Prevention of Future Deaths report 2021-0184

Regulation 28: Report to Prevent Future Deaths 

Response by Cambridgeshire County Council into the Matters of Concern in 
respect of the deaths of: 

Samantha Gould and Christine Gould 

1.  Overnight assistance for adolescent mental health patients being cared 

for at home but with high levels of need (For CPFT and CCC). 

As stated in the Safeguarding Partnership Review in respect of Christine Gould seen 
by the Coroner, there is no national approach, framework or guidance that supports 
multi-agency  services  to  provide  a  joined-up  approach  to  children  with  significant 
mental health difficulties, despite the high risk of harm. Local areas have been left to 
develop services and systems for these children and young people in isolation, and 
there has been a need for significant learning in this area. Local partners involved in 
delivery of services for children [referred to as ‘The Local Partnership’] has taken this 
requirement seriously and has responded in the following ways.    

Recognition  of  Emotional  Health  and  Well  Being  Needs  and  Requirement  for 
Enhanced Support Services 

The Strong Families Strong Communities: securing best outcomes for children and 
young people strategy launched in March 2021 reflects the expectation that support 
is now intended to range from preventative measures in schools, the local 
community and early help all the way up to Tier 3 CAMHS support, social care 
services and ultimately Tier 4 provision for very unwell young people.  It is important 
to remember that even young people with acute needs may well be able to access 
services at universal or targeted level that can offer support to them or their families. 

For example, a new Partnership, YOUnited, launched on 1 July 2021. This was 
established to bring together mental and emotional health services for children and 
young people in Cambridgeshire and Peterborough. This Partnership is made up of 
Cambridgeshire and Peterborough NHS Foundation Trust, Cambridgeshire 
Community Services NHS Trust, Centre 33 and Ormiston Families. It is intended that 
together they will bring their expertise to help build relationships across our mental 
health and care system to ensure clinical services, voluntary organisations and local 
authority services work closer together to support children and young people with 
their mental health and wellbeing. Funded by Cambridgeshire and Peterborough 
Clinical Commissioning Group (CCG), Cambridgeshire County Council and 
Peterborough City Council, this is a significant step forward in providing a more 
integrated service for children and young people in this area, and colleagues believe 
the innovative partnership approach between the NHS and voluntary sector will bring 
improved benefits to children, young people and their families 

 
  
 
 The Emotional Health and Well-Being Service run by Cambridgeshire Community 
Services comprising 3 separate teams (Emotional Health and Well-Being Practitioner 
Team; Children’s Well-Being Practitioner Team; Mental Health Support 
Teams) are linked in with this work, as well as representatives from Fullscope – a 
consortium of charities working across Peterborough and Cambridgeshire with a 
shared mission to improve the mental health and well-being of children and young 
people.   

This integrated delivery model became part of the Cambridgeshire and Peterborough 
NHS Foundation Trust contract from April 2021 and the fundamental principle of this 
approach is to develop an integrated solution to deliver children and young people’s 
mental health and emotional wellbeing support services. Evidence and experiences 
of users and professionals suggest that a system approach will create the right 
environment that brings commissioners, organisations, and people together to 
deliver better outcomes for children and young people with mental health concerns. 
This involves working across traditional silos ensuring resources are used and 
allocated flexibly beyond traditional service boundaries and in response to learning 
from data, feedback and needs.  

There is a comprehensive mobilisation plan to support the move to this new way of 
working. One of the first tasks of the YOUnited Partnership will be to launch a single 
point of referral for all the services, to make it easier for young people to navigate 
and access the right support when they need it.  

The  new  service will provide  mental  health  and  emotional  support  for  children  and 
young  people  aged  0–25  years. There  will  be particular  effort to  include  those who 
identify  with  the  following characteristics: Learning  Disability;  Special  Education 
Needs  and  Disabilities;  Neurodevelopmental  needs  including  Autism  and  Attention 
Hyperactivity  Disorder;  LGBTQ+;  English  as  an  additional  language;  sensory 
impairments; vulnerable children and young people; Not in Education Employment and 
Training; Children in Care; Children in Need or in need of Protection; those exposed 
to adverse childhood experiences; refugees; and hard to engage children and young 
people.  

Support for More Acute Mental Health Needs 

Although  young  people  with  the  most  complex  mental  and  emotional  health  needs 
represent only a very small percentage of the overall population who are experiencing 
mental  ill-health,  it  is  vital  that  we  better  understand  and  meet  those  needs. 
Cambridgeshire County Council has been working closely with Health colleagues in 
Cambridgeshire and Peterborough Foundation Trust and the Clinical Commissioning 
Group to review and understand how support to young people and their families can 
be  improved  both  prior  to  admission  and  upon  discharge,  taking  into  account  the 
lessons  learned  from  the  deaths  of  Sam  and  Chris  Gould.  The  Safeguarding 

 
 
 
 
 Partnership  Review highlights  that a  number of  changes  have  already  taken  place, 
including: 

•  An effective agreement between the local inpatient unit and Children’s 
Services in relation to Children’s Services’ duties under Section 85 of 
the Children Act 1989 and Section 117 of the Mental Health Act 1983  

•  A Children and Young People’s Mental Health and Emotional 

Wellbeing Board has been established including partners from the 
multi-agency network and the voluntary sector. Regular Complex Case 
Meetings involving senior leads from Children’s Social Care, NHS 
England and senior clinicians within mental health to discuss complex 
T4 cases and to support discharge planning. 

•  Monthly meetings with Children’s Services and health safeguarding 
leads (acute, community & primary care) to address the needs of 
individual vulnerable children when required, facilitate early 
professional resolution and to discern emerging themes. 
•  Weekly complex case meetings in the local inpatient general 

adolescent unit to provide a holistic approach to meeting needs & 
support discharge planning. 

•  Significant work in progress to co-produce a safeguarding children 

policy with parents and children in CAMHS. 

•  Regular safeguarding supervision for mental health staff across Tier 4 
and CAMHS services has been embedded resulting in improved multi 
agency working. 

Young people need to be seen in the context of their families, and parental 
responsibility, resources and wishes of parents or carers do also need to be taken 
into account when assessing and making plans for young people, as well as taking 
into consideration the wishes and feelings of young people themselves. From 
Cambridgeshire Children’s Services’ perspective, we would undertake an 
assessment of need under Section 17 of the Children Act 1989 when a young 
person was referred to us meeting the criteria for such assessment. If the young 
person had been formally detained under the Mental Health Act, we would also take 
account of our Section 117 duties under the Mental Health Act and consider what 
services we could offer to support the young person either in the community or to 
return to it. Health colleagues would be undertaking parallel assessments as may 
Education colleagues, and all agencies would then bring their specialist perspectives 
together at planning meetings with the young person and his or her family. 

Out of Hours Support 

Mental Health Provision 

 
 
 
 Please note that this section has been completed based on information from CPFT.  

We are aware that CPFT are committed to working with the CCG to continue to 
develop services for children with significant mental health difficulties. Since the 
death of Sam and Chris Gould the CCG have commissioned a CAMHS crisis team. 
This provides direct access for children and families to a CAMHS professional to 
provide advice and home, hospital or clinic based face to face assessments. This 
service is commissioned by the CCG to operate 8-8 five days a week and offer brief 
interventions (up to two weeks). 

Outside of these times young people and families have direct access to the First 
Response Service (FRS), an all age 24/7 telephone advice crisis service. This 
service has embedded CAMHS practitioners and a CAMHS consultant to provide 
direct work and supervision for non-CAMHS staff. 

Additionally, the CCG have commissioned a CAMHS home treatment team. 
Recruitment to this is ongoing it will work intensively with young people and families 
as an alternative to hospitalization. This is a multi-disciplinary team and will be able 
to will operate 9-9 with up to 3 contacts per day in the family home to provide 
treatment to young people and families. This will include supporting rapid discharge 
of patients from hospital who may not be best helped by hospital admission. As part 
of this the home treatment team is developing a DBT treatment programme for 
children with severe self-harm. 

This service is not commissioned to provide 24/7 in home support for young people. 
If this level of support were needed then this would be raised through either the joint 
funding panel or through the CCG Section 117 funding stream. 

The discussion about the need for 24/7 in home care will continue with the CCG and 
the Local Authority and whether any needs are best met though bespoke 
arrangements or the demand is such as to require a fully funded service. 

Respite Care, Community Support and Alternative Provision 

In the specific example of respite care outside the home, this would need careful 
consideration by the professional network. It is unlikely that commissioning respite 
care outside of the family home would be recommended as a first step, however if 
there is an identified need to offer a regular provision for a young person, this could 
be considered under Short Breaks provision, and would be commissioned jointly by 
the CCG and Local Authority. 

Families are now able to request assessment for Direct Payments, which would 
allow parents (and the young person) to choose their own carer(s). The worker 
would need to have the relevant skills and expertise around supporting complex 
mental health needs and may need to be a health worker. In addition, there are also 

 
 now significant technological aids that can support with caring for those with 
additional needs, and a family could see if these would be of benefit, including bed, 
mat and door sensors. This would all need to be assessed for the individual and 
agreed jointly between the Local Authority and Health as a shared package of 
support. 

The two agencies in conjunction with education SEN services operate a shared 
approach to assessment and provision of packages in respect of other children with 
additional needs that may need to be met across the partnership already, and it has 
been formally agreed that we will now include children and young people with 
significant mental health needs in this care pathway. This allows the three partners 
to consider prevention, support and de-escalation at all stages of a young person’s 
care journey depending on need and enables parents and carers to engage with the 
wider network as a single support system. 

Cases in this area are managed through continuing care or Section 117 health 
pathways and through Section 17 of the 1989 Act or Chronically Sick and Disabled 
Persons Act support from Children’s Services. For those with enduring conditions, 
there is also the benefit of planned transition to Adult Services as they turn 18.  

For some young people, there can be an assessed need for them to live away from 
home outside of a hospital context, either temporarily or as a longer-term plan. Some 
young people cannot be cared for by their families and may become Looked After 
Children by the Local Authority. The nature of the placement is very much 
determined according to individual need and the particular circumstances of a young 
person. Sometimes, a highly specialist residential environment is needed. These are 
a scarce resource and may not be available locally. However, a more flexible semi-
independent supported accommodation provision can usually be provided in the 
local area. This type of provision continues to link into local CAMHS and education 
services; these are usually bespoke packages and will vary from young person to 
young person. It would be expected that these are also joint funded by Health and 
the Local Authority. 

Governance Arrangements 

The whole multi-agency process is supported by the Joint Access to Support Panel 
(JASP). It is able to offer support in terms of identified and emerging risks and advise 
on prevention, mitigation and management. Identifying themes and gaps in provision 
through JASP also informs strategy and assists in the future planning and 
commissioning of services for local children and young people. JASP also ensures a 
focus on individualised child focused plans, independence and empowerment and 
remaining close to home where at all possible. 

There is a strategic focus with a number of standard agenda items including 
Transitions, Continuing Care/ Continuing Health Care, Section 117 and Tier 4 

 concerns. The ‘Continuing Care’ agenda item reviews recent referrals, assessments 
and reviews and therefore ensures, as per the Continuing Care policy, timely review 
of cases where the child or young person has a Continuing Care need. The ‘Section 
117/Tier 4’ agenda item facilitates operational and strategic oversight where a multi-
agency approach is required to ensure shared statutory obligations are met. 

There is a Joint Funding Protocol to support the work of the panel and reflects the 
objective of having a shared view regarding funding arrangements. The protocol 
outlines the objectives, principles and joint funding arrangement required by 
Education, Health and Social Care to identify, agree and secure appropriate joint 
funding arrangements for individual children and young people who have special 
educational needs and/or disabilities and/or mental health needs; and/or are children 
in care to Cambridgeshire or Peterborough. 

The protocol is intended to support joint funding discussions and ensure consistency 
and provides a standardised governance framework, within which all placements and 
funding arrangements will be agreed, recorded and auditable throughout the duration 
of the child/young person's placement or package of support. 

The JASP Terms of Reference are included at Appendix 1 for information. 

2.   Involvement of CCC alongside CPFT in complex adolescent mental 
health cases where the risk is of suicide / self-harm (For CCC). 

The Coroner has expressed concern that frontline staff in the County Council may 
not have sufficient knowledge, guidance and supervision from the organisation to 
support them in working with this very complex area of practice. There were 
shortcomings identified in terms of a complete understanding of roles and 
responsibilities at the time of the deaths of Sam and Chris Gould, and this has been 
acknowledged by the Council. 

New Policies 

Since that time, however, there are clear policies in place which staff can and do use 
to support them in the delivery of their day to day duties. I attach the latest version of 
the Children Living Away from Home for 3 Months or More Section 85 and 86 
Children Act 1989 (CA’89) & Section 117, (MHA’89) Referral, Assessment & After 
Care Procedure to this response for information. It has been updated to include clear 
guidance on the matter of parent carer assessments for disabled children and is 
included at Appendix 2. As noted above, children and young people with significant 
mental health needs are now specifically included within this care pathway, meaning 
that parents are able to request parent carer assessments in their own right.  

This has been shared with all staff in relevant early help and social care services, 
and support and management oversight is offered regularly by senior managers to 

 the specific teams that hold most of these type of cases. There is one route through 
which new contacts in relation to young people with mental health difficulties can be 
made, and staff in the Integrated Front Door (who review all such requests for 
services) have been required to familiarise themselves with our statutory duties and 
the relevant policy documents. We operate a frequent audit dip sample process 
around all contacts, and any areas where there may still be uncertainty are picked up 
through that process and addressed. 

Strong Families Strong Communities Strategy and Contextual Safeguarding 

Young people who are then assessed can either receive support currently from our 
Early Help Service or our Adolescent Service, depending on the individual’s level of 
need. All staff in these areas have received the new guidance and are provided with 
a minimum of monthly supervision to help them review any difficult issues or areas 
where there may be queries around the local partnership, and who might be best to 
deliver particular services to an individual young person. As we move into the new 
early help strategy already described to the Coroner, Strong Families, Strong 
Communities: securing best outcomes for children and young people, we will also be 
developing a formalised approach to contextual safeguarding across the Local 
Children’s Safeguarding Partnership. This approach is known for its innovative 
reframing of sexual and criminal exploitation where there continues to be a 
perpetrator of harm to young people, but is also very effective in helping practitioners 
to understand the widest possible context in which vulnerable young people are 
frequently functioning. Our model looks to draw on effective interventions with young 
people who misuse drugs or alcohol or use violent interactions with others as forms 
of self-harm as well as the more established mental health definitions around cutting, 
eating disorders, anxiety, depression and other long-term mental illnesses. The 
importance of a trusted adult and the ability to make connections and effect change 
at key moments is a core principle of the contextual safeguarding framework and will 
be key for improving outcomes for young people with additional mental health needs. 

The Strategy is attached for reference at Appendix 3. 

Mental Health Training 

To support the new approach, there will be more detailed bespoke training delivered 
around emotional and mental well-being, serious mental illness and the role of 
Children’s Services in supporting young people and their families in this area. These 
changes will begin to be put in place over the remainder of the current financial year. 

The current training programme includes a specific focus on Adolescent Mental 
Health. This training supports practitioners to understand factors that influence 
teenagers’ cognitive, emotional and social development, give an insight into young 
people’s experience of anxiety and depression and identify the signs and risks of self 
harm, and consider minimisation strategies. It will also provide an understanding of 

 ADHD and the impact on a young person’s life. Direct work with adolescents will also 
be explored to develop practice in this area. 

Adult Mental Health training is also available to Children’s Services staff, supporting 
practitioners to improve their knowledge of Mental Health issues with particular 
emphasis on Dual Diagnosis; to include mental health and autism, mental health and 
learning disability, mental health and addictions.  

Importantly, for those navigating mental health legislation as well, we provide training 
to enhance practitioners’ understanding of the Mental Health Act 1983 through 
focusing on critical aspects of the Act; exploring the Code of Practice; section 117 
responsibilities; Continuing Health Care and the Care Programme Approach. This 
training is also being reviewed to ensure it supports practitioners who are working 
with young people transitioning to adult services. 

Education Developments 

In education terms, there has been considerable work undertaken to ensure that 
staff are clear about roles and responsibilities, and are in a stronger position to 
support and advocate for young people. 

The role of the Education Inclusion officer is now clearly defined to provide guidance 
and critically evaluate the quality assurance and monitoring functions in Secondary 
Schools (and Academies) that support the improvement of attendance and 
educational outcomes for those most vulnerable children and young people who are at 
risk of exclusion or not receiving their full educational entitlement. Where appropriate, 
they broker, and quality assure, packages of individual support for those most 
vulnerable families and students. 

They are key in championing the needs of vulnerable children and young people 
aged between 11-16 years old who have complex or severe needs and who are at 
risk of failing to achieve full participation in learning. All staff have now been through 
rigorous training with regards to the quality assurance of all Alternative Provision 
(AP) packages for students – including training around ensuring schools holding and 
maintaining a live AP register evidencing safeguarding checks, hours of education, 
providers and what quality assurances framework they have been through with our 
service. 

Officers are now equipped not only to offer the right advice and support on offer to 
our AP students and their families, but will critically scrutinize decisions made by 
schools to place a student on AP; will track their progress and attendance, and will 
ask schools to evidence this and multi-agency decision making around planning and 
reviewing for each student. Staff are all aware and trained about the legal 
requirements of ‘off rolling’ students, educational entitlement and thresholds for 
alternative provision, whether these are in relation to behavioural or medical needs. 

As part of their ongoing training and professional development, all officers also 
access both safeguarding and mental health awareness training through a number of 
different means: staff training sessions; complex case discussions; and during their 

 
 
 
 
  
  
 
 monthly 1:1 sessions with their line managers. Staff have access to the CAMHS 
Mental Health online training module, which incorporates a considerable amount of 
reading and encourages self-research in areas of particular interest in relation to 
barriers to learning for those students with mental health issues. 

Conclusion 

There remain complexities around consent to involvement with our services and the 
young people we are typically trying to support are of an age where they can make 
decisions about who they do and do not want working with them. Our staff are much 
more aware now of their wider responsibilities to partnership working and the critical 
importance of young people being seen alone to ensure their wishes and feelings 
are fully understood. They are also clear that parents or carers in these 
circumstances have the option of a carer’s assessment in their own right, and this 
may mean that other services are also become available to help the family in a 
broader context. The range of support available to young people and their families 
has developed significantly as discussed in point 1 above, and staff do know the 
routes through which they can access support as needed. 

There will continue to be examples of cases where there is complication in terms of 
who should be taking the professional lead for a young person, and what services 
may or may not offered by each agency. In those circumstances, staff are now 
aware that they can follow the established routes around joint partnership packages 
of support and escalation processes if needed. These are also detailed in section 1 
above. 

Mental health needs of young people have assumed a much higher profile across 
the country and in Cambridgeshire following the impact of the Covid 19 pandemic as 
well as the lessons learnt from the tragic deaths of Sam and Chris. The importance 
of our responsibilities, support and advocacy for young people in challenging and 
vulnerable situations is very much at the forefront of our new service design going 
forward.  

Assistant Director 

Children’s Early Help and Social Care Services 

Peterborough and Cambridgeshire Councils 

 
  
 
 Appendix 1 

 
     Peterborough City Council (PCC) & Cambridgeshire County Council (CCC) Joint Agency Support Panel (JASP)  Terms of Reference Purpose  The Joint Agency Support Panel (JASP) will be responsible for  - supporting and advising Peterborough City Council (PCC)/Cambridgeshire County Council (CCC) and Cambridgeshire & Peterborough Clinical Commissioning Group (C&PCCG) in reaching decisions about resources - approving requests for packages of support and/or placements for children and young people*, where there are joint funding arrangements in place and/or if the case is deemed complex - approving funding for packages of support and/or placements for children and young people - reviewing packages of support and/or placements for children and young people, where there are joint funding arrangements in place and/or if the case is deemed complex - approving joint funding arrangements for package of support; whether the arrangement is between Social Care, Health and Education or any combination of the three agencies - supporting children and young people with complex needs to access an appropriate range of educational, health and social care provision - providing a forum to explore and develop creative, inclusive and multi-agency responses to meeting the needs of children and young people with complex needs  * A child is defined as any person under 18; a young person is generally described as a person from 14 to 17 years of age; an adult is defined as any person 18 years of age and above. Applications for resources for persons aged 18 or over will be considered by JASP for Peterborough City Council (above responsibilities being upheld) and the Learning Disability Partnership (LDP) Adult and Autism Team (AAT) County Wide Quality Assurance (QA) Panel for Cambridgeshire County Council. The cases heard at JASP will relate to children and young people with additional needs; these needs may include a diagnosed learning disability/learning difficulties, a physical disability, sensory impairments, communication difficulties and complex/significant medical, therapy, mental health, behavioural needs. Objectives JASP focuses on children and young people who have particularly complex needs, where a multi-agency response across health, education and social care is needed for those needs to be met. Cases heard at JASP will refer to children and young people with disabilities and complex needs who require more substantial packages of support than those which can be agreed at Short Breaks Panel (PCC) or Disabled Children’s Panel (CCC); they will also be, in the main, joint funded packages of support. Cases heard at JASP may also be those requiring escalation and/or those where there are issues relating to a number of service areas which require resolution. This operational focus will also include capturing funding reconciliations (taking into account Social Care, Education & Health); this will be done on a quarterly basis, in line with the Continuing Care Practice Guidance. All joint funding arrangements will be captured in a Joint Funding Agreement Form, for each case.  The strategic focus of JASP will be:  
 
 Appendix 2 

 Children Living Away from Home for 3 Months or More Section 85 and 86 Children Act 1989 (CA’89) & Section 117, (MHA’89)  Referral, Assessment & After Care Procedure  Context  Sections 85 & 86 CA’89 place a duty on Local Authorities (LA) to assess the safety and welfare of children living in residential education or hospital provision for any continuous period exceeding/or likely to exceed 12 weeks.   The legislation is aimed particularly at ensuring the safety and support needs of disabled children and young people and those accessing Tier 4 specialist in-patient care as a result of severe and/or complex mental health conditions that cannot be adequately treated by community CAMH services.  The responsible LA has a duty to take such steps as are reasonably practicable to determine whether the child's welfare is adequately safeguarded and promoted while they are in one of those settings, and to consider whether there is a need to exercise any functions under the CA’89 with respect to the child or young person.  Determining the Responsible Local Authority Where the establishment in which the child or young person is residing is in the public sector (e.g. NHS hospital, local authority residential special school), ‘responsible authority” means:  • The local authority within whose area the child or young person was ordinarily resident immediately before being accommodated; or • Where the child or young person was not ordinarily resident within the area of any local authority, the local authority within whose area the accommodation is situated.  Where the establishment in which the child or young person is residing is in the private sector (e.g. private hospital, care home), the ‘responsible authority” means (s.86 CA’89) the local authority within whose area the establishment is situated.  Where the child or young person is residing in a private establishment but funded by a public sector organisation, e.g. a Clinical Commissioning Group (CCG), then this will fall within section 85, rather than section 86, and the ‘responsible authority’ will be the authority within whose area the child or young person was ordinarily resident immediately before being accommodated in the hospital.  Notification to the LA on Admission Upon admission, NHS England or the setting, i.e. Residential ‘special needs’ schools (joint or single agency funded, ‘in’ and ‘out’ of area) including maintained and non-maintained boarding schools, Hospitals, including small ‘local’ hospitals and independent/private hospitals and Psychiatric units including private and voluntary sector units and those that treat young people with severe mental health needs, must notify the LA where the child or young person normally resides.  Notifications are required as soon as a child or young person is going to be/likely to be resident within a setting for 12 weeks or more and when a child is discharged after a 3-month period.   
 Appendix 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Strong families, strong communities 
Securing best outcomes for children 

Cambridgeshire and Peterborough Early Help Strategy 

April 2021 

This strategy sets out a partnership vision and action plan for Early Help across Cambridgeshire and 
Peterborough for the next five years. 

 
 
 
 
 
 What is Early Help? 

Early help is providing the right children, young people and families with the right support, in the right place at the right 
time. We all believe that by supporting children and families earlier we can stop any problems they are facing from 
getting worse and help them to find the solutions that will make their lives better in the future. We can do this by 
working together, building on children’s and families’ strengths, and developing their capacity to make positive changes 
for themselves.  

Our ambition 

We believe that delivering Early Help well has the potential to transform the lives of children, young people and their 
families across Cambridgeshire and Peterborough. We are committed to reducing inequalities and providing high quality 
early help to families makes an important contribution to achieving that aim. We make no apologies for setting out a 
vision that is very ambitious. Our goals, which flow on from the three Best Start in Life headline goals, are that: 

In order to achieve these high-level goals, we have identified five intermediate outcomes. We believe that if we focus on 
these things then we will have the biggest and most lasting impact on our overall goals. Our intermediate outcomes are: 

Strong families 
The care and love provided by strong, supportive families is the essential foundation for enabling children and young 
people to lead safe, healthy and successful lives. 
Trusted relationships 
Forming positive, trusting relationships with adults (both inside and outside the family) and with their peers gives 
children and young people emotional stability and opportunities to flourish in life and learning. 
Safe places and positive activities 
Safe places to socialise and a wide range of activities that build self-esteem, excite young people and create a sense of 
belonging are all important contributors to children and young people growing up healthy and happy.  
Capacity to manage challenges 
An important component of secure mental health and good emotional wellbeing is the capacity of a child or young 
person to cope with setbacks and manage the inevitable ups and downs of life. 
Enjoyment of life and learning 
Ultimately children and young people who are thriving find enjoyment in their everyday lives and find their learning 
rewarding. This is what we hope for, for all our children and young people.  

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 Our principles 

We have a strong set of guiding principles that inform our approach to Early Help across our partnership. These are: 
Children and young people are at the heart of what we do.  
We will listen to children and young people’s views and feelings and understand the impact on them and their family. 
We build capacity, not create dependency.  
We will work with children, young people and families to recognise and build on their strengths. We will help them 
develop the skills to solve problems and overcome challenges. 
We work as a partnership to effect change.  
Early Help is everyone’s business. We will draw on the skills and knowledge of all the partners who work with children 
and families. 
We intervene early to prevent problems from getting worse.  
We will not wait before problems become unmanageable before we offer help, and we recognise that support might 
come from a range of different places. 
We work with the whole family.  
We know that children and young people live in families, so we will work with the family as a whole, and the individuals 
within the family, to understand their needs and develop holistic support. 
We join up our systems and processes.  
Families will tell their story once and will work with a trusted professional throughout their journey. 
We use evidence to inform what we do.  
Our offer of support will be guided by the latest research and evidence of what works. We will be bold and innovate, but 
always test the impact of new approaches. 
We work in places and communities.  
We will build the capacity of communities to support their members, create local networks of professionals who work 
together, and target our support to meet the different needs of individual places. 

How we work together to deliver Early Help 

Early Help is not a service in a conventional sense. It is a philosophy of how we can utilise all the resources available in 
families, communities, the voluntary sector and public bodies to provide timely and effective support when it is needed. 
In Cambridgeshire and Peterborough our Early Help offer comprises three key dimensions: 

 Our expectation, as a partnership, is that children, young people and families will receive support at the lowest level of 
intervention that can meet their needs. That means that we can use our collective capacity in the most efficient way to 
support as many children and young people as possible. We know that the needs of children, young people and their 
families change over time and therefore may be supported at different levels in the system depending on what is 
happening in their lives. 
Community support 
Our ambition is that most children, young people or families who encounter difficulties can be supported to overcome 
these with the resources available in their communities. In Cambridgeshire and Peterborough, we have a thriving 
voluntary and community sector offering a wide range of positive activities, supportive networks, drop-in sessions and 
advice. Our aim, over the next three years, is to develop and grow this capacity further, make it easier for parents, young 
people and professionals to find the support that they need and create better opportunities for bringing all those who 
work with children and young people together to share information and knowledge about what works.  

More support 
Some children, young people and their families, will need individual help to successfully overcome the challenges they 
are facing. For these families, or young people, we aim to offer earlier and more bespoke support, organised through a 
trusted professional. The trusted professional can be anybody who has a strong relationship with the family and the 
capacity to work with them on what they want to achieve. This might be, for example, someone who works in the child’s 
school, a health professional such as a GP or practice nurse or youth club worker.  

 
 
 For families or young people who need this level of support, the Lead Professional will work with the family or young 
person to complete an early help assessment. This is an honest assessment of the family or young person’s strengths and 
weaknesses. They will then use this to work with the family to create an Early Help plan which sets out the goals that the 
family or young person want to achieve, and the support that they will need to get there. The Lead Professional will not 
provide all the support that a family might need at this level, but they will be a consistent point of contact, brokering in 
the extra help and advice that might be needed. Examples of the types of help that families might receive include access 
to parenting courses either online or in groups, counselling or lower-level mental health support, or the range of support 
offered through children and family centres. 

Targeted support 
For a minority of families, the support that a trusted professional can offer, even bringing in a range of additional 
specialist services, will not be enough. For families or young people who need more help, Cambridgeshire and 
Peterborough offer bespoke targeted support delivered both online and in the home, that is designed to address 
immediate barriers and rapidly build the capacity and resilience that a family or young person need to get their lives back 
on track.  
The nature of the intensive support on offer will depend on the needs of the family or young person and will be set out 
clearly in the Early Help plan. However, it might typically involve one or more homes visits a week for a period of time, 
prompt access to a range of specialist services or interventions and regular online conversations to build confidence and 
embed learning.  
The targeted support offer will be delivered by a dedicated early help or specialist practitioner, who may be a member of 
a local authority team or work for an organisation that has been commissioned by the local authority to deliver this 
support offer. Whoever delivers the support will work in the same way with the family, and to the same exacting 
standards.  
To enable us to help children, young people and their families more effectively we are creating a consistent approach to 
organising our local authority teams across Cambridgeshire and Peterborough.  
There will be one worker or team per family, where this is possible and in the best interests of the children concerned. 
Across both Cambridgeshire and Peterborough, services will be a mixture of direct delivery and commissioned provision. 
The service will be place based, and work across four geographical quadrants. In each quadrant the following teams will 
be brought together and operate as an integrated service: 

•  A Child and Family Centre with the attached Children and Family Centre staff 

•  0-11 Targeted Children’s Support Team(s)  

•  11-19 Targeted Youth Support Team(s)  

•  10-19 Specialist Support Team(s) – these are combined YOS and social care teams 

•  Transition (education) service – this focuses on school transition issues and NEET/ NIAP, and liaison with 

Education colleagues where education is a complex issue for the young people with whom we are working 

• 

Leaving Care Team 

Specialist partners or smaller teams will also be linked to each area including:  

 
 •  Police 

•  Probation 

•  Mental Health 

•  Drug and Alcohol 

•  Sexually Harmful Behaviours/ ISS High Risk 

•  SAFE team 

•  Other commissioned provision, for example parenting programmes. 

Each area will also run a volunteer provision, and support the local community through parenting programme delivery, 
befrienders, Princes Trust, and mentors.  
The four quadrants will each be managed by a dedicated head of service. Each head of service will also be the lead for 
one specialist area across the entirety of Cambridgeshire and Peterborough. The specialist areas of focus will be strong 
families; learning and participation; exploitation of vulnerable and at-risk adolescents; and physical and mental health.  
The purpose of these changes will be to enable greater alignment across Cambridgeshire and Peterborough, to deliver a 
more joined up service for children and families and to enable closer working with partners on a place-based approach. 

Joining the dots 

Working together effectively as a partnership to deliver Early Help relies on clear systems and processes that are easy to 
use and enable excellent practice. Our popular Back to Basics online training session is available to colleagues from across 
the partnership, supporting professionals to develop the skills and knowledge required to guide families through the Early 
Help assessment process. For further details and booking please click here. 
Early help assessments 
The early help journey for families in Cambridgeshire and Peterborough starts with an Early Help assessment. It is an 
impartial and honest assessment of strengths, opportunities and challenges that is undertaken with the family, and only 
ever with their permission. It should be completed when more than one unmet need would benefit from a multi-agency 
support approach. More guidance on the early help assessment tools and process can be found here in the Effective 
Support for Children and Families in Peterborough and Cambridgeshire document.  
Early Help assessments (EHAs) are also used as a gateway to access several other forms of support. 
From 2021, an Early Help assessment will need to be completed by a professional looking to access a 
neurodevelopmental assessment in both Peterborough and Cambridgeshire and the Early Support 
Pathway in both local authorities. In Peterborough, an EHA is also needed to access a place on a 
commissioned evidence-based parenting programme, a Behaviour Panel referral, and specialist sleep 
support.  
Early help plan 
The Early Help plan is where families and professionals record their goals for the future and the steps that they are going 
to take to reach those goals. All Early Help plans in Peterborough and Cambridgeshire will follow the same structure 
whether they are developed by a Lead Professional or an Early Help practitioner. A critical attribute of the plan is that it is 

 
 developed with the family and owned by them. It is also the benchmark against which progress for the family or young 
person is measured.  
The Early Help hub 
The Early Help Hub is the first point of contact for families and professionals doing an Early Help Assessment. It 
coordinates access to targeted early help services in Cambridgeshire and Peterborough and provides advice and guidance 
on cases managed by the professionals already involved. The Early Help Hub receives contacts for children and families 
who require multi agency support through Early Help Services to support their needs. 
Team around the family 
The Team Around the Family describes the group of professionals or wider family members who are involved in providing 
support or advice to a family. It provides an opportunity for the family and professionals to work together on achieving a 
family’s goals. The Lead Professional will normally coordinate the different contributions of the individuals within the 
Team around the Family. This will generally be managed through regular meetings of the Team around the Family and 
monitoring progress against the Early Help plan.  
Every contact counts 
The Team Around the Family provides a focal point for decision-making and planning for the professionals and 
practitioners who are most directly involved in providing early help for a family. However, we know that there will be a 
wider range of trusted adults who engage regularly with children, young people and families and who can ensure that 
their daily interactions support the early help goals and principles and can make ‘every contact count’ in a positive way. 
The wider range of trusted adults might include anyone from GPs to neighbourhood policing teams, housing officers to 
faith and community leaders. As part of this strategy, we are committed to rolling out a wider programme of 
communication and training to ensure that everyone who interacts with children, young people and their families 
regularly has the skills and understanding they need to support the early help goals by making every contact count. This 
might entail skills in active listening and asking open questions; understanding of how to identify signs of risk; awareness 
of the goals of the early help strategy and how these can be supported through day-to-day activities; or knowing how to 
share information safely or connect a family to other forms of support and guidance.  
Collective decision-making 
Early help is a partnership endeavour. Creating the opportunity for partners to come together to contribute to shared 
decisions about how a family can best be supported is therefore an important underpinning of how we work. In each of 
the four quadrants there will be a regular forum for partners to discuss families or young people where additional 
professional input might be needed. In Peterborough, the MASG panel will continue to perform this function. In 
Cambridgeshire, a new multi-agency forum will be convened on a regular basis in each quadrant. It will provide an 
opportunity for Lead Professionals to refer a family or young person with whom they have been working and for whom 
progress has slowed or risks have escalated for a multi-agency discussion and decision-making about future support 
options. The Early Help Hub will also recommend cases for an initial partnership-based discussion where the way forward 
is not clear cut. These regular fora will generally be held virtually to encourage strong attendance. 
Common practice model 
We will be more effective in supporting families if all those delivering Early Help, from ‘community support’ to ‘targeted 
support’, are able to use a common language and a common approach. The way that professionals or other adults work 
with families and young people is the ‘practice model’ and defines the way in which that interaction takes place. From 
2021 we will be adopting Motivational Interviewing as our shared practice model across all Early Help. This is the same 
practice model as is currently used by Children’s Social Care teams across Cambridgeshire and Peterborough. 
Motivational Interviewing is based on the belief that every person has the potential for change. It is a strengths-based 
approach to supporting children and families which encompasses four key principles - empathy, congruence, positive 
regard and supporting self-efficacy. Practitioners use skills such as open-ended questions, reflection, active listening, 
affirmations and summarising to support a child, young person or parent / carer to recognise their own qualities and 
strengths and to draw on these to modify any behaviours which may not be positive and those which are having a 
detrimental impact on their wellbeing and the wellbeing of others. Because the model relies on the individual effecting 
his or her own change, any immediate change is more likely to be sustained in the long term.  

 Moving towards a shared practice model of Motivational Interviewing will be supported through a multi-agency training 
programme for staff and partners and regular opportunities for reflective practice to embed and refine new ways of 
working. 
In addition to Motivational Interviewing as the core practice model there are several tools and approaches that early help 
practitioners and lead professionals may use with families. A guide to these, and how and when they might be most 
usefully deployed has been developed by the Cambridgeshire and Peterborough partnership board and is available here. 
Sharing information 
The ability to share information quickly and securely about a family with trusted professionals is critical to effective 
partnership working for early help. To that end we have invested in the development of an early help module as part of 
our integrated case management system for Children’s Services. The Liquid Logic early help module is now being 
extensively used by early help practitioners in children’s services, as well as partners in schools and health. Early feedback 
suggests that professionals find the system easy to use and navigate. Over the coming months we will be consolidating 
the effective use of the system by those who have received access and training. We will also look for opportunities to 
expand the network of people working with families who are able to share essential information through the system, for 
example by broadening access to VCS providers and groups where appropriate and useful. This will help secure our 
commitment that families need only tell their story once, while placing the concept of consent and data protection at the 
heart of what we do.   
Measuring progress 
Our commitment to continuing to improve our partnership-wide early help offer depends on our ability to accurately and 
consistently measure the progress made by the children and families whom we support. In Peterborough, our tool for 
measuring the progress made by an individual family is the Outcomes Star. In Cambridgeshire we use a bespoke tool for 
measuring progress called the Measuring and Assessing Progress tool (MAP). In the short term, as we establish a more 
joined up approach to early help across Cambridgeshire and Peterborough, we will carry out a comparative audit of how 
outcomes and progress are assessed across the two local authorities and synthesise, as far as possible, the two 
approaches. In the medium term we will await the announcements on the future of the Supporting Families programme, 
and the accountability framework that may accompany this, before co-designing a future approach to measuring 
progress and tracking outcomes, building on the best of what is currently in place in both local authorities and across 
partners.  
Specialist Support 
Some children, young people and families will need to access specialist assessments and support as a result of risks that 
have been identified. Specialist assessments for our most complex and at-risk young people will be available through 
Asset Plus Assessments and/or Child and Family Assessment. This support can only be accessed through Youth Offending 
Service Police and Court referral processes and Effective Support for Children and Families processes if young people 
meet the required threshold (see the Effective Support for Children and Families in Peterborough and Cambridgeshire 
document). For young people and families with more complex needs we will work within a partnership contextual 
safeguarding framework and will utilise approaches such as motivational interviewing and trauma informed practice 
ensuring every contact counts and building on relationships with trusted adults.        

The voice of children, young people and their families 

Listening to children, young people and families, and then acting on what they tell us, is central to making sure that this 
strategy, and the actions that flow from it, remain relevant and purposeful. We will therefore put in place a structured 
programme of engagement with children, young people and families that uses some existing and some new 
communication routes. The information gathered through this ongoing programme will help us first to test the principles 
and goals of this strategy and subsequently to monitor how well we are putting them into practice. The feedback routes 
that we will employ are summarised below: 

•  Regular surveys of children and young people conducted by the safeguarding board.  

•  Annual digital health questionnaires provided to families with children in reception year and year 6, and for 

young people in year 9. 

 •  The work of youth and community coordinators and the Youth Voice and Youth Engagement Partnership. 

•  Regular structured feedback on YOS and mental health and emotional wellbeing services.  

•  Capturing the voice of children and young people in measuring progress against early help plans.  

•  Recommissioning an annual survey, across Cambridgeshire and Peterborough, of children and young people in 

schools.  

Our priorities 

Based on an analysis of our data and extensive consultation with staff, partners and children and young people we have 
identified the following strategic priorities to guide our work to deliver early help over the next three years. These are 
priorities to which all those engaged in the early help partnership can contribute and are arranged against the four 
thematic areas of focus. 

Area of focus 

Key priorities 

Develop a new model of blended support for families bringing together the best of 
virtual and face to face interactions. 
Harness the full potential of children and families’ centres, building on the principles of 
Best Start in Life. 
Address the areas of need that have been exacerbated through the pandemic including 
financial hardship and domestic abuse.  
Support children aged 9 to 12 to make a successful transition to adolescence. 
Improve outcomes for children and young people presenting to early help with 
challenging behaviour. 
Actively support children and young people to re-engage with learning, positive activities 
and employment in response to the pandemic. 
Create more opportunities for high quality preventative work with at-risk adolescents 
and their younger siblings particularly targeting those at risk of involvement in serious 
crime, violence or exploitation. 
Develop a partnership wide approach to contextual safeguarding for at-risk adolescents. 
Work with young people in the youth justice system to reduce re-offending and support 
them onto positive pathways. 
Provide support earlier for children and young people experiencing poor emotional 
wellbeing to stop issues from becoming entrenched.  
Enable families to adopt healthy lifestyles and good health routines including improved 
nutrition, more physical activity, better oral health and keeping up immunisations. 
Work with children and young people to embed an understanding of safe, healthy and 
kind relationships and make a successful transition into adulthood. 

Strong families 

Learning and 
participation 

Vulnerable and at-risk 
adolescents 

Physical and mental 
health 

Strong families 

In both Cambridgeshire and Peterborough, the rate of referrals to children’s social care reduced in 2019-20 at a much 
greater rate than nationally. This means that in Cambridgeshire considerably fewer children and young people were 

 
 
 
 
 
 referred to children’s social care per 10,000 population than nationally or in similar authorities. In Peterborough, the rate 
remains above the national average and slightly above the rate in similar authorities but is falling more quickly. It is also 
encouraging that the rate of children with new child protection plans in 2019-20 reduced in both local authorities and is 
now below the national average and below the average in similar local authorities in both Peterborough and 
Cambridgeshire. These data are very positive and suggest that the partnership wide provision of early help may be 
helping to reduce the need for more specialist and more costly interventions.   
However, the impact of the Covid pandemic over the last 12 months has been profound and we are only just beginning to 
understand the potential implications for families. In recent months we have begun to see increasing incidence of 
domestic violence and many more families experiencing financial hardship than previously. This is bringing children and 
families to the attention of early help who may never before have needed support. We are also aware that the pandemic 
has been a particularly challenging and isolating period for many of our young carers. Data shows that in both 
Cambridgeshire and Peterborough challenging behaviour in the home, poor behaviour in school, parenting concerns and 
poor parental mental health all feature in the ten most common reasons for an early help assessment. Extended 
lockdowns and time away from school are likely to impact negatively on all these factors which suggest they should be a 
real focus for the partnership going forward.  
At the same time, some of the changes to the way we have worked during the pandemic offer real opportunities for 
rethinking and improving the way in which early help is delivered through the partnership. Locality hubs have become 
more vibrant and there is a structure in place to take these forward. Working with a range of partners, both statutory and 
community, has accelerated. Professionals believe that joint work and planning around the most vulnerable children has 
improved and there is an opportunity to reimagine services on a new ‘hybrid’ model which combines the best of virtual 
and face to face interactions.  
What we can do as a partnership 

Priority 
Develop a new model of 
blended support for 
families bringing together 
the best of virtual and face 
to face interactions. 

Harness the full potential 
of children and families’ 
centres, building on the 
principles of Best Start in 
Life. 

Address the areas of need 
that have been 
exacerbated through the 
pandemic including 
financial hardship and 
domestic abuse.  

Actions 
•  Evaluate families’ experience of virtual and face to face support, and the relative 

progress made by families, to create a new blended offer for piloting and roll out.  

•  Strengthen and refine the protocols for working with families where there are 

multiple children of different ages and/or with different levels of need so that their 
experience of support is more joined up.  

•  Develop greater consistency in the children and family centre offer so that we have 

confidence that all families can access a good range of services.  

•  Create local networks of professionals working with families, centred around 

children’s centres and working on the basis of every contact counts.  

•  Work across children’s and adult’s services to streamline and strengthen the offer 

for children and young people experiencing domestic violence and parental conflict 
resolution.  

• 

Identify families made ‘newly vulnerable’ as a result of the pandemic and create an 
offer of support to get them back on their feet. 

Learning and participation 

The disruption that all children and young people have experienced to their education as a result of the pandemic has 
been profound, and all the evidence suggests that children from more disadvantaged backgrounds are likely to suffer the 
greatest negative impacts. This context will set the agenda for early help for years to come.  
Data and information collected before the pandemic points to some of the key areas of focus going forward. We know 
that children presenting with challenging behaviour either in the home or at school has historically been one of the most 

 
 
 common reasons for a referral to early help. Despite the significant progress made on reducing both permanent and fixed 
term exclusions in secondary schools in Cambridgeshire, primary fixed term exclusions still remain a cause for concern. In 
Peterborough fixed term and permanent exclusions in both phases of education are above national averages.    
The age group that might be a particular focus for our efforts over the next period are the ‘transition years’ of 9- to 12-
year-olds. Evidence collected from a wide range of partners and professionals, which underpins the development of this 
strategy, suggests that the offer of support for this age group, in terms of preventative work and early intervention, is not 
currently sufficient. Children aged 9 to 12 currently represent between 20% and 25% of the overall early help cohort in 
Cambridgeshire and Peterborough. Interestingly, on average in Cambridgeshire and Peterborough schools progress and 
attainment made by primary aged pupils is below national averages.  
At the other end of the age spectrum our young people aged 16 to 18, embarking on their adult lives, have experienced a 
very turbulent period with uncertainty over examination results and challenges around planning their next steps in 
learning. Before the pandemic, the percentage of 16- to 17-year-olds not in education, employment or training was high 
in Peterborough and above that of similar authorities in Cambridgeshire. Going forward identifying and supporting those 
young people at most risk of disengagement as a result of the pandemic will be a key priority. 
What we can do as a partnership 

Priority 
Support children aged 9 to 
12 to make a successful 
transition to adolescence. 

Actions 
•  Share and promote good practice on primary to secondary transition. 

•  Ensure sufficient positive activities and safe places for 9- to 12-year-olds. 

•  Develop a core family support offer for 9- to 12-year-olds. 

•  Encourage more parents to undertake the Triple P for Teens parenting programme, 

and evaluate its impact. 

Improve outcomes for 
children and young people 
presenting to early help 
with challenging behaviour. 

•  Based on a graduated response to behaviour, develop a wrap-around multi-agency 
offer for children and young people exhibiting challenging behaviour in a home, 
community or school environment.  

•  Put in place more joined up support around children at risk of exclusion in primary, 

including high quality roll-on roll-off alternative provision. 

Actively support children 
and young people to re-
engage with learning, 
positive activities and 
employment in response to 
the pandemic. 

•  Work with partners in the community to develop positive individual and family 

interventions and support for young people engaging in disruptive behaviour outside 
the home and school. 

•  Work with schools and community groups to identify the children and young people 

most at-risk of disengaging and put in place pre-emptive support.  

•  Work with young people at risk of becoming NEET to overcome the disruption to 
their learning and provide support, advice and guidance to enable them to make 
positive decisions about their futures. 

•  Support young people who are not in employment, education or training to re-

engage with learning and work through tailored information, advice and guidance 
and practical help to get them back on track.  

Vulnerable and at-risk adolescents 
In both Cambridgeshire and Peterborough, the percentage of young people entering the youth justice system is below 
national average, and the average in similar authorities, having fallen dramatically in recent years. This is really 
encouraging and suggests that a focus on prevention is leading to better outcomes. However, we also see the complexity 
of cases is increasing. Furthermore, the capacity to support intervention before young people engage in risky or criminal 

 
 behaviour is limited and there is a need to join up resources across the partnership to have the greatest possible impact 
on prevention. It remains a challenge that for many of those young people who enter care as a teenager, there may have 
been opportunities to intervene earlier had the right support and capacity been in place.   
For many of those young people who might previously have been at risk of exploitation or criminalisation, the pandemic 
will have reduced the range of positive activities and supports in their lives. Without the safety net offered by school, 
clubs, sports or youth activities many of these young people will be even more vulnerable than they were previously. 
Indeed, there are early indications that young people’s engagement in anti-social behaviour, gang-related activity, or 
serious crime, violence or exploitation may now be higher than it was a year ago. It is therefore a priority for this strategy 
to find ways to instill protective behaviours and support young people earlier to prevent the escalation of risk and need.  
What we can do as a partnership 

Priority 
Create more opportunities 
for high quality 
preventative work with at-
risk adolescents and their 
younger siblings 
particularly targeting those 
at risk of involvement in 
serious crime, violence or 
exploitation. 

Actions 
•  Strengthen the role that lead professionals, from a range of agencies and 

organisations, play in supporting at-risk adolescents, including identifying ‘teachable 
moments’. 

•  Strengthen the network of providers offering youth support to share information 

and priorities more effectively. 

• 

Identify young people at risk of becoming engaged in serious crime, violence, 
exploitation or organised criminal activity and put in place a bespoke support 
package to develop protective behaviours and protective networks. 

•  Work across partners and agencies to prioritise the younger siblings of exploited, 
risk-taking or criminalised young people for bespoke support through a Lead 
Professional and other support networks. 

Develop a partnership wide 
approach to contextual 
safeguarding for at-risk 
adolescents. 

•  Roll out training, guidance and support for a wide range of practitioners who work 

with vulnerable young people in contextual safeguarding. 

•  Provide CPD for specialist practitioners working with the highest-risk individuals, 

including trauma informed practice/interventions. 

•  Work with partners to identify young people early who might be at risk of criminal or 
sexual exploitation, or who might be vulnerable to pressures from outside their 
family environment and put in place appropriate support.  

Work with young people in 
the youth justice system to 
reduce re-offending and 
support them onto positive 
pathways. 

•  Draw on youth justice expertise and capacity to prevent young people from engaging 
in criminal activity and to reduce the occurrence of reoffending and harm against 
others.  

•  Work with partners to ensure that young people in the youth justice system have the 
support they need in terms of education, employment and health to make progress. 

Promoting good mental and physical health 
Providing timely support for children and young people’s mental health, when their needs are moderate rather than 
severe, in order to prevent problems from escalating, has long been a challenge in Cambridgeshire and Peterborough. 
This challenge is faced by many areas of the country and has been identified by the Children’s Commissioner as a priority 
for the future wellbeing of children and young people in England. The pandemic is likely to exacerbate many of the 
underlying causes of anxiety and poor mental health including deprivation, bereavement, isolation, and pressure 
associated with exams or education. There are already reports, nationally, of increased incidents of issues such as self-

 
 
 
 harm and eating disorders. Working to support both young people and parents who are suffering from poor mental 
health, early enough and with sufficient expertise, to prevent some of these challenges escalating and becoming acute 
should be a priority for the whole partnership. The new integrated approach to commissioning mental health support, 
coupled with distributing expertise and skills for enabling emotional wellbeing, is a key element of this strategy.  
In terms of physical health, we know that many of the referrals to community health teams are related to the 
consequences of adopting unhealthy nutritional habits and poor health routines. These include issues related to weight-
gain, incontinence, digestive problems and poor oral health. Many of these health complications can be addressed 
successfully by earlier adoption of healthy eating habits, including good hydration, active lifestyles and maintaining health 
routines.  
At the same time, the pandemic has taken a toll on the physical health of children and young people in terms of reduced 
opportunities for exercise, sport and play; routine appointments with healthcare providers that may not have taken 
place; and fewer opportunities for therapeutic interventions. We need to take the time to understand the impact of this 
changed landscape and put in place the support that will enable an improvement in children’s physical health over time. 
Moreover, in the context of the pandemic, vaccine hesitancy is seldom out of the news. Poor take-up of childhood and 
adolescent immunisations has been a challenge in more disadvantaged communities within Cambridgeshire and 
Peterborough for many years. We need a targeted approach to building communities’ trust in healthcare providers and 
developing their understanding of the essential contribution vaccines make to children’s ongoing health.  
What we can do as a partnership 

Priority 
Provide support earlier for 
children and young people 
experiencing poor 
emotional wellbeing to 
stop issues from becoming 
entrenched.  

Actions 
•  Create clarity of referral pathways between different levels of support, with a single 

front door.  

•  Build capacity and strength of partners to support children and young people with 

mild to moderate needs.  

•  Recommission an integrated support offer for the sub-CAMHS threshold. 

•  Pilot the offer of specialist supervision, advice or reflective practice to support 

practitioners to manage higher risk elements.  

Enable families to adopt 
healthy lifestyles and good 
health routines including 
improved nutrition, more 
physical activity, better 
oral health and keeping up 
immunisations. 

• 

Join up parenting programmes, the healthy child programme, and school nursing to 
provide families with support on nutrition, healthy lifestyles and good health 
routines in order to reduce the need for specialist referrals for weight gain, 
continence or digestive issues.  

•  Continue to promote ongoing uptake of immunisations through childhood and into 

adolescence, with a particular focus on uptake of the flu and HPV vaccines.  

• 

Identify children at high risk of poor oral health and work proactively with their 
families to promote good oral hygiene. 

•  Harness the capacity of the healthy child programme, curriculum opportunities in 
schools and expertise in the voluntary and community sector to develop a strong 
understanding and appreciation of safe and kind relationships.  

•  Develop a multi-agency approach to tackling bullying and in particular the 

emergence of cyber bullying.  

Work with children and 
young people to embed an 
understanding of safe, 
healthy and kind 
relationships and make a 
successful transition into 
adulthood. 

 
 Outcomes framework 

To measure whether we are having the impact that we hope, we have constructed the attached outcomes framework 
that is organised against our headline goals.

23.07.21 

Mr Nicholas Moss QC 
Assistant Coroner for Peterborough and 
Cambridgeshire 

BY  EMAIL. 

r~1:k1 

Cambridgeshire and 
Peterborough 
NHS Foundation Trust 

Legal Services Department 
Elizabeth House 
Fulbourn Hospital 
Cambridge 
CB21  5EF 

Website: www.coft.nhs.uk 

Dear Mr Moss QC, 

Inquests touching the deaths of Sam and Chris Gould - response to Report to Prevent Future Deaths. 

I write in response to your Report to Prevent Future Deaths, dated 28.05.21. Within that report, you raised 
four issues of concern,  namely: 

(1)  Overnight assistance for adolescent mental health patients being cared for at home but with high 

levels of need (For CPFT and CCC).  I heard evidence of increased funding for CPFT being used to extend 
home treatment options,  but that this would  be  unlikely to  extend to a 24/7 service.  I also  heard 
evidence from  CCC that available support would  now be considered  under s17 Children Act or s117 
Mental Health Act or both  but that this would  need to be jointly funded  between social care and  health. 
I remain concerned that a clear pathway to securing overnight assistance  (even  if only on  a respite  basis) 
for similar cases of exceptional  need  has not yet been clearly agreed  between CPFT and CCC.  I am 
concerned that if alternative supported accommodation  in  the community were the best solution, there 
does not appear to  be provision for it in-area,  so that admission to  a mental health unit becomes more 
likely. 

(2)  Not for CPFT but included for completeness 

Involvement of CCC alongside  CPFT in complex adolescent mental  health cases where the risk is  of 
suicide/ self-harm  (For CCC).  In  some  respects CCC's  involvement in Chris and  Sam's care  (social care 
and  education) lacked direction, focus,  knowledge and  efficiency.  I heard evidence of improvements in 
training in  the relevant education and  social work teams, and concerning the new Strong Families, 
Strong Communities Securing Best Outcomes for Children Strategy (March 2021).  Further, that CCC  is 
restructuring all of its early help and  adolescent services and  will be  implementing a formal contextual 
safeguarding framework and  that these developments will be in  place  by the end  of 2021.  I am 
concerned that in  the midst of restructuring and  new guidance, there remains a risk that education 
inclusion officers and social workers on the ground may still not have sufficient knowledge, guidance and 
supervision to ensure that CCC give practical and  robust support to parents and  adolescent patients, 
alongside treating healthcare agencies,  where the main  risk of serious harm to the child  is from self-

Page 1 of 4 

 harm or suicide arising from adolescent mental health disorders, rather than neglect of harm  by a third 
party. 

(3)  Diagnosis of Borderline Personality Disorder (For CPFT).  I am concerned that the evidence in Chris' case, 

in particular, suggested  a degree of age-related reluctance consistently to use the terminology of 
Borderline Personality Disorder (or Emerging Personality Disorder or EUPD), even when a highly 
specialist second  opinion had  supported this and appeared to have been accepted. There are  risks 
associated with a reluctance to use a personality disorder diagnosis (c.f.  Position Statement from the 
Royal College of Psychiatrists dated January 2020). I received evidence that there have already been 
some changes/improvements in the preparedness to recognise Borderline Personality Disorder and that 
further consideration will be given in the context of the new ICD 11. 

(4)  AWOL patients from Darwin Centre for Young People (For CPFT).  I heard evidence that since Chris' 

death, staff have been reminded of the applicable policies; and that an audit has shown good 
compliance with the provision for calling the local signallers.  I heard evidence that there is to be  a 
further review of CPFT's own AWOL policy. I remain concerned that: (i) CPFT's own policy is too lengthy 
and complex to serve as  reference-guidance during a live AWOL incident. In particular the flow chart 
summary is  unnecessarily complex and  hard to follow (at least as a tool to consult during a stressful 
incident); (ii) there is a risk of confusion in  having two policies both of which are meant to be followed; 
(iii) there did not appear be desktop-drills/ other training exercises/ information grab-packs (etc.) to 
ensure that all  nurses in  charge are  properly equipped and trained to deal with AWOL incidents 
efficiently (iv) steps ought to be taken at managerial level to ensure that the confusion over the two 
policies and whether one had  been superseded (evidence of which only emerged during the inquest) 
cannot recur in this, or other areas, when new policies are introduced. 

CPFT has considered with care the issues that you raised, and I will now address points (1), (3) and (4)  in 
turn. (Point (2)  has been directed to CCC}. 

Point (1) 

CPFT are committed to working with the CCG  to continue to develop services for children with significant 
mental health difficulties. Since the death of Sam  and Chris Gould the CCG  have commissioned the 
expansion of the First Response Service (FRS) to include a dedicated CAMHS crisis team. This provides direct 
access for children and families to a CAMHS  professional to provide advice and  home, hospital or clinic based 
face to face assessments. This service is commissioned by the CCG  to operate 8-8 five days a week and offer 
brief interventions (up to two weeks). 

Outside of these times young people and families have direct access to the FRS,  an all age  24/7 telephone 
advice crisis service. This service has embedded CAMHS practitioners and  a CAMHS consultant to provide 
direct work and supervision for non-CAMHS staff. 

Additionally, the CCG  have commissioned a CAMHS home treatment team. Recruitment to this is ongoing. It 
will work intensively with young people and families as an alternative to hospitalisation. This is a multi­
disciplinary team and will be able to operate 9-9 with up to 3 contacts per day in the family home to provide 
treatment to young people and families. This will include supporting rapid discharge of patients from 
hospital who may not be  best helped by hospital admission. As  part of this the home treatment team is 
developing a DBT treatment programme for children with severe self-harm. 
This service is  not commissioned to provide 24/7 in  home support for young people. If this level of support 
were needed then this would be  raised through either the joint funding panel or through the CCG  Section 
117 funding stream. 

Page  2 of 4 

 The discussion about the need for 24/7 in home care will continue with the CCG  and the Local Authority and 
whether any needs are best met though bespoke arrangements, or the demand is such as to require a fully 
funded service. 

I also refer the coroner to CCC's separate  response, to this point. 

Point (3) 

CPFT have been reviewing diagnostic processes in the light of the coroner's recommendations and the new 
ICD  11 (International classification of Disease).  National implementation of the ICD  11 will follow in January 
2022. ICD 11 changes many of the current diagnostic classifications including removing the diagnosis of 
emotionally unstable personality disorder. Rather than identifying discrete personality disorders the new ICD 
11 defines mild, moderate or severe personality disorder and then and  optional clarifying behaviour 
description. There six subtype descriptions any number of which can  be  combined. One ofthese is 
"borderline pattern". 

There are also changes to the diagnosis that will make it easier to use the diagnosis for CAMHS  professionals. 
One is that personality disorders are no longer listed as  "disorders of adult personality" but acknowledge 
that personality disorders can start in chi.ldhood. It is  recognised that personality disorders are  long lasting so 
ICD 11 specifies that the features must have been present for at least two years. Another difference is that, 
while ICD-10 states that Personality Disorders tend to be stable over time, the ICD-11 guideline explicitly 
states that "Personality Disorders are only "relatively" stable after young adulthood and  may change such 
that a person who had a Personality Disorder during young adulthood no longer has one by middle age." 
These two things taken together will reduce the reluctance to use a personality disorder in older adolescents 
however, due to the duration criteria it is still unlikely that teenagers will meet the diagnostic threshold 
before the age of 16. 

In CPFT we will be reminding all doctors of the changes to ICD 11 and we have contacted our electronic 
medical records provider to ask that they confirm that the changes will be embedded in the system. 

The changes in diagnostic recommendations will be subject to ongoing research and review and further 
research into personality disorders will hopefully lead to clearer therapeutic recommendations for young 
people with these severe and  life limiting conditions. 

Point (4) 

CPFT accepts the concerns with regard to the AWOL policy and  has commenced the process of reviewing 
this.  In  order to ensure that the concerns about meaningfulness and  useability are fully addressed this will 
involve engagement with staff groups, service users and carers.  That work is expected to be completed by 
October 2021.  In the meantime clarity has been given with regard to the superseded policy. 

The Trust is currently undertaking a full  review of all policies which will ensure that they are fully in line with 
the latest best practice guidance and that they are written in such a way that they are clearly 
understandable and  usable by all members of staff. The  review is led  by myself as  Medical Director and 

, the Director of Nursing, Allied Health Professions and Quality, and will run over the next six 

months. 

Page 3 of 4 

 I hope that this response provides assurance to Chris and Sam's family and yourself that the CPFT has taken 
the learning from the Inquest very seriously and  has and continues to improve its policies and put in place 
measures to ensure safe and  effective services. 

Yours sincerely 

Dr
Medical Director, Cambridgeshire and Peterborough NHS  Foundation Trust 

Page 4 of 4

Security Classification/FOI 2000 

Official 

Force/organisation 
NPCC Coordination Committee 

Merseyside Police 
Violence and Public Protection 

Date created 

13.07.2021 

Mr Nicholas Moss QC 
Assistant Coroner 
Cambridgeshire and Peterborough Coronial Services 
Lawrence Court 
Princes Street 
Huntingdon  
PE29 3PA 

Dear Mr Moss,  

Date 13th July 2021 

RE: REGULATION 28 REPORT RELATING TO THE INQUESTS INTO THE DEATHS OF 
SAMANTHA GOULD AND CHRISTINE GOULD  

I write in formal response to the Regulation 28 Prevention of Future Deaths Report dated 28th 
May 2021, in respect of the inquests of twin sisters Samantha and Christine Gould.   
By way of introduction, I am 
recently appointed National Police Chiefs’ Council Lead for Child Protection, Abuse and 
Investigation, having taken over the portfolio from Chief Constable 
I recognise that the parents of Samantha and Christine will be keen to understand the 
actions taken in response to the Regulation 28 Report and at this point, I wish to place on 
record my sincere condolences to the parents in respect of the tragic loss of both of their 
daughters.   

, Deputy Chief Constable of Merseyside and the 

.  

 from Cambridgeshire and my Staff 

With the assistance of Chief Superintendent 
Officer, Detective Inspector 
, I have received a detailed briefing in relation to 
the case and studied the Regulation 28 Report closely. Please find below full details of the 
actions that I have commissioned to respond to the specific points raised within the report.    
I have worked closely with colleagues from the College of Policing to review the current 
Authorised Professional Practice (APP) in the context of the points arising from these 
inquests and it is evident that the inquests have identified a gap in the current APP. APP is 
national guidance that applies to every UK Police Force and underpins the National Policing 
curriculum for police investigative learning and development. 
To that end, I have agreed with the College of Policing an immediate addition to the relevant 
APP.  Appropriate cross reference to this new content will be added to other areas of 
guidance as these are refreshed. This has also been brought to the attention of the NPCC 
interviewing lead who will raise the issue with Ministry of Justice for inclusion in the ABE 
guidance 

 I have included a copy of the agreed amendment below which will provide clarity and 
direction to investigating officers should this situation arise: 

  National Police Chiefs’ Council (NPCC) 1st Floor, 10 Victoria Street, London SW1H 0NN -

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 Witness reluctance to attend an interview or provide a statement 

A victim/witness may be reluctant to attend an interview or provide a statement. Where this 
happens, investigators should sensitively try to establish why they are reluctant and, where 
possible, take steps to mitigate these reasons and provide reassurance. This may include 
explaining the investigative process and the offences under investigation and emphasising 
that, if at any time they change their mind, they should contact the officer in the case or 
named contact. It may also be appropriate to sensitively explain the impact that not attending 
an interview or providing a statement may have on the wider investigation. This may include 
not being able to proceed with the investigation or court proceedings. 

The investigating officer should agree a contact strategy with the victim/witness, or their 
nominated representative, to provide updates on the investigation and ongoing reassurance. 
Where appropriate, the victim/witness should be offered the opportunity to reconsider their 
decision not to provide an account and/or statement. They should not be put under any 
pressure to do so.  

The investigating officer should make a record of the reasons why the victim/witness is 
reluctant, and any mitigating action. They should also record all contact with the 
victim/witness and the content of any discussions.  

I am also personally writing to the Chair of every Local Safeguarding Children Partnership   
to highlight this change and seek their support in sharing it with all relevant board members. 
This will support improved awareness across all agencies that the option and opportunity for 
a victim to re-engage with an investigation remains open to them at any point, in particular 
where there is a material change in circumstances, including their health. 
I trust that the above actions respond in full to the matters of concern raised within the 
Regulation 28 Report and you are reassured in relation to the steps I have taken, such that 
they cover the totality of the identified concerns and address the identified learning. 
In the event you wish to discuss this further or should you require any further information 
then please do not hesitate to contact me through my Staff Officer, details below.  

Yours Sincerely 

NPCC Lead Child Protection and Abuse Investigations 
Deputy Chief Constable, Merseyside Police 

D/Insp 
Staff Officer to Deputy Chief Constable 

  2