well with her foster carer. However on the
13th of March 2013 she left her foster carer's home and did not return until the
20th of March 2013. When asked where she had been Aleysha said that she had
been with her mother.

In early June 2013 the head of Aleysha's year at school had a preventative
meeting with her and her foster carer to address a perceived deterioration in
Aleysha's behaviour. Aleysha did not engage at that meeting, and her behaviour
was perceived to continue to be poor.

On or about the 8th of June 2013 Aleysha again left her foster carer's home and
did not return until the 20th of June, on this occasion saying that she had been
with her sister.

On the 25th of June 2013 whilst Aleysha's sister was visiting her at her foster
carer's home Aleysha reported to her carer that her sister had taken an
overdose. The following evening, the 27th of June, Aleysha herself took an
overdose of aspirin and paracetamol. She was taken to the Royal Bolton
Hospital where she initially refused treatment, and even after consenting she
later removed the cannula administering intravenous medication and had to be
persuaded to have it restored. During Aleysha's hospital admission clinicians
from the Child and Adolescent Mental Health Services (CAMHS) assessed her
and a further appointment was made for her to see a CAMHS clinical
psychologist after her discharge from hospital. On the 5th of July 2013 Aleysha
attended that appointment with her foster carer. Aleysha did not want any
further involvement with CAMHS and as Aleysha’s risk of further self harm was,
for various reasons, believed to be reduced, it was decided that there was no
ongoing role for CAMHS at that time, although an offer of re-referral was made
should matters change.

When Aleysha returned to school after the summer holiday in September 2013
she was perceived as continuing to be uncooperative and difficult to engage.

On a date between in or about October 2013 and at or about Christmas of 2013
one of the Social Workers involved with Aleysha was informed by Aleysha's
foster carer that Aleysha had inflicted some superficial cuts upon herself. The
social worker believed that this was a historical event and did not ask Aleysha
about it.

On the 7th of January 2014 Aleysha and her sister both took overdoses of
aspirin and they were taken to the Royal Bolton Hospital. Clinicians wanted to
admit Aleysha to the hospital for observation because she was believed to have
taken a potentially life threatening overdose, but Aleysha refused to be
admitted. She was seen by a Doctor in the Accident and Emergency Department
of the Hospital, who decided that she had the capacity to refuse treatment and
noted that she was discharged. Aleysha was subsequently seen by a Doctor
specializing in mental health, who had concerns that Aleysha did not, in fact,
have the capacity to refuse treatment, However medical staff would not then
admit Aleysha to the hospital because a medical doctor had discharged her.
Whilst discussions about this were continuing Aleysha left the hospital with her
sister, who was also refusing treatment. Aleysha and her sister were returned to
the hospital the following morning, and a mental health nurse who was a
member of the Rapid Assessment Interface Discharge (RAID) team then
assessed Aleysha. Aleysha continued to refuse to be admitted to hospital and

was then assessed to have the capacity to make that decision. In the course of
the assessment Aleysha told the mental health nurse that she had self- harmed

by cutting herself, although she had not done that recently. That information
was not passed to other agencies. Particularly it was not contained in the
information subsequently passed to CAMHS nor was it given to Social Services

nor Aleysha's school. During the assessment Aleysha stated that she did not
then want to end her life but that she had wanted to do so at the time when
she had taken the overdose. At the conclusion of the assessment it was
determined that whilst Aleysha was not at immediate risk of self harm she was
at ongoing risk of impulsive self harm, and arrangements were made for her to
have an appointment with CAMHS, despite Aleysha stating that she would not
attend. Aleysha was also referred to the Safeguarding Children Team at the
Royal Bolton Hospital.

On the 8th of January 2014 Aleysha was seen by her school nurse, who had
been informed of her hospital attendance by the Safeguarding team. Aleysha
declined further support from the nurse, who did not then contact Aleysha
again.

On the 8th of February 2014 Aleysha and her sister were seen to be on the
wrong side of the fencing of a road bridge where they were at risk of jumping
or falling onto the carriageway below. Police Officers attended, and Aleysha
walked off the bridge. She was then detained by the Police under the terms of
the Mental Health Act and taken to the Royal Bolton Hospital, where she was
seen by two Doctors specializing in psychiatry and an Approved Mental Health
Professional who was a social worker, for the purpose of a Mental Health Act
assessment. Aleysha did not fully engage during the assessment, and denied
that she had intended to harm herself when she had been on the bridge. The
assessment concluded that Aleysha was not at immediate risk of self-harm, but
that she remained at ongoing risk of impulsive self-harm. Aleysha was then
discharged from detention under the Menta! Health Act. A further referral was
made to the Safeguarding team and to CAMHS, although Aleysha again said
that she would not attend at CAMHS, stating that she didn't need it. On the 11th
of February 2014 a secretary working for the CAMHS team telephoned Aleysha
and offered her an appointment with a mental health practitioner on the 17th of
February, which Aleysha refused. On the 18th of February a social worker
contacted a mental health nurse at CAMHS in order to share information
regarding Aleysha particularly with regard to the events of the 8th of February
described above. The ensuing discussion included an acknowledgement of the
risks presented to Aleysha as a consequence of her impulsive behaviour when
she was with her sister. Aleysha's refusal to engage with CAMHS was also
discussed and the Social Worker planned that Aleysha's foster carer should be
contacted and asked to encourage Aleysha to attend an appointment with
CAMHS. On the 25th of February a multi agency meeting was held by social
services to address Aleysha's self harming behaviour and her refusal to engage
with CAMHS. CAMHS were not invited to this, nor to any other meeting. It was
agreed that in view of Aleysha's refusal to engage with mental health services
her foster carer should receive some training as to means of promoting
Aleysha's engagement with those services. This training had not been put into
place by the time of Aleysha's death on the 3rd of April 2014.

to her bad behaviour. A meeting took place with Aleysha and her foster carer

On the 6th of March 2014 Aleysha was excluded from school for five days due
and an individual programme of lessons was agreed, so as to support Aleysha

during the period leading up to her forthcoming public examinations.

On the 2nd of April 2014 a pupil at Aleysha's school told Aleysha's head of year
that Aleysha had self-harmed by cutting her arms. Aleysha's social worker and
her foster carer were informed and when they saw Aleysha an ambulance was
summonsed and Aleysha was taken to the Royal Bolton Hospital with her foster
carer following. When Aleysha was treated she was found to have twenty-nine
recent lacerations on her left arm, together with scarring from older wounds.
Neither Aleysha's foster carer nor Social Services had previously been aware
that Aleysha was self-harming to this level. Whilst Aleysha's wound were being
closed the treating nurse asked Aleysha if she wanted to see anyone from the
RAID team, but Aleysha declined. Despite this the nurse contacted the RAID
team and a mental health nurse assessed Aleysha. The assessment concluded
that on this occasion Aleysha's self-harm was not an acute incident of attempted
suicide but that Aleysha remained at ongoing risk of impulsive self-harm. The
means of treating this risk was ongoing psychological therapy such as was
offered by CAMHS and the nurse conducting the assessment encouraged Alysha
to attend CAMHS despite her expressed reluctance to do so.

At about 3pm on the 3rd of April 2014 Aleysha was found deceased by her
foster carer at their home address Es. She had hanged
herself. Prior to her death she had been researching websites relating to suicide
and hanging. She had also taken amphetamine, which could have induced
depression.

CORONER'S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to

concern, In my opinion there is a risk that future deaths will occur unless action
is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:

Evidence was given at the Inquest that self harm in young people is becoming a
public health crisis. Evidence revealed that 3 out of 10 young people have self
harmed at some time during their lives. Accordingly the matters of concern
revealed were as follows:-

(1) That it should be considered that the system of training for those
working with young people, including teachers, school nurses, foster
carers, social workers, mental health workers and medical nurses and
doctors should be reviewed so as to ensure that these professionals
should be alert for signs of self harm and should take opportunities to
discover themselves so that those harming themselves can be offered
help and support. By way of example evidence was given at the Inquest
that the annual health check offered to looked after children did not
include a blood pressure check. If a blood pressure check was included
this would provide an opportunity for signs of self harm to be revealed.

(2) That it should be considered that additional information and
encouragement could be offered to young people to inform those able to

help for example teachers, nurses, health professionals etc. when a

young person becomes aware that another young person is self harming. |
The shocking self harm to which Aleysha Martine Karla McLoughlin had
subjected herself was only revealed when a school friend brought it to
the attention of a teacher. There was no evidence that there was any
system in place to encourage the passing of such information.

(3) That it should be considered that systems such as those now being
developed in Bolton should be further developed so as to ensure that
multi agency discussions involving all relevant agencies are held urgently
for those at risk of self harm and particularly for those who do not
engage. Evidence was given that meetings concerning Aleysha Martine
Karle McLoughlin did not include the Child and Adolescent Mental Health
Services although evidence was given that their input would have been
valuable.

(4) That it should be considered that a particular pathway of help for young
people who resist engagement should be developed. There was no
evidence that any such formal pathway had been shared at the present
time.

(5) That a review of the capacity of the agencies involved in helping young
people who are self harming to address those matters appropriately
should be considered. |

ACTION SHOULD BE TAKEN

In my opinion urgent action should be taken to prevent future deaths and I
believe you and your organisation have the power to take such action.

YOUR RESPONSE |

You are under a duty to respond to this report within 56 days of the date of this
report, namely by 3" June 2015. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise you must explain why no action
is proposed.

COPIES and PUBLICATION +

I have sent a copy_of my report to the Chief Coroner and to the following
Interested — (mother), perro —_ Ml
(sister), NS (grandfather),

(great aunt), mies (foster mother), Cd
(solicitor for Greater Manchester West Mental Health), Tt—~—O™T
(Litigation Department, Royal Bolton Hospital), EN (Solicitor, Bolton
Council) and to the LOCAL SAFEGUARDING BOARD (where the deceased was
under 18).

Iam also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or

summary form. He may send a copy of this report to any person who he
believes may find it useful or of interest. You may make representations to me,
the coroner, at the time of your response, about the release or the publication

of your response by the Chief Coroner.

Signed

Norn nrg:

M Jennifer Leeming

8" April 2015

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

| RECENWED
18 JUN 205

Rt Hon Alistair Burt MP
Minister of State for Community and Social Care

ae

Department Hsoeosssesee wey,

of H ealt h Richmond House
79 Whitehall

London

SWIA 2NS

POC3 000940 145 Tel: 020 7210 4850

Ms J. Leeming

Senior Coroner

H.M. Coroners Court

Paderborn House, Howell Croft North

Bolton 16 JUN 2015

BLI 1QY

(ees As Leen ns

Thank you for your letter of 8 April following the inquest into the death of Aleysha
McLoughlin. I was sorry to hear of Ms McLoughlin’s death and wish to extend my
sincere condolences to her family.

I note that you sent your report to the Department for Education (DfE) and the
Department of Communities and Local Government (DCLG). Officials have
discussed this case and I hope that you will accept this reply on behalf of each of the
departments concerned.

You raise the following matters of concern:

(1) That it should be considered that the system of training for those working with
young people, including teachers, school nurses, foster carers, social workers,
mental health workers and medical nurses and doctors should be reviewed so as to
ensure that these professionals should be alert for signs of self-harm and should take
opportunities to discover themselves so that those harming themselves can be offered
help and support. By way of example evidence was given at the Inquest that the
annual health check offered to looked after children did not include a blood pressure
check. If a blood pressure check was included this would provide an opportunity for
signs of self-harm to be revealed.

(2) That it should be considered that additional information and

encouragement could be offered to young people to inform those able to

help for example teachers, nurses, health professionals etc. when a young person
becomes aware that another young person is self-harming. The shocking self-harm
to which Aleysha Martine Karla McLoughlin had subjected herself was only

revealed when a school friend brought it to the attention of a teacher. There was no
evidence that there was any system in place to encourage the passing of such
information.

(3) That it should be considered that systems such as those now being developed in
Bolton should be further developed so as to ensure that multi agency discussions
involving all relevant agencies are held urgently for those at risk of self-harm and
particularly for those who do not engage. Evidence was given that meetings
concerning Aleysha Martine KarlaMcLoughlin did not include the Child and
Adolescent Mental Health Services although evidence was given that their input
would have been valuable.

(4) That it should be considered that a particular pathway of help for young people
who resist engagement should be developed. There was no evidence that any such
formal pathway had been shared at the present time.

(5) That a review of the capacity of the agencies involved in helping young people
who are self-harming to address those matters appropriately should be considered.

Your concerns focus on those who have a role working with children and young
people and who are therefore in a position to protect those children and young
people who are vulnerable and at risk. You rightly raise issues concerning the
professional training of staff, the effectiveness of current services and the sharing of
information between individuals and agencies.

Many of the matters of concern you raise have been considered by the work of the
Children and Young People’s Mental Health Taskforce (jointly chaired by the
Department of Health and NHS England). The Taskforce has tackled the particular
issue of highly vulnerable children and young people such as Aleysha who do not
use services, and made a series of proposals. These include, for example, making
sure that children and young people who do not attend appointments are not then
discharged from services. Instead the reasons for not attending are actively followed
up So contact is maintained and offers of further support continue.

The Government’s report on the work of the Taskforce, ‘Future in Mind’ (published
in March 2015), establishes a clear and powerful consensus about how to make it
easier for children, young people, and those who care for them to access high quality
mental health care when they need it. It sets out a national ambition to transform the
design of services for children and young people with mental health needs.

NHS England is leading a service transformation programme to reshape the way
mental health services for children and young people are commissioned and

ae

Department
of Health

delivered over the next 5 years. In addition NHS England will prioritise further
investment in areas that can demonstrate robust action planning. This will be done
through the publication of Local Transformation Plans based on the overarching
principles described in the Taskforce report.

NHS England’s current planning guidance ‘Forward View into Action’ also
emphasises the importance of joint work. To support this, NHS England has
published a model service specification for Child and Adolescent Mental Health
services, targeted and specialist services to enable local commissioners to
commission robust services with clear multiagency care pathways. In addition, NHS
England’s Children and Young People’s “Improving Access to Psychological
Therapies” programme will support the delivery of evidence based, outcomes
focussed treatments including a Systemic Family Therapy module that incorporates
treatment and avoidance of self-harm.

Provision exists under Section 14 of the Children Act 2004 for Local Safeguarding
Children Boards (LSCBs) to have responsibility for safeguarding and promoting the
welfare of children and ensuring the effectiveness of local agencies in this respect.

DfE has forwarded a copy of your letter to ao: the Association of
Independent LSCB Chairs asking him to consider the points you raise. DfE has also
introduced a number of reforms of social work practice to protect vulnerable people.

In November 2014, DfE published a statement of the knowledge and skills required
for child and family social work. This was produced by the Chief Social Worker for
Children and Families, shaped by feedback from nearly a thousand social workers. It
is the definitive statement of what social workers need to know, and what they
should be able to do, to make the right decisions for vulnerable families. The
statement will help deliver the highest level of protection and will be used:

e as a cornerstone for university social work courses, including the “Step Up
to Social Work” training programmes, and what will be utilised in plans
for teaching partnerships;

e for development of an effective and robust assessment and accreditation
system for child and family social workers to ensure absolute public
confidence in the quality of practice undertaken by social workers.

The accreditation system will be built around three new statuses: approved child and
family practitioner; practice supervisor; and practice leader. Obtaining one of these
statuses will be dependent upon completion of a rigorous ‘pass or fail’ assessment.
These new accreditations will provide a national, practice focused career pathway
based on the highest levels of skill and knowledge.

DfE is developing the assessment and accreditation processes. Decisions about
implementation will be made in consultation with the social work sector.

Lastly, DCLG is focussed on supporting local services to provide early, integrated
support for people who need the most help. Central to this is a need to ensure
effective sharing of information between agencies and developing effective multi-
agency approaches. The department supports the Public Service Transformation
Network and the Early Intervention Foundation to help councils and their local
partners in the co-design and co-production of better outcomes for vulnerable
people. DCLG also supports local authorities on the delivery of the expanded
troubled families programme. This aims to directly help up to 400,000 families over
the next five years, transforming lives by improving the way local services operate,
crucially joining up and co-ordinating the support they offer these families. The
criteria that determine whether a family might be helped by this programme cover
issues such as children or young people who have been identified and assessed as
needing support, who are not attending school regularly or family members with a
range of physical and mental health problems.

I am grateful to you for bringing the sad circumstances of Ms McLoughlin’s death
our attention.

hw sincere,
Q
Peo

ALISTAIR BURT

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