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1. The review process
1.1
This summary outlines the process undertaken by Brighton & Hove City Council in reviewing the death of Adult T, a 59 year old woman, who was killed by her grandson, Child 1, in January 2021. This review was conducted under section 9 of the Domestic Violence, Crime & Victims Act 2004.
1.2
The review sought information from relevant agencies and professionals involved; and it was supported by a Review Panel representing local agencies and services. Family members were offered the opportunity to contribute, but this was declined.
1.3
The review began in February 2021 and concluded in September 2023; delays were due to waiting for the outcome of a police investigation and subsequent criminal trial. There was also considerable delay in waiting to hear back from the Home Office Quality Assurance Panel before the reports could be published.
2. Contributors to the review
2.1
All agencies that had, or might have had, contact with members of the family were contacted in February 2021 to ask for preliminary information. This included 27 separate agencies or service types that may have offered services.
2.2
From this original list and early contact, 4 agencies or services were asked to submit Individual Management Reports (IMRs).
This included:
- School A
- GP Practice 1
- College B
- Private Consultant
3. Review Panel members
3.1
A Review Panel was established, and comprised of the following agency representation;
Kevin Ball, Independent Chair and report author - Independent chair
Anne Clark, Strategic Lead Commissioner Domestic Abuse and Violence Against Women & Girls - Brighton & Hove City Council
Rose Hawkins, Strategy & Partnership Officer for Domestic & Sexual Violence - Brighton & Hove City Council
Jane Wooderson, later replaced by Helen Upton, Detective Sergeant, Strategic Safeguarding Team - Sussex Police
Justin Grantham, Interim Head of Safeguarding - Brighton & Hove City Council, Education Services
Alex Cooter, Adolescent Service Manager - RU-OK
Gill Clark, Adolescent Service Manager - Youth Offending Service
Louise Jackson, Designated Nurse Safeguarding Children - NHS Sussex (Integrated Care Board)
Alex Morris, Designated Nurse Safeguarding Adults - NHS Sussex (Integrated Care Board)
5. Terms of reference for the review
5.1
Those agencies providing Individual Management Reviews were asked to consider the following lines of enquiry as part of the terms of reference:
a) Relevant agency or service contact and involvement with Adult T and Child 1 from March 2018 to January 2021.
b) Any issues which help professionals gain a sense about any early trauma or family difficulty for Child 1, that may provide learning for future service provision.
c) Any issues in relation to ethnicity, culture, class, linguistic or religious identity regarding Adult T or Child 1.
d) The sharing and use of information which can maximise support and safeguards, particularly in relation to:
- special educational needs assessment pathways and links between the private and statutory sectors
- specialist mental health assessment pathways and links between the private and statutory sectors
- substance misuse and consideration about thresholds for stepping up intervention from any service or professional involved with the family
e) Any issues relating to professional interactions about Child 1 ordinarily requiring parental consent.
f) Any barriers to family members seeking help on behalf of Child 1.
g) The impact of COVID-19 restrictions on circumstances for Adult T and Child 1.
h) The impact of organisational change over the period covered by the review for any professionals or services which came into contact with relevant family members; whether this was a contributing factor in service delivery, and how this impacted on the service provided to any member of the family.
i) Whether there were any concerns amongst family or friends or within the community, and if so, how such concerns might have been harnessed to enable intervention and support.
6. Summary chronology
6.1
Review of information submitted in regards to Adult T highlights no relevant issues of interest to a Domestic Homicide Review.
6.2
In 2018 Adult T confirmed with Child 1’s school that he would be seeing an Independent Consultant, privately, for an ADHD assessment due to long standing problems with schooling as well as a recent concern about a lack of progress. Prior to this, there had been some incidents of inappropriate physical and sexualised behaviour with peers of Child 1 – these had all been dealt with appropriately and in accordance with policy and procedures in place at the time.
6.3
The outcome of the assessment was that Child 1 was diagnosed with ADHD and an agreement to trial Elvanse, a prolonged release medication for ADHD. Over the following months the dosage of prescribed medication was adjusted until he became more settled and leading to Adult T to report to the Consultant
‘… he seems to be going well on the 40mg and his latest school report is amazing – compared to all the reports that have gone before! Child 1 likes to take them even when skateboarding because his tricks are much better and easier …’.
Adult T had advised Child 1
‘… he must decide when he needs them …’ as she thought they would only be needed for studying. The Private Consultant confirmed that this approach was acceptable, ‘… as in the management of teenagers of this age, increasing self-management is encouraged unless there is obvious cognitive or emotional immaturity …’.
The Private Consultant updated the GP Practice in October 2018 summarising the helpful response to the medication and the positive reports from Child 1, Adult T and school. The update included a request for the GP Practice to continue with the prescription plan and to review the situation in 2 months.
6.4
Later in 2018 Adult T reported to the Private Consultant that he had been getting into some trouble at school, that his pupils had been dilated and wondering if the medication could be the cause. The Private Consultant responded by stating that the medication was unlikely to be the cause and suggested asking whether Child 1 was experimenting with recreational drugs; this issue was not raised again and the medication regime was continued.
6.5
In September 2019 Child 1 began studying at College B, a Further Education establishment. Information about the incident between Child 1 behaving inappropriately towards another pupil in his school in 2018 was appropriately shared, as was concern about him potentially using cannabis. College B had no record of information about an ADHD diagnosis being shared by either Child 1, Child 1’s father, Adult T or School A.
Child 1 successfully completed 1 year at College B from September 2019 through to July 2020; despite the challenges faced between March and July 2020 with COVID-19 and the national restrictions in place.
6.6
Child 1 enrolled on to the second year of his college course in October 2020 however his non-attendance became a common issue. Also, in October 2020 Adult T made contact with the Private Consultant asking for advice stating
‘… we are having problems with Child 1. He is now 17 years old and attending College B which he really enjoys but he has also started smoking weed and still continues to take Elvanse. He is often not turning up at college and although promising to come to work [part time job] he is also not turning up.
He is suffering paranoia and we are all getting annoyed with him rather than helping. He still says he can’t do anything without Elvanse but with the weed as well he has become impossible to reason with. He wants to be in his room all day and it’s an effort to get him to do anything – there are lots of promises but they don’t last long …’ .
The Private Consultant responded by advising that the use of recreational drugs was outside of her area of expertise and that some skilled counselling would be beneficial – highlighting that the assessment of his paranoia and drug use was of prime importance and recommending an independent psychology service; this recommendation was not followed through. Information about this contact was not shared with the GP Practice by the Private Consultant.
The Private Consultant asked Adult T to be kept informed with a view to reviewing progress later in the autumn term. There was no further contact with the Private Consultant from either Child 1 or Adult T.
6.7
In December 2020 Adult T contacted the GP Practice to discuss worries about Child 1, citing behaviour changes, using substances, dropping out of college, demanding money to buy drugs and upsetting the family. Advice was given about accessing different services but there is no information to indicate that these services, or another private route, were approached nor provided any service to Child 1. The services Adult T was signposted to were for adults, not children.
6.8
In January 2021 Child 1 contacted the Police to advised that he had killed Adult T. Following assessment at the point of being charged by the Police, no mental health issues were noted, although he did disclose ADHD and depression on arrest.
6.9
As a result of hair strand testing by the Police following Child 1’s arrest and detention, the presence of a large number of illicit substances including cannabis, amphetamine, MDMA, cocaine and ketamine were confirmed; these results signified usage in the preceding weeks.
Toxicology results from blood and urine samples showed the presence of cannabis which had been reported as commensurate with recent use relatively soon before his arrest, although it could not be confirmed if cannabis had been used prior to or after the fatal assault. No amphetamine was found in Child 1’s blood or urine, indicating that he had not taken his prescribed medication, Elvanse, for at least 1 to 2 days prior to the assault.
This accords with his father’s account of him taking the prescribed medication away from Child 1 a few days earlier, because of how it was negatively affecting his behaviour.
7. Key issues arising from the review
7.1
Other than when Child 1 came to stay with her on what has been reported as a fairly frequent basis, Adult T lived by herself. No information has been provided to this review despite an extensive request, by any agency, professional or family member, to suggest domestic abuse was present in any relationships she may have had with anyone.
7.2
There has been no indication that there was any concern about the quality of the relationship between Adult T and Child 1 – nothing to suggest any abuse or coercion. The only issues highlighted by family members are the known struggles and challenges they all faced in sometimes (but not always) dealing with Child 1’s behaviours.
7.3
Child 1’s mother died when he was 4 years of age. Such an early and significant loss for any child will undoubtedly have had an impact. Research about adverse childhood experiences helps us understand how this may sometimes affect development and life chances. An important consideration following such a profound event is the extent of support provided to the child to help them come to terms with, and accommodate to, circumstances.
It is clear that close family members provided support to Child 1 and that Adult T provided a considerable amount of maternal support for him; it highlights an attachment between them that was made stronger through an early bereavement.
7.4
It is therefore helpful to remind all professionals about the importance of providing support to children who experience significant bereavements during their childhood, but also offering support to the adults who care for children – both of whom will be experiencing their own sense of grief and loss.
7.5
No information has been submitted to this review to suggest that ethnicity, culture, class, linguistic or religious identity had been problematic for either Adult T or Child 1. The issue of class (based on a perspective about economic or financial capacity and opportunity) is of interest and has some relevance to identifying learning. In this case, the use of a private consultant and an independent school (each of which requires fees, as opposed to accessing statutory services) is evident.
The point of interest is how the use of private services link and work together with either the statutory or universal framework of services, and, when behaviour or events take a turn for the worse, the effectiveness of information being shared and risk evaluated. Responsibility for the exchange of information, particularly in matters relating to the safety, welfare and protection of a child – but also an adult - is the same regardless of setting, whether private, independent or statutory.
7.6
Based on their records, School A only became aware of Child 1’s ADHD diagnosis and use of medication via information provided by Child 1’s father, following an email exchange. School A were aware of Child 1 under-going assessment to provide support for his GCSE exams, but not that this then extended into him being assessed for a mental health problem. They were therefore not aware of the full extent of his diagnosis.
7.7
Based on review of their records, College B had no information that Child 1 was diagnosed with ADHD or used prescribed medication to manage it.
7.8
The GP Practice was not aware of any special educational needs that Child 1 may have had. Child 1 had not been subject to any statutory process for assessment under the Education, Health & Care Plan offered by the local authority, and had no identified special educational needs.
7.9
In terms of mental health issues, information was not sought from the GP by the Private Consultant at the point of initial assessment in September 2018; any family history or medical information provided to the Private Consultant was from self-reporting by Child 1, Adult T and Child 1’s father The initial assessment was also based on the educational Psychology report completed in February 2018, plus a report provided by School A and a questionnaire completed by Child 1’s father.
NICE guidance (Attention deficit hyperactivity disorder: diagnosis and management, NICE guideline [NG87] Published: 14 March 2018, Last updated: 13 September 2019) refers to the diagnosis of ADHD needing ‘
… a full clinical and psychosocial assessment of the person; this should include discussion about behaviour and symptoms in the different domains and settings of the person's everyday life and a full developmental and psychiatric history and observer reports and assessment of the person's mental state. … As part of the diagnostic process, include an assessment of the person's needs, coexisting conditions, social, familial and educational or occupational circumstances and physical health. For children and young people, there should also be an assessment of their parents' or carers' mental health …’.
Based on the guidance, it seems that gaining information from GPs is not an explicit expectation. Given that GP records can hold a lifelong account of health and medical issues, the absence of any expectation to seek information at the point of initial assessment and initial diagnosis, seems at odds with acquiring an objective and full developmental and psychiatric history.
Review Panel members debated this apparent juxtaposition extensively and noted the Private Consultant’s reflections from review of this case. It is possible to access many health care services without the knowledge or involvement of a GP; and which provides a valuable pathway and source of support for many people. In this case, even if the Private Consultant had gained earlier input from the GP it is unlikely to have altered the diagnosis and treatment plan for prescribed medication.
On this basis, the Review Panel did not consider it proportionate to justify a recommendation on this point – with any requests for changes to the guidance likely being disproportionate and based on the unpredictable and extreme events of just one case.
7.10
Information was shared with the GP Practice by Adult T about the involvement of the Private Consultant in December 2018, with a letter from the Private Consultant in October 2018; the letter set out the assessment and treatment plan. A further, and final, letter was sent to the GP Practice by the Private Consultant in January 2019 following a treatment review. At no time were the concerns about possible experimentation with recreational drugs, raised in November 2018 by Adult T with the Private Consultant, raised during this treatment review.
The Private Consultant recognises that this was an oversight; it occurring because of being impressed with Child 1’s overall progress and improvement in school. The information provided about possible experimentation with recreational drugs was also not shared with the GP Practice; again, an omission by the Private Consultant based on Child 1’s increased confidence and sense of achievement.
7.11
In response to Child 1’s changes in behaviour, Adult T contacted the GP Practice in December 2020 to request further help. The GP Practice was unable to offer any support, instead informing Adult T about 3 local support services; however, all of these are for over 18-year-olds (Pavilions, MIND, YMCA) – there was no consideration of signposting to the local service for under 18-year-olds, RU-OK Service.
Also, it has been noted that the GP Practice could have done more to make contact with the Private Consultant to seek clarification about the level of input being provided. This highlights that information was not shared, nor was it sought.
7.12
All of the above instances reflect learning about the importance of information sharing and working in a collaborative manner.
The impact of the COVID-19 pandemic, and the associated restrictions that were imposed, are likely to have been a contributory factor to Child 1’s deteriorating circumstances. Whilst Child 1 successfully completed his first year at College the second year was more problematic and when family members began to notice a difference in Child 1’s behaviours, his attitude to college and withdrawing from his studies, but also his use of cannabis increasing.
8. Conclusion
8.1
This review has mainly examined the involvement of agencies and services with an adolescent male who had been diagnosed with ADHD, was using prescribed medication to manage his symptoms, but was also using recreational drugs. The adolescent male killed Adult T, who was trying to help him and who had been a great and reliable source of support and kindness throughout his childhood.
8.2
The review has benefitted from information being provided by those agencies and professionals most closely involved during the time under review; this however was limited. Family members were offered the opportunity to contribute but this was declined, with them preferring to remain private about what had happened.
8.3
Learning has been identified, and one recommendation has been made. It is hoped that this will help reduce and counter the use of recreational drugs alongside prescribed medication and the potential dangerous impact such a combination can have.
9. Lessons to be learned
9.1
Based on the limited information available from agencies, but also family members not wanting to engage in the review process, learning from this case is somewhat limited. The review has identified some learning points which are important and clearly reflect a theme around communication and information sharing.
9.2
From a risk management perspective, they remind us about the unpredictable impact of recreational drug use especially when used alongside prescribed medication, and the importance of professionals knowing about dual usage so that risk can be assessed, and safety measures put in place if necessary.
Indeed, the sentencing remarks from the Judge about Child 1, in the criminal trial highlight this as a learning point
' ... I am quite satisfied that the principal factor in you developing the psychotic episode was because of your use of drugs, smoking cannabis and abusing the Elvanse, in particular. None of the psychiatrists who have reported in this case at any point have suggested you had shown any signs of mental illness prior to you starting to use drugs, and you’ve not suffered any mental illness since save for the weeks immediately afterwards when you, undoubtedly, had an adjustment disorder as a result of finding yourself in custody charged with murder.
Similarly, none of the psychiatrists suggest there was a combination of factors in your life that, by themselves, made you particularly susceptible to mental breakdown if considered in isolation from your drug use. None of your family or friends have suggested, in their evidence, that there were any difficulties out of the norm until the time you started to use drugs, in particular to smoke a lot of cannabis and to deliberately overuse your amphetamine-based Elvanse medication.
And that makes this case an utterly dreadful example of what can result from taking illegal drugs and abusing prescription medication ...'.
The use of a private pathway to gain diagnosis and ongoing support is not necessarily problematic in itself, but when information is not shared in a timely or effective manner, it may impact on shared support or risk management.
9.3
The GP Practice has reflected on their own learning as a result of this review:
- Concerns were raised by a family member about a change in Child 1’s behaviour and about potential substance misuse; Child 1 was being regularly prescribed medication for ADHD. Child 1 was not directly contacted to explore the concerns further, meaning that risk and vulnerability was not fully assessed.
- Signposting to substance misuse services did not occur and the services that were discussed with Adult T were all for adults. Child 1, at the time, was 17 years and 9 months of age but would likely not have been able to access those adult services.
- Opportunities for professional curiosity existed, which were not taken; these arose in conversation with Adult T and confirming where Child 1 lived, plus exploring the impact of drug use on Child 1, and the household.
- There was an opportunity for the GP Practice, as the prescribing primary care service, to liaise with the Private Consultant about his behaviour change. Additionally, opportunities were not taken to request more clear documentation about whether Child 1 had been reviewed by the Private Consultant and for any other relevant documentation that may have been useful to have on record.
9.4
School A has reflected on their learning, which includes:
- The importance of assessment reports being available to the school, and having a copy on record in order to better understand a child’s needs and circumstances. Requesting, and following up, with parents and professionals is an important step to ensure this happens.
9.5
The Private Consultant has indicated learning as;
- To remain more alert and exercise greater professional curiosity about information provided during assessments and reviews which may be an indicator of risk or vulnerability,
- To share information with other agencies, as necessary, particularly when risks or concerns are raised that are outside of their area of expertise. GP Practices are likely to hold other potentially relevant information about a patient that may not have come to light at the point of an initial assessment, given that contact with the GP is often not made at that early stage.
10. Recommendations from the review
10.1
Where those agencies and individuals that have contributed to this review have identified learning, actions have been agreed and recorded in a separate action plan.
10.2
The following recommendation is for Brighton & Hove Violence Against Women and Girls Unit to;
1. Work with relevant agencies and other strategic partnerships to promote awareness about the unpredictable risks associated with recreational drug use, especially when used alongside prescribed medication. To consider methods to cascade this important message via existing work in local secondary schools, independent schools and further education establishments and post 16 years training providers.