Inquiry launched after four teenagers’ deaths

• Review under way following three suicides and a drugs death in past two years
• The Safeguarding Children’s Partnership Board is to carry out four individual serious case reviews into the deaths
• It will publish its findings in a single anonymised report
• Details of the inquiry were revealed during an inquest into the death of 15-year-old Siobhan Harvey, who took her own life last May while battling depression

A SERIOUS case review is being undertaken by a children’s safeguarding team to see if lessons can be learned following the deaths of four teenagers.

The Safeguarding Children’s Partnership Board is to carry out four individual serious case reviews into the deaths and will publish its findings in a single anonymised report.

Details of the inquiry were revealed during an inquest into the death of 15-year-old Siobhan Harvey, who took her own life last May while battling depression.

Neither the Deputy Viscount nor the board have disclosed details of the other three cases, but the inquiry comes after two other teenage suicides and one drugs death during the past two years.

However, Glenys Johnston, chairman of the board, stressed to the inquest that there was ‘no connection whatsoever’ between Siobhan’s death and the other teenagers who will be included in the review.

Speaking following the inquest Mrs Johnston said serious case reviews were important as they could help agencies such as the police, health and education improve safeguarding measures in the future.

‘We look at each case individually and consider whether there is learning,’ Mrs Johnston said. ‘That is the most important thing.

‘They are not about blame. They are just about saying “how did agencies work together, what went really well and are there things that could have gone better”?’

‘They are very, very important pieces of work and we don’t undertake them lightly because they are a lot of work.

‘We are very thorough. We make sure we are very accurate. They are not investigations. We are not police officers.’

The inquest heard that Siobhan, a Beaulieu pupil who was using the Child and Adolescent Mental Health Services at the time of her death after suffering depression, was found dead in her bedroom at her St Saviour home on 28 May last year.

• The board has oversight of the Island’s safeguarding measures and is charged with providing a co-ordinated approach to protection across the Island’s care agencies.
• The organisation, which was launched in 2013, also provides adult safeguarding training and is responsible for commissioning any serious case reviews that are needed following an apparent failure in care procedures.
• The Safeguarding Partnership Board is ultimately overseen by chairwoman Glenys Johnston, but is broadly split between two sub groups –the Safeguarding Adults Board, which oversees agency measures for Islanders aged 18 and older, and the Safeguarding Children’s Board.
• Both sections comprise senior representatives from key care and protection units in Jersey. Together, these partner agencies provide a co-ordinated approach to the protection of a range of Islanders, families and carers.
• While it is not responsible for delivering services directly, the SPB has oversight of safeguarding measures put in place in the Island. It provides adult safeguarding training, meets regularly to co-ordinate different agencies’ work on specific cases, clarifies the needs and means for child and adult protection, monitors safeguarding systems and implements policies to promote the welfare of children and adults.
• The group’s work can extend to investigating allegations made against people who work with children or adults, and they also publish guidance on best practice when it comes to protection.
• They are also charged with monitoring all aspects of protection services, including complaints relating to agencies under the SPB umbrella.
• Serious case reviews are commissioned by the board where abuse or neglect of an adult is known or suspected, when the individual has died or been seriously harmed, and when there is serious concern about the way in which agencies have worked together.
• These reviews aim to discover what lessons can be learned and what changes can be made to improve safeguarding measures. They are not designed to apportion blame where death or serious injury has occurred.

Giving evidence, Detective Constable Verity Thomas said that the internet history from Siobhan’s iPad revealed she had posted online messages about her suicidal thoughts and how she had previously attempted to take her own life.

There was no evidence that Siobhan, who had been prescribed the antidepressant Fluoxetine, had been the victim of bullying.

In the months leading up to her death, Siobhan, increasingly isolated herself from friends and family and withdrew from her hobbies including gymnastics and singing, the inquest heard.

Concerned after noticing their daughter had begun self-harming, parents Andrew and Mia persuaded Siobhan to go to her GP, who referred her to CAMHS.

The inquest heard that Siobhan was initially told she faced a 14-week wait until her first appointment with CAMHS, which would have been in June last year, and that a ‘furious’ Mr Harvey wrote to the Citizens Advice Bureau and the Health Minister about the long wait.

Mrs Harvey also told the inquest that they attempted to access a private child psychologist in Jersey but were told there were none in the Island.

Following a cancellation, Siobhan was given an initial assessment by Dr Robert Lam, a consultant child and adolescent psychologist, on 22 March.

Giving evidence Dr Lam said that Siobhan ‘did not want to engage’ and added that she had told him that she did not know why she was feeling the way she did.

Deputy Viscount Advocate Mark Harris recorded a verdict that Siobhan took her own life while suffering from depression.

Following Siobhan’s death last year, Mr and Mrs Harvey, along with son Michael, released a statement.

It said: ‘She always cared about others, maybe more than herself and was always prepared to listen.

‘From the messages of support we know how much she was loved and the impact she had on others when she came into contact with them.’

• The creation of a MultiAgency Safeguarding Hub to provide a single point of contact for all safeguarding children concerns.
• The Jersey MultiAgency Public Protection Arrangements, which monitor high-risk sexual, violent and other dangerous offenders, was used.
• The Multi-Agency Risk Assessment Conference, which focuses on victims of domestic abuse and develops plans to support them, was used.
• A Sexual Assault Referral Centre, which provides specialist advice, was created.
• A review of early-help services was carried out.
• The SPB worked together to manage the risk of young people at risk of suicide or self-harm.
• The board developed a States Safe Recruitment Policy.
• A position for a designated nurse to provide advice and support for nursing staff was created.