No safety plan in place to help tragic Sunderland teenager Thomas Brookes, says report
No safety plan was ever put in place to support a troubled teenager who died of a drugs overdose at home, a report has found.
Sixteen-year-old Thomas Brookes was found dead by mum Helen Wardropper at home in Westheath Avenue, Grangetown, on Saturday, September 28, 2019.
Recording a conclusion of misadventure at an inquest last week, assistant coroner Karin Welsh said she had identified a number of ‘woeful shortcomings’ in the handling of Thomas’ return home from secure accommodation, but could not say any of the problems had led directly to his death.
Now Sunderland Safeguarding Children Partnership (SSCP) – which includes Sunderland City Council, Sunderland Clinical Commissioning Group and Northumbria Police – has released the results of a serious case review into Thomas’ death.
The report – which refers to Thomas as Child FC and his mum as MFC – identifies a number of problems and offers six recommendations to ensure such a situation does not occur again.
It says: “Agency records referred to the ‘safety plans’, which were put in place at various times. In effect, these were simply crisis telephone numbers couched in terms of a ‘safety plan’.
“There was no safety plan ever put in place for Child FC, even when it would have been appropriate to do so. It was misleading to describe the giving out of emergency contact numbers to MFC as a safety plan.”
At the time, the city’s children’s service, Together for Children (TFC), was going through a high turnover of staff. Work with Thomas was ‘certainly compromised’ by the frequent changes of social workers and managers but this had not been flagged up multi-agency meetings or raised with senior managers.
Although Early Help services were involved with the family from September 2017, it was not until December that a decision was made to undertake a Child in Need assessment. "TFC acknowledged that this intervention should have taken place much earlier in response to reported concerns,” says the report.
The possibility Thomas was being exploited by adults in the ‘County Lines’ drug trade was not adequately explored: “There was very little curiosity by professionals as to where Child FC was buying his drugs and from whom, and importantly, how he was he paying for them,” says the report.
"These issues were not explored as well as they might have been, especially given the suggestion that some young people and older peers with whom Child FC was associating, were known to police, CSC (children’s social services) and MSET (Missing, Slavery, Exploitation and Trafficking).”
Thomas had been referred to the MSET service in January 2018 but ‘whilst his vulnerabilities were recognised, the team was of the view that there was no additional evidence or police intelligence to indicate exploitation and he was exited from MSET four months later’.
"At one point, Child FC was placed in the top ten of young people missing about whom there were concerns but this does not seem to have impacted upon any direct work being undertaken with Child FC nor provide any additional services or oversight.”
There had been no co-ordinated effort to assess Thomas’ risk of death: “The risks of Child FC’s death as a result of his self-harming behaviours were significantly high, and known to be so, and yet no risk assessment was undertaken,” says the report.
It found: “Professionals were clearly committed to safeguarding Child FC and keeping him safe but without a clearly defined multi-agency action plan, professionals worked as individuals and delivered different interventions.”
Thomas had been placed in secure accommodation top stop him taking drugs, but efforts to find a placement outside Sunderland had been unsuccessful and he had been returned home ‘without any assessment of ongoing risks, without a team around the family and without any discussions with MFC as to what she might have to do differently’, says the report.
"Just assuming that preventing Child FC from taking drugs would affect any longer term change, was somewhat naïve."
The report concludes SSCP should:
*urge the Department of Education to address the chronic shortage of placements nationwide, including secure accommodation;
*continue to build a robust framework for multi-agency work with adolescents at risk;
*consider how to improve collaboration between agencies;
*seek assurance from partners that managerial oversight ‘is robust and in line with best practice’;
*ensure key tools are used to support multi-agency decision-making:
*consider how to ensure professionals have the necessary skills to build and maintain high quality relationships with children and parents.
An SSCP statement said Thomas’ death was ‘desperately sad and had a devastating impact on his family and on all those who knew him’.
“Agencies from across the city worked hard to support and protect this young person and the wide range of needs he had in the period covered by the review,” it says.
"Partners from safeguarding agencies across the city have worked together to identify the learning that has come out of the review.
"It is essential we learn from the issues raised and make sure that we are doing our very best to protect vulnerable young people in our city.
"This case also highlights the acute national shortage of suitable, safe and secure residential care for cared for children with complex needs. We need more specialist safe and secure places where children can get the help they need.
"Many of the issues in this report have already been addressed by the agencies involved.”
The statement added that: “We completely recognise that there were times when opportunities to intervene and get him the support he needed were missed and examples of where the agencies involved could have done better.
"Although Ofsted recently found that Children’s Services in Sunderland are outstanding and have been transformed, they were rated inadequate at that time and they fully accept that the quality of support they provided did not meet the standards that the family rightly expected.
"Services have improved immeasurably over the last two years. This transformation has been recognised by Ofsted which recently rated Sunderland children’s services, which are delivered by Together for Children on behalf of the City Council, as outstanding. Together for Children has successfully reduced staff turnover and the number of agency workers within children’s social care. By investing in a stable and permanent workforce, families have a constant point of contact to ensure continuity and relationship building.
“Very sadly the actions already taken did not come in time to help this young person but it gives us confidence that were a similar situation to arise it would be dealt with differently.”