PFD report

Leah BARBER · Prevention of Future Deaths report

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Issued 3 Aug 2023•West Yorkshire (Western)

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of an integrated overview of Council involvement with individuals
  2. Absence of a single point of oversight for deaths involving previous Council involvement
    Part of recurring concern: Failure to identify and address recurring safety issues through organisational learningPart of recurring concern: Failure to learn from deaths through systematic review
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Maintain a departmental risk register and management-team oversight of child deaths, serious incidents, significant events, actions and lessons learned.

    Stated by Bradford City CouncilStated completedThe respondent said that this action was complete when they made their response on 4 August 2023.
  2. Action

    Implement serious-incident and significant-event guidance, forms and escalation processes requiring service actions, senior review and departmental management-team oversight.

    Stated by Bradford City CouncilStated completedThe respondent said that this action was complete when they made their response on 4 August 2023.
  3. Action

    Implement Children’s Services Review Guidance, a notification form and coordinated processes to collect information, identify systemic issues, pursue enquiries and make recommendations after a child’s death.

    Stated by Bradford City CouncilStated completedThe respondent said that this action was complete when they made their response on 4 August 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing oversight, notification and information-sharing processes are considered sufficient to ensure organisational oversight and learning from child deaths.

    Stated by Bradford City CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of an integrated overview of Council involvement with individuals

Wider context from the report

“A detailed review of the evidence in this case, which included evidence from two Schools (████████), as well as from Bradford Children's Social Services, the TRACKS Education team (at Bradford Council), the SCIL Team and the Council's SEND Team, revealed that no one person or department at Bradford Council had an overview of Council's involvement in relation to Leah (prior to her death). Of greater concern was that that remained so after each of the Council departments involved were notified that Leah had passed away. Every organisation which had contact with the Coroner's service in relation to Leah's death, with the exception of Bradford Council, was able to provide the Court with an overview/analysis of their involvement with Leah prior to her death and (where appropriate) the lessons they had learnt as a result their involvement with Leah. The Police and the local Mental Health Trust were examples of two public bodies who had and were able to provide an overview/analysis to the Court in terms of their involvement with Leah and confirm whether there were any lessons to be learned by them. The evidence provided by witnesses from the various Bradford Council teams which were involved with Leah, showed a clear disconnect in the involvement of the various Council departments. That was not caused by those individuals who had provided written statements to the Court or the two who attended to provide oral evidence. Whilst the Inquest hearing did not identify actions/omissions on the part of individuals/teams within the Council which more than minimally, negligibly or trivially contributed to Leah's death, the concern is that Bradford Council appeared not to have a system/process in place which allowed anyone (whether an individual / a team) within the Council to have an overview of deaths where there had been previous Council involvement with the deceased (in this case a child). In the apparent absence of such oversight Bradford Council would not be able to learn lessons from such cases (or even know if there were lessons to be learned). The absence of such a single point of oversight as was apparent in Leah's case, contributes to the risk that future deaths could occur unless action is taken. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Absence of a single point of oversight for deaths involving previous Council involvement

Wider context from the report

“A detailed review of the evidence in this case, which included evidence from two Schools (████████), as well as from Bradford Children's Social Services, the TRACKS Education team (at Bradford Council), the SCIL Team and the Council's SEND Team, revealed that no one person or department at Bradford Council had an overview of Council's involvement in relation to Leah (prior to her death). Of greater concern was that that remained so after each of the Council departments involved were notified that Leah had passed away. Every organisation which had contact with the Coroner's service in relation to Leah's death, with the exception of Bradford Council, was able to provide the Court with an overview/analysis of their involvement with Leah prior to her death and (where appropriate) the lessons they had learnt as a result their involvement with Leah. The Police and the local Mental Health Trust were examples of two public bodies who had and were able to provide an overview/analysis to the Court in terms of their involvement with Leah and confirm whether there were any lessons to be learned by them. The evidence provided by witnesses from the various Bradford Council teams which were involved with Leah, showed a clear disconnect in the involvement of the various Council departments. That was not caused by those individuals who had provided written statements to the Court or the two who attended to provide oral evidence. Whilst the Inquest hearing did not identify actions/omissions on the part of individuals/teams within the Council which more than minimally, negligibly or trivially contributed to Leah's death, the concern is that Bradford Council appeared not to have a system/process in place which allowed anyone (whether an individual / a team) within the Council to have an overview of deaths where there had been previous Council involvement with the deceased (in this case a child). In the apparent absence of such oversight Bradford Council would not be able to learn lessons from such cases (or even know if there were lessons to be learned). The absence of such a single point of oversight as was apparent in Leah's case, contributes to the risk that future deaths could occur unless action is taken. ”

Is this part of a recurring concern?

Yes — Failure to identify and address recurring safety issues through organisational learning; Failure to learn from deaths through systematic review.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Maintain a departmental risk register and management-team oversight of child deaths, serious incidents, significant events, actions and lessons learned.

Verbatim wording from the response

“The Children’s Services Departmental Management Team (DMT) now maintain a risk register to ensure their oversight of any serious incidents or significant events and that current progress is made on identified actions, and that lessons learned are acted on. At the DMT meeting the circumstances of the incident is discussed between the Director of Children’s Services (DCS) and the Assistant Directors (ADs) within Children Services. Where appropriate, actions are agreed, including the team that will coordinate a response. The child remains on the risk register until the actions have been resolved. This change means that the DCS as an individual and the appropriate team asked to coordinate the actions, have oversight and responsibility for those actions.”

Source location

Response from City of Bradford Council
Page 2 · response
Published 4 August 2023

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

Implement serious-incident and significant-event guidance, forms and escalation processes requiring service actions, senior review and departmental management-team oversight.

Verbatim wording from the response

“The Serious Incident or Significant Events Guidance, Form and processes, were further developed and implemented in 2020. These processes are used when there is a death of any child, including where abuse or neglect are thought to have contributed to the child’s death. This also includes death by suspected suicide. One of the key changes to the form was the requirement for the relevant Head of Service (HoS) to set out the actions to be taken and for the relevant Assistant Director to give a view about any additional actions need to be taken. This is sent to the DCS to review and is then discussed on Departmental Management Team as outlined earlier. This makes sure that senior leaders in Children’s Services are sighted and reviewing information and decisions about a significant or serious event quickly. This change was put in place in November 2021.”

Source location

Response from City of Bradford Council
Page 2 · response
Published 4 August 2023

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

Implement Children’s Services Review Guidance, a notification form and coordinated processes to collect information, identify systemic issues, pursue enquiries and make recommendations after a child’s death.

Verbatim wording from the response

“There have been improvements to the notification process following the death of a child since 2019. Children’s Services Review Guidance (2022) has been produced and this includes a new form and improved processes that systematically collects information within children services when a child has died. This form also seeks to identify systemic issues, key lines of enquiry and provides recommendations. This is coordinated by the Council’s Education Safeguarding Team.”

Source location

Response from City of Bradford Council
Page 2 · response
Published 4 August 2023

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 oversight, notification and information-sharing processes are considered sufficient to ensure organisational oversight and learning from child deaths.

Verbatim wording from the response

“Having taken time to look into the concerns, I am able to reassure you that following Leah’s death we do now have strengthened processes to make sure that we have organisational oversight where we have more than one team involved and a child dies. We acknowledge that our staff who gave evidence at the inquest did not share the arrangements that have been put in place since Leah’s death.”

Source location

Response from City of Bradford Council
Page 1 · response
Published 4 August 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Implement the six suicide-prevention recommendations identified in the Child Death Overview Panel report.

    Stated by Bradford City CouncilStated completedThe respondent said that this action was complete when they made their response on 4 August 2023.
  2. 2

    Update the council-wide suicide-prevention group’s terms of reference and assign responsibility for district-wide suicide-prevention training.

    Stated by Bradford City CouncilStated completedThe respondent said that this action was complete when they made their response on 4 August 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The Child Death Overview Panel cannot review the death until all relevant legal processes have been completed.

    Stated by Bradford City CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 six suicide-prevention recommendations identified in the Child Death Overview Panel report.

Verbatim wording from the response

“Although, the Child Death Overview Panel (CDOP) are not able to review Leah’s death until all the relevant legal process have been completed, the CDOP identified that there had been two deaths by suicide in the year that Leah died and produced a report in 2022 that outlined six recommendations to prevent suicide. These recommendations were implemented. Bradford council also has a council wide suicide prevention group (SPG) and the terms of reference for this group were updated in 2021. This group is responsible for district wide suicide prevention training.”

Source location

Response from City of Bradford Council
Page 3 · response
Published 4 August 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Update the council-wide suicide-prevention group’s terms of reference and assign responsibility for district-wide suicide-prevention training.

Verbatim wording from the response

“Although, the Child Death Overview Panel (CDOP) are not able to review Leah’s death until all the relevant legal process have been completed, the CDOP identified that there had been two deaths by suicide in the year that Leah died and produced a report in 2022 that outlined six recommendations to prevent suicide. These recommendations were implemented. Bradford council also has a council wide suicide prevention group (SPG) and the terms of reference for this group were updated in 2021. This group is responsible for district wide suicide prevention training.”

Source location

Response from City of Bradford Council
Page 3 · response
Published 4 August 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Child Death Overview Panel cannot review the death until all relevant legal processes have been completed.

Verbatim wording from the response

“Although, the Child Death Overview Panel (CDOP) are not able to review Leah’s death until all the relevant legal process have been completed, the CDOP identified that there had been two deaths by suicide in the year that Leah died and produced a report in 2022 that outlined six recommendations to prevent suicide. These recommendations were implemented. Bradford council also has a council wide suicide prevention group (SPG) and the terms of reference for this group were updated in 2021. This group is responsible for district wide suicide prevention training.”

Source location

Response from City of Bradford Council
Page 3 · response
Published 4 August 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026