Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0408, written 26 Nov 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Nov 2021 |
|---|---|
| Reference | 2021-0408 |
| Deceased | Frances Thomas |
| Coroner | Karen Henderson |
| Coroner area | Surrey |
| Category | Other related deaths · Suicide (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.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Frances Rose Thomas A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: Secretary of State for Education 1 CORONER Dr Karen Henderson, HM Assistant Coroner for Surrey 2 CORONER’S LEGAL POWERS I make this report under paragraph 7(1) of Schedule 5 to The Coroners and Justice Act 2009. 3 INVESTIGATION and INQUEST On 28th November 2018 I commenced an investigation into the death of 10th October 2021 I concluded the Frances Rose Thomas On the Investigation. The medical cause of death given was: 1a. Suspension I returned a conclusion of minimally contributed to by the failures of: with Frankie’s death more than 1. Stepping Stone School: a. To provide an effective e-security system as tasked to do so by the department of Education. b. To ensure Frankie’s use of the iPad was monitored to confirm her safety. c. To provide Frankie with supervision when not attending lessons despite having an Educational Health Care Plan in place. 2. : a. A lack of robustness in their policies to remove age content that allowed Frankie to read inappropriate stories on their platform on the day of her death featuring , an act which she goes on to complete herself. 4 CIRCUMSTANCES OF THE DEATH Frances Rose Thomas (Frankie) was a vulnerable teenager with a number of significant underlying difficulties including childhood trauma, high functioning autism, oppositional behaviour and impulsivity. Stepping Stones School is a school for students with moderate physical or learning difficulties. Frankie was offered a place in year 8 and started in April 2016 with an Educational Care Plan in place. Throughout her time at the school Frankie often refused to attend lessons and at the time of her death rarely attended more than one lesson a week. When not attending lessons, she was left on her own without any formal supervision. During this time, she had access to a school computer and an iPad. During the Inquest I heard evidence Frankie only had access to the during school time using electronic devices supplied by the school. There was an e-security system in place for school computers but it was not monitored by nominated safeguarding leads. This allowed Frankie (as it did for all students) to freely access the observation as to what websites were being accessed and for an assessment to be made of their appropriateness. Furthermore, the iPads had no e-security system in place at all, again allowing Frankie to freely access the without any supervision. without any On the day of her death, Frankie was found to have accessed The stories that Frankie accessed on this platform featured . After school Frankie went home and undertakes a similar act resulting in her death on 25th September 2018. 5 CORONER’S CONCERNS 1. I heard evidence that the Department of Education have devolved responsibility for e-security systems with schools having to ‘tender’ for web filtering software and hardware. However, the guidelines issued by the Department of Education require updating and are insufficiently robust to ensure their effectiveness and meet the changing demands of e-security in schools. 2. There is a wide range of software vendors providing different lists of blocklists with different vendors enabling different categories with no oversight or regulatory guidance by the Department of Education as to what ‘blocklists’ are either acceptable and/or suitable for a school environment. 3. is not a specifically blocked and not only can it be accessed by Key Stage 4 students there is encouragement to do so in some schools. However, I heard evidence that the sites Frankie . accessed through independent scrutiny by Furthermore, to remove age inappropriate stories put on their inadequate there is platform. 4. Some websites are only blocked when there is a particular key word in the URL If the relevant trigger word (e.g. ) is not there it makes it difficult for the filter to ‘see’ the content of the website to be able to block it, hence why stories on could be read. However, there are software systems available that acts as a ‘key logger’ and ‘screen reader’. Whilst this will not block the site it will generate a report to the nominated safeguarding individual for further action. Yet it has not been considered or is part of the guidelines issued by the Department of Education 5. In summary, on the evidence I heard there appears to be inadequate regulatory oversight with now outdated guidance issued by the Department of Education with regard to robust standards of e-security systems within schools. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the people listed in paragraph one have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES I have sent a copy of this report to the following: 1. 2. Stepping Stones School 3. 4. The Chief Coroner In addition to this report, I am 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, he believes, may find it useful or of interest. You may make representations to me at the time of your response, about the release or the publication of your response by the Chief Coroner. Signed: Karen Henderson DATED this 26th day of November 2021
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.
Rt Hon Nadhim Zahawi MP Secretary of State Sanctuary Buildings Great Smith Street Westminster London SW1P 3BT www.education.gov.uk/contactus/dfe Dr Henderson Assistant Coroner Dear Dr Henderson 21 January 2022 I received your Prevention of Future Deaths Report, regarding the tragic death of Frances Rose Thomas, on 6 December 2021. This is a heart-breaking case, and I share your concerns about the widespread availability of content online that promotes and advertises methods for suicide and self-harm. My thoughts are with Frances’ family and everyone that knew her. I would like to assure you that the department takes the issues raised in the report very seriously. My department’s Keeping Children Safe in Education (KCSIE) statutory guidance places a legal obligation on all schools and colleges to safeguard and promote the welfare of children. The breadth of issues classified within online safety is considerable but can be categorised into four areas of risk which are: Content, Contact, Conduct and Commerce. KCSIE is clear that schools and colleges should consider how online safety is reflected as required in all relevant policies and procedures and that governing bodies and proprietors should be doing all that they reasonably can to limit children’s exposure to risks from the school’s IT system. As part of this requirement, governing bodies and proprietors should ensure their school has appropriate filters and monitoring systems in place. To help schools understand what ‘appropriate’ might look like, KCSIE signposts to further detailed guidance from the UK Safer Internet Centre. KCSIE is also clear on the options open to schools when considering monitoring. This ranges from physical monitoring, to log file information monitoring, to active (school led) and pro-active (third party led) monitoring. The appropriateness of any filter and monitoring systems is rightly a matter for individual schools. The needs of individual schools will be unique to their own local circumstances. For example, a small rural school’s filtering and monitoring needs will be different to that of a large urban school and the needs of primary schools will be different to the needs of secondary schools. School leaders are best placed to decide what will be appropriate for their school and the needs of their children having regards to the strong expectations set out in KCSIE. However, I am very aware that technology in this area evolves and changes rapidly and it is important that schools do not lose sight of this. As such, KCSIE is clear on the importance of a whole school approach to online safety. As well as filtering and monitoring, schools and colleges should also consider staff training, annual risk assessments reflecting the risks children face, educating children to navigate the online world safely, and a clear policy on the use of mobile technology. KCSIE signposts schools to tools and additional advice in this space. This includes, the “360 safe website”, which provides a free online safety self-review tool (12,575 schools in England are signed up), it can be found here: https://360safe.org.uk/. In addition, the UK Council for Internet Safety has published “Online safety in schools and colleges: Questions for the governing board” which helps governors to challenge their senior leadership teams on the effectiveness of their schools online safety approach. We have significantly strengthened online safety in KCSIE in recent years - especially in 2021. This includes considering how online safety is reflected as required in all relevant policies and considering online safety whilst planning the curriculum, any teacher training, the role and responsibilities of the designated safeguarding lead and any parental engagement. We continue to review what more we can do to support schools and colleges and see where we can strengthen the guidance further. On 11 January, we launched a public consultation on KCSIE which runs until 8 March. To help us build the evidence base, we have included a question specifically relating to filtering and monitoring systems, which asks schools if they feel able to make informed decisions on which filtering and monitoring systems your school or college should use? Following consultation, we plan to publish revised guidance later this year. Furthermore, to support schools to have the appropriate safeguarding systems in place, under both child and data protection legislation, we will also be launching a set of digital, data and technology standards from Spring 2022, including standards on data and cyber security, and how to support more robust monitoring and filtering. Through consultation with the education and technology sector, we will explore options on how to ensure schools meet these standards to support system-wide safeguarding policies and how we can further support them to understand and improve their digital environments. In May 2021, the government published the draft Online Safety Bill, which will give tech companies new responsibilities to protect their users. It will apply to services which host user-generated content or facilitate user-to-user interactions, as well as to search services. Services in scope will have to remove and limit the spread of illegal content, such as content which assists or encourages suicide. The strongest protections in the Bill are for children. Where in-scope companies are likely to be accessed by children, they will be required to do far more to protect children from content and activity which is legal but may be harmful to them, such as bullying and the promotion of self- harm online. We have confirmed our decision to appoint Ofcom as regulator and our intention to give them a range of enforcement powers which will include substantial fines and, where appropriate, business disruption measures (including blocking). There will also be a criminal offence for senior managers who fail to ensure their company complies with Ofcom’s information requests, to push strong compliance in this area. The Bill was subject to pre-legislative scrutiny by a Joint Committee of MPs and Peers, who reported with their recommendations on 14 December 2021. We are considering fully and carefully these recommendations and are committed to introducing the Bill as soon as possible. In the meantime, we are working closely with Ofcom to ensure that the implementation of the framework is as short as possible, following passage of the legislation. We are also clear that companies should not wait for the legislation to protect their users online. We are also working with the Children’s Commissioner to support parents to help their children navigate the internet safely and recently met with technology companies to ask them to do more to keep young people safe, ahead of the Online Safety Bill coming into effect. The Children's Commissioner is working on her final recommendations to us and to DCMS, which we will fully consider and respond to in due course. Let me turn now to your concerns about the periods Frankie was left unsupervised. There is an expectation that when in school, children should be in class. We do, however, recognise that there may be occasions where an exception is made for some children as it may not be in their best interests to be in class. That said, even when not in class, children should still have access to suitable learning with appropriate support and supervision. In deciding what was appropriate we would expect a school or college to take account of any vulnerabilities and complex needs that a child might have. The government recognises that more broadly the current Special Educational Needs and Disabilities (SEND) system could be improved, we are therefore currently conducting a SEND Review covering a wide range of SEND issues and expect to publish proposals from that Review for public consultation in a Green Paper in the first 3 months of 2022. Finally, with regards to the concerns raised specifically in relation to WATTPAD, I must advise that this issue falls outside of this department’s remit but has been passed to DCMS for its consideration, I am also aware that DCMS is working closely with DHSC on tackling harmful suicide/self-harm content online. Yours sincerely, Rt Hon Nadhim Zahawi MP Secretary of State for Education
See every Prevention of Future Deaths report matching Suicide (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.