Lessons learned after damning case reviews

DEATHS: Catalogue of failures found in tragedies involving two young people

Missed opportunities, confusion and inadequate resources have all been spotlighted in damning case reviews around two Angus tragedies involving young people.

The reviews are entirely separate, although both victims were receiving support and intervention from a number of agencies and services.

While highlighting areas of good practice, the reviews revealed a catalogue of failures and officials have pledged lessons will be learned from the deaths.

The significant case reviews were published by Angus Child Protection Committee (ACPC) and Angus Adult Protection Committee (AAPC) into the deaths of a 17-year-old who took her own life in 2017, and an 18-year-old who died in autumn 2018, respectively.

The 17-year old, Isabelle – not her real name – had experienced secure and open care and the review found there had been a “significant inconsistency” in the way a diagnosis of autism had been dealt with. She took her own life in 2017.

It said shortcomings in the understanding of Isabelle’s autism diagnosis had “compromised the coherence of planning and delivery of care” in the years before her death.

The other victim, O18, was known to many services and subject to an adult support and protection plan at the time of their death.

Significant adverse childhood experiences, substance use, poor mental health, homelessness and offending featured heavily in O18’s life, particularly between the ages of 16 and 18.

The review said the role of the Angus Early Screening Group in appropriately diverting Police VPDS (vulnerable person database) reports was conflated in O18s case and “hampered effective decision-making at a point in time”.

Margo Williamson, chairwoman of Angus Chief Officers Group (COG), said: “As a COG we have very much heard and accepted what the independent reviewers have said and the need for improvement across our services and systems for young people, whether they are in children’s or adult services.

“Both the adult and the child protection committees are determined to ensure that the learning and recommendations arising from these reports enhances current good work and opportunities to make children, adults and families safe in Angus.”

Alison Todd, independent chairwoman of Angus Child Protection Committee, said: “I want to emphasise that Isabelle’s voice has been at the heart of this review and how determined we are to work together to make improvements that enable better experiences and outcomes for children, young people and families in Angus.

“This review holds a mirror to those services, where areas of good practice exist, where changes have already been made and where further improvement is required to ensure that the delivery of better experiences and outcomes is achieved and sustained.”

Ewen West, independent chairman of Angus Adult Protection Committee, said: “It is clear to me that the professionals involved in this vital area of work are absolutely dedicated, conscientious and caring and were profoundly upset by the tragic death of O18, and our thoughts and condolences are with their family.

“No single agency is responsible for the harm that happened to O18 in September 2018 that resulted in their death and there is no one identifiable action that would have changed matters.

“Individual mental health and wellbeing is a feature of this review. It can affect anyone at any time.

“This is perhaps something that we are more aware of now – during the Covid-19 pandemic – than we have ever been before. If you need help or know someone who is in need of help, then please reach out.”

Picture: Paul Reid. Margo Williamson.