19 Jan 2023 Lance Scott Walker · Prevention of Future Deaths report West London
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Concerns raised 9 Insufficient scrutiny and approval of new accommodation providers View source Lack of regulatory oversight of supported accommodation for 18-21 year olds View source Lack of a standard referral form for supported housing service users aged 16-25 View source Insufficient contractual oversight of accommodation providers View source Insufficient provider knowledge of complex resident needs View source Inadequate checking and auditing of placement forms and referral information View source Inadequate staffing in supported accommodation View source Failure to perform adequate due diligence when matching individuals in accommodation View source Inadequate training among supported accommodation providers View source See 6 more concerns
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Lance Scott Walker · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lance Scott Walker, an 18-year-old looked-after child, was placed in unregulated accommodation in 2016, where another 18-year-old resident was later placed. Eleven days after they were placed together, the other resident fatally stabbed Lance in the afternoon of 15 August 2016. Concerns included the use and oversight of unregulated accommodation, inadequate assessment and communication of the other resident’s risks and needs, shortcomings in placement and provider due diligence, and failures in information-sharing and management.
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 London Borough of Ealing; that does not assign responsibility.
PFD Monitor interpretation Insufficient scrutiny and approval of new accommodation providers
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Ealing; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight of supported accommodation for 18-21 year olds
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector , resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Ealing; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard referral form for supported housing service users aged 16-25
Wider context from the report “2 Response requested from London Borough of Ealing, London Borough of Islington and the West London Alliance
There is currently no standard referral form for service users aged 16-25 to be referred into supported housing. This means that best practise is not universally followed and it is more difficult for stakeholders to have to deal with a number of different forms. Vital information can potentially be missed and issues not highlighted when a variety of forms are used for the same referral procedure. Consideration should be given to adopting a standard form across the West London Alliance, or even a national standard using “best practise” as the benchmark, for clarity and ease of reference.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Ealing; that does not assign responsibility.
PFD Monitor interpretation Insufficient contractual oversight of accommodation providers
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Ealing; that does not assign responsibility.
PFD Monitor interpretation Insufficient provider knowledge of complex resident needs
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Ealing; that does not assign responsibility.
PFD Monitor interpretation Inadequate checking and auditing of placement forms and referral information
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals , with consideration on the introduction of mandatory fields for specific information to be included . The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Ealing; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing in supported accommodation
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training, staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Ealing; that does not assign responsibility.
PFD Monitor interpretation Failure to perform adequate due diligence when matching individuals in accommodation
Wider context from the report “3 Response from London Borough of Ealing
The Court was advised that the inquest had raised several points that will be further considered but that have not yet been addressed following this tragic death. In particular, system review of the “due diligence” in matching of individuals in the accommodation needs to be carried out and further lessons can be learnt in relation to the Borough’s obligations in this regard. Strengthening the contractual elements between the Borough and Providers would ensure additional oversight of these relationships. Additional work in double checking and auditing placement forms needs further review to learn from the issues encountered in this case, and to improve the consistency and standard of referrals, with consideration on the introduction of mandatory fields for specific information to be included. The Borough undertook to enhance “New provider” scrutiny and approval in the light of the inquest findings. Confirmation of these positive steps and actions should be provided to allay the jury and Court’s concerns arising from this inquiry.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Ealing; that does not assign responsibility.
PFD Monitor interpretation Inadequate training among supported accommodation providers
Wider context from the report “1 Response requested from Secretary of State for Education and Secretary of State for Health and Social Care
Lance was only exposed to his killer because he was obliged to live in the designated accommodation. Although the 2 relevant Councils were duty bound to house both individuals up until the age of 21 under the Leaving Care Act, there is currently no provision for the over 18’s. Regulation is being introduced for 16-17 year olds in April 2023.
Both Councils were in agreement that Regulation of this sector would be welcomed to support them in carrying out their statutory obligations. A set of minimum requirements to introduce clear guidance across the sector would benefit the residents, the providers and all stakeholders in this particularly challenging sector. Currently OFSTED does not have an obligation to be involved and this falls outside the CQC’s regulation as the provision is not for “care” but support. The provision is made from an entirely un-regulated sector, resulting in some organisations offering accommodation with inadequate training , staffing or knowledge to meet the complex needs of some of our most vulnerable individuals. Consideration should be given to introducing regulation for at least 18-21 year old individuals. This issue remains a concern for all those who work within it.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations