Concerns raised 3 Lack of communication and engagement between agencies involved in Ollie’s care View source Failure to act on Ollie’s stated pronoun preference View source Failure to record important discussions between early help and the school View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ollie Lee · 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
Ollie Lee, who had a history of suicidal thoughts and self-harm, died by suicide on 6 October 2024. The principal concerns were poor communication and engagement between the agencies involved, including failures to share information about self-harm and CAMHS discharge, which resulted in missed opportunities for continued mental health support. Important discussions about Ollie’s preferred name and pronouns were also not recorded or acted upon.
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. The report was sent to Barnsley Academy; that does not assign responsibility.
PFD Monitor interpretation Lack of communication and engagement between agencies involved in Ollie’s care
Wider context from the report “1) Poor communication and engagement between the agencies involved with Ollie including her school, CAMHS and targeted early help.
2) A lack of communication and engagement between targeted early help and CAMHS despite both agencies being aware that the other was involved. This led to a confusing picture and a missed opportunity for Ollie to remain open to CAMHS and receive psycho social intervention and continued support from CAMHS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barnsley Academy; that does not assign responsibility.
PFD Monitor interpretation Failure to act on Ollie’s stated pronoun preference
Wider context from the report “3) There was no record of important discussions that occurred between early help and the school and Ollie’s preference in relation to pronouns was not acted upon .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Barnsley Academy; that does not assign responsibility.
PFD Monitor interpretation Failure to record important discussions between early help and the school
Wider context from the report “3) There was no record of important discussions that occurred between early help and the school and Ollie’s preference in relation to pronouns was not acted upon.
” Open source report
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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 Adapt escalation protocols so the school contacts the crisis team directly when students self-harm or may harm themselves.
Verbatim wording from the response “• As a result of CAMHS sharing the crisis flowchart with schools, Barnsley Academy has adapted its protocols around escalating concerns for students who have self-harmed or are deemed to be at risk of harming themselves (including suicidal ideation). Whereas previously, parents or carers would have been advised to take their child to A&E to seek support, school now contacts the crisis team directly.” Source location Response from Barnsley Community Academy
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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 Formalise safeguarding quality assurance guidance covering information-sharing audits and termly complex-case reviews.
Verbatim wording from the response “• In addition to training colleagues, Barnsley Academy has formalised its Safeguarding Quality Assurance and Supervision process guidance (Appendix 3) to ensure that specific reference is made to quality assurance of relevant information sharing across multiple agencies. Within the guidance the Designated Safeguarding Lead completes routine quality assurance audits (Appendix 4) to ensure efficiency and compliance in relation to CPOMs logs and to monitor the effectiveness of multi-agency working. Within the guidance, there is also clear reference made to quality assuring multi-agency working as part of termly complex case file reviews. Whilst the working practices have been in place for much longer, the formal guidance was updated on 5 June 2026 and outlines training commitments as well as quality assurance processes to ensure routine practice and accountability.” Source location Response from Barnsley Community Academy
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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 Train safeguarding colleagues to routinely share relevant information with all agencies involved in multi-agency support.
Verbatim wording from the response “• Barnsley Academy has completed regular professional development training with all safeguarding trained colleagues (DSLs/DDSLs) within the Academy, including most recently on Thursday 4 June 2026. The focus of the most recent training was around ensuring that where multi-agency support is in place for a student and their family, all relevant information is shared as routine with all agencies involved. Furthermore, particular emphasis was placed upon information sharing across agencies even when other stakeholders (e.g. a parent or Family Support Worker) state that they will share that information (Appendix 2).” Source location Response from Barnsley Community Academy
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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 routine CPOMS auditing using trained safeguarding leadership, templates and a formal audit schedule.
Verbatim wording from the response “• Following the findings in November 2025, the Designated Safeguarding Lead has been trained on auditing CPOMs logs and has been provided with an auditing template and guidance from United Learning (Appendix 4). Auditing is now in place as routine to ensure the quality of recording is consistent. Where any areas of inconsistency are identified, including around agency communication, it is followed up through training with individuals or wider groups of staff, as applicable. A formal auditing schedule is outlined in the Safeguarding Quality Assurance and Supervision process guidance (Appendix 3).” Source location Response from Barnsley Community Academy
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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 Hold termly Compass Be liaison meetings focused on next steps for identified students with mental health concerns.
Verbatim wording from the response “Mental Health Services - The school has continued to hold link meetings once per term with a school liaison from Compass Be. However, as well as discussing whole school support, these meetings have become more focused to address next steps for specific caseloads of identified students, where mental health concerns have been raised.” Source location Response from Barnsley Community Academy
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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 Train seven additional staff in Early Help processes and use an Early Help Practitioner as the school liaison.
Verbatim wording from the response “Targeted Early Help - Within school, an additional 7 members of staff have received central local authority training around Early Help processes since March 2025. As well as increased capacity to support referral processes, this has further enhanced staff understanding of how targeted early help services work and has made communication more efficient through a strengthening of cross-agency professional relationships and networks. As forementioned, from July 2024, Barnsley Academy has been allocated an Early Help Practitioner within targeted early help services who acts as a direct school liaison and primary point of contact. This has led to more proactive communication and support between early help and school.” Source location Response from Barnsley Community Academy
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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 CPOMS profile pinning to identify agencies involved with students and improve communication oversight.
Verbatim wording from the response “• Following the updated guidance from the Department for Education’s Working together to improve school attendance in August 2024 (Appendix 1), school safeguarding leaders updated their approach to ease identification of agencies involved with students via the use of ‘pinning’ on CPOMs profiles. Whilst we recognise that this action was taken prior to Ollie’s death in October 2024, this has supported the ease and efficiency of communication with agencies and has provided a clearer oversight of their involvement for school leaders.” Source location Response from Barnsley Community Academy
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations