Prevention of Future Deaths reports · 2018
Regulation 28 report to prevent future deaths, reference 2018-0363, written 21 Nov 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 21 Nov 2018 |
|---|---|
| Reference | 2018-0363 |
| Deceased | Ben Walmsley |
| Coroner | Joanne Kearsley |
| Coroner area | Manchester North |
| Category | Child Death (from 2015) · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 4. Secretary of State for Educations - Department of Education 2. CORONER 1am Ms Joanne Kearsley, Senior Coroner for the Coroner area of Manchester North __| CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroner’s and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 | INVESTIGATION and INQUEST On the 19" November 2018 | concluded an Inquest into the death of Ben Walmsley date of birth 21.09.2002 who died on the 04.02.2018 aged 15 years old. CIRCUMSTANCES OF DEATH The circumstances of the death are that on the 4" February 2018 Ben Walmsley committed suicide at his home address by hanging. Ben had little involvement with any services at the time of his death. Bury Safeguarding Childrens Board have undertaken a Serious Case review into previous contact and a number of learning points arise from this. However during the course of the Inquest evidence was heard on one specific issue which | am of the opinion needs to be addressed in order to prevent future deaths. Details of this are set out below. CORONER’S CONCERNS CORONER'S CONE 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:- During the course of the investigation into Bens death it emerged that on a number of days in the month prior to his death he had searched on the school (St Phillips Secondary school) computers “how to kill myself *, “how to tie a noose” and “ why | shouldn't commit suicide”. It was explained to the Court that the school filters are accessed via Smoothwall which provides age appropriate filtered content. Whilst Ben could not access these pages as they were blocked , there was no mechanism in place at the time for the school to be made aware that a pupil may have attempted to search for such pages. The Court heard evidence that at the time of Ben's death the only monitoring was in lessons and was solely reliant on the teacher trying to watch what students were doing. The school has 900 pupils and the Court heard in any one day there can be 412,000 attempts by pupils to access blocked content. Not all of these would be as concerning as the content Ben was trying to access, some may relate to social media pages which the school does not allow. Evidence was provided to the Court that since Ben’s death, Smoothwall have now upgraded functionality and | Staff now receive notifications when blocked high risk safeguarding categories are attempting to be accessed. These alerts are “real time” notifications and go to three identified members of staff. Since this installation staff have been notified of two other children attempting to access similar sites to Ben and have taken action to speak to them and also to speak to their parents to offer support. However it is not known if this functionality is mandatory for all schools or indeed whether other software providers who are used by schools have this option. If schools do not have this facility you may wish to consider disseminating this information, this is of course a matter for yourself. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe each of you respectively have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 16" January 2019. |, 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 Persons namely:- the parents of Ben Walmsley 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 from. He may senda 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. 21* November 2018
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