Concerns raised 12 Investigation process failing to identify all learning from deaths View source Failure to implement and embed required policy and process changes View source Failure to maintain a personal ligature risk assessment View source Lack of documentation of decisions to remove personal ligature risk assessments View source Investigation process failing to trigger safety changes View source Delayed completion of required staff training View source Failure to complete scheduled 7am support-plan checks View source Failure to communicate historic Child Sexual Exploitation risk between care homes View source Lack of a step-down process for ad hoc waking night cover View source Failure to document investigations after deaths View source Lack of documentation explaining or justifying care plan deviations View source Lack of policy governing decisions to implement ad hoc waking night cover View source See 9 more concerns
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AI-generated summary
Ash BANNISTER · 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
Ash Bannister, a 16-year-old who was gender neutral, died in a residential care home on 7 August 2021 after being found hanging. Principal concerns included the removal of Ash’s personal Ligature Risk Assessment without documented reasons, inadequate documentation and communication, inconsistent waking-night cover, failure to follow the support plan, staff training gaps, and an investigation process described as not fit for purpose.
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 United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Investigation process failing to identify all learning from deaths
Wider context from the report “It was accepted by United Children’s Services that their investigation policy and process was not fit for purpose because it failed to identify all of the learning arising from Ash’s death . If an investigation was undertaken by United Children’s Services after Ash’s death it:
(1) Was not documented;
(2) Failed to identify all of the learning uncovered at the inquest ;
(3) Failed to trigger any changes at United Children’s Services.
The investigation process in place at United Children’s Services is therefore not fit for purpose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to implement and embed required policy and process changes
Wider context from the report “I have concerns about policies and processes in place at United Children’s Services, including the investigations policy, the policies governing risk assessments, in particular the ligature risk assessment, and the ad hoc waking nights process. I heard evidence at the inquest about United Children’s Service’s plan to make, what appear on the face of it, to be broad and wide-reaching changes to their policies and processes.
However, at the time of writing this report those changes have not been discussed, finalised, implemented or embedded . The children in the care of United Children’s Services will, in my opinion, remain at risk until such time as appropriate and effective action is taken and the necessary changes are implemented and embedded at the company and within their care homes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain a personal ligature risk assessment
Wider context from the report “I heard evidence to confirm that at some point between the April 2021 review and Ash’s death a decision to remove Ash’s personal Ligature Risk Assessment was made. United Children’s Services were unable to tell me the date on which the decision to remove Ash’s Ligature Risk Assessment was made because there is no documentation relating to the date on which that decision was made or the reasons why that decision was made. This lack of documentation is a grave concern.
Ash died on 7 August 2021 from 1a) Hanging (suspension placing a ligature around the neck) there was no personal Ligature Risk Assessment in place at the time of death .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation of decisions to remove personal ligature risk assessments
Wider context from the report “I heard evidence to confirm that at some point between the April 2021 review and Ash’s death a decision to remove Ash’s personal Ligature Risk Assessment was made. United Children’s Services were unable to tell me the date on which the decision to remove Ash’s Ligature Risk Assessment was made because there is no documentation relating to the date on which that decision was made or the reasons why that decision was made . This lack of documentation is a grave concern.
Ash died on 7 August 2021 from 1a) Hanging (suspension placing a ligature around the neck) there was no personal Ligature Risk Assessment in place at the time of death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Investigation process failing to trigger safety changes
Wider context from the report “It was accepted by United Children’s Services that their investigation policy and process was not fit for purpose because it failed to identify all of the learning arising from Ash’s death. If an investigation was undertaken by United Children’s Services after Ash’s death it:
(1) Was not documented;
(2) Failed to identify all of the learning uncovered at the inquest;
(3) Failed to trigger any changes at United Children’s Services .
The investigation process in place at United Children’s Services is therefore not fit for purpose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Delayed completion of required staff training
Wider context from the report “The Court heard evidence from one member of staff who worked at a United Children’s Services care home for a period of 4.5 months and did not know what Child Sexual Exploitation was.
The Court heard evidence to confirm that new staff members have 6 months to complete all of their training meaning it is possible to have staff members working with children with complex needs and vulnerabilities who do not have a full understanding of the spectrum of their needs due to not having completed all of their training yet .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete scheduled 7am support-plan checks
Wider context from the report “Ash’s support plan stipulated that Ash was to be checked on every morning at 7am. Ash was not checked upon at 7am on the morning of her death , this is a breach of Ash’s support plan.
There was nothing documented in any of the records disclosed to the Court to explain why the support plan was deviated from on this occasion. I was told by care home workers that they would not expect to check on a teenager at 7am at the weekend in a normal family home. The residential care home where Ash was living was not a normal family home but a therapeutic home for children with complex needs. The evidence from the Operations Manager at United Children’s Services who run the home was that Ash should have been checked on at 7am .
Ash’s support plan was incorrectly deviated from without any documentation, explanation or justification as to why. This should not have happened.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate historic Child Sexual Exploitation risk between care homes
Wider context from the report “I heard evidence to confirm there was no documentation created by United Children’s Services to detail the date on which Ash’s Ligature Risk Assessment was deemed to be no longer required or to explain the rationale behind the making of that decision.
There is no documentation to explain or justify the deviation from Ash’s care plan on the morning that Ash died.
Further, the Court heard evidence to confirm that there was little or no communication of Ash’s historic Child Sexual Exploitation risk between the two United Children’s Services care homes when Ash moved from The Oaks to The Laurels in July 2020.
Lack of documentation and poor communication is 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 United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a step-down process for ad hoc waking night cover
Wider context from the report “The decision to implement ad hoc waking night cover is not a decision which is governed by policy at United Children’s Services. I heard evidence to confirm that the decision is based upon the gut instinct of the staff on duty at the time. The fact there is no policy to specifically deal with ad hoc waking nights means the decision making around the same will not be consistent and therefore the level of care provided to the children in the care of United Children’s Services is heavily dependent on which staff member is on duty at the time that the care is needed.
Further, there is no step down process to wean children off ad hoc waking night cover . In Ash’s case Ash went from having a staff member outside her door throughout the night from 5 to 6 August 2021 to having a period of 11 hours where Ash was entirely unsupervised throughout the night from 6 to 7 August 2021. It was during those 11 unsupervised hours that Ash ended their life.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to document investigations after deaths
Wider context from the report “It was accepted by United Children’s Services that their investigation policy and process was not fit for purpose because it failed to identify all of the learning arising from Ash’s death. If an investigation was undertaken by United Children’s Services after Ash’s death it:
(1) Was not documented;
(2) Failed to identify all of the learning uncovered at the inquest;
(3) Failed to trigger any changes at United Children’s Services.
The investigation process in place at United Children’s Services is therefore not fit for purpose.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of documentation explaining or justifying care plan deviations
Wider context from the report “I heard evidence to confirm there was no documentation created by United Children’s Services to detail the date on which Ash’s Ligature Risk Assessment was deemed to be no longer required or to explain the rationale behind the making of that decision.
There is no documentation to explain or justify the deviation from Ash’s care plan on the morning that Ash died.
Further, the Court heard evidence to confirm that there was little or no communication of Ash’s historic Child Sexual Exploitation risk between the two United Children’s Services care homes when Ash moved from The Oaks to The Laurels in July 2020.
Lack of documentation and poor communication is 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 United Children's Services Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of policy governing decisions to implement ad hoc waking night cover
Wider context from the report “The decision to implement ad hoc waking night cover is not a decision which is governed by policy at United Children’s Services. I heard evidence to confirm that the decision is based upon the gut instinct of the staff on duty at the time . The fact there is no policy to specifically deal with ad hoc waking nights means the decision making around the same will not be consistent and therefore the level of care provided to the children in the care of United Children’s Services is heavily dependent on which staff member is on duty at the time that the care is needed.
Further, there is no step down process to wean children off ad hoc waking night cover. In Ash’s case Ash went from having a staff member outside her door throughout the night from 5 to 6 August 2021 to having a period of 11 hours where Ash was entirely unsupervised throughout the night from 6 to 7 August 2021. It was during those 11 unsupervised hours that Ash ended their life.
” Open source report
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Addressed via: United Children’s Services via its legal representative.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations