Lesson to be learnt from hanged teenager
Lessons will be learnt from the fatal hanging of a 15-year-old boy seen by
250 professionals.
That is the conclusion of a serious case review into
the death of Attention Deficit Hyperactivity Disorder (ADHD) sufferer - referred
to only as 'child B' - after he was found suspended from his bedroom door with a
t-shirt around his neck.
Having been affected by domestic violence,
physical and emotional abuse, mental health issues and bullying, he was placed
on the child protection register several times.
The independent review, commissioned by the Safeguarding Children
Board, is the first relating to a child from a Milton Keynes school in the last
decade.
It says: 'The family's repeated failure to engage should have been
seen as a cause for raised concerns. Instead there was not a coherent
multi-agency response.'
The review required reports by the council's
social care, education and housing services, the health authority, police and
charity The Children's Society.
It mentions the fact that Child B was
'very unhappy at school' and had a morbid interest in death, at least once
saying he wanted to kill himself.
Since 2005, Child B attended the school
- which is not named - where children were locked in classrooms and
inappropriately restrained.
The review says: 'The school had no
anti-bullying policy and there was no evidence of a child protection procedure
being in place.'
The author infers 'there was a culture of bullying and
deceit within the school, perpetuated by the head downwards. It therefore seems
extremely likely that B and other vulnerable young people were allowed to be
bullied as part of the school regime.'
The purpose is not to lay blame,
but to find lessons that can be learned, and his death 'must be seen as another
factor in the world of a young man noted for his impulsive and dangerous
behaviours'.
At his inquest the coroner said he could not be sure whether
the boy, who took Ritalin, intended to kill himself.
The review adds that
the boy's headteacher withheld evidence during the inquiry into his death and
appears to have been dishonest during the boy's inquest.
Now each agency
involved with B must make an action plan.
Concerns raised about Ofsted's
involvement and the fact the lack of verbatim notes from the inquest will be
passed on to the Government.
Chairman of the Safeguarding Children's
Board, Vivien Salisbury, said: “This child’s death is a tragic event and our
sympathies are with all those close to him. The review helps us to identify
areas where local agencies can improve and indeed where they have worked well
together. An action plan for each agency is in place to ensure the lessons
learnt from this case are taken on board and acted on."
Sharon Scott,
director of children’s services, said: “This young man’s death was a tragic
event. Both the inquest and the serious case review concluded that his death
could not have been predicted nor easily prevented by public services.
“However, we see there is opportunity to learn from this review and to
continue to improve practice for the future, including taking action to address
the review recommendations."
Story First Published: 31/03/2009 19:28:42