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Training and resources for professionals

Learning briefing: Riley – Teenage suicide

The Incident

Riley was a young person living with a parent and younger sibling. The family had not long moved to Devon. There had been a history of domestic abuse between Riley’s parents. Riley’s parent had chronic physical and mental health needs that affected their ability to undertake daily activities and were known to adult mental health services and adult social care. On the day of their death, Riley had argued with their parent as they had declined to buy them cannabis, something that they had done in the past. It is thought Riley then took some of their parent’s medication and contacted a friend, who was concerned for their welfare and rang the police. Police arrived at the address and found them unwell. An ambulance was called. Sadly, Riley died despite resuscitation attempts.

Good practice arising

Riley’s GP recorded that they had a long history of low mood, poor school attendance and had previously received counselling. Riley undertook a lot of tasks around the house and the GP recognised Riley as a Young Carer. It was recorded that school had put a Young Carers package in place and had organised counselling. The GP reminded Riley of Kooth’s services and how to access GP services if they wanted to talk. Riley’s parent was seen regularly due to their chronic health issues. An Early Help referral was offered but declined.

The surgery has taken an action to add Young Carers to their Vulnerable Patient Register to enable regular review and have updated their new patient questionnaire for under 18s to enquire whether they are Young Carers so they are able to support and signpost as necessary.

Reflection on practice

Riley was on roll at College. Their attendance was poor. They were on a reduced timetable and described as having low level special educational needs. College was concerned about their use of drugs and tobacco, resulting in bag searches and information sharing with the police. They did not initiate a Team around the Family (TAF) meeting due to the Covid lockdown. After Riley left school, the College had no contact with the family. It appears that Riley was not in education, training, or employment (NEET).

Adult mental health services recognised Riley as a young carer and a referral was made to Adult Social Care for an assessment. An assumption was made that the Adult Social Care assessment would result in a referral to Young Carer support services. This did not occur.

The use of cannabis was not considered by agencies to be a potential flag of vulnerability, a sign of not coping and a more trauma-informed response given including referral to appropriate support agencies.

Riley had ease of access to their parent’s medication. Safe storage of medication is often only considered when very young children are in the household. GP and Pharmacists could remind patients of the safe storage of medicines and raise awareness of the risk of access for older children at risk of suicide. There was no Early Help process. Several services identified need, but assumptions were made about the referrals and there was a lack of coordination that denied a more holistic view of the family being taken or the level of Riley’s vulnerability understood

Recommendations

Whilst the pandemic continues, all education settings should review their decision-making process around making referrals to Early Help services especially when absence from school leaves young people more vulnerable.

Where education settings have not received information from previous settings, they should robustly follow up to ensure they have all relevant information. It is reasonable to take further action if information is not received within two weeks to ensure safeguarding issues are not missed.

Staff in adult services need to be proactive in identifying Young Carers and know how to refer to Young Carers and other support services.

All GP practices should add Young Carers to their Vulnerable Patient Register to enable regular review and they should update their new patient questionnaire for U18s to enquire whether they are Young Carers.

If you are concerned that a child is being abused please call

0345 155 1071

or email mashsecure@devon.gov.uk.

Professionals should complete the MASH contact form.

If it’s an emergency call 999


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