Alex Kelly
28 Dec 2014 · Coroner Patricia Harding · Mid Kent & Medway
The coroner's concerns
1. sentenced without forensic psychiatric assessment
“[the deceased] a vulnerable looked after child of 15 years with complex unresolved emotional issues and undiagnosed mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender's Institution without the benefit of a forensic psychiatric assessment”
2. lack of named social worker
“[the deceased] was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody”
3. documentation transfer failure
“Social workers did not transfer documentation including emails onto Framework i in a timely manner or at all”
4. lack of urgent communication protocol
“There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work”
5. inadequate corporate parent awareness
“Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child's welfare whilst in custody”
6. unreported agency shortcomings
“Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management”
Responses
2014-0555-Response-by-Central-North-West-London-NHS-Trust.pdf ↗· HMP Cookham Wood
2014-0555-Response-by-Medway-Youth-Offending-Service.pdf ↗· Medway Youth Offending Team
2014-0555-Response-by-Ministry-of-Justice.pdf ↗· Ministry of Justice
2014-0555-Response-by-Oxleas-NHS-Trust.pdf ↗· Oxleas NHS Foundation Trust
Stated action
“we have implemented a series of standards to ensure that we monitor its use and implementation. All new admissions to the prison are offered these assessments and the take up rate is over 98%. Those who initially refuse are approached to be assessed at a later date.”
2014-0555-Response-by-Tower-Hamlets.pdf ↗· Tower Hamlets Council