Secure Accommodation Order - reasons.
Before : |
R. J. MacRae, Esq., Deputy Bailiff, and Jurats Ramsden and Averty |
Between |
The Minister for Children and Education |
Applicant |
|
(1) A (the Mother) |
First Respondent |
And |
(2) YY (the Child) (through her Guardian) |
Second Respondent |
IN THE MATTER OF THE CHILDREN (JERSEY) LAW 2002
AND IN THE MATTER OF YY (THE CHILD) (SECURE ACCOMMODATION ORDER)
Advocate P. F. Byrne for the Minister
Advocate D. C. Robinson for the First Respondent
Advocate M. R. Godden for the Second Respondent
judgment
the deputy bailiff:
1. On 25th May 2022 we granted an application by the Minister for a Secure Accommodation Order under Article 22(1) of the Children (Jersey) Law 2002 in respect of the Second Respondent ("YY"), [redacted]. We now give our reasons for making this order.
2. YY is currently placed at Accommodation F under a Secure Accommodation Order made by the Court on 8th March 2022 which the Minister seeks to extend until the eve of YY's 18th birthday.
3. YY suffers from an emotionally unstable personality disorder which can put herself and others at risk, and has been known to abscond, be aggressive towards others, self-harm and damage property.
4. She was made subject to a care order on 16th April 2019. Owing to the non-availability of an appropriate on-Island placement, she had been placed in October 2018 at [Accommodation A] in Scotland with substantial support. Unfortunately, that placement broke down. She was made subject to a Community Treatment Order under Scottish Law in February 2021, but unfortunately no alternative and appropriate placements were available in the United Kingdom at the time, and the decision was taken to return YY to Jersey, as was her wish. She returned to the Island on 20th March 2021.
5. Following her return her challenging behaviour escalated with increasing incidents of harm to herself and others and on 6th June 2021 she was detained under Article 21 of the Mental Health (Jersey) Law 2016 at Accommodation E for a period of assessment. She was then discharged to Accommodation C on 17th June 2021 but owing to her behaviours and to the inability of the Children's Service to keep her safe, she was detained by the police that same day and her detention for 72 hours was then authorised by the Service Director, Mark Owers, at Accommodation F on 17th June 2021. Secure accommodation orders have subsequently been granted by the Court and renewed, resulting in her residing at Accommodation F since then.
6. YY experienced trauma in her early childhood which has had a significant effect on her day to day functioning.
7. Today we have heard evidence from the social worker, Dr Catherine Keep (Consultant in Child & Adolescent Psychiatry & Clinical Lead CAMHS (Child and Adolescent Mental Health Service)), and the Guardian.
8. Recent behaviour of concern in March alone included YY threatening to burn down Accommodation F and trying to set alight plants in the courtyard. She said she wanted to go to hospital, and she needs specialist accommodation in the UK. On the same occasion she was seen cutting her left arm repeatedly with a piece of glass from the window of a door that she had broken and she smeared blood over herself and wrote in her own blood on the wall.
9. Later in March she smashed a plate (by mistake she was given a ceramic plate) and she spent 15 minutes self-harming with the broken pieces. Later the same month she used an electric cable to make a ligature. When staff attempted to remove it from her, there was a tug of war and she tried to bite a member of staff. Afterwards she took fairy lights off the wall in the lounge area and tried to tie them in a knot.
10. Article 22(1) of the Law provides as follows:
"Subject to the following provisions of this Article, a child who is being looked after by the Minister may not be placed, and, if placed, may not be kept, in secure accommodation unless it appears -
(a) that -
(i) the child has a history of absconding and is likely to abscond from any other description of accommodation, and
(ii) if the child absconds, he or she is likely to suffer significant harm; or
(b) that if the child is kept in any other description of accommodation he or she is likely to injure himself or herself or other persons."
11. Article 22(3) provides:
"The court hearing an application under this Article shall decide whether the necessary criteria for keeping a child in secure accommodation are satisfied and if so it shall make an order -
(a) authorizing the child to be so kept; and
(b) specifying the maximum period for which the child may be so kept."
12. YY will cease to be a child in 2022, when she turns 18, and her care will transfer from the Children's Service to the Adult Mental Health Services. However, Children's Service will continue to have responsibility for providing assistance for YY as a care leaver and that Service should continue to work with the other professional to progress her care.
13. It was YY's wish that she be present during and, to the extent appropriate, participate in the proceedings. The guardian supported her in this and said her request was not unreasonable. Dr Keep, the consultant child and adolescent psychiatrist, who gave evidence on behalf of the Minister, expressed the view that it may be overwhelming for YY to attend the hearing and participate in it. We spoke to YY directly ourselves, prior to making a ruling on this matter, and she with the assistance of the guardian, expressed her clear wish to participate in the proceedings.
14. We had no doubt that in the circumstances it was proper for YY to be present throughout the hearing and to give instructions to her advocate, which she did. We had a short break every hour or so for her comfort and convenience. We were in no doubt that it was preferable, on the facts of this case, for YY to hear all that was being said about her and contribute in the way described. It probably would have been inappropriate for her to have given evidence and been cross-examined but that was not suggested at any stage.
15. YY was, as was clear from the questions asked on her behalf, keen to know:
(i) What was going to happen to her when she was 18;
(ii) Where was she going to live at that stage?
(iii) For what reasons was it that a facility in the United Kingdom was being identified for her;
(iv) If she was sent to the United Kingdom, would her family be able to visit her?
(v) What would be the duration of a placement in the United Kingdom and how often would it be reviewed?
(vi) What would happen at the end of that placement and, in particular, what arrangements were being made for her to live independently in the community in Jersey, either on discharge from such a unit or in any event?
16. We were satisfied that these were quite proper questions for YY to ask and they were questions that ought to have been answered at or shortly after the hearing.
17. Dr Keep told us that units appropriate to provide suitable care for adults with YY's needs were few. Accommodation H, a hospital in the UK, was a 12 bedded unit for women suffering from emotional disorders. It was a locked unit which accepted patients detained under the equivalent to the Jersey mental health legislation. It was a caring and nurturing setting; the issue was whether or not Accommodation H would be able to safely manage YY's dysregulated behaviour. If they had a bed available, the duration of the placement would likely be 6-12 months. It was important for YY to cooperate with an assessment by Accommodation H. Although in recent weeks YY had been more settled at Accommodation F, she still needed treatment at a specialist unit. In Jersey, the only available unit was Accommodation E which was, on the clear evidence that we heard, an inappropriate facility for YY to reside in other than for a very short "holding" period. Dr Keep said that if a bed could not be found before YY's 18th birthday, an option was a specialist unit for adults in the United Kingdom with Accommodation E being an "interim placement". It appeared likely to be the case that members of YY's family would be able to visit her at Accommodation H or other similar units. One other potential unit was the Naseby Ward in Northamptonshire, which had been requested to come to Jersey and assess YY. The Naseby was also a secure 15 bedded unit for women with emotionally unstable personality disorders. On direct questioning from the Court, it became clear that YY had not been told what life would be like in these units and it was essential that this be explained to her so that she understood what the daily routine and the expectations of her would be in such accommodation.
18. We were told that specialist units in the United Kingdom would offer an intense intervention, including dialectical behavioural therapy which would be integral to YY's care. YY would receive more comprehensive treatment than is delivered now or is available in Jersey. In respect to YY's preference for a small unit, Dr Keep explained that there were not many units available, and she was unaware of any units with less than 15 beds.
19. There is no bespoke community placement available in Jersey for YY, but it was accepted by Dr Keep that YY would return to Jersey, possibly reasonably soon after her treatment and that she would need somewhere to live. In that environment she would need support and Dr Keep said that she had discussed YY's housing needs with adult social care. There would need to be coordination with the community mental health team and YY needs a support worker during the day and the evening and that YY feared being left without support. YY would likely require help with her daily living activities and would need to learn how to live independently. Dr Keep said it would probably take a couple of months to put together a package of support for YY in the community and it was possible that, at least for an initial period, she would need staff with her overnight.
20. The social worker allocated to this case in October 2021 also gave evidence. She confirmed that it was the policy to support children who leave care until the age of 25. She said that YY had been allocated a personal adviser who would meet her in the coming weeks and also visit her in the United Kingdom in order to assess her needs. YY could not apply for housing in Jersey until she is 18, at that stage she would go on the waiting list for an Andium Homes property. She would be given some priority owing to her status as a care leaver. The extent to which she was given assistance would be dependent on an assessment by adult mental health which had not taken place yet but would take place whilst she was in the United Kingdom in her placement. The cost of family visiting YY whilst being placed in the United Kingdom would be supported as part of her care leavers package.
21. The social worker also agreed that a placement in Accommodation E was not a long-term solution to YY's challenges and that the Maudsley Hospital, in its report dated 4th March 2022 stated that she should not be residing at Accommodation E. The Maudsley provided a comprehensive account of YY's mental health history, an assessment of YY's risk of harm to herself and others and interim and long-term placement needs. YY is vulnerable to harm from others in the community and her longstanding emotional needs have led her to use substances and have contact with exploitative individuals. She is protected from such risks at Accommodation F. She also presents a moderate to high risk of violence to others which again is reduced at present whilst at Accommodation F. YY responds well to a high level of supervision and support to mitigate her impulsivity and risk-taking behaviour, including proactive structures and strategies to manage her time. The report said "there are a number of options being considered for [YY's] immediate care needs prior to her moving to a bespoke, one-to-one specialist placement in Jersey". Accordingly, it is clear from the report from the Maudsley and the evidence of Dr Keep that that is the care in Jersey which YY will need in the short to medium term. As to the option of detention under the Mental Health legislation the Maudsley report said that, although such a setting would medically manage the risk of harm to herself and restrict her liberty, prolonged hospital admissions are not recommended for individuals with emerging unstable personality disorder, would be contrary to the guidance issued by NICE, there would be no access to evidence based specialist psychological support and would be contrary to YY's wishes with an increased risk of harm to herself and the subsequent use of restraint.
22. As to a specialist placement in the United Kingdom, at the time that the Maudsley report was commissioned such a move was thought to be against YY's wishes. However, YY was prepared to go to such an establishment once it was properly explained to her, for treatment. At such a unit, according to the Maudsley, the staff would have expertise in complex emotional and behavioural difficulties such as YY's; YY will be able to engage in evidence based psychological intervention and she will be supported in other ways so as to reduce the risk of harm to herself and others; such a unit would also support her transition to adulthood. In the absence of a specialist residential placement on the Island (which does not exist) the Maudsley recommended that a specialist off-Island placement was identified with the "minimisation of transitions" being important for YY, because treatment for people with emerging personality disorders requires a "planned therapeutic environment which can be maintained over long periods". The Maudsley said "This is particularly important from the transition period between CAMHS and adult services".
23. The social worker said her preference was that YY could stay at Accommodation F even for a short period beyond the age of 18 until a placement in the United Kingdom was available, but she was told that it was not possible for YY to be placed at Accommodation F beyond her 18th birthday.
24. The social worker has visited properties in the community, including flats where YY could be placed and had discussed the same with her.
25. In her evidence, the guardian said that although YY had no objection to the renewal of the secure accommodation order, she wanted clarity about her future. In our view, she is entitled to that clarity. Her return to Accommodation F was the "only real option on the table" according to the guardian. The guardian expressed concern about the lack of secure/semi-secure therapeutic provision in the Island and only such provision could keep YY safe when she becomes an adult.
26. The recent improvement in the quality of care provided to YY at Accommodation F had been attained as the staff are now better able to support her and better understand her needs. As to her wishes for the future, YY wanted to live in a flat in Jersey supported by people she knew after she has received treatment in the unit in the United Kingdom. The guardian agreed that Accommodation E was not a workable option.
27. The guardian was concerned, and we share her concerns, that the Minister has undertaken insufficient contingency planning as to the sort of supported accommodation in the community that YY will need at some point relatively soon after her 18th birthday when she was either discharged after a short stay in Accommodation E (assuming she met the requirements for admission under the Mental Health Law) or after discharge from a period in a specialist UK unit as described above. The guardian said that YY will need a home in Jersey and a network of support and that there was a "hole in the care plan".
28. The guardian said that Accommodation E is an adult mental health unit for people in various states of crisis and was not an appropriate or particularly safe environment for this young person at this stage in their life. The guardian, when she was cross-examined, said that in 2019 she and others were repeatedly told that appropriate accommodation would be identified for YY in Jersey but this had not happened. The guardian said "it worries me that her needs had been known for so long and we are still in an emergency situation. Her needs have been known about for a long time. It is regrettable that she does not know where she is going to live at 18".
29. At our request, we were shown the notes of a meeting on 24th May 2022 attended by, inter alia, the social worker and Dr Keep which was "focussed upon an alternative community-based option for [YY's] care at the point that she turns 18, if an off island placement that is able to meet her needs is not commission (sic)". The note read "all agreed that to provide such an alternative presented significant challenges which between now and 23rd August are insurmountable". The note went on to conclude that adult mental health services need to "work to build therapeutic relationships with [YY] whilst she is at [Accommodation F] to make her transition from [Accommodation F] to [Accommodation E] as safe as possible".
30. We were disappointed that YY finds herself in this situation when her needs have been known about for so long. Furthermore, we were extremely surprised that our suggestion that the care plan be amended merely to provide that "consideration will be given - if a UK placement cannot be found or breaks down - to resourcing a residential unit for [YY] with support that meets her needs" was rejected by the Minister, notwithstanding that that suggestion was supported by the advocate for the mother and the advocate for the child and the guardian.
31. It is very unusual for the Minister to reject a modest suggested improvement to the care plan, and for this reason we declined to approve the care plan that was placed before us. That the Minister was not prepared even to consider such a proposal when the needs of YY are plain, was a matter of concern to us and we indicated that we would direct that this judgment be provided to the Children's Commissioner for her to consider this matter further by reference to the powers available to her.
32. We were prepared, in the circumstances, to renew the secure accommodation order but were concerned about YY's care when she reaches 18 whether or not a UK unit was identified in the interim. We urge the Minister for be more active in preparing for the time in the near future when YY will need to be accommodated in Jersey, in the community, with appropriate support. We also expressed the wish that Mr Andy Weir, Director of Mental Health and Adult Social Care, who we were informed is personally responsible for identifying a placement for YY, should make the identification of and securing of the funding for such a placement a high priority for himself and the officers assisting him.
Authorities
Children (Jersey) Law 2002.
Mental Health (Jersey) Law 2016.