A shocking report into the death of a transgender teenager in Perth and Kinross has led to demands for “immediate action” from ministers.
Scottish Liberal Democrat Willie Rennie said it was clear local mental health services had become “overrun” and must be helped to get “back on track”.
The North East Fife MSP called for a response from the Holyrood government after we revealed the findings of a long-delayed probe into the death of a 17-year-old.
Last night, the government said it expected all recommendations from the report to be “fully actioned” and that it would “consider any national learning from this tragic case”.
The “sensitive and intelligent” pupil took their own life shortly after being informed by education chiefs that they would not grant the family’s wish that the teenager be allowed to attend the specialist New School Butterstone for an extra year.
The death in February 2017 set in motion a breakdown in the turbulent relationship between Perth and Kinross Council and senior staff at the school, near Dunkeld, which controversially closed at short notice in November 2018.
The significant case review report said that, at one point, the vulnerable teen was being supported by more than 14 separate professionals across all health services, and there was “clear evidence of silo working”.
The youngster was said to have been “repeatedly relaying a troubling and complex narrative to many agency professionals”.
Listening but not hearing
The concerns were being “listened to at the time” but the officials involved later admitted they were not always being “properly heard and understood”.
Concerns about Child and Adolescent Mental Health Services (CAMHS) were also laid bare in the study, which was undertaken for Perth and Kinross child protection committee.
It said the local CAMHS service at the time was “under considerable pressure”, with an “ever-changing staff group, increasing referrals, long waiting times and workers were managing high caseload numbers”.
CAMHS staff had referred the 17-year-old to specialised health and support services in relation to their growing sense of gender dysphoria.
However, the report said “information sharing gaps” meant there was an “incomplete picture” in terms of the pupil’s history of self-harming and suicidal thoughts.
During the review, key staff within CAMHS and at the specialist health services agreed that “had these concerns been fully known” they would have delayed the teenager’s referral for specialised treatment and possible gender re-assignment at that time.
Mr Rennie said: “This is a tragic case and my heart goes out to the family of the teenager who has died.
“It’s disappointing that the case review of this death has taken such a long time but now that a number of failings have been identified, it is important that the recommendations are now implemented swiftly.
“The council must ensure that child protection services are consistently evolving and improving.
‘Immediate action’
“There will also need to be an acknowledgement from the Scottish Government that local mental health services are overrun and will require immediate action at a national level to get them back on track.”
Pressures on CAMHS have been repeatedly raised across Scotland in recent years.
The report listed a series of improvements which have already been made to services in the area in the wake of the tragedy, including greater information-sharing, training, monitoring and advocacy arrangements.
There were also 17 further recommendations to learn lessons from the death.
A Scottish Government spokeswoman said: “This is a heart-breaking case and our thoughts go to all of those affected.
“Perth and Kinross child protection committee have accepted the review findings and have already implemented changes in a number of areas.
“We expect all improvement recommendations to be fully actioned.
“We are liaising with professionals in Perth and Kinross to support improvement work and we will consider any national learning from this tragic case.”
She added that the Scottish Government and COSLA would publish a new Suicide Prevention Strategy and Action Plan in September 2022.
The National Suicide Prevention Leadership Group is setting up a Youth Advisory Group to inform and improve policy from the perspective of those with lived experience.
“We have invested £40 million to enable health boards to improve children and adolescent mental health services and we have provided an additional £15 million to councils to deliver locally based mental health and wellbeing support for five-24-year-olds in their communities,” the government spokeswoman said.
“We continue to support local authorities with £16m in funding to ensure that every secondary school has access to counselling services.”
Thomas Glen, Perth & Kinross Council chief executive, said this week: “We recognise that this was an extremely complex and at times very challenging set of circumstances, and the Chief Officers’ Group acknowledges the findings and accepts all of the recommendations included within the learning review summary report.
“We are assured about the amount of improvement work already undertaken across the partnership, however we are not complacent and will continue to receive regular updates via the child protection committee.”
When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org ,or visit samaritans.org to find your nearest branch.