Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0120, written 12 Apr 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 12 Apr 2017 |
|---|---|
| Reference | 2017-0120 |
| Deceased | Chadrack Mulo |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Other related deaths · Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Chadrack Mbala MULO (died 18.10.16)
THIS REPORT IS BEING SENT TO:
1. The Right Honourable Edward Timpson MP
Minister of State for
Vulnerable Children and Families
Department for Education
Piccadilly Gate
Store Street
Manchester
M1 2WD
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 26 October 2016, one of my assistant coroners, William Dolman,
commenced an investigation into the death of Chadrack Mbala Mulo,
aged 4 years. The investigation concluded at the end of the inquest on 10
April 2017. At inquest, I made a determination as follows.
learning difficulties and, when his mother died
Chadrack had
unexpectedly at home on 1 or 2 October 2016, he did not know how to
call for help or feed himself properly. He died a fortnight later of
dehydration and starvation. He was then found within approximately 48
hours.
1
His medical cause of death was:
1a dehydration and acute protein-energy malnutrition
2 autism spectrum disorder (ASD)
4
CIRCUMSTANCES OF THE DEATH
Chadrack’s mother suffered a sudden death in epilepsy, probably on 1 or
2 October 2016. Chadrack was not seen in school after 30 September
2016.
The staff at Morningside Primary School were concerned and rang his
mother on several occasions. They also visited the home twice, but could
not gain access to the block of flats where Chadrack and his mother lived.
The likelihood is that Chadrack lived alone in the family home for over a
fortnight after his mother’s death. He was found a couple of days after
his own death, with his arms around her body. She was by then very
decomposed.
5
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. The school had a telephone number for Chadrack’s mother, but
not for any other family member or friend. Now, they insist that for
every child in the school they have the telephone number of three
different adults.
2. If a child unexpectedly fails to attend and no relevant adult can be
contacted via phone, staff at the school do not now wait three to
five days as they did then, but instead immediately send a member
of staff to the family home.
They now make a distinction between an attendance issue that
may warrant a penalty (not the case for Chadrack because he was
under the age of five years) and a potential welfare issue.
3. If there is no answer at the family home when staff members
attend, they now immediately contact the police, who in most
cases are likely to force entry.
2
This protocol seems very sensible, but is clearly driven by the appalling
tragedy of Chadrack’s death. It seems unlikely that other schools in
Hackney, elsewhere in London, or indeed in the rest of England & Wales,
have such a system in place.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 19 June 2017. I, 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.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Mark Lucraft QC, the Chief Coroner of England & Wales
City & Hackney Safeguarding Children Board
, headteacher, Morningside Primary School
, Chadrack’s father
, Chadrack’s auntie
I 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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
12.04.17
3
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.
Robert Goodwill MP Minister of State Sanctuary Buildings 20 Great Smith Street Westminster London SW1P 3BT tel: 0370 000 2288 www.education.gov.uk/help/contactus Coroner ME Hassell Senior Coroner, Inner North London St Pancras Coroner's Court Camley St London N1C 4PP ie Hassell 19" June 2017 Cat ' My predecessor, Edward Timpson, received your Prevention of Future Death report, regarding the tragic death of Chadrack Mbala Mulo, on 20 April 2017. This is a heart- breaking case and my thoughts are with all those who knew Chadrack and his mother. ! would like to stress that the Department takes the issues raised in the report very seriously and will take action in light of your recommendations. The school only held a single number for Chadrack’s mother and no contact number for any other family member or friend. | have asked Departmental officials to examine how we can best update the statutory ‘Keeping Children Safe in Education’ guidance and the ‘School Attendance’ guidance so that they reflect best practice and recommend that schools hold more than one contact number. You make an important distinction in your report between attendance issues and welfare issues and underline that school staff should be considering welfare when managing attendance. In this area too, the Department will examine how best we can update attendance and safeguarding guidance to make this link clearer. | would anticipate that guidance will continue to make clear that professional judgement should be used in deciding when child safety or welfare concerns should be escalated to children's social care services and/or the police. | have also asked the Department to identify the best way to reinforce this point further in the attendance and safeguarding guidance. | will ensure that changes to strengthen the guidance will be made at the earliest opportunity, subject to formal consultation on the safeguarding guidance. | have asked Departmental officials to forward your report to Her Majesty's Chief inspector of Education, Children’s Services and Skills for her consideration. Robert Goodwill MP Minister of State
See every Prevention of Future Deaths report matching Child Death (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.