1. Child / Adult Y – Guernsey Serious Case Review
Hilary Corrick Ranger – Independent Author

2. Introduction
On a January evening in 2015 Adult Y died, having been hit by a car in Kent. The police investigation which followed suggested that she may have taken her own life by deliberately stepping out in front of the car. At the time of her death she was 18 years old. She had been in the care of Guernsey Health and Social Services Department since she was 6 years old, and by then was a care leaver.

3. Child Y’s story

4. Key life events Attachment disruption;
Move to Guernsey: new people, new language, new culture;
Entry into care and permanency planning;
Placement out of jurisdiction;
Long term foster home breakdown;
Placement and discharge from specialist unit;
Independent living placement

5. Key themes Ongoing themes: Attachment issues; Identity and culture;
Domestic violence;
Contact;
Relationships;
Emotional development
Later:
Uncertainty about her future;
Numbers of changes, and how to manage change;
Mental health

6. Agencies involved Guernsey
Children’s Social Care and Care Leavers’ Teams;
Complex Needs Panel;
Health services;
Police
Kent
CMHT
Kent and Canterbury Hospital;
CRHT;
CAMHS
Education;
Police

7. Other agencies IFA; Specialist Adolescent Unit;
Independent Living service

8. Good Practice Commitment of the post 16 social worker;
Long term consistent IRO;
Guernsey’s commitment to increased support at times of crisis;
Kent CAMHS provided a service through transition;
Prompt and responsive CRISIS mental health team;

9. More good practice
All hospital assessments were through and professional;
Identification of Adult Y as vulnerable and transport provided for her discharge from hospital;
IFA provided good and consistent support to the foster carers and Child Y;
The IFA communicated well with Guernsey and advocated on behalf of the child;

10. Even more good practice
The adolescent unit were person centred in their decision to keep Child Y when she became an adult;
Support from the school;
Good communication by the school;
Timely and ongoing mental health support in Guernsey;
Exemplary support by the independent living support worker.

11. Key Learning Themes
Good outcomes for children and young people in care are achieved by engaging their wider family throughout their care career;
Children with fractured attachments need imaginative, positive and sustained therapeutic work as soon as they enter the care system;
There are significant negative consequences of placing children far from their community;
Care leavers need support across a wide range of services well into adulthood;
Transition between CAMHS and AMH, as well as a range of other services should be undertaken in a holistic way, starting with joint work prior to adulthood and continuing as long as necessary.

12. Recommendations
Establish a Family Group Conferencing Service for children and families on the threshold of care, and within the care system;
Develop a range of mechanisms to work with hard to engage families – to use the child’s first language, respect and support family origins, and ensure international links are explored and established;
Therapeutic Fostering Service – wrap around care;
Employ locally based social workers for children placed out of jurisdiction;;
Review the role of the Complex Needs Panel;
Explore multi-agency support for children in care up to the age of 25, including a Named Doctor and Nurse and a Virtual School;
Review transition to Sixth Form and FE;
Ensure all children on entry into care are assessed for psychological and emotional harm as part of their health assessment.