Tiya Chauhan

Sam Gyimah MP
Parliamentary Under Secretary of State for Childcare and Education

Sanctuary Buildings Great Smith Street Westminster London SW1P 3BT
tel: 0370 000 2288 ~www.education.gov.uk/help/contactus

Dr Fiona Wilcox

HM Senior Coroner
Westminster Coroner’s Court
Horseferry Road

London

SwiP 2ED

ar’becember 2014

Dear Dr Wilcox,

Thank you for your letter of 24 November, enclosing a Regulation 28 report following
the investigation into the death of Tiya Chetan Chauhan on 24 August 2012. | am
replying as the minister responsible.

The Statutory Framework for the Early Years Foundation Stage (EYFS) requires
registered childcare providers to keep children safe and to use their professional
judgement in doing so, with provision regulated and inspected by Ofsted in line with
the EYFS requirements. In a recent debate, initiated by the hard work of the founders
of Millie's Trust, the parents of Millie Thompson (a child who died at a nursery

in 2012), | announced that | intend to issue additional guidance to the early years
sector in 2015 under the EYFS banner. This will be principally about what constitutes
good paediatric first aid provision in settings.

Providers already know that they have to have sufficient first aiders to be able to
respond quickly to emergencies and choking does of course need such a response. |
will use this guidance to point out the dangers of using raw jelly in play with young
children without sufficient supervision as an example of a choking hazard. In addition
to the guidance, | committed to undertaking a review of the first aid requirements to
see if there is any further action needed on this important issue.

Thank you for writing on this important matter.

Yours sincerely,

Sam Gyimah MP

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Dr Fiona Wilcox
HM Senior Coroner

Inner West London .
Westminster Coroner's Court as 7 6
65 Horseferry Road Wf
London

SW10 2ED

CS February 2015 Our i

Dear Tbr Ladless .

Thank you for forwarding the Regulation 28 Report in connection with your
investigation into the death of Miss Tiya Chauhan. It was clearly a tragic incident
and | note your concern about the risk of future deaths unless action is taken.

The Food Standards Agency (FSA) has considered the areas of concern detailed in
your Report and as part of the process have met with relevant Ofsted officials to
discuss the incident and consider the appropriate action in relation to each of the 4
matters of concern highlighted in your Report.

With regard to your first point, and alerting nurseries and other childcare settings
about the issue, | understand that Ofsted intend to include specific information on
the incident in their next newsletter to local authority Directors of Children’s
Services. This will highlight the particular risks associated with raw jelly cubes in
childcare and school settings. The FSA will separately forward this information to
UK local authority environmental health services, to similarly highlight the risks so
that environmental health officers are able to consider them during their routine food
safety inspections of these establishments.

In relation to your concerns over the lack of warning about the issue on packaging,
the FSA will forward a copy of your report to relevant industry manufacturing and
retail trade bodies, for their information and consideration. | can confirm that there is
no specific legal requirement (in what is an area of law closely harmonised at EU
level) for such food to contain a warning on the label or on a point of sale notice if
sold loose. However, this is something that a particular manufacturer or retailer

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might consider voluntarily, as has been the case with foods such as grapes or
cherry tomatoes where similar choking incidents have occurred.

| note your reference to parents being made aware of the risks associated with raw
jelly cubes. A number of specialist websites for parents or carers did highlight this
issue following the incident. Problems associated with food choking hazards is also
something included in relevant NHS information. However, | will ensure your report
and your specific concerns about raw jelly cubes is copied to relevant officials in the
Department of Health for their consideration in relation to early years food advice to
parents.

| am aware that Ofsted will be liaising with the Local Government Association over
what more can be done to disseminate understanding of this issue, and the FSA will
maintain contact with Ofsted during this process to provide any relevant food safety
information.

| am hopeful that the combination of the measures referred to above will reduce the
likelihood of such a tragic cause of death being repeated.

Yours sincerely,

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raising standards
27 January 2015 ‘ improving lives

‘Dr Fiona Wilcox

HM Senior Coroner
Westminster's Coroner’s.Court
Horseferry Road

London

SW1P 2ED

Chief Operating Officer

Dear Dr Wilcox,
FINAL OFSTED RESPONSE TO CORONER'S REGULATION 28 REPORT

I refer to your Regulation 28 Report, dated 28 September 2014 and addressed to,
amongst others, the Chair of Ofsted which you made following the conclusion of the
Inquest into the tragic death of Tiya Chauhan on 24 August 2012 after an incident at
Dicky Birds Nursery, Wimbledon. ‘The Chair. has asked me, as Chief Operating
Officer, to respond on his behalf.

The report required Ofsted, as a named recipient of the Report, to respond by

14 November 2014. You kindly agreed to an extension of this date of 27 January
2015 since Ofsted did not receive the Report and we only became aware of it on
2 December 2014 through the Department for Education.

Ofsted takes very seriously its obligations in relation to the regulation and inspection
of the providers of childcare, including nurseries, under the Childcare Act 2006.
These obligations are to be undertaken with particular regard to its general statutory
duty to have regard to the need to safeguard children*.

In light of the outcomes of the Inquest and its statutory responsibilities, Ofsted has
given careful consideration to the four matters of concern set out in your report and
the action which Ofsted is able to take in relation to these concerns to prevent future .
deaths of a similar nature. These are detailed below.

As part of this consideration, Ofsted has met with relevant Food Standards Agency
Officials to discuss the incident and the matters of concern to ensure that our
response is appropriate and coordinated with other agencies and bodies. We have
contacted the Local Government Association by email and are currently liaising with
them in order to discuss your Report with them to ensure that all your concerns are
appropriately addressed. .

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That nurseries, other childcare and school settings and even parents may
be using raw jelly during play without appreciating the especial risks of
choking that a cube of jelly presents.

Ofsted will be including details of the inquest, including its findings of the risks
associated with the use of raw jelly during play by children, in its next regular
newsletter to all Directors of Children’s Services (DCSs) in local authorities in
England. As we explained in our evidence, local authorities, not Ofsted, have the
statutory duty to provide information, advice and guidance to childcare providers. It
is therefore for local authorities to advise individual providers of the risks posed by
raw jelly, but Ofsted can support this by bringing to their attention the matters
highlighted in the inquest. The aim of this will be to highlight the risks of raw jelly
play by children in childcare and school settings. It will be for the DCS’s to decide
how best to disseminate this information further to these settings.

Ofsted has given careful consideration to whether it should write out to all registered
childcare providers but has concluded that this would be outside Ofsted’s statutory
remit. As mentioned above, Ofsted cannot advise settings on how to deliver the
requirements of the Early Years Foundation Stage (EYFS) since legislative provisions
clearly place the obligation for advice and training of childcare settings on Local
Authorities. : ; ;

The newsletter will highlight to DCS’s that the relevant concerns are relevant not
only for nurseries but also for childminders and other providers of early years
childcare including schools. In relation to schools, we will also provide a copy of the
newsletter to the Department for Education (DfE) given they have policy ;
responsibility for schools and also are the registration authority for independent
schools including academies and free schools. You will also wish to note that we
have kept DfE informed about the inquest and ensured that they have been kept
aware of the evidence given by Ofsted and the inquest outcomes. ,

That packets of raw jelly do not contain a warning that cubes of jelly
present a choking risk to children.

The inclusion of warnings on the packaging of food items and products is not a
matter for Ofsted. We have discussed this concern with the FSA and have agreed
~ that they will respond to you on the possibility for further action.

That raw jelly cubes may be used in play with young children without
sufficient supervision.

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Ofsted
The Ofsted Newsletter referred to in relation to the first concern will alert DCSs to

the findings of the Inquest that there are risks associated with the use of raw jelly
cubes in play with young children without adequate supervision.

In inspecting registered early years providers, Ofsted inspects compliance with the
EYFS requirements including those relating to the risk assessment of activities and
supervision. Any breach of EYFS requirements arising from unsafe practices would
result in appropriate regulatory action by Ofsted. We will ensure that the findings-of
the inquest are disseminated to Ofsted and contracted inspectors of EY provisions so
that they are aware of the risks of the use of raw jelly in activities in their inspection
of EYFS compliance. As was made clear at the inquest, the use of raw jelly in
activities in play is not specifically precluded by the EYFS. This means that
inspection outcomes and regulatory action would be determined by whether EYFS
requirements relating to supervision and risk assessments were breached by a
provider due to unsafe practices involving raw jelly in play activities rather than the
use of raw jelly of itself. Inspectors could not advise or require providers to cease
the use of raw jelly if they became aware that it was being used in play activities.

That LAs and Ofsted learn lessons from this tragic death and ensure
appropriate warnings are communicated to the settings overseen by them
and training and inspection is organised and implemented as required to
mitigate the risk from raw jelly play.

We have highlighted above the action that Ofsted has concluded is within its
statutory in terms of ensuring that the findings of the inquest are communicated to
local authorities that have statutory responsibility for the provision of advice and
training of childcare settings as well as to Ofsted and contracted inspectors. As set
out above, Ofsted’s statutory role is to regulate and inspect registered settings and
Ofsted does not have statutory responsibility for the provision of advice and training
of providers which falls to local authorities.

I hope that the measures outlined above combined with action to be taken by the
FSA assist in your alleviating your concerns about the risk of further death from the
use of raw jelly cubes in play by children.

Yours sincerely

Chief Operating Officer