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Investigation and inquest
On the 29 August 2018 the Senior Coroner commenced an investigation into the death of Shneur Zalman Kaye. The inquest concluded on 17 January 2020 when I recorded a conclusion of Misadventure.
Circumstances of the death
Shneur died at home on 24 August 2018, by reason of suffocation caused by inhalation of helium. He was 14 years old. For some years, Shneur had experienced behavioural difficulties. He had been diagnosed with ADHD and had been supported by the community paediatric team. His treatment included regular medication.
On 17 April 2017, Shneur was conveyed to North Manchester General Hospital following erratic behaviour and a suggestion of an overdose. North West Ambulance service filed a Safeguarding Referral with the Multi Agency Safeguarding Hub (MASH) operated by Bury on 17 April 2017. At that time, Shneur was not attending any local authority maintained school. He was not previously known to Social Services. On 19 April 2017, the social worker decided there was no need for action and the referral was closed. Prior to closure of the referral, there was no contact made with the family or with Shneur himself. Following this decision, neither the fact of the referral nor the reasons it was shared with any third party, service or agency.
Coroner’s concerns
1. The decision to close a referral without prior contact with parents (where there is no safeguarding or legal reason why such contact should not be made) potentially deprives the Social Worker of the opportunity to contextualise the event or concern which has triggered the referral, and of forming an informed view of the welfare of the child to whom the referral relates;
2...The evidence received by the Court indicates that the closure of the safeguarding referral marks an end to social services involvement. Despite this no attempt is made to share the fact of the referral or the reasons for it with any third party, service or agency. This may have the unintended result of depriving third parties (including parents) and agencies already participating in the care and welfare of a child from being alerted to the concern and taking appropriate action (including accessing other services) in response to it. The submissions made on behalf of the council indicate these practices are driven by considerations of data protection compliance The practice imperils the precedence to be given to the paramountcy principle and has the potential to undermine the protection of children who are the subject of referral.
Information checked against the published report and official responses