Recurring concern

Failure to provide autism-informed care and communication for children

Get email alerts

Request correction

First reported 2 Feb 2016•Latest report 30 Mar 2026

Definition

What this concern includes

Includes failures in child-facing care or support arrangements specifically dedicated to autism-informed practice, including autism training and competence, recognition of autism-related needs, adapted communication, reasonable adjustments and staff understanding of how autism affects mental-health, self-harm, treatment or safeguarding risks.

Not included

Excludes generic staff training, communication or cultural deficiencies where autism or neurodivergent needs are not materially identified.
Excludes failures in autism diagnosis, referral or treatment access where the unsafe condition is service availability or assessment rather than autism-informed delivery of care and communication.
Excludes mental-health-only assessment or treatment failures where autism-informed care is not the shared unsafe condition; use a more specific mental-health parent where supported.
Excludes failures concerning learning disability alone without an autism or neurodivergence-related care or communication component.

Reports: 4
Individual concerns: 8
Date range: 2016–2026
Stated actions: 13

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Child Safeguarding Practice Review Panel1

Department for Education1

Department of Health and Social Care1

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1

Essex Partnership University NHS Foundation Trust1

George Eliot Hospital NHS Trust1

NHS England1

NHS Surrey and Sussex Integrated Care Board1

Royal College of General Practitioners1

Surrey and Borders Partnership NHS Foundation Trust1

Surrey County Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

30 Mar2026
Warwickshire
Concerns raised1
1. Lack of practical mechanisms for adapting assessment of neurodivergent children
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Run monthly multidisciplinary simulation sessions covering paediatric abdominal pain, neurodivergence, communication and escalation.
  Stated by George Eliot Hospital NHS TrustStated in progress
2. Action
  Amend the paediatric casualty card to record children’s communication, sensory or behavioural needs.
  Stated by George Eliot Hospital NHS TrustStated in progress
3. Action
  Provide specialist Play Specialist support to improve communication and reduce anxiety for neurodivergent children.
  Stated by George Eliot Hospital NHS TrustStated completed
1. Action
  Implement the FLACC behavioural pain assessment tool within the Clinical Assessment Unit.
  Stated by George Eliot Hospital NHS TrustStated in progress
2. Action
  Develop and deliver a communications campaign promoting Hospital Passports and “All About Me” tools.
  Stated by George Eliot Hospital NHS TrustStated in progress
Respondent positions 1
1. Position
  Practical mechanisms in GIRFT guidance fall outside the Trust’s direct remit; the Trust will comply with any enhanced guidance GIRFT issues.
  Stated by George Eliot Hospital NHS TrustOutside remit
AI-generated summary

Ethan Michael Hanson · 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

Ethan was assessed by his GP and then at hospital for abdominal pain, vomiting and concern about appendicitis, but was discharged without senior review after abnormal observations and the GP’s concerns were not transferred to the hospital assessment. He later collapsed, suffered cardiac arrest, and died after imaging confirmed perforated appendicitis, peritonitis and sepsis. The principal concerns include inaccurate or incomplete observations and pain assessment, pathway and escalation arrangements that did not align with guidance, inadequate support for assessing neurodivergent children and parents, and loss of critical information during transfer from primary to hospital care.

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 practical mechanisms for adapting assessment of neurodivergent children
Wider context from the report
“GIRFT guidance lacks practical mechanisms for assessing neurodivergent children and parents The GIRFT guidance recognises that neurodivergent children may be more difficult to assess or diagnose, but it does not provide practical mechanisms for clinicians to adapt history-taking, pain assessment or communication. The guidance does not consider the risk that a neurodivergent parent may struggle to convey concern, may appear reassured when they are frightened, or may find questions and instructions confusing or intimidating. The absence of such mechanisms risks misunderstanding children’s symptoms and misinterpreting parental reassurance. ”
Source location
Ethan Michael Hanson · Prevention of Future Deaths report
Page 4 · 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
Run monthly multidisciplinary simulation sessions covering paediatric abdominal pain, neurodivergence, communication and escalation.

Verbatim wording from the response
“• The learning from this case is being built into a simulation programme. The upcoming CAU simulation sessions will involve a wider multi-disciplinary group and will include scenarios around abdominal pain, including neurodivergent children, to support better recognition, communication, and escalation. These sessions are held monthly.”

Source location
Response from George Eliot Hospital NHS Trust
Page 3 · response
Published 25 June 2026
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
Amend the paediatric casualty card to record children’s communication, sensory or behavioural needs.

Verbatim wording from the response
“• The paediatric casualty card is currently being amended to include whether the parent/carer has any potential neurodiverse implications which may affect communication. This has been discussed with the Paediatric Neurodiversity & Learning Disability Lead for South Warwickshire NHS University Foundation Trust (SWFT). This has identified that the question to be placed on the casualty card should be “does this child have any communication, sensory or”

Source location
Response from George Eliot Hospital NHS Trust
Page 4 · response
Published 25 June 2026
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
Provide specialist Play Specialist support to improve communication and reduce anxiety for neurodivergent children.

Verbatim wording from the response
“• The Trust has a Play Specialist in post, providing specialist support to reduce anxiety and enhance communication for neurodivergent children through appropriate tools and techniques.”

Source location
Response from George Eliot Hospital NHS Trust
Page 5 · response
Published 25 June 2026
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
Implement the FLACC behavioural pain assessment tool within the Clinical Assessment Unit.

Verbatim wording from the response
“• The FLACC (Face, Legs, Activity, Cry, Consolability) behavioural pain assessment tool is being implemented within CAU to support more consistent and appropriate pain assessment, with full implementation anticipated by the end of June 2026.”

Source location
Response from George Eliot Hospital NHS Trust
Page 5 · response
Published 25 June 2026
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
Develop and deliver a communications campaign promoting Hospital Passports and “All About Me” tools.

Verbatim wording from the response
“• The Trust’s Communications Team is developing a formal communications plan, in partnership with the Paediatric Neurodiversity & Learning Disability Lead, to increase awareness and utilisation of Hospital Passports and “All About Me” tools. This will include a public-facing campaign, commencing in July 2026 and continuing thereafter.”

Source location
Response from George Eliot Hospital NHS Trust
Page 5 · response
Published 25 June 2026
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
Practical mechanisms in GIRFT guidance fall outside the Trust’s direct remit; the Trust will comply with any enhanced guidance GIRFT issues.

Verbatim wording from the response
“The Trust acknowledges the concerns raised regarding the absence of practical mechanisms within the GIRFT guidance to support assessment and communication with neurodivergent children and their families. However, this matter falls outside the Trust’s direct remit. GIRFT has been made aware of these considerations through receipt of the Coroner’s Regulation 28 Report to Prevent Future Deaths. The Trust will, however, ensure full compliance with any enhanced or updated guidance issued by GIRFT in response to these findings.”

Source location
Response from George Eliot Hospital NHS Trust
Page 4 · response
Published 25 June 2026
Open published response
8 Feb2026
Essex
Concerns raised1
1. Lack of staff training in autism
This report raised 30 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement Oliver McGowan mandatory learning-disability and autism training across the Trust.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Provide bespoke autism-awareness training within the CAMHS substantive-staff induction programme.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Elise Kay Louise Sebastian · 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

Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.

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 staff training in autism
Wider context from the report
“1. Mental Health Trust Staff on Longfield Ward: a. Elise was neurodiverse and staff were not trained in Autism b. were inexperienced. The majority were new bank and agency staff with limited experience working with detained children, and this matter had been raised by the Care Quality Commission about other Trust services in January 2021. c. Did not have sufficient staffing to conduct observations required by the doctors for patients on the ward. This was known to the mental health Trust management and had been raised by the ward manager. During the time of Elise’s admission, the staff member allocated for observations was required to conduct approximately 66 observations within an hour. This was not logistically possible. Management knew that staffing allocation on Longview Ward was not sufficient to conduct the required levels of observations to keep the patients safe. Evidence was heard during the inquest that there are still observations that are not being conducted either as required or at all within the Trust and remains an ongoing concern. Datix reporting incidents are not always raised. d. The mental health Trust implemented a system called Oxevision with a Project Board to assist with the planning and roll out of the new system. There were difficulties with the roll out on St.Aubyns ward who were part of the pilot, due to WiFi coverage and the Oxevision system not operating correctly. e. The clinical management at the Trust Project Board meeting overseeing the roll out for Oxevision, required that ward staff implement a procedure where the Oxevision fixed monitor in the ward office be observed by a member of staff whilst the WiFi problem was resolved. This did not happen on Longview Ward. f. The Trust Project Group had reports that WiFi was not working and any issues were required to be reported as incident reports on Datix forms but these were not being completed. The Trust Project Board did not question why they were not receiving the Datix forms with the known issues. There was no oversight of what was required to ensure that the roll-out was operating appropriately and/or what the Project Board expected in the interim whilst the WiFi difficulties were being investigated. g. Not all the Trust staff on the ward were trained to use the Oxevision System. h. There was disputed evidence about the volume on the fixed terminal for Oxevision in the office about whether the alert volume could be turned down or ‘muted’. It was established that there was no incident unrelated to Elise’s death where a doctor did turn this volume down on the ward. ”
Source location
Elise Kay Louise Sebastian · Prevention of Future Deaths report
Page 2 · 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
Implement Oliver McGowan mandatory learning-disability and autism training across the Trust.

Verbatim wording from the response
“Response: During the evidence provided at this Inquest, it was acknowledged that the Trust did not have autism training provisions in place at the time of the incident. As part of the learning that has been taken from this case, the ‘Oliver McGowan’ training module has been implemented at the Trust.”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 1 · response
Published 13 February 2026
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
Provide bespoke autism-awareness training within the CAMHS substantive-staff induction programme.

Verbatim wording from the response
“In addition to the above training, the Children and Young People’s mental health services (CAMHS) have a bespoke CAMHS Autism training which is part of a 4 day specific training module for substantive staff on appointment. Within this training, 2 days are focused on Autism awareness training. This training compliments the Oliver McGowan training (details of this training package were shared during the Inquest).”

Source location
2026-0078 - Response from Essex University Partnership Trust
Page 2 · response
Published 13 February 2026
Open published response
31 Jan2022
Surrey
Concerns raised5
1. Lack of mandatory Autism training for Education and SEN staff
2. Lack of specific safeguarding guidance for children with disabilities
3. Lack of comprehensive, relevant and mandatory Autism training across state agencies
1. Lack of mandatory Autism training for Children’s Services staff
2. Lack of mandatory Autism training for child mental health referral triage staff
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Make autism awareness training mandatory for staff working directly with children and young people, including new starters, and monitor individual uptake.
  Stated by Surrey County CouncilStated completed
2. Action
  Roll out further autism, self-harm and suicidal-ideation training to relevant Education and Children’s Services staff.
  Stated by Surrey County CouncilStated planned
3. Action
  Consider necessary changes to statutory safeguarding guidance, including Working Together to Safeguard Children, after receiving the review’s final report and recommendations.
  Stated by Department for EducationStated planned
1. Action
  Disseminate thematic-review learning and the Suicide Prevention Toolbox through accredited events, webinars, training, publications and professional meetings.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
2. Action
  Deliver mandatory Autism Awareness training to CYPS staff, initially prioritising the Access and Advice Team.
  Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progress
Respondent positions 2
1. Position
  The Secretary of State for Health and Social Care will address mandatory learning disability and autism training under Concern 12.
  Stated by Department for EducationRedirects responsibility
1. Position
  The Department will consider statutory guidance changes, including Working Together revisions, only after receiving the social care review’s final report and recommendations.
  Stated by Department for EducationUnable to act
AI-generated summary

OSKAR MILES NASH · 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

Oskar Nash was 14 when he died by suicide on 9 January 2020 after a history of autism, anxiety, suicidal ideation and self-harm. The report identified failures including the lack of clinical mental-health assessment and support, an inappropriate mainstream-school placement, inadequate information in his Education, Health and Care Plan, and failures by children’s services to assess and respond to his risks. The report also raised ongoing concerns about autism training, referral triage, information sharing, safeguarding guidance and post-death investigations.

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 mandatory Autism training for Education and SEN staff
Wider context from the report
“The evidence at the inquest revealed that the staff in the Education / SEN Department, including SEN caseworkers, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis. ”
Source location
OSKAR MILES NASH · 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
Lack of specific safeguarding guidance for children with disabilities
Wider context from the report
“I am concerned that “Working Together” does not provide clearer guidance specifically for the safeguarding of children with disabilities, including Autism, and the approach to be taken by agencies to parents and families. ”
Source location
OSKAR MILES NASH · Prevention of Future Deaths report
Page 8 · 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 comprehensive, relevant and mandatory Autism training across state agencies
Wider context from the report
“At the prevention of future deaths hearing, I heard evidence of more training being available, but also of an ongoing absence of comprehensive, relevant and mandatory training. I was told that the National Autism Strategy does not currently include a timetabled commitment for relevant mandatory Autism training to be provided to all state agencies working directly with autistic adults and children. I am concerned that this poses an ongoing risk to autistic children and their ability to access the services they require for their support, welfare, and safeguarding. ”
Source location
OSKAR MILES NASH · Prevention of Future Deaths report
Page 8 · 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 mandatory Autism training for Children’s Services staff
Wider context from the report
“The evidence at the inquest revealed that the staff in SCC’s Children’s Services Department, including Social Workers and other Team members, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis. ”
Source location
OSKAR MILES NASH · 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
Lack of mandatory Autism training for child mental health referral triage staff
Wider context from the report
“The evidence at the inquest revealed that the staff responsible for the triage of referrals to child mental health services had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I have been told that the triaging process is now undertaken by an “Access and Advice Team” but I am concerned that there continues to be no requirement for the staff in that Team to undertake relevant Autism training on a mandatory basis. ”
Source location
OSKAR MILES NASH · Prevention of Future Deaths report
Page 4 · 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
Make autism awareness training mandatory for staff working directly with children and young people, including new starters, and monitor individual uptake.

Verbatim wording from the response
“Response: On 30 November 2021 the Executive Director for Children Families, Lifelong Learning and Culture wrote to all staff in the Directorate setting out the Autism Awareness Training offer available for all staff in the Directorate.”

Source location
2022-0031-Response-from-Surrey-County-Council_Published
Page 1 · response
Published 3 February 2022
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
Roll out further autism, self-harm and suicidal-ideation training to relevant Education and Children’s Services staff.

Verbatim wording from the response
“The training does not currently capture fully the link between autism and self harm or suicidal ideation, and the associated risks. The SCC Children’s Academy is currently in the process of reviewing the training required in order to equip all frontline workers to recognise this risk and is in the process of identifying the most appropriate further training package for relevant staff to broaden understanding around this. SCC is committed to rolling out this further training package at the very earliest opportunity.”

Source location
2022-0031-Response-from-Surrey-County-Council_Published
Page 2 · response
Published 3 February 2022
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
Consider necessary changes to statutory safeguarding guidance, including Working Together to Safeguard Children, after receiving the review’s final report and recommendations.

Verbatim wording from the response
“The Department will consider any necessary changes to statutory guidance, including revisions to Working Together to Safeguard Children (Concern 11), as part of that wider programme of reform, once it has received the full and final report and recommendations of the Review. Substantive revisions to guidance will be subject to full consultation.”

Source location
2022-0031-Response-from-Department-for-Education_Published
Page 3 · response
Published 3 February 2022
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
Disseminate thematic-review learning and the Suicide Prevention Toolbox through accredited events, webinars, training, publications and professional meetings.

Verbatim wording from the response
“Dissemination of learning from the thematic review:”

Source location
2022-0031-Response-from-Surrey-Heartlands-CCG_Published
Page 3 · response
Published 3 February 2022
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
Deliver mandatory Autism Awareness training to CYPS staff, initially prioritising the Access and Advice Team.

Verbatim wording from the response
“Our response A new “Autism Awareness” half-day training course, provided by the Association for Psychological Therapies (APT), has been added to the mandatory training matrix for all CYPS staff. The course is designed to raise staff’s knowledge and awareness of the importance of autism and covers issues such as:”

Source location
2022-0031-Surrey-and-Borders-Partnership-NHS-Foundation-Trust_Published-1
Page 1 · response
Published 3 February 2022
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
The Secretary of State for Health and Social Care will address mandatory learning disability and autism training under Concern 12.

Verbatim wording from the response
“There were clearly failings in Oskar’s case. We recognise that the current special education and disability system, established through the Children and Families Act 2014, does not consistently deliver the services needed by children and young people and their families. That is why we have undertaken a comprehensive review of how the system has evolved since 2014 and how it can be made to work best for all families, ensuring quality of provision is the same across the country. In doing so we have placed a clear focus on the importance of joined-up support, working in collaboration with the Department of Health and Social Care (and the Secretary of State for Health and Social Care, will be writing to you with regard to mandatory training in learning disability and autism (Concern 12)).”

Source location
2022-0031-Response-from-Department-for-Education_Published
Page 2 · response
Published 3 February 2022
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
The Department will consider statutory guidance changes, including Working Together revisions, only after receiving the social care review’s final report and recommendations.

Verbatim wording from the response
“The Department will consider any necessary changes to statutory guidance, including revisions to Working Together to Safeguard Children (Concern 11), as part of that wider programme of reform, once it has received the full and final report and recommendations of the Review. Substantive revisions to guidance will be subject to full consultation.”

Source location
2022-0031-Response-from-Department-for-Education_Published
Page 3 · response
Published 3 February 2022
Open published response
2 Feb2016
South Yorkshire (Eastern)
Concerns raised1
1. Lack of guidance for communicating with children with disabilities such as autism
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review the Paediatric IPOC and require documentation of communication needs and disability-related communication limitations.
  Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completed
AI-generated summary

Marc Jason Stephen Poole · 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

Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.

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 guidance for communicating with children with disabilities such as autism
Wider context from the report
“(1) Poor communication on a number of levels Insufficient discussion with the parents regarding history, insufficient weight attached to the information they did provide at the time of admission and subsequently. Absence of any protocols of guidance as to how best to communicate with children with disabilities such as autism as MJ had. Communications between staff were poor, HCAs to nurses, nurses to doctors and between junior doctors and senior doctors. Ineffective communication of microbiology results which had been phoned through to the ward but not immediately passed on to those who needed to undertake assessment. ”
Source location
Marc Jason Stephen Poole · Prevention of Future Deaths report
Page 2 · 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 the Paediatric IPOC and require documentation of communication needs and disability-related communication limitations.

Verbatim wording from the response
“With respect to the discussion with the parents regarding a child’s clinical history, in order to ensure better communication the team have reviewed the Paediatric IPOC. Staff have been made aware of the need to listen to parents and take their views into consideration when assessing the clinical picture in any child who is admitted. Should children suffer from disabilities, medical and nursing staff will record, under the respective part of the Paediatric IPOC, how such children are communicated with and whether their disability limits their ability to communicate with strangers and hence the need to have more detailed and in depth conversations with parents. This situation will continue to pertain throughout the child’s stay in hospital.”

Source location
Marc-Poole-Response
Page 2 · response
Published 2 February 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of practical mechanisms for adapting assessment of neurodivergent children

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of staff training in autism

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised5

Lack of mandatory Autism training for Education and SEN staff

Lack of specific safeguarding guidance for children with disabilities

Lack of comprehensive, relevant and mandatory Autism training across state agencies

Lack of mandatory Autism training for Children’s Services staff

Lack of mandatory Autism training for child mental health referral triage staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of guidance for communicating with children with disabilities such as autism

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 5

Respondent positions 1

Actions described in response 2

Actions described in response 5

Respondent positions 2

Actions described in response 1