31 Dec 2021 Yousef Ghaleb Makki · Prevention of Future Deaths report Manchester South
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Concerns raised 3 Easy purchase of knives during school break time View source Lack of understanding among teenagers of the risks inherent in carrying knives View source Culture among teenagers that normalises or valorises knife possession 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
Yousef Ghaleb Makki · 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
Yousef Ghaleb Makki was stabbed in the chest on Gorse Bank Road on 2 March 2019 and died at Manchester Royal Infirmary that day. The inquest heard concerns about a culture among some teenagers of viewing knife possession as impressive, inadequate understanding of its risks, and the ease with which the knife was purchased during school break time.
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 Easy purchase of knives during school break time
Wider context from the report “The inquest heard evidence that there was a culture amongst some teenagers who saw the possession of knives as being impressive and did not understand the risks that are inherent in the carrying of knives.
The knife that Yousef was stabbed with was a ████████ that had been purchased with ease ████████ during break time at school . It was clear from the evidence that schools and education play a vital role in attitudes to carrying knives by teenagers.
” 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 among teenagers of the risks inherent in carrying knives
Wider context from the report “The inquest heard evidence that there was a culture amongst some teenagers who saw the possession of knives as being impressive and did not understand the risks that are inherent in the carrying of knives .
The knife that Yousef was stabbed with was a ████████ that had been purchased with ease ████████ during break time at school. It was clear from the evidence that schools and education play a vital role in attitudes to carrying knives by teenagers.
” 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 Culture among teenagers that normalises or valorises knife possession
Wider context from the report “The inquest heard evidence that there was a culture amongst some teenagers who saw the possession of knives as being impressive and did not understand the risks that are inherent in the carrying of knives.
The knife that Yousef was stabbed with was a ████████ that had been purchased with ease ████████ during break time at school. It was clear from the evidence that schools and education play a vital role in attitudes to carrying knives by teenagers.
” Open source report
26 Nov 2021 Frances Rose Thomas · Prevention of Future Deaths report Surrey
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Concerns raised 7 Lack of regulatory oversight and guidance on acceptable school blocklists View source Inadequate independent scrutiny of age-inappropriate stories on an online platform View source Failure to specifically block age-inappropriate online content accessible to pupils View source Web filtering failing to detect content when trigger words are absent from URLs View source Outdated and insufficiently robust Department of Education e-security guidance for schools View source Failure to include key-logger and screen-reader reporting systems in e-security guidance View source Inadequate regulatory oversight and outdated guidance on school e-security standards 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
Frances Rose Thomas · 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
Frances Rose Thomas was a vulnerable teenager who, while attending Stepping Stones School, was often left without formal supervision and had unsupervised access to school electronic devices. On 25 September 2018, after accessing material at school, she went home and undertook a similar act resulting in her death. The report raised concerns about inadequate school e-security, monitoring and supervision, outdated regulatory guidance, and insufficient controls over age-inappropriate content on an online platform.
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 regulatory oversight and guidance on acceptable school blocklists
Wider context from the report “2. There is a wide range of software vendors providing different lists of blocklists with different vendors enabling different categories with no oversight or regulatory guidance by the Department of Education as to what ‘blocklists’ are either acceptable and/or suitable for a school environment .
” 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 independent scrutiny of age-inappropriate stories on an online platform
Wider context from the report “3. ████████ is not a specifically blocked ████████ and not only can it be accessed by Key Stage 4 students there is encouragement to do so in some schools. However, I heard evidence that the sites Frankie accessed through ████████████████████████████████████████████████████████████. Furthermore, there is inadequate independent scrutiny by ████████ to remove age inappropriate stories put on their platform .
” 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 specifically block age-inappropriate online content accessible to pupils
Wider context from the report “3. ████████ is not a specifically blocked ████████ and not only can it be accessed by Key Stage 4 students there is encouragement to do so in some schools . However, I heard evidence that the sites Frankie accessed through ████████████████████████████████████████████████████████████. Furthermore, there is inadequate independent scrutiny by ████████ to remove age inappropriate stories put on their platform.
” 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 Web filtering failing to detect content when trigger words are absent from URLs
Wider context from the report “4. Some websites are only blocked when there is a particular key word in the URL if the relevant trigger word (e.g. ████████) is not there it makes it difficult for the filter to ‘see’ the content of the website to be able to block it , hence why stories on ████████ could be read. However, there are software systems available that acts as a ‘key logger’ and ‘screen reader’. Whilst this will not block the site it will generate a report to the nominated safeguarding individual for further action. Yet it has not been considered or is part of the guidelines issued by the Department of 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 Outdated and insufficiently robust Department of Education e-security guidance for schools
Wider context from the report “1. I heard evidence that the Department of Education have devolved responsibility for e-security systems with schools having to ‘tender’ for web filtering software and hardware. However, the guidelines issued by the Department of Education require updating and are insufficiently robust to ensure their effectiveness and meet the changing demands of ████████ e-security in schools .
” 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 include key-logger and screen-reader reporting systems in e-security guidance
Wider context from the report “4. Some websites are only blocked when there is a particular key word in the URL if the relevant trigger word (e.g. ████████) is not there it makes it difficult for the filter to ‘see’ the content of the website to be able to block it, hence why stories on ████████ could be read. However, there are software systems available that acts as a ‘key logger’ and ‘screen reader’. Whilst this will not block the site it will generate a report to the nominated safeguarding individual for further action. Yet it has not been considered or is part of the guidelines issued by the Department of 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 Inadequate regulatory oversight and outdated guidance on school e-security standards
Wider context from the report “5. In summary, on the evidence I heard there appears to be inadequate regulatory oversight with now outdated guidance issued by the Department of Education with regard to robust standards of e-security systems within schools .
” 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 a public consultation on revised Keeping Children Safe in Education guidance, including filtering and monitoring systems.
Verbatim wording from the response “We continue to review what more we can do to support schools and colleges and see where we can strengthen the guidance further. On 11 January, we launched a public consultation on KCSIE which runs until 8 March. To help us build the evidence base, we have included a question specifically relating to filtering and monitoring systems, which asks schools if they feel able to make informed decisions on which filtering and monitoring systems your school or college should use? Following consultation, we plan to publish revised guidance later this year.” Source location 2021-0408-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch digital, data and technology standards covering data security, cyber security, monitoring and filtering.
Verbatim wording from the response “Furthermore, to support schools to have the appropriate safeguarding systems in place, under both child and data protection legislation, we will also be launching a set of digital, data and technology standards from Spring 2022, including standards on data and cyber security, and how to support more robust monitoring and filtering. Through consultation with the education and technology sector, we will explore options on how to ensure schools meet these standards to support system-wide safeguarding policies and how we can further support them to understand and improve their digital environments.” Source location 2021-0408-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce the Online Safety Bill.
Verbatim wording from the response “The Bill was subject to pre-legislative scrutiny by a Joint Committee of MPs and Peers, who reported with their recommendations on 14 December 2021. We are considering fully and carefully these recommendations and are committed to introducing the Bill as soon as possible. In the meantime, we are working closely with Ofcom to ensure that the implementation of the framework is as short as possible, following passage of the legislation. We are also clear that companies should not wait for the legislation to protect their users online.” Source location 2021-0408-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage technology companies to request stronger protection for young people online.
Verbatim wording from the response “We are also working with the Children’s Commissioner to support parents to help their children navigate the internet safely and recently met with technology companies to ask them to do more to keep young people safe, ahead of the Online Safety Bill coming into effect. The Children's Commissioner is working on her final recommendations to us and to DCMS, which we will fully consider and respond to in due course.” Source location 2021-0408-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish revised Keeping Children Safe in Education guidance following consultation.
Verbatim wording from the response “We continue to review what more we can do to support schools and colleges and see where we can strengthen the guidance further. On 11 January, we launched a public consultation on KCSIE which runs until 8 March. To help us build the evidence base, we have included a question specifically relating to filtering and monitoring systems, which asks schools if they feel able to make informed decisions on which filtering and monitoring systems your school or college should use? Following consultation, we plan to publish revised guidance later this year.” Source location 2021-0408-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen online-safety requirements in Keeping Children Safe in Education guidance.
Verbatim wording from the response “We have significantly strengthened online safety in KCSIE in recent years - especially in 2021. This includes considering how online safety is reflected as required in all relevant policies and considering online safety whilst planning the curriculum, any teacher training, the role and responsibilities of the designated safeguarding lead and any parental engagement.” Source location 2021-0408-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Confirm Ofcom’s appointment as regulator for the Online Safety framework.
Verbatim wording from the response “We have confirmed our decision to appoint Ofcom as regulator and our intention to give them a range of enforcement powers which will include substantial fines and, where appropriate, business disruption measures (including blocking). There will also be a criminal offence for senior managers who fail to ensure their company complies with Ofcom’s information requests, to push strong compliance in this area.” Source location 2021-0408-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual schools and their leaders are responsible for deciding appropriate filtering and monitoring systems according to local circumstances.
Verbatim wording from the response “The appropriateness of any filter and monitoring systems is rightly a matter for individual schools. The needs of individual schools will be unique to their own local circumstances. For example, a small rural school’s filtering and monitoring needs will be different to that of a large urban school and the needs of primary schools will be different to the” Source location 2021-0408-Response-from-Department-for-Education_Published
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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 Concerns about Wattpad fall outside the department’s remit.
Verbatim wording from the response “Finally, with regards to the concerns raised specifically in relation to WATTPAD, I must advise that this issue falls outside of this department’s remit but has been passed to DCMS for its consideration, I am also aware that DCMS is working closely with DHSC on tackling harmful suicide/self-harm content online.” Source location 2021-0408-Response-from-Department-for-Education_Published
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for considering Wattpad concerns was passed to DCMS.
Verbatim wording from the response “Finally, with regards to the concerns raised specifically in relation to WATTPAD, I must advise that this issue falls outside of this department’s remit but has been passed to DCMS for its consideration, I am also aware that DCMS is working closely with DHSC on tackling harmful suicide/self-harm content online.” Source location 2021-0408-Response-from-Department-for-Education_Published
Open published response
3 Nov 2021 Saskia Jones and 2 others · Prevention of Future Deaths report London City
View report summary
Concerns raised 24 Failure to inform MAPPA panels about regularity and form of overt offender-management contact View source Insufficient consideration of extremist offenders’ dishonest self-presentation View source Failure to share and consider counter-terrorism police intelligence in MAPPA management View source Failure to properly reason and record offender-manager licence-condition approvals View source Failure to provide MAPPA panels important prison-history information View source Failure to provide MAPPA panels direct input from the preparing forensic psychologist View source Failure to communicate between offender managers and event organisers before extremist offenders attend events View source Insufficient risk assessment and management for prison higher education programmes involving post-release offender contact View source Sudden disruption of DDP mentoring arrangements View source Sudden loss of supervised internet access for employment searches View source Failure to complete the full structured assessment before changing an OASys risk rating View source Failure to properly consider security-sensitive information in MAPPA decisions View source Lack of precautionary search capability for terrorist offenders on licence View source Failure to detect Class A drug use by terrorist offenders on licence View source Unavailability of offender risk-profile information to prison-based higher education providers View source Failure to ensure all MAPPA meeting attendees receive meeting minutes View source Failure to ensure direct forensic psychologist involvement in ERG 22+ assessment reports View source Failure to assess risks of continuing close contact between serious offenders and young students View source Excessive reliance on compliance in management of extremist offenders View source Failure to communicate high-risk event attendance to host venues View source Failure to directly address risks when approving licence-condition changes View source Lack of formal risk assessment for higher education events held outside university premises View source Failure of MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes View source Failure to record proper rationale for changes to OASys risk ratings View source See 21 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
Saskia Jones and 2 others · 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 29 November 2019, Usman Khan carried out a terrorist attack at Fishmongers’ Hall, fatally stabbing Saskia Jones and Jack Merritt before being fatally shot by firearms officers on London Bridge. The report raised concerns about risk assessment and communication for events involving high-risk offenders, and about the assessment, information-sharing, supervision and management of terrorist offenders released into the community.
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 inform MAPPA panels about regularity and form of overt offender-management contact
Wider context from the report “The facts of this case give cause for concern that MAPPA panels responsible for managing terrorist offenders may be unaware of the regularity and form of contact with police officers responsible for overt offender management .
” 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 consideration of extremist offenders’ dishonest self-presentation
Wider context from the report “The facts of this case give rise to concern that probation officers may give insufficient regard to instances of dishonesty in self-presentation by extremist offenders .
” 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 share and consider counter-terrorism police intelligence in MAPPA management
Wider context from the report “This case gives cause for concern that counter-terrorism police may be in possession of intelligence or information which may be useful to the management of an offender by the MAPPA panel, but that such intelligence or information may not be brought to the knowledge of or taken into account by MAPPA agencies .
” 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 properly reason and record offender-manager licence-condition approvals
Wider context from the report “This case gives rise to concern that offender managers may take significant decisions to give approvals under licence conditions without those decisions being properly reasoned and recorded .
” 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 provide MAPPA panels important prison-history information
Wider context from the report “The facts of this case give cause for concern that some members of MAPPA panels responsible for managing extremist offenders may not be aware of important information from the offender’s time in prison .
” 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 provide MAPPA panels direct input from the preparing forensic psychologist
Wider context from the report “It is a matter for concern that MAPPA panels managing even the most serious offenders may not have the benefit of hearing directly from a forensic psychologist who has prepared an ERG report shortly prior to the offender’s release .
” 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 between offender managers and event organisers before extremist offenders attend events
Wider context from the report “This case gives rise to concern that an extremist offender may be permitted to attend an event or venue without there having been proper communication between the probation and police officers responsible for managing the offender and the event organisers and/or venue hosts .
” 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 risk assessment and management for prison higher education programmes involving post-release offender contact
Wider context from the report “Consideration should be given to whether further measures of risk assessment and management can be introduced for any higher education programmes running in prisons which involve continued contact with offenders after their release into the community .
” 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 Sudden disruption of DDP mentoring arrangements
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work.
” 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 Sudden loss of supervised internet access for employment searches
Wider context from the report “This case gives rise to concern that mentoring arrangements under the DDP could be disrupted suddenly in the case of a person whose risk of re-engaging in extremism was known to be related to social isolation. It also gives rise to concern that an offender could be suddenly deprived of the means to use the internet under supervision to search for work .
” 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 the full structured assessment before changing an OASys risk rating
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale.
” 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 properly consider security-sensitive information in MAPPA decisions
Wider context from the report “The facts of this case give cause for concern that security sensitive information may not be properly taken into account in decision-making by MAPPA panels concerning the management of terrorist offenders.
” 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 precautionary search capability for terrorist offenders on licence
Wider context from the report “The facts of this case gave cause for concern that those involved in managing terrorist offenders on licence may lack a valuable means of addressing risks they pose, namely an ability to carry out a search on a precautionary 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 Failure to detect Class A drug use by terrorist offenders on licence
Wider context from the report “The facts of this case give cause for concern that a terrorist offender on licence, who was subject both to strict licence conditions and to a priority investigation, could obtain and use Class A drugs without that being detected .
” 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 offender risk-profile information to prison-based higher education providers
Wider context from the report “It is a matter of concern that Learning Together could operate courses in prisons in the way it did without being given information about the risk profiles of offenders joining courses .
” 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 all MAPPA meeting attendees receive meeting minutes
Wider context from the report “Based on the evidence in this case, there is cause for concern that effective procedures are not in place to ensure that all MAPPA meeting attendees receive meeting minutes .
” 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 direct forensic psychologist involvement in ERG 22+ assessment reports
Wider context from the report “Notwithstanding the measures which the NPS has put in place since the attack, there remains cause for concern that ERG 22+ assessment reports may be prepared by a CTPO without the direct involvement of a forensic psychologist .
” 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 risks of continuing close contact between serious offenders and young students
Wider context from the report “It is a matter of concern that focussed consideration was not given to the risks of serious offenders being placed in close and continuing contact with young students .
” 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 Excessive reliance on compliance in management of extremist offenders
Wider context from the report “Based on the facts of this case, there is cause for concern that probation officers may attach excessive weight in their management of extremist offenders to “compliance” (i.e. absence of evidence of breach of licence conditions and police behaviour).
” 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 high-risk event attendance to host venues
Wider context from the report “It is a matter of concern that a major event could be held by a University at a livery company hall in London without clear communication of the fact that it would be attended by serving and recently released serious offenders .
” 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 directly address risks when approving licence-condition changes
Wider context from the report “This case gives cause for concern that an offender manager and/or MAPPA panel participants could approve a permission, variation or relaxation in relation to a licence condition without directly addressing the potential risks involved .
” 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 formal risk assessment for higher education events held outside university premises
Wider context from the report “It is a matter of concern that there was no such risk assessment for Learning Together events as set out above.
” 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 MAPPA panels to conduct clearly reasoned discussion and decision-making on licence-condition changes
Wider context from the report “The facts of this case give rise to concern that important decisions on approvals, variations and relaxations in relation to licence conditions may be taken without clearly reasoned discussion and decision-making in MAPPA panels .
” 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 record proper rationale for changes to OASys risk ratings
Wider context from the report “The facts of this case give rise to concern that an OASys risk rating for an offender may be changed without the offender manager conducting the full assessment exercise (using the structured form) and that the change may be recorded without proper rationale .
” 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 Engage higher education colleagues to encourage effective communications between event organisers and host venues for high-risk events.
Verbatim wording from the response “• I will engage with colleagues in the higher education sector to encourage action be taken to implement this recommendation.” Source location 2021-0362-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage higher education colleagues to encourage formal risk assessments for significant off-campus academic events and courses.
Verbatim wording from the response “• I will engage with colleagues in the higher education sector to encourage action be taken to implement this recommendation.” Source location 2021-0362-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage Office for Students colleagues to encourage higher education providers to consider event-organiser and host-venue communications in risk-management procedures.
Verbatim wording from the response “• My officials have spoken to colleagues at the Office for Students to encourage them to take action and I welcome their intention to write to all English higher education providers to draw attention to this recommendation, with the aim of encouraging them to consider effective communications between event organisers and host venues as part of their event and risk management procedures.” Source location 2021-0362-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue engaging HMPPS in developing a framework defining prisons’ and higher education providers’ roles and responsibilities for partnership learning involving prisoners or released offenders.
Verbatim wording from the response “• My officials have engaged with colleagues in Her Majesty’s Prisons and Probation Service (HMPPS) and I welcome the planned work to design a new framework to clearly define the roles and responsibilities of prisons and higher education providers when they work in partnership to deliver learning where students study alongside serving prisoners or those released on licence. This will include reference to risk assessment guidance that has been developed for partner organisations who hold events where prison leavers may be invited to attend. I have asked my officials to continue engaging in this process.” Source location 2021-0362-Response-from-Department-for-Education_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage Office for Students colleagues to encourage higher education providers to implement formal risk assessments for significant off-campus events and courses.
Verbatim wording from the response “• My officials have spoken to colleagues at the Office for Students to encourage them to take action and I welcome their intention to write to all English higher education providers to draw their attention to the report and its recommendations, to encourage them to ensure significant academic events and courses held outside of university premises should be subject to proper formal risk assessment, especially if they take place in environments with particular risk (such as prisons) and if they are attended by individuals who pose particular risks.” Source location 2021-0362-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 Higher education providers, as independent autonomous institutions, are responsible for their own governance and risk management.
Verbatim wording from the response “• Higher education providers are independent autonomous institutions and therefore responsible for their own governance and risk management.” Source location 2021-0362-Response-from-Department-for-Education_Published
Open published response
20 May 2021 Anastasia Ekaterina UGLOW · Prevention of Future Deaths report Avon
View report summary
Concerns raised 1 Lack of sepsis awareness in schools 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
Anastasia Ekaterina UGLOW · 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
Anastasia Ekaterina Uglow became increasingly unwell during a school trip to New York after having been unwell beforehand. She developed septic shock, collapsed in cardiac arrest and died at Mount Sinai Hospital on 19 December 2019. The principal concern was the need to raise awareness of sepsis in schools, including among staff supervising school trips.
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 sepsis awareness in schools
Wider context from the report “In this case it became clear that Ana’s school is already taking the step to include within their first aid training for staff – sepsis awareness.
This case clearly demonstrates how awful this condition is and how tragic the consequences are if it left untreated.
My report is therefore written to consider raising sepsis awareness within all schools .
” Open source report
16 May 2021 Sarah Margaret Clarke · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 12 Insufficiently robust systems for managing, treating and safeguarding high-risk students with mental health problems View source Failure to verify the safety of distressed students from self-harm View source Higher incidence of student mental health difficulties, self-harm and suicide View source Failure to implement national guidance to reduce student suicide View source Failure to complete a serious incident report on CWB working practices View source Failure to undertake reflection on CWB working practices View source Lack of national guidance on basic university mental health service requirements View source Failure to secure local NHS mental health service involvement in CWB service provision View source Lack of internal oversight of CWB service provision View source Insufficient communication and learning between CWB and local NHS mental health services View source Lack of external regulatory oversight of CWB service provision View source Failure to establish robust systems confirming student safety View source See 9 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
Sarah Margaret Clarke · 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
Sarah Margaret Clarke, a 23-year-old university student with significant mental health difficulties, was found deceased in her university accommodation on 21 November 2019 after sending an email indicating that she intended to end her life. The concerns included inadequate follow-up after she became extremely distressed, insufficiently robust systems for managing and safeguarding students at high risk of self-harm, and failure to implement relevant national guidance or provide adequate oversight and learning.
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 Insufficiently robust systems for managing, treating and safeguarding high-risk students with mental health problems
Wider context from the report “3. The organisation and systems at the CWB were insufficiently robust to appropriately manage, treat and safeguard students known to have mental health problems and be at high risk to themselves on a background of a lack of national guidance of what are the basic requirements for universities to provide such 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 Failure to verify the safety of distressed students from self-harm
Wider context from the report “2. Sarah was known to have significant mental health difficulties exacerbated by a recent bereavement and other personal difficulties. On 19th November 2019 after Sarah hung up on the administrator and was knowingly extremely distressed, CWB staff did not take steps to reassure themselves that Sarah was safe from self-harm .
” 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 Higher incidence of student mental health difficulties, self-harm and suicide
Wider context from the report “1. I heard evidence students have a higher incidence of mental health difficulties, self-harm and suicide exacerbated by multifactorial issues such as being effectively itinerant with work and other social pressures.
” 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 implement national guidance to reduce student suicide
Wider context from the report “4. National guidance issued in September 2018 to reduce the incidence of suicide in the student population had not been implemented by CWB at the time of Sarah’s 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 Failure to complete a serious incident report on CWB working practices
Wider context from the report “7. There was no serious incident report completed by US as to the working practices of the CWB and no reflection has taken place and no steps have been taken to put into place by CWB to provide more robust systems to confirm the safety of students such as Sarah.
” 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 undertake reflection on CWB working practices
Wider context from the report “7. There was no serious incident report completed by US as to the working practices of the CWB and no reflection has taken place and no steps have been taken to put into place by CWB to provide more robust systems to confirm the safety of students such as Sarah.
” 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 on basic university mental health service requirements
Wider context from the report “3. The organisation and systems at the CWB were insufficiently robust to appropriately manage, treat and safeguard students known to have mental health problems and be at high risk to themselves on a background of a lack of national guidance of what are the basic requirements for universities to provide such 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 Failure to secure local NHS mental health service involvement in CWB service provision
Wider context from the report “6. There was little communication or learning between and a lack of involvement sought or offered by local NHS mental health services to ensure the service provided by CWB was within an acceptable standard.
” 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 internal oversight of CWB service provision
Wider context from the report “5. There was no internal (by CWB) or external regulatory (by US) oversight as to the service provision at CWB before Sarah’s death or indeed after her 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 Insufficient communication and learning between CWB and local NHS mental health services
Wider context from the report “6. There was little communication or learning between and a lack of involvement sought or offered by local NHS mental health services to ensure the service provided by CWB was within an acceptable standard.
” 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 external regulatory oversight of CWB service provision
Wider context from the report “5. There was no internal (by CWB) or external regulatory (by US) oversight as to the service provision at CWB before Sarah’s death or indeed after her 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 Failure to establish robust systems confirming student safety
Wider context from the report “7. There was no serious incident report completed by US as to the working practices of the CWB and no reflection has taken place and no steps have been taken to put into place by CWB to provide more robust systems to confirm the safety of students such as Sarah.
” Open source report
30 Mar 2020 JORDAN MICHAEL AIRA · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 4 Lack of physical boundaries preventing public access to railway tracks View source Failure of warning signs to warn of the risk of immediate death from touching the live rail View source Lack of a national curriculum requirement to teach pupils about the risk posed by the live rail View source Emergency telephone located adjacent to railway track View source See 1 more concern
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
JORDAN MICHAEL AIRA · 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
Jordan Michael Aira was electrocuted after walking onto the railway lines at Ashford Station in the early hours of 23 March 2019. The concerns included inadequate physical barriers, the location of the emergency telephone, warning signs that did not explicitly warn of immediate death from touching the live rail, and no national curriculum requirement to teach pupils about the risk posed by live rails.
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 physical boundaries preventing public access to railway tracks
Wider context from the report “1. There were no physical boundaries at the end of the platform preventing members of the public accessing the railway tracks .
” 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 warning signs to warn of the risk of immediate death from touching the live rail
Wider context from the report “3. The warning signs in place which are standard in the rail industry do not in terms warn of the risk of immediate death if you touch the live rail .
” 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 national curriculum requirement to teach pupils about the risk posed by the live rail
Wider context from the report “4. There is no requirement in the national curriculum to teach pupils about the risk posed by the live rail .
” 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 Emergency telephone located adjacent to railway track
Wider context from the report “2. The emergency telephone which may be used by members of the public is located adjacent to the railway track .
” Open source report
31 Dec 2019 Jacob Andrew Bates · Prevention of Future Deaths report Derby and Derbyshire
View report summary
Concerns raised 4 Placement of vulnerable 16-to-18-year-olds in unregulated placements View source Lack of statutory requirements for provider staff competency, training, policies and procedures View source Absence of regulatory inspection and assessment of placement providers View source Inadequate local-authority scrutiny of placement-provider competence and safety View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jacob Andrew Bates · 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
Jacob Andrew Bates, who had autism, mental health problems and a history of serious self-harm, died by suicide on 15 July 2017 after placing plastic ties around his neck as ligatures. The report raised serious concerns that vulnerable young people, including those with complex needs and significant risks, were being placed in unregulated settings without statutory oversight of staff competency, policies or procedures.
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 Placement of vulnerable 16-to-18-year-olds in unregulated placements
Wider context from the report “Evidence was given at the inquest hearing by two former employees at the placement that they had no prior experience of working with young people (indeed no experience of working in any form of care-related work) and were left in charge of the unit where Jacob was placed after a very short period of commencing employment (one former staff member said that he had only completed two shadowing sessions before being asked to be in sole charge of the unit overnight).
The evidence of the responsible local authority was that it had not sought evidence from the placement provider as to staff competency and training, or that suitable policies and procedures were in place; it effectively accepted the assurances of the provider.
The local authority stated that it now has systems providing for greater scrutiny and diligence but it was explained that where residential/supported provision is solely for young people aged 16 to 18 that provision falls outside of the statutory regime of inspection and regulatory compliance as enforced by Ofsted. My understanding is that the issue of unregulated placements for 16 to 18 year olds has been widely highlighted as a cause for concern but the evidence of a senior local authority manager at inquest was that she was unaware of any plans nationally to address the issue despite concerns having been very widely raised.
1. Vulnerable young people, aged 16 to 18, are being placed in unregulated placements.
2. Any young person under the age of 18 placed in an unregulated placement is likely to have very significant vulnerabilities, and it is likely that young people with complex needs and at significant risk are being placed in such placements ; indeed this was the case for Jacob.
3. As the placements are unregulated there are no statutory regulations to comply with relating to competency and appropriate policies and procedures by the provider and there is no regulatory body to check and assess those providers. This is clearly a very concerning situation given the very high level needs that some of the young people will have.
4. The lack of statutory regulation then places an onus on local authorities to check that a provider is competent and safe. Whilst in making individual placements it must be the duty of a local authority to satisfy itself as best as it is able that placements are ‘safe’, given the pressures on local authorities it cannot be the case that they are in a position to mirror the type and nature of inspection and oversight that might be provided by a regulator such as Ofsted.
5. In view of the points made above the lack of statutory regulation is placing vulnerable young people at risk, and there is a realistic possibility that deaths may occur.
” 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 requirements for provider staff competency, training, policies and procedures
Wider context from the report “Evidence was given at the inquest hearing by two former employees at the placement that they had no prior experience of working with young people (indeed no experience of working in any form of care-related work) and were left in charge of the unit where Jacob was placed after a very short period of commencing employment (one former staff member said that he had only completed two shadowing sessions before being asked to be in sole charge of the unit overnight).
The evidence of the responsible local authority was that it had not sought evidence from the placement provider as to staff competency and training, or that suitable policies and procedures were in place; it effectively accepted the assurances of the provider.
The local authority stated that it now has systems providing for greater scrutiny and diligence but it was explained that where residential/supported provision is solely for young people aged 16 to 18 that provision falls outside of the statutory regime of inspection and regulatory compliance as enforced by Ofsted. My understanding is that the issue of unregulated placements for 16 to 18 year olds has been widely highlighted as a cause for concern but the evidence of a senior local authority manager at inquest was that she was unaware of any plans nationally to address the issue despite concerns having been very widely raised.
1. Vulnerable young people, aged 16 to 18, are being placed in unregulated placements.
2. Any young person under the age of 18 placed in an unregulated placement is likely to have very significant vulnerabilities, and it is likely that young people with complex needs and at significant risk are being placed in such placements; indeed this was the case for Jacob.
3. As the placements are unregulated there are no statutory regulations to comply with relating to competency and appropriate policies and procedures by the provider and there is no regulatory body to check and assess those providers. This is clearly a very concerning situation given the very high level needs that some of the young people will have.
4. The lack of statutory regulation then places an onus on local authorities to check that a provider is competent and safe. Whilst in making individual placements it must be the duty of a local authority to satisfy itself as best as it is able that placements are ‘safe’, given the pressures on local authorities it cannot be the case that they are in a position to mirror the type and nature of inspection and oversight that might be provided by a regulator such as Ofsted.
5. In view of the points made above the lack of statutory regulation is placing vulnerable young people at risk, and there is a realistic possibility that deaths may occur.
” 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 regulatory inspection and assessment of placement providers
Wider context from the report “Evidence was given at the inquest hearing by two former employees at the placement that they had no prior experience of working with young people (indeed no experience of working in any form of care-related work) and were left in charge of the unit where Jacob was placed after a very short period of commencing employment (one former staff member said that he had only completed two shadowing sessions before being asked to be in sole charge of the unit overnight).
The evidence of the responsible local authority was that it had not sought evidence from the placement provider as to staff competency and training, or that suitable policies and procedures were in place; it effectively accepted the assurances of the provider.
The local authority stated that it now has systems providing for greater scrutiny and diligence but it was explained that where residential/supported provision is solely for young people aged 16 to 18 that provision falls outside of the statutory regime of inspection and regulatory compliance as enforced by Ofsted. My understanding is that the issue of unregulated placements for 16 to 18 year olds has been widely highlighted as a cause for concern but the evidence of a senior local authority manager at inquest was that she was unaware of any plans nationally to address the issue despite concerns having been very widely raised.
1. Vulnerable young people, aged 16 to 18, are being placed in unregulated placements.
2. Any young person under the age of 18 placed in an unregulated placement is likely to have very significant vulnerabilities, and it is likely that young people with complex needs and at significant risk are being placed in such placements; indeed this was the case for Jacob.
3. As the placements are unregulated there are no statutory regulations to comply with relating to competency and appropriate policies and procedures by the provider and there is no regulatory body to check and assess those providers . This is clearly a very concerning situation given the very high level needs that some of the young people will have.
4. The lack of statutory regulation then places an onus on local authorities to check that a provider is competent and safe. Whilst in making individual placements it must be the duty of a local authority to satisfy itself as best as it is able that placements are ‘safe’, given the pressures on local authorities it cannot be the case that they are in a position to mirror the type and nature of inspection and oversight that might be provided by a regulator such as Ofsted.
5. In view of the points made above the lack of statutory regulation is placing vulnerable young people at risk, and there is a realistic possibility that deaths may occur.
” 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 local-authority scrutiny of placement-provider competence and safety
Wider context from the report “Evidence was given at the inquest hearing by two former employees at the placement that they had no prior experience of working with young people (indeed no experience of working in any form of care-related work) and were left in charge of the unit where Jacob was placed after a very short period of commencing employment (one former staff member said that he had only completed two shadowing sessions before being asked to be in sole charge of the unit overnight).
The evidence of the responsible local authority was that it had not sought evidence from the placement provider as to staff competency and training, or that suitable policies and procedures were in place ; it effectively accepted the assurances of the provider.
The local authority stated that it now has systems providing for greater scrutiny and diligence but it was explained that where residential/supported provision is solely for young people aged 16 to 18 that provision falls outside of the statutory regime of inspection and regulatory compliance as enforced by Ofsted. My understanding is that the issue of unregulated placements for 16 to 18 year olds has been widely highlighted as a cause for concern but the evidence of a senior local authority manager at inquest was that she was unaware of any plans nationally to address the issue despite concerns having been very widely raised.
1. Vulnerable young people, aged 16 to 18, are being placed in unregulated placements.
2. Any young person under the age of 18 placed in an unregulated placement is likely to have very significant vulnerabilities, and it is likely that young people with complex needs and at significant risk are being placed in such placements; indeed this was the case for Jacob.
3. As the placements are unregulated there are no statutory regulations to comply with relating to competency and appropriate policies and procedures by the provider and there is no regulatory body to check and assess those providers. This is clearly a very concerning situation given the very high level needs that some of the young people will have.
4. The lack of statutory regulation then places an onus on local authorities to check that a provider is competent and safe. Whilst in making individual placements it must be the duty of a local authority to satisfy itself as best as it is able that placements are ‘safe’, given the pressures on local authorities it cannot be the case that they are in a position to mirror the type and nature of inspection and oversight that might be provided by a regulator such as Ofsted .
5. In view of the points made above the lack of statutory regulation is placing vulnerable young people at risk, and there is a realistic possibility that deaths may occur.
” 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 Launch a consultation on proposals to ensure unregulated provision is used appropriately and meets young people’s needs.
Verbatim wording from the response “I share your concerns that unregulated settings are not always good enough, and that some children are being placed at risk or in settings that cannot meet their needs. It is clear that reform is urgently needed, and this is why on 12 February 2020 I launched a consultation on a range of proposals to ensure that unregulated provision is being used appropriately and meets the needs of the young people placed there.” Source location 2019-0456-Response-from-the-Secretary-of-State-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 a response to the consultation, including a timetable for reforms taken forward.
Verbatim wording from the response “It is a priority for this Government that children and young people in care have the support, protection and care they deserve. The independently led Care Review will also take a fundamental look across children’s social care with the aim of better supporting, protecting and improving the outcomes of vulnerable children and young people. However, I am clear that the issue of unregulated provision cannot wait and requires immediate and decisive action to be taken. Following the consultation we will consider the responses received and publish a response which will include a timetable for any reforms that will be taken forward.” Source location 2019-0456-Response-from-the-Secretary-of-State-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 responses to the consultation on unregulated provision reforms.
Verbatim wording from the response “It is a priority for this Government that children and young people in care have the support, protection and care they deserve. The independently led Care Review will also take a fundamental look across children’s social care with the aim of better supporting, protecting and improving the outcomes of vulnerable children and young people. However, I am clear that the issue of unregulated provision cannot wait and requires immediate and decisive action to be taken. Following the consultation we will consider the responses received and publish a response which will include a timetable for any reforms that will be taken forward.” Source location 2019-0456-Response-from-the-Secretary-of-State-for-Education
Open published response
19 Nov 2019 Katie Croft · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 15 Failure to share Child and Family Assessments in accordance with best practice View source Unclear dissemination of safeguarding investigation lessons beyond the local area View source Failure to establish available recordings and the scope of relevant social media evidence before case closure View source Lack of a formal school follow-up procedure after a Child and Family Assessment View source Lack of a mechanism for schools to receive relevant Child and Family Assessment information View source Failure to conduct a further face-to-face conversation with the child View source Lack of clear exam-board guidance for teachers to minimise risk to pupils when teaching sensitive material View source Failure to consider victimless prosecution before closing matters View source Failure to provide teachers with relevant information about a pupil's self-harm history and vulnerability View source Failure to fully hear the voice of the child throughout safeguarding investigations View source Failure to ensure case officers attend safeguarding strategy meetings View source Failure to complete Child and Family Assessments in accordance with best practice amid reliance on agency social workers View source Lack of officer capability in joint working with social services and applying the voice of the child View source Delays in seizing key digital evidence View source Failure to allocate appropriately experienced specialist officers to alleged sexual offences View source See 12 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
Katie Croft · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Katie Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to share Child and Family Assessments in accordance with best practice
Wider context from the report “2. The Local Authority at the time were using a substantial number of agency social workers. As a result the Child and Family Assessment was not completed in accordance with best practice and not shared in accordance with expectations around best practice . The Local Authority has since made significant progress in moving away from a reliance on agency staff to fill gaps in social work cover. The inquest was told that agency social workers are still used extensively in other Local Authorities creating a risk that a similar situation could arise;
” 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 dissemination of safeguarding investigation lessons beyond the local area
Wider context from the report “4. It was accepted by witnesses for both the Local Authority and GMP that the voice of the child was not fully heard throughout their investigations. They via the safeguarding board commissioned an independent report whose findings and recommendations have been fully adopted by the safeguarding board. It was unclear what if any steps would be taken to disseminate the lessons pan GM or 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 establish available recordings and the scope of relevant social media evidence before case closure
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages . No attempt was made to have a further face to face conversation with Katie;
” 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 formal school follow-up procedure after a Child and Family Assessment
Wider context from the report “5. A further concern identified was that there was no mechanism for the school to be formally aware of information within the Child and Family Assessment. As a result there was no formal follow-up procedure set out in the best practice national guidance the school was working within . The inquest heard that Katie’s school recognising this gap has built on the working together guidance to develop guidance that ensures there is a proactive approach to engaging with a child and their family post the writing of a Child and Family Assessment;
” 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 mechanism for schools to receive relevant Child and Family Assessment information
Wider context from the report “5. A further concern identified was that there was no mechanism for the school to be formally aware of information within the Child and Family Assessment . As a result there was no formal follow-up procedure set out in the best practice national guidance the school was working within. The inquest heard that Katie’s school recognising this gap has built on the working together guidance to develop guidance that ensures there is a proactive approach to engaging with a child and their family post the writing of a Child and Family Assessment;
” 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 a further face-to-face conversation with the child
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie ;
” 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 clear exam-board guidance for teachers to minimise risk to pupils when teaching sensitive material
Wider context from the report “6. On the day Katie committed suicide she had attended a GCSE English class. The exam board required poetry syllabus was being studied that day. The lesson included a poem where the contextualisation of it included the use of suicide. The teacher delivering the lesson had no way of understanding the history of self-harm of Katie and her particular vulnerability when delivering a set text in accordance with the exam board requirements. It was unclear what if any guidance is given by the exam board to assist teachers minimising risk to pupils in this scenario .
” 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 victimless prosecution before closing matters
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution ; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” 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 provide teachers with relevant information about a pupil's self-harm history and vulnerability
Wider context from the report “6. On the day Katie committed suicide she had attended a GCSE English class. The exam board required poetry syllabus was being studied that day. The lesson included a poem where the contextualisation of it included the use of suicide. The teacher delivering the lesson had no way of understanding the history of self-harm of Katie and her particular vulnerability when delivering a set text in accordance with the exam board requirements. It was unclear what if any guidance is given by the exam board to assist teachers minimising risk to pupils in this scenario.
” 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 fully hear the voice of the child throughout safeguarding investigations
Wider context from the report “4. It was accepted by witnesses for both the Local Authority and GMP that the voice of the child was not fully heard throughout their investigations . They via the safeguarding board commissioned an independent report whose findings and recommendations have been fully adopted by the safeguarding board. It was unclear what if any steps would be taken to disseminate the lessons pan GM or 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 ensure case officers attend safeguarding strategy meetings
Wider context from the report “3. At the safeguarding strategy meeting an officer allocated to attend such meetings on behalf of GMP attended rather than an officer allocated to the case . As a result the quality of information sharing and understanding of the allegation was more limited . On the particular police division in question this practice has stopped. It was unclear how common the approach is on a wider 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 Failure to complete Child and Family Assessments in accordance with best practice amid reliance on agency social workers
Wider context from the report “2. The Local Authority at the time were using a substantial number of agency social workers . As a result the Child and Family Assessment was not completed in accordance with best practice and not shared in accordance with expectations around best practice. The Local Authority has since made significant progress in moving away from a reliance on agency staff to fill gaps in social work cover. The inquest was told that agency social workers are still used extensively in other Local Authorities creating a risk that a similar situation could arise;
” 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 officer capability in joint working with social services and applying the voice of the child
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case . At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” 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 in seizing key digital evidence
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience. The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed . The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” 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 allocate appropriately experienced specialist officers to alleged sexual offences
Wider context from the report “1. The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie’s allegations. As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer . It was allocated to a probationary police constable with approximately 6 months experience . The officer did not seize the phone which contained key social media contents until her third visit on the initial evening the offence was disclosed. The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie;
” Open source report
1 Oct 2019 Oliver Sharp · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Failure of schools to recognise risks and early signs associated with acceleration ahead of chronological school age View source Additional challenge associated with disability labelling for ageing children with autism View source Long waiting lists for autism assessments View source Variation and limited transition provision in post-16 mental health services View source See 1 more concern
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
Oliver Sharp · 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 Sharp died after taking a fatal dose of heroin; his death was confirmed at Wythenshawe Hospital on 18 October 2018. The inquest identified concerns about failures by mental health services to recognise and respond to his increasing level of risk during his transition from child and adolescent mental health services to reduced post-16 provision, as well as concerns about delays in autism assessment and variation in post-16 services.
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 schools to recognise risks and early signs associated with acceleration ahead of chronological school age
Wider context from the report “During the inquest evidence was heard that acceleration ahead of a chronological school age might cause relatively few difficulties in peer relationships up to about year 9 but post that as children entered adolescence it could become a significant issue impacting a child’s mental health and ability to cope . Where it did happen, there needed to be an understanding by schools of the risks and early signs indicating a need for additional support to try to reduce the likelihood of self-harming behaviours and the potential need for additional support.
” 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 Additional challenge associated with disability labelling for ageing children with autism
Wider context from the report “The inquest heard that Oliver had found the autism label and the label of disability that was attached to it very difficult to accept as time went on . There was evidence that particularly with ageing children with autism the idea that they had a disability created additional challenge .
The language that it would have been more helpful to use widely would have been difference rather than disability.
” 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 Long waiting lists for autism assessments
Wider context from the report “The inquest was told that it is important for autism to be diagnosed as early as possible so that appropriate support can be put in place. Early diagnosis was impacted by a national picture of long waiting lists for ADOS assessments . In Stockport there was approximately a 6 month waiting list for assessment . This was against a national picture of 12-24 month waits in some areas .
” 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 Variation and limited transition provision in post-16 mental health services
Wider context from the report “The inquest was told that the provision of mental health services post 16 varies widely across the country . In some areas there is a CAMHS 16-25 mental health service provision similar to the national 16 and under service whereas in other areas there a limited transition service or move back to primary care for re-referral to adult services . The inquest was told that this creates a cliff edge high risk situation for adolescents . The reason for the difference was resources and decisions taken by CCGs.
” Open source report
Concerns raised 2 Insufficient qualified and experienced staffing in Local Authorities serving high proportions of young people in care View source Failure to integrate care, adolescent mental health and education pastoral services View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Daniel Cameron SHORROCKS · 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
Daniel Cameron SHORROCKS discussed ending his life with a friend on 1 January 2018, sent a text stating “Dead at Berry Head”, and was found dead at the foot of a cliff at Berry Head. The report’s concerns relate to the availability of qualified and experienced staff for local authorities with many young people in care, and the integration of care, adolescent mental health, and education pastoral services.
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 qualified and experienced staffing in Local Authorities serving high proportions of young people in care
Wider context from the report “(1) I ask please that your Department reviews the availability of resources to those Local Authorities which have a high proportion of young people in care and disproportionately few qualified and experienced staff .
” 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 integrate care, adolescent mental health and education pastoral services
Wider context from the report “(2) I would also ask your Department to review the integration of services between Local Authority Care Services, Adolescent Mental Health Services and Pastoral Care provided in education settings .
” 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 Establish NHS-funded Mental Health Support Teams in 20–25% of the country by 2023 to provide additional school- and college-based mental health support.
Verbatim wording from the response “Improving the join up between local health and education services is at the heart of this programme of work led by NHS England, the Department of Health and Social Care, the Department for Education and Health Education England. The new NHS funded Mental Health Support Teams resulting from the consultation, which will be established in 20-25 per cent of the country by 2023, are designed to work in and around schools and colleges to provide additional capacity to address the mental health needs of children and young people. These teams will deliver interventions for those with mild to moderate mental health issues, support education settings to develop whole school or college approaches to promote good mental health and help children and young people with more severe needs to access the right support by working with schools and colleges to provide a link to specialist NHS services.” Source location 2019-0282-Response-by-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 Review the care system to ensure care placements and settings support looked-after children and young adults.
Verbatim wording from the response “Firstly, you asked that we review the availability of resources to those local authority care services which have a high proportion of young people in care and disproportionately few qualified staff.” Source location 2019-0282-Response-by-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 Make the Department for Education-funded Link Programme available across England to connect schools, colleges and children’s mental health services.
Verbatim wording from the response “Finally, to further support the integration between schools and colleges, and local mental health services, over the next four years, from 2019 to 2023, the Department for Education-funded Link Programme will be made available to all areas and CCGs, and through them to every school and college (including alternative provision settings) and children and young people's mental health services in England. The Link Programme encourages better join-up and communication between education settings and specialist children and young people’s mental health services. This will help more children and young people get the right support when they need it and help prevent individuals falling between the cracks in provision or experiencing poor transition between services.” Source location 2019-0282-Response-by-Department-of-Health-and-Social-Care
Open published response
25 Jul 2019 Owen Arron Wynne Williams · Prevention of Future Deaths report West Yorkshire (West)
View report summary
Concerns raised 4 Delays in staff support availability after unexpected A level results View source Delayed UCAS availability after educational institutions release student results View source Lack of national agreement on the timing and manner of A level results release View source Lack of national requirement for advance direct parental communication about A level results release and potential unexpected results View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Owen Arron Wynne Williams · 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
Owen Williams was found unresponsive, suspended by a rope tied to a tree in a secluded wooded area, after accessing A level results that did not meet the grades required for his intended university course; his death was confirmed later that day. The report identified concerns about the lack of national consistency in how and when A level results are released, delays before support is available, UCAS opening later, and the absence of a national requirement to inform parents in advance about the results-release system and potential impact of unexpected results.
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 Delays in staff support availability after unexpected A level results
Wider context from the report “I heard evidence from the Principal of the college that Owen attended that there is wide variance both locally and nationally of the timing and way in which colleges release A level results, some release results electronically as early as 6.00 am and later the same morning provide a facility within the school and college to provide support to students, some colleges / schools require the students to physically attend to obtain their results, when at the same time support by staff members is immediately on hand.
I understand UCAS is available from 8.00 am onwards, once again some hours after some students have obtained their results.
In particular, from the evidence presented to me it appears:-
1. That there is no national agreement across all educational institutions to the timing and manner in which A level results are released.
2. That there can be a significant time lag between results being released by some schools and colleges and the timing of when there is the availability of staff to provide support to those students that may have received unexpected results.
3. That UCAS is presently available some hours after some educational institutions have released student results.
4. That there is no national requirement for educational establishments to communicate directly to parents in advance of results day and explain the system in place for the release of the A level results at the educational establishment that their child is attending and to alert them to the potential that unexpected results can occur and to be alert to the impact that this may have upon their child.
” 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 UCAS availability after educational institutions release student results
Wider context from the report “I heard evidence from the Principal of the college that Owen attended that there is wide variance both locally and nationally of the timing and way in which colleges release A level results, some release results electronically as early as 6.00 am and later the same morning provide a facility within the school and college to provide support to students, some colleges / schools require the students to physically attend to obtain their results, when at the same time support by staff members is immediately on hand.
I understand UCAS is available from 8.00 am onwards, once again some hours after some students have obtained their results.
In particular, from the evidence presented to me it appears:-
1. That there is no national agreement across all educational institutions to the timing and manner in which A level results are released.
2. That there can be a significant time lag between results being released by some schools and colleges and the timing of when there is the availability of staff to provide support to those students that may have received unexpected results.
3. That UCAS is presently available some hours after some educational institutions have released student results.
4. That there is no national requirement for educational establishments to communicate directly to parents in advance of results day and explain the system in place for the release of the A level results at the educational establishment that their child is attending and to alert them to the potential that unexpected results can occur and to be alert to the impact that this may have upon their child.
” 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 agreement on the timing and manner of A level results release
Wider context from the report “I heard evidence from the Principal of the college that Owen attended that there is wide variance both locally and nationally of the timing and way in which colleges release A level results, some release results electronically as early as 6.00 am and later the same morning provide a facility within the school and college to provide support to students, some colleges / schools require the students to physically attend to obtain their results, when at the same time support by staff members is immediately on hand.
I understand UCAS is available from 8.00 am onwards, once again some hours after some students have obtained their results.
In particular, from the evidence presented to me it appears:-
1. That there is no national agreement across all educational institutions to the timing and manner in which A level results are released.
2. That there can be a significant time lag between results being released by some schools and colleges and the timing of when there is the availability of staff to provide support to those students that may have received unexpected results.
3. That UCAS is presently available some hours after some educational institutions have released student results.
4. That there is no national requirement for educational establishments to communicate directly to parents in advance of results day and explain the system in place for the release of the A level results at the educational establishment that their child is attending and to alert them to the potential that unexpected results can occur and to be alert to the impact that this may have upon their child.
” 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 requirement for advance direct parental communication about A level results release and potential unexpected results
Wider context from the report “I heard evidence from the Principal of the college that Owen attended that there is wide variance both locally and nationally of the timing and way in which colleges release A level results, some release results electronically as early as 6.00 am and later the same morning provide a facility within the school and college to provide support to students, some colleges / schools require the students to physically attend to obtain their results, when at the same time support by staff members is immediately on hand.
I understand UCAS is available from 8.00 am onwards, once again some hours after some students have obtained their results.
In particular, from the evidence presented to me it appears:-
1. That there is no national agreement across all educational institutions to the timing and manner in which A level results are released.
2. That there can be a significant time lag between results being released by some schools and colleges and the timing of when there is the availability of staff to provide support to those students that may have received unexpected results.
3. That UCAS is presently available some hours after some educational institutions have released student results.
4. That there is no national requirement for educational establishments to communicate directly to parents in advance of results day and explain the system in place for the release of the A level results at the educational establishment that their child is attending and to alert them to the potential that unexpected results can occur and to be alert to the impact that this may have upon their child.
” 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 Jointly host a roundtable with UCAS and education-sector organisations to consider the student journey and agree support for pupils encountering exam-result difficulties.
Verbatim wording from the response “I am determined that we avoid any situations where students with unexpected results feel that they have nowhere to turn. In order to ensure that no pupil finds themselves in this situation, later this year, my department will be jointly hosting a roundtable with UCAS, who are responsible for the release of information about university places on the morning of A level results day. We will invite organisations from across the education sector to consider the student journey – from sitting exams to receiving results – to agree how, together, we can ensure that pupils are supported should they encounter difficulties. Attendees will include the JCQ (Joint Council of Qualifications) and the Sixth Form Colleges Association (SFCA). I understand that UCAS and the SFCA will be responding to you separately.” Source location 2019-0250-Response-by-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 Exam-results release timing is determined by JCQ for GCSE, AS and A levels, and by individual awarding organisations for other qualifications.
Verbatim wording from the response “The time at which GCSE, AS and A level results can be released by schools to pupils is a matter for the JCQ, a membership organisation representing independent awarding organisations including the four exam boards offering GCSE, AS and A level exams in England. The JCQ oversees exam processes” Source location 2019-0250-Response-by-Department-for-Education
Open published response
24 Jul 2019 Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 11 Failure of mental health trusts to communicate placement information with private providers and families View source Failure to consider discharge medication and prescribing risk View source Failure of discharge planning to share risk information with GPs and families View source Failure of private providers to obtain relevant clinical information from referring services View source Failure to provide care coordination after placement with a private provider View source Insufficient mental health training and specialist liaison for university welfare staff View source Failure of universities to identify early signs of anxiety and mental health issues in students View source Lack of alternative mental health provision for young adults View source Lack of suitable acute mental health beds for young adults View source Inadequate guidance on glass balustrade safety where climbable furniture is adjacent View source Failure to communicate the change in risk level when patients leave a secure environment 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
Hannah Dolly Kaur Bharaj · 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 Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.
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 mental health trusts to communicate placement information with private providers and families
Wider context from the report “4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement . A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken 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 consider discharge medication and prescribing risk
Wider context from the report “2. There was no clear evidence of consideration of discharge medication and risk around prescribing of medication post discharge from the EDU . As a result Hannah was prescribed a month’s supply of medication;
” 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 discharge planning to share risk information with GPs and families
Wider context from the report “1. The inquest heard that discharge planning including communication with GPs and families around risk was not effective . Key information was not shared with the GP or the family particularly when care moved back to the family ;
” 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 private providers to obtain relevant clinical information from referring services
Wider context from the report “5.The expectations around information sharing with private providers and the expectation on private providers contracted by the NHS to seek information. The Priory did not request any notes from the EDU about Hannah . As a result they were unaware of detailed information held by the Trust regarding previously expressed suicidal ideation ;
” 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 provide care coordination after placement with a private provider
Wider context from the report “4. Communication with private providers by NHS trusts once mental health trusts have placed individuals in private settings. During the time that Hannah was placed at the Priory the mental health trust who placed her did not have any discussion with Hannah, her family or the Priory regarding the placement. A care coordinator had been allocated by the Trust once requested by the Priory but no care coordination had taken 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 Insufficient mental health training and specialist liaison for university welfare staff
Wider context from the report “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing. As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage. The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective ;
” 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 universities to identify early signs of anxiety and mental health issues in students
Wider context from the report “7. The inquest was told by the clinical lead for Eating Disorders of the high risk of Eating Disorders in high achieving students on courses such as medicine. In such cases, the inquest was told universities need to be alert to early signs of anxiety that risk leading to eating disorders developing . As part of this understanding by universities the inquest was told of the need to recognise early signs of mental health issues and listen carefully from an early stage . The skill set/training of academics in welfare roles in relation to mental health was described as key and specific work with Eating Disorder services and training of those involved in welfare programmes supporting students can be effective;
” 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 alternative mental health provision for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative . The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her;
” 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 suitable acute mental health beds for young adults
Wider context from the report “3. The suitability of acute mental health beds for young adults and lack of alternative provision The inquest heard that Hannah went to an acute adult psychiatric bed because the EDU felt that it was the wrong environment for her and there was no other alternative. The inquest heard that there were concerns regarding the placement of a young adult in such a setting and how frightening it was to her;
” 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 guidance on glass balustrade safety where climbable furniture is adjacent
Wider context from the report “8. The guidance in relation to the height of glass balustrades where items such as tables, in cafes open to the public including children and other vulnerable people, are placed in close proximity to the glass. The glass balustrade in John Lewis was at a height that accorded with the required standard but by simply climbing onto the table that was adjacent to the balustrade Hannah was able to easily go over the balustrade.
” 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 the change in risk level when patients leave a secure environment
Wider context from the report “6. Understanding and communication by the Priory about the change in risk level when Hannah moved from a secure environment to periods of time outside the unit in the care of her family;
” Open source report
10 May 2019 Karanbir Singh CHEEMA · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 12 Failure to transmit allergy action plans to schools View source Lack of standardisation of allergy action plans across hospitals and schools View source Omission of second adrenaline auto-injector guidance from the emergency call algorithm View source Failure to ensure that school medication is in date View source Lack of awareness that a second adrenaline auto-injector should be administered after deterioration or non-improvement View source Delays in time-critical asthma and allergy review appointments View source Lack of school pupil understanding of allergies and the consequences of allergen exposure View source Failure to check or audit school allergy care plans and medication boxes View source Lack of awareness that adrenaline should be administered immediately for respiratory compromise after allergen exposure View source Insufficient availability of two adrenaline auto-injectors at all times View source Failure to communicate emergency adrenaline instructions effectively in school staff training View source Absence of emergency adrenaline instructions on EpiPen packaging View source See 9 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
Karanbir Singh CHEEMA · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Karanbir Singh CHEEMA, a pupil at William Perkin High School with multiple food allergies and asthma, went into anaphylactic shock after another pupil threw cheese at him on 28 June 2017 and died. Concerns included inadequate awareness of his allergies, insufficient checking and availability of EpiPens, an out-of-date EpiPen, failures in sharing and standardising allergy action plans, a cancelled follow-up appointment, and shortcomings in emergency response guidance and training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Education; that does not assign responsibility.
PFD Monitor interpretation Failure to transmit allergy action plans to schools
Wider context from the report “5. The allergy action plan drafted by Karanbir’s doctors at Ealing Hospital did not find its way to his school . There is no standardised approach to this , for example always sending a copy to the school designated safeguarding lead, as well as giving parents/carers a copy for themselves and a copy for the school in case the posted version does not arrive.
” 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 standardisation of allergy action plans across hospitals and schools
Wider context from the report “4. Allergy action plans are not standardised across hospitals and schools , so messages are not as clearly delivered as they could be . This is vital particularly when they may be read for the first time in a desperate situation where panic has set in.
” 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 Omission of second adrenaline auto-injector guidance from the emergency call algorithm
Wider context from the report “11. The London Ambulance Service 999 operator did not at any time suggest that a second EpiPen be given , because this is not contained within the algorithm . That could be remedied internationally.
” 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 that school medication is in date
Wider context from the report “3. Karanbir’s EpiPen was out of date . There must be systems in place to ensure that medication in schools is in date .
” 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 awareness that a second adrenaline auto-injector should be administered after deterioration or non-improvement
Wider context from the report “8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately, before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement .
” 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 in time-critical asthma and allergy review appointments
Wider context from the report “6. Karanbir’s treating doctors wanted him to re-attend for asthma and allergy review four months after his last consultation. An appointment was made but cancelled by the hospital . By the time of his death four months later he had still not been seen again . There needed to be recognition of the time critical nature of this appointment. It needed to be re-booked without delay.
” 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 school pupil understanding of allergies and the consequences of allergen exposure
Wider context from the report “1. The pupils at Karanbir’s school had a patchy understanding of his allergies, what they were and the consequences of exposure to allergens . Targeted education about this would improve safety.
” 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 check or audit school allergy care plans and medication boxes
Wider context from the report “2. Karanbir’s school care plan and medical box were not checked or audited to ensure, for example, that his care plan stipulated two EpiPens® (adrenaline auto-injectors), the box contained two EpiPens.
” 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 awareness that adrenaline should be administered immediately for respiratory compromise after allergen exposure
Wider context from the report “8. There appears to be a lack of awareness nationally of the simple but vital messages that:
- if a person with an allergy has been exposed to an allergen and develops any respiratory compromise, so any breathing difficulty at all, then adrenaline (via EpiPen or other) should be administered immediately , before any asthma pump and even before calling for help;
- if there is a deterioration after giving one EpiPen, then another should be administered immediately, or in any event after five minutes if there is no improvement.
” 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 availability of two adrenaline auto-injectors at all times
Wider context from the report “7. Karanbir had one EpiPen at home, one at school and one at his father’s home . There is clearly a need for medical teams to emphasise that two EpiPens must be available at all times .
” 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 emergency adrenaline instructions effectively in school staff training
Wider context from the report “10. These instructions were not communicated effectively as part of the school staff’s first aid and EpiPen 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 Absence of emergency adrenaline instructions on EpiPen packaging
Wider context from the report “9. The EpiPen box does not contain these instructions on the outside .
” Open source report
2 May 2019 Benjamin James Charles MURRAY · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Failure to ensure that mental health disclosure is de-stigmatised and does not deter university admission View source Lack of post-death investigation reports for student deaths View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Benjamin James Charles MURRAY · 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 5 May 2018, Ben was found beneath the Clifton suspension bridge after walking onto the bridge, climbing onto the buttress wall and propelling himself forward. The inquest concluded that his death was suicide. The report raised concerns about mental health disclosure by university applicants, the pastoral role of universities during transition to higher education, and the absence of university investigation reports following a student 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 ensure that mental health disclosure is de-stigmatised and does not deter university admission
Wider context from the report “2. For UCAS, The Department of Education and The Minister for Suicide Prevention
The concern over mental health disclosure either on the UCAS application form or indeed to a prospective University.
I am told that currently such disclosure is at 37%. There needs to be a move towards de-stigmatising mental health and ensuring that students are made aware that by disclosing mental health problems on their UCAS form or to their prospective University that it will not affect getting a place at University.
” 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 post-death investigation reports for student deaths
Wider context from the report “3. For Bristol University, The Department of Education and The Minister for Suicide Prevention
The transition from home to University can be a challenging time for some students and Universities clearly have the primary role of education however this inquest has demonstrated they also carry out an important pastoral role.
It is not the role of the Coroner to investigate Ben’s journey through University in light of the circumstances of his tragic death and the limited scope. That said as a Coroner has a duty to consider prevention of future deaths it was appropriate in this case that aspects of Ben’s progress were investigated by me.
In addition currently the University sector does not carry out an investigation report (such as a root cause analysis or sudden untoward investigation) after a death of a student. Such a written report usually affords an opportunity to review what happened; what was done well/the good practice points; areas of concern, if there are any, and importantly what lessons can be learned often with a formal written action plan. Such a document is also very helpful to the Coroner when considering and discharging this duty. Such a formal process and document most importantly assists in preventing 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 Establish the national Learning from Deaths policy framework to guide investigation, learning and engagement with bereaved families.
Verbatim wording from the response “Universities UK’s ‘Suicide-safer Universities’ guidance on postvention, developed in conjunction with our Departments and the Office for Students, recommends carrying out a serious incident review to facilitate research, data collection and monitoring to get to the bottom of what has happened, and the lessons learned. This also includes sharing experiences of best practice and knowledge with others. As referred to above, the guidance was published in September 2018, ahead of the 2018/19 academic year, with every UUK member receiving a printed version. The Universities Minister will work with Universities UK in the forthcoming academic year to remind Higher Education providers of this recommendation in the 2018 Universities UK guidance.” Source location 2019-0155-Response-by-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 measures and a strategic approach through the Education Transitions Network to support students’ transition into higher education and protect wellbeing.
Verbatim wording from the response “Students can experience pressures in moving from school/college to University. The Education Transitions Network was launched in March by the Department for Education to examine ways to help students deal with the pressures and challenges that may arise when starting university. More information is available on GOV.UK: https://www.gov.uk/government/news/government-creates-new-student-mental-health-taskforce.” Source location 2019-0155-Response-by-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 Universities UK during the forthcoming academic year to remind higher education providers about recommending serious incident reviews.
Verbatim wording from the response “Universities UK’s ‘Suicide-safer Universities’ guidance on postvention, developed in conjunction with our Departments and the Office for Students, recommends carrying out a serious incident review to facilitate research, data collection and monitoring to get to the bottom of what has happened, and the lessons learned. This also includes sharing experiences of best practice and knowledge with others. As referred to above, the guidance was published in September 2018, ahead of the 2018/19 academic year, with every UUK member receiving a printed version. The Universities Minister will work with Universities UK in the forthcoming academic year to remind Higher Education providers of this recommendation in the 2018 Universities UK guidance.” Source location 2019-0155-Response-by-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 Higher education providers are responsible for their own admissions processes, including handling mental health disclosure during admissions.
Verbatim wording from the response “Concern 2: You raise the important issue of mental health disclosure to HE providers, students and advisers, either via the UCAS application process or direct to the provider. UCAS provides a range of information and advice to all audiences in relation to mental health and the support HE providers can offer. HE providers are responsible for their own admissions processes, however the government also has a role to play in promoting an environment in which students feel able to disclose a mental health condition without concern that this may be detrimental to their chances of either securing an offer, or thriving at that place of study.” Source location 2019-0155-Response-by-Department-for-Education
Open published response
12 Dec 2018 Edward James Farmer · Prevention of Future Deaths report Newcastle upon Tyne
View report summary
Concerns raised 2 Risks of participating in initiation events View source Risks of alcohol consumption within a short period 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
Edward James Farmer · 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
Edward James Farmer, a first-year student, attended an initiation event where he consumed large quantities of alcohol and was later found unresponsive without signs of breathing or a pulse. He died despite medical intervention, due to a hypoxic brain injury following a prolonged cardiorespiratory arrest. The report raised concerns about the risks of excessive alcohol consumption, recognising people at risk, timely medical intervention, and initiation events.
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 Risks of participating in initiation events
Wider context from the report “(1) That consideration be given to conducting a national campaign dealing with the:
a. Inherent risks of alcohol consumption within a short period
b. How to identify persons at risk
c. The importance of timely medical intervention
The campaign should address the inherent risks of participating in initiation events.
” 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 Risks of alcohol consumption within a short period
Wider context from the report “(1) That consideration be given to conducting a national campaign dealing with the:
a. Inherent risks of alcohol consumption within a short period
b. How to identify persons at risk
c. The importance of timely medical intervention
The campaign should address the inherent risks of participating in initiation events.
” Open source report
21 Nov 2018 Ben Walmsley · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Lack of automated safeguarding alerts for high-risk pupil searches on school computers 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
Ben Walmsley · 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
Ben Walmsley died by suicide at his home on 4 February 2018, by hanging. Before his death, he searched school computers for suicide-related content, but the school had no mechanism to be alerted to blocked high-risk searches; the report raised concern about whether similar monitoring functionality was mandatory or available across schools and software providers.
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 automated safeguarding alerts for high-risk pupil searches on school computers
Wider context from the report “It was explained to the Court that the school filters are accessed via Smoothwall which provides age appropriate filtered content. Whilst Ben could not access these pages as they were blocked , there was no mechanism in place at the time for the school to be made aware that a pupil may have attempted to search for such pages .
The Court heard evidence that at the time of Ben's death the only monitoring was in lessons and was solely reliant on the teacher trying to watch what students were doing . The school has 900 pupils and the Court heard in any one day there can be 12,000 attempts by pupils to access blocked content. Not all of these would be as concerning as the content Ben was trying to access, some may relate to social media pages which the school does not allow.
Evidence was provided to the Court that since Ben’s death, Smoothwall have now upgraded functionality and staff now receive notifications when blocked high risk safeguarding categories are attempting to be accessed.
These alerts are “real time” notifications and go to three identified members of staff. Since the installation staff have been notified of two other children attempting to access similar sites to Ben and have taken action to speak to them and also to speak to their parents to offer support.
However it is not known if this functionality is mandatory for all schools or indeed whether other software providers who are used by schools have this option.
If schools do not have this facility you may wish to consider disseminating this information, this is of course a matter for yourself.
” Open source report
18 Jan 2018 Master Abdul-Jamal Ottun · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 12 Failure to assess the safest site of entry to open water View source Lack of required swimming education and adequate pool access in secondary schools View source Inadequate risk assessment for school trips involving open-water swimming View source Reliance on inadequate parental self-reporting of children’s swimming ability View source Failure to assess the necessary equipment for open-water activities View source Failure to teach children swimming skills sufficient for safety in deep cold open waters View source Inadequate pre-assessment of swimming ability before outdoor swimming activities View source Lack of central guidance for formal pre-trip assessment of swimming ability View source Inadequate supervision during open-water school activities View source Failure to plan how rescue would be conducted during open-water activities View source Failure to assess the risks of unacclimatised swimmers entering cold open natural waters View source Failure to consider the need for a lifeguard during open-water school activities View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Master Abdul-Jamal Ottun · 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
Master Abdul-Jamal Ottun, a 17-year-old school student, drowned while swimming in Shawnigan Lake, British Columbia, during a school rugby tour on 12 July 2015. The principal concerns were the adequacy of risk assessment and supervision, including the lack of consideration of a lifeguard, the risks of cold open water, the safest entry point, necessary equipment, and rescue 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 Failure to assess the safest site of entry to open water
Wider context from the report “He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water , of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue.
” 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 required swimming education and adequate pool access in secondary schools
Wider context from the report “He said that in this country schools do not teach children to swim to a sufficiently high standard to be safe. Children are often expected to swim 25m in a heated pool, which gives no skills to save oneself in deep cold open waters. This compares with New Zealand, where 400m is the target used in education. Swimming is not in British schools’ curricula: there is no requirement for any swimming at secondary school and access to pools is limited .
” 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 risk assessment for school trips involving open-water swimming
Wider context from the report “He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene . There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue.
” 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 Reliance on inadequate parental self-reporting of children’s swimming ability
Wider context from the report “He said that child deaths will continue to occur unless there is a fundamental change in the curriculum and in the pre-assessment of swimming ability before school trips and occasions when swimming outdoors. In this case, parents indicated on a form the swimming ability of their children in one of three boxes (strong/ moderate/ weak) This he said was wholly inadequate , as they often have no accurate idea of the adequacy of their children’s swimming.
” 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 the necessary equipment for open-water activities
Wider context from the report “He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment , and the way to conduct the rescue.
” 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 teach children swimming skills sufficient for safety in deep cold open waters
Wider context from the report “He said that in this country schools do not teach children to swim to a sufficiently high standard to be safe . Children are often expected to swim 25m in a heated pool, which gives no skills to save oneself in deep cold open waters . This compares with New Zealand, where 400m is the target used in education. Swimming is not in British schools’ curricula: there is no requirement for any swimming at secondary school and access to pools is limited.
” 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 pre-assessment of swimming ability before outdoor swimming activities
Wider context from the report “He said that child deaths will continue to occur unless there is a fundamental change in the curriculum and in the pre-assessment of swimming ability before school trips and occasions when swimming outdoors . In this case, parents indicated on a form the swimming ability of their children in one of three boxes (strong/ moderate/ weak) This he said was wholly inadequate, as they often have no accurate idea of the adequacy of their children’s swimming.
” 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 central guidance for formal pre-trip assessment of swimming ability
Wider context from the report “Wellington County Grammar have taken a wide range of steps to reduce risk in the future. However the Headteacher said he was reluctant to introduce formal pre-trip assessment of swimming ability without 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 Inadequate supervision during open-water school activities
Wider context from the report “He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision , which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue.
” 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 how rescue would be conducted during open-water activities
Wider context from the report “He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue .
” 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 the risks of unacclimatised swimmers entering cold open natural waters
Wider context from the report “He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters , the necessary equipment, and the way to conduct the rescue.
” 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 need for a lifeguard during open-water school activities
Wider context from the report “He was critical of the adequacy of the risk assessment conducted in planning the trip and at the scene. There was no consideration of the need for a lifeguard and inadequate supervision, which prevented proper consideration of the safest site of entry to water, of the risks of unacclimatised swimmers entering cold open natural waters, the necessary equipment, and the way to conduct the rescue.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the national primary physical education curriculum requirements for swimming, water safety and safe self-rescue.
Verbatim wording from the response “The new physical education curriculum, developed with a range of sector experts, was introduced in 2014. Swimming and water safety is compulsory in the national curriculum at primary levels - key stages 1 and 2. The curriculum sets out the expectation that all pupils should be taught to:” Source location 2018-0020-Response-by-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 the independent report’s recommendations for improving curriculum swimming.
Verbatim wording from the response “I can assure you that we are aware of the inherent risks of water-based activities and that my department is committed to reducing the number of deaths by drowning. To this end, we tasked an independent group of experts from across the swimming sector to submit an independent report setting out recommendations for improving curriculum swimming as part of the Sporting Future strategy. The group published their report in July 2017 and we subsequently established an implementation group, and are currently reviewing the recommendations in the report. In response to the report, we have already provided schools with more flexibility to use their PE and School Sport Premium funding to support Top-up swimming lessons, as well as funding teacher training to support delivery of high quality swimming lessons.” Source location 2018-0020-Response-by-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 Commission an independent swimming-sector expert group to report recommendations for improving curriculum swimming.
Verbatim wording from the response “I can assure you that we are aware of the inherent risks of water-based activities and that my department is committed to reducing the number of deaths by drowning. To this end, we tasked an independent group of experts from across the swimming sector to submit an independent report setting out recommendations for improving curriculum swimming as part of the Sporting Future strategy. The group published their report in July 2017 and we subsequently established an implementation group, and are currently reviewing the recommendations in the report. In response to the report, we have already provided schools with more flexibility to use their PE and School Sport Premium funding to support Top-up swimming lessons, as well as funding teacher training to support delivery of high quality swimming lessons.” Source location 2018-0020-Response-by-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 Give schools greater flexibility to use PE and School Sport Premium funding for top-up swimming lessons.
Verbatim wording from the response “I can assure you that we are aware of the inherent risks of water-based activities and that my department is committed to reducing the number of deaths by drowning. To this end, we tasked an independent group of experts from across the swimming sector to submit an independent report setting out recommendations for improving curriculum swimming as part of the Sporting Future strategy. The group published their report in July 2017 and we subsequently established an implementation group, and are currently reviewing the recommendations in the report. In response to the report, we have already provided schools with more flexibility to use their PE and School Sport Premium funding to support Top-up swimming lessons, as well as funding teacher training to support delivery of high quality swimming lessons.” Source location 2018-0020-Response-by-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 revised guidance for schools and colleges undertaking educational visits.
Verbatim wording from the response “We are currently reviewing the guidance we provide to schools and colleges undertaking educational visits. Our intention is to remind schools and colleges about the importance of careful planning when visits involve water based activities, especially where these are undertaken abroad. As part of our review, we have discussed with stakeholders how we can better signpost the advice and support that is available to schools and colleges on this important matter. We are due to publish revised guidance later in the year.” Source location 2018-0020-Response-by-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 educational-visits guidance to strengthen advice on planning water-based activities, particularly overseas visits.
Verbatim wording from the response “We are currently reviewing the guidance we provide to schools and colleges undertaking educational visits. Our intention is to remind schools and colleges about the importance of careful planning when visits involve water based activities, especially where these are undertaken abroad. As part of our review, we have discussed with stakeholders how we can better signpost the advice and support that is available to schools and colleges on this important matter. We are due to publish revised guidance later in the year.” Source location 2018-0020-Response-by-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 teacher training to support delivery of high-quality swimming lessons.
Verbatim wording from the response “I can assure you that we are aware of the inherent risks of water-based activities and that my department is committed to reducing the number of deaths by drowning. To this end, we tasked an independent group of experts from across the swimming sector to submit an independent report setting out recommendations for improving curriculum swimming as part of the Sporting Future strategy. The group published their report in July 2017 and we subsequently established an implementation group, and are currently reviewing the recommendations in the report. In response to the report, we have already provided schools with more flexibility to use their PE and School Sport Premium funding to support Top-up swimming lessons, as well as funding teacher training to support delivery of high quality swimming lessons.” Source location 2018-0020-Response-by-Department-for-Education
Open published response
12 Apr 2017 Chadrack Mbala MULO · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Delays in conducting a home welfare visit after unexplained non-attendance View source Lack of comparable non-attendance welfare response systems in other schools View source Failure to immediately contact police when no one answers at the family home View source Lack of multiple adult contact numbers for each child View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Chadrack Mbala MULO · 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
Chadrack Mbala Mulo, aged four, died of dehydration and acute protein-energy malnutrition after his mother died unexpectedly at home and he was left alone for approximately a fortnight. He was found about 48 hours after his death. The substantive concerns were that the school had contact details only for his mother, did not immediately visit the home when he failed to attend, and did not immediately contact the police when staff could not gain access.
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 Delays in conducting a home welfare visit after unexplained non-attendance
Wider context from the report “2. If a child unexpectedly fails to attend and no relevant adult can be contacted via phone, staff at the school do not now wait three to five days as they did then , but instead immediately send a member of staff to the family home.
They now make a distinction between an attendance issue that may warrant a penalty (not the case for Chadrack because he was under the age of five years) and a potential welfare issue.
” 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 comparable non-attendance welfare response systems in other schools
Wider context from the report “3. If there is no answer at the family home when staff members attend, they now immediately contact the police, who in most cases are likely to force entry.
This protocol seems very sensible, but is clearly driven by the appalling tragedy of Chadrack’s death. It seems unlikely that other schools in Hackney, elsewhere in London, or indeed in the rest of England & Wales, have such a system in 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 immediately contact police when no one answers at the family home
Wider context from the report “3. If there is no answer at the family home when staff members attend, they now immediately contact the police , who in most cases are likely to force entry.
This protocol seems very sensible, but is clearly driven by the appalling tragedy of Chadrack’s death. It seems unlikely that other schools in Hackney, elsewhere in London, or indeed in the rest of England & Wales, have such a system in 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 multiple adult contact numbers for each child
Wider context from the report “1. The school had a telephone number for Chadrack’s mother, but not for any other family member or friend . Now, they insist that for every child in the school they have the telephone number of three different adults.
” 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 Identify how to reinforce guidance on escalating child safety or welfare concerns to children’s social care services or police.
Verbatim wording from the response “I would anticipate that guidance will continue to make clear that professional judgement should be used in deciding when child safety or welfare concerns should be escalated to children’s social care services and/or the police. I have also asked the Department to identify the best way to reinforce this point further in the attendance and safeguarding guidance.” Source location 2017-0120-Response-by-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 Examine how to update safeguarding and attendance guidance to recommend that schools hold more than one contact number.
Verbatim wording from the response “The school only held a single number for Chadrack’s mother and no contact number for any other family member or friend. I have asked Departmental officials to examine how we can best update the statutory ‘Keeping Children Safe in Education’ guidance and the ‘School Attendance’ guidance so that they reflect best practice and recommend that schools hold more than one contact number.” Source location 2017-0120-Response-by-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 Examine how to update attendance and safeguarding guidance to clarify links between attendance management and welfare considerations.
Verbatim wording from the response “You make an important distinction in your report between attendance issues and welfare issues and underline that school staff should be considering welfare when managing attendance. In this area too, the Department will examine how best we can update attendance and safeguarding guidance to make this link clearer.” Source location 2017-0120-Response-by-Department-for-Education
Open published response
25 Oct 2016 Jane Louise Reason · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 3 Insufficient public education in the use of public access defibrillators View source Inadequate placement of public access defibrillators View source Insufficient availability of public access defibrillators in colleges and schools 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
Jane Louise Reason · 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
Jane Louise Reason, a lecturer, collapsed at work on 28 April 2016 and was later declared deceased in hospital; the medical cause of death was recorded as hypertensive heart disease. The inquest highlighted the importance of early defibrillation and CPR and raised concern about the availability and public education surrounding public access defibrillators, particularly in colleges and schools.
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 public education in the use of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use .
” 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 placement of public access defibrillators
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” 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 availability of public access defibrillators in colleges and schools
Wider context from the report “1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school . Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.
” 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 a guide on automated external defibrillators.
Verbatim wording from the response “My department published a guide on automated external defibrillators in April 2016, which is available at: tinyurl.com/zn82vva. Since this tragic incident, we have published new guidance that is more relevant to further education colleges. I shall be writing to the Association of Colleges to draw this guidance to the attention of their members.” Source location 2016-0376-Response-by-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 guidance on automated external defibrillators relevant to further education colleges.
Verbatim wording from the response “My department published a guide on automated external defibrillators in April 2016, which is available at: tinyurl.com/zn82vva. Since this tragic incident, we have published new guidance that is more relevant to further education colleges. I shall be writing to the Association of Colleges to draw this guidance to the attention of their members.” Source location 2016-0376-Response-by-Department-for-Education
Open published response
23 Sep 2016 Karnel Kane Haughton · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5 Serious injuries to children from fainting-inducing activities View source Lack of support and guidance for parents and children concerned about fainting-inducing activities View source Lack of national guidance for schools and youth groups on fainting-inducing activities, risks and warning signs View source Reliance solely on media to raise national awareness of fainting-inducing activities without careful handling View source Openly accessible, uncensored online videos of children and adolescents engaging in fainting-inducing activities without warnings 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
Karnel Kane Haughton · 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
Karnel Kane Haughton, aged 12, was found unconscious at home with a ligature around his neck and died at Birmingham Heartlands Hospital on 1 June 2016. The report considered that he had likely been engaging in the “choking game”. Concerns included the open availability of uncensored online videos, the lack of national guidance and dedicated support, and the risk that poorly handled awareness-raising could encourage children to try these activities.
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 Serious injuries to children from fainting-inducing activities
Wider context from the report “3. Information received by the West Midlands Police indicated that there have been other incidents of children being seriously injured as a result of these sorts of activities across the country .
” 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 support and guidance for parents and children concerned about fainting-inducing activities
Wider context from the report “5. There is no charity or other institution which provides support and guidance to parents or children specifically on these activities if they have a 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 Lack of national guidance for schools and youth groups on fainting-inducing activities, risks and warning signs
Wider context from the report “4. Although local guidance and information for teachers has been issued by Birmingham City Council as a result of Karnel’s death there is no national guidance for schools or youth groups to alert them to these activities, the risks and provide details of warning signs .
” 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 Reliance solely on media to raise national awareness of fainting-inducing activities without careful handling
Wider context from the report “6. Leaving the raising of national awareness on this topic solely to the media is dangerous because there is a real risk that if the subject matter is not handled carefully children will be incited to experiment with these sorts of activities .
” 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 Openly accessible, uncensored online videos of children and adolescents engaging in fainting-inducing activities without warnings
Wider context from the report “2. Several witnesses gave evidence that on the internet, on sites such as you tube, there are thousands of videos of children and adolescents engaging in the ‘Choking Game’, the ‘Pass out Challenge’ and other activities whereby the children either on their own or with the assistance of others deliberately induce the sensation of fainting or passing out by various means, these videos are openly accessible, uncensored and contain no warnings .
” Open source report
25 May 2016 Christopher James B Sears · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Inability of schools to inform bus companies about concerns without a formal diagnosis View source Lack of requirements for contracted pupil-transport bus companies to ensure driver Basic Life Support training View source Failure to provide Basic Life Support training as routine secondary education View source Lack of a Basic Life Support qualification requirement for pupil-transport drivers View source Absence of emergency-response protocols for drivers driving buses View source Inability to put protective measures in place for bus transport concerns View source See 3 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
Christopher James B Sears · 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
Christopher James B Sears, a 13-year-old boy, died on 13 November 2014 after a seizure-like episode on a school bus; resuscitation attempts were unsuccessful. The report raised concerns about the absence of Basic Life Support training and emergency protocols for school-bus drivers, delays in calling emergency services, and difficulties alerting the bus company where there was no formal diagnosis.
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 Inability of schools to inform bus companies about concerns without a formal diagnosis
Wider context from the report “4. The school were unable to inform the bus company concerned without a formal diagnosis and to put protective measures in 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 requirements for contracted pupil-transport bus companies to ensure driver Basic Life Support training
Wider context from the report “1. There is no requirement for bus companies tendering for contracts from Local Authorities to transport pupils/students to ensure all their drivers have undergone training in Basic Life Support .
” 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 provide Basic Life Support training as routine secondary education
Wider context from the report “5. Basic Life Support training is not taught as a matter of course to young adults in secondary education and is not part of the national curriculum .
” 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 Basic Life Support qualification requirement for pupil-transport drivers
Wider context from the report “2. There is no requirement for drivers transporting pupils/students to hold a Basic Life Support qualification .
” 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 emergency-response protocols for drivers driving buses
Wider context from the report “3. No protocols were in place to assist a driver as to what to do in an emergency situation whilst driving a bus including the need to call the emergency services at the earliest opportunity .
” 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 Inability to put protective measures in place for bus transport concerns
Wider context from the report “4. The school were unable to inform the bus company concerned without a formal diagnosis and to put protective measures in place .
” 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 Consult on a revised version of the guidance on school transport.
Verbatim wording from the response “It is our intention that LAs should ensure that school bus drivers and escorts have training in basic life support skills and in the implementation of emergency protocols (your third ‘Matter of Concern’). We intend to consult on a revised version of the guidance on school transport in the autumn. Subject to any responses received in response to this consultation, we will consider whether we should further clarify both the description of the training that drivers should undertake and our expectation that training for bus drivers and escorts should include basic life support training alongside the implementation of healthcare protocols, including emergency protocols.” Source location 2016-0212-Response-by-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 clarifying training expectations for school bus drivers and escorts, including basic life support and emergency healthcare protocols.
Verbatim wording from the response “It is our intention that LAs should ensure that school bus drivers and escorts have training in basic life support skills and in the implementation of emergency protocols (your third ‘Matter of Concern’). We intend to consult on a revised version of the guidance on school transport in the autumn. Subject to any responses received in response to this consultation, we will consider whether we should further clarify both the description of the training that drivers should undertake and our expectation that training for bus drivers and escorts should include basic life support training alongside the implementation of healthcare protocols, including emergency protocols.” Source location 2016-0212-Response-by-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 statutory duty requiring governing bodies to support pupils with medical conditions.
Verbatim wording from the response “On your concern that the school did not, as a result of no medical diagnosis, have a medical plan in place, we have already introduced a new duty on governing bodies to support pupils with medical conditions. This was introduced by Section 100 of the Children and Families Act 2014 which came into force on 1 September 2014. Our aim is to give parents confidence that the right support and systems will be put in place to ensure that pupils receive the support they need. This is a clear signal to schools that supporting pupils with medical conditions is an important issue and will help them to meet their legal responsibilities.” Source location 2016-0212-Response-by-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 Add a reference to medical-support planning advice in home-to-school transport guidance.
Verbatim wording from the response “We believe this provides the right level of guidance to schools to ensure that effective healthcare plans are put in place, whilst allowing the flexibility they need when handling an individual pupil’s needs. We will, however, ensure that there is a reference to this advice within our guidance on home to school transport so that LAs are aware of the responsibilities of schools in drawing up such plans.” Source location 2016-0212-Response-by-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 Promote a programme of study covering emergency procedures and basic first aid for young people.
Verbatim wording from the response “• Promoting a programme of study that teaches young people how to recognise and follow health and safety procedures and how to use emergency and basic first aid.” Source location 2016-0212-Response-by-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 Issue statutory guidance setting minimum expectations for school policies, procedures and individual healthcare plans for pupils with medical conditions.
Verbatim wording from the response “The statutory guidance came into force alongside the new duty on 1 September 2014 and is available at https://www.gov.uk/government/publications/supporting-pupils-at-school-with-medical-conditions--3. The guidance sets out our minimum expectations of schools, and covers the preparation and implementation of school policies for supporting pupils with medical conditions and the use of individual care plans. Schools must have a ‘supporting pupils with medical conditions’ policy. The governing board should ensure that policies, plans, procedures and systems are properly and effectively implemented.” Source location 2016-0212-Response-by-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 voluntary PSHE arrangements, guidance and promoted resources are considered sufficient to support pupils’ first-aid and emergency medical training.
Verbatim wording from the response “Finally, on your concern that basic life support training is not taught as a matter of course to young adults, whilst schools are not under a statutory duty to provide emergency life skills teaching, many do teach it as part of personal, social, health and economic (PSHE) education.” Source location 2016-0212-Response-by-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 requiring bus companies to provide drivers with basic life support training rests with the Department for Transport.
Verbatim wording from the response “Your concern that LA contractual arrangements do not require tendering bus companies to ensure that their drivers are qualified in basic life support skills is a matter for the Department for Transport (DfT), and we understand that Andrew Jones is replying separately to you on this issue.” Source location 2016-0212-Response-by-Department-for-Education
Open published response
5 Feb 2016 Samantha MacDonald · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to keep bedroom window restrictors in good working order View source Failure of bedroom window restrictors to resist determined efforts to open windows 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
Samantha MacDonald · 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 25 October 2015, 20-year-old Samantha Jane MacDonald jumped from the window of her bedroom on the 14th floor of student accommodation in Salford and died. The window restrictor, which would have prevented the window opening sufficiently, was broken; similar devices in the building had also been found broken, raising concerns about the robustness and assessment of window restrictors in student accommodation.
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 keep bedroom window restrictors in good working order
Wider context from the report “Samantha Macdonald jumped from the window of her bedroom on the 14th floor of her student accommodation in Salford. The window was not required to be used as a fire exit because it was too high. The window was fitted with a device that restricted the distance for which it would open. Evidence was heard that the device complied with the relevant British Standard and Planning regulations. If it had been in good working order it would have prevented the window from opening sufficiently to allow Samantha’s exit. It was, however, broken. Evidence revealed that the device could be broken by the application of force without the use of any tool. It was not possible to discover exactly when the device had been broken although it had been working during Samantha’s tenancy. Similar devices fitted to other bedrooms in the building had been found to be broken from time to time. The building is a non-smoking building that is entirely devoted to student accommodation, and witnesses believed that the devices had probably been broken so that students smoking in their rooms could avoid detection. Evidence was heard that in accommodation occupied by adults who might be determined to forcibly defeat window restrictors, for example in a healthcare setting, risk assessments were recommended to be reviewed and consideration given to replacing restrictors with more substantial or robust devices, and /or adding a second restrictor to better resist determined efforts to open the window, thus lessening the risk of persons falling either accidentally or otherwise. It is considered that such assessments would also be appropriate in student accommodation such as that occupied by Samantha Macdonald.
” 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 bedroom window restrictors to resist determined efforts to open windows
Wider context from the report “Samantha Macdonald jumped from the window of her bedroom on the 14th floor of her student accommodation in Salford. The window was not required to be used as a fire exit because it was too high. The window was fitted with a device that restricted the distance for which it would open. Evidence was heard that the device complied with the relevant British Standard and Planning regulations. If it had been in good working order it would have prevented the window from opening sufficiently to allow Samantha’s exit. It was, however, broken. Evidence revealed that the device could be broken by the application of force without the use of any tool. It was not possible to discover exactly when the device had been broken although it had been working during Samantha’s tenancy. Similar devices fitted to other bedrooms in the building had been found to be broken from time to time. The building is a non-smoking building that is entirely devoted to student accommodation, and witnesses believed that the devices had probably been broken so that students smoking in their rooms could avoid detection. Evidence was heard that in accommodation occupied by adults who might be determined to forcibly defeat window restrictors, for example in a healthcare setting, risk assessments were recommended to be reviewed and consideration given to replacing restrictors with more substantial or robust devices, and /or adding a second restrictor to better resist determined efforts to open the window , thus lessening the risk of persons falling either accidentally or otherwise. It is considered that such assessments would also be appropriate in student accommodation such as that occupied by Samantha Macdonald.
” Open source report
14 Jul 2015 Emma Carpenter · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 5 Lack of inpatient beds for mentally ill children and adolescents View source Lack of sustainable long-term commissioning for specialist eating disorder services for children and adolescents View source Lack of clear connections between mental health professionals and education pastoral care staff View source Failure of school nurses to attend multidisciplinary meetings reliably View source Lack of professional links between the specialist Eating Disorder Service and Bassetlaw Hospital 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
Emma Carpenter · 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
Emma Carpenter was treated as an outpatient by child and adolescent mental health services from February 2004 to November 2006 and died from multi-organ failure caused by severe anorexia nervosa. The report identified insufficient physical-health monitoring, lack of specialist paediatric or physician input, and delay in accessing effective inpatient treatment as concerns.
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 inpatient beds for mentally ill children and adolescents
Wider context from the report “2. There remains still a national lack of provision of inpatient beds for mentally ill children and adolescents including those who suffer from eating disorders .
” 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 sustainable long-term commissioning for specialist eating disorder services for children and adolescents
Wider context from the report “1. Although the Trust has now set up a specialist Eating Disorder Service for children and adolescents, there is only short term funding in place for this service and a lack of commitment from Commissioners for its long term future .
” 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 clear connections between mental health professionals and education pastoral care staff
Wider context from the report “4. In the absence of school nurses, there is a lack of clear connections between the mental health professionals and those in the education system who have responsibility for the pastoral care of mentally ill children and adolescents .
” 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 nurses to attend multidisciplinary meetings reliably
Wider context from the report “3. Although the view of mental health professionals was that it was important for school nurses to attend Multi Disciplinary Meetings to understand and assist with care planning, this does not happen on a regular, reliable basis due to lack of funding for school nurses.
” 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 links between the specialist Eating Disorder Service and Bassetlaw Hospital
Wider context from the report “1. The Trust has now set up a specialist Eating Disorder Service for children and adolescents, and reports that although this service now has good professional links with named paediatricians at Kings Mill Hospital and Queen’s Medical Centre, there are no equivalent links with Bassetlaw Hospital .
” Open source report
22 Apr 2015 Jack · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 1 Lack of UK regulations requiring child-resistant barriers around private swimming pools 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
Jack · 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, a three-year-old boy, was found at the bottom of his family’s unfenced swimming pool after being left in the care of his 20-year-old brother. The substantive concern was that the lack of UK regulations requiring child-resistant barriers around private swimming pools could contribute to future child drownings.
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 UK regulations requiring child-resistant barriers around private swimming pools
Wider context from the report “I received evidence that in Australia and France it is compulsory to fence private swimming pools with child resistant barriers. I am concerned that the lack of regulations in the UK could contribute to future death from children drowning in unfenced swimming pools.
” Open source report
8 Apr 2015 Aleysha Martine Karla McLoughlin · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 6 Unavailability of a shared formal pathway of help for young people who resist engagement View source Failure to hold urgent multi-agency discussions involving all relevant agencies for young people at risk of self-harm View source Insufficient agency capacity to address self-harm appropriately View source Lack of a system encouraging young people to report another young person’s self-harm to those able to help View source Omission of blood pressure checks from annual health checks for looked after children View source Failure of training for professionals working with young people to support recognition and discovery of self-harm View source See 3 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
Aleysha Martine Karla McLoughlin · 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
Aleysha Martine Karla McLoughlin, aged 16, died by hanging at her foster home on 3 April 2014 after a history of self-harm, overdoses and assessed ongoing risk of impulsive self-harm. The concerns included training for professionals to recognise self-harm, systems for sharing information when young people self-harm, urgent multi-agency discussions including mental health services, and a formal support pathway for young people who resist engagement.
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 Unavailability of a shared formal pathway of help for young people who resist engagement
Wider context from the report “(4) That it should be considered that a particular pathway of help for young people who resist engagement should be developed. There was no evidence that any such formal pathway had been shared at the present 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 Failure to hold urgent multi-agency discussions involving all relevant agencies for young people at risk of self-harm
Wider context from the report “(3) That it should be considered that systems such as those now being developed in Bolton should be further developed so as to ensure that multi agency discussions involving all relevant agencies are held urgently for those at risk of self harm and particularly for those who do not engage . Evidence was given that meetings concerning Aleysha Martine Karla McLoughlin did not include the Child and Adolescent Mental Health Services although evidence was given that their input would have been valuable.
” 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 agency capacity to address self-harm appropriately
Wider context from the report “(5) That a review of the capacity of the agencies involved in helping young people who are self harming to address those matters appropriately should be considered.
” 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 system encouraging young people to report another young person’s self-harm to those able to help
Wider context from the report “(2) That it should be considered that additional information and encouragement could be offered to young people to inform those able to help for example teachers, nurses, health professionals etc. when a young person becomes aware that another young person is self harming. The shocking self harm to which Aleysha Martine Karla McLoughlin had subjected herself was only revealed when a school friend brought it to the attention of a teacher. There was no evidence that there was any system in place to encourage the passing of such information .
” 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 Omission of blood pressure checks from annual health checks for looked after children
Wider context from the report “(1) That it should be considered that the system of training for those working with young people, including teachers, school nurses, foster carers, social workers, mental health workers and medical nurses and doctors should be reviewed so as to ensure that these professionals should be alert for signs of self harm and should take opportunities to discover themselves so that those harming themselves can be offered help and support. By way of example evidence was given at the Inquest that the annual health check offered to looked after children did not include a blood pressure check . If a blood pressure check was included this would provide an opportunity for signs of self harm to be revealed .
” 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 training for professionals working with young people to support recognition and discovery of self-harm
Wider context from the report “(1) That it should be considered that the system of training for those working with young people, including teachers, school nurses, foster carers, social workers, mental health workers and medical nurses and doctors should be reviewed so as to ensure that these professionals should be alert for signs of self harm and should take opportunities to discover themselves so that those harming themselves can be offered help and support. By way of example evidence was given at the Inquest that the annual health check offered to looked after children did not include a blood pressure check. If a blood pressure check was included this would provide an opportunity for signs of self harm to be revealed.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations