10 Feb 2021 Lily-Mai HURRELL SAINT GEORGE · Prevention of Future Deaths report Inner North London
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Concerns raised 2 Failure to prevent discharge into unsupervised parental care despite professional concerns View source Delay in implementing an agreed residential placement View source
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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
Lily-Mai HURRELL SAINT GEORGE · 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
Lily-Mai Hurrell Saint George, aged 10 weeks, suffered fatal injuries after being hurt by an adult while in the exclusive care of her parents on 31 January 2018. The principal concern was that Haringey Children’s Services discharged her into her parents’ unsupervised care despite professionals expressing the view that she should not be discharged in those circumstances.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Haringey; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent discharge into unsupervised parental care despite professional concerns
Wider context from the report “Many healthcare and other professionals expressed the view that Lily-Mai should not be discharged into the unsupervised care of her parents , but Haringey Children’s Services nevertheless facilitated that discharge from hospital on Thursday, 25 January 2018. Lily-Mai suffered her fatal injuries six days later.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Haringey; that does not assign responsibility.
PFD Monitor interpretation Delay in implementing an agreed residential placement
Wider context from the report “A legal gateway meeting took place on Wednesday, 31 January 2018 and the decision made that Lily-Mai should be placed in a residential unit , with both her parents if they would consent. Lily-Mai presented to the emergency services that evening, before such a placement was made .
” Open source report
21 Oct 2014 Mary Elizabeth Grace Stroman · Prevention of Future Deaths report Wiltshire and Swindon
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Concerns raised 3 Delay in decision making for funding long-term therapeutic placements View source Failure to consult joint-funding partners before terminating placements View source Failure to adequately assess safeguarding risk against the benefits of placement continuity 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
Mary Elizabeth Grace Stroman · 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
Mary Elizabeth Grace Stroman, aged 16, died on 15 January 2014 after lying on a railway line and being struck by a train. The inquest concluded that she took her own life while suffering from Complex Post Traumatic Stress Disorder. The principal concerns were delays in funding her long-term therapeutic placement and the temporary termination of a later placement without consultation with the other funding authority, including potential effects on vulnerable individuals’ mental health and safety.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to London Borough of Haringey; that does not assign responsibility.
PFD Monitor interpretation Delay in decision making for funding long-term therapeutic placements
Wider context from the report “(1) Delay in the decision making process as regards funding the long term therapeutic placement
As early as February 2012 ████████ as indicated in the previous section was supportive of the need for Mary to be placed on a therapeutic placement scheme away from the London Borough of Islington. That view was supported by ████████ from Priory North and I am aware that they wrote to your local authority in November 2012 expressing their concerns due to the lack of progress . Due to the involvement of Islington who were supportive of the proposal from a healthcare perspective Mary's educational and Child social services responsibilities fell to your local authority following the family's move to Haringey during the summer of 2011. I heard evidence in the form of a report from ████████ who stated that at a Haringey Complex Care Panel Meeting on the 09 May 2012 it was agreed that Mary's case for joint funded placement would be advanced. A letter from the panel subsequently stated that it accepted that Mary's needs to be given the opportunity to live outside the family home and that a range of options were going to be explored. I was informed by ████████ that this decision was overturned by Children's Services on the basis it did not meet a threshold for accommodation under Section 20 and that it would not be in Mary's best interests. I am aware of the involvement of a local MP and the Stroma Family's lawyers who highlighted the local authority's duty here in terms of context and it was not until March 2013 that funding was authorised by your local authority . Again in ████████ report he makes reference to a further report being commissioned by Haringey Children's Services in September 2012. The assessment was completed by ████████ and it concluded “My experience…. may be reflective of the paralysis within the care system around this patient but ultimately of the patient's own predicament”. Whilst in the terms of Mary's Inquest I did not find a direct causal link between the delay in funding Mary's placement I am concerned in relation to future cases that could impact on an individual's mental state and mental health. It is quite clear from the expert opinion evidence that I have read Mary's educational needs in particular were not being satisfied in either Simmons House or Priory North hence a potential initial recommendation. The welfare of the child must be paramount and I would ask that you review the practises and procedures that were adopted here resulting in the decision to fund Mary's long term therapeutic placement with a view to ascertaining as to whether or not lessons could be learned with a view to improving the process and reducing the delay. I fully appreciate that Mary's case was exceptionally complex but I am concerned that the delay could affect other individuals if placed in a similar situation that may lead to self harming and even 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 London Borough of Haringey; that does not assign responsibility.
PFD Monitor interpretation Failure to consult joint-funding partners before terminating placements
Wider context from the report “(2) The temporary termination of the placement at Tumblewood - August/September 2013
As part of the evidence I was aware that Mary's placement was temporarily terminated as a result of an OFSTED inspection. Many pupils at Tumblewood including Mary arrive with a history of disrupted education. One of the reasons Mary was placed at Tumblewood was for this reason given her significant history of time as a voluntary inpatient in hospital and as an inpatient at another establishment both of which were felt by those involved not to address and meet her educational needs sufficiently. I am concerned as part of the process here that given there was joint funding that the decision to terminate appears to be have been taken by your local authority without consultation with the other partner involved - Islington . I am additionally concerned as regards the general decision making process here assessing the safeguarding risk as compared to the benefit of allowing Mary to continue and return to her placement after the holiday period to an environment that provided stability rather than a situation whereby the alternative did not address her educational needs and was unsettling. At the Inquest I was satisfied that at the time of her death any issues that arose following her forced absence from Tumblewood were being addressed from the educational perspective which included involving Mary in that decision making process and that there was no direct causal link with her death. My concern is as regards the way your authority handles matters in the future which could potentially unsettle an individual's mental state possibly resulting in self-harm or even death. Again can I ask you to review the matter with a view to looking to identify any learning points and to communicate them back to me? In evidence I was unaware of any other pupil whose placement had been terminated as a result of the same report.
” Open source report × Source evidence
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 Haringey; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately assess safeguarding risk against the benefits of placement continuity
Wider context from the report “(2) The temporary termination of the placement at Tumblewood - August/September 2013
As part of the evidence I was aware that Mary's placement was temporarily terminated as a result of an OFSTED inspection. Many pupils at Tumblewood including Mary arrive with a history of disrupted education. One of the reasons Mary was placed at Tumblewood was for this reason given her significant history of time as a voluntary inpatient in hospital and as an inpatient at another establishment both of which were felt by those involved not to address and meet her educational needs sufficiently. I am concerned as part of the process here that given there was joint funding that the decision to terminate appears to be have been taken by your local authority without consultation with the other partner involved - Islington. I am additionally concerned as regards the general decision making process here assessing the safeguarding risk as compared to the benefit of allowing Mary to continue and return to her placement after the holiday period to an environment that provided stability rather than a situation whereby the alternative did not address her educational needs and was unsettling . At the Inquest I was satisfied that at the time of her death any issues that arose following her forced absence from Tumblewood were being addressed from the educational perspective which included involving Mary in that decision making process and that there was no direct causal link with her death. My concern is as regards the way your authority handles matters in the future which could potentially unsettle an individual's mental state possibly resulting in self-harm or even death. Again can I ask you to review the matter with a view to looking to identify any learning points and to communicate them back to me? In evidence I was unaware of any other pupil whose placement had been terminated as a result of the same report.
” 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 Refresh the Complex Care Panel with revised membership, including the lead commissioner, to improve information sharing and joint-funded placement decisions.
Verbatim wording from the response “• Importantly there has also been a significant improvement in joint working with partner agencies. The functioning of the Complex Care Panel (which looks at cases of this nature) has been refreshed with revised membership, including the lead commissioner from Haringey Commissioning Group. This has enabled more effective information sharing and will lead to increased timely and informed decision making relating to our joint funded placements.” Source location 2014-0454-Response-by-Haringey-Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require placements in establishments rated good or outstanding by Ofsted and complete risk assessments with partner and parental consultation if a rating becomes inadequate.
Verbatim wording from the response “• At the point of making a placement, we make it clear to parents and partners that we will only make placements in an establishment that are graded good or outstanding by Ofsted and if the establishment grade at any stage changes to inadequate, we will complete a risk assessment and consult with partners and also parents to make an informed decision (based on the particulars of each individual case).” Source location 2014-0454-Response-by-Haringey-Council
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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 management oversight of case decision-making and assessment timeliness through weekly performance scrutiny.
Verbatim wording from the response “• Strengthened management and oversight over decision making in our cases, including the timeliness of assessments. This, alongside other indicators of quality are reviewed and further scrutinised by the Director of Children’s Services in weekly performance meetings with all Heads of Service.” Source location 2014-0454-Response-by-Haringey-Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There was no direct causal link between the delays or temporary suspension and the tragic incident.
Verbatim wording from the response “I note that it is acknowledged in your report that there is no direct causal link between the delays and the temporary suspension and the tragic incident. Despite this, we sincerely regret that our management of the case was not as effective and timely as it should have been.” Source location 2014-0454-Response-by-Haringey-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations