Frances Rose Thomas · Prevention of Future Deaths report

On 28th November 2018 I commenced an investigation into the death of Frances Rose Thomas On the 10th October 2021 I concluded the Investigation. The medical cause of death given was:

1a. Suspension

I returned a conclusion of ████████ with Frankie’s death more than minimally contributed to by the failures of:

1. Stepping Stone School:

a. To provide an effective e-security system as tasked to do so by the department of Education.
b. To ensure Frankie’s use of the iPad was monitored to confirm her ████████ safety.
c. To provide Frankie with supervision when not attending lessons despite having an Educational Health Care Plan in place.

2. ████████:

a. A lack of robustness in their policies to remove age inappropriate ████████ content that allowed Frankie to read stories on their platform on the day of her death featuring ████████████████████████████████████████████████████, an act which she goes on to complete herself.

Frances Rose Thomas (Frankie) was a vulnerable teenager with a number of significant underlying difficulties including childhood trauma, high functioning autism, oppositional behaviour and impulsivity.

Stepping Stones School is a school for students with moderate physical or learning difficulties. Frankie was offered a place in year 8 and started in April 2016 with an Educational Care Plan in place. Throughout her time at the school Frankie often refused to attend lessons and at the time of her death rarely attended more than one lesson a week. When not attending lessons, she was left on her own without any formal supervision. During this time, she had access to a school computer and an iPad.

During the Inquest I heard evidence Frankie only had access to the ████████ during school time using electronic devices supplied by the school. There was an e-security system in place for school computers but it was not monitored by nominated safeguarding leads. This allowed Frankie (as it did for all students) to freely access the ████████ without any observation as to what websites were being accessed and for an assessment to be made of their appropriateness. Furthermore, the iPads had no e-security system in place at all, again allowing Frankie to freely access the ████████ without any supervision.

On the day of her death, Frankie was found to have accessed ████████
████████████████████████████████████████████████████████████
████████████████████████████████████████████████████████████
The stories that Frankie accessed on this platform featured
████████████████████████████████████████████████████████████. After school Frankie went home and undertakes a similar act resulting in her death on 25th September 2018.

1. I heard evidence that the Department of Education have devolved responsibility for e-security systems with schools having to ‘tender’ for web filtering software and hardware. However, the guidelines issued by the Department of Education require updating and are insufficiently robust to ensure their effectiveness and meet the changing demands of ████████ e-security in schools.

2. There is a wide range of software vendors providing different lists of blocklists with different vendors enabling different categories with no oversight or regulatory guidance by the Department of Education as to what ‘blocklists’ are either acceptable and/or suitable for a school environment.

3. ████████ is not a specifically blocked ████████ and not only can it be accessed by Key Stage 4 students there is encouragement to do so in some schools. However, I heard evidence that the sites Frankie accessed through ████████████████████████████████████████████████████████████. Furthermore, there is inadequate independent scrutiny by ████████ to remove age inappropriate stories put on their platform.

4. Some websites are only blocked when there is a particular key word in the URL if the relevant trigger word (e.g. ████████) is not there it makes it difficult for the filter to ‘see’ the content of the website to be able to block it, hence why stories on ████████ could be read. However, there are software systems available that acts as a ‘key logger’ and ‘screen reader’. Whilst this will not block the site it will generate a report to the nominated safeguarding individual for further action. Yet it has not been considered or is part of the guidelines issued by the Department of Education

5. In summary, on the evidence I heard there appears to be inadequate regulatory oversight with now outdated guidance issued by the Department of Education with regard to robust standards of e-security systems within schools.