Serious case review: Child T
About serious case reviews (SCRs)
A serious case review (SCR) is a locally conducted multi-agency review. It looks into cases where an abused or neglected child has been seriously hurt or died. It examines whether the agencies involved worked together well to protect the child.
Its purpose is to:
- find out if there are things that can be learned about how agencies work together to protect children
- identify what needs to change and improve practice.
Background
A serious case review was carried out for Child T, who died at the age of 18. Child T had diabetes and lived with his mother. He was found to be in very poor condition, both physically and mentally, and showed signs of severe neglect.
The SCR identified important things that we can learn from this case, especially about:
- self-neglect
- mental capacity
- legal issues
- control
- the transition between services for children and adults.
This report summarises the key findings and lessons learned. All staff and managers are encouraged to discuss this report and reflect on the lessons learned to improve our practices.
The full Child T SCR report and a Child T learning briefing are on the East Sussex Safeguarding Children Partnership website.
The key findings of the serious case review
Mental capacity in 16 and 17 year olds
Even though the Mental Capacity Act (MCA) applies to people from the age of 16, no one assessed Child T's mental capacity before he went to hospital.
This was despite concerns about his school attendance, health appointments and medical treatment. There was also an opportunity to assess Child T's mother's mental capacity, as there were concerns about her ability to understand Child T's needs and her diabetes.
For young people aged 16 to 17, the rules about decision making are different from those for adults. In some cases, parents or other people with parental responsibility can make decisions for their child until they turn 18.
Although the MCA applies to people aged 16 and 17, there are some important differences in how it applies to young people compared to adults over the age of 18.
Parental responsibility
The Mental Health Act (MHA) Code of Practice includes guidance on the scope of parental responsibility:
If child is competent, or the young person has capacity to make a decision, parents should not be relied upon.
Where the child is not competent, or young person lacks capacity, the question of whether the parents can consent to a particular decision needs to be assessed. It should consider the circumstances of the case, taking into account:
- Is the decision something that a parent ‘should reasonably be expected to make’?
This covers points such as the type and invasiveness of the proposed action, the age, maturity and understanding of the child or young person and whether the child or young person is resisting the decision. - Are ‘there any factors that might undermine the validity of parental consent’? For example, the parent lacks capacity to make the decision, or is unable to focus on what course of action is in the child or young person’s best interests.
Self-neglect and mental capacity
Self-neglect was not identified as a problem for Child T until he was in hospital. The hospital and ambulance service were concerned about his poor physical condition.
It can be difficult for professionals to decide whether to help an individual make their own decisions. Even if those decisions are not good, or to protect them from the risks of self-neglect.
Self-neglect is a complex issue that is influenced by many factors, including physical, mental, social, personal, and environmental circumstances. It is often the result of past trauma, bereavement, or abuse. This can lead to someone feeling demotivated and having a low self-esteem, which makes it difficult for them to accept help. Positive results can be achieved by understanding each person's unique situation.
The Mental Capacity Act 2005 is crucial in determining what action may or may not be taken in self-neglect cases. It applies to everyone involved in the care, treatment and support of people aged 16 and over who are unable to make all or some decisions for themselves
What factors can affect mental capacity?
Child T had complex and significant health problems, including unstable diabetes and urinary infections. These physiological issues can have an impact on mental capacity and should always be considered by professionals when undertaking MCA assessments. It is important to carry out capacity assessments and provide support at a time when the person is at their highest level of functioning.
Child T had a complex relationship with his mother, marked by co-dependency and signs of control and coercion by his mother. It was hard for professionals to hear and listen to Child T’s voice. He would frequently look to his mother to answer any questions. Often Child T’s mother would not adhere to medical advice and was insistent on undertaking her son’s care herself.
The impact of both of these areas was an important consideration in Child T’s ability to make informed decisions and choices about his care and treatment.
Key learning from the case
Mental Capacity Act – 5 statutory principles
- A person must be assumed to have capacity unless it is established that they lack capacity.
- A person is not to be treated as unable to make a decision unless all practicable steps to help him or her to do so have been taken without success.
- A person is not to be treated as unable to make a decision merely because he or she makes an unwise decision.
- An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in their best interests.
- Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action.
A person should be presumed to have capacity. However, there may be cases where someone lacks understanding of the impact of their self-neglecting behaviour on their own or others’ wellbeing.
When someone's behaviour or circumstances cast doubt as to whether they have capacity to make a decision, then a mental capacity assessment should be carried out.
Good practice mental capacity assessments
- When assessing the mental capacity of someone who is self-neglecting, consider carrying out joint capacity assessments. For example, involving an occupational therapist, nurse or psychologist working alongside a social worker.
- Any mental capacity assessment must be time-specific and relate to a specific intervention or action.
- Provide information in an appropriate format and use communication methods which the person is most familiar with.
- Record the actual questions as they were asked, and the responses provided.
- Consider whether having another person present (such as a parent, family member or friend) would help the person. Is there is a duty to provide an Independent Mental Capacity Advocate (IMCA) or independent advocate under the Care Act 2014?
- When considering support from another individual, balance this alongside your professional judgement as to whether the individual involved may exert undue pressure or coercion.
It is important to clearly document how a worker has maximised a person's autonomy and involvement within the capacity assessment, ensuring they have been given all practical support to themselves.
In relation to self-neglect, this will include exploring the person’s understanding of their behaviours and associated risks. Can they report back to you:
- What the risks are?
- That they know their behaviour places them at risk?
- The consequences of taking these risks?
Individuals who are difficult or reluctant to engage
Individuals who self-neglect may be reluctant, or find it difficult, to engage in the assessment of capacity.
See guidance on engagement in section 2.8.5 of the Sussex multi-agency procedures to support adults who self-neglect
Inherent jurisdiction
The High Court can intervene in the life of a person who has capacity but still requires protection for certain reasons. This includes not being able to take a decision freely because of coercion, undue influence or constraint.
Child T could have been identified as a vulnerable person, if legal advice had been sought by health or social care professionals.
Taking a case to the High Court can be considered in extreme cases of self-neglect, where a person with capacity is:
- at risk of serious harm or death, and refuses all offers of support or interventions, or
- is unduly influenced by someone else.
The High Court may intervene in such cases, although the presumption is always to protect the adult's human rights.
You should seek legal advice should before taking this option.
Transition between children’s and adults services
NICE transition guidelines were published in February 2016. These note the importance of a planned and coordinated approach to support young people with care and support needs who are transitioning between children’s and adults services.
The guidelines suggest that a single practitioner should act as a ‘named worker’ to aid a smooth transition. Ideally, this should be a worker who has developed a meaningful relationship with the young person.
Once young people have transitioned to adult services, they may need support after transfer. If a young person has moved to adult services and does not attend meetings and appointments or engage with services, Adult Social Care and Health, working within safeguarding protocols, should:
- try to contact the young person and their family
- follow up with the young person
- involve other relevant professionals, including the GP.
Remember, a person is a child until they are 18 years old. Seek appropriate safeguarding supervision and follow children’s procedures when required.
Key learning points to discuss
Do you work with people (including young people aged 16 to 18) who may lack capacity to make certain decisions?
- How would you approach this?
- Do you know how to get the support you need?
Are you and your team familiar with the Sussex policy and procedures on self-neglect?
- Are you confident in recognising self-neglect?
Are you confident in recognising signs of coercion and control?
- Do you need more support or training?
Further reading
Sussex safeguarding adults policy and procedures
Sussex multi-agency procedures to support adults who self-neglect
Mental Capacity Act Code of Practice | GOV.UK
East Sussex Learning Portal | East Sussex County Council for training on self-neglect and coercion and control
