Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0422, written 20 Dec 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Dec 2021 |
|---|---|
| Reference | 2021-0422 |
| Deceased | Oliver Weston |
| Coroner | Dr James Adeley |
| Coroner area | Lancashire & Blackburn with Darwen |
| Category | Child Death (from 2015) · Mental Health related deaths · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Senior Coroner for Lancashire & Blackburn with Darwen
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO: OFSTED
1
CORONER
I am Dr James Adeley, Senior Coroner for Lancashire & Blackburn with Darwen
CORONER’S LEGAL POWERS
2
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 4th June 2021 I commenced an investigation into the death of Oliver Brassington Weston, 17
years of age. The investigation concluded at the end of the inquest Thursday, 16 December
2021 . The conclusion of the inquest was:
"Oliver Brassington Weston died on the evening of Friday, 22 March 2019 at Cumbria
View House by the
were unclear as to
was applied but it was an impulsive act."
. Oliver's intentions
4
CIRCUMSTANCES OF THE DEATH
Oliver Brassington Weston was a looked after child placed in a home by Stockton Borough
Council. On one and 14 February 2019 Oliver undertook
. On the evening of 22 March 2019 Oliver, in an impulsive act,
.
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. –
known to OFSTED were a key line of enquiry
[BRIEF SUMMARY OF MATTERS OF CONCERN]
(1) there was no documented evidence as to whether a monitoring or inspection visit was
required following the death of a looked after child
(2) the preplanning of the visit was deficient in that there was no indication that the four potential
episodes of
(3) the safeguarding documentation, which was entirely relevant, was not considered by the
inspector
(4) other significant information indexed in the file, such as an annual psychological review, was
not considered by the inspector
(5) in almost every instance where OFSTED was critical of the Home it was either found to be
based on insufficiency of enquiry, misinterpretation of the available evidence or drawing
unsupportable conclusions from the available documentation resulting in OFSTED accepting that
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
none of the breaches of the Regulations could be sustained against the Home.
(6) on review by an inspector familiar with the home and a senior manager, a lack of critical
appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have
been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns
were raised in the Regulation 44 reports
(7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which
was relied upon by the senior manager in not publishing this report. OFSTED has provided no
guidance to senior managers as to what constitutes "exceptional circumstances" which in this
instance was taken to include the death of a child: in almost all other looked after child deaths,
the death of the child was not sufficient to constitute "exceptional circumstances". A lack of
guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should
be published
(8) following an unannounced monitoring visit where the manager of the Home and the
Responsible Individual were not present, no attempt was made to clarify any matters of concern
with such individuals
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe 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
1 March 2022. 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 Chief Coroner and to the following Interested Persons
family and to the LOCAL SAFEGUARDING BOARD (where the deceased was under 18)].
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 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.
9
Dated 20 December 2021
Signature
for Lancashire & Blackburn with Darwen
Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB
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