Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0242, written 29 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 May 2014 |
|---|---|
| Reference | 2014-0242 |
| Deceased | Dana Baker |
| Coroner | Geraint Williams |
| Coroner area | Worcestershire |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Worcestershire Safeguarding Childrens Board 3. CORONER | am Geraint Urias Williams, Senior Coroner, for the coroner area of Worcestershire CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 3“ March 2044 | commenced an investigation into the death of Dana Louise Baker then aged 16 years. The investigation concluded at the end of the inquest on 29" May 2014. The conclusion of the inquest was suicide contributed to by a failure to protect from a known tisk of suicide, the medical cause of death being hanging.. CIRCUMSTANCES OF THE DEATH Dana Louise Baker was a looked after child under the care of Worcestershire County Council. It was known that a breakdown of her foster placement would lead to extreme distress with a consequent risk that she might kill herself. When the placement did breakdown Dana was allowed to stay with an adult friend and the following day she hanged herself in a public place. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) As outlined in the IMR's, the Serious Case Review and the draft Overview Report there was a lack of knowledge and understanding as between various agencies involved with Dana and inadequate communication between them. (2) The IMR's are kept confidential and not even shared as between Agencies concerned. Some IMR authors indicated that they could not comment on areas of “mutual concern" because they were unaware of the content of other Agency's IMR's. (3) (3) ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action by way of considering whether IMR's should be routinely shared as between individual Agencies so that a full picture of any identified failings can be produced. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 234 July 2014 1, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Personc fT chict Executive of Worcestershire Acute NHS Hospitals Trust, Chief Executive of South Staffordshire NHS Trust, Chief Executive of Child Care Bureau, Chief Executive of Worcestershire County Council and Chief Executive of Health and Care Trust. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Signed ee G U Williams 29th day of May 2013 H M Senior Coroner .
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
WORCESTERSHIRE SAFEGUARDING CHILDREN BOARD Working Together to Safeguard Children and Young People Independent Chair — Diana Fulbrook “i Independent Chair WSCB C/o The Pines Bilford Road Worcester WR3 8PU Mr G.U. Williams HM Coroner The Court House Bewdley Road Stourport-on-Severn Worcestershire DY13 8XE 30'" June 2014 Dear Mr Williams, | am responding to your Regulation 28 Report to Prevent Future Deaths, dated 29 May 2014. Your letter was also addressed to the Chief Executive of Worcestershire County Council, but | assume it was intended for the Local Safeguarding Children Board. Whilst | set out our response below, | should make the point that Worcestershire Safeguarding Children Board is one of 146 Local Safeguarding Children Boards (LSCBs) in England. We follow, but do not set national practice, and | wonder if your report may have been better directed to the Department for Education. You have requested that Worcestershire Safeguarding Children Board (WSCB) should give consideration to the routine sharing of Individual Management Reviews (IMRs) between agencies, so that a full picture of any identified failings can be obtained in order to prevent future deaths. In response, | will outline the guidance in place at the time the EW Serious Case Review (SCR) was undertaken, that which is now in place and WSCB's response to this. The EW Serious Case Review was commenced in March 2011 and hence was undertaken in line with the government guidance contained in Working Together to Safeguard Children 2010. Under this guidance a Serious Case Review Panel Page 1 of 3 was established comprising senior representatives of all the key agencies involved with the child and family. These representatives were independent of the management of the work the respective agencies had undertaken with the family. The Panel received copies of all the IMRs and jointly analysed these with the aim of identifying the key lessons learnt and recommendations for individual agencies and WSCB, which are contained in the Overview Report. Working Together to Safeguard Children has since been substantially revised, and was reissued in 2013. This includes changes to the guidance in respect of Serious Case Reviews, which is contained in Chapter 4: Learning and " improvement framework. The new guidance encourages Local Safeguarding Children Boards to use a wider range of learning models when undertaking SCRs and Case Reviews, including the systems methodology, as recommended by Professor Munro. (The Munro. Review of Child Protection: Final Report: A Child Centred System, published by Department for Education in May 2011.) The systems methodology promotes the greater engagement of practitioners and managers in the SCR process and focuses on why those involved acted in a certain way at the time, with the aim of understanding the actions of individual practitioners as well as the functioning of the multi-agency system, and hence learning lessons. Agency Reports are produced by the key agencies involved with the child and family and these are shared with all the practitioners and managers prior to a meeting, or series of meetings. During the process an overview of agencies’ involvement can be gained and key findings and lessons to be learnt identified. This approach supports a closer examination of key episodes and decision making points in agencies' work with a family. The final Overview Report is shared and agreed by all those involved in the process prior to presentation to the LSCB. in response to this guidance a number of models have been developed nationally, including the Social Care Institute for Excellence (SCIE) and the Significant Incident Learning Process (SILP) models. WSCB has already undertaken Case Reviews using both of these models and the feedback to date has been positive. Whilst the process can be challenging for practitioners and managers, they also welcome the opportunity for closer engagement, reflection and learning. : | would suggest that the current government guidance contained in Working Together to Safeguard Children 2013, together with the knowledge that Worcestershire Safeguarding Children Board has fully embraced this guidance, would help to address the issue of the sharing of IMRs which you have raised in the Regulation Report. Government guidance has been developed in the time since EW's death and WSCB has responded positively to this change. The sharing of IMRs between agencies on the Panel has always been a key element of the SCR process and the more collaborative ‘systems approach’ Page 2 of 3 reinforces the importance the Board has always recognised of openness between agencies in order that services can be improved to lessen the likelihood of something similar happening again. Please do not hesitate to contact me for any further information which you may require. Yours sincerely corer 7” WSCB Page 3 of 3
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