Learning summary published following Serious Case Management Review

Thursday, 11 November 2021

A summary of learning has been published by the Safeguarding Board following a statutory Serious Case Management Review.

The review examined the circumstances leading up to a vulnerable adolescent being admitted to hospital having become extremely ill from taking a quantity of recreational drugs. The young person was in care at the time of the incident.  

For the purposes of the review, and to protect their identity, this individual has been referred to as ‘Child J’.

An independent off-Island expert – Dr Russell Wate QPM – was commissioned by the Safeguarding Board to carry out the review and produce a learning summary which will guide improvements to services for children. 

The review found that Child J had suffered a number of adverse childhood experiences from a young age. These are potentially traumatic events during childhood and can often lead to chronic health and social problems in adulthood as well as having a negative impact on educational outcomes and future job opportunities.

The experiences of Child J resulted in an escalation of risk taking behaviours, ultimately leaving them open to being potentially exploited by criminals.

The independent report sets out a number of learning points and recommendations. 

Broadly, these cover the need for government agencies to work together to form a strategy to prevent young people being exploited or harmed outside the family home or enlisted into criminal activity – an approach known as contextual safeguarding.  It will ensure there is an improved understanding of the risks of significant harm to children and young people outside of their family and will enable services to determine what action is most appropriate to reduce this harm.

The report also recommends that all agencies that work with young people adopt a vulnerable adolescent service strategy and an early help strategy. This will ensure that young people and their families get help and support as soon as possible with the aim of preventing long term issues.

The review also recognises that this work needs to be underpinned by a professional framework that improves professionals’ knowledge and understanding of the impact of adverse childhood experiences.  This will enable practitioners to provide an appropriate and informed response to other young people in the future. The review also discusses the importance of identifying ‘reachable moments’ which are unplanned opportunities for a breakthrough with young people at risk of exploitation.

The Independent Chair of the Safeguarding Board, Lesley Walker, said:

'It can, understandably, be concerning when the need arises to commission a review of the safeguarding measures in place to protect a vulnerable adolescent.  Nevertheless, it is important that when practice can be improved, we embrace the opportunity and implement changes. This review provides a number of recommendations that, when fully implemented, will reduce the risk to other young people in the future. Work is already underway across the Isle of Man Government and its agencies to address the identified learning. 

'The purpose of these reviews is not to apportion blame, but instead to establish the facts, identify learning – both what worked well and what needs to be improved – and to support agencies to bring about change as a result.  This is with the ultimate aim of raising standards and improving practice to properly safeguard and protect vulnerable individuals in the Isle of Man.'

Ms Walker continued:

'One of the notable features of the review was the concern that all professionals working with this young person had for their safety and the total commitment to implement the learning to improve practice.

'Overall, it is the statutory role of the Safeguarding Board to support all of the agencies involved in implementing improvements so that similar situations can be avoided in the future. The Safeguarding Board will be receiving regular assurance reports about the work of the agencies involved to implement the recommendations.'

A copy of the learning report is available to be downloaded.

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