Yunis Hadi

Lambeth

Laura Tagliavini
Assistant Coroner
Inner London, South

25 August 2018

Dear Ms Tagliavini,

Action related to Regulation 28 from the Coroner (Inner London, South): Report to
Prevent Future Deaths

| am writing further to your report following the inquest about Yunis Malik Hadi who tragically
died on 28" January 2018 following an incident whilst eating food at the South Lambeth
islamic Centre (the ‘Centre’.

| understand that, following the inquest, you contacted the Lambeth Safeguarding Children
Board (LSCB) requesting information and action to prevent future deaths. | am now providing
a response as the statutory Director of Children’s Services, advising you of the actions that
have been taken by Lambeth Council.

As you know, Yunis was a resident in the London Borough of Wandsworth child at the time of
his death, however, the incident that led to his death occurred at the Centre which is located in
the London Borough of Lambeth. The formal role for a local authority is limited in this
instance. The incident was investigated by the police and there was no individual who was
found to have caused harm to a child. It is therefore not within the remit of the LADO. Keeping
Children Safe in Education is designed for schools and colleges and Working Together to
Safeguard Children is a requirement for statutory organisations.

You will note that the local authority's role in relation to this provider is relatively limited and
that the Charity Commission has responsibility for overseeing the governance of charities
such as this. You will also be aware that the Wandsworth Child Death Overview Panel
(CDOP) is undertaking its own review because the chiid lived in Wandsworth at the time of his
death.

A range of actions followed on from the local authority's notifications of the child’s tragic death.

1. Information has been gathered and evaluated by relevant local authority officers
including the Locai Authority Designated Officer.

2. There has been telephone communication between the Lambeth Council Education
Safeguarding lead and South Lambeth Islamic Centre administrator (31% July 2018).
There has also been telephone communication conversation between the South
Lambeth Islamic Centre Chair of Trustees and Lambeth’s Senior School Improvement
Adviser (15 August 2018).

3. A safeguarding audit of the Centre was undertaken by the Lambeth School
Safeguarding Manager (9" August 2078).

4. We have confirmed that the Centre is registered with the Charity Commission and we
have therefore updated the Compliance, Visits and Inspection officer in the
Commission’s investigations, Monitoring and Enforcement Directorate of the
Commission about the issues of concern.

5. Ofsted have aiso been notified of the incident, however, the provision is not registered
with them as an educational provision (and does not need to be).

Responses to the specific issues raised by the Coroner

1. A lack of formal training among adult volunteers/teachers in first aid Including
response to choking incidents.

The local authority does not offer free first aid training, however, subsequent to the incident
the Education Safeguarding Manager contacted the Centre to advise about training that can
be accessed through agencies such as St John's Ambulance or the British Red Cross.

The Prevent Programme Manager in Lambeth Council spoke to a trustee at the Centre on ‘st
February 2018 and asked if the training had been completed. When he was told that it had
not, he sent details of training. He then followed this up further and was advised that the
Centre was having to raise funds for the training.

The Centre Chair subsequently confirmed on 1* August 2018 that first aid training had now
taken place (on 8th August 2018) and that 24 members of staff had been trained in
emergency first aid. Procedures have now changed so that there is at least one trained staff
member at every session. The incident had happened in ‘shoe area’ which is a small corridor
which they had not previously regarded as a problem. This is now supervised whenever
children are arriving or departing the building. The incident happened on a Sunday when there
were fewer adults in the building due to fewer children being on site.

2. A lack of emergency medical equipment i.e. defibrillators

There is no requirement in law for an establishment to have a defibrillator, however, following
a conversation between Lambeth Council’s Senior Schools and Education Improvement
Adviser (18! August 2018), the Chair of Trustees of the Centre has advised that a defibrillator
and training would be purchased.

3. A lack of oversight to ensure first aid safeguarding and supervision is up to date
and relevant

Foliowing the safeguarding audit undertaken by the local authority, the Centre agreed that
staff should receive Level 1 safeguarding training from the Local Authority. The Centre Chair
reported that this had been done but when the Senior Adviser asked for detailed information
about this, the Chair realised it had not. The training will take place on 19" September 2018.
Level 3 designated lead training is free of charge from the LSCB and remains on offer to the
Centre.

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It is clearly crucial that the provision has in place an adequate and appropriate safeguarding
policy. The Charity Commission states what such a policy should include. Further support
has been offered by the Local Authority and the model policy for schools has been shared
with the Centre. The Charity Commission are also available to support and have resources on
their website.

The Centre allows others to use the setting at the weekend and the Centre has therefore been
advised by the Local Authority’s safeguarding manager that it needs to have safeguarding
children policies and procedures explicitly stated in their lettings policy.

Follow-up

The Charity Commission will be advised of this letter to enable their action and follow-up.
Additionally Lambeth Council (schools safeguarding team) will follow-up on the actions
indicated above through the safeguarding training provision taking place in mid-September
and also via a visit by the Council’s Food, Health and Safety Manager. As indicated, we do
not have any specific enforcement powers in relation to these matters. Any further findings
from the Wandsworth Child Death Overview Panel, once completed, will be undertaken by
Lambeth Council and its statutory partners once that review has concluded and its
tecommendations are known.

| hope that the above information is helpful. Please do not hesitate to contact me should you
require further information.

Yours sincerely

Agro (he 2 La

Strategic Director - Children's Services

Web: www.lambeth.gov.uk

Copy:

re Director of Public Health,

HS Chair of Lambeth Safeguarding Children Board,
no liance Visits and Inspections Officer, Charity Commission

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