1 May 2026 Natasha Hill · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Limited national dissemination of local safeguarding protocols View source Failure to formally review safeguarding, domestic violence or controlling or coercive behaviour risks affecting teenagers approaching 18 View source Lack of consistent criteria and central guidance for safeguarding offender management functions View source Lack of specific protection for young people against adults creating safeguarding risks View source Lack of one single national policy for policing and child sexual exploitation View source Lack of guidance on missing persons, runaways and return-to-home interviews View source Lack of a young person's team covering transition from under-18 services to adult safeguarding teams View source See 4 more concerns
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
Natasha Hill · 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
Natasha Hill, who had been in care and was experiencing grooming, exploitation, self-harm, substance misuse and domestic violence, was pronounced dead at her abuser’s home in the early hours of 15 April 2018. The jury concluded that she was unlawfully killed by her abuser. The report raised concerns about safeguarding during the transition to adulthood, protection from exploitation and domestic abuse, and coordination of relevant policing and safeguarding policies.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Limited national dissemination of local safeguarding protocols
Wider context from the report “• To consider the wider dissemination of existing local protocols nationally , for example the London Exploitation Protocol.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to formally review safeguarding, domestic violence or controlling or coercive behaviour risks affecting teenagers approaching 18
Wider context from the report “• Anyone requiring/needing/suffering
o Safeguarding
o Domestic violence
o Controlling/ coercive behaviour
And incurring the consequential risks, as a teenager approaching 18 should be formally reviewed by an adult safeguarding team ad the independent reviewing officer .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent criteria and central guidance for safeguarding offender management functions
Wider context from the report “• Re safeguarding offender management, the use of VOO's and the creation of POETs/ DAPST and RMUs: consideration should be given to the creation of one set of criteria with one name whose role it is to cover and create a central 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of specific protection for young people against adults creating safeguarding risks
Wider context from the report “• Thought should be given to the creation of a young person's protection by way of creation of an extension to the CAWN for the young person, against the adult creating that safeguarding risk e.g. young person's abuse warning notice.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of one single national policy for policing and child sexual exploitation
Wider context from the report “• The creation of one single national policy for policing and child sexual exploitation following the groundwork laid down by Operation Hydrant and local Forces.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on missing persons, runaways and return-to-home interviews
Wider context from the report “• The provision of guidance in respect of missing persons/ runaways and the return to home interviews to assist the actions of the police and local councils.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of a young person's team covering transition from under-18 services to adult safeguarding teams
Wider context from the report “• Thought should be given to creating a young person's team covering the transition from under 18 (MACE) to adult safeguarding teams e.g. For the period 18-22 .
” 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 an urgent review of adult safeguarding powers and duties, including consultation on updated safeguarding guidance and consideration of transition safeguards.
Verbatim wording from the response “• The National Adult Safeguarding Board will be conducting an urgent review of adult safeguarding powers and duties. The first part of that work will be to consult on updating the safeguarding chapter of Care and support statutory guidance (CASSG). As part of this update, we will consider what guidance can be provided to strengthen safeguarding in the context of the transition of young people to adult services. In that process we will take the learning from this PFD report and consider the recommendation that when a teenager with care and support needs approaches 18 they should be reviewed formally by an adult safeguarding team and the independent reviewing officer.” Source location Response from Department for Education
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 Update guidance for children who go missing from home or care in collaboration with operational partners and sector stakeholders.
Verbatim wording from the response “• The Department for Education, working with colleagues across government, will be updating the content of the guidance for children who go missing from home or care. We will be working closely with a wide range of operational partners and sector stakeholders as part of this process, including on the format for this guidance, to ensure a robust multi-agency response to missing children.” Source location Response from Department for Education
Open published response
4 Feb 2026 Georgia Charlotte SCARFF · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Absence of a single standard safeguarding information management tool for schools and colleges View source Failure of staff to record important safeguarding detail in CPOMS View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Georgia Charlotte SCARFF · 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
Georgia Charlotte SCARFF, aged 16, died immediately on 15 April 2024 after stepping into the path of a lorry on the A14 near Bury St Edmunds; the inquest concluded that she had been experiencing anxiety and acted impulsively in taking her own life. Concerns were raised that staff were not always proficient in using CPOMS, resulting in important safeguarding information not being recorded, and that the absence of a single standard safeguarding information management tool could create risks to life.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Absence of a single standard safeguarding information management tool for schools and colleges
Wider context from the report “However, the Court also heard evidence that there is no single standard safeguarding information management tool for schools and colleges . Teachers moving between schools and colleges must familiarise themselves with different processes and tools depending on that used by an individual school or college.
I am concerned that the absence of a single standard safeguarding information management tool for schools and colleges may result in a risk to life due to teachers being unfamiliar with different management tools and as a consequence important information relating to safeguarding not being recorded in children’s safeguarding records.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to record important safeguarding detail in CPOMS
Wider context from the report “However, the Court also heard evidence that not all staff were familiar with or proficient in the use of CPOMS which, although not causative of Georgia’s death, led to important information not being recorded in Georgia’s CPOMS record .
I am concerned that in another case the failure to record important safeguarding detail may result in a risk to life.
” Open source report
14 Jan 2026 Oliver Anderson Long · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 5 Failure of consumers to check gambling-site licensing before access View source Failure of the self-exclusion scheme to cover overseas unlicensed gambling sites View source Lack of consumer awareness when accessing unlicensed gambling sites View source Lack of adequate public health information and warnings about unlicensed gambling-site risks View source Absence of gambling-harm protection features on unlicensed sites View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver Anderson Long · 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
Oliver Anderson Long, known as Ollie, was found dead on 23 February 2024 after travelling to East Sussex and leaving notes indicating an intention to take his own life from cliffs. He had a history including gambling disorder and, despite self-exclusion from licensed online gambling, was able to access unlicensed gambling sites. The principal concern was that unlicensed sites are outside the protections of regulated gambling and that there is inadequate public health information and warning about their risks.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of consumers to check gambling-site licensing before access
Wider context from the report “Consumers are unlikely to check that a site is licenced prior to accessing it , particularly if the advert for the site is in a trusted space, such as on social media . The result is that people who are at risk of gambling-related harm in accessing these sites are not protected by features such as limit setting and slowing down of gains, and they may not be aware that these features are unlikely to be present on the site they are using.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of the self-exclusion scheme to cover overseas unlicensed gambling sites
Wider context from the report “I heard evidence from Ollie's family and the Gambling Commission in respect of the efficacy of the UK self-exclusion scheme, GamStop, which allows customers to bar themselves from all forms of legal and licenced online betting. This scheme, however, does not capture overseas unlicensed sites and people who have self-excluded (as Ollie did) may be able to access these sites or are being deliberately targeted by them .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of consumer awareness when accessing unlicensed gambling sites
Wider context from the report “Additionally, I heard evidence that consumers may not be aware that they have accessed an unlicensed site and in doing so have moved outside of the realm of the regulated area .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate public health information and warnings about unlicensed gambling-site risks
Wider context from the report “There is, in my view, a lack of adequate public health information and warning relating to the risks posed by unlicenced gambling sites .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Absence of gambling-harm protection features on unlicensed sites
Wider context from the report “Consumers are unlikely to check that a site is licenced prior to accessing it, particularly if the advert for the site is in a trusted space, such as on social media. The result is that people who are at risk of gambling-related harm in accessing these sites are not protected by features such as limit setting and slowing down of gains , and they may not be aware that these features are unlikely to be present on the site they are using .
” Open source report
×
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 organisations identified in the report may be best placed to provide a comprehensive response and address the concerns.
Verbatim wording from the response “Officials within the Department for Education have undertaken a review of the report and fully recognise the importance of the issues you have raised. Following this consideration, we have concluded that responsibility for these matters lies outside the remit of this Department. The organisations identified within the report may be best placed to provide you with a full and comprehensive response, and we trust they will be able to address your concerns appropriately.” Source location Response from Department for Education
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 Responsibility for the matters raised lies outside the Department’s remit, so it will not undertake responsive safety work.
Verbatim wording from the response “Officials within the Department for Education have undertaken a review of the report and fully recognise the importance of the issues you have raised. Following this consideration, we have concluded that responsibility for these matters lies outside the remit of this Department. The organisations identified within the report may be best placed to provide you with a full and comprehensive response, and we trust they will be able to address your concerns appropriately.” Source location Response from Department for Education
Open published response
5 Dec 2025 Leonardo Cardoso Machado · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Children working alone at night delivering to private homes View source Risk of road traffic collisions involving children working at night on powered two-wheeled vehicles View source Lack of oversight of the rental of food delivery licences to children under 18 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Leonardo Cardoso Machado · 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
Leonardo Cardoso Machado, aged 17, died on 16 April 2023 after losing control of a motorcycle while travelling at speed and colliding with metal railings. The report raised concerns about limited oversight of rented food delivery licences being provided to children under 18, and the resulting risks of lone night work and road traffic collisions.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Children working alone at night delivering to private homes
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position ;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Risk of road traffic collisions involving children working at night on powered two-wheeled vehicles
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of oversight of the rental of food delivery licences to children under 18
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit . This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age , which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death.
” Open source report
Concerns raised 5 Failure to procure interpreting services through agencies specialising in British Sign Language View source Lack of availability of British Sign Language qualifications and training View source Failure to recruit and retain sufficient BSL-proficient clinicians View source Lack of statutory regulation for British Sign Language interpreters View source Lack of British Sign Language interpreters available to support deaf mental health patients View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Imogen Alice NUNN · 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
Imogen Alice Nunn died at home on 1 January 2023 after consuming a substance she had obtained approximately six weeks earlier, during a period of deteriorating mental health. The report raises concerns about failures in mental-health risk management and the shortage of British Sign Language interpreters and BSL-proficient clinicians supporting deaf patients.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to procure interpreting services through agencies specialising in British Sign Language
Wider context from the report “1. Matter for the Cabinet Office (Equalities. The Disability Unit/BSL Advisory Board. Sponsoring the Procurement Act 2023.
AND the Minister of State (Minister for Social Security and Disability)
The Chief Executive of the NRCPD provided evidence that the Procurement Act offers NHS bodies and Integrated Care Boards (ICBs) the opportunity to collaborate with organisations like NRCPD to develop contracts that improve the delivery of BSL interpreting services. At present, contracts for interpreting services are often awarded to larger agencies, where BSL interpreting forms only a small part of broader contracts primarily focused on spoken languages, rather than being handled by agencies specialising in BSL. Evidence also highlighted the absence of statutory regulation for BSL interpreters. The NRCPD Chief Executive emphasised that establishing a statutory regulator would help professionalise and elevate the status of BSL interpreters, which in turn would promote the role and increase the number of specialists available to support deaf mental health patients. Since the Cabinet Office holds responsibility for disabilities, I raise these concerns regarding the national shortage of BSL interpreters and the lack of regulation in this area.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of availability of British Sign Language qualifications and training
Wider context from the report “3. Matter for the Department of Education.
Evidence was heard that the lack of BSL interpreters was in part due to the lack of availability of BSL qualifications and training .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to recruit and retain sufficient BSL-proficient clinicians
Wider context from the report “2. Department of Health and Social Care
Evidence indicates that clinicians who are fluent in British Sign Language (BSL) provide a significantly better experience for deaf patients compared to non-BSL - speaking clinicians relying solely on interpreters.
The NHS England response to the earlier Prevention of Future Deaths (PFD) report outlined the role of Integrated Care Boards (ICBs) in commissioning interpreting services for NHS Trusts. However, there is a clear shortage of BSL-proficient clinicians , and insufficient efforts are being made to recruit and retain these professionals . This gap is failing to meet the needs of deaf individuals.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of statutory regulation for British Sign Language interpreters
Wider context from the report “1. Matter for the Cabinet Office (Equalities. The Disability Unit/BSL Advisory Board. Sponsoring the Procurement Act 2023.
AND the Minister of State (Minister for Social Security and Disability)
The Chief Executive of the NRCPD provided evidence that the Procurement Act offers NHS bodies and Integrated Care Boards (ICBs) the opportunity to collaborate with organisations like NRCPD to develop contracts that improve the delivery of BSL interpreting services. At present, contracts for interpreting services are often awarded to larger agencies, where BSL interpreting forms only a small part of broader contracts primarily focused on spoken languages, rather than being handled by agencies specialising in BSL. Evidence also highlighted the absence of statutory regulation for BSL interpreters. The NRCPD Chief Executive emphasised that establishing a statutory regulator would help professionalise and elevate the status of BSL interpreters, which in turn would promote the role and increase the number of specialists available to support deaf mental health patients. Since the Cabinet Office holds responsibility for disabilities, I raise these concerns regarding the national shortage of BSL interpreters and the lack of regulation in this area .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of British Sign Language interpreters available to support deaf mental health patients
Wider context from the report “It was issued before the Inquest had concluded as it had already become apparent that there was a real lack of British Sign Language Interpreters (BSLs) able to help support Deaf patients in the community who were being treated with mental health difficulties . This was putting this cohort of individuals at risk . The overall lack of British Sign Language Interpreters was also evidenced directly by the Court in that this Inquest has had to be delayed/adjourned for two months due to there being no available Interpreters to interpreter for two deaf/mute witnesses over the two week period of the Inquest.
” Open source report
Concerns raised 2 Lack of a national interface for safeguarding reporting and communication between schools and relevant agencies View source Lack of national guidance and standards for safeguarding referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lucy-Anne DYSON · 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
Lucy Rushton died on 23 June 2019 in the early hours of the morning following a prolonged, severe and brutal attack, with multiple blunt force injuries; the narrative conclusion recorded that she was unlawfully killed. The principal concerns were the lack of a national interface for sharing safeguarding information between schools and relevant agencies, and the lack of national guidance or standards governing safeguarding referrals.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of a national interface for safeguarding reporting and communication between schools and relevant agencies
Wider context from the report “1. The lack of a national interface to enable reporting/communication between schools using safeguarding record keeping systems (e.g. CPOMS) and relevant agencies, including Police and Children’s Services.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance and standards for safeguarding referrals
Wider context from the report “2. The lack of national guidance/standards means agencies with safeguarding duties for children are receiving referrals that either rely too heavily on the individual referrer’s judgement about what should be included, or where no referral is made at all .
” 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 Run local pilots testing the consistent child identifier with existing safeguarding systems and databases to inform national interoperability standards.
Verbatim wording from the response “• Pilots and Implementation Planning
The Department has initiated a series of local pilots to test the implementation of the consistent child identifier and its interoperability with existing safeguarding systems (such as CPOMS) and local authority databases. Learning from these pilots will inform national standards for interoperability between systems.” Source location Response from Department for Education
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 national data standards with education, local authority and technology partners for secure connections between school safeguarding systems and partner agencies.
Verbatim wording from the response “• System and Process Reform
Alongside legislative changes, the Department is convening education, local authority, and technology partners to develop national data standards to enable secure, accurate connections between school safeguarding systems and partner agencies.” Source location Response from Department for Education
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 Update and publish Keeping Children Safe in Education guidance to support consistent recognition, referral and response to safeguarding concerns.
Verbatim wording from the response “• Keeping Children Safe in Education (KCSIE) (2024)
Schools and colleges have a critical role to play in protecting children and keeping them safe. The Department publishes the statutory safeguarding guidance Keeping Children Safe in Education (KCSIE) to support schools and colleges in carrying out their duties to safeguard and promote the welfare of children. KCSIE makes clear that every school must have a Designated Safeguarding Lead who takes lead responsibility for safeguarding and child protection. Part 1 of the guidance, which should be read by all staff who work directly with children, sets out that all staff should know what to do if they have concerns about a child and should be aware of the process for making referrals to local authority children’s social care and for statutory assessments under the Children Act 1989.” Source location Response from Department for Education
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 Introduce a consistent child identifier through the Children’s Wellbeing and Schools Bill to enable secure cross-agency record matching.
Verbatim wording from the response “• Single unique identifier
The Children’s Wellbeing and Schools Bill, introduced in Parliament on 17th December will protect children at risk of abuse, stopping vulnerable children falling through cracks in services, and deliver a core guarantee of high standards with space for innovation in every child’s education.” Source location Response from Department for Education
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 Families First Partnership reforms, including multi-agency child protection teams and integrated front-door models for triaging contacts and referrals.
Verbatim wording from the response “• Families First Partnership Programme
Through this programme, we are delivering national reforms to Family Help, multi-agency child protection, and Family Group Decision Making. The reforms include establishing multi-agency child protection teams that bring together education, police, health, and social care professionals to take decisive action where significant harm is identified. The programme also promotes integrated ‘front door’ models for triaging contacts and referrals, ensuring concerns are directed appropriately and consistently.” Source location Response from Department for Education
Open published response
Concerns raised 5 Failure to document relevant placement risks and complete required forms View source Inadequate communication of placement risks View source Failure to assess and collate risks to foster carers and other children in the placement View source Lack of foster placement capacity View source Senior decision-making not based on all appropriate information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Marcia Grant · 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
Marcia Grant, a foster carer, died on 5 April 2023 after suffering significant chest injuries when a vehicle driven by her foster child collided with her. The report identified concerns about a shortage of placements, incomplete documentation and communication of risks, and inadequate risk assessment when placing the child with the Grant family.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to document relevant placement risks and complete required forms
Wider context from the report “(2) Documentation and communication. Both the lack of documentation recording all the relevant risks , failure to complete forms and the lack of adequate communication of the risks in this matter led to a child being placed with a family where numerous individuals considered this was an inappropriate placement. Senior decision making was not based on all the appropriate information identifying there are inadequate systems and processes.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of placement risks
Wider context from the report “(2) Documentation and communication. Both the lack of documentation recording all the relevant risks, failure to complete forms and the lack of adequate communication of the risks in this matter led to a child being placed with a family where numerous individuals considered this was an inappropriate placement. Senior decision making was not based on all the appropriate information identifying there are inadequate systems and processes.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and collate risks to foster carers and other children in the placement
Wider context from the report “(3) Risk Assessment. Evidence was heard about the risks posed by the Child but no evidence that the risk to the foster carers or the other child in their care had been considered or assessed . Again there was lack of documentation and no formal risk assessment document or collated risk profile for all individuals to allow proper consideration of risks.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of foster placement capacity
Wider context from the report “(1) Lack of placements. The lack of foster placements placed significant strain on the Local Authority to consider creative solutions to try and avoid an unauthorised placement. This led to an unsuitable placement being accepted. I was informed the shortage of placements is a both a local and a national issue and therefore both Rotherham Metropolitan Borough Council and the Minister for the Department for Education are asked to consider this concern.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Senior decision-making not based on all appropriate information
Wider context from the report “(2) Documentation and communication. Both the lack of documentation recording all the relevant risks, failure to complete forms and the lack of adequate communication of the risks in this matter led to a child being placed with a family where numerous individuals considered this was an inappropriate placement. Senior decision making was not based on all the appropriate information identifying there are inadequate systems and processes .
” 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 Roll out the Mockingbird foster-care retention model, including peer support, respite and training.
Verbatim wording from the response “We have also invested in rolling out a foster care retention model called Mockingbird, an innovative evidence-based approach involving six to ten families grouped into a constellation around a hub home carer. Mockingbird includes peer support, respite and training. It was found to substantially improve retention by an independent evaluation, which showed that participating households were 82% less likely to deregister than households who did not participate.” Source location Response from Department for Education
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 Support local-authority foster-carer recruitment through regional hubs and area communications campaigns.
Verbatim wording from the response “We have already made progress on this issue through our investments in recruitment and retention within local authorities. The Department has been supporting over 60% of local authorities across England in 10 regional recruitment support hubs, most of which launched in the spring and summer of 2024. These hubs, backed by regional communications campaigns in each area, support” Source location Response from Department for Education
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 Announce comprehensive new measures to reform fostering and increase foster-carer numbers.
Verbatim wording from the response “We will shortly be announcing comprehensive measures to reform the fostering system, and are considering the voices and experiences raised that Marcia’s family raised as part of these reforms.” Source location Response from Department for Education
Open published response
19 Aug 2025 Gemma May Weeks · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 3 Lack of understanding of the health consequences of chronic ketamine use outside professional circles View source Lack of understanding of ketamine risks among the age group most at risk of starting use View source Lack of public understanding of the dangers of acute and chronic ketamine use View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Gemma May Weeks · 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
Gemma May Weeks, a long-term ketamine user, was found deceased on 26 January 2025 after consuming high levels of ketamine and another substance; the combined effects caused her death. The report raises concerns that the acute and chronic risks of ketamine, including addiction and severe bladder damage, are not well understood by the public, potential first-time users, and groups at greatest risk of starting to use it.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the health consequences of chronic ketamine use outside professional circles
Wider context from the report “2. I have concerns with regard to the following:
i. The dangers and risk associated with both acute and chronic ketamine use are not well understood by the public and potential first time users of the drug. Ketamine’s classification as a class B controlled drug may give an impression that the dangers associated with its use are reduced as compared with class A drugs.
ii. There is little understanding of the risks and dangers of ketamine use amongst the age group that appear to be at most risk of starting to use the drug.
iii. The health consequences of chronic ketamine use are well understood by those that encounter them, including drug treatment providers and those working in healthcare. Those consequences are not, however, well understood outside of those circles.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of ketamine risks among the age group most at risk of starting use
Wider context from the report “2. I have concerns with regard to the following:
i. The dangers and risk associated with both acute and chronic ketamine use are not well understood by the public and potential first time users of the drug. Ketamine’s classification as a class B controlled drug may give an impression that the dangers associated with its use are reduced as compared with class A drugs.
ii. There is little understanding of the risks and dangers of ketamine use amongst the age group that appear to be at most risk of starting to use the drug.
iii. The health consequences of chronic ketamine use are well understood by those that encounter them, including drug treatment providers and those working in healthcare. Those consequences are not, however, well understood outside of those circles.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of public understanding of the dangers of acute and chronic ketamine use
Wider context from the report “2. I have concerns with regard to the following:
i. The dangers and risk associated with both acute and chronic ketamine use are not well understood by the public and potential first time users of the drug. Ketamine’s classification as a class B controlled drug may give an impression that the dangers associated with its use are reduced as compared with class A drugs.
ii. There is little understanding of the risks and dangers of ketamine use amongst the age group that appear to be at most risk of starting to use the drug.
iii. The health consequences of chronic ketamine use are well understood by those that encounter them, including drug treatment providers and those working in healthcare. Those consequences are not, however, well understood outside of those circles.
” 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 Maintain and update FRANK drug information and advice for young people, parents and practitioners, including emerging ketamine evidence and trends.
Verbatim wording from the response “More broadly, the Government continues to work to educate young people on the harms and risks around drug taking via the FRANK website, referenced in the RSHE statutory guidance, which provides drug information and advice to young people, parents and practitioners. This site keeps content up to date with emerging evidence and trends, including on ketamine. Ketamine | Effects of Ketamine | FRANK .” Source location Response from Department for Education
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 quality drug, alcohol and tobacco teaching resources for primary and secondary teachers through collaboration with OHID and the PSHE Association.
Verbatim wording from the response “The department worked with the Office for Health Improvement and Disparities (OHID) and the PSHE Association to make sure good quality teaching resources are available for teachers delivering drug, alcohol and tobacco education. The lesson plans target primary and secondary students, teaching them how to manage influences and pressure, and keep themselves healthy and safe. And separately, we know many local areas will develop their own resources, including teaching about the dangers of ketamine.” Source location Response from Department for Education
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 Publish updated RSHE statutory guidance covering drug, alcohol, tobacco and vaping education.
Verbatim wording from the response “Schools have an important role in educating pupils about the dangers of harmful substances and relationships, sex and health education (RSHE) has been statutory in schools since September 2020. My department recently published updated RSHE statutory guidance which includes curriculum content on drugs, alcohol, tobacco and vaping.” Source location Response from Department for Education
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 Existing statutory RSHE guidance and school flexibility are relied on to let schools tailor teaching to local issues, including ketamine dangers.
Verbatim wording from the response “The statutory guidance provides high-level content to guide schools’ teaching, but schools have the freedom and flexibility to ensure the curriculum meets the needs of their pupils. This flexibility allows schools to respond to local public health and wider community issues, and tailor the content to meet pupils’ needs so they can respond to issues as they arise, including the dangers of taking ketamine.” Source location Response from Department for Education
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 Home Office is responsible for responding to concerns about ketamine’s classification under the Misuse of Drugs Act 1971.
Verbatim wording from the response “I am sending this letter in response to the Regulation 28 Report to prevent Future Deaths, and accompanying reasons detailed in the report dated 19th August 2025. I know that you sent your report to the Home Secretary and the Secretary of State for Health and Social Care too. Ministers in the Home Office will be replying to your concerns about the classification of ketamine under the Misuse of Drugs Act 1971, and Ministers at the Department for Health and Social Care will be addressing harm reduction and prevention.” Source location Response from Department for Education
Open published response
8 Nov 2024 Alexander Rogers · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 3 Lack of effective, fair and unbiased formal channels for reporting serious concerns View source Social ostracism and exclusion of students based on allegations or perceptions of wrongdoing View source Failure to use formal processes and proper investigation or evidence when addressing allegations of serious misconduct View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alexander Rogers · 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
Alexander Rogers died after jumping from a location in Oxford into the River Thames and suffering a fatal head injury; the inquest concluded suicide. In the preceding days, he had experienced alleged social ostracism, including name calling, targeted behaviour, exclusion and rejection. The report identified concerns that social ostrism among students may pose significant risks to mental health and well-being, including through isolation, shame and worthlessness, although it did not find that this culture specifically caused or contributed to Alexander’s death.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of effective, fair and unbiased formal channels for reporting serious concerns
Wider context from the report “In accordance with guidance to Universities, the College had commissioned an independent Serious Incident Review conducted by ████████, a specialist in mental health, and that Review identified evidence of a concerning practice of social ostracism among students, often referred to as a ‘cancel culture’. Her evidence was that this behaviour, where individuals are isolated and excluded from social groups based on allegations or perceptions of wrongdoing, poses a significant risk to student mental health and well-being.
Both ████████ and the Director of Student Welfare at Oxford University, ████████, were of the view that this practice was likely in evidence in other higher education institutions although there was some uncertainty as to his prevalence.
████████ has made a number of recommendations specific to the to the College and University which they are implementing with some diligence.
It was acknowledged this was complex and highly-sensitive issue in student life. Accordingly, I have attached a redacted extract from the ████████’s Review which sets out the evidence-base for this culture and its potential effects and risk, together with her proposals as to how it may be addressed through awareness raising and education.
I did not find on the balance of probabilities that this culture specifically caused or contributed to Alexander’s death, but it did give rise to a concern that circumstances creating a risk of future deaths could occur.
• Prevalence of social ostracism: Evidence suggests that social ostracism is a recognized practice within student communities, with multiple cases observed and acknowledged by both students and staff. The evidence was that this may be an issue more broadly for Universities in the UK.
• Social ostracism as 'self-policing': Students appear to employ social ostracism as a means of 'self-policing' their community, often in response to allegations of serious misconduct. This occurs in the absence of formal processes and without proper investigation or evidence.
• Negative impact on mental health: Social ostracism can have severe and lasting negative impacts on mental health. It can lead to feelings of isolation, shame, guilt, and worthlessness, all of which are recognized risk factors for suicide.
• Lack of trust in formal processes: The prevalence of social ostracism may be linked to a lack of trust in formal channels for reporting serious concerns . Students may perceive these processes as ineffective, unfair, or biased , leading them to seek alternative means of addressing perceived wrongdoing.
• Normalization of exclusionary behaviour: There is concern that social ostracism has become normalized within student communities, with individuals viewing it as an expected and accepted response to certain allegations or behaviours. This normalization hinders the development of healthy and supportive social environments.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Social ostracism and exclusion of students based on allegations or perceptions of wrongdoing
Wider context from the report “In accordance with guidance to Universities, the College had commissioned an independent Serious Incident Review conducted by ████████, a specialist in mental health, and that Review identified evidence of a concerning practice of social ostracism among students , often referred to as a ‘cancel culture’. Her evidence was that this behaviour, where individuals are isolated and excluded from social groups based on allegations or perceptions of wrongdoing , poses a significant risk to student mental health and well-being.
Both ████████ and the Director of Student Welfare at Oxford University, ████████, were of the view that this practice was likely in evidence in other higher education institutions although there was some uncertainty as to his prevalence.
████████ has made a number of recommendations specific to the to the College and University which they are implementing with some diligence.
It was acknowledged this was complex and highly-sensitive issue in student life. Accordingly, I have attached a redacted extract from the ████████’s Review which sets out the evidence-base for this culture and its potential effects and risk, together with her proposals as to how it may be addressed through awareness raising and education.
I did not find on the balance of probabilities that this culture specifically caused or contributed to Alexander’s death, but it did give rise to a concern that circumstances creating a risk of future deaths could occur.
• Prevalence of social ostracism: Evidence suggests that social ostracism is a recognized practice within student communities, with multiple cases observed and acknowledged by both students and staff . The evidence was that this may be an issue more broadly for Universities in the UK.
• Social ostracism as 'self-policing': Students appear to employ social ostracism as a means of 'self-policing' their community, often in response to allegations of serious misconduct. This occurs in the absence of formal processes and without proper investigation or evidence.
• Negative impact on mental health: Social ostracism can have severe and lasting negative impacts on mental health. It can lead to feelings of isolation, shame, guilt, and worthlessness, all of which are recognized risk factors for suicide.
• Lack of trust in formal processes: The prevalence of social ostracism may be linked to a lack of trust in formal channels for reporting serious concerns. Students may perceive these processes as ineffective, unfair, or biased, leading them to seek alternative means of addressing perceived wrongdoing.
• Normalization of exclusionary behaviour: There is concern that social ostracism has become normalized within student communities , with individuals viewing it as an expected and accepted response to certain allegations or behaviours. This normalization hinders the development of healthy and supportive social environments.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to use formal processes and proper investigation or evidence when addressing allegations of serious misconduct
Wider context from the report “In accordance with guidance to Universities, the College had commissioned an independent Serious Incident Review conducted by ████████, a specialist in mental health, and that Review identified evidence of a concerning practice of social ostracism among students, often referred to as a ‘cancel culture’. Her evidence was that this behaviour, where individuals are isolated and excluded from social groups based on allegations or perceptions of wrongdoing, poses a significant risk to student mental health and well-being.
Both ████████ and the Director of Student Welfare at Oxford University, ████████, were of the view that this practice was likely in evidence in other higher education institutions although there was some uncertainty as to his prevalence.
████████ has made a number of recommendations specific to the to the College and University which they are implementing with some diligence.
It was acknowledged this was complex and highly-sensitive issue in student life. Accordingly, I have attached a redacted extract from the ████████’s Review which sets out the evidence-base for this culture and its potential effects and risk, together with her proposals as to how it may be addressed through awareness raising and education.
I did not find on the balance of probabilities that this culture specifically caused or contributed to Alexander’s death, but it did give rise to a concern that circumstances creating a risk of future deaths could occur.
• Prevalence of social ostracism: Evidence suggests that social ostracism is a recognized practice within student communities, with multiple cases observed and acknowledged by both students and staff. The evidence was that this may be an issue more broadly for Universities in the UK.
• Social ostracism as 'self-policing': Students appear to employ social ostracism as a means of 'self-policing' their community , often in response to allegations of serious misconduct. This occurs in the absence of formal processes and without proper investigation or evidence.
• Negative impact on mental health: Social ostracism can have severe and lasting negative impacts on mental health. It can lead to feelings of isolation, shame, guilt, and worthlessness, all of which are recognized risk factors for suicide.
• Lack of trust in formal processes: The prevalence of social ostracism may be linked to a lack of trust in formal channels for reporting serious concerns. Students may perceive these processes as ineffective, unfair, or biased, leading them to seek alternative means of addressing perceived wrongdoing.
• Normalization of exclusionary behaviour: There is concern that social ostracism has become normalized within student communities, with individuals viewing it as an expected and accepted response to certain allegations or behaviours. This normalization hinders the development of healthy and supportive social environments.
” 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 Convene an early-2025 roundtable with experts, university welfare officials and students on social ostracism and trust in formal processes.
Verbatim wording from the response “2) We will work with experts and leading university student welfare officials” Source location Response from Department for Education
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 Work with sector bodies to help higher education providers implement new harassment and sexual misconduct measures.
Verbatim wording from the response “1) Action by the OfS to bring more consistency and rigour to the handling of harassment and sexual misconduct allegations in higher education settings.
The OfS has introduced new regulatory requirements for preventing and addressing harassment and sexual misconduct which will be a condition of being registered with the OfS. This new condition of registration (condition E6) will come into force from August 2025. DfE and the OfS are working with sector bodies to help providers implement the new measures. All universities and colleges registered with the OfS will be required to publish and maintain policies and procedures that set out how they will deal with incidents of harassment and sexual misconduct. They will need to provide students with training on policies and processes, and ensure they understand behaviour that may constitute harassment and sexual misconduct.” Source location Response from Department for Education
Open published response
14 Oct 2024 Jennifer Sharren Chalkley · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 3 Lack of a national system for guaranteed transfer of safeguarding information View source Delayed transfer of safeguarding information at the start of a new term View source Misunderstanding that £6,000 must be spent before applying for a statutory assessment View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to Department for Education; that does not assign responsibility.
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.
” 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 Department for Education; that does not assign responsibility.
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” .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Misunderstanding that £6,000 must be spent before applying for a statutory assessment
Wider context from the report “At the prevention of future deaths hearing, it was confirmed that there is no statutory or other requirement for a school to have to spend an additional £6,000 per annum in meeting a child’s SEN needs before applying for a statutory assessment. I am concerned that the misunderstanding by schools and colleges is delaying or preventing applications for statutory assessments being made in some cases and thereby acting as a barrier to ensuring all children and young people with additional needs are receiving effective support as soon as possible . I am concerned that this creates or increases the risk of avoidable suicidality developing.
I heard that, in response to this misconception, Surrey County Council has, since Jennifer’s death, updated its guidance on the criteria that will be considered to determine when a statutory assessment will be conducted and that the new guidance seeks to make it clear that there is no requirement for £6,000 to be spent before an application for assessment can be made. However, the evidence I received from a local college showed that the misunderstanding persists, despite the updated guidance. It seems therefore that further action is needed to ensure that all Surrey schools and colleges understand, clearly, that spending an additional £6,000 on a child is not a pre-requisite to applying for a statutory assessment.
I heard too that this misunderstanding probably originates from the School and Early Years Finance (England) Regulations 2023 (and their previous iterations), which set the high needs costs threshold at £6,000; it seems that the confusion may also stem from information issued by the Education and Skills Funding Agency.
I am concerned that the misconception persists nationally and that, for the reasons set out above, action is needed to ensure that all schools and colleges understand, clearly, that spending an additional £6,000 on a child is not a pre-requisite to applying for a statutory assessment.
” 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 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
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 Write to local authorities reminding them that the statutory EHC plan assessment threshold is distinct from the £6,000 SEN support threshold.
Verbatim wording from the response “In the light of your concerns, we have reviewed the relevant guidance from the DfE and the Education, Skills and Funding Agency (ESFA). We have not identified any ambiguity in that guidance, but in view of the concerns raised we have written to local authorities to remind them that the threshold to be considered for an EHC plan is as set out in the Children and Families Act 2014. The expectation on mainstream schools and colleges of meeting the costs of additional SEN support up to £6,000 does not prevent a child or young person being brought to the local authority’s attention as potentially having special educational needs which require provision according to an EHC plan, thereby requiring the local authority to decide whether to conduct an EHC needs assessment.” Source location Response from Department for Education
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 Review relevant EHC plan guidance and identify whether it contains ambiguity.
Verbatim wording from the response “In the light of your concerns, we have reviewed the relevant guidance from the DfE and the Education, Skills and Funding Agency (ESFA). We have not identified any ambiguity in that guidance, but in view of the concerns raised we have written to local authorities to remind them that the threshold to be considered for an EHC plan is as set out in the Children and Families Act 2014. The expectation on mainstream schools and colleges of meeting the costs of additional SEN support up to £6,000 does not prevent a child or young person being brought to the local authority’s attention as potentially having special educational needs which require provision according to an EHC plan, thereby requiring the local authority to decide whether to conduct an EHC needs assessment.” Source location Response from Department for Education
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
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 Relevant Department and ESFA guidance contains no ambiguity about the statutory threshold for EHC needs assessments.
Verbatim wording from the response “In the light of your concerns, we have reviewed the relevant guidance from the DfE and the Education, Skills and Funding Agency (ESFA). We have not identified any ambiguity in that guidance, but in view of the concerns raised we have written to local authorities to remind them that the threshold to be considered for an EHC plan is as set out in the Children and Families Act 2014. The expectation on mainstream schools and colleges of meeting the costs of additional SEN support up to £6,000 does not prevent a child or young person being brought to the local authority’s attention as potentially having special educational needs which require provision according to an EHC plan, thereby requiring the local authority to decide whether to conduct an EHC needs assessment.” Source location Response from Department for Education
Open published response
10 Oct 2024 Sunnah Summayah Khan and Joseph Ian Abbess · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2 Lack of awareness of water risks and how to manage them View source Lack of water-risk education for children through the national classroom curriculum View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Sunnah Summayah Khan and Joseph Ian Abbess · 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
On 31 May 2023, 12-year-old Sunnah Summayah Khan and 17-year-old Joseph Ian Abbess entered the waters at Bournemouth East Beach and were later found unresponsive after an intense flash rip current occurred. Both died later that day despite resuscitation attempts. The report raises concerns about public awareness of water risks and the lack of consistent water-safety education for children through the national classroom curriculum.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of water risks and how to manage them
Wider context from the report “2. I have concerns with regard to the following:
i. There are inherent dangers of using any form of water and it is crucial for people to have an awareness of these risks and how to manage them as the lack of awareness could lead to more deaths from drowning .
ii. An ideal opportunity to warn and inform all members of the public would be through educating children of the risks. The lack of providing education to children around these risks through the national classroom curriculum could lead to future deaths.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of water-risk education for children through the national classroom curriculum
Wider context from the report “2. I have concerns with regard to the following:
i. There are inherent dangers of using any form of water and it is crucial for people to have an awareness of these risks and how to manage them as the lack of awareness could lead to more deaths from drowning.
ii. An ideal opportunity to warn and inform all members of the public would be through educating children of the risks. The lack of providing education to children around these risks through the national classroom curriculum could lead to future deaths .
” 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 Conduct the independent Curriculum and Assessment Review to develop a curriculum preparing children and young people for life and work.
Verbatim wording from the response “I agree that schools have a crucial role to play in helping ensure all children learn to swim and know how to keep themselves safe in and around water. This can be especially important for those pupils who may not have the opportunity to take part in swimming and water safety lessons outside of school. We have set up an independent Curriculum and Assessment Review which is seeking to deliver a curriculum that ensures children and young people leave compulsory education ready for life and ready for work, building the knowledge, skills and attributes young people need to thrive. In parallel we are carrying out further engagement on changes to be made to statutory Health Education.” Source location Response from Department for Education
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 how statutory curriculum changes can complement existing swimming lessons and ensure pupils learn water safety, including the water safety code.
Verbatim wording from the response “In making those changes, we will look at how best to complement swimming and water safety lessons already delivered through the PE curriculum, to ensure that all pupils are taught about water safety, including the water safety code, as recommended in the report. This consideration will build on the work and opportunities that are already underway.” Source location Response from Department for Education
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 Support the annual Drowning Prevention Week campaign to raise water-safety awareness across schools.
Verbatim wording from the response “The Department has supported the RLSS UK’s annual Drowning Prevention Week to help raise awareness across schools. I was pleased to learn that RLSS UK report that this year’s campaign reached over 1.25 million children. I will take this opportunity to commit to the Department supporting the 2025 campaign to help more schools to participate.” Source location Response from Department for Education
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 Fund the Inclusion 2024 programme to increase and improve opportunities for children with special educational needs and disabilities to participate in physical education, sport and physical activity.
Verbatim wording from the response “It is important that all children have the opportunity to learn to swim and know the dangers of water. We are funding the Inclusion 2024 programme, which is led by the Youth Sport Trust, to increase and improve opportunities for children with special educational needs and disabilities to take part in PE, sport and physical activity. The programme includes a specific project focussing on swimming and water safety, which is led by Swim England. A series of free tools, guidance and advice have been developed and are available on Swim England’s website. These resources are also being extended onto nasen’s Inclusive Education Hub, so they can reach more teachers.” Source location Response from Department for Education
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 Support the 2025 Drowning Prevention Week campaign to enable more schools to participate.
Verbatim wording from the response “The Department has supported the RLSS UK’s annual Drowning Prevention Week to help raise awareness across schools. I was pleased to learn that RLSS UK report that this year’s campaign reached over 1.25 million children. I will take this opportunity to commit to the Department supporting the 2025 campaign to help more schools to participate.” Source location Response from Department for Education
Open published response
20 Aug 2024 Miss Hannah Enola Angela Ayomipo Jacobs · Prevention of Future Deaths report East London
View report summary
Concerns raised 2 Absence of an appropriate structure to educate schools, patients and parents about carrying adrenaline autoinjectors during journeys to and from school View source Lack of arrangements to contain the risk of anaphylaxis during journeys to and from school View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Miss Hannah Enola Angela Ayomipo Jacobs · 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
Hannah Jacobs, aged 13, died on 8 February 2023 after consuming a dairy milk hot chocolate despite having severe dairy allergies and developing anaphylaxis. She and her mother were not carrying an adrenaline auto-injector, and the available paediatric injector at the pharmacy was an insufficient dosage. The report identified concerns about arrangements for carrying auto-injectors between home and school and the need to educate schools, patients and parents about carrying them.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Absence of an appropriate structure to educate schools, patients and parents about carrying adrenaline autoinjectors during journeys to and from school
Wider context from the report “• Hannah was regularly prescribed Epi-pens (AAI) and had 2 at home and 2 at school. There was no consideration about how to contain the risk of anaphylaxis on the journey to and from school.
• Her paediatrician gave evidence at the inquest and acknowledged it was a difficult issue as the pens can be misused, lost, forgotten, leaving an absence of pens at home at the weekend. However, the largest cause of mortality in anaphylaxis is the absence of a readily available adrenaline autoinjector.
• The risk of future deaths in the context of anaphylaxis remain in the absence of an appropriate structure to educate the school, patients and the parents of the importance of carrying an AAI on their way to and from school.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of arrangements to contain the risk of anaphylaxis during journeys to and from school
Wider context from the report “• Hannah was regularly prescribed Epi-pens (AAI) and had 2 at home and 2 at school. There was no consideration about how to contain the risk of anaphylaxis on the journey to and from school.
• Her paediatrician gave evidence at the inquest and acknowledged it was a difficult issue as the pens can be misused, lost, forgotten, leaving an absence of pens at home at the weekend. However, the largest cause of mortality in anaphylaxis is the absence of a readily available adrenaline autoinjector.
• The risk of future deaths in the context of anaphylaxis remain in the absence of an appropriate structure to educate the school, patients and the parents of the importance of carrying an AAI on their way to and from school.
” 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 Publish guidance enabling schools to obtain and use spare adrenaline auto-injectors in emergencies, including advice on carrying two devices and access during travel.
Verbatim wording from the response “In 2017, the Department of Health published non-statutory guidance to accompany a legislative change to allow schools to purchase spare AAIs from a pharmacy, without a prescription and for use in an emergency situation. This guidance gives clear advice to schools on the recognition and management of an allergic reaction and anaphylaxis, and outlines when and how an AAI should be administered for pupils in schools. The guidance states that children at risk of anaphylaxis should have their prescribed AAIs at school for use in an emergency, and in line with MHRA advice, those prescribed AAIs should carry two devices at all times. The guidance also states that depending on their level of understanding and competence, children and particularly teenagers should carry their AAIs on their person at all times or they should be quickly and easily accessible at all times.” Source location Joint response from DHSC & DfE
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 Maintain guidance on school use of adrenaline auto-injectors under review, including access during travel to and from school.
Verbatim wording from the response “forgets to bring the AAIs to school each day. Where this occurs, the guidance states that the pupil must still have access to an AAI when travelling to and from school.” Source location Joint response from DHSC & DfE
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 Current MHRA guidance is considered sufficient to address advice on carrying two adrenaline autoinjectors and using them promptly; no revision is planned.
Verbatim wording from the response “In June 2023, the MHRA launched new guidance to highlight the latest safety advice from the Commission on Human Medicines (CHM)’s working group on the safe and effective use of AAIs. The guidance included advice for healthcare professionals to provide to patients and carers and reinforces the importance of carrying 2 AAIs at all times, and using AAIs without delay if anaphylaxis is suspected, even if in doubt about the severity of the event. The guidance can be accessed at the following link:
https://www.gov.uk/government/publications/adrenaline-auto-injectors-aais-safety-campaign/adrenaline-auto-injectors-aais” Source location Joint response from DHSC & DfE
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 Existing school duties and guidance are considered sufficient to require allergy arrangements and access to adrenaline autoinjectors during travel to and from school.
Verbatim wording from the response “Section 100 of the Children and Families Act 2014 places a legal duty on schools to make arrangements for supporting pupils at their school with medical conditions. The accompanying statutory guidance - Supporting Pupils at School with Medical Conditions - is not voluntary; schools are legally required to have regard to this guidance when carrying out their section 100 duty.” Source location Joint response from DHSC & DfE
Open published response
29 Jul 2024 Lamarah Grace Scarlett · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 9 Lack of a requirement for transport crew to be qualified first aiders View source Lack of a comprehensive schedule for inspection of transport operators View source Lack of mandatory training or forums for transport operators to receive cascaded information View source Inadequacy of the passenger assessment test View source Fragmented access to organisations causing confusion and inconsistency for transport operators View source Failure of transport crew to read and understand patient safety plans View source Failure to conduct contractually required home visits between passengers and transport crew View source Failure to notify the local authority of transport crew personnel changes View source Failure to understand the need for proper handovers at drop-off and pick-up View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Lamarah Grace Scarlett · 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
Lamarah Grace Scarlett, a 12-year-old girl with alternating hemiplegia of childhood, became distressed and experienced breathing difficulties while being transported home from school on 24 September 2021. Her head became hyperextended, obstructing her airway; she arrived home unresponsive and was pronounced deceased despite resuscitation efforts. Concerns included the regulation, training, safety-plan compliance, handovers, first-aid qualifications, assessment, and oversight of operators providing home-to-school transport for children with special educational needs.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of a requirement for transport crew to be qualified first aiders
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders ,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of a comprehensive schedule for inspection of transport operators
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators ,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory training or forums for transport operators to receive cascaded information
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Inadequacy of the passenger assessment test
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement ,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Fragmented access to organisations causing confusion and inconsistency for transport operators
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of transport crew to read and understand patient safety plans
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew ,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct contractually required home visits between passengers and transport crew
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required ,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the local authority of transport crew personnel changes
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew ,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to understand the need for proper handovers at drop-off and pick-up
Wider context from the report “Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children?
The following specific issues were identified:
• The patient safety plans are not always read and understood by transport crew,
• Home visits between passenger and transport crew often do not occur when contractually required,
• The local authority are often not notified of personnel changes in the transport crew,
• The need for proper handovers at drop off and pick up is not understood
• There is no requirement for transport crew to be qualified first aiders,
• The passenger assessment test requires further improvement,
• There is no comprehensive schedule for inspection of transport operators,
• There is no mandatory training or forums for operators to attend where information can be cascaded to them.
• Operators have to approach multiple organisations which leads to confusion and inconsistency.
” 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 Publish statutory guidance strengthening local-authority arrangements for children’s home-to-school travel, including medical-needs risk assessment, suitable support and staff training.
Verbatim wording from the response “The Department for Education publishes statutory guidance to assist local authorities in meeting their home-to-school transport duty. The latest version of the guidance was published in 2023 and includes much more comprehensive guidance about meeting a child’s needs than the version that was available at the time of Lamarah’s death. It is available here: www.gov.uk/government/publications/home-to-school-travel-and-transport-guidance. I believe it goes a long way to addressing the concerns you have raised in this case. In particular, it recommends that drivers and passenger assistants are trained in basic life support skills. It expects local authorities to conduct risk assessments, to consider how a child’s medical needs might affect them during their journey, and to put in place proportionate arrangements to manage those needs.” Source location Response from Department for Education
Open published response
23 Jul 2024 Nathan Tesla George Scantlebury · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1 Lack of suitable placements for high-risk children with complex mental health needs View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Nathan Tesla George Scantlebury · 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
Nathan Scantlebury, aged 16, died in hospital shortly after being found unresponsive with a ████████ tight around his neck on 25 September 2019. The principal concerns were the lack of suitable placements for children with complex mental health needs and failures relating to the suitability and management of his placement and care arrangements.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable placements for high-risk children with complex mental health needs
Wider context from the report “The lack of availability of suitable placements for high risk children with complex mental health needs which is both a local and a national issue which has been ongoing for a number of years.
” 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 Engage local authorities and integrated care boards to identify barriers, enabling factors and transferable learning for suitable integrated provision.
Verbatim wording from the response “We have undertaken engagement with Local Authorities (LAs) and Integrated Care Boards (ICBs) to build our understanding of (a) barriers and enabling factors to providing suitable provision with integrated care that meets the needs of children and (b) what can be learned, in terms of national and local policy making, from LAs which have been successful in setting up and registering such provision. NHSE are currently planning a webinar (postponed from June due to the election), co-chaired with DfE, for/with sector leads, clinicians, children and young people and their parents/carers,” Source location Response from Department for Education
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 Jointly lead cross-government work to improve integrated care and health services for children in complex situations at risk of deprivation of liberty.
Verbatim wording from the response “We know that capital investment alone will not be sufficient. Since July 2023 officials from DfE and from NHS England (“NHSE”) have been jointly leading cross-government work to improve the provision of integrated care and health services for children who are in complex situations and are currently, or are at risk of, being deprived of their liberty, by ensuring that there is an aligned cross-government approach to commissioning and delivering the best possible models of care. The terms of reference for the Task and Finish Group (TFG) established to drive this forward can be found on our Gov.uk page, Improving cross-sector support for children in complex situations with multiple needs task and finish group.” Source location Response from Department for Education
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 Improve joint working between local systems on funding and support for children with complex needs, including co-designing or commissioning suitable provision.
Verbatim wording from the response “In addition to suitable places and suitable models of care, we want to see improvements to the way health and social care partners work together for complex and vulnerable children. DfE is undertaking work on how to improve joint working between local systems when considering how to fund and support children with complex needs, to support ways of working required to co-design or commission provision for children like Nathan. NHSE is leading on a new set of Peer Collaboratives, which will bring together LAs/ICBs with senior commitment to co-design, test and learn the practicalities of implementing integrated pathways. The purpose is to surface and explore common obstacles to system change in order to identify national changes required and begin to test potential solutions to inform the development of future pilots to improve support for this cohort.” Source location Response from Department for Education
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 Maintain the cross-government commitment to designing, commissioning and delivering integrated models of care for children in the most complex situations.
Verbatim wording from the response “We remain committed to the vision of the TFG: to improve how system partners work together to support and improve outcomes for children and young people who are currently (or are at risk of) being deprived of their liberty and who are in the most complex situations, by ensuring that there is an aligned cross government approach to design, commission and deliver the best possible models of care, integrated across children’s social care, health, education and youth justice.” Source location Response from Department for Education
Open published response
Concerns raised 5 Lack of refresher training on baby weaning for nursery staff View source Insufficient staff knowledge and training on baby weaning and safe nursery feeding View source Failure to elicit, record, review and apply accurate information about children’s individual weaning stages View source Lack of refresher training for paediatric first aid staff between three-year renewals View source Insufficient numbers of qualified paediatric first aiders present on site View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver Steeper · 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
Oliver Steeper choked on finely chopped pasta bolognaise at a nursery on 23 September 2021 and died on 29 September 2021 after suffering a hypoxic/ischaemic brain injury. The report raises concerns about the number and validity period of paediatric first-aid qualifications available at nurseries, the standard of first aid provided, and staff education and systems for assessing and recording babies’ weaning stages.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of refresher training on baby weaning for nursery staff
Wider context from the report “3. Staff Education Regarding Weaning Stages
Evidence has been heard during the course of the inquest concerning nursery staffs' understanding of the different stages of weaning that a child moves through. It was not clear that staff appreciated the importance of mirroring weaning at home with weaning at nursery. Staff (and systems) did not appear to ensure that detailed and accurate information about a child’s individual weaning stage was elicited from parents, recorded, audited, reviewed and applied. It was not clear that staff appreciated the importance of eliciting and recording this detailed information from the family.
Despite staff members having levels 1, 2 and 3 Diplomas in Childcare and Education, there was limited evidence of any knowledge or training on the stages of baby weaning and the risk of a child choking on food. As such, it is not clear that the content of those qualifications adequately covers stages of weaning and how to safely wean in the nursery environment. Even if the training does cover this, it is not apparent that any refresher training is provided to nursery staff holding these qualifications, to ensure that they are up to date in their knowledge, i.e. continuing professional development .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff knowledge and training on baby weaning and safe nursery feeding
Wider context from the report “3. Staff Education Regarding Weaning Stages
Evidence has been heard during the course of the inquest concerning nursery staffs' understanding of the different stages of weaning that a child moves through. It was not clear that staff appreciated the importance of mirroring weaning at home with weaning at nursery. Staff (and systems) did not appear to ensure that detailed and accurate information about a child’s individual weaning stage was elicited from parents, recorded, audited, reviewed and applied. It was not clear that staff appreciated the importance of eliciting and recording this detailed information from the family.
Despite staff members having levels 1, 2 and 3 Diplomas in Childcare and Education, there was limited evidence of any knowledge or training on the stages of baby weaning and the risk of a child choking on food . As such, it is not clear that the content of those qualifications adequately covers stages of weaning and how to safely wean in the nursery environment . Even if the training does cover this, it is not apparent that any refresher training is provided to nursery staff holding these qualifications, to ensure that they are up to date in their knowledge, i.e. continuing professional development.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to elicit, record, review and apply accurate information about children’s individual weaning stages
Wider context from the report “3. Staff Education Regarding Weaning Stages
Evidence has been heard during the course of the inquest concerning nursery staffs' understanding of the different stages of weaning that a child moves through. It was not clear that staff appreciated the importance of mirroring weaning at home with weaning at nursery. Staff (and systems) did not appear to ensure that detailed and accurate information about a child’s individual weaning stage was elicited from parents, recorded, audited, reviewed and applied. It was not clear that staff appreciated the importance of eliciting and recording this detailed information from the family.
Despite staff members having levels 1, 2 and 3 Diplomas in Childcare and Education, there was limited evidence of any knowledge or training on the stages of baby weaning and the risk of a child choking on food. As such, it is not clear that the content of those qualifications adequately covers stages of weaning and how to safely wean in the nursery environment. Even if the training does cover this, it is not apparent that any refresher training is provided to nursery staff holding these qualifications, to ensure that they are up to date in their knowledge, i.e. continuing professional development.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of refresher training for paediatric first aid staff between three-year renewals
Wider context from the report “2. Paediatric First Aid Training Validity Period.
Evidence heard at the inquest was that staff PFA certificates lasted for a period of 3 years before requiring renewal.
The EYFS Framework currently states as follows:
[§3.25]: PFA training must be renewed every three years and be relevant for workers caring for young children and where relevant, babies.
The guidelines for the management of paediatric choking that were current at the time of this incident were published by the Resuscitation Council UK, and this remains the case today.
It was apparent from the evidence heard in this inquest that when confronted with an emergency situation with a choking child, the nursery staff were not able to comply with the Resuscitation Council UK guidelines. The expert stated: “the first aid care delivered overall was of a relatively poor standard for nursery staff trained and current in paediatric first aid.”
I am concerned that staff with a valid PFA training certificate, may have had that training up to 3 years earlier without having had any refresher training in the interim . They would still be compliant with the EYFS statutory framework requirements, but staff may not be able to recall the detail of their training to ensure correct and effective first aid is given, due to the passage of time .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient numbers of qualified paediatric first aiders present on site
Wider context from the report “1. Paediatric First Aid (PFA) Requirements
I have heard evidence during the course of the inquest that the Early Years Foundation Stage Statutory Framework For Group and School-Based Providers stated that of all the staff on site “at least one” member of staff must have a valid paediatric first aid certificate.
Whilst I accept that providers could potentially have more, there is a risk that there is only one PFA certified member of staff on site, and that this would still be compliant within the framework mandate .
If there is only one PFA certified staff member, they may be solely responsible for providing first aid for all the children on site. If that one staff member is unavailable or indisposed when an emergency situation arises, or simply is unable to render the required first aid by nature of the traumatic events unfolding, this may in turn have a serious and detrimental effect on the child requiring assistance. Other staff members, who perhaps have not had recent PFA training, or staff with no PFA training at all, may have to urgently deal with the evolving situation.
There is always a risk that young children, particularly weaning babies like Oliver, will require emergency first aid due to sudden choking. In the 20 years between 2001 and 2021, the Office for National statistics recorded 40 deaths due to choking in infants (children aged less than one year) in England and Wales.
I am concerned that the Framework does not mandate an increased number of qualified paediatric first aiders to be present on site. I have reviewed the current EYFS statutory framework, published 8th December 2023 and updated 4th January 2024. This contains the same provision as that which was in force at the time of Oliver’s death in 2021. See paragraph 3.29.
” 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 Assess qualifications against the revised criteria and add approved qualifications to the Early Years Qualifications List.
Verbatim wording from the response “20. Following the publication of the new EYE criteria, the Department asked awarding organisations and training providers to update their qualifications at Levels 3, 4, 5, 7 and 8*2 to meet the new criteria and submit them to DfE for assessment and approval by September 2024, in order to remain on the EYQL after September 2024. These qualifications must then be delivered for “first teach” for new learners by September 2025 at the latest, so that new learners starting on a qualification from September 2025 take on an approved qualification. As part of its business-as-usual activity, the Department is currently in the process of approving qualifications against the new criteria and will be adding approved qualifications to the EYQL by September 2024.” Source location Response from Department for Education
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 sector guidance on food safety, choking prevention and introducing babies to solid food.
Verbatim wording from the response “26. In addition to the EYFS statutory requirements, we have also produced information for the sector regarding food safety and choking prevention which was published in July 2021, and introducing babies to solid food which was published in March 2024. This can be found on the DfE owned “Help for early years provider’s” platform:” Source location Response from Department for Education
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 Complete the EYFS safeguarding consultation and use its findings to develop proposed safer-eating requirements.
Verbatim wording from the response “12. The requirements outlined above when implemented together should ensure that there is a PFA member of staff available and ready to respond to incidents quickly. However, the Department recognises the importance of staff members being PFA trained, especially whilst children are eating, which is why in the recent EYFS safeguarding consultation which closed on 17 June 2024, we have put forward the following proposals:” Source location Response from Department for Education
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 Review and publish revised Level 3 Early Years Educator qualification criteria incorporating weaning and choking-prevention content.
Verbatim wording from the response “19. The Level 3 Early Years Educator (EYE) qualifications criteria were recently reviewed in order to improve the quality of the criteria and by extension the quality of early years qualifications at Level 3 and above, and ensure better-quality care for children as a result. Following the review and subsequent public consultation, the Department published the new Level 3 EYE qualifications criteria in April 2023. The new criteria can be found at Annex E of the Early years qualification requirements and standards document and will come into effect from 1 September 2024.” Source location Response from Department for Education
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 Awarding organisations and training providers are responsible for developing and delivering qualification content that meets the Department’s early-years criteria.
Verbatim wording from the response “17. The Department sets the standards (the early years qualifications criteria) which underpin early years qualifications. The qualifications criteria we hold are the Level 2 Early Years Practitioner criteria, and the Level 3 Early Years Educator criteria, and can be found in the Early Years Qualifications and Standards document.” Source location Response from Department for Education
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 Existing staffing, supervision and paediatric first-aid requirements should ensure a trained responder is available quickly during emergencies.
Verbatim wording from the response “‘3.30. Providers should take into account the number of children, staff, and layout of premises to ensure that a paediatric first aider is able to respond to emergencies quickly.’” Source location Response from Department for Education
Open published response
Concerns raised 17 Failure to require safety-training reference material View source Superficial and inadequate safety training View source Lack of independent periodic auditing and inspection View source Failure to impose and define effective restricted duties View source Failure to complete a timely Fatal Accident Inquiry Panel investigation View source Lack of robust training-compliance monitoring and responsibility clarity View source Delays and gaps in mandatory training completion View source Failure of central oversight of local safety execution View source Failure to ensure permit-holder competence and permit-scope clarity View source Failure to plan and provide appropriate first aid kits View source Failure to communicate death-related learning to coroners View source Lack of a culture of candour View source Failure to verify supplementary first-aid learning View source Insufficient safety-team resources and local reach View source Appointment of leaders without suitable competence or qualifications View source Insufficient Local Training Manager capacity View source Overly discretionary validation of inadequate training View source See 14 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin David Leonard · 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
Benjamin David Leonard, aged 16, died after slipping and falling from a cliff while descending the Great Orme during an Explorer Scout trip in North Wales. The report identifies concerns about inadequate planning, risk assessment, briefing, supervision, training, safeguarding, first-aid provision, oversight and the Scouts Association’s response to the death.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to require safety-training reference material
Wider context from the report “13. Whilst reference material is available in the course, it is not mandatory reading and not required in order to complete the click through course.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Superficial and inadequate safety training
Wider context from the report “12. Safety training is predominantly done online. Having seen and forensically within the hearing, undertaken an exercise to complete the current Safety Module, I am concerned that the course is superficial at best and fundamentally basic . It can be completed in 12 minutes . It is unsurprising that the current pass rate is now correspondingly high. This causes concern as an introductory module needed to equip thousands of leaders with an understanding of how to complete a risk assessment in order to keep Scouts safe. It does not embed the fundamental principles of safety and safe scouting .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of independent periodic auditing and inspection
Wider context from the report “2. I am also concerned that, whilst the Charity Commission has regulatory oversight, there is no robust regulator who independently and periodically audits and inspects the systems, processes and training of The Scouts Association or the granting of permits for adventurous activities, hill walking and Nights Away permits. Further, The Scouts Association permit scheme for adventurous activities is exempt from regulation by the Health and Safety Executive (‘HSE’).
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to impose and define effective restricted duties
Wider context from the report “14. There was a plain reluctance to prioritise the safety of young people following Ben’s death in that, the leaders ████████ were not subjected to “Restricted Duties” until 17.10.18 when Ben had died on 26.8.18 and in the time from Ben’s death, ████████ had taken part in a camp called “Deep Heat”. POR (Policy, Organisation and Rules) indicated the neutral act of suspension should have been imposed as a minimum for ████████. Once the restricted duties were issued, there was confusion as to whether these related to individuals or specific activities and at least one of the leaders continued in their Scouting obligations with no restrictions as it related to “Scouts” rather than “Explorer Scouts” and so the restrictions were ineffective .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a timely Fatal Accident Inquiry Panel investigation
Wider context from the report “4. As of 22.2.24, over 5 years since Ben’s death there is still no Fatal Accident Inquiry Panel Report in existence . Further still, even the prospective panel members for this investigation have not been identified . A document I have received entitled ‘BL Great Orme Learning and Actions Update’ dated 30.9.19 is inadequate when considering the root and branch type of review needed following a child fatality to identify and address issues of safety and safeguarding – particularly these having been identified as significant issues on the day of Ben’s death and despite this fact – no investigation followed -with The Scouts Association maintaining this was due to a live police investigation initially, and latterly due to this inquest.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of robust training-compliance monitoring and responsibility clarity
Wider context from the report “20. I have heard evidence that The Scouts Association headquarters maintain that it is for the County and District as autonomous charities to monitor and audit training compliance. I am concerned that there are not robust systems of analysis, reporting and clarity as to the responsibilities of the County and District and what The Scouts Association require from the County and District in respect of:
i. Training compliance;
ii. Completion of induction training within 5 months;
iii. Completion of the full adult training scheme/ wood beads within 2 years;
iv. Appointment to roles – both pre provisional, provisional, and full appointment;
v. Granting of permits.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Delays and gaps in mandatory training completion
Wider context from the report “29. These statistics lead to the clear conclusion that there were widespread and significant gaps in training being completed in a timely manner , with concerns surrounding the training provision in the Stockport District.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of central oversight of local safety execution
Wider context from the report “36. The Scouts Association is distant from its membership through its federated branches of 8000 charities and layers of hierarchy meaning that it cannot know how health and safety is executed at ground level . Training and POR are generated centrally, yet The Scouts Association defer accountability for safeguarding and safety to the individual charities .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure permit-holder competence and permit-scope clarity
Wider context from the report “38. The example of ████████ having been granted his Nights Away permit simply by providing a list of camps he had been on, demonstrates that there was no robust system in place to ensure that a permit holder responsible for children’s safety was suitably qualified . There is no evidence he had the necessary skills and competencies to be granted such a permit. There was also a lack of clarity on where permits would be required for activities outside of the ordinary Scouts meeting place.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to plan and provide appropriate first aid kits
Wider context from the report “32. I did not receive any evidence to suggest that, following an appropriate risk assessment for the Great Orme trip, there was a plan as to what type of first aid kit was required . None of the leaders had a first aid kit with them when they embarked on the walk up the Great Orme or on a 3-hour hike on the Saturday.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate death-related learning to coroners
Wider context from the report “11. I therefore have concerns that not all matters regarding deaths connected with the Scouting Movement and Association are being communicated , even by provision of draft report and recommendations, to His Majesty’s Coroners of England and Wales to inform PFD issues and a Coroner’s PFD reporting duties.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of a culture of candour
Wider context from the report “1. I am concerned that there is not a culture of candour within The Scouts Association (‘TSA’) and the impact that this has on safety 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to verify supplementary first-aid learning
Wider context from the report “34. There was a system in place whereby if a learner had a first aid at work certificate, they could self-certify that they had undertaken further learning, for Child CPR, hypothermia and meningitis to comply with Module 10 First Response. There were no checks to ensure that this further learning had been done, nor was it assessed .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient safety-team resources and local reach
Wider context from the report “37. The centralised safeguarding team and safety team are not on par with each other in terms of resources and reach to local level . Safety is not prioritised in the same way as safeguarding has been . Safeguarding is reacted to more quickly than safety by The Scouts Association.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Appointment of leaders without suitable competence or qualifications
Wider context from the report “19. This gives rise to a concern that there are other appointed Leaders in post who are not suitably competent or qualified in respect of the fundamental issues of safety 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient Local Training Manager capacity
Wider context from the report “31. I am concerned by evidence at the inquest that, presently, Stockport only has 6 Local Training Managers in post where 9 are required . The remaining 3 are “awaiting appointment” .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Overly discretionary validation of inadequate training
Wider context from the report “23. For Local Training Managers (‘LTM’) a process for validation exists whereby a training adviser interprets the Training Advisers Guide and has a broad scope within which they can validate a learner’s training . This creates a risk of the approval of superficial and inadequate learning .
” 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 Continue assessing the case and practicalities for further regulation of out-of-school settings.
Verbatim wording from the response “Existing Work on Regulatory Models” Source location Response from Department for Education
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 The proposed registration and inspection model was not pursued because existing legal powers were considered sufficient to intervene in concerning out-of-school settings.
Verbatim wording from the response “27. Specifically, in November 2015, we consulted on a proposed model of regulation for Out-of-School Settings, based on registration and risk-based inspection⁴. However, the strong negative feedback received from respondents, including that the proposed model risked placing unnecessary burdens on the many settings already providing enriching education and activities in a safe environment,” Source location Response from Department for Education
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 The Department cannot comment on the Scout Association’s internal structure, workings, or implementation of internal policies and procedures.
Verbatim wording from the response “6. Finally, we would note that various matters identified in your report concern the internal structure and workings of the Scout Association (for example their internal FAIP process). Where feasible, we have sought to address all matters of concern, but unfortunately we cannot comment on the internal set-up and structure of individual organisations, or charities in the case of the Scout Association. We understand that the Scout Association will provide a response to your report which we expect will address these issues. Similarly, we understand that the Charity Commission will provide a response which we expect will address matters relating to charity trustees’ legal duties and responsibilities in managing their charity.” Source location Response from Department for Education
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 The Scout Association and the Charity Commission are expected to address matters concerning internal operations and charity trustees’ legal duties, respectively.
Verbatim wording from the response “6. Finally, we would note that various matters identified in your report concern the internal structure and workings of the Scout Association (for example their internal FAIP process). Where feasible, we have sought to address all matters of concern, but unfortunately we cannot comment on the internal set-up and structure of individual organisations, or charities in the case of the Scout Association. We understand that the Scout Association will provide a response to your report which we expect will address these issues. Similarly, we understand that the Charity Commission will provide a response which we expect will address matters relating to charity trustees’ legal duties and responsibilities in managing their charity.” Source location Response from Department for Education
Open published response
14 Feb 2024 Alfie Anthony Kevin Nicholls · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 8 Insufficient school nurse service capacity for identifying health issues and supporting professionals View source Failure to use EHCPs holistically to integrate health and education information View source Unavailability of regular dietitian input for children with eating disorders View source Insufficient publication and guidance on medical emergencies in eating disorders beyond psychiatry View source Failure to establish effective cross-sector strategies for identifying and managing ARFID View source Lack of understanding of ARFID-related medical risk in acute medical settings View source Lack of professional awareness of ARFID and how to approach it View source Failure to consider the health impact of poor and restricted eating in children with autism View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Alfie Anthony Kevin Nicholls · 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
Alfie Anthony Kevin Nicholls, a child with autism and a severely restricted diet, collapsed at home on 17 December 2021 and died at Stepping Hill Hospital despite attempts to resuscitate him. A post-mortem examination found significant malnutrition, and the report identified concerns about poor communication between professionals and the family, limited recognition and understanding of ARFID and medical risk, and insufficient coordinated support and resources.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient school nurse service capacity for identifying health issues and supporting professionals
Wider context from the report “5. The Inquest heard that the school nurse service could play a vital role in identifying health issues and supporting other professionals . This key role was significantly impacted by the high demand on the service and the very high caseloads school nurses working with complex children were being asked to carry nationally.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to use EHCPs holistically to integrate health and education information
Wider context from the report “4. Whilst there was an Education, Health and Care Plan (EHCP) in place for Alfie there was little evidence that EHCPs were being used as a holistic tool to understand the inter relationship between health and education . There was evidence that those writing EHCPs needed to consider a child more holistically for the EHCP to cover all the aspects that it was meant to cover and not just to focus on education .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Unavailability of regular dietitian input for children with eating disorders
Wider context from the report “6. The role of a dietitian in supporting children with eating disorders could be fundamental in maximising the nutritional value of what they consumed. Demands on the service and a limited understanding of how they could work to support children with disorders such as ARFID (nationally) meant that there was rarely regular input from dieticians .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient publication and guidance on medical emergencies in eating disorders beyond psychiatry
Wider context from the report “7. ARFID, the Inquest was told, could lead to medical emergencies in eating disorders (MEED). The evidence given at the Inquest was that whilst this concept had been the subject of guidance amongst Psychiatrists it had been less publicised and there had been far less guidance by other Royal Colleges . In particular the Inquest was told that MEED needed to be far better understood by medical professionals in acute settings such as Emergency Departments and Paediatrics to avoid a situation where the impact of ARFID and the medical risk it posed was not understood until it was too late.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to establish effective cross-sector strategies for identifying and managing ARFID
Wider context from the report “2. Evidence before the Inquest was that in addition to there being increased awareness amongst professionals there needed to be strategies within and across Health, Education and Social care to ensure effective strategies were put in place and those with ARFID or at risk of developing ARFID were identified and managed effectively .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of ARFID-related medical risk in acute medical settings
Wider context from the report “7. ARFID, the Inquest was told, could lead to medical emergencies in eating disorders (MEED). The evidence given at the Inquest was that whilst this concept had been the subject of guidance amongst Psychiatrists it had been less publicised and there had been far less guidance by other Royal Colleges. In particular the Inquest was told that MEED needed to be far better understood by medical professionals in acute settings such as Emergency Departments and Paediatrics to avoid a situation where the impact of ARFID and the medical risk it posed was not understood until it was too late .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of professional awareness of ARFID and how to approach it
Wider context from the report “1. The inquest heard evidence that Avoidant Restrictive Food Intake Disorder (ARFID) was not widely understood by those involved with children and adults who may be impacted by it . That included a lack of awareness of what it was and how to approach it amongst Health, Education and Social Work professionals . The inquest was told that until awareness of it improved then similar situations to that of Alfie could go unrecognised with similar consequences.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to consider the health impact of poor and restricted eating in children with autism
Wider context from the report “3. A feature of the evidence before the Inquest was a normalisation of poor and restricted eating by children with autism . This meant that the impact on their overall health and wellbeing was not considered . Children with autism were measured against each other in relation to their eating with phrases such as “we have children with poorer diets …” being used.
” 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 Build CQC colleagues’ awareness of issues affecting autistic people and people with learning disabilities, including nutrition concerns.
Verbatim wording from the response “Training plays a crucial role in ensuring there is a wider understanding of ARFID amongst health professionals. That is why the Workforce, Training and Education Team at NHS England have commissioned ARFID training for people working within children’s eating disorder services and for the non-specialist workforce. Separately, the CQC Operations Team support operational colleagues across CQC through ongoing awareness building of issues affecting autistic children, young people, and adults, and those with a learning disability. As part of this awareness raising, the team will seek to improve colleague’s understanding of the concerns raised by the report, including regarding nutrition.” Source location Response from Department of Health and Social Care
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 Pilot EHCP improvements, including testing a new template for clearer specification and quantification of education, health and care provision.
Verbatim wording from the response “DfE is currently leading work to pilot improvements to the EHCP system, including testing a new EHCP template, and the findings of your report have been shared with the team leading this work. The new EHCP template seeks to deliver better quality plans which are more clearly specified and quantified across education, health and care. If the evidence generated through the change programme supports it, the DfE will look at the best way to roll the new template out more widely.” Source location Response from Department of Health and Social Care
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 Commission ARFID training for children’s eating-disorder services and non-specialist workforces.
Verbatim wording from the response “Training plays a crucial role in ensuring there is a wider understanding of ARFID amongst health professionals. That is why the Workforce, Training and Education Team at NHS England have commissioned ARFID training for people working within children’s eating disorder services and for the non-specialist workforce. Separately, the CQC Operations Team support operational colleagues across CQC through ongoing awareness building of issues affecting autistic children, young people, and adults, and those with a learning disability. As part of this awareness raising, the team will seek to improve colleague’s understanding of the concerns raised by the report, including regarding nutrition.” Source location Response from Department of Health and Social Care
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 Refresh children’s and young people’s eating-disorder guidance to strengthen ARFID identification, intervention, tailored care and cross-service integration.
Verbatim wording from the response “I agree that ARFID is an under-recognised condition which is why NHS England is refreshing guidance on children and young people's eating disorders, to increase the focus on ARFID as well as early identification and intervention. Updated guidance will highlight the importance of improved integration between dedicated community eating disorder services, wider children and young people's mental health and neurodevelopmental services, schools, colleges and” Source location Response from Department of Health and Social Care
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 Continue working with systems and healthcare professionals to support wider adoption of the MEED guidance.
Verbatim wording from the response “You highlighted the importance of raising awareness of the medical emergencies in eating disorders (MEED) guidance and I can assure you that NHS England continues to work with systems and healthcare professionals to support the wider adoption of the MEED guidance. This commitment was recently reiterated in the Suicide prevention in England: 5-year cross-sector strategy which was published last year.” Source location Response from Department of Health and Social Care
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 ICBs, or NHS England where relevant, must ensure healthcare provision specified in an EHCP is made available.
Verbatim wording from the response “Where an assessment of an individual child or young person’s needs indicates that support from services outside of education such as health or social care is required, it is important that they receive it as quickly as possible. Relevant local clinicians, such as community paediatricians, will participate in the development of the child’s or young person’s EHCP, advising on the child’s needs and the provision appropriate to meet them. All partners involved (including education settings, the local authority, health services and other providers) should work closely together to agree arrangements for funding responsibilities and accessing or commissioning specialist services as appropriate.” Source location Response from Department of Health and Social Care
Open published response
12 Dec 2023 Ruth Carla Perry · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 12 Failure to formalise post-inspection confidentiality arrangements in written policy View source Lack of training or policy for recognising and responding to school leader distress during inspections View source Failure of overall inspection labels to distinguish materially different school performance View source Lack of clarity about the form of expanded school leader wellbeing support View source Lack of policy for pausing inspections because of school leader distress View source Failure to conduct or require learning reviews of inspection-related concerns View source Failure to weigh school leader welfare in inspection communications View source Absence of a clear escalation path for unresolved inspection concerns View source Lack of policy on who may attend meetings with inspectors View source Lack of written policy or guidance for communicating available mental health support options View source Failure to conduct or require internal reviews of inspection-related matters View source Lack of written policy or guidance for Reading Borough Council's proactive response to Ofsted concerns View source See 9 more concerns
Responses linked to these concerns
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AI-generated summary
Ruth Carla Perry · 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
Ruth Carla Perry’s mental health deteriorated significantly during and after an Ofsted inspection of Caversham Primary School in November 2022. She displayed suicidal ideation and planning a few days later, and took her own life on 8 January 2023; the inquest concluded that her suicide was contributed to by the inspection. The principal concerns included the conduct and fairness of the inspection, limited Ofsted training and policy for managing school leader distress, confidentiality requirements, report publication timescales, and aspects of the inspection system affecting school leader welfare.
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× 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise post-inspection confidentiality arrangements in written policy
Wider context from the report “4. The confidentiality requirement after an inspection. Some changes have been made already, but this is not yet written into policy. Given how long this policy has been in place, school leaders may fear discussing outcomes with colleagues outside of the school, and mental health professionals, unless this is expressly dealt with in written policy.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of training or policy for recognising and responding to school leader distress during inspections
Wider context from the report “2. There is an almost complete absence of Ofsted training or published policy in the following areas:
a. Signs of distress in school leaders during an inspection (this will be obvious to some, but not to all).
b. Practical steps to deal with such distress.
c. Pausing an inspection by reason of the distress of a school leader.
d. Who can attend meetings with the inspectors during the inspection process.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of overall inspection labels to distinguish materially different school performance
Wider context from the report “1. The first of these relates to my hypothetical schools A and B point, referred to above. I am concerned about the impact on school leader welfare that this system may continue to have. Transparency and ease of message to parents is not currently weighed against teacher welfare. The current system allows a school which is inadequate in all areas to receive the same overall label as a school which is good in all areas, but with some safeguarding issues which can be repaired by the time the report is published.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about the form of expanded school leader wellbeing support
Wider context from the report “7. In an Ofsted publication dated 12th June 2023, the Secretary of State for Education was quoted as follows: “We must ensure our school leaders have the support they need, which is why today we are significantly expanding our wellbeing support. This expansion will help make sure headteachers have access to support whenever they need it”. The Ofsted witness was not able to clarify what form this additional support has taken.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of policy for pausing inspections because of school leader distress
Wider context from the report “2. There is an almost complete absence of Ofsted training or published policy in the following areas:
a. Signs of distress in school leaders during an inspection (this will be obvious to some, but not to all).
b. Practical steps to deal with such distress.
c. Pausing an inspection by reason of the distress of a school leader.
d. Who can attend meetings with the inspectors during the inspection process.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct or require learning reviews of inspection-related concerns
Wider context from the report “6. No learning review of these matters was conducted by Ofsted. There is no policy requiring this to be done.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to weigh school leader welfare in inspection communications
Wider context from the report “1. The first of these relates to my hypothetical schools A and B point, referred to above. I am concerned about the impact on school leader welfare that this system may continue to have. Transparency and ease of message to parents is not currently weighed against teacher welfare. The current system allows a school which is inadequate in all areas to receive the same overall label as a school which is good in all areas, but with some safeguarding issues which can be repaired by the time the report is published.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Absence of a clear escalation path for unresolved inspection concerns
Wider context from the report “3. Absence of a clear path to raise concerns during an inspection if these cannot be resolved directly with the lead inspector.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of policy on who may attend meetings with inspectors
Wider context from the report “2. There is an almost complete absence of Ofsted training or published policy in the following areas:
a. Signs of distress in school leaders during an inspection (this will be obvious to some, but not to all).
b. Practical steps to deal with such distress.
c. Pausing an inspection by reason of the distress of a school leader.
d. Who can attend meetings with the inspectors during the inspection process.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of written policy or guidance for communicating available mental health support options
Wider context from the report “3. We heard in evidence that school leaders have received correspondence from Reading Borough Council about what mental health support options are available. I am concerned to know whether there is now written policy or guidance about communicating this, so that this continues to happen in future years .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct or require internal reviews of inspection-related matters
Wider context from the report “2. Reading Borough Council also did not carry out any form of internal review . I was not made aware of any policy setting out when such an internal review should take place.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of written policy or guidance for Reading Borough Council's proactive response to Ofsted concerns
Wider context from the report “1. Reading Borough Council indicated an intention to adopt a much more robust and proactive approach to dealing with Ofsted, particularly where there are concerns about an inspection. This is not written policy or guidance – which may go some way towards reassuring school leaders that their employer ‘has their back’ – both now and in future years.
” 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 Write to all Responsible Bodies, attach the Department’s and Ofsted’s responses, and set out system responsibilities and the Department’s support offer.
Verbatim wording from the response “The primary duty of care to school leaders rests with the employer – and that will be either a local authority, an academy trust or a governing board, and to provide support in fulfilling this role effectively, the Department will write to all Responsible Bodies, attaching this response to your Report, and that of Ofsted. We will set out” Source location Response from Department for Education
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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 Ensure Regions Group officials know about expanded wellbeing support and proactively share it with Responsible Bodies.
Verbatim wording from the response “Within the Department, Regions Group will ensure all officials are aware of the expanded wellbeing support and will proactively share information about this with Responsible Bodies as part of our business as usual engagement with local authorities and academy trusts.” Source location Response from Department for Education
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 Fund and expand professional supervision and counselling support for school and college leaders through Education Support.
Verbatim wording from the response “The Department is funding the charity, Education Support, to provide professional supervision and counselling to school and college leaders. Over 1,400 leaders have benefitted from the support so far and in June 2023, we announced the expansion of the programme, by doubling places for this year, so that more school leaders can have access to this valuable support. School and college leaders working in state funded schools and colleges can access support by visiting Education Support's website. This programme will end in March 2024 and will be replaced by a new programme.” Source location Response from Department for Education
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 Procure a new three-year professional supervision and counselling support package for school and college leaders from April 2024.
Verbatim wording from the response “On 15 January 2024, the Department announced a new £1.5 million investment to procure a contractor to deliver a new three-year professional supervision and counselling support package for school and college leaders from April 2024. The new programme will have the capacity to support at least 2,500 leaders and will enable school and college leaders to continue to receive this valuable support. The” Source location Response from Department for Education
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 Primary responsibility for supporting school leaders rests with their employers: local authorities, academy trusts, or governing boards.
Verbatim wording from the response “School leaders play a vitally important role, and it is the responsibility of all agencies – the Department, Ofsted, governing boards, local authorities and academy trusts to ensure that they receive the right support.” Source location Response from Department for Education
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 Ofsted leads the response to inspection concerns outside the Department’s direct responsibilities, with the Department engaging on Ofsted’s changes.
Verbatim wording from the response “A series of changes to the inspection arrangements were announced in June 2023. These were an important start but, as evidenced by the Report, did not go far enough. Ofsted’s response to the Report, which DfE officials and I have discussed in detail with ████████, Ofsted’s new Chief Inspector, sets out fully the changes to inspection that were made prior to the inquest, and importantly, subsequently to the inquest. These include immediate steps taken pre-Christmas and the important inspector training that has taken place at the start of January 2024.” Source location Response from Department for Education
Open published response
Concerns raised 5 Excessive waiting times for NHS mental health services View source Failure to refer students to NHS mental health services when they are receiving other support View source Unclear allocation of school-procured psychology support View source Lack of a clear process for receiving outputs from support services View source Lack of a clear process for referring students to support services View source See 2 more concerns
Responses linked to these concerns
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AI-generated summary
Alex Dews · 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
Alex Dews went to a bridge at Dearne Valley Country Park on 14 July 2022, fell into shallow water, and died at Sheffield Children’s Hospital on 18 July 2022. The report raises concerns about school documentation and assessment processes, barriers to referral to NHS mental health services, unclear allocation of school-procured psychology support, and inadequate communication with the support provider.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Excessive waiting times for NHS mental health services
Wider context from the report “1. Alex was not referred by school to NHS mental health services as a result of their experience that if Alex was in receipt of any other support he would not be accepted onto the waiting list (which would be in excess of 10 months to be seen) .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to refer students to NHS mental health services when they are receiving other support
Wider context from the report “1. Alex was not referred by school to NHS mental health services as a result of their experience that if Alex was in receipt of any other support he would not be accepted onto the waiting list (which would be in excess of 10 months to be seen).
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Unclear allocation of school-procured psychology support
Wider context from the report “2. The school chose to provide Alex with school procured psychology support however the process of allocation of provision was not clear .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear process for receiving outputs from support services
Wider context from the report “3. The school did not have a clear communication process with the provider of support to either refer the student into services or to receive outputs from those services once the student completed their sessions
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear process for referring students to support services
Wider context from the report “3. The school did not have a clear communication process with the provider of support to either refer the student into services or to receive outputs from those services once the student completed their sessions
” Open source report
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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 Decisions about appropriate school support services are delegated to school leaders rather than prescribed by the Department.
Verbatim wording from the response “The Department for Education is not prescriptive in what support services schools can use – that authority is delegated to school leaders to ensure that the support is tailored for children by those who know them best. Schools have delegated budgets to make those decisions and should escalate cases to children’s social care or to child and adolescent mental health services when there is cause for concern over and above the support that a school puts in place.” Source location Response from Department for Education
Open published response
5 Oct 2023 Jessica Evie BAKER · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 2 Failure of school commuter coach drivers to wear seatbelts View source Failure of school commuter coach passengers to use fitted seatbelts 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
Jessica Evie BAKER · 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
Jessica Evie Baker, a 15-year-old pupil, died after being partially ejected and trapped beneath a school coach during a motorway collision. The report raises concerns that seatbelts fitted to the coach did not appear to be used and asks about government advice and public information on seatbelt use for school commuter coaches.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of school commuter coach drivers to wear seatbelts
Wider context from the report “This was a school commuter coach travelling on a motorway. It was constructed after 2001 and will have had seat belts fitted. Review of CCTV does not show the seatbelts were being used.
This coach had secondary school children on board. Some of the pupils those below 14 years of age would be expected to wear seatbelts under driver supervision.
The driver did not appear to be wearing a seat belt.
A distinction should be drawn between school buses in built-up areas and school commuter coaches travelling a distance using A roads and the motorway network – with regard to the availability and use of seatbelts.
I take judicial notice that using seat belts can prevent some injury altogether, make inevitable injury less severe and reduce the risk of fatal injury.
1. What advice does government through the Department of Transport, or the Department of Education give to schools and colleges when contracting for school bus commuter products – about the use of seatbelts?
2. What public information campaigns are being run about the additional road safety provided by the use of seatbelts?
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of school commuter coach passengers to use fitted seatbelts
Wider context from the report “This was a school commuter coach travelling on a motorway. It was constructed after 2001 and will have had seat belts fitted. Review of CCTV does not show the seatbelts were being used.
This coach had secondary school children on board. Some of the pupils those below 14 years of age would be expected to wear seatbelts under driver supervision.
The driver did not appear to be wearing a seat belt.
A distinction should be drawn between school buses in built-up areas and school commuter coaches travelling a distance using A roads and the motorway network – with regard to the availability and use of seatbelts.
I take judicial notice that using seat belts can prevent some injury altogether, make inevitable injury less severe and reduce the risk of fatal injury.
1. What advice does government through the Department of Transport, or the Department of Education give to schools and colleges when contracting for school bus commuter products – about the use of seatbelts?
2. What public information campaigns are being run about the additional road safety provided by the use of seatbelts?
” 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 Add a reference to the personal seat-belt responsibility of children aged 14 and over to the THINK! road-safety website.
Verbatim wording from the response “This is something the DfT takes very seriously and is why DfT runs its THINK! campaigns. The THINK! team produces educational materials for schools and dedicated advice for drivers and other road users. DfT recognises that the section of the THINK! website dealing with road safety laws would benefit from the addition of a” Source location Response from Department for Transport and Department for Education
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 Review further opportunities to increase the visibility of seat-belt advice for passengers and drivers.
Verbatim wording from the response “reference to children aged 14 plus being personally responsible for wearing their seat belt. This has now been added and DfT Officials are reviewing further opportunities to increase the presence of seat belt wearing advice for passengers and drivers. DfT will do this by the end of the year.” Source location Response from Department for Transport and Department for Education
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 and launch a national THINK! campaign promoting seat-belt wearing, including potential messages about buses and coaches.
Verbatim wording from the response “THINK! is the DFT’s long-running and respected road safety campaign. THINK! aims to reduce the number of people killed and seriously injured on the roads by changing attitudes and behaviours among those at most risk. In 2021 30% of car occupant fatalities were not wearing a seat belt compared with 19% in 2013. 17-29 year olds are over represented in fatalities: 40% v 30% of all car occupants in 2021. The team is currently working on a dedicated campaign to promote seat belt wearing; the first national seat belt campaign since 2011. It will be launched in March 2024. This campaign will be targeting those most at risk – young men. The campaign will also, however, provide an opportunity to raise awareness on a national scale and can include wider messages, for example about wearing seat belts on buses and coaches, within the stakeholder toolkit and social content.” Source location Response from Department for Transport and Department for Education
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 Share updated seat-belt compliance guidance and campaign messaging with education settings through sector communications and digital channels.
Verbatim wording from the response “DfE will work closely with the THINK campaign team at DfT to ensure education materials on seat belt compliance are shared with education settings and are embedded. This will include sharing DfT’s updated guidance on seat belt compliance and messaging from campaigns on seat belt safety in communications to the sector as well as across our own digital channels. This will coincide with the update to the DfT’s website and campaign launch in March 2024. DfE also proposes to make a small amendment to the existing statutory guidance on home-to-school travel to state that parts of it, including the sections on promoting good behaviour in transport, will be of particular relevance to schools that arrange home-to-school transport for their pupils. DfE will aim to do this early in the New Year.” Source location Response from Department for Transport and Department for Education
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 Request that DVSA remind bus operators of their seat-belt notification obligations by the end of December 2023.
Verbatim wording from the response “A bus operator is required to take reasonable steps to notify passengers of the requirement to wear a seat belt. This can be done through official announcements, audio-visual presentations, or prominently displayed signs at each seat. It is an offence to fail to comply with this requirement. To address this, we have requested that the Driver and Vehicle Standards Agency (DVSA) remind operators of their obligation through a communication to be sent out by the end of December 2023. This will help to ensure that passengers are properly informed about the necessity of wearing seat belts.” Source location Response from Department for Transport and Department for Education
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 Practical fairness and distraction risks prevent imposing a legal duty on coach drivers to ensure under-14s wear seat belts.
Verbatim wording from the response “This lacuna is something that the DfT has considered on several occasions over many years and has considered again upon receipt of your report. After careful consideration, it maintains the position that imposing a legal obligation on coach drivers to ensure that all children aged under 14 wear seat belts would be inappropriate. Such a requirement is seen as unfair to drivers, considering the potential number of children on a coach, and it could pose a distraction with significant road safety implications. As a result, the DfT does not intend to make any changes to the current seat belt wearing requirements.” Source location Response from Department for Transport and Department for Education
Open published response
3 Apr 2023 Name not published · Prevention of Future Deaths report Blackpool and the Fylde
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Concerns raised 1 Delays in timely assessment of young people View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Name not published · 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
████████ died at home on 24 September 2022 after becoming unresponsive following a hanging incident; he could not be revived despite resuscitation efforts, and the inquest recorded misadventure. At the time of his death, he was awaiting assessment for autism after a wait of around three years. The report raised concern that delays in assessment and insufficient support placed him and other children at risk, and that earlier diagnosis and support might have avoided his death.
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× 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Delays in timely assessment of young people
Wider context from the report “• With finite resources, it is acknowledged that it may not be possible for all young people to be assessed in as timely a manner as required, but there must surely come a point whereby, notwithstanding those finite resources, the wait for assessment is taking too long .
• The wait for assessment placed ████████ at risk , and other children will be similarly at risk in the absence of a timely assessment .
• It is possible that he had been diagnosed earlier, and with enough time for the relevant professionals to have been able to carry out some meaningful work with him, and had his extremely supportive Parents been given more support, ████████ death may have been avoided.
” Open source report
19 Jan 2023 Lance Scott Walker · Prevention of Future Deaths report West London
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Concerns raised 9 Insufficient scrutiny and approval of new accommodation providers View source Lack of regulatory oversight of supported accommodation for 18-21 year olds View source Lack of a standard referral form for supported housing service users aged 16-25 View source Insufficient contractual oversight of accommodation providers View source Insufficient provider knowledge of complex resident needs View source Inadequate checking and auditing of placement forms and referral information View source Inadequate staffing in supported accommodation View source Failure to perform adequate due diligence when matching individuals in accommodation View source Inadequate training among supported accommodation providers View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Lance Scott Walker · 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
Lance Scott Walker, an 18-year-old looked-after child, was placed in unregulated accommodation in 2016, where another 18-year-old resident was later placed. Eleven days after they were placed together, the other resident fatally stabbed Lance in the afternoon of 15 August 2016. Concerns included the use and oversight of unregulated accommodation, inadequate assessment and communication of the other resident’s risks and needs, shortcomings in placement and provider due diligence, and failures in information-sharing and management.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient scrutiny and approval of new accommodation providers
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight of supported accommodation for 18-21 year olds
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector , resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard referral form for supported housing service users aged 16-25
Wider context from the report “2 Response requested from London Borough of Ealing, London Borough of Islington and the West London Alliance
There is currently no standard referral form for service users aged 16-25 to be referred into supported housing. This means that best practise is not universally followed and it is more difficult for stakeholders to have to deal with a number of different forms. Vital information can potentially be missed and issues not highlighted when a variety of forms are used for the same referral procedure. Consideration should be given to adopting a standard form across the West London Alliance, or even a national standard using “best practise” as the benchmark, for clarity and ease of reference.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient contractual oversight of accommodation providers
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient provider knowledge of complex resident needs
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Inadequate checking and auditing of placement forms and referral information
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals , with consideration on the introduction of mandatory fields for specific information to be included . The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing in supported accommodation
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to perform adequate due diligence when matching individuals in accommodation
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Inadequate training among supported accommodation providers
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training , staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” Open source report
Concerns raised 11 Continuing gaps in gambling-related information View source Lack of medical professional training in diagnosing and treating gambling addiction View source Failure of gambling regulation to stop gambling by people with obvious gambling addiction View source Lack of understanding that gambling addiction is not the individual's fault View source Continuing gaps in gambling warnings View source Lack of gambling education for school children View source Insufficient gambling warnings to prevent gambling View source Insufficient information to prevent gambling or inform people about available help and treatment View source Insufficient GP training and knowledge to deal effectively with gambling problems View source Continuing gaps in gambling addiction treatment View source Insufficient treatment for gambling addiction View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
JACK WILLIAM RAMSEY RITCHIE · 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
Jack William Ramsey Ritchie died on 22 November 2017 from multiple injuries after an incident in Hanoi, Vietnam, in which the evidence indicated he intended to take his own life. The report raised concerns about gambling regulation, warnings, information, treatment, professional training, the stigma associated with gambling addiction, and limited education for young people about gambling harms.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Continuing gaps in gambling-related information
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment , the evidence showed there were still significant gaps in these areas . One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of medical professional training in diagnosing and treating gambling addiction
Wider context from the report “- The treatment available to and received by Jack was insufficient to cure his addiction – this in part was due to a lack of training for medical professionals around the diagnosis and treatment of gambling addiction
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of gambling regulation to stop gambling by people with obvious gambling addiction
Wider context from the report “- That the system of regulation in force at the time of his death did not stop Jack gambling at a point when he was obviously addicted to gambling
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding that gambling addiction is not the individual's fault
Wider context from the report “- Jack didn’t understand that being addicted to gambling wasn’t his fault . That lack of understanding lead to feelings of shame and hopelessness which in turn, contributed to him feeling suicidal
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Continuing gaps in gambling warnings
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings , information, training and treatment, the evidence showed there were still significant gaps in these areas . One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Lack of gambling education for school children
Wider context from the report “- The evidence was that young people were the most at risk from the harms of gambling yet there was and still appears to be, very little education for school children on the subject .
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient gambling warnings to prevent gambling
Wider context from the report “- The warnings Jack received were insufficient to prevent him gambling
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient information to prevent gambling or inform people about available help and treatment
Wider context from the report “- The information available to Jack was insufficient to prevent him gambling or to inform him of the help / treatments available
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient GP training and knowledge to deal effectively with gambling problems
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment, the evidence showed there were still significant gaps in these areas. One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems . This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Continuing gaps in gambling addiction treatment
Wider context from the report “- That in the time since Jack’s death, whilst there have been improvements made in the areas of warnings, information, training and treatment , the evidence showed there were still significant gaps in these areas . One notable gap was the fact that evidence suggested GPs currently have insufficient training and knowledge to deal effectively with gambling problems. This was of particular concern given many gamblers affected are likely to contact a GP as their first attempt to seek help
” 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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Insufficient treatment for gambling addiction
Wider context from the report “- The treatment available to and received by Jack was insufficient to cure his addiction – this in part was due to a lack of training for medical professionals around the diagnosis and treatment of gambling addiction
” Open source report
23 Feb 2022 Adrian Vincent Balog · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 1 Failure of national safeguarding guidance to identify childhood obesity as a sign or symptom of neglect View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Adrian Vincent Balog · 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
Adrian Vincent Balog died at age 13 on 2 April 2015 at Royal Manchester Children’s Hospital after longstanding morbid obesity, dilated cardiomyopathy and heparin-induced thrombocytopenia. His obesity made him ineligible for heart transplantation and interim mechanical support, and the inquest concluded that it significantly contributed to his death. A principal concern was that national safeguarding guidance did not identify obesity as a sign or symptom of neglect, unlike malnourishment or being underweight.
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 Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure of national safeguarding guidance to identify childhood obesity as a sign or symptom of neglect
Wider context from the report “In the two government documents there is no reference to ‘obesity’ relating to signs and symptoms of neglect in children. The absence of such a reference is a matter of concern as to how obesity in children is viewed as a public health issue in comparison to malnourished or underweight children (which are both referenced as signs and symptoms of neglect).
The consensus from the public health witnesses was that obesity should be included within national guidance as a sign of symptom of neglect in order to protect children at risk.
” 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 Consider the Review’s recommendations, including the matters raised in the coroner’s report.
Verbatim wording from the response “We will need to consider the detail of the recommendations and we will work with experts in the sector to develop our response to the report with a view to publish a detailed and ambitious implementation strategy later this year. I will ensure that the matters you have raised in your report are considered in the context of the recommendations made in the Review and I hope that my response provides the reassurance you need that this matter will be looked at soon.” Source location Response from Secretary of State for the Department for Education
Open published response
31 Jan 2022 OSKAR MILES NASH · Prevention of Future Deaths report Surrey
View report summary
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
Each statement is shown once, even when linked to more than one concern.
×
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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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 Department for Education; 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
×
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
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
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
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 Child Safeguarding Practice Review Panel will respond to Concern 10 and oversee the relevant national safeguarding review.
Verbatim wording from the response “Further, I can confirm that the Child Safeguarding Practice Review Panel has received your notice and will be responding to you (in relation to Concern 10) in due course. The national panel is responsible for identifying and overseeing the review of serious child safeguarding cases which, in its view, raise issues that are complex or of national importance and maintains oversight of the system of national and local reviews and how effectively it is operating.” Source location 2022-0031-Response-from-Department-for-Education_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