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.
On 12 July 2025, I commenced an investigation into the death of the child, Joshua Lee Allcock, born on the 7 March 2017, who died on the 3 January 2023. The investigation concluded at the end of the inquest on 5 December 2025.
The inquest was heard before me and the conclusion at inquest was a narrative conclusion:
The deceased died from severe dehydration due to limited fluid intake. This was exacerbated by his conditions of autism and Avoidant Restrictive food intake disorder (ARFID).
The medical cause of Joshua’s death was recorded as:
1a Cerebral Venous Infarction, Brain Swelling and Coning 1b Dural Sinovenous Thrombosis 1c Dehydration with Hypernatremia
Circumstances of the death
1. Joshua Lee Allcock was a 5-year-old boy with complex medical needs. He had suspected autism although this was never formally diagnosed. He would only drink milk and had a limited diet. As a consequence, he was diagnosed with anaemia.
2. After concerns were raised about his mother looking after Joshua, due to missed appointments with health professionals, attending school and her illicit drug use. Joshua was placed into the care of foster parents on the 21 December 2022 after a risk assessment by Walsall Local authority and care proceedings.
3. The foster parents were presented at the time with inadequate information about his dietary needs and were encouraged to try different foods and liquids including fruit juice as part of his diet.
4. However, Joshua was reluctant to eat and drink these alternatives and continued to drink milk. Over the course of the week, he developed dehydration and was admitted to Walsall Manor Hospital on the 25 December 2022 but later discharged when he didn't at that time present with acute dehydration.
5. He was also seen by a GP on the 28 December 2022, but again his examination did not detect dehydration which was a potential missed opportunity for earlier intervention.
6. By the 29 December 2022 he was readmitted to Walsall Manor Hospital and was severely dehydrated. His condition declined rapidly, and he was transferred to Birmingham Children's Hospital. Despite intensive treatment he died on the 3 January 2023.
Coroner’s concerns
1. During the course of the inquest, I heard evidence from health professionals from the Hospital Trust, Local authority service providers and an expert, Paediatric Nephrologist.
2. My concern is that Joshua was never formally diagnosed with Autism and there appears to be nationally, a variation in practice before an assessment for autism can be made. Some areas specify 3 years of age or above but there is no clear national guidance.
3. Regrettably, without a formal diagnosis of autism being made, there was no onward referral to dieticians with experience of autism and therefore an understanding of the link between autism and Avoidant restrictive food intake disorder (ARFID).
4. In addition, I heard expert evidence that Joshua’s death wasn’t an isolated incident and another autistic child died in very similar circumstances by developing dehydration.
5. The expert evidence also indicated that the Capillary Refill Time (CRT) test used to assess dehydration by checking peripheral blood flow is a very insensitive test and can provide misleading reassurance. Therefore, my concern is that young children with similar circumstances to Joshua maybe at risk when assessing levels of dehydration. NHS England may wish to consider reviewing their guidance for health professionals.
6. In summary, all the agencies involved in Joshua’s care, may wish to consider reviewing your guidance and approach for assessing children with complex medical needs of autism and ARFID.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised4
Use of insensitive Capillary Refill Time testing for dehydration assessment
Risk of dehydration among autistic children in similar circumstances
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.11
Action
Require written information and escalation guidance in placement planning for children with complex health or dietary needs.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Incorporate ARFID into mandatory training and workshops for social workers and foster carers.
Stated byWalsall Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Update and roll out foster-carer training on autism, special educational needs and ARFID.
Stated byWalsall Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Share learning about autism, ARFID and dehydration risks with safeguarding partners.
Stated byWalsall Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Publish guidance for commissioners and providers on children’s eating disorder services, including ARFID care and reasonable adaptations for additional needs.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Produce national framework and operational guidance requiring access to autism assessments for people of all ages.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Educate clinicians to assess dehydration in children, recognise early signs, and use appropriate clinical indicators.
Deliver training on identifying dehydration in children, including assessing fluid intake and output, weight, and other relevant indicators.
Stated byBirchills Health CentreStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Discuss autism, ARFID, and other risk groups to support increased suspicion of dehydration and earlier secondary-care assessment despite normal clinical findings.
Stated byBirchills Health CentreStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Provide an established autism pathway for children under five.
Stated byWalsall Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Maintain an established pathway for assessing children under five.
Stated byWalsall Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5
Position
Assessment of dehydration is a basic professional competency, so NHS England does not publish dedicated guidance on it.
Stated byNHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
National autism assessment guidance exists and does not impose a minimum assessment age.
Stated byNHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Further national dehydration guidance is unlikely to increase recognition because clinicians are taught to use multiple assessment indicators.
Stated byNHS EnglandNo action considered necessaryThe respondent said that no further action was needed.
Position
CRT is moderately effective and useful as one sign, but should not be used alone to assess dehydration.
Stated byNHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing under-five and autism pathways are relied on alongside national guidance to address concerns about unclear autism diagnostic guidance.
Stated byWalsall Healthcare NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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.37
1
Deliver and continue rolling out GCP2 training to children’s social care staff.
Stated byWalsall Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
2
Establish a parental advocacy service offering family support before Child Protection Conferences.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
3
Establish Consultant Social Worker roles in each locality to guide practitioners, including on direct work skills.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
4
Hold a reflective discussion with strategic safeguarding leaders to incorporate review and inquest learning into safeguarding practice.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
5
Audit multidisciplinary meeting use and impact through multi-agency and internal quality assurance.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
6
Deliver additional management training for Team Managers and Child Protection Conference Chairs.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
7
Implement and review a protocol with the 0–19 Health Service to provide an overview of children’s health needs.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
8
Operate multidisciplinary meetings, supported by a policy and toolkit, for children with complex health or developmental needs.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
9
Review and share the Safeguarding Partnership FAST escalation process with children’s social care managers and practitioners.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
10
Contribute to developing and disseminating a multi-agency Was Not Brought policy.
Stated byWalsall Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
11
Require the Disabled Children and Young People’s Team to co-work with Family Safeguarding for children with significant developmental delay.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
12
Communicate requirements for inviting health professionals to Child Protection Core Groups through management and team briefings.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
13
Maintain neglect oversight through a steering group overseeing use of the NSPCC GCP2 tool.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
14
Provide supervision, oversight and training to scrutinise child protection plans and avoid delays in action.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
15
Share existing Was Not Brought policy information across the children’s services workforce.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
16
Train practitioners in chronologies and require multi-agency chronologies for children subject to child protection enquiries.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
17
Review and update the midway review process for child protection plans and share it with Child Protection Chairs.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
18
Employ a Neglect Lead to drive GCP2 training and neglect-practice improvement.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
19
Deliver mandatory direct-work training for Children’s Social Care practitioners, including communication with disabled children and children with developmental delay.
Stated byWalsall Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
20
Introduce and evaluate new multi-agency processes through the Families First for Children reform programme.
Stated byWalsall Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
21
Operate the Multi-Agency Child Protection Team and Lead Child Protection Practitioner model for information-sharing, escalation and oversight.
Stated byWalsall Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
22
Operate the Regulation 28 Working Group to discuss reports and share key learning across national and regional NHS services.
Stated byNHS EnglandStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
23
Work collaboratively with Black Country Integrated Care System partners to apply learning from the case to system-wide improvements.
Introduce protocols strengthening coordination and information sharing between health services and social care for children supported by multiple professionals.
Establish a Multi-Agency Child Protection Team to strengthen child-protection coordination, information sharing, analysis, decision-making, and expertise.
Increase awareness of ARFID and its links with autism and neurodevelopmental conditions, while reinforcing escalation to secondary care when concerns arise.
Publish the Child Safeguarding Practice Review and provide ongoing oversight of its action plan and agency plans through performance monitoring and auditing.
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