"D" was 16 when they were referred to LCS, having been hospitalised for 3 years with mental health issues, anorexia and self-harm. They had no sense of self-worth, inappropriate attachment to nurses and was at high risk of death by misadventure. They was institutionalised, incredibly resistant to engagement, and didn’t believe they’d be safe outside the hospital, despite being discharge ready.
Recognising these risks at initial referral, we arranged a meeting with the hospital, Eating Disorders Team (EDT), and CSC staff to collaboratively review risk assessments and develop a risk management plan which "D" agreed. This was reviewed regularly – at planned weekly intervals, and immediately following any incidents i.e. missing episodes.
To manage risks around their eating disorder and mental health concerns, it was agreed the Mental Health team would lead the placement, with the home treatment team visiting ""D 3 times a day, with LCS staff present at every meeting, supporting "D" to engage.
"D"’s risk management plan was specific to them, and included:
- Integrating all elements of their Community Treatment Order – with clear instructions for staff on how to respond to challenges (up to and including calling police and informing them of CTO breach)
- That, initially, they were never to be left alone. This included seating waking night staff outside their bedroom door to offer reassurance (equipped with a script developed by mental health team) when they woke, and supervised (timed) bathroom visits
- Carefully managed communications with "D" – including a suggested script used at night, and meal times
- Highly structured days – including reminding D of planned staff changeovers, and activity wind-down in the evening to ensure they weren't startled by changes
- Following the meal-planner provided by EDT – including supporting "D" to shop for/prepare food
- Comprehensive staff briefing – outlining the “dos and don'ts” when supporting "D", and shared language – ensuring consistency of approach/boundaries with all agencies
- Recognising the disruptive influence their mother had, and working with "D" to carefully managing contact to minimise this
- Planning step-downs
We used Dialectical Behavioural Therapy – with the support of health teams – to manage risks.
We ensured all staff working with "D" were aware of triggers and warning signs for self-harm (in their case lack of boundaries, routine changes and negative contact with their mother) – and appropriate preventative measures.
This included staff modifying their behaviours and interactions with "D" – being fun, affectionate, praising and warm when they were complying with the CTO, and minimising drama when they didn’t and calmly, neutrally calling home help team.
More case studies
16-year-old "A"’s history included 22 placement breakdowns in the two years before referral to LCS. They frequently went missing, engaged in substance misuse and experienced sexual exploitation.
"B" was a 16-year-old nearing the end of a custodial sentence when referred to LCS. They had a history of abuse that resulted in racist behaviours and were involved in petty crimes, shoplifting and gang activity.
16-year-old "C" was referred to an LCS Shared House as “medium risk”. The referral identified risks including inappropriate sexual behaviour, frequent missing episodes and hygiene issues, including bedwetting.
"T" was 16 when they were referred to an LCS Shared House. They’d been in 20+ placements over the last few years. They had low self-esteem, was self-conscious and struggled with depression and intense emotional outbursts.
Post Support Approach
"G" had autism, learning disabilities, and required 24/7 support, with sleep-in night workers. The planned outcome was for LCS to prepare him for a semi-supported adult placement.
Preparation for Independence
"F" was referred to LCS and offered placement in a shared house after a kinship placement broke down. Their mother had substance misuse issues and their father and brother were in jail – with offences including armed robbery.
"H" had highly complex needs, a history including self-harm and repeated suicide attempts, historic sexual abuse, extreme attachment issues, high-risk sexual behaviours and grooming.