IMPORTANT NOTICE
This judgment was delivered in private. The judge has given leave for this version of the judgment to be published on condition that (irrespective of what is contained in the judgment) in any published version of the judgment the anonymity of the child and members of their her family must be strictly preserved. All persons, including representatives of the media, must ensure that this condition is strictly complied with. Failure to do so will be a contempt of court.

Case No: DJ 13 C08224   
IN THE FAMILY COURT AT LANCASTER
IN THE MATTER OF THE CHILDREN ACT 1989
AND IN THE MATTER OF X (A CHILD)
Date: 28th January 2015

Before :

Her Honour Judge Sarah Singleton QC 
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Between :

	XBC	Applicant	
	- and -		
	    X(1)

    X’s mother(2)

    X’s grandparent(3)	

Respondents	

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Miss Julia Cheetham (Counsel instructed by the Solicitor for the Local Authority) for XBC
Miss Rebecca Gregg (Counsel instructed by the solicitor for X’s Mother) for X’s mother
Mr Marsh the solicitor for X’s grandparent
Miss Wylie the solicitor for X instructed by her Children’s Guardian
Mr. Simon Burrows (Counsel instructed by a Health Authority) for a Health Authority invited to attend and participate but not a party to the proceedings

Hearing dates: 15th January 2015 at Lancaster
This part of the Judgment handed down at Leyland Family Court hearing Centre on 28th January 2015

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JUDGMENT
1.	Over the last 16 months I have been dealing with proceedings under the Children Act 1989 concerning X who is now 16 years old. XBC brought proceedings in respect of her in September 2013 when she was 15 years old. They applied for a care order under section 31 and during those proceedings they made applications for secure accommodation orders under section 25 to permit them to place X in secure accommodation.

2.	This is the only part of the judgment in X's case which, with the agreement of all parties, I propose to make public; I wish to avoid publishing anything which might to lead to the identification of X. 
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3.	X's family have had serious concerns about her conduct and personality since she was very young. From time to time they sought help to deal with her. During her adolescence her behaviour became markedly worse. She frequently absconded from home (43 times between July 2012 and January 2013) She committed offences including violent offences. She abused drugs and alcohol. She put herself at risk of sexual assault and exploitation and was believed to be spending time in the company of men known to be a sexual risk to children. The LA commenced proceedings after she attended hospital having suffered an injury strongly suggestive of a sinister sexual assault. No one has yet ascertained what really happened to X on that occasion because her explanations for the injury have been neither consistent nor realistic. The LA commenced proceedings and sought to move her to a small specialist unit in a rural setting some distance from her home. 

4.	X's conduct in response to that move was even more extreme than usual. She carried out violent assaults on carers and escorts and made what was observed to be a very serious attempt to harm herself. She was referred to a consultant psychiatrist in the area of the rural specialist unit. He was very concerned about her and her mental health. At the first hearing after these events HHJ Lancaster, when he was renewing the interim care order and making the first of a series of secure accommodation orders, directed the local authority to arrange an urgent psychiatric assessment of X. 

5.	The making of the secure accommodation order meant that X was moved again and placed in a secure unit outside her home area and the area of the local authority bringing these proceedings. A preliminary assessment of her mental health was undertaken by a community psychiatric nurse working for a service commissioned to work in the secure unit where X was placed. He concluded that X was not showing signs of acute mental illness at the time of his assessment. This took her out of the ambit of the commissioned service. There followed, shortly after, an assessment for the purposes of the proceedings by a jointly instructed consultant child and adolescent psychiatrist. She agreed that X was not showing signs of acute mental illness but did consider that she fitted the diagnostic criteria for Attention Deficit Hyperactivity Disorder. She recommended that X's treating clinicians consider a trial of medication for this disorder. At the time she recommended this X was enthusiastic to engage with such a trial. 

6.	Unfortunately such a trial of medication never took place before X was moved from the secure accommodation after being there for nearly 6 months. X is no longer minded to seek or engage with a further clinical assessment and medication trial recommended. An opportunity to improve her situation with treatment for a condition diagnosed by the consultant clinician instructed within the proceedings was therefore missed.

7.	This seems, upon review, to have been because:-

•	X fell between geographical and commissioning areas;
•	the treatment recommended was not within the ambit of the specially commissioned service for the unit where she was placed;
•	the process required to refer X to a service which was commissioned to undertake that which the joint expert recommended was opaque and labyrinthine;
•	X turned 16 during the proceedings which compounded the commissioning and referring difficulties because some child and adolescent services are not delivered to 16 to 18 year olds.

8.	I became sufficiently concerned that X may have suffered harm as a result of her health need having remained unmet in the circumstances that I have set out that I requested the local authority to prepare a chronology of what had occurred to be submitted to all the relevant agencies for their comments as to its accuracy and implications. This was in order for me to consider whether I should make findings of fact about this issue to be included in my judgment at the end of the Care proceedings.  All the parties to the Care proceedings supported this course of action.

9.	After the preparation of the chronology and as a result of a further order a number of professionals from the key agencies participated in a meeting at which the difficulties that had been encountered in X's case were discussed. Thanks to the dedication and approach of the professionals who attended that meeting it was extremely constructive both in identifying where matters had gone wrong for X and in drawing conclusions about how such problems might be avoided in the future. None of the parties before the Court pursued any findings either of harm resulting from the problems which beset X’s case or to pursue any findings of attributability of such harm. This seemed to me to be a proper and proportionate approach and I did not consider it appropriate to require such an exercise in the circumstances of this case. Counsel for the local authority (Miss Cheetham - soon to be Miss Cheetham QC) has distilled the conclusions of that meeting into a short document which I annexe as an appendix to this judgment. 

10.	I have granted a final care order in respect of X and delivered a private judgment addressing the threshold criteria, the need or not for a care order and the care plan of the LA which I have approved.  I do not propose to publish that part of the judgment because some of the rather dramatic facts in the background would make it all too easy to identify X.  I should record, however, that these proceedings went on for many more months than would normally be usual or acceptable because of the particular difficulties besetting X and the uncertainty of all the parties before the Court as to the right care plan for her. 

11.	I have simply been dealing with one child, in one case, with one local authority and one set of health agencies. It is not appropriate or proper for me sitting as a Circuit Judge in a Family Court case heard at this level to seek to issue guidelines or to influence policy. However, it is the experience of all the agencies and professionals in this case that X is not the only child impacted by the difficulties which applied. It therefore seems to me to be right for me to publish this short judgment. I do so both to record the very constructive work that was done in X’s case at the interdisciplinary meeting but also in the hope that their conclusions may prove to be useful for others working in similar cases in whatever capacity. I understand that the document produced by Miss Cheetham is to be a template for a good practice review in this region next year. For all these reasons I annexe it to this judgment.

Judgment Ends.

Appendix

LESSONS LEARNED AND SUGGESTIONS FOR FUTURE PRACTICE
(Document prepared by Miss Cheetham Counsel for XBC from the minutes of a  multi agency and multi disciplinary meeting)
1.	All of those involved in the care of young people in secure settings whether directly or indirectly should be aware of and apply the Healthcare Standards for Children and Young People in Secure Settings of June 2013. 

2.	The care pathway demonstrated by X’s experience emphasises the importance of the standards which relate to the following areas:

•	The need for the use of a recognised and reliable health screening tool such as the Comprehensive Health Assessment Tool (CHAT) upon the young person’s arrival at the unit preferably within 2 hours of their admission; and for such assessment to be administered by a qualified medical professional with experience of caring for young people in secure settings.

•	Where a young person is identified as being at risk of harm or urgent health concerns are identified the need for immediate and continuing action to be taken to safeguard the young person.

•	The need for an agreed pathway to facilitate prompt further assessment and ensure that healthcare professionals in the secure setting are aware of the local referral and consultation routes.

•	The need for named individuals for points of contact within the different agencies.

•	The need for access to primary healthcare provision at the same level as the young person would enjoy in a domestic setting and for them to be made aware that they can access it.

•	The need upon transfer to the community or to another secure or care setting for a summary of the health record of the young person to be prepared so that it can be sent to the GP and healthcare managers of any future setting. The summary should include any recommendations for future care.

3.	Local authorities should ensure that their contracts with providers are clear, robust and mutually understood.

4.	Those involved in the delivery of provision for secure accommodation should be aware that where the order is made pursuant to Section 25 of the Children Act 1989 the court is required to undertake its own evaluation of the evidence to support the making of an order and it is expected that any institution where the child is placed will co-operate with requests from the court to provide evidence where necessary.

5.	Those involved in the delivery of care to children and young people in secure setting need to be aware of the commissioning pathways for care. Training for social workers in children’s services and secure units as to the commissioning pathways would be useful.  

6.	A disagreement regarding commissioning should never be an obstruction to a young person receiving medical assessment or treatment.

7.	 There is an urgent need for policy development in relation to the provision of CAMHS services for Looked After Children who are placed out of area because at present the access to such services is entirely dependant on a child being registered with the GP in the area. The breakdown of an out of area placement results in the child’s inability to access secondary health care due to having to re-register with a GP and can mean that the young person goes to the bottom of a waiting list in a new area. Different health commissioning exist arrangements in different areas  which can add to the confusion. The system should be made less complex and pathways clearer. 

8.	Named Nurses for Looked After Children have a critical role to play in the dissemination of information, particularly where a child has frequent placement moves to different areas where immediate direct contact can usually be made with their counterpart. They are currently underused in this respect.

9.	A system whereby a named nurse could be made available to triage a child in their domestic or residential setting out of hours could avoid a situation where children and young people are referred to Accident and Emergency Departments at times of crisis.

10.	There is a gap in some areas in CAMHS for young people between the ages of 16 and 18 in particular where they have a diagnosis of ADHD. 
   
11.	.Children in secure accommodation and/or those with multiple placement moves are particularly vulnerable and encounter particular difficulties in accessing consistent medical care.