A DANGEROUSLY diabetic teenager who died in Herefordshire Council’s care just two months after being made homeless was “let down” by the agencies working with him, a case review out today (Wed) confirms.
The review concludes that the 17-year-old – identified only as HH – died at a supported housing unit in May last year because he did not take medication for his condition and was not “adequately supported” in his treatment by his mother or his corporate parents.
Professionals did not work together “sufficiently well” to ensure the complex health and social needs of HH were “adequately and consistently” met and were even “confused” as to whether or not HH could be classed as a child.
OFSTED currently rates the council’s child safeguarding service as “inadequate.” The independent review of HH’s case was commissioned by the Herefordshire Safeguarding Children Board (HSCB).
David McCallum, HSCB chair, said: “This is a very sad case brought about because not all the agencies involved understood the severity of this young man’s medical condition.
“His age was another significant factor: it is sometimes difficult working with older young people as they are more likely to challenge those supporting them. However, the review concludes that HH was let down by the agencies working with him. Every agency and practitioner involved in this case would have wanted a different outcome for him and we are all sorry for his death.”
Originally from Poland, HH was diagnosed with type-1 diabetes in January 2012, a life-threatening condition if not managed well. The review identified that HH had experienced neglect at home and this included lack of parental involvement in helping him manage his diabetes. As a result, he became subject to a Child in Need (CIN) plan following a child protection conference held in January last year.
A month later, HH became homeless when his mother asked him to leave. The council arranged for him to live in supported lodgings before he moved into a supported semi-independent housing. The review identified that information sharing between agencies was not as “robust” as it should have been during these moves, nor was the risk from HH’s non-compliance with his testing and medication regime fully understood.
The review concluded that HH died because he was not adequately supported in his diabetes treatment by either mother or his corporate parents, and because professionals did not work together sufficiently well to ensure his complex health and social needs were adequately and consistently met.
The processes and expectations of single and multi-agency work in place at the time of his death were not always followed, and while this did not directly cause his death, it meant that , with complex health needs, he did not receive the “focus and persistent oversight” he needed.
As a 17 year old, there was confusion over whether he was an adult or a child, and this definition determined the level and type of support he received to manage his medical condition, the review found.
As such, not all the staff and agencies involved in supporting HH understood that type-1 diabetes is a potentially fatal condition if not treated properly.
The review lists 10 key recommendations as “lessons to be shared” by the agencies involved: 1. All agencies need to recognise young people’s vulnerabilities as well as their rights and responsibilities as young adults. They also need to evidence that they have recognised 16 and 17 year old service users as children.
2. Professionals need to be open-minded about what makes a young person vulnerable, and be clear that lack of compliance with medication for health conditions is potentially risky.
3. Non-medical staff need to ensure they receive advice and support from health colleagues when working with children with significant health issues.
4. Non-health professionals need to be informed that type-1 diabetes is a potentially fatal condition.
5. A comprehensive risk assessment should be carried out by any placement before a child with diabetes or other serious health condition is admitted. This includes input from health colleagues and any previous placements if applicable.
6. Staff must be reminded that after every significant change of circumstance, assessments and plans need reviewing to ensure that the impact of any changes have been thoroughly considered.
7. That any multi-agency training input on neglect provides a section on the specific issues for young people aged 14 plus. This should include lack of compliance with medication for health conditions.
8. There needs to be clear transition planning from children’s services to adults services for 16 and 17 year olds with additional health needs, which considers issues with lack of engagement.
9. Professionals need to be creative when supporting and monitoring teenagers.
10. That children and young people assessed as being Children in Need, and who are the subject of a CIN plan are not currently identifiable and flagged to all agencies checking systems in respect of vulnerable children.
You can view the full report here.