Agenda item

Suicide - Independent Review of Actions and Future Strategy

Minutes:

1. Introduction

 

The Chair welcomed everyone to the meeting and introductions were made.

 

2. Purpose of the Meeting

 

Councillor Roche, in his opening statement :-

 

i) explained that there was only one item on this agenda, which was the specific purpose of considering the independent review of actions taken following a group of suicide events in Rotherham and the future strategy in tackling the risk of suicides.

 

ii) stated that the thoughts of everyone at the meeting went out to all parents affected by these tragedies and that those present shared the deep sorrow. The key was to take action and do as much as possible to make sure that such incidents did not happen again. The purpose of the meeting was to look at the work done and determine how it could be performed better by a number of different agencies.

 

iii) expressed thanks to the Councillors of the Wickersley electoral Ward, who had originally brought the issues formally to the attention of the agencies and had worked hard on ways of moving the issues forward.

 

iv) stated that the agencies must look back, learn the lessons and acknowledge that things must be better. Actions, strategies and processes had to be put in place to make improvements, intervene at an earlier stage and prevent suicide happening.  Support needed to be provided for the bereaved families and friends, which would be straightforward to access. The aim was to take forward an effective suicide prevention strategy, with the co-operation of all agencies and schools.

 

3. Suicide in Rotherham - Independent Review of Actions and Future Strategy

 

Introducing both the covering report, the report of the Independent Review (NB: executive summary) and the supporting documents submitted to the meeting, Jo Abbott offered condolences to the families, stating that she had met family members previously. She was aware that the pain and grief were tremendous. People in the agencies wanted to do what they could to prevent suicide and incidents of self-harm from happening again.

 

The purpose of the submitted report was :-

 

(1) to report formally the key findings of the independent report commissioned by the Council to examine circumstances surrounding the four deaths by suicide of boys and young men in Rotherham, aged between 15 and 19 years of age, since 5th November 2011 and two identified self-harm incidents as late as March 2014.  Two of those who died by suicide and one of the self-harm incidents were students attending School A;   and

 

(2) to present Rotherham’s Suicide Prevention Action Plan and its model Rotherham Suicide and Serious Self-Harm Community Response Plan for consideration and approval  by the Health and Wellbeing Board.

 

Attached to the report were three appendices:-

 

a) Executive Summary of An Independent Review of Actions Taken Following a Group of Suicide events in Rotherham;  (nb: the full document is available on the Council’s website);

 

b) Draft Rotherham Suicide Prevention and Self-Harm Action Plan;

 

c) Rotherham Suicide and Serious Self-Harm Community Response Plan.

 

There were five key aims to the independent review:-

 

1) To provide a supportive critique to the work undertaken to date in relation to prevention measures and response plans in the event of future suicides/unexpected deaths.

 

2) To determine whether there was an appropriate response to assessing and meeting the needs of the specified cohort of young people who have been identified as being closely affected by the events.

 

3) To identify areas of work that has been undertaken to date, which requires redesign or additional specific interventions.

 

4) To develop a plan for a whole system approach to prevention of young people suicides and self-harm in Rotherham and ways in which any barriers could be overcome.

 

5) To recommend governance and reporting arrangements for the performance management of the Suicide Prevention and Self-Harm Strategy and the Community Plan

 

The Health and Wellbeing Board noted that the updated Rotherham Suicide and Serious Self-Harm Community Response Plan was developed during the response to the incidents referred to above. This Plan had subsequently been used in schools across Rotherham who have had incidents of serious self-harm amongst their pupils. The schools involved had provided positive feedback about using the plan which addresses a wider community response through ‘circles of vulnerability’. This aspect did not replace the support that the NHS, Social Care and the South Yorkshire Police may be providing for individuals and their families.

 

The submitted Rotherham Suicide Prevention and Self-Harm Action Plan incorporated the recommendations from the independent review, as well as the six areas for action as outlined in the Department of Health Suicide Prevention Strategy 2012.

 

The Board noted that the Child Death Overview Panel had discussed the common issues affecting the incidents. After discussions with Public Health England, it was confirmed that there were no United Kingdom national guidelines for dealing with teenage suicides, although The Samaritans have produced comprehensive guidance for use in schools. Instead, use was being made of the ‘Melbourne guidelines’ from Australia.

 

In order to increase the national knowledge about teenage suicides, Public Health England recommended independent authors who could write a review of lessons learned. Rotherham Borough Council subsequently commissioned the independent review, the report of which was being submitted that day.

 

The draft Rotherham Suicide Prevention and Self-Harm Action Plan included the lessons learned from the independent review, plus the six areas for action, identified in the Department of Health Suicide Prevention Strategy 2012 and built on best practice. There was also the Mental Health Crisis Care Concordat, which partners of the Health and Wellbeing Board has signed up to. The Concordat included identifying people in crisis and signposting them to Services.

 

Since the series of incidents of suicide and self-harm, various initiatives had been implemented, including:-

 

-          a bereavement pathway for children bereaved by suicide;

-          a suicide prevention conference aimed at front line workers;

-          suicide prevention training such as Applied Suicide Intervention Skills Training (ASIST) and Mental Health First Aid (for front line staff);

-          CARE about suicide cards for front line staff (Concern, Ask, Respond, Explain);

-          work with the Rotherham Youth Cabinet on self-harm (focus on mental health issues);

-          GPs ‘top tips’ in suicide prevention had been developed;

-          Rotherham guidance on self-harm (recognition that there was more work to do).

 

Alongside the development of these initiatives, the All Party Parliamentary Group on Suicide and Self-Harm published an “Inquiry into Local Suicide Prevention Plans in England” during January 2015. Bench-marking showed that Rotherham performed well against other local authorities in Yorkshire and the Humber. Examples of Rotherham’s work were included as good practice, eg: CARE cards and the Suicide Conference.

 

Ruth Fletcher-Brown referred to the ‘Melbourne guidelines’, which led to the development of the Rotherham Suicide and Serious Self-Harm Community Response Plan. The latter was a partnership response plan, including representation from all of the various agencies.

 

The response to the ‘circles of vulnerability’ was a model used in the Rotherham Suicide and Serious Self-Harm Community Response Plan to identify all groups which may be at risk. Good practice suggested flooding the school community with advice and support, etc., as well as information about the ways of noticing the signs that someone was in distress. The situation in schools would be monitored to ascertain whether any specific staff training should be provided.  Schools which had actively engaged in the community response work had been pleased with the support being provided.  It was the responsibility of all agencies to be involved in the prevention work. The Community Response Plan was an evolving document.  Any recommendations formulated nationally would be incorporated into the Community Response Plan.

 

The intention was to report on progress to future meetings of the Health and Wellbeing Board, as well as the provision of workforce development and support for staff in the various agencies. The Suicide Prevention and Self-Harm Group was accountable to the Health and Wellbeing Board.

 

Ruth Fletcher-Brown informed the Board that Rotherham was part of the South Yorkshire Real Time Suicide Surveillance pilot scheme. In the event of a suicide happening, agencies should be informed within 24 to 48 hours. This allowed for a fast response both to support families in their bereavement and also to prevent the contagion (spread) of suicides. Traditionally, agencies had to wait for the Coroner’s verdict which may take up to 18 months after a death. This delay was too late for work to be carried out in supporting families and communities and to offer “post-vention” to prevent further suicides.

 

Questions by members of the Health and Wellbeing Board

 

(a) Councillor Roche referred to the use of the word ‘clusters’ (for several incidents of suicide) and asked whether the definition or use of the word was accurate in this context?

 

Response – Public Health England had advised that agencies should exercise a great deal of caution in the use of this term.  There had been several suicides in Bridgend (Wales) but, after lengthy analysis using a specialist IT system, they had not been deemed to be a ‘cluster’. The ‘Melbourne guidelines’ included a definition of “having more than you would expect.”  There could be an increasing incidence of ‘copycat’ suicides. Again, it was vital that agencies responded quickly and prevented any more incidents. Rather than talking about ‘clusters’, the preference was to refer to ‘multiple suicides’. Rotherham instead addressed unusual and complex multiple suicides.

 

(b) Councillor Roche asked whether all schools and academies were engaging with agencies and with the implementation of the Community Response Plan?

 

Response – There had been a good response from most schools.  School A (referred to in the report) had not responded initially and used a targeted approach. The Community Response Plan followed best practice and advocated a whole community response.

 

(c) Councillor Roche – did the draft Rotherham Suicide Prevention and Self-Harm Action Plan include all the points contained within the Independent Review report (eg: on the provision of counselling)?

 

Response -  Yes, all of the recommendations were dealt within the Action Plan (and officers would check that this was the case).

 

With regard to the specific issue of the Rotherham Borough Council Chief Executive writing to the Secretary of State for Education and to the Secretary of State for Health, concerning the engagement of School A in the multi-agency response, together with this Council’s Strategic Director of Children and Young People’s Services, Commissioner Manzie stated that there would be further dialogue with the Head Teacher and the Governing Body of School A on this matter. The reference to Government Ministers would be a last resort, to be used only if the dialogue with School A did not result in satisfactory progress being made.

 

Chief Superintendent Jason Harwin extended the sympathies of the South Yorkshire Police to the families present. He explained that the South Yorkshire Police were learning the necessary lessons, especially in respect of faster communications and the timeliness of investigations. The safeguarding of people was the first priority, including the need to keep vulnerable people safe. The South Yorkshire Police service structures had changed as a consequence of the lessons learned.

 

The Members of the Health and Wellbeing Board referred to the recommendation concerning the reporting of progress on the implementation of the Rotherham Suicide Prevention and Self-Harm Action Plan and agreed that the first progress report must be submitted to a meeting of the Board within three months.

 

The Council’s Strategic Director of Children and Young People’s Services, Ian Thomas, also expressed sympathy for the families present. He said that whether a school was an academy or a local authority-maintained school, the engagement in the process was necessary and the Authority would intervene with both types of school.  All schools had the responsibility of responding effectively. The Regional Schools Commissioner for East Midlands Yorkshire and Humber, Jenny Bexon-Smith, was also available to hold schools to account in this important matter.

 

The Board noted that most schools welcomed the provision of guidance. Schools also now had representation on the Rotherham Local Safeguarding Children Board and it was intended that schools would be represented on the new Children’s Trust arrangements.

 

The Board noted that discussions at the Council’s Health Select Commission (Autumn 2014) had highlighted the lack of Mental Health Services for children and also the lack of Early Help Services. Workforce development would ensure that staff would develop the skills to identify, at an early stage, any signs of suicide tendencies; and also understand the need to put in place help for parents at an earlier stage.

 

(d) Councillor Roche asked about the availability of Mental Health Nurses in schools.

 

Response – Chris Edwards extended the sympathies of NHS Rotherham to the families present.  He confirmed that the School Nurses should be able to refer pupils immediately to the Mental Health Services available within NHS Rotherham.

 

Mr. Tony Clabby (Chief Executive, Healthwatch Rotherham) referred to recent experiences and staff undertaking the Applied Suicide Intervention Skills Training (ASIST).  Training was being provided within the community as well, it was not only a matter of workforce development.

 

The Board acknowledged that Rotherham has a good track record of providing Adult and Youth Mental Health First Aid, with service delivery reaching a high standard.  Ruth Fletcher-Brown reported that the National Youth Mental Health First Aid course had not yet been developed as a peer-to-peer course.  The Rotherham Youth Cabinet appeared to be keen to keep its focus on mental health as one of its main issues.  All agencies should be prepared to be involved in this work. This approach should include an investigation of the scope of peer group support and how to train young people to deliver this sort of first aid. The Kirklees Council area (Huddersfield) and areas of London had also developed this approach.

 

The Health and Wellbeing Board agreed that peer-to-peer approaches should be included in the Rotherham Suicide Prevention and Self-Harm Action Plan.

 

Mr. Tony Clabby stated that all agencies ought to be smarter and more flexible in what they did.  80 young people had signed up to participate in peer group activity at Wales High School. They would require training because young people preferred speaking to their age group peers.

 

Julie Kitlowski agreed that the Rotherham Youth Cabinet was already undertaking some very good work. The NHS commissioning process ensured that there was investment in some Mental Health and Support Services, yet there were sometimes too many services, causing confusion for parents and children.  More work should be done to simplify this matter.

 

(e) Councillor Roche asked about the bi-monthly meetings of the Rotherham Suicide Prevention and Self-Harm Group and whether the meetings occurred frequently enough.

 

Response – Ruth Fletcher-Brown replied that Rotherham was a real-time suicide prevention pilot area. Information gathered by the South Yorkshire Police and from the Rotherham Clinical Commissioning Group (CCG) was shared with the Suicide Audit Group. This Group, which included Public Health, CCG, RDaSH and the South Yorkshire Police, met bi-monthly. There might at times be a need to have more frequent meetings, although the bi-monthly pattern was considered to be sufficient at the present time.  The information provided by the Police and by the CCG was carefully assessed by the Public Health service, upon receipt.

 

(f) Councillor Roche pointed out that the flowchart of contacts, within the Community Response Plan, ought to include Public Health alerting the Leader of the Borough Council, as well as the Advisory Cabinet Members for Public Health and for Children’s Services, in the ‘Partners Activated’ section.

 

(g) Councillor Roche stated that any reporting to the Regional Schools Commissioner for East Midlands, Yorkshire and the Humber should refer not only to schools, but also to the academies as well.

 

Response – it was agreed that the reporting to the Regional Schools Commissioner would include issues concerning schools, academies and colleges.

 

It was noted that future meetings of the Health and Wellbeing Board would take place on Wednesday, 8th July, 2015 (morning), Wednesday, 26th August 2015 and on Wednesday, 30th September 2015. The initial progress report on the implementation of the Rotherham Suicide Prevention and Self Harm Action Plan should be submitted to a Board meeting no later than Wednesday, 30th September, 2015.

 

Councillor Roche commented that the Health and Wellbeing Board must keep this issue to the forefront of its agenda and maintain a system of monitoring the progress and work of the Rotherham Suicide Prevention and Self-Harm Group.

 

Chief Superintendent Harwin commented that, whilst the focus of this discussion was correctly on children and young people, there must also be consideration of the incidence of suicide amongst adults.

 

Mr. Tony Clabby commented that the speed of information being made available by agencies was good, enabling the prevention work to begin at an earlier stage. Often, it was necessary to have to wait for the result of an inquest, which did not always deliver a verdict of suicide.

 

Comments and Questions by parents present at the meeting

 

Q1)    Almost without exception, all individuals I met after Oliver’s death were well-intentioned and helpful. But it was apparent that the systems and policies served to form barriers between the different organisations. The initial Police response and investigation was very good and the Police officers on the ground were supportive. Even though it was a known fact that it was an apparent suicide, assumptions were made.  The Police ought to be better and faster at what they have to do.  It seemed that the Police were subservient to the Coroner’s Office in the remit of their investigations.  That remit looked at four points, but they did not include investigating any connection between the various deaths. Therefore the investigation could not have been sufficiently thorough.  Did the Coroner set the terms of the Police investigation?  This aspect ought to be checked.

 

Response  - Commissioner Manzie confirmed that the parent’s comments would be passed on to the Coroner (it was also noted that the parent had sent an e mail message to the Coroner, in similar vein, in 2013).

 

Chief Superintendent Harwin commented on the point about the assumption of the death being suicide. The CID would undertake an investigation because suicide was treated as a suspicious death. However, Police Officers had received training so as not to make that type of assumption in the future. The Police were obliged to report any death to the Coroner. The terms of an investigation, as decreed by the Coroner, ought to be told to parents. As responsible agencies, we have to ensure we prevent other deaths happening.

 

Q2)   The situation in Bridgend, Wales, was a cluster of deaths by suicide. What was the downside of not using the term ‘cluster’.  Should the term ‘cluster’ be used to ensure that families had better and faster access to services?

 

Response - The Samaritans provided good guidance to the media about reports of suicide. There were fears that the use of the term ‘cluster’ in a widespread way could be inflammatory and might encourage more suicides.

 

Q3) Was the issue treated differently when it was known as a cluster ?

 

Response -  Jo Abbott replied that no, agencies would not do that. The starting point had to be from the position of preventing suicide and preventing others from copying a suicide. It could be difficult to ascertain whether there were connections between cases.  It was always hard to find out exactly what the reasons were for any one case of suicide, as it was often the end point of a complex history of risk factors. Further national guidance was being published by Public Health England, during 2015, to help agencies respond to suicide. Whether the term ‘cluster’ was used, or whether it was called a series of multiple suicides, the imperative was to support family and friends and prevent further incidents by protecting vulnerable people.

 

Q4)  The Director of Public Health did not identify a connection between the two suicide cases initially. The Director, at the time, did raise the matter with the Child Death Overview Panel (of which he was the Chair). There was initial contact between the two mothers, using social media. I was later contacted myself, from my former wife. I had also known Joyce Thacker because I had been a school governor. The matter had been raised in March of that year (2013) and Joyce Thacker had said that she would contact the Director of Public Health.

 

Response – The Child Death Overview Panel (CDOP) procedure did note the circumstances of the suicides, occurring 18 months apart and the two deaths being connected to School A.

 

Commissioner Manzie explained that the new appointee to the post of Director of Public Health would begin work on Monday, 29th June, 2015.  An important initial task would be to focus on work with schools.  The intention was to ensure the rapid identification of commonalities between cases, such as geography, institution attended, whatever the detail may be.  The events over the period in question were horrible and much work had since taken place to ensure that, in future, there would be a much higher chance of making connections.  The South Yorkshire pilot scheme concerning ‘real-time’ suicide surveillance was one such improvement. The Community Response Plan would contain everything together and, within a short space of time, all factors would be in place.

 

A parent also commented that agencies need to be quicker with their actions, even with ‘real time’ surveillance.

 

Q5) The concentric circles model ought to be included in the ‘real-time’ surveillance model and firmly embedded in it.

 

Q6) The assumption in the prevention plan and elsewhere was that the circumstances of a suicide case were unique. How did the agencies know that?

 

Response - The national advice available informed agencies that each suicide was driven by a unique set of circumstances, due to the age range, proximity, link to a school etc.

 

A parent commented that enough monitoring had taken place for the agencies to be able to say the case was unique. Perhaps there was a national vacuum (of information provision) on this. Agencies must not be complacent when they made their assumptions.

 

Another parent referred to the Police response and the involvement of a paediatric doctor. Advice had been given to contact School A.  On telephoning the school the next day, we had asked the Police why it had been necessary to contact the school.  The Police had referred to a ‘spate’ of suicides at School A.

 

Q7)   Father of Jack - Young people preferred talking to young people of the same age. Jack used Facebook a lot, sometimes early in the morning.  There were conversations about X-box and Playstation games.  Jack’s brothers and friends had not yet come to terms with his loss.  It was important not to expect every young person always to communicate about every issue, even with their closest friends.

 

Response – Communication (and the lack of it) was the key point to make here.

 

A parent commented that, as parents, we would not always look for preventative support until something awful happens.

 

Another parent (mum) commented that there was not always accountability in schools.

 

Q8) The incidence of online bullying was not properly monitored.  Jack was linked to different groups via X-box games, Facebook, etc.

 

Response – Jo Abbott replied that the recommendations contained within the independent review report asked the Health and Wellbeing Board to make public mental health and resilience for young people priorities in the re-fresh of the Strategy. Youngsters needed to be both happy and resilient.

 

Q9) One father thanked the Authority and other agencies for making parents feel welcome at today’s meeting.  He said that it was good that preventative work will be undertaken. Agencies must engage with the young people and get them on board with the work on prevention of suicide. As a parent, it had been a nightmare to go through this. We must make improvements in the future.  Funding for Mental Health Services would be vital. Suicide was the biggest killer of young people, so it was important to get the issue sorted out. Parents would not always know how to cope. You go through counselling and find a way of dealing with it. You have to do so, to be able to move forward. There was another tragedy because his best friend was involved.  Perhaps that may have been a factor. The other tragedies had not just been suicide.  It was good for agencies to involve parents. We appreciate the invitation to come and speak to officials.  Some of us had not seen a copy of the report and the other documents.

 

Response – A full set of reports and supporting documents, considered by the Health and Wellbeing Board, would be provided for all parents. Details of appropriate agencies and officials had been given to all parents identified within the report.

 

Jo Abbott confirmed that the agencies now had a pathway of support for children and young people, up to the age of 18 years, if people in that age group were bereaved as a result of suicide, or some other traumatic event. Schools would know the individual circumstances and generally have faster access to the Mental Health Services (CAMHS). There would be help for siblings. The feedback from families using this support pathway had been positive, with families agreeing that the service was a good one.  It was helpful for everyone to know that the support was there. The Rotherham Suicide Prevention and Self-Harm Group was investigating the possible establishment of a similar pathway of support for adults.  It was very helpful for agencies to receive the parents’ feedback and their views on the support available at the time of the incidents.

 

The advice provided by the South Yorkshire Police was specific to the investigation of incidents. But, there also needed to be a balanced approach taken to the range of support services known to be helpful to parents. The provision of emotional support was especially important.

 

Tony Clabby commented that the information available from the CAMHS Mental Health Services had improved. However, the timely access to Mental Health Services had not. The transition from the CAMHS Service to the Adult Mental Health Services was a very vulnerable time for any person.

 

Q10) A parent stated that it was helpful to have a single point of contact for families across the whole period of time until the inquest was closed.  This was an intense need. Families would not be bothered where that contact person was based.

 

Q11) A parent referred to the report’s references to School A and the interventions made in that School.  Did the report address those children and young people who were not pupils of School A, but may still have suffered some level of impact (eg: young people from primary schools or youth clubs)?

 

Response – Ruth Fletcher-Brown replied that the Community Response Plan would include circles of vulnerability, for example: faith schools, children and young people in other establishments and elsewhere. Agencies must look beyond an immediate area for any contacts there may be with other children and young people.  A comprehensive improvement plan was being put into place.  The timeliness of access to appropriate support services was also improving.

 

Q12) A parent commented that it was good that lessons were being learned and agencies were moving forward on this difficult matter.  Prevention and post-incident intervention were important.  If these response and improvement plans were all put in place, would this all achieve the outcomes we want?  We have to look back at the tragic incidents with that objective in mind.  We must ask – has the appropriate action been taken.

 

A parent thanked the agencies for the invitation to this meeting.

 

General discussion

 

Councillor Ellis commented that the language of suicide and self-harm was very difficult to cope with.  The careful monitoring of the improvement action plans must be thorough.  When the boxes were ticked for the ‘red-amber-green’ ratings, was there sufficient notice taken of timescales?  Was there the correct investigation of the individual circumstances of any incident?  The necessary budget details were not included in the improvement and action plans.  The budget situation was known to be difficult, yet it was important that all of the different agencies want to be a part of this.  There would probably be an impact because of reductions in the budgets for some Health Services and for some schools.

 

A ‘whole community approach’ was essential in dealing with loss.  Councillor Ellis had become aware because her own children were of similar age to the individuals and they had found out by using social media. It would not be easy to take a ‘whole school approach’ when dealing with the various academies and types of school. There was now not such strong contact between the academies and the Local Authority, so a heavy-handed approach may sometimes have to be used. The risk or even fear of reputational damage should not prevent people (and agencies) getting involved to do good work.

 

Councillor Roche stated that the Community Response Plan had to be a ‘living’ plan and the Health and Wellbeing Board must keep it under continual review. Actions were more important than plans on paper. It was difficult to comment on the budget issues.

 

There followed a discussion involving Councillor Ellis and Chris Edwards (CCG) about NHS Rotherham’s budget of £200,000 for Children’s Mental Health Services in the 2015/16 financial year. The plan was for the Services to be a big area of investment, not a budget cut. Councillor Ellis asked about the measurement of success and how much money would be invested in prevention?

 

There was a discussion about schools and academies, with an emphasis on the importance of the whole community approach. This included a statement from a parent who was critical of an apparent lack of co-operation from academies and schools. They should all be co-operating when it was the lives of young people which were at stake. It should not be a difficult issue (to co-operate) because the safety of children and young people was so important

 

It was emphasised that most schools had regular Safeguarding meetings held at the Rockingham Professional Development Centre, Kimberworth Park. Schools were making good progress with this issue and appreciated the help they would receive from the range of agencies.  The Strategic Director, Ian Thomas, stated that the Borough Council was working hard to strengthen the partnerships with schools, via the arrangements of the Children’s Trust Board. There was a process of escalation to the Regional Schools Commissioner if the academies did not want to join in.  The Borough Council had that commitment.

 

Tony Clabby referred to the cases of young people’s engagement with the Mental Health Services. What happened in situations where they were sectioned or admitted to a hospital away from the Rotherham Borough area?  The Board was informed that there would have to be an investigation of any serious incident which had taken place. All health providers were accountable to the Clinical Commissioning Group, which would ultimately give its independent view on an individual case.

 

Another parent commented that it was hard to understand why it (suicide) had happened.  As parents, they had not seen it coming.  Other parents would go through this in the future and you did not get any warning. Self-harm was different, because you could see some of the signs. But it could still be very hard for parents to pick up on it.

 

Decisions of the Health and Wellbeing Board

 

Resolved:-  (1)  To approve the recommendations contained within the submitted report and as set out at (a) to (c) below and with the amendment to recommendation (c) from “at least annually” (suggested in the independent report) to the timescales below :-

 

(a) That the Health and Wellbeing Board notes the Executive Summary of the Independent Review.

 

(b) That the Health and Wellbeing Board accepts and endorses the Rotherham Suicide Prevention and Self-Harm Action Plan and tasks the Rotherham Suicide Prevention and Self-Harm Group to implement it.

 

(c) That the Rotherham Suicide Prevention and Self-Harm Group is tasked to provide a minimum of a quarterly update to the Health and Wellbeing Board about progress made in implementing the plan (frequency increased from the suggested annual update).

 

(d) That the Health and Wellbeing Board accepts and endorses the Rotherham Suicide and Serious Self-Harm Community Response Plan, the use of which will be promoted by the Director of Public Health in the case of any future incidents.

 

(2) To support the seven recommendations listed in the report of the Independent Review:-

 

i)       Local stakeholders, led by an agreed lead agency, should agree procedures for the ongoing development of the Community Response Plan and the associated Action Plan (with clear timescales and identified leads) ensuring the Action Plan remains an ongoing and up to date plan.

 

ii)     The Rotherham School Incident Plan should be updated alongside the community response plan to include available support services for suicide/self-harm within Rotherham.

 

iii)    The current Rotherham Suicide Prevention Strategy Action Plan should be updated and thereafter re-updated annually and include the use of suicide audit to inform its redrafting.

 

iv)    The Rotherham Health and Wellbeing Board should develop a Public Health Mental Health and Wellbeing Strategy within which the emotional needs of young people are clearly addressed and are prioritised at Cabinet level in the Council.

 

v)     A clear communications strategy should be developed between Rotherham MBC and its strategic partners.  This should proactively promote suicide prevention approaches.

 

vi)    The Rotherham Police and Coroner’s Office should consider some of their specific roles and responses to deaths by suicide in light of this report.

 

vii)   Primary Care and Mental Health Service commissioners should review their relevant commissioning strategies in light of this report.

 

(3) To approve the additional items, as discussed at the meeting and listed below:

 

a) All agencies must learn the appropriate lessons from these incidents and ensure the long-term focus on appropriate preventative measures being in place.

 

 b) To investigate thoroughly the possibility of establishing one single point of contact for parents’ wishing to seek help and access support services.

 

c) The reports and documents, including appropriate contact details, to be provided for parents attending this meeting.

 

d) The implementation of a whole school approach to preventative work and ensuring the participation of all academies and schools.

 

e) To ensure the engagement of all academies and schools in the implementation of the Action Plan and the Community Response Plan and, if necessary, to refer those unwilling to participate to the Regional Schools Commissioner for East Midlands, Yorkshire and the Humber.

 

f) To ensure that pupils have fast access to the School Nursing Services.

 

g) The investigations of suicide incidents must include the examination of any links to other, earlier suicides, because an individual’s difficulties may develop over a long period of time.

 

h) To provide the impetus which will ensure the improvement of the focus of a range of partner agencies involved with CAMHS (Child and Adolescent Mental Health Services), noting that the transition from CAMHS to Adult Support Services is a particular issue.

 

i) To ensure that agencies do not make too narrow an assessment of the needs of young people or parents who were seeking help and support; there may be a diverse range of options for the provision of the necessary support, available from a wide variety of organisations.

 

j) To investigate, with the Rotherham Youth Cabinet, the possibility of a system of peer group support being available for young people.

 

k) To have further dialogue with the Governing Body and the Head Teacher of School A on the issue of suicide and self-harm, with reference to Government Ministers only as a last resort, if satisfactory progress was not made.

 

(l) The Director of Public Health to consider sharing the learning with a wider audience, including Public Health England, NHS England and other local authorities.

 

The Chair, Councillor Roche, thanked everyone for their participation in and contributions to this meeting.

Supporting documents: