Independent chair and report author: Kevin Ball
Remarks from the sentencing Judge in the criminal trial (Rex v Anonymous [2023] UKHL Lewes Crown Court 2023) included the following description of the victim, Adult T;
' ... she was a highly successful and very well-respected businesswoman. Well known in the area and throughout the wider region. As well as being known through her businesses, her popularity was due, in no small part, to the huge amount of support that she gave to many charities and organisations, not just financially but giving of her time too, as a trustee, hosting and attending fundraisers for the less fortunate in society. And she was described by many people as the heart and soul of local life, a stalwart of the community, and someone with a generosity of spirit that drew many people to her.
She was an inspiration to many, and people speak of her sense of fun and interest in everyone and everything, and how much time she devoted to helping other people. It is clear to me that she was a major figure in the life of all her family too, and that they were all at the very heart of her life.
It is, perhaps, the greatest testament to her that she leaves behind loving and understanding children and grandchildren, prepared not only to forgive you for what you have done but who continue to support you. Her grandchildren were clearly a great source of joy in her life, that included you and it is impossible to forget the evidence I heard at trial as to how much she loved you and how much she did for you ...'
This Domestic Homicide Review examines the contact and involvement of professionals and organisations with a 59-year-old woman and her 17-year-old paternal grandson.
For the purposes of this review the woman will be known as Adult T and the grandson will be known as Child 1.
In January 2021 Child 1 called the Police stating that he had killed his grandmother. Adult T was found in the house deceased having suffered multiple stab wounds. Child 1 was arrested on suspicion of her murder. During the Police investigation witness statements were taken, including those from a long standing friend of Adult T, who described her as
… a warm and generous person who was very supportive of her family. She adored her children and grandchildren and would do anything for them ...’.
The friend has described how Adult T would regularly have Child 1 to stay with her over the years, with him seeing it as a second home, but also them going on holiday and enjoying one another’s company. The friend also described how Adult T was increasingly becoming more worried about Child 1 in the preceding months before her death, concerned about his illicit drug use.
The Domestic Violence, Crime & Victims Act 2004 sets out the circumstances when a Domestic Homicide Review should be considered referring to the circumstances in which the death of a person aged 16 years or over has, or appears to have, resulted from violence, abuse or neglect by
a) a person to whom he or she was related or with whom he or she had been in an intimate personal relationship, or
b) a member of the same household as himself or herself.
Using these criteria, the Chair of the Brighton & Hove City Council Community Safety Partnership, on behalf of the Board determined in February 2021, that a review should be completed.
Based on Multi-agency statutory guidance, the purpose of any Domestic Homicide Review is to:
Domestic Homicide Reviews are not inquiries into how a person died or who was responsible for the death; those are matters for Coroners and criminal Courts respectively to determine.
Child 1 was arrested on suspicion of Adult T’s murder at the time of the incident. Following a thorough Police investigation and criminal trial Child 1 (now an adult) pleaded guilty to manslaughter; he was subsequently acquitted of murder and found guilty of manslaughter and sentenced to 15 years in prison.
Understandably, the family have been deeply shocked but also conflicted by what has happened. Brighton & Hove City Council Community Safety Partnership and the Independent Chair of this DHR wish to extend their deepest condolences to the family.
Following the decision in February 2021 to commence a Domestic Homicide Review the following steps were taken by the Brighton & Hove City Council;
A. Requests for information about any contact or involvement with both Adult T and Child 1 were made to the following agencies:
B. Brighton & Hove City Council appointed Kevin Ball as the Independent Chair and report author for this Domestic Homicide Review.
He is an experienced Chair and report author, notably of cases involving the harm or death of children, but also Domestic Homicide Reviews.
He has a background in social work, and over 32 years of experience working across children’s services ranging from statutory social work and management (operational and strategic) to inspection, Government Adviser, NSPCC Consultant and independent consultant; having worked for a local authority, regulatory body, central Government and the NSPCC.
Over his career, he has acquired a body of knowledge about domestic abuse through direct case work, case reviews and audit, and research and training, which supports his work as a Chair and reviewer of Domestic Homicide Reviews.
During his career, he has worked in a multi-agency and partnership context and has a thorough understanding about the expectations, challenges and strengths of working across complex multi-agency systems in the field of public protection.
In the last 10 years he has specifically focused on supporting statutory partnerships identify learning from critical or serious incidents and consider improvement action. He has contributed to the production of Quality Markers for Serious Case Reviews, developed by the Social Care Institute for Excellence & the NSPCC – which are directly transferable and applicable to the conduct of Domestic Homicide Reviews. He has completed the Home Office on-line training for Domestic Homicide Reviews and the Chair training course provided by Advocacy after Fatal Domestic Abuse (AAFDA). He has no association with any agencies involved and is not a member of the Brighton & Hove City Council Community Safety Partnership. There is no conflict of interest.
C. In April 2021 an initial scoping discussion was held involving the Independent Chair, the Strategy and Partnership Officer for Domestic and Sexual Violence for Brighton & Hove City Council, the Police Senior Investigating Officer and the Family Liaison Officer to assist the Independent Chair gain a better understanding about the situation relating to the Police investigation.
D. In May 2021 an initial Review Panel (see below) meeting was convened in order to provide oversight and scrutiny to the process, agree the Terms of Reference, offer relevant expertise and ensure the smooth and timely conclusion of the review.
Further meetings were scheduled as necessary; with Review Panels being held in July and December 2021. At that point the review was then paused due to awaiting criminal trial. The criminal trial concluded in March 2023, and further Review Panels were held in March and July 2023.
E. Following the initial Review Panel meeting in May 2021 the Independent Chair contacted the adult son of the deceased and Uncle to Child 1 (who had agreed to act as the family representative) to explain the purpose of the review and what it hoped to achieve, as well as seek their contributions. At that point, further contact was requested by the adult son to be only, as and when needed.
F. The detailed findings of all information provided to the review remained confidential. Information was available only to participating officers and professionals and their line managers. A confidentiality agreement was signed by DHR Panel members at the commencement of the DHR and reconfirmed at the start of each Panel meeting.
G. The final report was presented to the Brighton & Hove City Council Community Safety Partnership in September 2023. As such, the review process took 31 months to complete; the delay in completing it were due to needing to wait for the conclusion of the Police investigation and Court process.
H. The Executive Summary and Overview Report will be disseminated to:
The majority of agencies or services listed at 2.1 confirmed there had been no contact with Adult T. In terms of gaining any information into Adult T from a professional perspective, this was clearly a limiting factor. No information had been identified, anywhere, of any controlling, abusive or coercive behaviours between any member of this family, or between Adult T and Child 1.
Given this, the Review Panel and Independent Chair determined that the best focus for the review, to maximise learning, would be to examine any relevant information which particularly related to Child 1, and any potential factors which may have contributed to his behaviour and actions.
As such, the following lines of enquiry were agreed by the Review Panel, within 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:
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.
Despite an extensive and systematic trawl, and the very limited agency involvement with either Adult T or Child 1, Individual Management Reports or documentation was requested, and provided by, the following agencies and professionals;
The review has kept in mind the 9 protected characteristics under the Equality Act 2010:
Due to the age of Child 1 at the time of the incident, reporting restrictions were in place and therefore age, was considered to be a protected characteristic.
The characteristic of sex has not been discounted given the researched evidence of women being the greater victims of:
The remaining 7 characteristics were considered and discounted as not being relevant to any individuals in this case.
Given the length of time the review took to complete because of the delays in parallel processes, agency representation did change over time due to people’s circumstances changing. Where more than one name is listed, this reflects where there has been a change in representative.
The following agencies came together to form a Review Panel in order to assist the Chair as well as bring relevant expertise to the process;
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)
Seeking the contributions of family members, which has included the adult children of the deceased, has been an important consideration for this review.
The adult children of the victim have, understandably, found the whole situation very difficult to come to terms with, conflicted by the fact that their mother had been killed by one of her grandchildren.
Contact with an agreed family representative was achieved early on in the review process. At that point, further contact was requested to be only as, and when, necessary given that the family were not only grieving for the loss of Adult T, but were also trying to offer support to Child 1 during the unfolding Police investigation and subsequent criminal trial. The length of time between the decision to initiate a DHR in February 2021 and the conclusion of the criminal process in May 2023 did little to help or maintain any momentum in trying to establish a rapport.
Initially, face to face contact with family members was not possible due to the COVID-19 restrictions being in place. However, restrictions lifted over the course of the review and the Independent Chair offered to meet with two adult children of the deceased, which included Child 1’s father.
This offer was not taken up by either of these family members. Considerable efforts were made to try to re-engage the family in the review, also enlisting the support of the Family Liaison Officer and representatives from Victim Support, however these were unsuccessful. These efforts continued post-trial and sentencing, all without success. Ultimately, the family made an active decision not to contribute to the review by directly informing the Independent Chair in April 2023.
Adult T’s family were offered independent support from Victim Support (an independent charity that provides support to anyone affected by a crime) during the Police investigation and subsequent trial. Although there was initial engagement with one family member for a few telephone sessions, as per his wishes, he confirmed he did not require anything further after initial advice was given and his support options had been explored; the case was then closed.
Child 1, who was an adult by the time the Independent Chair was able to make contact, was also offered the opportunity to contribute in June 2023. This opportunity was declined.
Information from the Police investigation, including witness statements, was used to assist the Independent Chair to assess whether friends and other non-professional contacts, might be able to assist the review.
Based on the extensive information gathered by the Police from friends and colleagues during the course of their investigations, the Independent Chair did not consider it necessary or proportionate to explore these networks further and was satisfied that the information obtained from the witness statements provided sufficient confirmation of the issues that needed to be explored in this review.
Review of information submitted in regards to Adult T highlights no relevant issues of interest to a Domestic Homicide Review.
Given Child 1’s relationship with Adult T, review of chronological information submitted by agencies highlights a small number of episodes relating to Child 1 which are relevant for this review to explore. Some of these occurred prior to the timeframe under review but may, nonetheless be relevant. These are summarised below in chronological order.
Child 1’s mother died when he was 4 years of age; which was clearly a very sad and difficult time for the family.
Child 1 began attending School A – an independent school - in 2016 through to July 2019. In January 2017 Child 1 was involved in a ‘playfighting’ incident with another pupil which reportedly got out of hand.
A further similar incident occurred in July 2017, with two other pupils. Both incidents were appropriately dealt with by the school through their Behaviour Management Policy.
In February 2018 Child 1 was given a detention for pushing other pupils against lockers and shouting at a teacher; again, this was appropriately dealt with under the Behaviour Management Policy.
In January 2018, with the support of the school and his father, Child 1 completed an educational psychology screening assessment to assist him with his learning and exam access arrangements. Following this, further testing, particularly of Attention Deficit Hyperactivity Disorder (ADHD), was recommended by the screening assessment.
Attention deficit hyperactivity disorder (ADHD) is a condition that affects people's behaviour. People with ADHD can seem restless, may have trouble concentrating and may act on impulse.
Symptoms of ADHD tend to be noticed at an early age and may become more noticeable when a child's circumstances change, such as when they start school. Most cases are diagnosed when children are 6 to 12 years old. The symptoms of ADHD usually improve with age, but many adults who were diagnosed with the condition at a young age continue to experience problems. People with ADHD may have additional problems, such as sleep and anxiety disorders.
This was viewed as something that might be helpful to better understand the behavioural issues the school had experienced. In April 2018 Child 1 requested that his paternal grandmother, Adult T, was added to the contact details held by the school
‘… as she was more available than his father and more understanding … (submission to the DHR by School A.)
In June 2018 Adult T confirmed with the school that Child 1 would be seeing an Independent Consultant, privately, for an ADHD assessment, in September 2018.
Also in April 2018, Child 1 initiated inappropriate physical and sexualised behaviour with a female pupil in a local park. This was reported and resulted in Child 1 meeting the Headmaster with his father, and there being a recommendation that the matter should be referred to the Brighton & Hove Multi-Agency Safeguarding Hub (MASH).
(MASH – In Brighton & Hove, the Multi Agency Safeguarding Hub (MASH), Early Help Hub and Family Information Service have merged to become the Front Door for Families. The service is made up of professionals with different areas of expertise who work together to assess, decide and coordinate how best to support children, young people and their families where there are concerns).
This was completed by the school who were advised by the MASH that it was a pastoral matter that should be dealt with by the school. As a result, Child 1 was issued with a short term (4 day) suspension from school. This approach reflected the wishes of the female pupil’s parents in that they wanted the matter to be dealt with by the school.
Child 1 was assessed for ADHD by a Private Consultant in September 2018. This referral and assessment had been initiated by Adult T in the context of longstanding problems with schooling as well as a recent concern about his lack of progress.
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, for which a private prescription for a month’s supply was issued at 30mg per day.
Initial communication between Child 1, Adult T and the Private Consultant was via email, with reported positive effects on his school working but the effects of the medication wearing off in the afternoons. On advice, the dosage was increased, but this resulted in some mood effects and tiredness; further advice then suggested lowering the dosage to 40mg per day, which seemed to be a suitable dosage.
Adult T reported ‘
… 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 …' (submission to the DHR by the Private Consultant).
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.
In November 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.
At a later review meeting in January 2019 no issues were raised about this; the improvements previously noted by the school had been sustained and there was a high degree of confidence that the prescribed medication regime was appropriate and effective and it was considered appropriate for it to continue.
In June 2019 Adult T contacted the Private Consultant asking about moving to a lower dosage (30mg per day) for the summer holidays; this was agreed with a view that he might revert to 40mg per day once school re-started in September.
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.
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.
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 including the Pavilion’s (Adult Drug & Alcohol Service in Brighton & Hove), MIND and YMCA. All 3 of these services are for over 18-year-olds – which it appears was not conveyed to Adult T at the time. There is no information to indicate that these services, or another private route, were approached nor provided any service to Child 1.
As part of the criminal trial, the Court heard that on the day of Adult T’s death she researched the possibility of a relatively local private Clinic from the Priory Group, to treat addiction, but also any local Psychologists who may be able to offer support. Enquiries made as a result of this DHR confirmed that no actual contact was ever made with the Clinic.
In early January 2021 Child 1 contacted the Police to advised that he had killed his grandmother. 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. 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.
(MDMA - Methylenedioxy-methamphetamine is a synthetic drug that alters mood and perception (awareness of surrounding objects and conditions). It is chemically similar to both stimulants and hallucinogens, producing feelings of increased energy, pleasure, emotional warmth, and distorted sensory and time perception)
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 – 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.
In summary, the relationship between Child 1 and Adult T has been reported as a good one, with them never arguing, her being supportive and caring of him, and Child 1 often going to stay with her as a positive move when tensions became strained at home with his father, step-mother and family. Family members have been left completely shocked and confused about his actions.
1. Other than when Child 1 came to stay with her, 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.
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.
3. Given the very limited information available and the absence of any significantly concerning behaviours between Adult T and Child 1, the extreme nature of Child 1’s actions towards Adult T came as a complete surprise and shock to all involved; as such, the events were not viewed as predictable.
4. The review has gathered information about some factors relating to Child 1 which are of interest. These factors have allowed an opportunity to better understand what happened in context. This context is important because it has highlighted some risk factors which are known, through research, to be of concern and which can cause relationship problems, impact on behaviour, and result in negative or poor outcomes.
These will be examined below.
a) Domestic Homicide Reviews: Key findings from analysis of domestic homicide reviews
c) Complexity and challenge: a triennial analysis of SCRs 2014-2017, March 2020
5. The absence of family contribution to the review has been a limiting factor although this has not prevented learning from being identified.
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.
(Research from from Adverse childhood experiences: What we know, what we don’t know, and what should happen next, Asmussen, K., Fischer, F., Drayton, E., & McBride, T., February 2020, The Early Intervention Foundation).
5.1.2. Without additional information from close family members, it has not been possible to better understand how this early bereavement was managed with Child 1. However, and importantly, 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.
From this, it is 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.
Local specialist services do exist, and which can be accessed by all those that have experienced a bereavement. The statutory Child Death Review Panel Team, which covers the local area, now also maintains a list of services which can be shared with parents at their time of loss when a child dies, to support consideration about whether bereavement counselling might be helpful. This includes counselling and support services that would be available to children when a parent dies.
Services include, for example:
Additionally, parents and carers can access private counselling services.
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/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 (reference Care and support statutory guidance and National Support framework delivering safer and confident communities) - is the same regardless of setting, whether private, independent or statutory.
Based on the agreed lines of enquiry Sections 5.3 and 5.4 below explore these relevant issues. As noted , these findings cannot be viewed in any way, as being a predictive or contributory factor to events in January 2021; they do however, help us understand context but also capture learning.
The review has been particularly interested in examining the sharing, and use of information, in relation to special educational needs assessment and support but also specialist mental health assessment pathways that bridge the divide between the private and statutory sectors.
This includes consideration about information that was available regarding substance misuse and thresholds for stepping up intervention by any service or professional involved with the family. In this case, this relates to the use and sharing of information between School A, College B, the Private Consultant, and the GP Practice.
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.
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. These findings highlight learning that is examined further in section 6.
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.
Information obtained from previous schools highlights that Child 1 moved between state and independent schools before settling into School A; previous schools had not highlighted any concerns about his behaviour or special educational needs nor the possibility of ADHD.
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 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.
Between the date of registration (November 2018) and the last contact (December 2020) the GP Practice spoke successfully with either Adult T or Child 1’s father 4 times. The GP Practice spoke directly with Child 1 successfully three times with 3 further failed telephone attempts to make contact.
Two gaps in prescription requests have been noted; June to October 2019, and then October 2019 to March 2020. The GP Practice appropriately followed up these requests with a telephone conversation to discuss the gaps. On both occasions Child 1 confirmed that he had not been taking the medication as regularly as he should but that he now wished to start taking it more regularly. From this point forward (March 2020 to December 2020) the medication was requested and issued appropriately with correct procedure being followed.
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.
In October 2019 Child 1’s father informed the GP Practice that Child 1 was seeing a specialist in December 2019; but there was no further information received about this.
Child 1 was consulted with twice by the GP about his ADHD and his prescribed medication (March and May 2020 via telephone); both times the GP asked about his mood but did not ask about recreational drug use or alcohol use. Had the information from the Private Consultant or Adult T or his father been available, in would have helped a more rounded assessment of his overall welfare by the GP Practice.
During the March 2020 consultation, when Child 1 was aged 16 years and 11 months his patient notes were coded for ADHD, 14 months after he had been prescribed medication. Adult T had advised the GP Practice of his ADHD diagnosis in November 2018. This reflects a considerable delay in updating patient records.
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 three 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.
All of the above instances reflect learning about the importance of information sharing, contemporaneous record keeping, and working in a collaborative manner; this is detailed further in section 6.
Information provided by School A highlights a robust process is in place that ensures the appropriate parental consents are in place at the point of registration and enrolment with the school.
Information provided by the Private Consultant indicate that she was informed by Adult T that she was Child 1’s guardian. Child 1’s father had completed a questionnaire as part of the assessment process. Combined, this was assumed to mean that Adult T attended with Child 1 and could exercise parental capacity and make decisions on his behalf. Coupled with Child 1’s age and his own capacity and competence to consent to the consultation, the approach to assessment and treatment was entirely reasonable.
The GP Practice has acknowledged that at the time it did not have a consent policy and that the general approach if someone called on a patient’s behalf who was over 16 years of age, would be not to comment on whether the patient was registered at the Practice and then to inform the patient afterwards that someone had enquired about them.
If the registered patient wanted someone to speak on their behalf, they would ensure that consent to do so had been obtained. This procedure was not followed with regard to Child 1 when Adult T spoke to the GP; consent from Child 1 was not obtained and Child 1 was not informed after the event. Given the ongoing nature of the relationship between Adult T, Child 1 and the GP to that date, the assumptions made were not unreasonable – however the GP Practice has acknowledged that due process should be followed in future when patient’s turns 16 years of age and further communications may be likely. This has been included in the GP Practice action plan.
Given the family chose not to contribute to the review information it has not been possible to hear whether they experienced any barriers in seeking help on behalf of Child 1.
It is known that Adult T did try to seek help, by researching local psychology and clinical options, but there is no information to evidence this went beyond her initial research on the internet. The report has already highlighted that services that were suggested by the GP Practice were for adults, not children, and that there may be a lack of service provision for those people who are transitioning from child to adult services.
The impact of the COVID-19 pandemic, and the associated restrictions that were imposed cannot be ignored in this case. Restrictions were imposed in March 2020, some 7 months into Child 1’s first year at College B. At that time, he had nearly 4 months remaining until the end of the summer term. College B have reported that Child 1 successfully completed this first year, despite the challenges of teaching and supporting students from March to July 2020.
Restrictions were then eased somewhat from May 2020 with local arrangements made between students and further educational establishments. A further national lockdown was then re-imposed in November 2020; some 2 months into Child 1’s second year at College B and which remained in place until after the February 2021 half-term holiday. It is at this point in November 2020, that 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; and at which point Adult T began to seek additional support for him.
It is reasonable to form a view that the restrictions affected Child 1’s mood and emotional and mental health.
Research conducted by the Children’s Commissioner for England in early 2021 noted
‘… There is considerable uncertainty about the effect of the COVID-19 pandemic on children’s mental health. In 2020, the NHS published figures suggesting a large increase in the prevalence of children with a probable mental health disorder (up to 1 in 6 children with a probable mental disorder compared to 1 in 9 in 2017). This may well indicate a short term rise in need relating to the pandemic, but there is also a risk that this increased need will continue, at least in the medium term …’.
A briefing paper from the NSPCC also provides insights into children and young people’s thoughts during lockdown citing stress, feeling overwhelmed, fear, boredom, and lack of motivation as just some of the issues experienced.
No information has been provided to this review, from those agencies or professionals that have contributed, to indicate that any organisational change, impacted on service delivery.
It is recognised that there were changes in service providers in the Brighton & Hove area for those seeking support with substance misuse, from Pavilions to Change, Grow, Live, and domestic abuse services, from RISE to Victim Support. There is no evidence to indicate that this change materially impacted in this case given neither Adult T or Child 1 had any contact with these services.
Given the extensive Police investigation into the circumstances of Adult T’s death, and review of witness statements, the Independent Chair was able to review information from two of Adult T’s long standing friends, one of whom gave consent for her descriptions of Adult T and Child 1 to be used for the purpose of this DHR. Her reflections have been used in the opening section 1 and have provided useful context in terms of gaining an understanding about the love and care displayed by Adult T towards Child 1.
Family members have expressed a wish that they did not want any family or community members being involved given their extensive local connections. This request was entirely reasonable.
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. Nevertheless, the review has identified some learning points which are important and clearly reflect a theme around communication and information sharing.
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 ...'. (Rex v Anonymous [2023] UKHL Lewes Crown Court 2023
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.
The GP Practice has reflected on their own learning as a result of this review:
School A has reflected on their learning, which includes:
The Private Consultant has indicated learning as;
Adult T died in 2020 having been killed by her grandson, Child 1. Adult T has been described by long standing friends as a warm and generous person who was very supportive of her family. She adored her children and grandchildren and would do anything for them.
This Domestic Homicide Review was commissioned in order to establish what lessons might be learnt about how local professionals and agencies worked together, and consider any learning regarding preventability. Following a Police investigation and criminal trial, Child 1 was found guilty of manslaughter and sentenced to 15 years imprisonment.
The review has benefitted from information being submitted from a very small range of agencies given that there was very limited contact with Adult T. There had also been very little contact by agencies with Child 1. Regrettably, the review has not had the benefit of any input from family members or Child 1, who actively decided not to contribute to the review, despite concerted efforts to engage them in the process. This has somewhat limited to learning and context for the review.
A number of learning points have been captured; which revolve around the importance of information being shared as a way of helping all professionals involved provide the best support, but also assess and manage any risks. The risks associated with using recreational drug and the often-unpredictable impact these can have on anyone’s emotional and mental health has been evidenced as a critical issue in this case, especially when used alongside prescribed medication.
Based on the evidence examined and findings made, the review concludes with one recommendation for the Partnership.
Where those agencies and individuals that have contributed to this review have identified learning, actions have been agreed and recorded in an action plan. These actions have not been included in this overview report. Ongoing monitoring of implementing any changes and improvements remains the responsibility of those respective agencies or individuals, with oversight from the Community Safety Partnership.
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.