Simon came from a family where English was not their first language, however Simon was fluent in English and was sometimes relied upon by professionals to translate information for his parents. At the age of 15, Simon suffered a brain injury, which is said to have affected his behaviour and he struggled with his mental health. The following year, Simon made a significant attempted to end his life and was treated in hospital. Simon became an inpatient in hospital under section 2 and 3 of the Mental Health Act 1983 and Simon and his family were supported by a child in need (CiN) plan.

Shortly after his discharge, Simon’s mental health deteriorated, and he was detained under again Mental Health Act. The hospital where Simon was accommodated was a significant distance from his family and due to Covid, Simon was unable to visit home. During this period, Simon alleged that he had been the victim of a serious sexual assault but was deemed to unwell to be spoken to by Police at the time. Simon went on to make another disclosure relating to peers at his school being sexually abused whilst under the influence of substances. During his hospital admission, Simon was treated with anti-psychotic medication that caused Simon to gain weight which concerned him.

Simon was discharged from hospital 6 months later with a plan in place to for the Social Worker to support Simon regarding the allegation of sexual assault and a daily phone call from his Care Coordinator. Simon was offered a place at college and the Child in Need plan came to an end.

Simon continued to struggle with his mental health, and he would present at the local hospital stating that he felt unsafe and had suicidal ideation. At his next routine mental health appointment, Simon disclosed feeling unsafe at times and had thoughts to harm himself but had no plans to do so. The agreed plan was to increase his medication and steps were taken to remove anything from the family home that Simon could use to harm himself. Later that day Simon’s family and those working with him were unable to make contact with him and it was later discovered that Simon had sadly taken his own life.

Please see below for the Full Report and its findings:

Simon Child Safeguarding Practice Review - Report
Simon Child Safeguarding Practice Review - Lessons Learned Briefing 

7 Minute Briefing - Suicide Awareness
7 Minute Briefing - The Importance of History in Assessments 
7 Minute Briefing - Use of Interpreters and Translators