Information for General Practitioners/Social Workers Concerning Looked After Children who have a History of Self-Harm

The following guidance to general practitioners and social workers has been written in the light of multi-agency discussions following the death of a young person living in Local Authority residential care from an overdose of prescribed medication. This guidance suggests how best to manage the risks arising from prescribing medications to this particularly vulnerable group. It was written in consultation with Integrated Care Board's including GP representation. This guidance should be read alongside Nottinghamshire and Nottingham City Safeguarding Children Partnership Procedures.

It is, however, important to ensure that these young people have their right to confidentiality respected and their independence maintained - and that they are able to access appropriate and timely treatment.

Risk assessments are presently carried out by social workers and residential care workers, in partnership with the young person, when the young person is placed in a residential care setting. The young person agrees the content.

Where there is an identified risk of self-harm, this is recorded within the young person's risk assessment, and action plans are developed.

General practitioners are presently not consistently involved in the risk assessment even when the risk is of a clinical nature.

The information in the risk assessment is not routinely shared with the general practitioner, therefore when general practitioners prescribe they may be unaware of the young person's history and the associated risks.

Every effort should be made to ensure positive relationships are formed between the young people in residential care homes and their registered general practitioners. The aim of this is to ensure that young people are both confident and competent to access general practice services independently and responsibly. A variety of locally appropriate models of provision, such as visits to the home or accompanied visits to the practice, may need to be explored to achieve this.

Where there is a history of self-harming behaviour, particularly if this has involved misuse of prescribed or illegal drugs, a risk assessment should be drawn up in partnership with the young person, as currently.

The young person will be asked to consent to the general practitioner being involved in the risk assessment, and being made aware of the action plan arising from this. This will require careful explanation by the social worker to ensure consent, when given, is informed.

The consent of the young person should only be overridden when the social worker believes that failure to disclose the information may place the young person at risk of significant harm. In these cases, the young person should be told that the information will be shared anyway and should be given the reason for this.

When the information is shared with the general practitioner, he/she will ensure a system is in place to alert other relevant staff within the primary care team of this information. This should be taken into account when treating the young person.

Risk assessments must be current, accurate and relevant. They should be updated on a six monthly basis or earlier, if appropriate, and all involved in the risk assessment should be informed of all changes. All risk assessments should take into account current and past risk taking/self-harming behaviours and consider the cumulative risk as well as the current circumstances. Risk assessments should consider all relevant information held by all involved professionals.

If a young person with a risk of self-harm, particularly from misuse of prescribed or illegal drugs, requests a prescription for a drug that may enable them to self-harm, the general practitioner should record his / her exploration of the following options:

• Ascertain whether the prescription is really needed or other management options can be safely explored;
• Where clinically indicated and/or the risks of not prescribing outweigh the risks of prescribing, the general practitioner should encourage the young person to allow their social worker/residential care worker to be involved. This will enable the member of staff to offer support, and encourage correct dosing. Where appropriate, the member of staff could collect the prescription and ensure the medication is stored in a safe place within the residential care home on behalf of the young person;
• Where the young person will not allow a member of staff to be involved and they are deemed "Fraser Ruling competent", their statutory right to confidentiality and to receive treatment must be respected. If the general practitioner perceives the risk of not prescribing to outweigh the risk of prescribing, it is good practice to prescribe, whenever possible, these drugs which, whilst effective for their intended use, are least dangerous in overdose, and should consider prescribing fewer tablets at any one time (NICE guidelines).

N.B.

• The good practice principles contained within the above guidance should be applied to all looked after young people, whatever their current placement;
• If a Children's Social Care/health professional experiences difficulties in the implementation of this guidance, the escalation process set out in the Nottinghamshire and Nottingham City Safeguarding Children Partnership Procedures in order that the issues are resolved;
• Children's Social Care and/or health professionals may also seek advice from a consultant psychiatrist at CYPMHS if necessary.

NICE guidelines 'Self-harm in over 8s: short-term management and prevention of recurrence'.