During the debriefing, it was learned that typically, the agency does not complete a safety plan when a Children's Mental Health case is in assessment, which was the status of this case when the incident occurred.  This standard of practice influenced the caseworker's decision to not complete a safety plan. Additionally, this decision was supported by the fact that the subject child was not suicidal at the time the report was received and there was no indication the subject child was suicidal at the initial meeting with the mother. The caseworker also noted that the subject child had been seeing a therapist for approximately one year prior to the incident and believed that the therapist probably completed a safety plan with the subject child.  Lastly, the therapist did not indicate any concerns of suicidal ideation for the subject child to the agency.   
On April 28, 2016, the mother requested Children's Mental Health Services for the subject child; specifically, placement in a residential treatment facility.  The mother had previously contacted a residential treatment facility and was told she needed a county referral.  The case was assigned to the children's mental health caseworker on May 2, 2016 and a CMH intro letter was sent to the family that same day. The caseworker had a phone call with the mother on May 6, 2016 and a face-to-face visit took place on May 10, 2016.  The subject child was not present during the initial face-to-face visit as the caseworker let the family decide if the subject child should be present or not.  The caseworker had the mother sign releases of information during the initial visit to gather records from previous providers and sent them out on May 11.  The caseworker contacted the subject child's therapist that day, as well, to work on getting an updated diagnostic assessment.  The caseworker continued to gather information the next two days for an updated diagnostic assessment.  

The agency did not receive records from the hospital regarding the subject child's previous suicide attempt and did not get an updated diagnostic assessment prior to the subject child committing suicide on May 18, 2016.  Following the subject child's suicide, the caseworker attempted a home visit on May 20, 2016, but the family was not home.  The caseworker connected with the mother on June 15 to offer condolences and talk about services for the 12-year old sibling; however, the mother declined services.  The caseworker stated, “The case went exactly how they envisioned it to goâ€. 

The subject child was involved with the following services at the time of the incident: individual therapy, physical therapy, occupational therapy, school-linked mental health worker, medication management, and chiropractic services.  

Agency staff also provided the following information during the on-site meeting:
•	They see parents requesting placements too often and County partners direct families to contact the county for placement.