Lessons to be learned after troubled boy,10, was found hanged

Cumbria Local Safeguarding Children Board has today published the report of the Serious Case Review into the death of Child F.Child F was diagnosed as suffering from a Major Depressive Disorder and from Attention Deficit Hyperactivity Disorder (ADHD). He was prescribed medication for both conditions but. In late 2010 Child F took his own life..The purpose of a Serious Case Review is to learn lessons to improve how agencies work individually, and collectively, to safeguard and promote the welfare of children.

All agencies deeply regret that this tragic event happened. The child at the centre of this Serious Case Review had a sad and distressing life and his tragic death has clearly affected those around him and our thoughts are with his family and friends.

In cases such as this it is extremely important that all agencies who were involved with the child and their family learn the lessons from the case to try and ensure that this type of event does not happen again. Because this type of event is so rare agencies must be especially vigilant.

The report makes a number of different recommendations for how we should all improve our practice. Many of these relate to issues around how agencies assess the needs of children and in particular how they respond to evidence of self-harm or threats of suicide in children.

We believe the key lessons which are common to all agencies are:

*       The child must always be at the centre of our work and should be asked directly about their care and their feelings;

*       We should always take threats of suicide seriously: this applies not just to agencies and  professionals, but to families and communities;

*       Multiple medications to children should be carefully prescribed and monitored.

Full and comprehensive action plans have been produced in line with the recommendations of the Review. Cumbria Local Safeguarding Children Board will be overseeing progress on these plans, and holding the agencies to account for completing them.

Many of the actions have been implemented, and the remainder are well on their way to completion. The changes made will improve the quality of services provided to children and families in Cumbria.

Allan Buckley, Chair of Cumbria Local Safeguarding Children Board, said::"I acknowledge the tragic nature of this child’s death. I know that it was deeply distressing for everyone who was involved. The Review which followed was rigorous, lessons were identified, and swift action has been taken to ensure that those lessons lead to improved practice.

"Be assured that in the coming months and years, the Local Safeguarding Board and its partners will continue to work hard together to prevent a similar tragedy ever happening again in Cumbria.”