PFD report

Henry Joseph GRIERSON · Prevention of Future Deaths report

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Issued 4 Nov 2024•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.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
4

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 raised1

  1. Failure to maintain communication between the college and external mental health support organisations
    Part of recurring concern: Unreliable inter-agency information sharing for coordinated carePart of recurring concern: Unreliable multi-agency communication procedures
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

    Remind external agencies of their safeguarding information-sharing responsibilities under applicable national guidance.

    Stated by The Duchess of Somerset’s HospitalStated plannedThe respondent said that this action was planned when they made their response on 5 November 2024.
  2. Action

    Review and amend procedures for contacting external safeguarding agencies, including obtaining updates under Welfare Plans and during permanent exclusion.

    Stated by The Duchess of Somerset’s HospitalStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.
  3. Action

    Discuss multi-agency safeguarding communication with the NHS South West Yorkshire Partnership Foundation Trust.

    Stated by The Duchess of Somerset’s HospitalStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The NHS Trust responsible for CAMHS services is responsible for setting out steps to improve local information-sharing.

    Stated by The Duchess of Somerset’s HospitalRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Failure to maintain communication between the college and external mental health support organisations

Wider context from the report

“On the 13th November 2023 Henry Joseph Grierson with the consent of his Parents discontinued his referral and treatment from the organisation CAMHS, and on the 9th April 2024, Mr Grierson gave notice if his intention to discharge himself from the support organisation Recovery Steps. No evidence has been presented to this Inquest as to the knowledge of these matters by the safeguarding team at Huddersfield New College. No information concerning the current mental health issues of Mr Grierson had been provided to the College within a mitigation statement provided by him. The evidence before the Court is that the latest communication concerning Mr Grierson's mental health provided by CAMHS was dated October 2023. It is a matter of concern that communication between the college and CAMHS and Recovery Steps was not seemingly maintained to enable an awareness by the College of the current mental health of Mr Grierson in April 2024 and the decisions taken by himself and his family, to remove such external support. ”

Is this part of a recurring concern?

Yes — Unreliable inter-agency information sharing for coordinated care; Unreliable multi-agency communication procedures.

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

Remind external agencies of their safeguarding information-sharing responsibilities under applicable national guidance.

Verbatim wording from the response

“In terms of matters that are within our control, the College has reviewed and amended relevant policies and processes for contacting external agencies, particularly where a Welfare Plan has been created or when permanent exclusion is being implemented as a last resort. Included in this review of processes is College staff requesting and expecting updates from the external agencies involved in the safeguarding of a student, as identified and specified in their Welfare Plan. The College’s safeguarding team will remind external agencies of the responsibilities that they have to share safeguarding information, as detailed in ‘Keeping Children Safe in Education’ and ‘Working Together to Safeguard Children 2023’.”

Source location

Response from Huddersfield New College
Page 1 · response
Published 5 November 2024

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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

Review and amend procedures for contacting external safeguarding agencies, including obtaining updates under Welfare Plans and during permanent exclusion.

Verbatim wording from the response

“In terms of matters that are within our control, the College has reviewed and amended relevant policies and processes for contacting external agencies, particularly where a Welfare Plan has been created or when permanent exclusion is being implemented as a last resort. Included in this review of processes is College staff requesting and expecting updates from the external agencies involved in the safeguarding of a student, as identified and specified in their Welfare Plan. The College’s safeguarding team will remind external agencies of the responsibilities that they have to share safeguarding information, as detailed in ‘Keeping Children Safe in Education’ and ‘Working Together to Safeguard Children 2023’.”

Source location

Response from Huddersfield New College
Page 1 · response
Published 5 November 2024

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

Discuss multi-agency safeguarding communication with the NHS South West Yorkshire Partnership Foundation Trust.

Verbatim wording from the response

“Notwithstanding our view that the discussion around multi-agency co-operation is not completely within our purview, representatives from the College have discussed the issue with their counterparts at the NHS South West Yorkshire Partnership Foundation Trust who have responsibility for CAMHS. In terms of steps that may be taken locally to improve the communication of information we can only act on matters within our control. We understand that the Trust have agreed in principle to write to you to set out the steps they will take as the provider of CAMHS services to address the concern you have raised.”

Source location

Response from Huddersfield New College
Page 1 · response
Published 5 November 2024

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 NHS Trust responsible for CAMHS services is responsible for setting out steps to improve local information-sharing.

Verbatim wording from the response

“Notwithstanding our view that the discussion around multi-agency co-operation is not completely within our purview, representatives from the College have discussed the issue with their counterparts at the NHS South West Yorkshire Partnership Foundation Trust who have responsibility for CAMHS. In terms of steps that may be taken locally to improve the communication of information we can only act on matters within our control. We understand that the Trust have agreed in principle to write to you to set out the steps they will take as the provider of CAMHS services to address the concern you have raised.”

Source location

Response from Huddersfield New College
Page 1 · response
Published 5 November 2024

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

Implementing multi-agency communication changes is outside the College’s authority and requires discussion at a higher level.

Verbatim wording from the response

“The College will always do anything we can to support our students, and we welcome the Coroner’s findings. We agree with the Coroner’s conclusion that steps need to be taken to enhance the communication from organisations such as CAMHS to schools and colleges, but consider this to be a conversation that needs to be had at a much higher level. Given that the College does not have the power to make and implement changes on behalf of other organisations, we have met with representatives of the Department for Education to explain the issues and to bring their attention to the challenges regarding multi-agency communication. The provision of clearer guidance about what triggers communication from such organisations would provide valuable clarity for the whole sector.”

Source location

Response from Huddersfield New College
Page 1 · response
Published 5 November 2024

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.1

  1. 1

    Meet with Department for Education representatives to raise challenges concerning multi-agency safeguarding communication.

    Stated by The Duchess of Somerset’s HospitalStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.

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

Meet with Department for Education representatives to raise challenges concerning multi-agency safeguarding communication.

Verbatim wording from the response

“The College will always do anything we can to support our students, and we welcome the Coroner’s findings. We agree with the Coroner’s conclusion that steps need to be taken to enhance the communication from organisations such as CAMHS to schools and colleges, but consider this to be a conversation that needs to be had at a much higher level. Given that the College does not have the power to make and implement changes on behalf of other organisations, we have met with representatives of the Department for Education to explain the issues and to bring their attention to the challenges regarding multi-agency communication. The provision of clearer guidance about what triggers communication from such organisations would provide valuable clarity for the whole sector.”

Source location

Response from Huddersfield New College
Page 1 · response
Published 5 November 2024

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