Oskar Nash
The coroner's concerns
1. inadequate autism training for triage staff
“The evidence at the inquest revealed that the staff responsible for the triage of referrals to child mental health services had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child”
2. missed clinical assessment of referred children
“The evidence at the inquest revealed that, despite a series of referrals to child mental health services over many years, [the deceased] never received the clinical assessment he needed”
3. misclassification of risk levels
“The evidence showed that a referral to the child mental health services is triaged initially as being crisis, urgent, priority or routine”
4. inadequate recording of risk in Education, Health and Care Plans
“The evidence at the inquest showed that the clinicians who were responsible for ensuring that [the deceased]'s medical conditions, including his risk of self-harm and suicide, and his consequential needs, were properly and sufficiently recorded in his Education, Health and Care Plan, failed to do so”
5. insufficient autism awareness among SEN staff
“The evidence at the inquest revealed that the staff in the Education / SEN Department, including SEN caseworkers, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child”
6. inappropriate placement of autistic child into unsupportive mainstream school
“The evidence at the inquest showed that, in the months before his death, [the deceased] was moved from a special needs school and placed into a mainstream school which did not have the facilities or expertise sufficiently to meet his complex needs”
Responses
2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published.pdf ↗· National Child Safeguarding Review Panel
2022-0031-Response-from-Department-for-Education_Published.pdf ↗· Department for Education
Stated action · imminently
“we have undertaken a comprehensive review of how the system has evolved since 2014 and how it can be made to work best for all families, ensuring quality of provision is the same across the country.”
2022-0031-Response-from-Surrey-County-Council_Published.pdf ↗· Surrey County Council
Stated action · 31 March 2022
“On 30 November 2021 the Executive Director for Children Families, Lifelong Learning and Culture wrote to all staff in the Directorate setting out the Autism Awareness Training offer available for all staff in the Directorate. The training is now mandatory for all staff working directly with children and young people and must be completed by 31 March 2022. The uptake of the training is being monitored for each individual. The awareness training must also be completed by all new starters as they”
2022-0031-Response-from-Surrey-Heartlands-CCG_Published.pdf ↗· Surrey Heartlands Clinical Commissioning Group
2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1.pdf ↗· Surrey and Borders Partnership NHS Foundation Trust
Stated action
“The Trust's Access and Advice Team (AAT) provides a point of access to Mindworks Surrey and ensures that there is consistency of referral management, clinical screening and triage services.”
Stated action
“If a routine referral has been waiting for over four weeks to be triaged, then it is now subject to a harm review.”
Stated action
“The CYPS Standard Operating Procedures are being reviewed to ensure that staff are guided to consider safeguarding and liaising with the Surrey County Council c-SPA where children refuse to engage with care and treatment, record”