Shneur Kaye

HM Coroner’s Office 
HM Coroner’s Court – Manchester North 
Floors 2 & 3, Newgate House 
Newgate 
Rochdale 
OL16 1AT 

30th January 2024 

Dear Sirs, 

Bury Council apologise for the significant delay in responding to the Regulation 28: 
Report  to  Prevent  Future  Deaths,  dated  17th  January  2020.  The  delay  has  been 
caused by changes in leaders within both the Children’s Service Department and the 
Safeguarding Partnership Business Unit. 

Bury Council have reviewed the ‘Ruling’ of the Coroner, Edward Morgan, dated 24th 
August 2018, in relation to the death of Shneur Zalman Kaye (dob 16/09/03) and had 
completed a Serious Case Review (SCR).  An action plan, in response to the SCR 
was  created  by  the  Bury  Safeguarding  Children’s  Partnership,  who  monitored  the 
actions for the partnership.  

Matters of concern to the Coroner 

1.  The decision to close a referral without prior contact with parents (where there 
is  no  safeguarding  or  legal  reason  why  such  contact  should  not  be  made) 
potentially deprives the Social Worker of the opportunity to contextualise the 
event or concern which has triggered the referral, and of forming an informed 
view of the welfare of the child to whom the referral relates; 

2.  The  evidence  received  by  the  Court  indicates  that  the  closure  of  the 
safeguarding referral marks an end to social services involvement.  Despite this 
no attempt is made to share the fact of the referral or the reasons for it with any 
third party, service or agency.  This may have the unintended result of depriving 
third parties (including parents) and agencies already participating in the care 
and welfare of a child from being alerted to the concern and taking appropriate 
action (including accessing other services) in response to it. The submission 
made  on  behalf  of  the  council  indicate  these  practices  are  driven  by 
considerations  of  data  protection  compliance.  The  practice  imperils  the 
precedence to be given to the paramountcy principle and has the potential to 
undermine the protection of children who are subject of referral. 

Electronic or fax service of Legal documents is not accepted 

Town Hall, Knowsley Street, Bury, BL9 0SW
www.bury.gov.uk 

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 Bury’s response to the matters of concern raised by the Coroner 

In  early  2022,  Bury’s  Multi  Agency  Safeguarding  Hub  (MASH)  went  through  a 
systematic service review, which reviewed practice, operating principles, and practice 
standards.  Our vision, underpinned by practice principles states that  “all partners are 
committed to providing support to children and their families at the earliest opportunity 
and  work  with  them  at  the  lowest  point  of  intervention  in  line  with  our  children’s 
continuum of need, this reflects our Bury LETS strategy of offering services locally, 
seeking  Enterprising  solutions  with  families  to  support  change,  a  commitment  to 
Working  Together  in  partnership  with  families,  doing  with  them,  not  to  them  and 
building  on  family  strengths  to  support  change”.  Strength  based  practice  within  the 
MASH, working alongside of parents/carers and seeing them as an expert in their own 
right is standard practice and unless there is a safeguarding or legal reason not to, it 
is an expectation that parents/carers are spoken with as part of the process.  

In addition, the MASH consults with referrers to discuss concerns, clarify information 
and provide them with an outcome to their referral or to consider alternative support 
pathways should the recommendation not be a referral to Childrens Social Care.  

I hope that this letter provides some clarity to the steps that Bury have taken as a 
result of the tragic death of Shneur.  

Yours sincerely 

Interim Director of Social Care and Early Help 

Electronic or fax service of Legal documents is not accepted 

Town Hall, Knowsley Street, Bury, BL9 0SW
www.bury.gov.uk 

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Date: 20 March 2020 

Private & Confidential 

Medical Director 
North Manchester General Hospital 
Delaunays Road 
Crumpsall 
Manchester 
M8 5RB 

I write to you in response to your correspondence dated 21 January 2020. Thank you for bringing 
the concerns raised in the paragraph 37 letter report to my attention, I apologise that you have had 
to write to me with further concerns. The Northern Care Alliance is dedicated to ensuring patient 
safety is maintained throughout all services. 

I would like to take this opportunity to provide assurance to both you and the family that the Trust 
takes  the  concerns  raised  very  seriously  and  have  conducted  a  thorough  review.  At  the  outset 
please pass on my sincere condolences to the family, I am sorry they have been given cause for 
concern at such a difficult time. 

The concerns you have raised have been reviewed and addressed by the senior leadership team. 
In order to answer each point I have set them out below for ease of reference: 

Assumption regarding access to specialist services 

It was incorrectly assumed that, given Master Kaye was under the Community Paediatric Team, he 
would  also  have  been  receiving  input  from  specialist  services  or,  in  the  alternative,  his 
psychological  health  would  have  been  assessed  by  the  Community  Team  during  the  planned 
review in June 2017. I am aware that my colleague 
, Consultant Paediatrician 
and  Clinical  Director  for  Paediatrics,  was  at  the  inquest  and  has  de-briefed  his  colleagues 
regarding this.  Please accept our sincere apologise for this error. 

As you are aware, in order to avoid any confusion and the risk of some children not being followed 
up with appropriate mental health input, the process of discharge for every child attending at any 
Trust hospital, in circumstances such as Master Kaye, has now changed. All children who present 
to  Accident  and  Emergency  with  an  overdose  (irrespective  of  whether  it  is  suspected  and  /  or 
subsequently  ruled  out)  will  be  the  subject  of  a  Healthy  Young  Minds  /  CAMHS  referral.  This 
message has been relayed to the emergency department and paediatric staff (at all sites). 

As  a  direct  consequence  of  the  issues  raised  at  inquest, 
  has  instigated  a  meeting, 
between Pennine Acute and Pennine Care / HYM to discuss the referral process, explore whether 
it can be clarified and whether there are any improvements that can be made. This meeting is due 
to  go  ahead  on  25  March  2020  with  governance  leads  and  senior  managers  in  attendance, 
including:-

 
 

 

 

(North Division) 

(South Division) 

, Consultant Paediatrician and Clinical Director for Paediatrics – PAT 

, Consultant Child and Adolescent Psychiatrist - Clinical Director HYM 

, Consultant Child and Adolescent Psychiatrist - Clinical Director HYM 

, Consultant Child and Adolescent Psychiatrist – HYM 

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  
 

, Deputy Managing Director – HYM 

, Patient Safety Lead – HYM 

For  the  avoidance  of  doubt,  the  current  process  of  referring  any  child  with  a  suspected 
psychological  issue  stands,  until  a  better  alternative  (if  it  exists)  is  agreed  at  this  meeting.  The 
learning and outcome of this meeting will then be disseminated Trust wide. 

On 22 January 2020 a paediatric departmental teaching session took place. Much of that session 
was devoted to the learning arising from the Serious Case Review and inquest. 

The Community Paediatric Team do have access to all medical records and will have been able to 
consider  Master  Kaye’s  acute  admission  in  April  prior  to  reviewing  him  in  June  2017. 
Unfortunately,  on  this  occasion,  it  is  not  documented  whether  this  was  explored. 
  is 
aware  of  this  and  has  raised  it  with 
,  Consultant  Paediatrician  and  Community 
Paediatric Lead, who in turn has provided feedback to her team. 

I will be sharing this response with 
 and will be asking him to again reiterate to his team 
the importance of never assuming that just because a patient is under the care of the Paediatric 
Community Team that they will also be receiving input from the necessary specialist services.  

Safeguarding referrals 

I apologise that the evidence given to the Court gave the impression of a narrow understanding of 
safeguarding and the circumstances in which a safeguarding referral may be required. 

In my own experience, Northern Care Alliance NHS Group (NCA) staff are well versed in when a 
safeguarding referral is needed and there is good awareness of the need to consider a referral – 
irrespective of whether the patient presents with a physical or potential psychological issue. 

  has  discussed  the  issues  raised  at  inquest  with  the  clinical  directors  for  Accident  & 
Emergency  at  Fairfield,  Oldham  and  North  Manchester.  They  in  turn  have  communicated  the 
learning from the inquest within their teams. 

The Trust acknowledges that training and communication are essential in ensuring that everyone 
knows what safeguarding means and when and how it should be acted upon.  

In November 2019 the Trust ratified a new safeguard training strategy (enshrined within a formal 
policy) to provide additional assurance on the focus we have on safeguarding training. This 
strategy will enable the Care Organisations across the NCA to discharge their statutory duty to 
safeguard and promote the welfare of children. It is in line with the current statutory guidance 
‘Working Together to safeguard children’ (DFE, 2018) and will be reviewed against any future 
guidance to ensure compliance under Section 16 of the Children Act 2004. 

The training on the safeguarding of children and adults is now a mandatory course to be 
undertaken on induction to the Trust. Safeguarding E-Learning modules are also included within 
the pre-employment induction pack. 

To  protect  children  and  young  people  from  harm,  and  help  improve  their  wellbeing  (whether 
physical  or  mental),  the  NCA  ensure  that  all  healthcare  staff  must  have  the  competencies  to 
recognise  child  maltreatment,  opportunities  to  improve  childhood  wellbeing,  and  to  take  effective 
action  as  appropriate  to  their  role.  This  Training  strategy  provides  a  clear  framework  which 
identifies the competencies required for all healthcare staff. At inquest, I understand that you heard 

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 evidence on the different levels of training; levels 1-3 relate to different occupational groups, while 
level  4  and  5  are  related  to  specific  roles.  All  newly  employed  staff  will  now  undertake  the 
combined  level  1  and  level  2  safeguarding  children  E-learning  training  within  1  month  of 
employment.  This  combined  session  covers  the  basic  principles  of  safeguarding  children  and 
young people from potential harm (both physical and psychological) and provides details of who to 
contact for advice and support if a safeguarding concern arises. 

The combined programme provides core safeguarding / child protection training (level 1 and level 2 
training).  This  level  of  training  builds  on  the  competencies  outlined  for  level  1,  covering  in  more 
detail  the  understanding  of  child  maltreatment,  the  role  of  the  practitioner  in  identifying  and 
responding to potential abuse and the need to act as an advocate for the child/ren in their care. 

This programme provides staff with an understanding of the child protection legal framework and 
the processes for making referrals to social care and other external agencies as required. It also 
ensures  consideration  of  ethnicity,  culture,  race  and  religion  (of  particular  relevance  in  Master 
Kaye’s case) and highlights lessons learnt from serious case reviews. 

The e-learning programme is repeated as a 3 yearly update as part of the core mandatory training 
programme. All clinical and non-clinical staff must complete the safeguarding children and young 
people module as part of their mandatory training requirement. 

Training  is  delivered  or  overseen  by  experienced  safeguarding  professionals  from  the  corporate 
safeguarding team, via the multi-agency training pools supported by Local SCP’s and SAB’s and 
by approved guest speakers. 

I am confident that this new training strategy will ensure that the NCA are where we need to be in 
the identification of safeguarding issues (the whole spectrum) and how then to act upon them. 

The NCA also has in place a specific safeguarding policy for children. That policy emphasises that 
safeguarding is everyone’s responsibility and therefore all staff - clinical and non-clinical (acute and 
community),  volunteers  and  staff  contracted  to  NCA  need  to  appreciate  that  safeguarding  is  for 
everyone and that everyone is under a duty to raise concerns. All staff have easy access to this 
policy on the Trust intranet. 

In  addition  to  the  above,  an  action  plan  was  developed  following  receipt  of  the  Serious  Case 
Review and the recommendations have been appropriately acted upon. 

I do hope that this correspondence reassures you that the learning following the inquest has been 
reviewed in detail. I trust the above information addresses all the concerns raised; however, if you 
any further concerns please do not hesitate to contact me. The Trust would also be happy to meet 
with the family should they find that helpful? 

I would like to conclude by reiterating my sincere condolences to them at this difficult time. 

Yours sincerely, 

Medical Director North Manchester General Hospital 

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