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Summary of recommendations Recommendation 1 (TEWV): It is clear from the research that patients and their families (and some staff) were ignored and that their concerns and complaints are now found to be, on the whole, justified. The Trust must seek assurance that complaints, concerns and feedback are taken seriously and managed in line with The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 particularly in relation to recording receipt of a formal complaint. Additionally, feedback and concerns on a service must be comprehensively reported and reviewed on a frequent basis, and importantly, that feedback is acted upon. Recommendation 2 (TEWV): Formal corporate decision-making processes and outcomes were difficult to trace and evidence. The Trust should seek assurance that there is a ratified minute of key organisational decisions. Recommendation 3 (TEWV): Action plans relating to West Lane Hospital were not connected to improvement programmes or risk registers. The Trust should ensure that there is strategic oversight of actions through the Board, Committee or working group where multiple interventions are involved. This will ensure that actions are not duplicated with other activities or overlooked. Using a programme approach around improvement plans and risk registers increases the accountability and enforceability around actions. Recommendation 4 (TEWV): There were issues with the consistent application of Duty of Candour at the Trust. The Trust should seek assurance that there are now mechanisms in place to assess that the Duty of Candour Policy is effectively implemented. Additionally, where there has been a death in a service, whether through self-harm/suicide or homicide, that families are given appropriate, meaningful, timely and compassionate family liaison and support through personal contact with a nominated officer of the Trust. Recommendation 5 (TEWV, CNTW, North East & North Cumbria ICB, Middlesborough Council, NHSE and provider collaborative, and CQC): TEWV, CNTW and System Partners need to seek assurance that they have resolved the problems associated with the clinical transitions phase (between services and child to adult). A compound recommendation is required to address this deficit: a) TEWV must provide assurance that a full gap analysis between the 2018 Healthcare Safety Investigation Branch (HSIB) investigation and its own position has been completed. As the Trust still delivers Tier 3 CAMHS services they should expedite a review of processes and procedures in relation to transitions. b) CNTW need to expedite a review of processes and procedures in relation to transition of CNTW young person inpatient to adult services. c) Patient as well as stakeholder feedback associated with transitions between CAMHS and other services (such as AMHT) should be sought and incorporated into service redesign by all parties. d) Effective governance surrounding transitions was not always in place. The good practice relating to transitions which is described within NICE Guidance should be translated into practice and delivered by all parties. e) Where a young person is in receipt of T4 care and transferring back to T3, there must be a joint response between health and the relevant local authority children’s services (in this case Middlesborough Council) so that the young person is prepared for life in the community and can be properly supported and their risks appropriately managed. f) ICBs, NHSE and provider collaboratives must ensure that providers with a PICU have a written protocol that details the pathway for discharge, including timescales for involving in arrangements, the families and the young person. This will ensure that, wherever possible, a young person is not suddenly transferred without adequate preparation. Recommendation 6 (TEWV): There was a gap between the development and successful implementation of important care initiatives (such as least restrictive practice), plans and evidence-based changes to practice. The Trust must seek assurance that there are implementation plans for new initiatives, policies or procedures and that these are evidence-based, being implemented correctly within services and monitored appropriately. Recommendation 7: There was a lack of systematisation in relation to the identification, mitigation and actioning of known risks at a ward, service and corporate level. A compound recommendation is required to address this deficit: a. TEWV must ensure that risk assessments for young people in CAMHS are based on a psychological formulation and are developed by a multidisciplinary team in conjunction with the young person and their family. b. TEWV must ensure that proper training is provided to staff around clinical risk management and how to ensure that action is taken consistently. c. TEWV must provide assurance that it meets the requirements of the new Patient Safety Incident Response Framework by 2023. d. The North East & North Cumbria Integrated Care Board (ICB), NHSE, and provider collaborative must seek assurance that TEWV has a robust environmental and ligature risk assessment process and the ability to respond effectively and urgently to mitigate risks identified through this process (including risks identified on Tunstall Ward). e. North East & North Cumbria Integrated Care Board must assure themselves that CNTW are following the NHS Child and Adolescent Mental Health Services Tier 4 (CAMHS T4): General Adolescent Services including specialist eating disorder service specification and the QNIC standards for use of mobile phones and social media access in inpatient environments. f. The application of robust risk assessment forms part of the CQC regulatory framework. The CQC should routinely examine the quality and consistent application of TEWV’s clinical risk assessment, clinical risk training and the relationships to local and corporate risk registers. Recommendation 8 (TEWV): The function of Executive team meetings in terms of operational involvement lacked clarity. The Executive team meetings must clearly define and record actions which they are directly responsible for, or, where actions have been delegated. The ET should recognise that it has the mandate to form task and finish groups. Recommendation 9: Safeguarding between mental health providers and system partnerships was insufficient to protect young people in West Lane Hospital. Despite the availability of Working Together Guidance, responsibilities and obligations internally and externally between agencies (providers and system colleagues) were confused, interpreted differently by individuals and consequently gaps developed. A compound recommendation is required to address this deficit: a. NHS England Specialised Commissioning, the North East & North Cumbria ICB and provider collaborative and the South Tees Safeguarding Children Partnership Board and LADO should now all reflect upon matters raised within this report and determine whether further internal review is required to ensure proper learning occurs within each respective agency. All relevant Safeguarding Children’s partnerships need to ensure that there are sufficient mechanisms in place to prevent a recurrence of the same. b. The North East & North Cumbria ICB and provider collaboratives should obtain assurance that provider organisations have sound systems and processes to safeguard young people in mental health facilities, and these provide regular robust assurance to NHS England Specialised Commissioning of effective working. c. Middlesbrough Council and Health providers/ key partners must ensure that there is clarity about the roles and responsibilities of each agency in the planning and delivery of care to young people in Tier 4 CAMHS provision to ensure that support is holistic and meets the educational; social; physical health and emotional needs of children and young people as well as their mental health needs. d. Local Authorities and Health providers must provide appropriate challenge where there are concerns about unsafe discharge arrangements from Tier 4 inpatient care, including appropriate escalation up to chief officers where concerns for children’s safety are high. e. Durham County Council must ensure that responses to referrals are completed within expected time frames, and subsequent assessments always incorporate the views of the family and young person. f. North East and North Cumbria Integrated Care Board and the Provider Collaborative must consider the impact and risks on Tier 4 CAMHS if a local Safeguarding Board is found to be weak or inadequate, or a local provider is found to have a major staffing issue. g. Where Safeguarding concerns are raised about a child, these must include a formal consideration of other vulnerable family members for the lifespan of care. h. Middlesbrough Council must respond formally to serious concerns raised about the care and treatment of a young person under their care and explore concerns with the family and the young person. Recommendation 10 (TEWV): Reporting structures were disconnected between various tiers of governance, and this prevented the ‘drill-down’ required for effective oversight and effective learning. The Trust must ensure rounded reporting arrangements to support proper Board assurance consisting of both hard evidence and soft intelligence. This should include a ‘trigger tool’ when a ward or department is experiencing ‘stress’, such as failing to complete training, debriefs, high sickness absence, low staff morale and this should be viewed alongside patterns of incidents, harms and complaints. Recommendation 11: There were gaps in relation to both the commissioning of effective services and in relation to the regulatory oversight in relation to West Lane Hospital. Assurance seeking activity was weak with a lack of sufficient scrutiny of both hard and soft intelligence. A compound recommendation is required to address this deficit: a. NHS England Specialised Commissioning and the Care Quality Commission (CQC) must ensure that when there is enhanced surveillance of services following quality concerns, the themes and patterns of all incidents are rigorously scrutinised and analysed. b. NHS England Specialised Commissioning, the provider collaborative and the North East & North Cumbria ICB, should work together with the Directors of Children's Services in the North East region. This is to ensure that services are commissioned which will meet the needs of the growing number of young people with complex needs and challenging behaviours that require integrated health and social care responses. c. A demand and capacity review (under the provider collaboratives programme and in association with each local authority) should be undertaken to ensure services have the appropriate capacity locally to minimise placing children out of area and to ensure the availability of suitable specialist care. d. TEWV/NHS England, the provider collaborative and Middlesbrough Council must provide assurance that all looked after children specifically with a diagnosis of autism have care provided that is in line with the NICE guidance on autism spectrum disorder in under 19s: support and management, recognising the challenges in the system. Recommendation 12: (NHS England) A full assurance review of progress against the recommendations contained within this report must be completed in 6-12 TEWS response to the report TEWV-assurance-statement-20-March-2023.pdf

Key findings One in four teenagers aged 17-19 have a mental health difficulty, an increase from one in six in 2021. Poverty continues to have a strong link to young people’s poor mental health. Reversed patterns of probable mental health difficulty for boys/young men and girls/young women highlights the need for specific gender-specific approaches. Young people with a mental health difficulty are more likely to have negative experience of social media. Young people with a mental health difficulty are more likely to miss school and feel unsafe while at school.

Key findings Report commissioned by Look Ahead Care and Support finds increasing demand for children and young people’s crisis mental health services amidst challenges with existing services. Yet researchers heard from professionals, service users and their families and carers found that you “had to have attempted suicide multiple times to be offered inpatient support". Interviewees say A&E departments have become an ‘accidental hub’ for children and young people experiencing crisis but are ill equipped to offer the treatment required. Private sector providers now deliver the majority of support for hospitalised young people with mental health difficulties at “exceptionally high” cost. Report recommends alternative community crisis services, including supported housing away from hospital settings to reduce pressure on A&E and reduce costs by more than 50%

Key findings In 2022, 18.0% of children aged 7 to 16 years and 22.0% of young people aged 17 to 24 years had a probable mental disorder. In children aged 7 to 16 years, rates rose from 1 in 9 (12.1%) in 2017 to 1 in 6 (16.7%) in 2020. Rates of probable mental disorder then remained stable between 2020, 2021 and 2022. In young people aged 17 to 19 years, rates of a probable mental disorder rose from 1 in 10 (10.1%) in 2017 to 1 in 6 (17.7%) in 2020. Rates were stable between 2020 and 2021, but then increased from 1 in 6 (17.4%) in 2021 to 1 in 4 (25.7%) in 2022. 11 to 16 year olds with a probable mental disorder were less likely to feel safe at school (61.2%) than those unlikely to have a mental disorder (89.2%). They were also less likely to report enjoyment of learning or having a friend they could turn to for support. 1 in 8 (12.6%) 11 to 16 year old social media users reported that they had been bullied online. This was more than 1 in 4 (29.4%) among those with a probable mental disorder. 11 to 16 year old social media users with a probable mental disorder were less likely to report feeling safe online (48.4%) than those unlikely to have a disorder (66.5%). 1 in 5 (19.9%) 7 to 16 year olds lived in households that experienced a reduction in household income in the past year. This was more than 1 in 4 (28.6%) among children with a probable mental disorder. Among 17 to 22 year olds with a probable mental disorder, 14.8% reported living in a household that had experienced not being able to buy enough food or using a food bank in the past year, compared with 2.1% of young people unlikely to have a mental disorder.

Dashboards include: Restrictive Practice - CAMHS Low Secure Restrictive Practice - CAMHS Medium Secure Restrictive Practice - CAMHS PICU Restrictive Practice - CAMHS T4 Restrictive Practice - D/deaf (Adults) Restrictive Practice - D/deaf CAMHS Restrictive Practice - Eating Disorders (Adults) Restrictive Practice - High Secure (Adults) Restrictive Practice - Low Secure (Adults) Restrictive Practice - Medium Secure (Adults) Restrictive Practice - Obsessive Compulsive Disorder and Body Dysmorphic Disorder Service Restrictive Practice - Perinatal Restrictive Practice - Tier 4 Personality Disorder

Key points The report highlights the following key findings about children and young people's mental health: One in six children aged 6 to 16 were identified as having a probable mental health problem in July 2021, a huge increase from one in nine in 2017. Boys aged 6 to 10 are more likely to have a probable mental disorder than girls, but in 17 to 19-year-olds this pattern reverses, with rates higher in young women than young men. By the age of eight, 7 in 10 children report at least one adverse childhood experience (ACE).Three in four adolescents exposed to ACEs develop mental health problems by the age of 18, including major depression, conduct disorder, alcohol dependence, self harm, suicide attempts, and posttraumatic stress disorders (PTSD). In 2018, the suicide rate in women aged under 25 years had significantly increased since 2012 to its highest ever recorded level of 3.3 per 100,000. Nearly half of 17–19-year-olds with a diagnosable mental health disorder have selfharmed or attempted suicide at some point, rising to 53% for young women. In 2018-19, 24% of 17-year-olds reported having self-harmed in the previous year, and seven percent reported having self-harmed with suicidal intent at some point in their lives. 16% reported high levels of psychological distress. There was a 47% increase in the number of new emergency referrals to crisis care teams in under-18-year-olds between December 2019 and April 2021. Consistent findings showing people in marginalised groups are at greater risk of mental health problems, including people from Black, Asian and other minority ethnic backgrounds, lesbian, gay, bisexual and transgender people, disabled people and people who have had contact with the criminal justice system, among others. Recommendations A commitment from the next Prime Minister to fund an immediate £1bn children and young people’s mental health wellbeing recovery programme to improve the quality and effectiveness of mental health care and support, with guaranteed appointment and treatment times as part of a wider post pandemic commitment to children and young people. New local frameworks for children and young people’s wellbeing (aged 0-25) between health, children’s services, schools, youth offending teams and the police to provide an integrated approach with common performance targets and pooled financial contributions from all partners. Guaranteed mental health assessments for children and young people at points of vulnerability. This would mean an automatic assessment and guaranteed mental health package for children entering care and automatic assessments for children and young people at risk of exclusion from school, who go missing, at the point of arrest, or are involved in violence or crime. It would include a guarantee of assessment by education psychologists for any child at risk of exclusion. A national implementation programme to embed a whole school and college approach to mental health and wellbeing across all education settings in the country. This should include a commitment from Government to provide a funding package for Mental Health Support Teams beyond 2023/24 to ensure that all schools have access to this vital additional support by 2030. An ambitious programme of drop in mental health hubs delivered in the community. These new community drop-in centres will provide vital drop in access and work with local community groups to provide outreach support, funded by the new recovery programme. A national ‘Programmes on Prescription’ scheme in every area. Building on emerging local approaches, the roll out of a major funded programme of social prescribing for mental health wellbeing that enables GPs and health professionals to pay for sports and arts sessions, music, drama, activities, youth clubs, outings, and volunteering programmes to improve young people’s confidence, self-esteem, and skills and make friends. A major recruitment programme with ambitious targets to build the children and young people workforce required to meet this expansion of services. It is vitally important to ensure that this workforce is diverse and culturally competent. Wellbeing and mental health training and support for all professionals working with children and young people. Identifying and understanding the mental health needs of children is vital if they are to be offered the help they need. Make co-production and community work a cornerstone of mental health care to ensure long-term trusted relationships for young people and to give them a constant point of contact. Improved wellbeing on digital platforms. We know that many children feel more comfortable and sometimes prefer help online, which should also be extended and supported as an important strand of a local strategy. Better information and support for parents to support children and young people’s positive mental health and wellbeing. Improving the mental health and well-being of young people at risk of harm and being involved in the criminal justice system. This should be measured as a core aspect of NHS equality targets with leadership, resources, and delivery plans.

Coroner's Matters of Concern The concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment. Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation. That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act. Although I understand that there is a long term plan to extend young people’s services to age 25, but I remain concerned about the ongoing situation, and that a young person today could be faced with the same challenges in finding support pending substantive treatment. I believe this concern is the combined responsibility of Cambridgeshire County Council and CPFT. These organisations may wish to consult in preparing their response to this report. The inquest heard evidence about the considerable delay in obtaining appointments for the Gender Identity Clinic, and about the shortage of availability for psychological therapies such as CBT. These are matters for policy and funding. This report will therefore be copied to NHSE and The Secretary of State for Health for information purposes only.

The report found that access for children and young people was inadequate. It found that the system was complicated, and there was not a clear, easy way to get support. It made the following recommendations: The Secretary of State for Health and Social Care should make sure there is joint action across government to make children and young people’s mental health a national priority, working with ministers in health, social care, education, housing and local government Local organisations must work together to deliver a clear ‘local offer’ of the care and support available to children and young people Government, employers and schools should make sure that everyone that works, volunteers or cares for children and young people are trained to encourage good mental health and offer basic mental health support Ofsted should look at what schools are doing to support children and young people’s mental health when they inspect