What the serious case review found following the inquest into Amber Peat

The report by Nottinghamshire Safeguarding Children Board (NSCB), was commissioned as an inquest found health education and social care agencies missed 11 chances to help her before her death.

It examined what could be learned from the tragic events to improve child protection.

Amber, aged 13, died shortly after 17.50pm on Saturday, May 13, 2015 inside a hedgerow off Westfield Lane, Mansfield, as a result of hanging.

Amber had made her way directly inside the hedgerow after leaving her home address following an argument with her family.

Assistant coroner Laurinda Bower said she could not be sure if Amber intended to kill herself after she crept into bushes after going missing from home and hanged herself.

Miss Bower also said that social services missed “at least 11 opportunities” to intervene in Amber’s life.

A Serious Case Review was commissioned by the Board soon after Amber’s death. The purpose of the review was to examine what could be learnt that would lead to improvements in the way services worked with children and families. Amber had lived in Derbyshire and Nottinghamshire and the review therefore involved agencies from both areas.

The Review identified some areas where improvements should be made in the way agencies worked to safeguard children. Action to address these was commenced as soon as they were identified and progress was monitored by the Safeguarding Children Board.

Following conclusion of the inquest into Amber’s death, the evidence heard, and the findings of HM Coroner were reviewed. The Coroner noted that extensive work had been undertaken to ensure that safeguarding systems are as robust as they can be.

Chris Few, Independent Chair of the Nottinghamshire Safeguarding Children Board said: “We owe it to Amber to learn from what happened and Nottinghamshire Safeguarding Children Board commissioned an independent serious case review to examine what would lead to improvements in the way that agencies work to keep children safe.

“Action was commenced to address learning from the review as soon as it was identified and extensive work has been undertaken to ensure that safeguarding systems are as robust as they can be.”

The review led by Dr Cath Connor which does not identify Amber by name, but refers to her case as KN15 says:

“NSCB recognised the potential to learn lessons from this review regarding the way that agencies work together in Nottinghamshire and Derbyshire to safeguard children.

Working Together 2015 outlines the purpose of reviews is ‘to identify improvements which are needed and to consolidate good practice.

LSCBs and their partner organisations should translate the findings from reviews into programs of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children’.

Good practice and learning identified by this review are outlined within this report.

“This review established that while there were concerns for the emotional wellbeing of KN15, it could not have been predicted that she would take her own life.”

Steve Edwards, service director for Youth, Families and Social Work at NCC, said: “Nottinghamshire County Council accepts the findings of the Coroner’s Inquest and the recommendations of the Serious Case Review into the tragic death of Amber Peat in 2015.

“Our thoughts remain with Amber’s family and her friends.

“Both the Coroner’s Inquest and the Serious Case Review comment on two referrals into the Nottinghamshire MASH.

“In the years between Amber’s death in 2015 and today there have been ongoing revisions and improvements to processes within the MASH.

“The Coroner noted in her conclusion that ‘extensive work has been undertaken to ensure that safeguarding systems are as robust as they can be’.

“The MASH was subject to a positive Ofsted Inspection as recently as January this year.

“We continue to work to ensure that all our safeguarding systems are as safe as they can be.”

In a summary its key findings are:

1. Early intervention and support for families will be more effective, cohesive, and focussed, when delivered with a written assessment and plan to clarify the focus of the work and to enable outcomes to be monitored and evidenced.

2. Adults who present with mental health problems can have an impact on the whole family.

It is important that the needs of children who live with adults who have reported mental health problems in Nottinghamshire and Derbyshire should be systematically assessed by all partner agencies to ensure that children and families receive the support they require.

3. Assessments, following the identification of emerging needs, should explore the wishes and feelings of the child to further understand the cause of a child’s behaviour and possible underlying distress. The intervention should avoid only focusing on the behavioural change of the child.

4 The potential consequences for the child should be considered by those involved before sharing concerns about possible emotional abuse with parents/carers.

5 When a child moves school, professionals should be aware of a child’s history and alert to any gaps in that history.

Inquest was a damning indictment of agencies charged with safeguarding children says coronerSocial Services missed 11 opportunities to help Amber