2.5 High Risk, Complex Cases: Procedure and Guidance

This procedure and guidance has been produced to help those working with young people in circumstances where a young person is high risk or has complex needs, and may not engage with services that it is felt are needed in order to safeguard and promote their welfare. The lack of engagement may be of the young person’s own volition or influenced by others, e.g. in cases of child sexual exploitation.

The procedure should be applied in cases where all reasonable attempts to engage a young person have failed or where there is a belief that the young person is at high risk of significant harm or that they present a risk of significant harm to others. The Risk Management Pathway flowchart in the appendix provides examples (but is not an exhaustive list) of services or processes through which such cases might be identified.

The protocol is not an alternative to existing case management frameworks and processes, e.g. Child Protection case conferences, Looked After Children arrangements or Care Programme Approach. It should be considered as a ‘next step’ when the existing frameworks and processes are proving ineffective in safeguarding and supporting the needs of high risk, complex, harder to reach young people.

Individual cases discussed through the Complex Case Panel will remain subject to the normal case management procedures.

The Buckinghamshire Safeguarding Children Partnership (BSCP) has a role in overseeing these arrangements by:

• supporting the development of the Complex Case Panel and process
• regularly reviewing, through an annual report to the Partnership, whether:
  • the panel is achieving its intended impact on individual cases
  • whether the panel is fulfilling the recommendations of the relevant Serious Case Review
• updating this protocol and guidance document as required
• identifying gaps in commissioning to support higher risk, complex and harder to reach young people
• raising appropriate challenge to commissioners in response to any identified gaps in services
• identifying and sharing best practice.

The Complex Case Panel is a senior level multi-agency advice and consultation group. Its function is operational, but it has the ability to recognise wider service or policy gaps so it can make recommendations to the BSCP about strategic work that needs to be taken forward.

A monthly meeting of the Complex Case Panel is held to improve inter-agency risk management of children and young people.

Cases are brought to the panel for discussion by managers, practitioners and clinicians with case responsibility. The panel does not supersede or take over case responsibility, this remains unchanged.

The Complex Case Panel should be chaired by the Service Director in Children and Families, Buckinghamshire County Council.

The Complex Case Panel should include senior management from those agencies/services already engaged or trying to engage the young person. It should also include, as standing members, senior representation from social care, police, health education and the youth offending service (YOS). The meeting should have inclusion of, or access to, a local authority legal advisor.

Membership:

Chairperson: Service Director, Children and Families or in his/her absence: Director of Children’s Services, Health

Members: Other senior colleagues as required for specific case discussions. Specific invitations should be indicated on the case-referral form (some of these may become core members) 

• Service Director, Children and Young Peoples Services, Oxford Health
• Substance Misuse Services
• Domestic Abuse Services
• Learning/physical Disability Services
• Education Psychology Service
• RU Safe? (Barnardo’s)
• Community Paediatrician
• Social Care Emergency Duty Team (for information)
• Other agencies’ Out of Hours services (where applicable)
• Head of Service, YOS
• Designated Safeguarding Lead, Clinical Commissioning Group
• Detective Inspector, Public Protection, Police
• Legal representative
• Designated doctor for safeguarding.

Consideration must also be given to the involvement of parents or other significant carers/family members – by ensuring that their views, information and suggestions contribute to the development of the action plan. This can be either in the meeting itself or by gathering the information beforehand. This must be considered on a case by case basis.

By definition, the direct involvement of a complex or hard to reach young person in the meeting is likely to be difficult. However, efforts should be made to find any direct or indirect method of bringing their views and ideas to the discussion, e.g. involvement and/or attendance of an advocate.

The purpose of the panel is to:

• act as a point of escalation when other ‘business as usual’ functions have not delivered the desired outcome (It is not intended that the panel should replace or interfere with established processes)
• identify a lead agency and a named senior manager who will take ownership and be accountable for the joint plan  
• share the known or perceived risks – clarify perceptions/facts
• aim to achieve consensus about level of risk
• confirm which agencies/services have any contact – confirm the nature of the contacts/involvement
• share information about factors which might be preventing engagement
• identify gaps in provision
• develop a shared risk management plan to be adopted by all relevant agencies/services. This should include:
  • confirmation that there will be ‘no wrong door’ for this young person, i.e. there will be a proactive response to any contact made by the young person regardless of who he/she approaches (i.e. intervention should not be postponed – getting the help at the right time is essential)
  • sending a notification to identified agencies (including police [1], out-of-hours social care and health service provision) to adopt a flag or alternative measure which alerts staff to the fact that this young person is harder to reach and/or is considered to be at high risk (Those attending the meeting will be responsible for ensuring that the alerts reach relevant communication systems within their services and a flag attached to the young person’s details. Other services that are not represented at the Risk Management Meeting will be notified by the Chair.)
  • make an arrangement to alert agencies who should ensure that, wherever possible, attempts are made by those who come into contact with the young person to try to engage and offer support (As a minimum, those in contact should make a note of the young person’s appearance, behaviour and signpost him/her to services/help identified by the Risk Management Meeting.)
• report any contact with, or from, the young person directly (verbally, then followed in writing) to the allocated worker in social care within 24 hours (if not available, to their manager), so that tracking and feedback on the young person’s wellbeing can be monitored and any new opportunities responded to as soon as possible.
• consider drawing in other expertise to advise on how best to engage with the young person
• consider whether new or different outreach work is appropriate and by whom
• consider the number of agencies involved and whether this is problematic for the young person
• identify specific services and contact numbers to be promoted to the young person whenever they are seen or communicated with
• identify contingency plans to deal with unexpected or short-term crisis or increased risks
• identify monitoring arrangements
• set review meetings (minimum of one a month).

[1] The police are sometimes in an ideal position to help. They may be the first or only contact with statutory agencies that some vulnerable young people have because of the higher risk of association with criminal activity and vulnerability to crime.

The Complex Case Panel should regularly consider whether they need to keep a child or young person under the review of this group. As soon as the need for these arrangements is no longer required, all involved agencies must be informed.

Agencies must then remove any ‘High Risk, Complex, Hard to Reach’ notification or flag from their communication and recording systems. This will ensure that this priority arrangement remains focused on current selected high-risk cases.

The process seeks to deliver a flexible and holistic multi-agency response for children and young people who have identified multiple needs, whose planned outcomes are not being achieved despite the best efforts of the inter-agency core group, and for whom risks are increasing. For example:

• Neglect: cases with a Child Protection Plan which have had a plan for more than 18 months and where the area service manager has reviewed the case but remains concerned about the absence of progress due to gaps in provision/lack of a specialist assessment.
• Care order not made: cases where care proceedings have been instigated but have resulted in a care order not being made, against local authority advice.
• High-risk adolescents: cases of adolescents living in the community, whether with their families or in care, who are exhibiting behaviours which create a risk of significant harm, whether to self or others, through violence, offending, self-harm or serious substance misuse (they may be at risk of a secure order).
• Out of county placements: cases where adolescents have been placed at long distance and are lacking co-ordinated services from a range of professionals to be able to move in-county or have experienced multiple placements.
• Multiple complex needs at risk of poor outcomes: cases where adolescents have both mental health problems and substance misuse issues; or mental health problems and learning disability; or where two statutory proceedings are in place at the same time, e.g. criminal proceedings and child protection conferencing for a young person with sexually harmful behaviours.

This list is intended to be illustrative, not exhaustive.

The terms ‘hard to reach’ or ‘difficult to engage’ can be stigmatising in themselves; sometimes implying that the young person does not want help or is unable to be helped. For each young person affected it is crucial that we aim to understand what it is that prevents effective engagement with them. Without doing so, we are unlikely to find more successful approaches. For example, a young person without cash for necessary transport isn’t going to keep an appointment – and if she/he is now homeless, they probably have not received the letter of appointment in the first place.

When a young person does not engage with what is believed to be the necessary support, staff can feel powerless to help – and sometimes agencies have closed the case, leaving the young person even more vulnerable.

The Biennial analysis of Serious Case Reviews 2005 to 2009 revealed that a common factor in Serious Case Reviews was that local services just did not know what to do with the child/young person involved. By the time of the incident that led to a Serious Case Review being undertaken, agencies appeared to have run out of helping strategies (Brandon et al 2008). It was found that many of these young people had a long history of agency involvement, but that their specific needs and distress were often missed or were too challenging, or expensive, for services to meet.

Research with young runaways has indicated that thresholds for responding to maltreatment were seen by professionals as higher when young people reached the age of 15 (Rees G et al 2010).

Most of the older adolescents in the Biennial analysis died from suicide. Typically they had experienced a history of abuse and neglect, coupled with environmental factors such as domestic violence, parental mental health issues and poverty (Hindley et al 2006). Many were self-harming and misusing substances. Numerous placement breakdowns, running away, going missing, dangerous sexual activity, including exploitation, were common features too.

These young people might have been amenable to help if they had been offered the right approach (Finkelor D 2008).

Many children and young people who fit the category of ‘harder to reach’ and at risk of significant harm are Looked After by the local authority.

In Buckinghamshire, there have been similar findings from Serious Case Reviews involving the tragic deaths of young people. At several stages in their lives, these young people were viewed as harder to reach or difficult to engage for a range of different reasons. This guidance has therefore also been produced to help embed the specific lessons learned locally (see Serious Case Reviews on the BSCP website).

The extent to which parents and the community encourage young people to engage with the wider community and available services will impact on their confidence to make the most of opportunities and these services. We need to understand the young person’s ability to engage within the context of the experiences they may have inherited from their family and community, particularly in relation to fear and distrust of formal organisations.

Factors to consider include:

• family/community isolation or alienation from wider community
• hostility from local or wider community
• experience of institutional racism or other forms of discrimination
• criminal culture within family or community, including substance misuse and domestic violence
• previous child protection intervention
• previous disagreements with authority over what are viewed as problems and/or disagreement about their solutions
• previous dissatisfaction with agencies regarding access to support, thresholds for involvement or timeliness of response
• poverty – impact on self-esteem, aspiration and access to basic amenities (transport and activities involving costs)
• communication – barriers due to level of understanding/language/disability.

These factors are likely to have some bearing, directly or indirectly, on the young person’s ability to view agencies as a source of help or not. If the young person is not disengaged from their own family or community, then efforts to support may need to reassure those people who are more influential first.

While it is important to acknowledge that young people and families can make it hard to engage, professionals play an important part in this and must be aware of the factors which contribute to the process of engagement. ‘Workers can become paralysed by their own fears and anxieties, which can lead to the assessment process remaining incomplete’ (Brandon et al 2008).

People could be hard to reach because they think an organisation does not care about them, does not listen or even is irrelevant to them (Wilson 2001).

Agencies can spend too much time deciding on who is the most appropriate team to offer a service. This uncertainty and delay of input is likely to impact on the young person or family’s interest in accepting the support and therefore causing them to become difficult to engage with.

Organisational features that can undermine engagement:

• disagreement between agencies about responsibility and thresholds
• rigid application of threshold criteria
• reasons for a young person running away not addressed properly
• reluctance to identify mental illness and suicidal intent
• dealing with incidents but failing to recognise patterns – resources diverted towards short-term crisis not achieving long-term outcomes
• limited resources are poorly coordinated and integrated
• lack of specialist provision/advice
• different agency agendas and mutual misunderstandings – falling down the gap
• complicated procedures, bureaucratic, form filling etc.
• attitude of staff – bureaucratic, judgemental, cold, indifferent
• poor communication and accountability within an organisation – failure to escalate and address relevant concerns
• limited staff supervision – individual workers viewing lack of engagement as their personal failing and feeling de-skilled.

Common features of ‘harder to reach’ young people include:

• increased risk of abuse/neglect (including higher risk of exploitation)
• self-harm/risky behaviours (include risky sexual behaviour, drug and alcohol misuse)
• history of exclusion from school, with a consequent lack of practical and social skill to deal with peer pressure and a range of threats from detrimental lifestyles
• unsettled or poor experiences in care (residential or foster placements)
• homelessness – for some, the assumed normal safe places are in fact places of risk, e.g. the family, and the life they have ‘chosen’ now may be preferable to the life they left at home
• vulnerability to crime – both as victim and perpetrator – particularly if homeless, they become more dependent on crime as their method of survival
• delayed, or no, attention to health needs.

Factors that may act as barriers to seeking or receiving assistance include:

• communication difficulties – language barriers, learning disability, poor literacy, no contact address/numbers
• involvement in criminal activity – fear of judgemental response/prosecution
• misuse of drugs/alcohol – fear of judgemental response/prosecution
• peer pressure, e.g. gang culture
• reluctance or fear of being returned to family, residential or foster placement
• discomfort with, and/or fears of, judgemental response to sexual matters (e.g. sexual orientation, sexual health matters)
• difficulty in understanding the different roles of professionals they encounter.

‘We must recognise that the young person may be hard to reach in some contexts or locations, but not in others. The real critical part is matching the right solution to the right person. We need to be flexible with what we do, we need to coordinate things better and we need to work better together.’ Hendry (2007).

The following tips are good practice for working with any young person and may seem obvious. However, lessons from Serious Case Reviews and recent research indicate that for harder to reach young people, these practice issues remain significant:

• be honest and up front about what young people can expect and what not to expect from you/your service or placement – be transparent about why engagement is necessary
• establish what they want to happen and what they don’t want to happen
• provide clear and accurate information, including when it might be necessary to disclose information about them to others for the purposes of protecting them or others
• keep them informed of changes that are significant to them (find out what they want to know too)
• keep clear boundaries – working with vulnerable young people often means being flexible, but a trusting friendly relationship must not be blurred with involving them in your personal life (Provide relevant contact numbers, including out-of-hours numbers for emergencies.)
• wherever possible, work at the young person’s pace (Taking time to work at their pace can actually be a fast track to getting to what it is really important for them.)
• aim to promote discussion that allows the young person to make informed life choices, but be clear and honest about which aspects can be determined on their terms and which cannot
• make no assumption about sexual orientation – use neutral language, e.g. 'are you seeing anyone?' rather than 'do you have a boyfriend/girlfriend?'
• make the young person aware of how to voice dissatisfaction and/or complaints about your service
• don’t assume that young people are able to read and write sufficiently (A large number of hard to reach young people struggle with literacy. Establish the best form of communication, particularly when making appointments or sending directions/instructions etc.)
• ensure that appointments or other proposed activities are realistic – are there costs involved, transport issues, other commitments/timing issues?
• make every effort to keep appointments, keeping alternative arrangements to a minimum
• be positive – offer praise for every achievement, however small it seems
• persevere – if let down before by adults, hard to reach young people may try to test you. Keep going back for more and you are more likely to earn their trust and respect.

There are times when a young person’s behaviour may pose a risk to others and exclusion from the service needs to be considered.

Where the young person themselves is also viewed as being at risk of significant harm, a temporary exclusion should be the ultimate sanction until a Risk Management Meeting is held to develop a multi-agency action plan.

When working with young people who have already been excluded from a number of provisions in their lives, a permanent exclusion can reinforce a position of hopelessness. Consequently, a Risk Management action plan needs to be in place to direct any further decision making.