Recurring concern

Failure to ensure schools receive relevant child safeguarding information

First to latest report 10 May 2019 — 14 Oct 2024

Reports that mention this concern
3
Times this concern has been raised
5
Stated actions linked to this concern
4

What this concern includes

Includes failures of dedicated processes for transferring relevant child safeguarding, health or safety information from services, families or other responsible parties to schools, including absent mechanisms, non-standardised transmission, inaccessible information, and failures to confirm or ensure receipt.

What is not included
  • Excludes generic interagency information-sharing failures without a school-facing child-safety context.
  • Excludes school safeguarding-record, assessment or follow-up deficiencies where the failure is not the transfer of relevant information to the school.
  • Excludes communication failures involving hospitals, carers or other recipients when no school is a material recipient.
  • Excludes failures to provide information that is merely administrative or educational and has no identified child-safety relevance.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Jennifer Sharren Chalkley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jennifer Sharren Chalkley, aged 17, died by suicide on 12 October 2021 after being found hanging in her bedroom. The report identifies concerns about delays and misconceptions affecting Education, Health and Care Plan assessments, failures to transfer safeguarding information promptly when she changed college, and shortcomings in multi-agency assessment, information sharing and support for her mental health needs and suicide risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a national system for guaranteed transfer of safeguarding information

    Wider context from the report

    “I also heard that there is no centralised system that stores and transfers learning support and safeguarding information between schools and colleges, or other agencies who are supporting young people. Rather, the transfer of documents is undertaken by the individual schools and colleges concerned, with, I heard, variable levels of efficiency and reliability. In the circumstances, I am concerned that there is not a national system in place to require and facilitate the guaranteed transfer of safeguarding information in advance of a child or young person starting a new school or college at the start of a new term or academic year, and that this exposes a suicidal child or young person to additional and avoidable risk. ”

    Source location

    Jennifer Sharren Chalkley · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delayed transfer of safeguarding information at the start of a new term

    Wider context from the report

    “At the inquest hearing the evidence showed that in September 2021, shortly before her death, Jennifer commenced a course at a new college. I heard that the new college did not receive her safeguarding file from her previous educational establishment prior to her death on the 12th October 2021; as a result the new college’s ability to recognise and manage Jennifer’s needs and risks, including her risk of suicide, was undermined. I heard that the Keeping Children Safe in Education 2024 statutory guidance for schools and colleges, and its previous iterations, state that where a child leaves a school or college, the designated safeguarding lead should ensure that their child protection file is transferred to the new school or college as soon as possible, and within 5 days for an in-year transfer, or otherwise within the first 5 days of the start of a new term, to allow the new school or college to have support in place for when the child arrives. I am concerned that the requirement to transfer safeguarding information “within the first 5 days of the start of a new term” means that a child who is at risk of self-harm or suicide may start at a new school or college without that establishment having all or any of the information in the safeguarding file. As that information is likely to be relevant to their management of the risk, I am concerned that permitting transfers up to five days after the start of term undermines the stated intention that the new school or college should “have support in place for when the child arrives”. ”

    Source location

    Jennifer Sharren Chalkley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review statutory safeguarding guidance for opportunities to strengthen or clarify information-sharing requirements, including this section following the case.

    Verbatim wording from the response

    “There is therefore a national process for sharing information between schools and colleges, and the guidance on the timing of the sharing of relevant information is clear. We are very saddened to hear that, in Jennifer's case, her new college had not received the information within the specified time to ensure continuity of support for Jennifer. This was not in line with the duties and responsibilities placed on schools and colleges. We do regularly review the statutory safeguarding guidance to see where it could be strengthened or further clarification is needed, which is subject to public consultation. In view of this very tragic case, we will keep this section under review.”

    Source location

    Response from Department for Education
    Page 5 · response
    Published 14 October 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    A national process exists for transferring safeguarding information, with clear guidance on required timing between schools and colleges.

    Verbatim wording from the response

    “There is therefore a national process for sharing information between schools and colleges, and the guidance on the timing of the sharing of relevant information is clear. We are very saddened to hear that, in Jennifer's case, her new college had not received the information within the specified time to ensure continuity of support for Jennifer. This was not in line with the duties and responsibilities placed on schools and colleges. We do regularly review the statutory safeguarding guidance to see where it could be strengthened or further clarification is needed, which is subject to public consultation. In view of this very tragic case, we will keep this section under review.”

    Source location

    Response from Department for Education
    Page 5 · response
    Published 14 October 2024

    Open published response

  2. Manchester South

    AI-generated summary

    Katie Croft · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Katie Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a mechanism for schools to receive relevant Child and Family Assessment information

    Wider context from the report

    “5. A further concern identified was that there was no mechanism for the school to be formally aware of information within the Child and Family Assessment. As a result there was no formal follow-up procedure set out in the best practice national guidance the school was working within. The inquest heard that Katie’s school recognising this gap has built on the working together guidance to develop guidance that ensures there is a proactive approach to engaging with a child and their family post the writing of a Child and Family Assessment; ”

    Source location

    Katie Croft · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    Karanbir Singh CHEEMA · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and training.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to transmit allergy action plans to schools

    Wider context from the report

    “5. The allergy action plan drafted by Karanbir’s doctors at Ealing Hospital did not find its way to his school. There is no standardised approach to this, for example always sending a copy to the school designated safeguarding lead, as well as giving parents/carers a copy for themselves and a copy for the school in case the posted version does not arrive. ”

    Source location

    Karanbir Singh CHEEMA · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of standardisation of allergy action plans across hospitals and schools

    Wider context from the report

    “4. Allergy action plans are not standardised across hospitals and schools, so messages are not as clearly delivered as they could be. This is vital particularly when they may be read for the first time in a desperate situation where panic has set in. ”

    Source location

    Karanbir Singh CHEEMA · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Use and advocate a standardized BSACI allergy action plan, providing copies for home, school, GP, and clinical records.

    Verbatim wording from the response

    “1. Standardized allergy care plans Following this case, the paediatric allergy leads from Ealing and Northwick Park Hospital advise that they use and advocate the BSACI Allergy Action Plan for any child with an allergy – which is printed in colour from clinic and 2 copies are given to parents (one to be kept at home and one for them to share with the school nurse or welfare officer of the school), and this is shared with the GP and a copy is left in the clinical records.”

    Source location

    2019-0161-Response-by-London-North-West-University-Healthcare-NHS-Trust
    Page 2 · response
    Published 29 July 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Post or email each allergy action plan directly to the relevant school.

    Verbatim wording from the response

    “2. Sharing of the allergy care plan with the school I have been advised by the clinicians that the usual practice is training the parent (and child) first and informing them to tell the school of the child’s allergy and avoidance of the precipitant. Following Karanbir’s inquest, the Trust has added the additional process of posting or emailing each allergy plan to the school in question.”

    Source location

    2019-0161-Response-by-London-North-West-University-Healthcare-NHS-Trust
    Page 2 · response
    Published 29 July 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Present the standardized allergy action-plan process to the paediatric team through departmental clinical governance.

    Verbatim wording from the response

    “This information has been presented to the Paediatric team in the Departmental Clinical Governance meeting on 26 June 2019.”

    Source location

    2019-0161-Response-by-London-North-West-University-Healthcare-NHS-Trust
    Page 2 · response
    Published 29 July 2019

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026