Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0385, written 28 Aug 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 28 Aug 2014 |
|---|---|
| Reference | 2014-0385 |
| Deceased | Lauren Barfoot |
| Coroner | Lorna Tagliavini |
| Coroner area | London Inner (South) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
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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. 2. Mr Will Tuckley, Chief Executive of Bexley Social Services, Civic Offices, 2 Watling Street, Bexleyheath, Kent DA6 7AT 3. Mr Andy Marshall, Chief Executive of Ethelbert’s Children’s Services, Director Cheesemans Farmhouse, Alland Grange Lane, Manston, Kent 4, Borough Commander Metropolitan Police Services for Greenwich Borough, Greenwich Police Station, 31 Royal Hill, Greenwich SE10 8RR 4 CORONER | am Lorna Tagliavini Assistant Coroner, for the area of Inner London South 2 | 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. 3 | INVESTIGATION and INQUEST On 4" July 2012 an inquest was opened into the death of Lauren Barfoot aged 14 years. The inquest concluded on 1 August 2014 after an inquest held on 31% July and 1° August 2014. The conclusion of the inquest was: “Accidental death contributed to by failures in the sharing of information and pooling and use of resources by those in whose care Lauren was in at the time of her death.” 4 | CIRCUMSTANCES OF THE DEATH On 22" April 2012 Lauren became a “looked after child” pursuant to section 20 of the Children’s Act 1989 and was placed in Micawber House (“the home”) by the London Borough of Bexley Social Services, a home run by Ethelbert’s Children Services. From the outset, Lauren was frequently missing from Micawber House although would most often return the following day at the latest. On 22™ June 2012 Lauren went missing from the home and was reported by the staff at the Home to the MPS, and treated as a missing person by the Missing Person’s Unit (Greenwich Borough) from that date until her discovery in the porch of her putative father’s home address in the Plumstead, London SE18 area 5 | CORONER'S CONCERNS During the course of the inquest, the evidence revealed maiters 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) There was a failure by the London Borough of Bexley Social Services to record and make accessible, a comprehensive list of Lauren's friends, family and acquaintances and their addresses and contact numbers, with whom contact could be made in order to assist professionals in an effective search for Lauren. (2 ~ There was a failure by Ethelbert’s Children’s Services to relay full and detailed information to the Missing Person’s Unit (Greenwich) as to the level of risk classified as “high” in relation to Lauren’s misuse of solvent abuse and vulnerability of sexual exploitation. (3 = There was a failure by the MPS Missing Person's Unit (Greenwich) to carry out an effective search for Lauren as a consequence of the lack of information not shared with the Unit by those responsible for looking after and searching for Lauren, and therefore a missed opportunity for the Missing Person's Unit to classify Lauren as a “high risk missing person”. (4 = There was a failure by The London Borough of Bexley to hold a timely “strategy meeting” by those concerned in the care for Lauren after she had been missing for several days in order to pool information and resources in order to catty out an effective search for Lauren. ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe your organisations have the power to take such action. For example: (i) A full and regularly updated list of persons by both the London Borough of Bexley Social Services and Ethelbert’s Children’s Services with whom a “looked after” child is connected in order, to be able to make meaningful searches after absconding/missing. This list to be kept centrally or is readily accessible, whether electronically or in another format. (ii) The sharing of details of any relevant risk assessment carried out in respect of the missing child should be passed to the police in order they can make a properly and fully informed decision as to the level of resources needed in order to carry out an effective search. (iii) The holding of a timely strategy meeting at which information can be pooled and resources allocated and utilised effectively. (iv) The means by which the Missing Persons Unit (Greenwich) is able to access essential information in respect of a missing person, in order to carry out n effective prioritisation of resources required for any search. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23rd October 2074. |, 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 sen to the Chief Coroner and to the following Interested Persons mother), the London Borough of Bexley, Ethelbert's Children’s Services, the MPS and the Bexley Local Safeguarding Board as Lauren was under 18. lam 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. DATE SIGNED BY “LN Tagliavini «+ , 28 August 2014 ANU
4 responses 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.
LB of Bexley 23/10/2014 14:26:49 PAGE 3/004 Fax Server
TO:Ms Lorna Tagliavini COMPANY:Coroner Inner South District
Chief Executive's Office
Civic Offices x Ss
2 Wailing Street, Bexleyheath, Kent, DA6 7AT SS
020 8303 7777 SSG
www.bexley.gav.uk BANS
mir Direct Diat [i
yr 01554/2012 Date 23 October 2014
The person dealing with this matter is Will Tuckley
Ms Lorna Tagliavini
Coroner for Inner South District Greater London
Southwark Coroners Court
1 Tennis Street
Southwark
London SE1 1YD
Dear Ms Tagliavini
Re: Inquest concluded on 1 August 2014, into the death of Lauren Barfoot (aged 14)
Bexley's Children’s Services take its responsibility to looked after children very
seriously and have ensured that lessons have been learnt and implemented in social
work practice following this case. Bexley children’s social care services were
inspected by the external regulator Ofsted, under the Single Inspection Framework,
during March 2014. The Inspection independently reviewed practice regarding looked
after children who went missing and the following is an extract from the Ofsted report
published in May 2014:
‘When looked after children go missing an established triage system is used to
determine the action to be taken including whether a child protection enquiry is
necessary. Robust systems are in place to track and identify individual looked after
children who go missing and those who are at risk of sexual exploitation. These
children are regularly considered at multi-agency meetings and suitable contingency
plans are agreed. Sensitive interviews are undertaken with looked after children
when they return to their placements.’
In response to the regulation 28 report to prevent future deaths and the
recommended actions to be taken:
(i) A full and regularly updated list of persons by both the London
Borough of Bexley Social Services and Ethelbert’s Children’s
Services with whom a “looked after” child is connected in order to
be able to make meaningful searches after absconding/missing. This
list to be kept centrally or is readily accessible, whether
electronically or in another format
Bexley Children’s Social Care sends a letter and proforma document
recording the associations of young people to all residential providers.
Previously, Bexley relied on the residential providers own protocois in
respect of missing children. It was identified that these varied across the
country. The letter and proforma also sets out expectations regarding
having an up to date list available. By Bexley giving providers the process
and pro-forma documents, we can be confident that when a child goes
missing they are aware of our expectations in collecting information on
aN
C)
Listening to you, working for you Showers es Hone
persons the young person is connected to. All information will now be
returned to, and held centrally by, Bexley’s Placements Service.
{ii) The sharing of details of any relevant risk assessment carried out In
respect of the missing child should be passed to the police in order
they can make a properly and fully informed decision as to the level
of resources needed in order to carry out an effective search
A tisk assessment report is required in preparation for any strategy
meetings for missing looked after children. A strategy meeting is held
within three days of a child going missing. The social worker will provide
a risk assessment report to the meeting in accordance with the Bexley
Practice Guidance pro-forma for assessing risk. The meeting is chaired by
the Independent Reviewing Officer for the child. The tisk assessment
report requires comprehensive information about all possible contacts and
locations where the child may be found, including any information known
about risks presenting to the young person. The risk assessment report
will be passed to the police at the strategy meeting in order that they can
assess the level of risk and resources required so that they can carry out
an effective search for the missing young person. Subsequent strategy
meetings are held at 5 days and weekly thereafter.
(iti) The holding of a timely strategy meeting at which information can be
pooled and resources allocated and utilised effectively
Strategy meetings for missing looked after children are held within the
timescales set out in the “Children who go missing from Home or Care
Practice Guidance" implemented in May 2013. The holding of the strategy
meetings are overseen by the manager for the “looked after" Independent
Reviewing Officer service. The timeliness of ‘missing’ strategy meetings is
tracked in monthly performance reports and meetings, to ensure good
practice is maintained.
(iv) Relates to the Greenwich Police Missing Person’s Unit
| hope the information contained in this letter assures the Coroner that Bexley's
Children’s Services has responded appropriately to the concerns raised in the
Inquest.
Yours sincerely
Will Tuckley
Chief Executive
Ethelbert Childrens Services we ppnetes: Bviery nites Hay; e& Tran 39 0% Head Oifice Cheesemans Faimhouse Atland Grange Lone. Marston, Kent. C12 $82 pee Nes BA 62 HM Assistant Coroner Ms Tagliavini 1 Tennis Street London SE1 1YD Dear Madam Inquest Touching upon the death of Lauren Barfoot Heard 31 July - 1 August 2014 Further in the above matter we acknowledge receipt of the Regulation 28 Report that you kindly sent to Ethelbert Children’s Services, Having reviewed the same we attach for your kind attention copies of the following oN INVESTORS IN PEOPLE documents:- ¢ List of actions related to the collation and sharing of information re the gu placed child 1S0 9001 REGISTERED F1RM e Vulnerability Assessment ocr ¢ Met Police Missing Person Reporting Form “ene Once you have had an opportunity to review the action list we trust that you will . find the steps that we have implemented, address concerns in respect of the Cityae collation of information as to the risk assessment of a child and contact details Guilds which can be shared with other agencies. The missing persons reporting form is a document that the Metropolitan Police now issue and require us to complete on the arrival of a child. We understand that this is retained centrally by them and Is cross referenced by them when reports are recelved that the child has gone missing. In addition at the time of reporting that a child is missing, a telephone call would be made by the care manager providing the current circumstances and any additional details in relation to clothing, times and other relevant information. This information will enable the Police to undertake a full assessment. We continue to explore the possibility of sending an updated missing person form by email, to the police as outlined in action list, although to date our conversations with the Met have not proved successful. On a separate note and for the sake of completeness we would advise that there is a slightly different system in place within Kent Police (and potentially in other police force areas). In Kent we complete a vulnerability assessment on each child at ihe Ri Page 1 of 2 Exceeding Outcomes Website: www.efhelbertonline.co.uk E-mail: headoffice « ethelberthomes.co.uk Out of Hours: 01843 820030 Piente note: Gey Infor nation providert in this ‘etter bout a clest aay be cycled unites indcaled othenwase ye Ethelbert Childrens Services nels Every Cites i ~ Fy time of placement which Is passed to the Police and each child is then given a unique reference number (PID number). It is cross referenced to at the time of any subsequent missing person reports being made. Regrettably they currently do not have a facility for receiving information by email. A copy of the vulnerabllity assessment is attached. Yours faithfully Ethelbert Childrens Services Enc. e List of Actions ¢ Vulnerability Assessment Form « Met Police Missing Person Reporting Form Please Note: A hard copy of this letter and_atiachments have also been sent Recorded Delivery for the Atin. of SJ - Coroners Officer Website: www.eihelbertoniine,co.uk Email: headoffice@ethelbert.net Out of Hours: 01843 820030 Please note: Any information provided in tnis letter about a client may be disclosed untess indicoted otnenvise
Ethelbert Childrens Services we ppnetes: Bviery nites Hay; e& Tran 39 0% Head Oifice Cheesemans Faimhouse Atland Grange Lone. Marston, Kent. C12 $82 pee Nes BA 62 HM Assistant Coroner Ms Tagliavini 1 Tennis Street London SE1 1YD Dear Madam Inquest Touching upon the death of Lauren Barfoot Heard 31 July - 1 August 2014 Further in the above matter we acknowledge receipt of the Regulation 28 Report that you kindly sent to Ethelbert Children’s Services, Having reviewed the same we attach for your kind attention copies of the following oN INVESTORS IN PEOPLE documents:- ¢ List of actions related to the collation and sharing of information re the gu placed child 1S0 9001 REGISTERED F1RM e Vulnerability Assessment ocr ¢ Met Police Missing Person Reporting Form “ene Once you have had an opportunity to review the action list we trust that you will . find the steps that we have implemented, address concerns in respect of the Cityae collation of information as to the risk assessment of a child and contact details Guilds which can be shared with other agencies. The missing persons reporting form is a document that the Metropolitan Police now issue and require us to complete on the arrival of a child. We understand that this is retained centrally by them and Is cross referenced by them when reports are recelved that the child has gone missing. In addition at the time of reporting that a child is missing, a telephone call would be made by the care manager providing the current circumstances and any additional details in relation to clothing, times and other relevant information. This information will enable the Police to undertake a full assessment. We continue to explore the possibility of sending an updated missing person form by email, to the police as outlined in action list, although to date our conversations with the Met have not proved successful. On a separate note and for the sake of completeness we would advise that there is a slightly different system in place within Kent Police (and potentially in other police force areas). In Kent we complete a vulnerability assessment on each child at ihe Ri Page 1 of 2 Exceeding Outcomes Website: www.efhelbertonline.co.uk E-mail: headoffice « ethelberthomes.co.uk Out of Hours: 01843 820030 Piente note: Gey Infor nation providert in this ‘etter bout a clest aay be cycled unites indcaled othenwase ye Ethelbert Childrens Services nels Every Cites i ~ Fy time of placement which Is passed to the Police and each child is then given a unique reference number (PID number). It is cross referenced to at the time of any subsequent missing person reports being made. Regrettably they currently do not have a facility for receiving information by email. A copy of the vulnerabllity assessment is attached. Yours faithfully Ethelbert Childrens Services Enc. e List of Actions ¢ Vulnerability Assessment Form « Met Police Missing Person Reporting Form Please Note: A hard copy of this letter and_atiachments have also been sent Recorded Delivery for the Atin. of SJ - Coroners Officer Website: www.eihelbertoniine,co.uk Email: headoffice@ethelbert.net Out of Hours: 01843 820030 Please note: Any information provided in tnis letter about a client may be disclosed untess indicoted otnenvise
is TOTAL POLICING Territorial Policing RG - Greenwich Borough RG - Greenwich Police Station Assistant Coroner Tagliavini Plumstead Police Station 200 Plumstead High Street Southwark Coroners Court London 1 Tennis Street SE18 1JY SE11YD Telephone: 0208 284 9400 www.met.police.uk Your ref: 23 October 2014 Dear Assistant Coroner Tagliavini, Thank you for writing to me with a copy of your report in relation to the death of Lauren Barfoot. You have asked that | write to you detailing the response from Greenwich Police. | have included the relevant quotation from your report below. “There was a failure by the MPS Missing Persons Unit (Greenwich) to carry out an effective search for Lauren as a consequence of the lack of information not shared with the Unit by those responsible for looking after and searching for Lauren, and therefore a missed opportunity for the Missing Person's Unit to classify Lauren as a “high risk missing person”. Action identified by the Assistant Coroner which should be taken in relation to this matter. “The means by which the Missing Persons Unit (Greenwich) is able to access essential information in respect of a missing person, in order to carry out an effective prioritisation of resources required for any search’. | enclose a report detailing our actions, addressing the specific issues of information sharing and risk assessment, but also our broader response to the serious case review that followed Lauren's death. | have caused our response to be reviewed in light of the inquest to ensure that those measures introduced following the serious case review account for the issues taised in your report and are fully embedded in current practice. If you require any further information please do not hesitate to contact me. Yours Sincerely Detective Chief Superintendent Greenwich Borough Commander - Greenwich Borough Police
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