A few days before CYP Now’s visit to King’s College Hospital’s emergency department in Denmark Hill, south London, 15-year-old Junior Nkwelle was fatally stabbed on the Loughborough Estate less than a mile away. Although not thought to be gang-related, Junior’s murder and the subsequent charging of a 14-year-old girl and 16-year-old boy, illustrates the extent to which violence is a daily fact of life for some young people in the capital.
Junior was the seventh teenager to be murdered in London this year and the 144th since 2005 – a statistic that last year prompted the Home Office to produce a cross-government strategy for tackling gang and youth violence. The strategy highlighted youth work in hospital emergency departments as one example of good practice for reducing violent crime against children and young people. It recommended the youth violence prevention project at King’s, and a second run at St Thomas’s Hospital in Waterloo, as blueprints for others to follow.
A&E consultant Dr John Criddle was one of the driving forces behind setting up the St Thomas’s project in 2010. “In 2008, we were seeing young people coming back to emergency departments with escalating injuries,” he explains. “One we had treated came back and unfortunately couldn’t be saved. It made me think about how we worked and whether we could do something more to prevent the escalation.” A bid to Guy’s & St Thomas’s Charity resulted in a three-year grant – which ends in summer 2013 – and the creation of a partnership with charity Oasis.
Child safeguarding
King’s College Hospital, meanwhile, joined forces with local youth work charity Redthread but came at the problem from a slightly different perspective. Its project grew out of the hospital’s work around child safeguarding. “It became increasingly obvious to us that many of the injured children were known to a lot of other services”, explains Dr Emer Sutherland, consultant lead for children at King’s. “The young people were joining gangs as a result of the challenges in their lives.”
Dr Sutherland and Redthread chief executive John Poyton convinced the hospital to “take a leap of faith” and fund the project in 2006. “We assumed there were youth workers in trauma teams across the country,” says Poyton. “We were shocked when we didn’t find it anywhere else because it just makes sense.”
While the two hospitals adopt slightly different approaches, crucially, both of their projects focus on the importance of making a connection with a young person at the very early stages of their patient journey. Known as “teachable moments”, the idea is that pain and the recognition of vulnerability can be a catalyst for the young person to talk about their problems and engage with services. “When your guard is down and you’re away from the pressures of the home environment, you’re more open to assessing the choices you make,” explains Dr Sutherland.
Clinicians ask all young people who attend the emergency departments with injuries caused by violence whether they will consent to being referred to the youth worker. In serious cases – around a third of young patients at the King’s emergency department are knife or gunshot wound victims – a youth worker will try to meet the young person before they leave hospital. This could mean the youth worker comforting the young person after medical treatment, walking with them to the X-ray department or for more minor cases, giving them a call after a few days to arrange to meet and talk.
“Usually they are very open to engage – the doctors are seen as one of the establishment but youth workers speak a language they understand,” says Dr Sutherland.
Tom Isaac, Oasis youth worker at St Thomas’s, says that he tries to make contact within a couple of days of receiving a non-urgent referral from the emergency department “because if you leave it longer the wound may have healed and you’ve lost the opportunity”. Reassuring the young person that the service is confidential and independent from social services and the police is a big part of the initial discussion, he adds. Factors influencing the young person’s life and behaviour are also discussed. “It is quite a big conversation about the hopes they have for the future, which helps to build up a picture of the young person,” he says.
Regular follow-up meetings can go on for months, with young people encouraged to link into local projects that interest them. “We do a lot of one-to-one mentoring about life chances and slowly try to widen their horizons. There is often no push from families so you sometimes have to walk them down to the advice and guidance office or take them to a workshop.”
Shared data
Both sets of clinical staff now routinely collect and share details internally of how and where assaults of young people take place. Anonymised data is shared with police and the Home Office; it is analysed to map patterns in violent incidents and potential gang activity, which can help to shape the emergency department response.
Individual cases are also reviewed at weekly hospital safeguarding meetings where professionals from a number of agencies can discuss concerns about patients. “It’s important to have a multidisciplinary forum to discuss these often quite complex cases,” says Dr Criddle. “It’s about sharing information with other agencies, checking that the right things have been done and a forum for decision making.”
Youth workers regularly train clinical staff about how best to speak to young people and phrase questions in such a way that the patient engages with them. “Young people can be a challenging group, particularly for younger clinicians,” says Dr Criddle. “Tom’s team have strengths in communication skills with young people and we feed off that”.
Despite this, it is common for young patients suspected of having injuries caused by violence to clam up when questioned about it by emergency department staff, says Caroline McKenna, lead A&E nurse at St Thomas’s. For example, McKenna says one young person came into the emergency department with a knife injury to his hand, which he said was caused when he slipped doing the washing up. “The injury didn’t sit well with the story and he has now admitted he was stabbed”, she says. “We try and put it to them in an adult way that it is important to tell us what happened so we can treat it properly.”
Other challenges faced by the A&E teams include the police confiscating patients’ possessions such as mobile phones, to preserve evidence; pressure to minimise the amount of time patients stay in hospital makes the window of engagement potentially shorter; while the high turnover of staff is a barrier to relationship continuity.
These issues mean the services are constantly refining what they do. “We’ve tried to look at how we work smarter with the small amount of time we have got to work with these kids,” says Poyton. To this end, the emergency department at King’s has introduced a system that can help monitor repeat attendees and identify which patients are most likely to engage so that resources can be allocated accordingly.
King’s has also established “referral pathways” for young victims of violence who also have substance misuse or sexual health problems. “We are now actively looking for any signs of coercion from gangs during consultations,” says Dr Sutherland.
There is also a pledge from the King’s College Hospital NHS Foundation Trust to create a separate adolescent area in the soon-to-be redesigned A&E department, evidence of the trust’s commitment to the partnership, she adds.
Better integration of adolescent services across the hospital and building anti-gang partnerships with local authorities – with possible funding attached – are also part of the future vision.
Outreach work
Both hospitals already do outreach work – King’s recently held a focus group at the Loughborough Estate – and have good relationships with youth work projects and other agencies in these areas. Increasingly, this offers opportunities for the charities Redthread and Oasis to engage young people who might otherwise end up at A&E, so starting the intervention at an earlier stage.
For St Thomas’s, the key to the future of its project is to prove through hard evidence the impact it is having. Initial findings from research carried out by the Lifespan Research Group at Kingston University shows that 60 per cent of young people that used the service indicated they no longer took part in violence and 96 per cent were supportive of such youth work interventions in emergency departments.
“This is important work, but demonstrating value is hard as we can’t attribute change in violent crime to what we do,” explains Dr Criddle. Nevertheless, there is every likelihood that the efforts of the youth worker services at King’s College and St Thomas’s hospitals have played a major part in reducing the number of violent deaths of young Londoners over the past couple of years.
