NYSCP NYSCP Publish the Serious Case Review of "Clare" - North Yorkshire

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NYSCP Publish the Serious Case Review of “Clare”

NYSCP Publish the Serious Case Review of “Clare”

Clare sadly died on in March 2017 aged seventeen, whilst an in-patient at a Tier 4 mental health Hospital in Norfolk some 200 miles from her home in North Yorkshire. Clare had experienced emotional and mental health challenges over a number of years with interventions from a number of different organisations resulting in Clare being sectioned under the Mental Health Act 1983. She was found having tied a ligature around her neck.

Despite the tragic content of this Serious Case Review, Clare had many positive aspects to her character. Her parents describe her as fun loving, witty, caring, easy going with a big heart, being intelligent, artistic, a wonderful girl, articulate, having opinions on the world, sociable, somebody who loved animals and nature.

The learning identified from this review is in relation to: 

  • The importance of holistic assessment of a child’s health needs
  • Communication between schools and health professionals especially when a child moves between settings
  • Transfer of records and documentation, also particularly when a child moves area or setting
  • Child and Adolescent Mental Health Service (CAMHS) waiting times and the ability to respond when a child is first unwell, and to maintain that response
  • Care provided by specialist mental health Hospitals, especially given beds are scarce and provision often distant from a child’s home
  • The voice of the child and parents being taken seriously by professionals

An Executive Summary can be found here and the Full Serious Case Review can be found here.

If you work with children and families in North Yorkshire, there may be additional specific actions and lessons for your agency and your role. Please ask your manager, or contact your representative on the North Yorkshire Safeguarding Children Partnership, to find out more.

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