Jake Cahill

29 March 2022 

Mr R. Guy Davies 
Assistant Coroner 
Cornwall & the Isles of Scilly Coroner’s Area 
By email: cornwallcoroner@cornwall.gov.uk 

Dear Mr Davies 

Regulation 28 Prevention of Future Deaths letter 
Re: Jake Adam Cahill, deceased 

Thank you for your letter of 1 February outlining your decision to issue a report to 
prevent future deaths following the inquest into the death of Jake Cahill. As a mother 
of young teenage boys, I read your report with profound sadness at the tragedy of 
Jake’s death and wish to extend my most sincere condolences to Jake’s family and 
friends for their unimaginable loss.  

We accept your recommendation that the Youth Justice Board (YJB); 

‘reviews the guidance and procedures relating to the distribution and completion of 
the self-assessment form [AssetPlus] given to young persons’ 

In addition, I wish to assure you that the Youth Justice Board (YJB) has reviewed 
your conclusions fully and is committed always to engage with findings of 
investigations such as yours to ensure that where there is direct or indirect learning 
for the youth justice system, we can act upon this to promote continuous learning 
and support the prevention of harm.  

As an independent public body appointed by the Secretary of State, we have a 
statutory responsibility to oversee the whole of the youth justice system. Through the 
consolidation of our statutory functions, we support youth justice services to 
coordinate and deliver the provision of youth justice services.  

The YJB’s leadership of the system also places us in a unique position of being able 
to triangulate learning from the investigations of others with our own assessments 
and understanding of the system we lead.  

We fully recognise the importance of considered and appropriate engagement with 
children throughout the youth justice system. With this in mind we have to find the 
balance between issuing central direction and guidance, and supporting practitioners 
to exercise professional judgement in order to encourage the skills and knowledge 
that support direct work with children. AssetPlus itself is an assessment and 
interventions framework that focuses on the professional judgement of practitioners 
with the aim of enabling better-focused, holistic end-to-end assessment and 
intervention plans to improve outcomes for children. In the early days of the Covid 19 

 pandemic when public services were having to find new ways of working remotely, 
the robustness and appropriateness of interventions and tools were tested. The self-
assessment tool is key for engaging the child and their parent/carer but not 
envisaged for children to complete independently, however the AssetPlus user 
guidance did not explicitly prohibit this, and it is not unreasonable to conclude that 
unsupported engagement with questions about suicide and self-harm could have a 
significant impact on a child. For the YJB, accordingly, my priority has been to 
ensure that all youth justice services are aware that AssetPlus should not be used 
for unsupported self-assessment, and to instruct any that were doing so to cease 
immediately.  

Acting upon your findings, we have written to all youth justice services asking them 
to consider their approaches to undertaking AssetPlus self-assessments and to 
remind them of the key principles in conducting self-assessments with children. This 
correspondence has been shared with you at Annex A.  

I accept the need to review the AssetPlus guidance and we are already committed to 
reviewing this in the coming business year. In responding to your findings, this work 
will include within its scope, guidance that is specific to conducting self-assessments 
with children; particularly where they are more challenging to engage or where 
circumstances beyond the control of practitioners or the service dictates that these 
may have to be undertaken at a distance.  

We are also in the process of revising our case management guidance to the sector, 
please see case management guidance extract on assessment process at Annex B, 
which provides youth justice service practitioners and managers with practical advice 
on how to work with children in the youth justice system. We are planning on 
publishing a revised set of guidance later this year and will include additional text on 
how best to conduct self-assessments.  

My colleagues and I are absolutely committed to providing youth justice services with 
the guidance and support they need to deliver to the best of their ability. I believe the 
measures set out above strengthen the safety and wellbeing of children in the youth 
justice system and, I hope, offer you assurance that the lessons learned from Jake’s 
death will be effective in preventing any such tragedy from happening in the future.  

Yours sincerely 

CEO 
Youth Justice Board for England and Wales  

 
 
 
 
 
 
 
 
 
 Annex A – correspondence sent to youth justice services 

Following an inquest into the circumstances surrounding the suicide of a child under 
youth justice supervision in the community, the YJB has received a Coroner’s 
Prevention of Future Deaths (PFD) recommendation. The YJB always seeks to 
engage with the findings of investigations such as these to ensure that where there 
is direct or indirect learning for the youth justice system we are able to act upon this; 
to promote continuous learning, support the prevention of harm and disseminate this 
learning more widely for the benefit of outcomes for children.   

The Coroner’s matters of concern include the practice of how a self-assessment is 
undertaken with a child, given the sensitive issues touched upon within it, and the 
guidance in place to support this practice. The resulting PFD recommendation 
highlights that the YJB should review the guidance and procedures relating to the 
distribution and completion of the self-assessments [AssetPlus] given to children.  

The YJB has accepted this recommendation and will be committing to reviewing 
AssetPlus guidance. In responding to the Coroner’s findings, this will include within 
its scope guidance that is specific to conducting self-assessments with children; 
particularly where they are more challenging to engage or where circumstances 
beyond the control of practitioners or the service dictates that these may have to be 
undertaken at a distance.  

In the interim, and in the absence of this fuller updated guidance, we are asking 
services to consider their approaches to undertaking AssetPlus self-assessments 
and outline the following reminders, both to disseminate the learning from this sad 
incident and to support the ongoing safety and wellbeing of children in the system.   

Services are reminded that:  

•  Any engagement with a child should be fully in line with the child’s needs. 
•  Best practice would suggest that the best approach to engagement should be 
discussed with the child and their parents/carers beforehand. Wherever this is 
not possible, as a minimum, liaison with other professionals who know the 
family should be undertaken.  

•  There is a presumption that self-assessments that support the more holistic 

• 

assessment for a child, should be undertaken face to face.   
In the limited circumstances where professional judgement considers that a 
face to face self-assessment does not best support the child’s needs, the 
reasons should be fully recorded and a managerial discussion undertaken. 
•  Out of hours support and/or information that is available to the child and/or 

parents and carers is in place, understood and easily accessible to them.     

 
 
 
 
 
 
 
 
 
 Annex B – Case management guidance extract on assessment process 

The assessment process is unlikely to be a neutral event for a child, particularly 
those with little or no experience of the justice system and for those who have 
experienced adverse childhood experiences and trauma. The telling (and re-telling) 
of their stories to individuals they do not know may be difficult and painful. The youth 
justice service may also be one of a range of agencies which is assessing their 
needs.  

The assessment should not be conducted as an interview schedule. The way 
information is gathered is likely to be determined by the length of time you have 
known the child; any previous involvement with the justice system; their emotional 
well-being; problems with speech, language and communication and learning 
difficulties and disabilities.  

Services should fully engage children and, where appropriate, their parents and 
carers in the assessment process; encourage them to participate and tell their 
stories in their own way; and to think about what interventions would assist and be 
meaningful to them. Sensitivity and skill are needed when the child and parent/carers 
are present together. There should always be the opportunity to speak to them 
separately. They need to understand what the purpose of the assessment is, how it 
will be undertaken and the information obtained used.  

Particular attention should be given to: 

•  How questions are asked about sensitive issues such as family difficulties and 

adverse experiences  
•  Distress or discomfort  
•  Areas the child is reluctant to talk about   
•  What you can do to reduce anxiety  

The information gathering section of AssetPlus includes a section in which children 
and their parents/carers can undertake a self-assessment (in English or Welsh). This 
provides the opportunity for them to state their views about various aspects of their 
life (which can be compared over time). Self-assessment can play an important part 
in understanding the child’s experiences, identifying what is important to them and 
demonstrating their views are being taken into account.   

The option of undertaking a self-assessment should be provided to all children and 
their parents/carers, and consideration given to whether they need any assistance to 
do this and how this could be provided. 

How best to conduct a self-assessment should be fully considered in line with the 
child’s needs; best practice would suggest that this should be discussed with them 
and their parents/carers beforehand, and if this is not possible as a minimum liaison 
with professionals who know the family should be undertaken.  

There is a presumption that self-assessments should be undertaken face to face; in 
circumstances where professional judgement considers that a face to face self-
assessment does not best support the child’s needs the reasons should be fully 

 
 
 
 
 
 
 
 
 
 recorded and a managerial discussion undertaken. In all cases out of hours support 
and/or information should be available to the child and/or parents and carers, this 
should be understood and easily accessible to them.     
Self-assessment covers the following topics: 

friends 

family, home and relationships 

•  bail 
•  custody 
• 
•  smoking, drinking and drugs 
•  health and how I feel 
• 
•  school, college and work 
•  offending (statutory only) 
•  my future 
•  working with the youth justice service 
•  working with Probation 
• 
•  custody review 
•  end of intervention 

review 

The self-assessment section of AssetPlus should be re-visited at regular intervals to 
ensure the views of children and parents/carers are thoroughly considered 
throughout their period of involvement with the youth justice service (not just at the 
start or end), to encourage their active involvement and contribution to the 
development of their assessments and intervention plans.