Concerns raised 15 Inadequate information and record sharing before EHCP school placements View source Lack of mandatory Autism training for Education and SEN staff View source Lack of training and monitoring programme for EHCP medical advisers View source Failure to establish changed child mental health triage practices in written guidance View source Failure of the threshold of needs document to reflect risks for autistic children View source Lack of specific safeguarding guidance for children with disabilities View source Lack of clarity about schools’ information-sharing powers and duties View source Lack of clinician understanding of EHCP medical advice responsibilities View source Inappropriate closure or referral of child mental health referrals View source Lack of monitoring of access to clinical teams and referral outcomes View source Lack of comprehensive, relevant and mandatory Autism training across state agencies View source Insufficient process, guidance and oversight for effective post-death investigations View source Automatic categorisation of routine referrals as low risk View source Lack of mandatory Autism training for Children’s Services staff View source Lack of mandatory Autism training for child mental health referral triage staff View source See 12 more concerns
Responses linked to these concerns
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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. The report was sent to Child Safeguarding Practice Review Panel; that does not assign responsibility.
PFD Monitor interpretation Inadequate information and record sharing before EHCP school placements
Wider context from the report “I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing . On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.
I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP . I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents, and any data protection ramifications this may have.
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
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 .
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
PFD Monitor interpretation Lack of training and monitoring programme for EHCP medical advisers
Wider context from the report “On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process. I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities .
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
PFD Monitor interpretation Failure to establish changed child mental health triage practices in written guidance
Wider context from the report “I was told that the Standard Operating Procedure manual for the triage of referrals to children’s mental health services is to be updated to reflect the Trust’s new working practices but that this has not yet been done. I am concerned that important changes to the system of work (for example, the vital requirement that a referred child’s records are reviewed before any triaging decision is made and the child/family are spoken to) are not yet established in written guidance .
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
PFD Monitor interpretation Failure of the threshold of needs document to reflect risks for autistic children
Wider context from the report “Despite these changes, I remain concerned that the “threshold of needs” document does not adequately and clearly reflect the known risks of mental health difficulties, self-harm, and suicidal ideation for autistic children (given their prevalence in this group of children) and that, consequentially, there is an ongoing risk that an autistic child in these circumstances will be allocated an insufficient level of support , as was the case for Oskar.
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
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.
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about schools’ information-sharing powers and duties
Wider context from the report “I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing. On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.
I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP. I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents , and any data protection ramifications this may have.
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
PFD Monitor interpretation Lack of clinician understanding of EHCP medical advice responsibilities
Wider context from the report “On the basis of the evidence at the prevention of future deaths hearing, I am concerned that there continues to be a lack of understanding amongst the clinicians currently providing medical advice as part of the EHCP process as to their role in that process . I am further concerned that there is in place no programme for the training or monitoring of these clinicians in relation to these responsibilities.
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
PFD Monitor interpretation Inappropriate closure or referral of child mental health referrals
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies . In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
PFD Monitor interpretation Lack of monitoring of access to clinical teams and referral outcomes
Wider context from the report “However, on the basis of the evidence I heard at the prevention of future deaths hearing, including from a special needs school which has experience of referring its pupils, I am concerned that there is an ongoing risk that some referrals may be inappropriately closed (for example because the child, at an early stage, declines to engage) or inappropriately referred to non-clinical partner agencies. In this context, I am concerned that there is a lack of specific monitoring of what proportion of referred children reach a clinical team and the extent to which the outcomes match the expectations of the referrers (so that any ongoing “barriers” in the system, which may be preventing proper access to the clinical teams, can then be identified and eliminated).
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
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.
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
PFD Monitor interpretation Insufficient process, guidance and oversight for effective post-death investigations
Wider context from the report “Ineffective review by the child death review processes results in the risk of further deaths in similar circumstances and I am concerned that the local and/or national process, guidance and oversight are insufficient to ensure that an effective post-death investigation , which should not be dependent on the inquest process, is achieved in all cases.
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
PFD Monitor interpretation Automatic categorisation of routine referrals as low risk
Wider context from the report “The evidence showed that a referral to the child mental health services is triaged initially as being crisis, urgent, priority or routine. The criteria for crisis, urgent and priority referrals are specific and narrow and, consequently, the great majority of referrals are categorised as routine. I have been told that the routine referrals are automatically categorised as “low risk” . I am concerned about this as it is clear from the evidence that a child may not meet the criteria crisis, urgent or priority but, like Oskar Nash, may nevertheless be at a high or medium risk of harm. The Trust is currently receiving a high volume of referrals and so there is a considerable waiting time for its “routine” cases to be addressed. It seems inevitable, therefore, that there are children in this category who have been wrongly assumed to be at low risk of harm but who, in fact, face a high risk of harm which is currently unrecognised and unmanaged.
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
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 .
” 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 Child Safeguarding Practice Review Panel; that does not assign responsibility.
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 .
” 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 Conduct case-specific national reviews of the deaths of Arthur Labinjo-Hughes and Star Hobson and of safeguarding children with disabilities and complex health needs in residential settings.
Verbatim wording from the response “We continue to commission national thematic reviews and currently are undertaking a review of domestic abuse which we intend to publish shortly. In addition, we are carrying out two case-specific national reviews – one into the deaths of Arthur Labinjo-Hughes and Star Hobson, and one into safeguarding children with disabilities and complex health needs in residential settings - both of which will report later this year.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Develop an observatory function providing current data and information on serious safeguarding cases.
Verbatim wording from the response “We continue to monitor the learning from all rapid reviews and LCSPRs and are in the process of developing an observatory function to provide up-to-date data and information on all serious safeguarding cases, along with a case tracking system to enable us to monitor and report on the progress of reviews. We have, to date, and will continue to commission national analyses of the learning from rapid reviews and LCSPRs, and both of those pieces of work include some analysis of the quality of those reviews. We publish the findings of those analyses as part of our annual report.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Commission national analyses of learning and review quality, and publish their findings in annual reports.
Verbatim wording from the response “We continue to monitor the learning from all rapid reviews and LCSPRs and are in the process of developing an observatory function to provide up-to-date data and information on all serious safeguarding cases, along with a case tracking system to enable us to monitor and report on the progress of reviews. We have, to date, and will continue to commission national analyses of the learning from rapid reviews and LCSPRs, and both of those pieces of work include some analysis of the quality of those reviews. We publish the findings of those analyses as part of our annual report.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Develop a case-tracking system to monitor and report on review progress.
Verbatim wording from the response “We continue to monitor the learning from all rapid reviews and LCSPRs and are in the process of developing an observatory function to provide up-to-date data and information on all serious safeguarding cases, along with a case tracking system to enable us to monitor and report on the progress of reviews. We have, to date, and will continue to commission national analyses of the learning from rapid reviews and LCSPRs, and both of those pieces of work include some analysis of the quality of those reviews. We publish the findings of those analyses as part of our annual report.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Provide feedback to Safeguarding Partners on review content, quality, learning and national issues.
Verbatim wording from the response “In response to each rapid review and LCSPR which we receive as a Panel, we write to the Safeguarding Partners, providing feedback on the content and quality of the review, any learning arising from it, and actions we are taking as a Panel in response to any national issues identified. While initially much of this feedback was focused on the process and criteria for reviews, we have increasingly been more detailed and focused on issues of quality and learning. In cases which are particularly complex, or where we as a Panel have particular concerns about the quality of the review, we will often engage directly with the Safeguarding Partners through telephone calls or online or face-to-face meetings, offering advice, guidance and support.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Publish anonymised examples of high-quality rapid reviews as good-practice exemplars.
Verbatim wording from the response “In recognition of the ongoing issues around timeliness and quality, and taking note of your expressed concerns regarding the Oskar Nash rapid review, we are currently updating our practice guidance, with a much greater focus on issues of quality and learning in the reviews. We are planning also to publish some anonymised examples of good quality rapid reviews as exemplars of good practice.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Work with Safeguarding Partners to streamline and focus local safeguarding practice reviews to improve timeliness and learning.
Verbatim wording from the response “As a Panel we have noted improvements in both the timeliness and quality of rapid reviews over the past year. We continue to feedback to local Safeguarding Partners on the content and quality of their rapid reviews. We are now also receiving significant numbers of completed LCSPRs. To date, very few of these have been completed within the required timeframe of six months, and many have been delayed by a year or more. We consider this unacceptable and are working with Safeguarding Partners to ensure that they take a more streamlined and focused approach to learning through the LCSPRs, but we are aware that there is still a long way to go.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Produce and publish thematic national reviews to identify learning for safeguarding practice and system improvement.
Verbatim wording from the response “responsible for commissioning national reviews into cases which raise issues of national importance. To date we have completed and published three national reviews, each of which has been a thematic review, drawing on a number of cases relating to a particular theme: sudden unexpected death in infancy (SUDI); child criminal exploitation; and non-accidental injury in infants aged under one. Each of these thematic national reviews has sought to identify relevant learning to inform practice and system improvement within the relevant area. While the Panel has no immediate plans to announce a national review into suicide it remains a theme in which we have a very keen interest and we will continue to analyse the cases which we see to consider if a practice briefing or more detailed piece of thematic work in this space would aid system learning.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Monitor learning from rapid reviews and local safeguarding practice reviews.
Verbatim wording from the response “We continue to monitor the learning from all rapid reviews and LCSPRs and are in the process of developing an observatory function to provide up-to-date data and information on all serious safeguarding cases, along with a case tracking system to enable us to monitor and report on the progress of reviews. We have, to date, and will continue to commission national analyses of the learning from rapid reviews and LCSPRs, and both of those pieces of work include some analysis of the quality of those reviews. We publish the findings of those analyses as part of our annual report.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Update practice guidance to place greater emphasis on review quality and learning.
Verbatim wording from the response “In 2018 the Panel produced detailed practice guidance which outlined the process of reviews and our expectations for what makes for good quality reviews. We are in the process of updating this guidance in light of our learning since 2018.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Safeguarding practice reviews are not intended to investigate the cause or circumstances of a child’s death.
Verbatim wording from the response “The purpose of reviews of serious child safeguarding cases is ‘to identify improvements to be made to safeguard and promote the welfare of children’. Working Together 2018 stipulates that ‘Reviews should seek to prevent or reduce the risk of recurrence of similar incidents’. It goes on to state that they ‘are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose’. As such, these reviews are not intended to be investigations into the cause or circumstances of the death or serious harm, nor to determine whether any individual, organisation or agency was culpable.” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Child death review processes fall outside the Panel’s remit.
Verbatim wording from the response “We note the finding expressed within Concern 10 in relation to the child death review process, and note that responsibility for those processes rests with the Department for Health and Social Care, the National Child Mortality Database” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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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 Responsibility for child death review processes rests with health authorities, the mortality database team and local review partners.
Verbatim wording from the response “We note the finding expressed within Concern 10 in relation to the child death review process, and note that responsibility for those processes rests with the Department for Health and Social Care, the National Child Mortality Database” Source location 2022-0031-Response-from-Child-Safeguarding-Practice-Review-Panel_Published
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations