SAR Hermione

1. Introduction

1.1       Torbay and Devon Safeguarding Adults Board (TDSAP) have commissioned this Safeguarding Adults Review (SAR) in respect of “Hermione”, who experienced serious harm in circumstances where agencies could have worked together more effectively to prevent this.

1.2       Hermione was 21 years old in early 2021. She is a charming, intelligent and articulate White British woman, who is very likeable and engaging. Hermione has a love of the outdoors and is very active, undertakes volunteer work that she is passionate about and suits her caring nature and has been working with local agencies to improve services for other young people with autism. She was very honest during discussions about the events relevant to the review, with real insight into her own actions and needs and gave a balanced analysis of the ways in which different agencies and practitioners supported her. Hermione’s own words have been used to describe her experiences throughout this report. To ensure Hermione’s anonymity, the names of some of the agencies involved in her care have been anonymised, where disclosing these could potentially identify her.

1.3       Hermione has diagnoses of Autism Spectrum Disorder (ASD), Tourette’s Syndrome (although she has not shown symptoms of this for some time), Post Traumatic Stress Disorder, Attention Deficit Hyperactivity Disorder (ADHD). Her ASD and ADHD were diagnosed relatively late, at the age of 14, which meant that she struggled during school without the tools to understand her conditions. After expressing her intention to attempt suicide, she was detained in children’s psychiatric units under section 3 of the Mental Health Act 1983 (MHA) in Devon (the CAMHS Unit), then a paediatric intensive care unit in Berkshire (the PICU) prior to her 18th birthday, when she was discharged home to Devon. After a period at home, she was placed in a residential college for young people with autism in Somerset (College 1), which broke down in mid-2019 due to Hermione’s self-harming behaviour and suicide attempts. Hermione moved to a second specialist autism college with on-site mental health support in Dorset (College 2) in early 2020, where her self-harm continued to escalate. In early 2021, College 2 gave notice because Hermione was making plans to take her life and because a specialist placement could not be identified, a multi-disciplinary professionals’ meeting agreed a care plan to temporarily support Hermione in a hotel in Devon with a package of 3:1 support. However, Hermione absconded out a window and drank several bottles of Calpol, sending a note by email to College 2 that indicated her intention to take her life. She took a train, intending to travel to Beachy Head, but had to disembark after becoming ill and was found by police in Wiltshire. Hermione was taken to an acute hospital in Wiltshire where she was placed in an induced coma after an urgent decision was taken by clinicians to deprive her of her liberty and a best interest decision made to give her life-sustaining treatment, before being made subject to a Deprivation of Liberty Safeguards (DoLS) authorisation in the hospital’s emergency department. After being brought out of the coma, she was assessed as not being detainable under either the MHA or DoLS. She was subsequently transferred to a psychiatric ward in a Dorset hospital, initially as an informal patient then detained under the MHA, before being moved to a high dependency rehabilitation unit where she was diagnosed with Emotionally Unstable Personality Traits and her mental health stabilised after a lengthy period of treatment.

1.4       The author wishes to thank Hermione for her generous contribution to this review, it was a genuine pleasure to meet her – and her new pet, a delightful ball of mischief, who she clearly adores. The author is also grateful to the professionals who worked with Hermione for sharing their insight into her experiences so honestly. The affection that they hold towards her was very clear.

2. Scope of Review

Purpose of a Safeguarding Adults Review

2.1.     The purpose of having a SAR is not to re-investigate or to apportion blame; its purpose is:

·       To establish whether there are lessons to be learned from the circumstances of the case about the way in which local professionals and agencies work together to safeguard adults;

·       To review the effectiveness of procedures (both multi-agency and those of individual organisations);

·       To inform and improve local interagency practice;

·       To improve practice by acting on learning (developing best practice); and

·       To prepare or commission a summary report which brings together and analyses the findings of the various reports from agencies in order to make recommendations for future action.

2.2.     There is a strong focus in this report on understanding the underlying issues that informed agency and professionals’ actions and what, if anything, prevented them from being able to help and protect Hermione from harm.

Themes

2.3.     The TDSAP prioritised the following themes for illumination through the SAR:

a.     Was Hermione’s transition to adult services in line with expected standards? In particular, how well do practitioners from across the health, mental health and social care agencies understand care pathways (including s117 aftercare) and coordination across services for individuals who are neurodivergent or have personality disorders?

b.     How effective was the multi-agency response in recognising and then responding during this period to prevent an escalation of Hermione’s mental health and self-harm? Was this effectively managed across local authority/county borders?

c.     How effectively was risk managed, in particular:

i.     How did individual agency’s views on mental capacity affect risk management?

ii.     Was information regarding risk posed by Hermione’s behaviour appropriately shared with (and, later, by) her residential colleges then agency support staff in her temporary accommodation; were staff within these placements supported to effectively manage complex risk?

iii.     Does the local missing person’s protocol operate effectively?

iv.     Was a strength-based Making Safeguarding Personal approach utilised to involve Hermione and/or her family in the risk management process?

d.     How does commissioning function across the partnership and regional boundaries to facilitate identification or creation of care packages that can meet complex needs and how responsive is this to periods of crisis? How does local availability of resources impact on care planning, hospital discharge and safeguarding?

 

2.4.     The review also explored good practice and wider learning.

Methodology

2.5.     The TDSAP commissioned an independent reviewer to conduct a SAR using an adapted version of the Social Care Institute for Excellence Learning Together methodology. The learning produced through a SAR concerns ‘systems findings’. Systems findings identify social and organisational factors that make it harder or make it easier for practitioners to proactively safeguard, within and between agencies.

2.6.     The following agencies provided documentation to support the SAR:

·       Devon County Council Adult Social Care

·       Dorset NHS Foundation Trust

·       Dorset Healthcare Trust

·       Devon Partnership Trust

·       Salisbury NHS Foundation Trust

·       NHS Devon CCG (now One Devon Integrated Care Board)

·       Livewell Child and Adolescent Mental Health Services (CAMHS)

·       Devon and Cornwall Police

·       Wiltshire Police

·       College 1

·       College 2

·       Provider 1

·       Provider 2

·       Paediatric Intensive Care Units

2.7.     Multi-agency learning events took place, both with front-line practitioners who worked with Hermione and the leaders who oversaw the services involved in supporting her.

2.8.     Unfortunately, some agencies involved in the review were hindered in their efforts to provide information in respect of their response to Hermione, following a serious cyber-attack which resulted in officers being unable to access Hermione’s CAMHS and community mental health team (CMHT) files. Urgent work is being undertaken to restore all computer records, but this may take several months.

3. The Legal Framework

A Human Rights-based approach to managing suicide risk

3.1.     The legal framework around managing the risks to individuals who express suicidal ideation is complex and in some ways can present as contradictory. Personal freedoms must be weighed against duties placed on public bodies to protect lives and mitigate risks to vulnerable people. All public bodies must exercise their legal powers in an ethical way that complies with duties to the adult under the Mental Capacity Act, Human Rights Act 1998 and Equality Act 2010. Best interest considerations are ‘not an academic issue, but a necessary protection for the rights of people with disabilities. As the Act and the European Convention make clear, a conclusion that a person lacks decision-making capacity is not an ‘off-switch’ for his rights and freedoms. To state the obvious, the wishes, feelings, beliefs and values of people with a mental disability are as important to them as they are to anyone else, and may even be more important. It would be wrong in principle to apply any automatic discount to their point of view.’[1]

3.2.     While Article 2 of the European Convention on Human Rights (ECHR) places a duty on public bodies to prevent avoidable deaths, this must be balanced against the right to freedom from inhumane treatment (Article 3), the right to liberty (Article 5) and respect for your private and family life (Article 8). The right to life is not an absolute right and a series of high profile legal cases, such as the sad decision to turn off life support for Archie Battersby, show how the courts weigh these different, and at times competing human rights to take decisions in the individual’s best interest.[2]

3.3.     Of particular relevance in Hermione’s case is Article 5.1 ECHR which provides: “Everyone has the right to liberty and security of the person. No-one shall be deprived of his liberty save in the following cases and in accordance with a procedure proscribed by law …(e) the lawful detention of persons of unsound mind …”. There are two primary pieces of UK legislation that provide a legal framework to deprive someone of their liberty because they are of ‘unsound mind’, the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA). However, any intervention must be necessary to prevent harm to the person or others and proportionate to the likelihood and seriousness of those risks – the least interventionist approach must be used.

3.4.     A patient already in hospital can be detained under section 5(2) MHA for up to 72 hours, to allow an assessment to be undertaken to determine whether they need to be further detained. A person can be detained for the purpose of assessment for up to 28 days under section 2 MHA if they are suffering from a mental disorder of a nature or degree that warrants detention in hospital for assessment (or assessment followed by medical treatment) for at least a limited period; and ought to be detained in the interest of his or her own health or safety, or with a view to the protection of others. If they are assessed as needing to remain in hospital for medical treatment, a further application can be made under s3 MHA.

3.5.     The Mental Health Act 1983 Code of Practice[3] reinforces that when making any decision in relation to care, support of treatment under the Act, clinicians must apply five guiding principles, including using the least restrictive option that maximises independence, empowerment, respect and dignity. The MHA contains mechanisms for a patient subject to detention to be represented by an Independent Mental Health Advocate (IMHA) and request a review before the Mental Health Tribunal (although this does not apply to s5(2)[4]) and provided powers are properly used, treatment and care plans will comply with Article 5 ECHR.

3.6.     Outside of treatment under the MHA, the provision of care and treatment is only lawful if the person receiving the care/treatment has either given capacitated consent or, if the person lacks capacity, acts are done in accordance with the legal obligations under the Mental Capacity Act 2005 and the Human Rights Act 1998. The courts have held:

“Every adult capable of making decisions has an absolute right to accept or refuse medical treatment, regardless of the wisdom or consequences of the decision. The decision does not have to be justified to anyone. Without consent any invasion of the body, however well-meaning or therapeutic, will be a criminal assault”[5]

3.7.     The MCA sets out that a person lacks capacity in relation to a matter if at the material time they are unable to make a decision for themself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain. A person is unable to make a decision for themself if they are unable to understand the information relevant to the decision, to retain that information, to use or weigh that information as part of the decision making process, or to communicate their decision by any means. The fact that a person is only able to retain the information for a short period does not prevent them from being able to make the decision and capacity may fluctuate over time. There is a presumption of capacity unless otherwise evidenced and a person cannot be treated as lacking capacity, merely because someone else considers their decision to be unwise.

3.8.     The principles embedded in s4 MCA require that any decision taken on behalf of a person who lacks capacity to make it, follows the least interventionist approach, and is taken in the person’s best interest. This is not just the person’s medical best interest, but rather their welfare in the widest possible sense, considering the individual’s broader wishes and feelings, values and beliefs. All decisions should follow careful consideration of the individual circumstances of the person and focus on reaching the decision that is right for that person – not what is best for those around them, or what the “reasonable person” would want. The person who lacks capacity to make a decision should still be involved in the decision-making process as far as is possible, and those who know them best should be consulted.

3.9.     Public bodies have positive obligations under Article 5 so must ensure not only that they do not unlawfully deprive the person of their liberty, but must also intervene in circumstances where they know or ought to have known that the person is being unlawfully deprived of their liberty. Deprivation of Liberty Safeguards (DoLS) is the procedure prescribed in law that enables a local authority to authorise a detention of a resident of a care home or patient, who lacks capacity to consent to their care and treatment, in order to keep them safe from harm. In urgent circumstances, the managing authority (in Hermione’s case, the hospital) can grant itself an urgent authority to deprive the person of their liberty for up to 7 days, although they must request a standard authorisation from the local authority. Where the person continues to object to the proposed course of action, their advocate or representative should initiate a review or, if necessary, apply to the Court of Protection (CoP) to challenge the decision. However, if this does not happen, the onus will fall on the Best Interests assessor or agencies imposing the deprivation of liberty to seek legal advice with a view to making an application to the CoP for determination of the matter.

3.10.  Section 4B of the MCA also allows that in an emergency, if there are reasonable grounds to believe that the person lacks capacity, they can be deprived of their liberty to be given life-sustaining treatment or to act to prevent a deterioration in their condition, while authorisation is sought from the CoP or through DoLS. The CoP can also authorise deprivation of liberty in other settings, including supported accommodation in the community, although this will also fall within the remit of the local authority once Liberty Protection Safeguards replaces the DoLS regime.[6]

3.11.  It is also important to emphasise that under s.5 MCA, the requirement is for a ‘reasonable belief’ (on the basis of ‘reasonable steps’ having been taken to establish) that the person lacks capacity to consent to acts of care and treatment being carried out. Especially in a fast-moving situation where professionals have limited information, and in circumstances where not taking action could endanger the person’s life, the threshold for concluding that the person lacks capacity to decide whether or not to take their own life (or, by refusing medical treatment, to prevent reversal of steps they have already taken) is going to be low.

3.12.  In A Local Authority v Z [2004], which remains relevant although it pre-dates the MCA, Hedley J gave helpful guidance on a local authority’s duties in a case where a person had stated an intention to take her own life.[7] This includes investigating the person’s true position and intention; assessing whether they have the mental capacity to make and carry out their decision and intention; consider whether any other influence may be operating and to ensure they have all relevant information and know all available options. Having assessed these issues, the local authority should consider whether to make an application to the Court of Protection if they lack capacity having weighed the options in the person’s best interest, or invoke the inherent jurisdiction of the High Court so that the matter could be judicially investigated and determined. The judge noted that:

“In the event of the adult being competent to allow her in any lawful way to give effect to her decision although that should not preclude the giving of advice or assistance in accordance with what are perceived to be her best interests”

3.13.  The court also noted that section 1 of the Suicide Act 1961 repealed the rule that made suicide criminal, although it did not make suicide lawful. “It follows inevitably that our law does not penalise the decision of a competent person to take their own life. Moreover nor does the law prohibit them from so doing…”[8]

3.14.  However, the Supreme Court has subsequently found that an NHS Trust can violate its positive duty under Article 2 EHCR to take reasonable steps to protect a formal or informal patient known to be suffering mental illness from the risk of suicide, if there is a ‘real and immediate’ risk of death.[9] This duty to take reasonable steps to protect someone from a real and immediate risk of death will apply to all public bodies in exercise of their duties, including the police and those carrying out public functions, such as staff within her placements.

Section 117 aftercare, mental health support and transitions

3.15.  Section 117 of the MHA places an enforceable duty on the ICB and local authority to provide aftercare services to a person who has been detained under sections 3, 37, 45A, 47 or 48 of the MHA on discharge from hospital. An aftercare service is a service provided to meet a need arising from or related to the individual’s mental disorder, to treat and prevent a deterioration in their mental disorder, and reduce the risk of the individual being returned to hospital. This can be provided for a broad range of needs arising from the mental disorder, including immediate health and social care needs as well as, for example, employment support, or development of  independent living skills. This will include specialist accommodation if this is necessary to meet the person’s mental health needs. The ultimate aim is to maintain patients in the community, with as few restrictions as are necessary, wherever possible.

3.16.  The duty to provide s117 aftercare services is triggered on discharge from hospital, however, discharge planning should begin as soon as the person is detained under section 3, to identify the appropriate aftercare services necessary to meet their needs before they are discharged. If the Responsible Clinician is considering discharge, they should consider whether the person’s aftercare needs have been identified and addressed. The individual must be fully involved in any decision-making process with regards to the ending of aftercare, including, if appropriate consultation with their carers and advocate.

3.17.  Aftercare should be kept under review to ensure this continues to meet the person’s needs and will only end if both the ICB and local authority are satisfied that the person no longer needs this. It cannot be withdrawn simply because someone has been discharged from specialist mental health services, readmitted to hospital or after an arbitrary period. If aftercare is withdrawn, services can be reinstated if it becomes obvious that was premature.

3.18.  Adolescence is a period associated with increased rates of psychiatric morbidity, substance misuse and risk-taking behaviours, however, healthcare transition is often inadequately planned and executed. There is a risk of disengagement at this crucial time as a result. 2013 NICE guidance[10] on children with a diagnosis of autism also advocates that transition planning should start when the young person is 14, with an updated assessment of their needs to ensure a smooth transition to adult services. This further advocates a care planning approach to transfer between services in complex cases, which would have been appropriate in light of Hermione’s recent detention under section 3 of the Mental Health Act 1983.This guidance also requires staff to receive training and know how to assess risk, provide individualised care and make adjustments or adaptations to Health and Social Care processes to enable access and that they have skills to communicate with the young person. The expectation is that those providing care will anticipate and make adjustments to prevent behaviour that challenges or offer psychosocial interventions as a first line treatment for challenging behaviours.

Assessment of need for care and support, SEND duties and Continuing Healthcare

3.19.  Section 58 of the Care Act 2014 places a duty on the local authority to carry out a child’s needs assessment prior to their 18th birthday, to ensure that careful planning is in place to meet their care and support needs as they transition to the adult legal framework. The Care and Support Statutory guidance[11] sets out that an assessment should be carried out if a young person is ‘likely to have needs’, not just those needs that will be deemed eligible under the adult statute. This includes care and support that arise from or are related to a physical or mental impairment or illness (including a condition as a result of physical, mental, sensory, learning or cognitive disabilities or illnesses, substance misuse or brain injury), but not needs caused by other circumstantial factors.

3.20.  The guidance also sets out the reciprocal duty for relevant partners to cooperate for the purposes of transitions and paragraph 16.43 states: “Local authorities should have a clear understanding of their responsibilities, including funding arrangements, for young people and carers who are moving from children’s to adult services. Disputes between different departments within a local authority about who is responsible can be time consuming and can sometimes result in disruption to the young person or carer.” The ethos of the Care Act 2014 is that assessments should be needs-led and not restricted by available services. Diagnosis should not act as a barrier to support. Further, although the local authority can commission other services, including the ICB (through a section 75 agreement), to carry out assessments and provide care plans on their behalf, the statutory responsibility for ensuring that eligible care and support needs are met remains with the local authority.

3.21.  The Children and Families Act 2014 places duties on the local authority to start planning for young people with Education Health and Care plans (EHCPs) to prepare for adulthood from Year 9, with a particular focus on the young person’s ambitions and goals post-16. These duties include young people with EHCPs up to the age of 25 if they remain in education. The Special Educational Needs and Disabilities Code of Practice[12] describes the duty on education, health and social care to work together to plan and jointly commission services for these young people, explaining the interface between duties under the Children and Families Act 2014, the Care Act 2014 and the National Health Services Act 2006 for young people with special educational needs or disabilities with or without EHCPs. The Code of Practice sets out:

“…local governance arrangements must be in place to ensure clear accountability for commissioning services for children and young people with SEN and disabilities from birth to the age of 25. There must be clear decision-making structures so that partners can agree the changes that joint commissioning will bring in the design of services. This will help ensure that joint commissioning is focused on achieving agreed outcomes. Partners must also be clear about who is responsible for delivering what, who the decision-makers are in education, health and social care, and how partners will hold each other to account in the event of a disagreement. The partners must be able to make a decision on how they will meet the needs of children and young people with SEN or disabilities in every case.” (paragraph 3.25)

3.22.  The National Framework for Continuing Healthcare (CHC) also requires ICBs to have systems in place with local authorities to ensure clinicians are actively involved in transitional planning for anyone with significant health needs who may be eligible for CHC post their 18th birthday. This is relevant to this case because of a specific focus within the CHC Decision Support Tool on challenging behaviours, psychological and emotional needs. Formal screening for CHC eligibility should occur when a young person is 16 and eligibility determined in principle when the young person is 17.[13]

Responsibility across boundaries

3.23.  At times, the fact that Hermione moved across local authority boundaries created confusion in respect of who was responsible for taking action to safeguard or support her. There are two key tests that will apply to different duties for health and social care. Ordinary residence is the area that a person “…has adopted voluntarily and for settled purposes as part of the regular order of his life for the time being, whether of short or long duration.”[14] However, if the person goes into hospital or NHS accommodation, or is placed by a local authority in specified accommodation (including a care or residential home, supported accommodation or a shared lived scheme), they will be ‘deemed’ to remain ordinarily resident in the area they were ordinarily resident prior to moving into these placements.[15] Where the person lacks capacity to take a decision where they will live, the ‘voluntary’ aspect of the test should be disregarded, and instead the facts should be weighed to establish whether “…the purpose of the residence has a sufficient degree of continuity to be described as settled.”[16]

3.24.  The second relevant test is that of ‘physical presence’, which means that responsibility will rest with whichever area the person is physically located at the time of an incident or admission.

3.25.  Periods when the person is in hospital or placed in ‘specified accommodation’, which will include a specialist residential college provided as part of a package of s117 aftercare, are excluded for the purpose of determining ordinary residence, so Hermione remained ordinarily resident in Devon through the period relevant to this review.

3.26.  For clarity:

3.26.1.  The local authority responsible for meeting a person’s needs under the Care Act 2014 is where the person is ordinarily resident, unless they have no settled residence, when the test is physical presence, and the local authority carrying out the assessment is responsible for arranging a Care Act advocate to support the individual if they need this to engage with the assessment.

3.26.2.  The local authority responsible for meeting the person’s needs under s117 of the MHA is where the person was ordinarily resident at the time they were detained under the MHA, even if they have subsequently moved to a new area after discharge. The responsible ICB (or CCG prior to July 2022) will be where the person is registered with a GP practice prior to their detention.

3.26.3.  The local authority where the individual is physically present is responsible for organising an Approved Mental Health Practitioner (AMHP) to assess whether to make an application to detain the person under s2 or s3 of the MHA, although in limited circumstances, the AMHP can suggest that another area should do this if they consider this more appropriate.

3.26.4.  The local authority where the individual is physically present (including temporarily) when the incident that needs to be investigated takes place is responsible for carrying out any safeguarding enquiry under s42 Care Act 2014 and will be responsible for arranging a Care Act advocate to support the individual if they need this to engage with the investigation.

3.26.5.  Under the Mental Health Act (s130D) the registered establishment or hospital managers where the individual is detained is responsible for organising an advocate. Where a person is subject to a conditional discharge it is their responsible clinician who must arrange this. Where a person is subject to guardianship the local authority.

3.26.6.  Independent Mental Capacity Advocates, appointed in line with legal duties under s35 Mental Capacity Act 2005, can only work with an individual once they have been instructed by an appropriate person/ body. For accommodation decisions and care reviews this is likely to be the local authority responsible for the arrangements. For serious medical treatment decisions this will be a medical practitioner who has responsibility for the person’s treatment. For adult protection cases this will be the local authority coordinating the adult protection proceedings. For the IMCA roles in DOLS this will be the Supervisory Body.

[1] Mr Justice Peter Jackson in Wye Valley NHS Trust v B (Rev 1) [2015] EWCOP 60 (28 September 2015) (bailii.org)
[2] Barts Health NHS Trust v Dance & Ors (Re Archie Battersbee) [2022] EWFC 80 (15 July 2022) (bailii.org)
[3] Mental Health Act 1983 (publishing.service.gov.uk)
[4] There is also no legal right to an IMHA for people detained under sections 4, 135 and 136 of the Mental Health Act 1983
[5] Aintree University Hospitals NHS Trust v James [2014] AC 591
[6] Pursuant to the Mental Capacity (Amendment) Act 2019
[7] Local Authority v Z [2004] EWHC 2817 (Fam) (03 December 2004) (bailii.org)
[8] Local Authority v Z [2004] EWHC 2817 (Fam) (03 December 2004) (bailii.org)
[9] Savage v South Essex Partnership NHS Foundation Trust [2008] UKHL 74 (10 December 2008) (bailii.org) and Rabone and another v Pennine Care NHS Foundation Trust [2012] UKSC 2 https://www.supremecourt.uk./cases/docs/uksc-2010-0140-judgement.pdf
[10] Recommendations | Autism spectrum disorder in under 19s: support and management | Guidance | NICE
[11] Care and support statutory guidance – GOV.UK (www.gov.uk), para. 16.9
[12] SEND_Code_of_Practice_January_2015.pdf (publishing.service.gov.uk)
[13]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/746063/20181001_National_Framework_for_CHC_and_FNC_-_October_2018_Revised.pdf
[14] Shah v London Borough of Barnet [1983] 1 All ER 226 (HL)
[15] Section 39 Care Act 2014, the Care and Support (Ordinary Residence) (Specified Accommodation)Regulations 2014 and the Care and Support Statutory Guidance, Chapter 19
[16] Care and Support Statutory Guidance, Chapter 19, para. 19.32

4. Analysis of Agencies' Actions

Reasonable adjustments for people with autism

“I was comfortable in the first CAMHS Unit, initially it was just supposed to be a short-term placement to stabilise me, but it wasn’t safe for me to be in the community. I was regularly having complete meltdowns. They constantly told me that it was only temporary, you can’t stay here. After 5 months they said we’ll start doing some long-term work, but they couldn’t find me a placement. I had a suspended ligature on a Friday night, but when they opened the door, I fell down so they thought it wasn’t a serious attempt and gave me home leave on the Saturday, where I took a lot of paracetamol. I told them I’d had a dodgy Chinese when I got back to the ward as I knew I’d throw up at some point. My key worker knew that wasn’t it. A junior doctor saw me at the hospital, I think he misread the guidelines, so thought he had to wait four hours from admission to take bloods but that was twelve hours after I took the pills, so I got really, really ill. A liver consultant came down shouting at the other doctor that I would need to go on the transplant list. My mum was called and staff from the CAMHS Unit were coming to see me because they were told I wouldn’t make it. Suddenly I got well, so returned to the CAMHS Unit, but they didn’t tell me they were looking for somewhere else. I’d decided that I was going to get better, I was trying really hard. Two weeks later I was told at breakfast that I had an hour and a half to pack because transport was coming. I had a sense something was happening, one of my favourite staff was acting strangely and my mother had been told about the move but was asked not to tell me, so had come to see me the night before. I didn’t know where I was going or what was going to happen, it was such a shock. I was put in a full harness for transport, but it was too loose, so I tightened it. It made me feel more secure. But no one from the CAMHS Unit came in the transport with me and none of the transport staff spoke to me. The PICU was horrible. I arrived in the ‘fishbowl’ observation area, no one came to speak to me. I was terrified and shocked, to me there was no connection to the incident two weeks earlier. One of the first things they said to me was that if I didn’t eat they would intubate me. No one would answer my questions. I very rarely cry unless I’m angry, but the nurse turned around and said ‘those crocodile tears won’t work on me’. I just thought ‘where have I come to?’ I just wanted to speak to a doctor to find out why I was there and what the plan was, but it was more than 24 hours before a consultant spoke to me. Communication was so much harder because of my autism, and most of the staff spoke English as a second language so I found it difficult to communicate with them effectively. I was trying to be well behaved, but they were controlling me rather than communicating. At that point I was sleeping on the floor, I hated people watching me sleep, especially new people. With my PTSD I needed an escape route. They were blocking the door so I built a ‘hut’ with my mattress against the wall and slept under it. But their policy was 72 hours’ high observations on arrival, so the matron ripped the hut down in the morning. I wasn’t allowed to go the toilet alone so wouldn’t go to the toilet. I held it nearly 40 hours and was in agony, until finally they agreed not to look. At that stage I would have meltdowns if there was change, for example if lunch was late. About a month after I arrived, I came down for a meal on a Friday and found that they had changed the lunchroom, it was bright red with American diner-style banquettes and smelled of paint and vinyl, there was too much stimulus. I went back to my room and listened to my favourite audiobook under duvet, trying to calm down. A nurse came in, didn’t say anything, but ripped duvet open and dragged me out, telling me I couldn’t do that. I’d told them what I needed to calm down when I arrived. So I had a meltdown, I was hurting myself, hitting the door, screaming and threw up. I was dragged into a small room where I was able to calm down, I just needed some space. A doctor came and said ‘she’s fine’ and left. It was handled so badly. If I’d known there was going to be a change, I would have been able to explain what was wrong. I couldn’t eat in there because it smelled, but I wasn’t allowed to eat outside the lunchroom. I didn’t eat until the Monday, doctors said I was refusing to eat. I burst into tears, and told them I was starving and had been begging to eat, just somewhere else. They made arrangements for me to eat in a meeting room and once the lunchroom stopped smelling and I grew used to the colours, then I could use it. After 6 weeks, I had a notebook with metal on it, which I valued because I’d won it at my previous placement and wrote my diary in it. Then suddenly the PICU changed the rules and said I couldn’t have it. I needed time to think, so wedged myself between wall and booth, they were trying to drag me out. One of the staff said they were taking away my audiobook, and as he grabbed it, he accidentally broke the MP3 player, so everything escalated. I felt like they were shouting, there were many people. Someone new came in, he had recently transferred from an autism team, he told the other guy off, got the audiobook and put it on so I calmed down and came out. I just needed time to calm down. I’d never misused it, only ever used to calm down, so he was taking away my ability to self-soothe and sleep. They acknowledged it was bad practice. The PICU was a holding pen, I got no therapy. They would only give me a 1:1 if I had a crisis. A lot of the girls would have a ‘mini’ crisis, head bang for a few minutes in order to speak to someone. You shouldn’t have to injure yourself to speak to someone.”

4.1.     Professional understanding of the needs of people with autism has developed significantly in recent years. However, during the period relevant to this review, Hermione had many experiences where a failure to recognise or mitigate her triggers, or to respond appropriately when she started to become distressed, resulted in situations rapidly escalating. Although the need for routine and environments that are not over-stimulating have been well recognised for many years for people on the autistic spectrum, reasonable adjustments were often not made for Hermione by the Tier 4 mental health units where she was placed.

4.2.     In particular, provisions made to move her from one unit to another were not well managed. It is accepted that the decision not to tell Hermione in advance that she would move from the CAMHS Unit to the PICU was taken in part because PICU placements generally become available at short notice but mostly for her safety, to mitigate the risk that she would attempt to abscond or self-harm. However, once she was told this on the day of the move, a clear explanation of the rationale and information in respect of where she would be moving should have been given to her. A member of staff from the CAMHS Unit should have travelled with Hermione to support her and provide a handover of her health and care needs. Likewise, on arrival at the PICU, she should have been given a positive induction to the ward, promptly introduced to her treating consultants and an explanation given of her treatment plan. Leaders acknowledged that the admission process Hermione experienced did not comply with the PICU’s service level agreement in place at the time, that young people should be seen by a clinician within 6 hours of their arrival and a consultant within 24 hours of admission.

4.3.     The referral document from the CAMHS Unit to the PICU focussed on risk, not positive behaviour management. Throughout her admission to the PICU there were numerous incidents where staff demonstrated a lack of understanding of the needs of young people with autism, that not only caused the situation to escalate at the time, but have caused Hermione ongoing trauma subsequently. At the time of Hermione’s admission, the PICU was not rated by the Care Quality Commission (as it only rated individual services for independent providers) but the CQC recorded due to concerns about the proportion of agency staff, lack of specialist training and inconsistent governance. However, in 2020 the CAMHS PICU unit was rated ‘inadequate’ overall and it was placed in special measures, with particular concerns noted that young people did not receive person-centred care, a Positive Behaviour Support (PBS) approach was not used to support patients who posed a risk to themselves, sedation was overused and risk assessments were not up-to-date or detailed.

4.4.     PBS is a person-centred framework for supporting people with learning disabilities and/or autism that takes a person-centred approach to create a positive physical and social environment and develop constructive interventions that eliminate the need for aversive and restrictive practices.[17] By developing a sophisticated understanding of the individual’s triggers and approaches that work for them to diffuse situations before they escalate, there is evidence that the approach significantly decreases challenging behaviour and promotes positive skills.

4.5.     The PICU has now been taken over by Active Care Group, and substantial steps have been taken to improve services, including the roll-out of the PBS approach for all young people. A national programme using a specialist autism service[18) with experts by experience to analyse the ward environment for Tier 4 wards to identify physical triggers for people with autism has resulted in the ward being fully refurbished – including the lunchroom which Hermione found so over-stimulating. The number of young people admitted to the ward has also been reduced, both to reduce overcrowding and improve person-centred care. CAMHS Unit 1 was also planning to introduce a PBS system for young people.

4.6.     Hermione spoke positively of the supportive and caring environments at College 1 and College 2, both specialist colleges for young people with autism. She was particularly positive about College 2, where she felt that staff treated her as an adult and communicated with her in an honest, mature manner, even in respect of difficult subjects. She felt that their nuanced recognition and response to her behaviour and signs that her thoughts were becoming disordered meant that they were able to keep her safe while on college grounds.

“College 2 was amazing, they really cared. When things got difficult, they asked me what I needed to make things different, they treated me like an adult. College 2 always involved me in the discussion. When Covid happened I was terrified I would be thrown away. Just before lockdown I had Covid symptoms and had to go home, I thought they would never let me back because that’s what happened at College 1, but they wrote me a letter and kept my hamster at the college to reassure me. The consultant psychiatrists worked in collaboration with me to develop really good support plans, so when I had a crisis, staff didn’t have to think things through, they had a plan about how to respond to deescalate the situation.”

4.7.     There was little evidence of a PBS approach being taken during Hermione’s admission to the acute hospital in Wiltshire in February 2021. As a consequence of the Covid-19 pandemic, parts of the hospital had been separated for Covid patients, and staff in the Intensive Care Unit were very limited in respect of their ability to provide Hermione with a private room where she could be safely supervised. The only option, within the temporary Intensive Care Unit based in Theatre Recovery Unit while a mental health bed was sought, was an anaesthetic room off the Recovery Unit and credit is due to the hospital for its efforts in this regard. However, in addition to the constant noise and stimulation of an Intensive Care Unit in the middle of the pandemic, the room had four exits and limited steps could be taken to remove the physical risks in respect of Hermione’s very concerted efforts to self-harm, requiring her to be kept under 3:1 supervision at all times. Unfortunately, this constant observation, while necessary, was also escalating Hermione’s anxiety and making it nearly impossible for her to self-sooth. By the time Hermione was extubated after being sedated, the DCC’s Autism and ADHD team had shared good quality information in respect of her diagnoses, presentation, triggers, self-soothing methods, and risks. Hermione also noted a positive, person-centred approach being taken by hospital nurses, whose kindness she valued even in her distressed state. However, a more detailed plan setting out how staff should respond to specific behaviours and situations may have helped them to keep her safer in what was, unquestionably, a high risk and very stressful situation.

“When I was on the ICU there were two nurses who were amazing, they were speaking to me. One guy was great, he explained what was happening and why. They spoke through what they were going to do, not just to each other across me. Because I was calm enough to think it through, I was able to avoid the flight urge.”

4.8.     Child and Family Health Devon has now introduced a key worker whose role it is to provide support to reduce the risk of mental health admissions for young people with a diagnosis of autism, recognising that this environment can lead to an escalation of behaviour that can lead to being detained in a PICU. This is good practice, and may have facilitated use of alternative risk and behavioural management strategies to avoid the need for Hermione’s original admission.

Systems finding
4.9.     During the period relevant to the review, understanding of the needs of people with autism was not fully embedded across all partners and in particular, Tier 4 CAMHS units. Evidence-based initiatives have since been taken to improve the physical environment in Tier 4 units and the roll out of a person-centred Positive Behaviour Support approach for people on the autistic spectrum have resulted in significant progress being made by some partners, but these approaches need to be adopted more widely.

Recommendation 1: Partners across all relevant SAB areas need to consider how to make reasonable adjustments to ensure that they are providing services in a way that works equally well for people with neurodiversity, in accordance with duties under the Equality Act 2010.

Recommendation 2: When people with autism and/or learning disabilities are displaying challenging behaviours, partners need to ensure that detailed behavioural support plans travel with the individual during any transfers within or between agencies.

Recommendation 3: Where an individual has a complex network of professionals supporting them, a single document, with the names, photographs and contact details for the team around the person should be provided to the person by their lead professional and kept up to date.

[17] About Positive Behaviour Support – Positive Behaviour Support
[18) Autism Programme – NDTi

Transitions, discharge planning and s117 aftercare

“I asked if I could go to an 18-25 unit because I knew Mum would struggle with me at home, but they said they only took informal patients and I was on section. I spent my first morning as an adult in the PICU, then the rest of the day on the motorway back to Devon. Someone came from social care, she was lovely but when she stopped coming, I didn’t like the new person so disengaged. Practitioners thought being out of education was making me worse, but actually I was just getting worse. I was drinking too much because I was bored. No one came from mental health. I went from a PICU to nothing.”

4.10.     Although limited evidence was available from agencies in respect of the period leading up to Hermione’s 18th birthday, there was some evidence of transition planning while Hermione was in the CAMHS Unit. A referral was made to the CMHT and Care Planning Approach (CPA) meetings took place. It was recommended that a specialist residential college would be required to meet her needs, but the funding for this had not been agreed by Education and Social Care during her admission. The involvement of Education indicates that this was being progressed through Special Education Needs provisions and it is not clear whether funding was sought through section 117 pathways at the time, despite Hermione being detained under section 3 of the MHA. It does not appear that local pathways to hold partners to account for disagreements were used to resolve this impasse, in accordance with duties under the SEND Code of Practice. These discussions did not result in Hermione’s EHCP being updated, as her last plan was dated October 2016, prior to her mental health admission.

4.11.     However, as her self-harming behaviour increased, the CAMHS Unit recognised that it would be unsafe for Hermione to be discharged to the community and they urgently sought a PICU unit for her. Leaders noted that local CAMHS would remain the pivotal coordinators for transition planning wherever Hermione moved during this period, as Tier 4 beds are commissioned through NHS England rather than being commissioned locally and it is unpredictable where a bed will become available.

4.12.     When Hermione transferred to the PICU, a number of CPA meetings took place, attended by Hermione, her mother and professionals who had worked with Hermione in Devon including CAMHS, DCC’s Autism and ADHD team, and CSC. It was clearly recognised that Hermione’s mother would be unable to manage the serious risks to Hermione at home full time and discussions took place around potential residential placements. However, NHS England was reluctant to provide funding from a Continuing Healthcare perspective and Hermione became increasingly anxious about being ‘dumped’ on discharge. Although she offered to remain as an informal patient on an adult mental health ward, because she recognised her mother’s anxiety about managing her needs, this was not progressed by professionals, likely in recognition of the reality of moving from a CAMHS unit to an adult psychiatric ward, where other patients may be acutely psychotic and potentially aggressive or violent. The experience can be very traumatic, particularly for a vulnerable young person such as Hermione.

4.13.     Although the ward was not able to accommodate an adult due to its CQC registration, discharging Hermione on her 18th birthday was not good practice, either in terms of the impact on Hermione emotionally or from the perspective of ensuring continuity of services as she moved from the children’s to adults’ legal framework and services. An overly optimistic discharge plan was sent to Hermione’s GP for her to return home to her mother while a residential college was sought for her, with a view to this starting in January, although no placement had been identified. ASC provided a 40hours/week of care, but Hermione disengaged from this after her support worker changed, which should have triggered a review of her care plan to consider whether her needs could be met in another way. A referral was made for DPT’s Autism and ADHD Service to provide ‘fast-tracked’ mental health support, but  her case was never opened to adult community mental health services and she was not allocated a care coordinator at the time. A referral was made to the Joint After Child Abuse Team for PTSD treatment, but this was a CAMHS services and would not be available for an 18-year-old. Consequently, Hermione received no mental health support on discharge, nor was education provision arranged in the interim. The discharge plan was notable in that it summarised the circumstances of admission, risk analysis and history that had been provide by the CAMHS Unit, but there was no indication of any new insight into Hermione’s needs or diagnosis that had been developed during her time at The PICU. This appears to substantiate Hermione’s view that this was, in effect, a ‘holding pen’, rather than a therapeutic provision.

4.14.     Devon’s CAMHS, which is now managed by Child and Family Health Devon following a procurement in 2019, have introduced an Assertive Outreach team, who would be in weekly contact with the Tier 4 unit whether locally or out of area to carefully plan the young person’s return home, and acting as liaison with the CMHT if they were approaching transition age. NHS England have a South-West regional worker to support the escalation of any concerns in respect of a Tier 4 placement, as they commission and allocate the Tier 4 estate.

4.15.     Leaders discussed the fact that Hermione’s case was presented to s117 Panel to agree funding for College 1, however, there was little recognition that s117 is not merely a funding stream, it is a duty to provide holistic services to prevent the individual’s mental health from deteriorating. There is no indication that the community-based elements of Hermione’s discharge plan while waiting for a placement to become available at College 1 were considered in the context of a s117 aftercare plan, which may have provided other agencies with a forum to challenge the decision by the CMHT not to provide Hermione with mental health services during this period. Practitioners reported a custom and culture of viewing need through a funding lens, where assessments were often viewed as a mechanism for demand management.

4.16.     Hermione’s experience after her detention at the PICU, of being left at her mother’s home without any mental health support or education provision for a lengthy period, was repeated  when her placement at College 1 broke down. Again, clear multi-agency s117 aftercare planning should have taken place urgently, to ensure her holistic needs were met while a placement was found. Hermione excelled academically and without support or stimulation, she felt abandoned and struggled with depression. This also contributed to her overwhelming distress as her placement at College 2 broke down and no new placement could be sourced.

“I went to College 1 for the final term of the year and sat in on psychology lessons, and was doing sport. In that time I started struggling with my eating, but hid my weight loss by wearing larger sized clothes. I starting A-levels in September and excelled in psychology as I loved it. On the surface I was doing really, really well. I was spiralling so had a conversation with a support worker, then started to panic that I would lose my placement so bought paracetamol. I intended to tell staff after an hour so I wouldn’t have to take charcoal. I wanted to stay and get well, so needed to go to college, but they thought I wasn’t taking the overdose seriously. They told me I had to go home for the weekend to rest. I was calling at least weekly, maybe daily to see when I could come back. They told me they were setting up a house for people with mental health conditions in September and that I could come back. But then that was cancelled and that was that. I was home from March to December with no mental health support and no support for my eating disorder. I asked for tutoring because education is important to me, but they told me that this wasn’t available. It might because I was over 18, but I’m SEND so I know they’re still supposed to support my education. If I’d had support after I left College 1, I wouldn’t have been in such a bad place when I started College 2.”

4.17.     The role of the care coordinator requires someone with confidence and skill to coordinate managers, clinicians and other agencies, and a high level of legal literacy as other practitioners, even senior clinicians, may not understand the different legal frameworks that apply outside their fields. Devon Partnership Trust has a specialist care co-ordinator post for adults placed in Tier 4 units outside its area, however, post is not funded to work with someone until they are 18 years old, and ends once the person has settled on their return to Devon. When Hermione was placed in Beverley House, the out-of-area care coordinator started planning for her discharge and has continued to work with her since. She is a highly skilled, dedicated and caring practitioner who had a deep insight into Hermione’s needs and is a credit to her service. Hermione discussed how meaningful it had been for her to have an allocated worker who regularly visited and contacted her when she was placed so far from home, who proactively advocated for services to be put in place when she was ready for discharge and was able to bridge the gap between Beverley House and home, to provide her with continuity.

“Every time I moved, I had to adjust to a new set of strangers, and didn’t see anyone from the previous placement again. I had a lot of people on my team, and they changed all the time, it was very confusing. I wasn’t given names or contact details or introduced to people, often I didn’t even know their role or what they looked like. I would like to have had some consistency, someone who is assigned to you until you no longer need services. I was lucky at College 2, I made good friends there. But lots of people with mental health conditions don’t have a lot of friends, so it’s important to have someone who remembers your life story as you move around.”

Systems finding
4.18.     Insufficient Tier 4 and PICU beds locally, in particular CAMHS provision, means that young people with mental health needs can have significantly delayed admissions during periods of crisis and are frequently placed at distance, disrupting their positive support networks. Education Health and Care plans were not coproduced by the relevant agencies and in particular, limited input from Health resulted in a major gap in ensuring a young person’s rights to holistic planning were met, increasing the risk of requiring hospital admissions and meaning that critical information did not travel with Hermione. Transition planning and section 117 aftercare planning during admission to Tier 4 CAMHS units were not robust and lacked the necessary detail to effectively plan to meet Hermione’s complex needs post-18. Agencies did not sufficiently investigate what local services were realistically likely to be available to Hermione as an adult, identify alternative services to meet her needs, robustly challenge decisions not to offer a service, or hold each other to account.

Recommendation 4: The ICB and Devon County Council’s Social Care and Education departments should provide assurance to TDSAP that future integration plans will prioritise ensuring skilled health assessments are included in all EHCP when planning for adulthood.

Recommendation 5: The ICB should give consideration to funding a post for a CAMHS transitions care coordinator to lead in planning transitions and discharge for young people in Tier 4 mental health units. DCC and/or the ICB should also give consideration to funding a support worker, in a role similar to a personal advisor under the leaving care provisions, to provide continuity to young people who have been detained under s3 MHA but not looked after, up to the age of 25.

Recommendation 6: Partners should ensure that transitions pathways and interagency escalation policies are well publicised and that generous leadership supports staff to hold partners to account when coherent, robust and timely transition plans are not devised and implemented for young people.

Recommendation 7: TDSAP should seek assurance from CSC, ASC, CAMHS and the CMHT that transitions planning is effective and consistent for young people who are placed out of area, with clear contingency and care planning taking place whether they return to Devon or remain out of area post-18.

Recommendation 8: TDSAP should seek assurance from NHS England in respect of its plans to improve access to Tier 4 beds for young people up to the age of 25, that are local to them, to reduce reliance on acute admissions, avoid delays in young people obtaining the treatment they need and improve their experience of mental health services. Clarity should also be sought on how NHS England holds commissioned Tier 4 CAMHS providers to account for effective discharge and transition planning.

Mental health services for people with autism

4.19.     It is unclear whether the CMHT’s decision not to provide Hermione with mental health services on discharge from The PICU was because they took a view that she did not meet their criteria for a service because her needs were primarily perceived to be behavioural, relating to her neurodiversity. A number of practitioners noted that view to be common practice both at the time, and to date. Practitioners reported that there were significant barriers to secure a mental health service for people with a primary diagnosis of autism or other neurodiversity and social care partners noted that it could be extremely difficult to challenge health decisions due to a perceived power imbalance. One practitioner described a meeting following Hermione’s mental health crisis in February 2021, where professionals wanted Hermione to be told that her ‘behaviour was unacceptable’, reflecting a pervading attitude during that admission that she was being naughty, rather than recognising that she was so mentally disordered that she was detainable under the MHA.

4.20.     Both colleges reported significant barriers in sourcing mental health support for students who had been placed from other areas, either for ongoing therapeutic services or during periods of crisis. This was made even more difficult by having to manage students returning to their home area during holidays as the placing local authorities and CCGs would ‘drop them like hot potatoes’ upon placement, which posed a serious risk when placements started to breakdown, as happened when Hermione left College 2 as CHMT services cannot be reinstated until the person is physically residing in the CMHT’s area, even when the move is planned. Funding was not provided to the colleges to arrange additional mental health support when this was required and it could be very difficult to secure support from the placing agencies when the young person’s needs started to escalate.

“When I’m between placements there’s never any contingency planning preventing me from getting bad. I can’t get an urgent service. If I say to professionals that I’m going downhill, they tell me to come back when I’m really bad. I think they hope that if they leave it a while, I’ll get better.”

4.21.     College 1 were able to obtain early intervention support, but noted that local CMHT services did not have specialism in individuals with ASD and they experienced serious problems trying to gain a response during emergencies. College 2 were able to get a good response from the local CMHT during urgent situations, but struggled to arrange early therapeutic provision for young people whose needs were beginning to escalate. This was complicated by the advent of the Covid-19 lockdown, which had an enormous impact on the availability of mental health resources nationally due to staff shortages and increased demand. They described efforts to secure CMHT support for young people not registered with a local GP as ‘like walking through treacle’. Because Hermione’s EHCP had not been updated since prior to her admission to CAMHS Unit 1, this did not include explicit plans for these needs to be met and an assumption appeared to have been made that the on-site therapeutic provision, which was not intended to provide acute services, would be able to meet her needs. However, both colleges reported that these issues were commonly overlooked in EHCPs for young people. GP registration is a matter of local practice and practitioners considered that allowing dual registration in the person’s home and college area would significantly reduce these barriers.

“Do I have an EHCP? I’ve never been able to get a copy.”

4.22.     College 1’s understanding had been that Hermione’s needs primarily related to her education and neither college was informed that she had been detained for several months under the MHA before she turned 18. This was a serious gap, and meant that during periods of crisis, this essential information was not communicated to mental health services. Both colleges noted that referral processes have subsequently improved and that people were more confident in requesting and providing additional information to inform their decision-making and risk management processes. The Keeping Children Safe in Education statutory guidance[19] requires schools to transfer a young person’s child protection file when they transfer between education providers to ensure that significant safeguarding information is shared, however, there was no equivalent for post-18s.

4.23.     This situation was even more complicated when Hermione was admitted to the hospital in Wiltshire waiting for a mental health bed as the hospital was in Wiltshire, she was ordinarily resident in Devon, but Hermione was still registered with a GP in Dorset, which meant that a Dorset CCG was responsible for looking for her mental health bed. Practitioners commented that it was not uncommon for patients, particularly young people to remain in acute hospital beds for days or weeks, while a bed was sought in a mental health ward, due to a national shortage of mental health beds. Leaders recognised that a noisy emergency department was likely to escalate the behaviour of a young person on the autistic spectrum, but that they had little control as other agencies were responsible for sourcing beds and could not turn people in crisis away.

4.24.     The shortage of mental health beds for young people across South West England has been recognised and NHS England has secured £40million of funding to expand its establishment of beds for young people with a dual diagnosis of autism and mental health conditions. Leaders reported that these were being developed to reflect the needs of young people with autism in respect of a calm and soothing environment.

Systems finding
4.25.     During the relevant period, pathways for support for young people with a dual diagnosis of neurodiversity and mental health conditions were not well developed and specialist residential colleges struggled to obtain mental health support for young people placed out of area. Limited options in respect of specialist residential or educational provision or mental health beds for this cohort meant that practitioners struggled to identify alternative placements when placements were unable to manage escalating risks. S117 aftercare plans and/or care plans to meet Hermione’s needs between placements were inadequate. Although funding has been secured to increase the number of specialist beds for young people with a dual diagnosis across South West England, responsible agencies need to ensure that flexible joint commissioning arrangements are in place to meet these needs whilst this provision is developed and on an ongoing basis to meet the spectrum and volume of need locally.

Recommendation 9: Health and Social Care partners should develop a bespoke protocol for young people with neurodiversity and complex behavioural or mental health needs, supporting practitioners to understand the interface with other legal frameworks including s117 aftercare responsibilities and continuing healthcare. This should include a pathway to allow for more bespoke commissioned placements or support packages to target the needs of individuals, involving joint commissioning to ensure that there is a seamless spectrum of provision from individuals with pure social care needs to those with neurodiversity, continuing healthcare needs or who are being discharged from mental health wards.

Recommendation 10: The ICB and Social Care should consider how to ensure that when placing people with SEND and mental health needs out of area in specialist educational facilities, arrangements are in place for them to receive local CMHT therapeutic and crisis support both during term time and when they return home during holidays or during placement breakdowns. These plans should be consistently recorded in the person’s EHCP, together with key safeguarding information.

Recommendation 11: In situations where a person has frequent mental health admissions, clinical staff on keys wards should be invited, and commit to attending multi-agency professional and strategy meetings, to strengthen an integrated approach between hospital mental health teams and the wider professional network, with an aim to reducing reliance on mental health admissions and identify effective crisis plans.

Recommendation 12: The ICB and Social Care should provide assurance to TDSAP that clear contingency planning is taking place for all residential placements, and that in circumstances where a provider has given notice that they are unable to manage a situation with escalating risks, proactive and timely arrangements are made for alternative provision, using escalation routes promptly if a placement cannot be identified, and detailed care or s117 aftercare plans to support the new placements or arrangements.

[19] Keeping children safe in education 2022 (publishing.service.gov.uk)

Risk Management of emergency placement

“I was getting really bad over summer and thought they wouldn’t let me back. College 2 said ‘we love having you here but are looking for other places because we’re not sure this is the best place for you’. I knew I was so safe there, they wouldn’t let me hurt myself. I took an overdose, not enough to kill me, but knew that would get me sent home where I could do it. I went home, I thought I was never going back, and wanted to make it the best Christmas for my family ever as it would be my last. I was making a plan. I knew I struggled taking paracetamol, so did lots of research and worked out how much Lemsip to take, starving myself before. I took the equivalent of a huge dose of paracetamol, wore a jumper to hide the jaundice, and emptied vodka bottle to provide an explanation if I was sick. I went to sleep on Monday, woke up on Wednesday. College 2 knew by then I was going home to be able to make a suicide attempt, so they kept me there at massive risk to themselves. I was so unwell, nothing could have stopped me. But this is where I get angry, from September social services was supposed to be looking for a placement for me, but nothing had happened. It felt like a series of rejections, like no one wanted me and no one ever would.”

4.26.     From the point that College 2 told the local authority in September 2020 that they would no longer be able to manage the risks to Hermione if she continued to make suicide attempts, very active contingency planning should have taken place by the CCG (now ICB) and Adult Social Care to ensure a new placement could be arranged at short notice of the placement broke down. As Hermione’s self-harm started to escalate in December, these plans should have been put into effect.

4.27.     The CCG and local authority initially put out a joint tender to an educational placement with mental health provision, but when this could not be identified, efforts were made to identify alternative placements with additional supports in place. Practitioners noted that although the package of support initially agreed with Provider 1 was not ideal, the offer of 2:1 supervision was a higher level of supervision that Hermione would receive in a mental health placement. However, this did not take into consideration the fact that staff would not have any legal powers to enforce that supervision.

4.28.     Both Provider 1 and Provider 2 leaders commented that although some information was shared about ‘incidents’ involving Hermione, this was not sufficiently detailed for them to take a view as to whether they could meet her needs, adequately assess the risk and plan how to mitigate these. Again, the information that Hermione had previously been detained under the MHA was not relayed to them. Provider 1 had subsequently strengthened the detail they require in their referral forms, although they noted that placement teams would often edit the profiles of young people to ensure they would be offered a placement

4.29.     The placement that Provider 1 had intended to offer Hermione was still to be refurbished and was not ready by the date she had to leave College 2, so a hotel suite was sourced as an alternative. As the deadline for Hermione to move from College 2 approached, it became increasingly clear that the necessary support was not in place and Provider 1 were particularly concerned that Hermione’s CMHT support was contingent on her arriving in Devon early enough in the day to go to a GP surgery to register. Given that Hermione wanted to have a leaving lunch with her friends before being transported from Dorset, this was unrealistic. Neither agency was able to risk assess the hotel rooms in advance to identify suicide or escape risks or practicalities of providing supervision in that environment. The lack of clear communication or cohesive planning resulted in Provider 1 feeling ‘bulldozed’ and taking a view that it would have to withdraw its offer of a placement.

4.30.     Hermione had self-harmed the day before she moved from College 2 and it appears that all agencies anticipated that she would be admitted to hospital. When a decision was taken that she was not detainable and had capacity to take decisions about her care and hospital treatment, plans had to be expedited through Provider 2. This was an additional complication, as until this point, Provider 1 had been attending the risk planning meetings. Additionally, professionals had anticipated that the CMHT’s Home Treatment Team would provide mental health support for Hermione, but when she was taken for an assessment on arrival in Devon, they assessed that the involvement of additional professional was likely to increase Hermione’s stress and took the view that she should not be hospitalised. The fact that CMHTs will not allow people to register until they are physically in the area, even in Hermione’s circumstances where this was a planned move by the professional network including the CCG is a very serious issue that places patients at risk.

4.31.     Provider 2 were hampered by the fact that there was no legal framework in place to restrict Hermione or prevent her from leaving the placement. The risk management plan lacked logic – if the risks of Hermione trying to leave the placement or attempt suicide were so high that she required constant 3:1 supervision, it was illogical to predicate this arrangement on her consent. Hermione was aware of this and clearly described her efforts to lull agency staff into a sense of security that she would comply with the arrangements. Because the placement was not in a care home, hospital or supported accommodation within the definition in the MCA, authorisation from the Court of Protection would have been needed to restrict or restrain Hermione, although if a decision had been taken that this should be pursued, s4B of the MCA could have been used to put interim measures in place to stop her from leaving as a ‘vital act’. A meeting was arranged for Sunday 14 February to assess Hermione’s capacity and whether she needed to be deprived of her liberty, but this very clearly should have happened before the emergency placement began.

4.32.     In the absence of a legal framework, Provider 2 staff were conscious that they needed to negotiate with Hermione in respect of the supervision that could be put in place. Staff had training on the MCA and were aware of the limitations of how they could intervene. They were told that Hermione found being watched in the bathroom or while sleeping was triggering for her and that bathroom privacy had been agreed. While understandable from the perspective of positive behaviour support, clear conditions for these arrangements were not agreed, for example that 5 minute checks should be undertaken and the police and DCC contacted immediately if Hermione did not respond.

4.33.     Moving Hermione late on a Friday to this emergency arrangement was a poor decision, as this meant that Provider 2 staff had no easy way to contact the professionals who knew Hermione best as she was settling in, and as the situation developed, they had to liaise with out-of-hours and emergency duty team staff. Hermione felt rejected and was extremely distressed about the breakdown of the placement she loved, even though she recognised that they could not manage the risks to her. College 2 had provided comprehensive advice on how to recognise and manage Hermione’s behaviour including an Individual Risk Assessment and Positive Behaviour Support plan. However, this had originally been sent to Provider 1 and Provider 2 noted that they only received this when a folder was handed to agency staff when Hermione arrived at the hotel at 8pm. Because they had such limited time to pull together an emergency support plan, their agency staff could not be adequately briefed on the detail in this, particularly as the staff supervising Hermione rotated across shifts. In addition to the detailed documents provided, they felt that a concise summary of the most critical information at the front of the file such as the sophistication of Hermione’s planning, including key contact numbers for the people who knew Hermione best, could have enabled them to respond more swiftly and in a less trusting manner as events unfolded.

“There were locks on the windows at the hotel, but I managed to jimmy them. I was in the shower and told the staff I didn’t want them to knock, but they waited at least an hour before trying to call me. I’d been to 4 different shops to buy several bottles of Calpol, had already taken to overdose and got to the train station. By the time the staff phoned it was dark, I told them I could see them. I knew they would have been told that I liked going out into gardens and woods to calm down when I was stressed. I avoided the CCTV at the station and bought three different tickets for trains leaving within 10 minutes of each other so that no one would know where I was going. My plan was to go to Beachy Head, but I started to feel sick so got off the train at Salisbury, then realised I was near College 2 so decided to go to the woods near the school. I always loved it there. A lady saw me and became concerned, she literally saved my life, I think she worked in health or social care. I had practiced using an alias with a backstory, but I was so unwell I gave my real name and told the police that I was missing from Devon. The police officers didn’t believe I was missing, they thought I just wanted a ride home. I’d written a letter saying this wasn’t a spur of the moment decision, refusing treatment or a liver transplant, and handed that and my suicide note to the police. I’d saved half of one Calpol bottle in case I was sick, they found it, and thought that’s all I’d taken, they didn’t take it seriously at all. I could hear them on the phone trying to convince my carers to come collect me from Devon to take me to hospital”

Systems finding
4.34.     A lack of urgency in contingency planning for an alternative placement when the specialist residential college was no longer able to manage the escalating risks to Hermione left agencies scrambling to pull together a safeguarding plan in chaotic circumstances and the commissioned support agency was left to manage an unacceptable level of risk without adequate support. Practitioners were too emersed in the situation to have space to identify or mitigate the significant gaps in the risk management plan.

Recommendation 13: When there is no choice but to make urgent arrangements for a care plan to supervise a high-risk individual while an appropriate placement is sourced, senior managers should act as a critical friend to carefully examine the risks and mitigation measures involved. In addition to an Individual Risk Assessment and Positive Behaviour Support plan, a one-page summary of essential information and contacts should be provided by the commissioning agency so that shift staff can respond immediately to developing situations.

Recommendation 14: TDSAP should seek assurance from partners that high risk individuals are not being placed in hotels, even with a package of support, while suitable placements are sought as risks cannot be adequately managed in such an unpredictable environment

Police response

4.35.     The decision to provide police with a portfolio with Hermione’s details in advance of the placement starting was good in principle, this information provided was too vague to enable them to adequately weigh risks. In any event, the Devon Police ICT system did not automatically notify officers responding to the missing report that prior information had been provided, so officers on the day were not aware of this. Wiltshire Police, who eventually located Hermione, noted that they have a more modern ICT system, Niche, which does allow officers to access this type of intelligence, but different police forces cannot access each other’s ICT systems. The only method of sharing information between forces was through the Police National Computer, but this was only high level information that a person was reported missing, not detail in respect of risk analysis or intelligence to support their location.

4.36.     Provider 2 staff who contacted police advised that Hermione was still on the grounds of the hotel, in contact with them by mobile and sounded calm. The fact that no legal framework was in place that required Hermione to remain in her placement, for example through the MCA or MHA, reinforced the impression that this was a medium risk missing episode. If police had been told that she had recently made multiple suicide attempts and was under 3:1 supervision to stop her from self-harming, Hermione would have been graded be high risk. As soon as police received the information from College 2 that Hermione had sent a ‘goodbye’ email, she was regraded as high risk. It should be noted as good practice that there was evidence on the Devon police log that officers who were present at the hotel were already treating the case as high-risk despite this not being officially upgraded, including trying to get a drone unit to search for Hermione as a helicopter could not be used due to the poor weather conditions.

4.37.     However, senior officers noted that other agencies commonly held misconceptions in respect of the police response to high risk missing episodes, when in reality each response will vary based on the circumstances and tools available to the police may only suggest a general area to search. When intrusion into an individual’s private life is deemed necessary and proportionate to the level of risk, appropriate authorisation must be obtained, although an urgent oral authority can be obtained where the person is at imminent risk of serious harm.  The key difference, if Hermione’s case had been identified as high risk, would have been that a Lost Person’s Search manager would have been deployed to oversee a strategic approach to the search with support from a crisis communicator, but the delay in police being notified that Hermione was missing meant that any search would need to cover a very large area.

4.38.     Senior officers expressed concern that individuals with complex needs were regularly being placed in unsuitable accommodation which inevitably broke down, creating a high-risk situation in circumstances that could have been reasonably foreseen. They reported frequent calls from health or social care partners asking them to manage the risk for people with complex needs over the weekend because partners were not complying with their own legal duties to meet those needs. This was placing an enormous strain on limited police resources.

4.39.     Shared understanding of the criteria the police will apply when grading missing episodes can manage practitioners’ expectations of the police response, so that proportionate risk management plans can be implemented by the agency/s best placed to action these. A protocol should be developed in partnership between the police, social care, NHS trusts and hospitals to achieve a clearer mutual understanding of each other’s responsibilities and ensure a sustainable joint responsibility in respect to people missing from mental health services. This should seek to address reoccurring missing episodes, problematic volume and reporting approaches through effective partnership working and problem solving. This will ensure that police resources are available to provide an urgent response in cases that are assessed as high risk.

4.40.     The information Hermione shared in respect of the response she received from frontline officers when she was located was explored with Wiltshire Police, however, they noted some inconsistencies between her account and police records. In particular, officers reported that Hermione had not told them how much Calpol she had drunk, only disclosing this when she arrived at hospital. Senior officers confirmed that these issues would be further explored with frontline officers.

Systems finding
4.41.     Too much reliance was placed on the police to manage the identified risks in respect of Hermione absconding from her placement, without adequate understanding of how information was held and decisions would be weighed in order to identify the response. Delays in reporting Hermione missing, together with insufficient and inconsistent information that was provided to police, resulted in delays in locating her.

Recommendation 15: TDSAP and safeguarding partners should consider how to raise the profile of missing episodes as a safeguarding issue across the wider partnership and how to embed understanding of the police response to missing episodes amongst frontline staff, to support effective discussions with police about people with mental health conditions who cannot be contacted, and promote sustainable joint responsibility for managing risk.

Deprivation of Liberty in crisis situations

4.42.     When Hermione was brought to the acute hospital in Wiltshire following her overdose, she was explicitly refusing consent to treatment and fiercely fighting efforts to save her life. In light of the imminent threat to her life, emergency room doctors had to take an immediate decision whether to intervene when she did not consent to treatment, or allow Hermione to die a protracted death from liver failure. Doctors used the framework of s4B MCA, on the basis that they provided life sustaining treatment on the basis they reasonably believed Hermione to lack capacity to consent to this. The doctors are to be commended for their actions, which complied with their positive Article 2 duty to take necessary and proportionate steps secure the right to life of someone in a crisis situation.

4.43.     An urgent DoLS authorisation was subsequently given to enable Hermione to be detained under constant supervision and restrained where necessary once she was brought out of her induced coma. Throughout this period, Hermione was constantly testing the boundaries to see whether she could escape or harm herself. Provider 2 staff expressed discomfort with the nature and frequency of restraint used on Hermione, but lacked confidence to challenge this. Even when a DoLS authorisation is in place, restraint must only be used in a way that is necessary and proportionate to the risk. However, from 22 February, when the standard DoLS authorisation was not granted on the advice of the Best Interest assessor, until 27 February when she was detained under s5(2) MHA, further decisions to repeatedly restrain Hermione at the psychiatric hospital in Dorset did not comply with her rights under Article 5. While a decision to take emergency action during an unanticipated situation is unlikely to attract judicial sanction, to take the same steps repeatedly without a legal framework in place will not be treated lightly. A decision to interfere with someone’s Article 5 rights should not be arbitrary and a DoLS authorisation or detention under the MHA comes with a set of safeguards, intended to ensure that the least interventionist approach is taken. Again, the immediate decisions of individual frontline staff members to stop Hermione harming herself are not criticised, however, at a senior level, timely decisions needed to be made about what legal framework was appropriate in the circumstances and if agencies disagreed on this, senior leaders needed to act to resolve this and provide clear guidance to staff.

4.44.     Practitioners expressed a view that a critical factor in the decision not to detain Hermione under the MHA was a lack of mental health beds, although they noted that Hermione had a remarkable ability to present as very calm and rational seconds after being in a crisis. The Mental Health Liaison team, which offers a 9am-5pm service, saw Hermione when she was calm and did not observe her long enough to witness this rapidly fluctuating severe dysregulation so did not recommend detention under s2 or s5(2) MHA. The Provider 2 staff providing the 3:1 supervision were clear that Hermione was constantly making active plans to kill herself and opposed Hermione being discharged from hospital. Although AMHPs are required to take an independent decision about detention under the MHA, evidence should have been sought from the practitioners closely observing Hermione, to inform the AMHP’s understanding of her presentation. While the ethos of keeping people with Autistic Spectrum Disorder out of hospital is correct and in line with national guidance, this must reflect the needs of the individual. A person with ASD still has a right to mental health services.

4.45.     However, in light of the decision that Hermione could not be detained under the MHA and her objection to being detained, an application should have been made to the Court of Protection for authorisation to continue to deprive Hermione of her liberty, and section 4B MCA used to detain her in the interim. It appears that undue weight was given to the fact that Hermione could articulately discuss informal admission to hospital, consent to treatment or her intent to take her life. At the time, Hermione was experiencing persistent intrusive suicidal thoughts as a consequence of her autism, ADHD and PTSD which meant that in truth, she was unable to weigh the information relating to these decisions, as to her, there was no alternative. Her agreement to informal admission was with the express intention of having the opportunity to leave and complete suicide.

“I’ve read the Mental Health Act Code of Practice twice, so I knew exactly what I needed to say to ensure they wouldn’t section me. They assessed that I couldn’t be detained under the MHA or DoLS, but then repeatedly stopped me from leaving. I also knew what they were doing was illegal and that was frustrating. They didn’t look at my history and would comment that my suicide attempts were a ‘cry for help’. But I planned things really carefully and each time there was some external event that stopped my attempts succeeding. You just can’t rely on that external factor or the fact I love my family as evidence that I don’t intend to die. Each time they assessed my mental health, they said that I wasn’t ill enough to be sectioned. They managed to convince me that I was well enough to make the decision to kill myself. It might not be what they intended but that’s the message I got.”

4.46.     In practice, despite no legal framework being in place, Hermione was not allowed to leave either hospital and was repeatedly restrained when she did attempt to leave, including through use of intramuscular sedation and she has alleged repeated restraints in a prone decision, which is inconsistent with best practice[20] and Government guidance.[21] Training in respect of safe restraint should be certified to ensure this is of a high quality – NHS commissioned services are required to provide certified training services and the CQC expects this.[22] A safeguarding meeting subsequently chaired by Wiltshire Adult MASH Team queried whether the acute hospital fully complied with the Mental Capacity Act when making the decision to sedate Hermione, as they noted that from the recordings at the time, Hermione demonstrated having capacity in respect of whether she could consent to her treatment, indicating that the incorrect framework was used to provide this form of treatment.

“I kept pulling out the canula, they put me in a coma, and I came out 3 ½ days later. The first thing I said when I came out was ‘I refuse’. I had a lung infection, but I pulled out the antibiotics drip. They assessed me as not detainable under the MHA then restrained me 10 times. They were just holding me unlawfully. It was horrible, tiny room, 4 staff sitting there, I’d try to get out, they’d stop me and pin me to the bed. One of the security guards said ‘get off her’ and I calmed down. He actually spoke to me. There were three agency staff supervising me, one didn’t speak to me at all, the others were rude. There was no need for them to restrain me to the bed. I was put into the PICU at the hospital in Dorset as an informal patient, I think I said yes because I thought I’d be there and then be able to get out. It was all logistics for me. I even got outside leave, but I didn’t have a plan yet so didn’t try to leave. I asked to leave the PICU, I wanted to be discharged, but they said no and the doors were locked. It happened at least 5 times, they said they couldn’t discharge me when I’d be homeless. They completed a mental health assessment which concluded that I didn’t need to be sectioned.  I self-harmed badly enough to go to A&E and I needed stitches, I said that I wasn’t going back but security caught me, and I was taken back to the hospital in Dorset in a taxi with child locks with a health care assistant and student nurse sitting on each side. The response team was waiting, then I was restrained, but was struggling so hard they couldn’t get me up the stairs, I was put under a nurse’s holding power and given intramuscular sedation. I was restrained prone at least 5 times, it happened repeatedly. I would be punching myself over and over. Then I was told I would be moving to a placement in the Midlands.”

4.47.     Hermione should have been provided with an independent advocate, ideally one qualified to advocate under both the MHA and MCA given the complex situation. Although leaders noted that Hermione’s mother was visiting regularly during this period and could have advocated on her behalf, this was a complex situation that was likely to need someone with more detailed knowledge of the legal frameworks. A practical barrier was also noted that realistically, an advocate would not have been allocated and been able to visit within the short period of time Hermione was detained. However, there was real urgency in her circumstances and arrangements should be in place to secure an advocate within a short period in such cases. It was notable that even though she had been in such a heightened state at that time, Hermione could still recall which practitioners had responded in a manner she felt was punitive and who treated her with kindness. She was also conscious of the periods when she had been detained or restrained without a legal framework and felt aggrieved about this, although she recognised the reasons. Access to an advocate may have helped support Hermione to understand why some interventions were necessary at the time and well as providing an avenue for challenge where she considered these to be disproportionate or unlawful. For a person with a strong sense of fairness like Hermione, this was important from a therapeutic and psychological perspective, as well as to protect her legal rights.

Systems finding
4.48.     Confident decision making around mental capacity by emergency department doctors on admission at the acute hospital in Wiltshire in a complex and high risk situation was excellent practice and unquestionably saved Hermione’s life. Subsequently, uncertainty around the correct legal framework to safeguard and treat Hermione meant that technically, she was unlawfully deprived of her liberty as she was not free to leave while admitted as an informal patient (albeit this resulted in her Article 2 rights being protected), was repeatedly restrained and it is likely that this uncertainty contributed to delays in identifying an appropriate placement for her.

Recommendation 16: The SABs should seek assurance from partner agencies that they provide a rigorous MCA training programme to staff, including the concepts of executive and fluctuating capacity, with clear parameters about obtaining timely legal advice in situations where the individual opposes the regime imposed or capacity is in doubt. Partners should use the decision making by emergency room doctors as part of MCA training to support good practice in urgent situations.

Recommendation 17: Each SAB should take steps to raise the profile of advocacy services across partner agencies to ensure provision of advocates to support individuals’ involvement in the decision-making process and enable timely challenge, including through the courts where appropriate.

Recommendation 18: Each SAB should seek assurance from partners that restraint processes in all Health and Social Care settings comply with the Restraint Network Training Standards and those applying restraint have been trained in a BildACT accredited training.

Recommendation 19: The allegations that Hermione was repeatedly restrained for prolonged periods in a prone position and on her bed should be investigated by both hospitals where she was detained in February/March 2021.

[20] The Restraint Reduction Network Training Standards – Restraint Reduction Network
[21] Positive and Proactive Care: reducing the need for restrictive interventions Summary of key actions (publishing.service.gov.uk);
[22] Bild – Association of Certified Training (bildact.org.uk)

5. Glossary

ADHD	Attention Deficit Disorder
AMHP	Approved Mental Health Professional
ASD	Autistic Spectrum Disorder
CAMHS	Child and Adolescent Mental Health Service
CMHT	Community Mental Health Team
CoP	Court of Protection
CPA	Care Planning Approach
CQC	Care Quality Commission
DCC	Devon County Council
DCCG	NHS Devon Clinical Commissioning Group
DoLS	Deprivations of Liberty Safeguards
DPT	Devon Partnership Trust
ECHR	European Convention on Human Rights
GDPR	General Data Protection Regulation
ICB	Integrated Care Board
MCA	Mental Capacity Act 2005
MDT	Multi-disciplinary Team meeting
MHA	Mental Health Act 1983
NICE	National Institute of Clinical Excellence
PICU	Paediatric Intensive Care Units
PBS	Positive Behaviour Support
PTSD	Post Traumatic Stress Disorder
SAB	Safeguarding Adults Board
SAR	Safeguarding Adults Review
TDSAP	Torbay and Devon Safeguarding Adults Board

 

6. Appendix A: Recommendations

Recommendation 1: Partners across all relevant SAB areas need to consider how to make reasonable adjustments to ensure that they are providing services in a way that works equally well for people with neurodiversity, in accordance with duties under the Equality Act 2010.

Recommendation 2: When people with autism and/or learning disabilities are displaying challenging behaviours, partners need to ensure that detailed behavioural support plans travel with the individual during any transfers within or between agencies.

Recommendation 3: Where an individual has a complex network of professionals supporting them, a single document, with the names, photographs and contact details for the team around the person should be provided to the person by their lead professional and kept up to date

Recommendation 4: The ICB and Devon County Council’s Social Care and Education departments should provide assurance to TDSAP that future integration plans will prioritise ensuring skilled health assessments are included in all EHCP when planning for adulthood.

Recommendation 5: The ICB should give consideration to funding a post for a CAMHS transitions care coordinator to lead in planning transitions and discharge for young people in Tier 4 mental health units. DCC and/or the ICB should also give consideration to funding a support worker, in a role similar to a personal advisor under the leaving care provisions, to provide continuity to young people who have been detained under s3 MHA but not looked after, up to the age of 25.

Recommendation 6: Partners should ensure that transitions pathways and interagency escalation policies are well publicised and that generous leadership supports staff to hold partners to account when coherent, robust and timely transition plans are not devised and implemented for young people.

Recommendation 7: TDSAP should seek assurance from CSC, ASC, CAMHS and the CMHT that transitions planning is effective and consistent for young people who are placed out of area, with clear contingency and care planning taking place whether they return to Devon or remain out of area post-18.

Recommendation 8: TDSAP should seek assurance from NHS England in respect of its plans to improve access to Tier 4 beds for young people up to the age of 25, that are local to them, to reduce reliance on acute admissions, avoid delays in young people obtaining the treatment they need and improve their experience of mental health services. Clarity should also be sought on how NHS England holds commissioned Tier 4 CAMHS providers to account for effective discharge and transition planning.

Recommendation 9: Health and Social Care partners should develop a bespoke protocol for young people with neurodiversity and complex behavioural or mental health needs, supporting practitioners to understand the interface with other legal frameworks including s117 aftercare responsibilities and continuing healthcare. This should include a pathway to allow for more bespoke commissioned placements or support packages to target the needs of individuals, involving joint commissioning to ensure that there is a seamless spectrum of provision from individuals with pure social care needs to those with neurodiversity, continuing healthcare needs or who are being discharged from mental health wards.

Recommendation 10: The ICB and Social Care should consider how to ensure that when placing people with SEND and mental health needs out of area in specialist educational facilities, arrangements are in place for them to receive local CMHT therapeutic and crisis support both during term time and when they return home during holidays or during placement breakdowns. These plans should be consistently recorded in the person’s EHCP, together with key safeguarding information.

Recommendation 11: In situations where a person has frequent mental health admissions, clinical staff on keys wards should be invited, and commit to attending multi-agency professional and strategy meetings, to strengthen an integrated approach between hospital mental health teams and the wider professional network, with an aim to reducing reliance on mental health admissions and identify effective crisis plans.

Recommendation 12: The ICB and Social Care should provide assurance to TDSAP that clear contingency planning is taking place for all residential placements, and that in circumstances where a provider has given notice that they are unable to manage a situation with escalating risks, proactive and timely arrangements are made for alternative provision, using escalation routes promptly if a placement cannot be identified, and detailed care or s117 aftercare plans to support the new placements or arrangements.

Recommendation 13: When there is no choice but to make urgent arrangements for a care plan to supervise a high-risk individual while an appropriate placement is sourced, senior managers should act as a critical friend to carefully examine the risks and mitigation measures involved. In addition to an Individual Risk Assessment and Positive Behaviour Support plan, a one-page summary of essential information and contacts should be provided by the commissioning agency so that shift staff can respond immediately to developing situations.

Recommendation 14: TDSAP should seek assurance from partners that high risk individuals are not being placed in hotels, even with a package of support, while suitable placements are sought as risks cannot be adequately managed in such an unpredictable environment.

Recommendation 15: TDSAP and safeguarding partners should consider how to raise the profile of missing episodes as a safeguarding issue across the wider partnership and how to embed understanding of the police response to missing episodes amongst frontline staff, to support effective discussions with police about people with mental health conditions who cannot be contacted, and promote sustainable joint responsibility for managing risk.

Recommendation 16: The SABs should seek assurance from partner agencies that they provide a rigorous MCA training programme to staff, including the concepts of executive and fluctuating capacity, with clear parameters about obtaining timely legal advice in situations where the individual opposes the regime imposed or capacity is in doubt. Partners should use the decision making by emergency room doctors as part of MCA training to support good practice in urgent situations.

Recommendation 17: Each SAB should take steps to raise the profile of advocacy services across partner agencies to ensure provision of advocates to support individuals’ involvement in the decision-making process and enable timely challenge, including through the courts where appropriate.

Recommendation 18: Each SAB should seek assurance from partners that restraint processes in all Health and Social Care settings comply with the Restraint Network Training Standards and those applying restraint have been trained in a BildACT accredited training.

Recommendation 19: The allegations that Hermione was repeatedly restrained for prolonged periods in a prone position and on her bed should be investigated by both hospitals where she was detained in February/March 2021.

Report Author

Sarah Williams

Lead Reviewer