Pathways to care in the absence of a local specialist Forensic Service, what we do in York.

1. Pathways to care in the absence of a local specialist Forensic Service, what we do in York. By Bekki Whisker

2. Where did the journey start? As a lone YOT/CAMHS representative, working with high risk clients without clear referral pathways

3. Trigger Cases • B aged 15, • Arrested for serious sexual offences, • Learning difficulties, • Full care order directly following arrest. • Over a 4 month period he receives 7 different assessments as a result of the pathways leading from the family court system, criminal justice processes and CAMHS assessment.

4. P aged 15, • long history of CAMHS involvement • familial sexual abuse and domestic violence. • high risk behaviour within the home, - fire setting, substance misuse, fascination with weapons, sexualised behaviour, animal cruelty, TWOC, physically aggression. • Lack of consensus regarding risk assessment and risk management, from an internal and multi-agency perspective.

5. F is 16, • Well known to CS, YOT and CAMHS. • Assessed High risk offender for some time. • Long term neglect and parental substance misuse, • Huge difficulty with engagement with all services. • Receives a custodial sentence. • Within weeks he is sectioned, admitted to a secure hospital and medicated with anti-psychotic medication.

6. A aged 14, • Arrested for serious sexual offences • Court bail for an extended period, • Self-harm concern. • Absence of mental illness, no suicidal intent, very little evidence of self-harm – CAMHS discharge. • 2 months later the Court outcome is that he is unfit to plead and he receives a Hospital Order.

7. Z – 17 • serial fire setter • ?LD • CAMHS and CS advice to refer direct to fcamhs due to lack of specialist risk assessment skills – forensic report makes recommendations for the Local Authority and CAMHS

8. The problems? • Lack of local specialist forensic CAMHS and legal expertise • Poor co-ordination of services, a lack of partnership working, no one wants to take ownership of these cases • Limited success in terms of Court diversion • No support/supervision for those staff working as lone practitioners with these high risk clients • No forum to monitor the progress of cases/potential cases- they just get lost in the system, an offence is then often the trigger to action/assessment

9. The strengths? • We are a small city, we know our client group and we know our staff • Adult forensic mental health services wanted to help us • CAMHS, YOT and Childrens’ Services representatives had registered an interest in forensic cases • The Yot health Worker had developed a good understanding of the needs of this client group and had built some good relationships across the relevant agencies • There were enough interested and motivated individuals to make a multi-agency panel

10. So...the Forensic Panel began! • YOT Service Manager (Chair) • YOT CAMHS representative • YOT admin • CAMHS Psychiatrist • CAMH Service Manager • CAMHS Psychologist • Head of Services Resources (Children’s Services) • Adult Forensic Mental Health Practitioner • CAMHS Commissioner – (provided with minutes)

11. Where are the cases coming from?

12. The target client group • Assessed as posing a high risk of harm to others (YOT ROSH or similar) • Stuck cases • Those at risk of custody • Other forums have not been successful in addressing the emotional and mental health issues

13. 15 months of panel discussions 26 cases discussed • 3 females • 23 males • 2 cases raised by Children’s Services • 4 cases raised by CAMHS • 20 cases raised by YOT

14. Pathways

15. Outcomes

16. The panel currently provides: • Clarity to risk assessments • A consistent multi-agency response to risk management • Early identification and intervention • Better outcomes for high risk clients • An enhanced experience for clients in transition to adult services • Identification of local skills, experience and knowledge • An opportunity for professional challenge • An opportunity to explore diversion pathways for individuals

17. What are we missing? • Expertise • A service – the panel is a forum we don’t provide therapeutic input, consultation, written reports etc • Service Level Agreements and funding • Time – we meet monthly therefore we are not as responsive as some cases require • Court diversion schemes (we have had some success but they are minimal and messy) • Clear pathways and therapeutic provision to those young people who sexually harm • Specialist fcamhs assessments which are locally relevant to the service provision

18. How does the Panel measure up? The panel ‘felt right’ but this publication confirmed what we had identified and developed in York was not a local ‘whim’: Community Forensic Child and Adolescent Mental Health Services (FCAMHS): a map of current national provision and a proposed service model for the future. Final Report for the Department of Health . January 2013

19. The report findings: • Are locally relevant, similar issues identified • Evidence the need for Specialist Services and expertise • Highlight the unmet needs (but enables us to recognise the progress we have made in York) • Identify that we are targeting the correct clients for discussion • Identifies need for minimum standards for community FCAMH service provision and a standard commissioning framework to provide a level of consistency

20. Thank you, if you have any queries regarding the panel please contact: Angela Crossland, YOT Service Manager: Angela.crossland@york.gov.uk Tel: 01904 554565