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Special Report - Learning from practice: Deaths of children in care in Scotland

Reports published after a child in care in Scotland dies should be signed off by a chief social worker but should include contributions from other partners, the Care Inspectorate has stated.

Forty-two children in care in Scotland died between 2012 and 2018, and a further 19 young people in receipt of continuing care and aftercare also died over a four-year period from 2015–2018, the report added.

While many of the reports of deaths of looked after young people were signed off by a senior social work manager or the chief social work officer, some were signed off by first line managers, while a few were written and signed off by the allocated social worker. The Care Inspectorate said they would expect all reviews to be signed off by the chief social work officer whose responsibilities include promoting values and standards of professional practice, and who advises on the appropriate systems required to promote continuous improvement.

The reviews submitted were written predominantly from a social work perspective. The Care Inspectorate said this meant reviews were not sufficiently informed by contributions from other partners. In the best examples, a multi-agency approach was taken and this led to a more holistic approach to considering how well the child or young person’s needs had been met.

“The effectiveness of joint working is recognised as critical to improving outcomes for care experienced children and young people. The guidance would benefit from revision that would see partners in a local authority area submit a single shared report and supporting documentation to reflect joint working and collective leadership responsibility as corporate parents,” the report by the care Inspectorate said.

Potential learning

The 42 children in care in Scotland who died ranged in age from less than a year to 17-years-old. There were:

- 13 children under 5-years-old

- 5 children aged 5 to 11 years old

- 19 children aged 12 to 16-years-old

- 5 children aged between 17 and their 18th birthday

“Looked after children and young people who died lived in both rural and urban areas and came from 18 local authority areas. The remaining 14 areas did not report any deaths of looked after children between 1 January 2012 and 31 December 2018,” said the report.

The Looked After Children (Scotland) Regulations 2009 require local authorities to notify the Care Inspectorate of the death of a looked after child within one working day of the child’s death. Following such notification, the local authority is required to submit a full report within 28 days.

Since 2015, local authorities are required to notify the Care Inspectorate of the death of a young person in receipt of continuing care or aftercare services. However, unlike notifications of the deaths of looked after children, there is no requirement to submit a report and supporting documentation for the Care Inspectorate to review.

“This severely restricts any potential learning from the deaths of young people in receipt of these services,” the report said.

Most of the children and young people who died were looked after in the community at the time of their death at home, in kinship care or foster care. Some looked after children and young people had more than one placement at the time of their death, for example they were looked after at home or in kinship or foster care, and they were also provided with overnight residential respite.

Of the 19 young people aged between 18 and 26-years-old receiving aftercare who died, 15 were young men and 4 were young women.

“Over the four-year period from 1 January 2015 to 31 December 2018 and following the change in legal requirements, we received 19 notifications of the deaths of young people in receipt of continuing care or aftercare. Deaths of young men predominated among those in receipt of continuing care and aftercare. Almost all notifications were of the deaths of young people in receipt of aftercare. It would be helpful to know more about the lives of these young people and the circumstances surrounding their deaths. This would help in lessons to be learned and assess whether these children and young people were getting the appropriate level of support. However, without a report and supporting documentation to accompany these notifications, further analysis has not been possible,” said the report.

Three distinct categories

The Care Inspectorate said that currently they do not know whether a looked after child or young person is more likely to die in childhood than their peers and if so, why this is the case and what actions should be taken to reduce any deaths that are deemed to be preventable. The development of a national hub to oversee reviews of the deaths of children in Scotland, including the deaths of looked after children, should help to increase the understanding of trends and actions to reduce preventable deaths.

The deaths of looked after children and young people fall into three distinct categories:

- Those whose deaths while tragic, could be anticipated due to a life shortening condition or terminal illness.

- Those whose deaths were unexpected due to misadventure or where the cause of death was unexplained.

- Those young people whose risk-taking behaviours culminated in their untimely death.

Sixteen deaths were due to a life shortening condition or terminal illness, 12 were due to misadventure and 14 were as a result of risk-taking behaviours.

Those with life-shortening conditions had complex care needs. At the time of their death, they ranged in age from 1 to 17 years of age and were evenly divided between male and female. Four of these children were cared for at home by their parents and provided with short overnight breaks.
Another eight were looked after and accommodated in kinship or foster care or residential placements as parents were unable to meet their needs fully and keep them safe.

It was evident that children and young people with life shortening conditions and their carers benefited greatly from high-quality respite care tailored to meet their individual needs.

Life shortening illnesses

The report highlighted that:

- Staff formed sincere and dependable relationships with this group of looked after children, young people and carers, who in turn developed high levels of trust and confidence in their skills and professional judgement.

- Staff offered support to carers and other affected family members including brothers and sisters directly after the death of a looked after child or young person, often continuing to do so through the early stages of bereavement.

- There were examples of excellent care provided by parents, kinship carers, foster carers and members of staff from across services that optimised every aspect of these children’s and young people’s wellbeing.

- Staff in educational establishments and respite resources benefited from additional training in the day to day individualised care required by a child or young person, including some medical procedures. This increased the confidence and competence of staff.

- Identifying a member of staff to take on the role of health co-ordinator and to act as a single point of contact for health services significantly improved the management of cases involving a wide range of health specialists and improved joint working with education and social work services.

- Overall, it was evident that children and young people were experiencing tailored and very well-planned learning opportunities including those attending special schools.

- Looked after child reviews were helpfully combined with reviews of education plans including co-ordinated support plans and health plans such as emergency medicine care plans.

- When these looked after children and young people lived in households with other children, including their siblings, respite care was particularly helpful in enabling carers to spend time giving undivided attention to other family members.

- Respite took many forms and was provided by staff coming into a carers’ own home, providing children and young people with support services and activities in the community and most commonly, through a series of short breaks in specialist residential resources.

- Plans were put in place for those with a life-shortening condition or terminal illness to ensure children and young people died with dignity and in accordance with the wishes of parents, kinship carers, permanent foster carers and importantly, the children and young people themselves when they were able to express their views.

- Agile responses that overcame budgetary constraints to adapting homes, for example for wheelchair use, had a very positive impact on providing appropriate care at home or in care placements with kinship carers and foster carers.

- Timely permanency planning clarified the legal status of the child or young person and the rights of parents and foster carers to be involved in decision-making about end of life care. Securing this legal status was not always given enough priority when working with looked after children and young people with a life-shortening condition. In a few cases, this had the potential to lead to a conflict of interests between the child or young person, their birth parents and foster carers around the time of the child or young person’s death and subsequent funeral arrangements.


In terms of learning from practice where the death of a looked after child or young person was unexpected due to misadventure or unexplained, for example due to sudden unexpected death in infancy, the report found:

- Three young people looked after at home, in kinship and foster care respectively died in tragic circumstances associated with road traffic accidents and open water. Such deaths emphasise the importance of preventative work carried out by Police Scotland and the Scottish Fire and Rescue Service.

- The majority of children in this category were under five years of age when they died and seven were under a year old. It is of note that nearly half of all child deaths in Scotland are children under a year old. Looked after children in this category were typically born prematurely with some diagnosed with neonatal abstinence or foetal alcohol syndromes in addition to other health complications.

Risk taking

Regarding risk taking behaviours, there were 14 looked after young people who died in tragic circumstances that were typically as a culmination of life-threatening behaviours including substance misuse, self-harm and attempted suicides.

- These young people ranged in age from 13 to 17 years at the time of their death and most were young men.

- The lives of these young people were commonly characterised by a combination of adverse childhood experiences often resulting in uncontainable feelings of anger and distress, such as:
• anxious, insecure attachments or multiple care givers
• separation and loss of significant people in their lives, including siblings, through death or major disruption in family relationships
• physical and emotional neglect associated with parental alcohol and drug misuse or parental mental illness
• exposure to domestic violence and parental relationships characterised by conflict
• physical or sexual abuse perpetrated by a close family member without a protective parent • unstable and insecure family life with frequent changes of address including periods of homelessness exacerbating the detrimental impact of poverty and deprivation.

Mental health

Young people whose risk-taking behaviours culminated in their untimely deaths came to the attention of a wide range of services who offered help and support but then withdrew in response to a lack of engagement from the family and by the young person themselves as they got older. In recent years, as a result of implementing a Getting it right for every child approach, staff from a greater range of services have become increasingly alert to wellbeing concerns at an earlier stage.

The report highlighted that vulnerable-young-person procedures can be a useful tool in assessing and meeting the needs of young people whose behaviour may place them at risk. The Care Inspectorate would like to see them use adopted more widely; child protection committees that have not already done so may wish to consider whether practice would be strengthened by developing and implementing them.

There were good practice examples of staff showing persistence in engaging and maintaining relationships with looked after young people. Care experienced young people report that sincere and enduring relationships are what makes the most difference to them.

The report stated that a consistent feature of this group of looked after young people was long-standing needs in terms of mental wellbeing. “More needs to be done to ensure mental and emotional health services are available for vulnerable and looked after children and young people,” the report concluded.

A report on the deaths of looked after children in Scotland 2012-2018:

An overview from notifications and reports submitted to the Care Inspectorate

Working Together For Children

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