SAR Charlie - learning briefing
Background
This review was commissioned to explore the circumstances that led to the death of ‘Charlie’ in April 2021. Charlie was 18 years old and was transitioning from female to male.
Charlie had a substantial history with Children’s Social Care (CSC). He was known from soon after his birth and was twice placed on a child protection plan. Charlie was also a looked after child under Section 20 of the Children Act 1989.
Charlie came out as transgender in 2019. Prior to his death he was referred to the Gender and Identity Development Service but the service was unable to contact him. Charlie had some engagement with an LGBTQ+ charity, informing the charity workers that he wished to medically transition.
Sadly, Charlie struggled with mental health, alcohol misuse and significant self-harming episodes and declined hospital treatment.
Charlie had two periods in hospital under Section 2 of the Mental Health Act due to self-harm and the risk he posed to himself. After his second period in hospital, he was discharged to temporary accommodation in Brighton where he continued to self-harm and drink significant amounts of alcohol. Soon after he moved into temporary accommodation, it is believed, Charlie took his own life.
The review identified important learning for agencies, particularly in relation to:
- the transition of young people to adult services
- risk management and planning
- mental health
- self-harm
- Making Safeguarding Personal.
Areas of learning
1. Transitional safeguarding
Unchallenged perceptions of child and adulthood, vulnerability and capacity can lead to young people falling through the ‘safeguarding net’.
The safeguarding systems for children and adults are based on different legal and procedural frameworks. This has the potential to create gaps in operational practice. Basing safeguarding decisions on chronological age is fraught with challenges. It ignores the developmental and behavioural challenges of becoming an adult.
The model of transitional safeguarding requires whole system change. It needs a shared accountability by children’s safeguarding partners and strategic leads in adults’ services.
Bridging the Gap: Traditional safeguarding and the role of social work with adults suggests that transitional policy and practice should be underpinned by three intersecting areas:
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Contextual or ecological safeguarding. This recognises and responds to harms young people face in a variety of spaces beyond their family. It seeks to make these contexts safer rather than only focusing on the individual.
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Transitional or developmental safeguarding. This recognises the distinct developmental needs at this life stage. It encourages greater fluidity between children and adult safeguarding services. It needs an active effort to align systems to create a more holistic approach for those individuals.
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Relational safeguarding. This takes a person-centred, trauma-informed approach. It sees that relationships are an important aspect of therapeutic support. In addition, this includes using language that is inclusive and is not victim blaming.
A transitional approach is user-led, strengths-based and respects the young person's expertise. It enables them to take part in finding solutions rather than being a passive recipient.
2. Making safeguarding personal
Where there are concerns around engagement with services, this should result in further enquiry or assessment.
Agencies need to ensure a more person-centred, flexible and relationship-based approach to support and services.
The non-engagement of young people and adults should encourage professionals to work harder in meeting their specific needs rather than withdrawing support.
Independent advocacy and assertive outreach, needs to be encouraged where agencies struggle to engage with professionals.
3. Mental health
The Mental Health Act 1983 does not distinguish between different forms of mental disorder. It applies to personality disorders in the same way it applies to other mental disorders.
It is likely that the treatment options will be different, and this needs to be fully explained to the professional network working with young people and adults.
The review identified a lack of professional understanding between agencies about what constitutes mental ill health and the respective responsibilities of agencies. This can lead to professional disagreement, challenge, and frustration. There needs to be a mechanism in place to avoid this and ensure there is multi-agency shared understanding, training, and risk assessment.
Unplanned discharge from hospital, places local authorities and other support services under significant pressure. The decision to discharge should be the subject of multi-agency agreement and decision making to agree effective planning and risk management.
4. Risk management and planning
Following the second period in hospital, Charlie was discharged with no care arrangements in place. He was consulted on the placement options and chose a self-contained flat. He did not want the restrictive one-to-one staffing being offered at any alternative placement.
You need a careful risk assessment before placing young people in semi-supported accommodation with limited or no experience of living alone or semi-independently. This is even more important if there are no support mechanisms, including visiting patterns, in place.
The management of harm and risk of young people and adults needs to be shared across the multi-agency partnership. Consider using the child safeguarding system to assess risks and needs for young people over 16, particularly where self-harm is evident.
An Education Health and Care Plan (EHCP) can last until a young person is 25 years of age. Practitioners need to ensure EHCPs are factored into young adult care planning where they exist.
5. Self-harm
Charlie had suicidal thoughts and significantly self-harmed on many occasions and refused hospital treatment.
- NICE guidance on self-harm (September 2022) recommends considering an assessment of capacity under the Mental Capacity Act 2005 when young people or adults who are significantly self-harming are unable to make effective decisions for themselves whilst under the influence of drugs or alcohol.
- Young people’s use of alcohol should be risk-assessed, particularly if this is a trigger for self-harming behaviours. Alcohol use is as significant as self-harming behaviours. It needs to be given equal weight in terms of risk to health.
- East Sussex alcohol harm reduction strategy 2021-2026 priorities 2 and 3 note that Children’s services in East Sussex ensure effective interventions for young people where alcohol has been identified as an issue. Specialist assessment and treatment is provided for young people up to the age of 21 and to care leavers and vulnerable people up to 25 years via the multi-agency and multi-disciplinary Under 25s Substance Misuse Service.
6. Social media and suicide
When teens with mental health problems share thoughts about wanting to harm themselves on social media, it can be a sign that they are at risk of suicide.
To identify risks, professionals should take a person-centred approach. Talk to individuals about their needs and wants, abilities, experiences, influences and vulnerabilities, such as suicide, that may be amplified online.
There are various steps you can take to prevent and respond to risk. These include:
- Supporting the person to keep themselves safe online. Discuss the types of online activities which would be illegal or inappropriate, and where they would go for help and support if they need it.
- Checking your organisation has sufficient risk management policies and processes in place.
- The importance of safety plans - an agreed set of activities, strategies, people, and organisations to contact for support if:
- someone becomes suicidal
- their suicidal thoughts get worse
- they might self‑harm.
The Royal College of Psychiatrists believe that every person who is having suicidal thoughts or who has engaged in self‑harm should have a safety plan.
Key learning points
Reflecting on the key principles of transitional safeguarding, think about your practice and identify:
- What would you consider when offering a trauma-informed response to young adults experiencing harm?
- Assessments – how would you balance consideration of both the individual needs and developmental stage of the young adult, as well as the structural and contextual factors that influence their lives?
Further reading
Self-harm and suicide prevention | NHS England
Mental capacity multi-agency policy and procedures
Sussex safeguarding adults policy and procedures
Multi-agency risk management protocol
Multi-agency meetings - learning briefing
Preventing suicide: lesbian, gay, bisexual, trans young people toolkit | GOV.UK
Independent review of gender identity services for children and young people | Cass Review
Self-harm toolkit | Czone for schools
Multi-agency safeguarding courses
The East Sussex Learning Portal has safeguarding training on:
- Trauma-informed practice
- Suicide awareness
- Safeguarding issues in an LGBTQ context
- Mental Capacity Act
