Publication of Significant Case Reviews

Published on Wednesday 19 August 2020

Angus Child Protection Committee – “Isabelle”


Angus Adult Protection Committee – “Adult O18”

Significant Case Reviews have been published today (Wednesday 19 August 2020) by the Angus Child Protection Committee (ACPC) and Angus Adult Protection Committee (AAPC).

While the reviews are wholly separate to one another, the tragic loss of a vulnerable young life is at the heart of both and took place at period in their lives when both were receiving support and intervention by a number of agencies and services.

The families of “Isabelle” and “O18” have been updated, informed and involved throughout this process. All names have been changed to protect their identity and confidentiality.

The reviews were commissioned on behalf of the Angus Chief Officers Group for Public Protection* to maximise opportunities for local and national learning and improvement. Many recommendations made have been instigated and continue to be implemented. Areas of good practice and professionalism are also highlighted in each report.

Margo Williamson, Chair of Angus Chief Officers Group (COG) said “First most our thoughts are with the families of Isabelle and O18. As a COG we have very much heard and accepted what the independent reviewers have said and the need for improvement across our services and systems for young people, whether they are in children’s or adult services.

“We will be receiving regular reports from both the child and adult protection committees to ensure the findings and recommendations continue to be acted upon to create improvement.”

Both the adult and the child protection committees are determined to ensure that the learning and recommendations arising from these reports enhances current good work and opportunities to make children, adults and families safe in Angus.

Ewen West, Independent Chair of AAPC said: “It is imperative that our focus is on making vulnerable adults safe in Angus. This independent report arises from the most tragic of circumstances – the loss of a young life - but presents an important opportunity to look at the work our agencies carry out in this area and the interaction that takes place between them.

“It is clear to me that the professionals involved in this vital area of work are absolutely dedicated, conscientious and caring and were profoundly upset by the tragic death of O18 and our thoughts and condolences are with their family.

“The independent reviewers established that, on several occasions, professionals intervened to prevent O18 coming to significant harm and prevented their death a number of times. No single agency is responsible for the harm that happened to O18 in September 2018 that resulted in their death and there is no one identifiable action that would have changed matters.

“The contribution of those professionals to this review has been invaluable in learning any lessons, applying any improvements and accepting all recommendations. In endorsing this review, it falls to us all to ensure that where there is good practice it is upheld and where the service can improve, it does.

“Individual mental health and well-being is a feature of this review. It can affect anyone at any time. Anyone can become vulnerable and it can happen at any point in their life. It is vital that, in their time of need, anyone can access the appropriate services and support.

“This is perhaps something that we are more aware of now – during the COVID-19 pandemic - than we have ever been before. If you need help or know someone who is in need of help, then please reach out.”

Alison Todd, Independent Chair of ACPC said: “I want to emphasise that Isabelle’s voice has been at the heart of this review and how determined we are to work together to make improvements that enable better experiences and outcomes for children, young people and families in Angus.

“My thoughts and sympathies are with Isabelle’s family who have been fully involved in this process and were integral to the review’s findings and recommendations.

“Evidence-based change is crucial in directing how the services of all agencies can be delivered to those requiring our support and intervention. This review holds a mirror to those services, where areas of good practice exist, where changes have already been made and where further improvement is required to ensure that the delivery of better experiences and outcomes is achieved and sustained.

“The review highlights there was significant inconsistency in the extent to which Isabelle’s diagnosis of Autism was accepted, understood and considered. There is a lack of appropriate alternative resources where young people with complex and presenting needs, including mental health, can receive intensive intervention and support and remain safe.

“This is an issue that is relevant for child protection across Scotland and an area where we can and must do better.

“Angus CPC is engaging in work across the Tayside Regional Improvement Collaborative in developing a Tayside Mental Health Strategy for children and young people.”

AAPC Significant Case Review Adult O18 Report and ACPC Significant Case Review Isabelle Executive Summary are available now on the Angus Council website via

Information on a range of websites, helplines, local and national support groups which focus on mental health and wellbeing can be accessed via NHS Tayside’s Mental Health & Wellbeing Resources

Numbers include –

Samaritans - 116 123

Childline - 0800 1111 or 0808 800 5000

NHS 24 - 111

(All three operate 24 hours a day)

*Angus Chief Officer Group for Public Protection (COG) brings together agencies with a role to play in public protection, including Angus Council, Police Scotland, NHS Tayside, Angus Health & asocial Care Partnership, the Crown Office & Procurator Fiscal Service, Scotland’s Children’s Reporter Administration and voluntary sector partners to provide strategic leadership in developing effective public protection services for people at risk of harm in Angus.

Individually agencies are responsible for the public protection services delivered by our own organisations. Collectively, they are responsible for developing and delivering the best services possible through partnership working.

The Angus Child Protection Committee (ACPC) is the local strategic planning partnership responsible for developing and implementing child protection policy and strategy across and between agencies. The committee performs a number of crucial functions in Angus including the coordination of training for professional and other staff, the development of policies, procedures and protocols, ensuring the effectiveness and quality of local child protection services through continuous improvement and the provision of public information to support public engagement and participation in keeping children safe.

The Angus Adult Protection Committee (AAPC) is the local strategic planning partnership responsible for developing and implementing adult protection policy and strategy. AAPC functions include reviewing adult protection practices, improving cooperation, improving skills and knowledge, providing information and advice and promoting good communication.

Like the ACPC, its multi-agency membership includes representatives of NHS Tayside, Police Scotland, Angus Health & Social Care Partnership, Angus Council and others with a role to play in public protection.

Both the AAPC and AACPC report to Angus Chief Officer Group (COG) via their respective Independent Chairs.