Oskar Nash

Re : OSKAR MILES NASH, DECEASED  

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. The Chief Executive Officer of Surrey and Borders Partnership NHS

Foundation Trust [in relation to Concerns 1 to 5 below]

2. Chief Executive Officer of Surrey County Council [in relation to

Concerns 6 to 10 below]

3. Chief Executive Officer of Surrey Heartlands Clinical Commissioning

Group [in relation to Concern 10 below]

4. The Chair of the National Child Safeguarding Review Panel [in

relation to Concern 10 below]

5. Secretary of State for Education [in relation to Concerns 7, 10, 11 and

12 below]

6. Secretary of State for Health and Social Care [in relation to Concerns

10 and 12 below]

1  CORONER 

I am Richard Travers, HM Senior Coroner for Surrey. 

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7 of Schedule 5 to the Coroners and Justice 

Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 

2013. 

 3 

INVESTIGATION and INQUEST 

I commenced an investigation into the death of Oskar Miles Nash. The inquest 

concluded on the 10th September 2021 when I found that the medical cause of 

death was - 

Ia Multiple Traumatic Injuries 

and my conclusion as to the death was that - 

Oskar Nash died as a result of Suicide contributed to by neglect on  the part of 
Surrey and Borders Partnership NHS Foundation Trust’s Child and Adolescent 
Mental Health Service. 

Oskar Nash’s death was more than minimally contributed to by the failures of : 

(i) 

Surrey and Borders Partnership NHS Foundation Trust’s Child and 
Adolescent Mental Health Service :  

To undertake a clinical assessment of Oskar’s mental and emotional   
health at any stage, despite a series of requests for them to do so, and a 
consequential failure to diagnose, treat, monitor and otherwise support 
Oskar as necessary, in order to minimise his risk of suicide. 

(ii) 

Surrey County Council’s Special Educational Needs Department :  

(a)  To ensure that Oskar’s Educational, Health and Care Plan 

contained sufficient and updated information about his mental 
and emotional health needs and his risk of suicidal ideation, 
and the provision required to meet those needs, and  

(b)  To place Oskar in an appropriate school, rather than in March 

2019 his inappropriate placement in a mainstream school which 
did not have the facilities or expertise sufficiently to meet his 
complex needs. 

(iii) 

Surrey County Council’s Children’s Services Department and Targeted 
Youth Support Team :  

(a) To complete the required assessments following Oskar’s 
referral in November 2019, and to provide any effective 
intervention or support, and 

(b) To reallocate the management of his case to a Registered Social 
Worker following escalation of Oskar’s risk level in the course of 
November 2019. 

(iv) 

St. Dominic’s School and Cobham Free School : 

To ensure that there was a sufficient sharing of information about 
Oskar’s history, special needs and current situation, prior to his 

 
 
 
 
 
 
 
 
 
 
 
 
 transfer from a special needs school to a mainstream school in 
March 2019. 

I subsequently held a hearing to receive evidence relating to the prevention of 

future deaths and this was concluded on the 7th December 2021, with time allowed 

subsequently for written submissions. 

4  CIRCUMSTANCES OF THE DEATH 

Oskar Nash was 14 years old when he died. He had been diagnosed with autism at 
the age of 4 years and he suffered associated high anxiety throughout his life. It is 
likely that he also had one or more undiagnosed emotional or mental health 
condition(s). Oskar had a very significant history of periodic suicidal ideation and 
a history of self-harm, the risk of both of which receded when his needs were 
sufficiently supported. 

Oskar was well known to the Child and Adolescent Mental Health Service and to 
Children’s Services, having been the subject of a number of referrals to both. His 
education was managed by the Special Educational Needs Department of his local 
authority as he had been issued with an Educational, Health and Care Plan. All 
state agencies concerned with Oskar had knowledge of his history of suicidal 
ideation. 

In March 2019 Oskar transferred from a special needs school to a mainstream 
school. Initially he appeared to cope, but from early November 2019 onwards, he 
regularly refused to attend school and a period of escalating risk followed. 
Referrals were made to CAMHS and Children’s Services but Oskar did not 
receive any effective support.  

 On the 9th January 2020, Oskar Nash gained access to an area of 

 and, a short time later, at about 17.06 hours, he deliberately moved 

. His body was found 

the following morning. 

Full details of the events and failings which lead to Oskar Nash’s death are 
set out in my “Factual Findings and Conclusions” document, a copy of which 
is sent with this report. 

5  CORONER’S CONCERNS 

The evidence heard at the inquest revealed many matters giving rise to concern.  
The evidence received at the prevention of future deaths hearing showed that 
many of those concerns have been addressed.  

 
 
 
 
 
 
 
 
 
 
 
 
 However, in my opinion the following concerns remain and give rise to a 
continuing risk that future deaths could occur unless action is taken. In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows :  

A.  Surrey and Borders Partnership NHS Foundation Trust 

Concern 1 
The evidence at the inquest revealed that the staff responsible for the triage of 
referrals to child mental health services had insufficient understanding of Autism, 
its links to co-morbid mental health conditions, self-harm and suicidal ideation, 
and how to communicate with an autistic child. I have been told that the triaging 
process is now undertaken by an “Access and Advice Team” but I am concerned 
that there continues to be no requirement for the staff in that Team to undertake 
relevant Autism training on a mandatory basis. 

Concern 2  
The evidence at the inquest revealed that, despite a series of referrals to child 
mental health services over many years, Oskar Nash never received the clinical 
assessment he needed. I have been told that the system now in place ought to 
result in a child such as Oskar being seen and assessed by a clinical team. I am 
satisfied that the introduction of the Access and Advice Team, in the context of 
the new Mindworks service, is intended to ensure that a referred child’s needs are 
properly identified and met.   

However, on the basis of the evidence I heard at the prevention of future deaths 
hearing, including from a special needs school which has experience of referring 
its pupils, I am concerned that there is an ongoing risk that some referrals may be 
inappropriately closed (for example because the child, at an early stage, declines 
to engage) or inappropriately referred to non-clinical partner agencies. In this 
context, I am concerned that there is a lack of specific monitoring of what 
proportion of referred children reach a clinical team and the extent to which the 
outcomes match the expectations of the referrers (so that any ongoing “barriers” in 
the system, which may be preventing proper access to the clinical teams, can then 
be identified and eliminated). 

Concern 3 
The evidence showed that a referral to the child mental health services is triaged 
initially as being crisis, urgent, priority or routine. The criteria for crisis, urgent 
and priority referrals are specific and narrow and, consequently, the great majority 
of referrals are categorised as routine. I have been told that the routine referrals 
are automatically categorised as “low risk”. I am concerned about this as it is clear 

 
 
 
 
 
 
 from the evidence that a child may not meet the criteria crisis, urgent or priority 
but, like Oskar Nash, may nevertheless be at a high or medium risk of harm. The 
Trust is currently receiving a high volume of referrals and so there is a 
considerable waiting time for its “routine” cases to be addressed. It seems 
inevitable, therefore, that there are children in this category who have been 
wrongly assumed to be at low risk of harm but who, in fact, face a high risk of 
harm which is currently unrecognised and unmanaged. 

Concern 4 
I was told that the Standard Operating Procedure manual for the triage of referrals 
to children’s mental health services is to be updated to reflect the Trust’s new 
working practices but that this has not yet been done. I am concerned that 
important changes to the system of work (for example, the vital requirement that a 
referred child’s records are reviewed before any triaging decision is made and the 
child/family are spoken to) are not yet established in written guidance.  

Concern 5 
The evidence at the inquest showed that the clinicians who were responsible for 
ensuring that Oskar Nash’s medical conditions, including his risk of self-harm and 
suicide, and his consequential needs, were properly and sufficiently recorded in 
his Education, Health and Care Plan, failed to do so; this was in part because they 
did not fully understand their role and obligations in this regard.  

On the basis of the evidence at the prevention of future deaths hearing, I am 
concerned that there continues to be a lack of understanding amongst the 
clinicians currently providing medical advice as part of the EHCP process as to 
their role in that process. I am further concerned that there is in place no 
programme for the training or monitoring of these clinicians in relation to these 
responsibilities. 

B.  Surrey County Council (and National) 

(i) Education and Special Educational Needs Department 

Concern 6 
The evidence at the inquest revealed that the staff in the Education / SEN 
Department, including SEN caseworkers, had insufficient understanding of 
Autism, its links to co-morbid mental health conditions, self-harm and suicidal 
ideation, and how to communicate with an autistic child. I am concerned that there 
continues to be no requirement for the staff to undertake relevant Autism training 
on a mandatory basis. 

 
 
 
 
 
 
 
 
 Concern 7 
The evidence at the inquest showed that, in the months before his death, Oskar 
Nash was moved from a special needs school and placed into a mainstream school 
which did not have the facilities or expertise sufficiently to meet his complex 
needs. I found that the inappropriate placement, by SCC, of Oskar into the 
mainstream school contributed to his death. 

Prior to the placement, the mainstream school had been provided with Oskar’s 
Educational, Health and Care Plan, but this failed adequately to identify and 
record his mental and emotional health concerns, his risk of suicidal ideation, his 
consequential needs, and the provision required to meet those needs, and it had 
not been updated to reflect a series of subsequent reviews of the Plan and 
significant subsequent events. The mainstream school was not provided with any 
of the extensive and informative records from the special needs school from which 
he was being moved.   

I was told by the mainstream school that, had they seen the records held by his 
special needs school, they would have recognised their inability to meet his needs 
and informed the SEN Department accordingly. 

At the prevention of future deaths hearing, I was told that it continues to be the 
case that a prospective school will usually be provided by the SEN Department 
with the child’s EHCP only. Further, it was apparent that there is a lack of clarity 
as to the extent to which a current school may or should provide records or 
information to a prospective school. 

I am concerned that there is an ongoing risk that placements of children with 
EHCPs are being made on the basis of inadequate information and record sharing. 
On the evidence before me, it was clear that, even if an EHCP were 
comprehensive and fully updated (which may not be the case), it is unlikely to 
contain all matters of relevance to the question of a prospective school’s ability to 
meet the child’s needs. 

I was given no good reason why fuller information and record sharing, sufficient 
to ensure that the prospective school can properly assess its ability to meet the 
child’s needs, should not take place before any child with an EHCP is placed in a 
new school. I am concerned that there is no system in place, locally or nationally, 
to ensure this is achieved by the relevant SEN department for every child with an 
EHCP. I am also concerned that there is an ongoing lack of clarity as to schools’ 
powers and duties to share information and documents, and any data protection 
ramifications this may have. 

 
 
 
 
 
 
  
 (ii) Children’s Services Department 

Concern 8 
The evidence at the inquest revealed that the staff in SCC’s Children’s Services 
Department, including Social Workers and other Team members, had insufficient 
understanding of Autism, its links to co-morbid mental health conditions, self-
harm and suicidal ideation, and how to communicate with an autistic child. I am 
concerned that there continues to be no requirement for the staff to undertake 
relevant Autism training on a mandatory basis. 

Concern 9 
At the inquest I found that following Oskar Nash’s final referral to SCC’s 
Children’s Services Department, which was made approximately two months 
before his death, there was a failure to appreciate the seriousness of his situation 
and the risks arising, and a consequential failure to allocate his case appropriately. 
I found that this contributed to his death. The inappropriate allocation resulted, in 
part, from the application of SCC’s then “threshold of needs” document, which 
was used to inform the level at which support should be provided. 

At the prevention of future deaths hearing, I heard evidence about SCC’s revised 
“threshold of needs” document, as well as the recent guidance (including a 
“toolbox”) in relation to suicidality, which has been introduced since Oskar’s 
death.  

Despite these changes, I remain concerned that the “threshold of needs” document 
does not adequately and clearly reflect the known risks of mental health 
difficulties, self-harm, and suicidal ideation for autistic children (given their 
prevalence in this group of children) and that, consequentially, there is an ongoing 
risk that an autistic child in these circumstances will be allocated an insufficient 
level of support, as was the case for Oskar. 

C.  Surrey County Council and Surrey Heartlands Clinical 

Commissioning Group (and National) 

Concern 10 
At the prevention of future deaths hearing, I heard evidence concerning the post-
death reviews conducted into Oskar Nash’s death by the Surrey Child Death 
Review Partnership Team and the Surrey Safeguarding Children Partnership. The 
evidence showed that neither process resulted in a sufficient or effective 
investigation of the death; I consider that the evidence shows that fact finding was 

 
 
 
 
 
 
 
 
 
 superficial, there was no meaningful analysis of the part played by statutory 
agencies in the causation of his death, and only very limited learning was 
identified.  

Ineffective review by the child death review processes results in the risk of further 
deaths in similar circumstances and I am concerned that the local and/or national 
process, guidance and oversight are insufficient to ensure that an effective post-
death investigation, which should not be dependent on the inquest process, is 
achieved in all cases.  

D.  National Issues 

Concern 11 
From the evidence I heard at the inquest and the prevention of future deaths 
hearing, it was apparent that the national “Working Together” guidance focuses 
on children who are in need of safeguarding by reason of risks within the home or 
from other parental failures to keep the child safe. It was apparent that the 
consequential approach tends to look critically at the child’s family and parent(s) 
and their parenting skills, and that this is likely to be inappropriate if the child is in 
need through disability. I consider that this had a detrimental impact on the 
approach of agencies to Oskar and his family. 

I am concerned that “Working Together” does not provide clearer guidance 
specifically for the safeguarding of children with disabilities, including Autism, 
and the approach to be taken by agencies to parents and families. 

Concern 12 
The evidence at the inquest revealed a widespread lack of knowledge and 
understanding of Autism, its links to co-morbid mental health conditions, self-
harm and suicidal ideation, and how to communicate with an autistic child. There 
was a lack of training across all the state agencies from which I heard. At the 
prevention of future deaths hearing, I heard evidence of more training being 
available, but also of an ongoing absence of comprehensive, relevant and 
mandatory training.  

I was told that the National Autism Strategy does not currently include a 
timetabled commitment for relevant mandatory Autism training to be provided to 
all state agencies working directly with autistic adults and children. 

I am concerned that this poses an ongoing risk to autistic children and their ability 
to access the services they require for their support, welfare, and safeguarding. 

 
 
 
 
 
 
 
 
 
 ACTION SHOULD BE TAKEN 

6 

In my opinion action should be taken to prevent future deaths by addressing the 

concerns set out above and I believe your organisation 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 the 28th March 2022.  I, as 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, to the following Interested 

Persons and to the other organisations listed below which may find it useful or of 

interest: 

The Chief Constable of Surrey Police 

The Independent Office for Police Conduct 

College of Policing (FAO the Autism Lead) 

Cobham Free School 

St. Dominic’s School 

Relate West Surrey 

Relate 

British Transport Police 

I am also under a duty to send a copy of your response to the Chief Coroner.  

I may also send a copy of your response to any other person who I believe may 

find it useful or of interest.  

 
 
 
                                                                              
 
 
 
 
 
 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 

31st January 2022                                                                       Richard Travers

25 March 2022 

Child Safeguarding  
Practice Review Panel 

Dear Mr Travers, 

Oskar Miles Nash, Deceased - Regulation 28 report to prevent future 
deaths 

I am writing further to your Regulation 28 report in relation to Oskar Miles 
Nash.  We note with concern your conclusion that Oskar died as a result of 
Suicide contributed to by neglect on the part of Surrey and Borders 
Partnership NHS Foundation Trust’s Child and Adolescent Mental Health 
Service, and that his death was more than minimally contributed to by the 
various failures of: Surrey and Borders Partnership NHS Foundation Trust’s 
Child and Adolescent Mental Health Service; Surrey County Council’s Special 
Educational Needs Department; Surrey County Council’s Children’s Services 
Department and Targeted Youth Support Team; and St Dominic’s School and 
Cobham Free School, as outlined in your report. 

We note your finding in Concern 10 that neither of the post-death reviews 
conducted into Oscar Nash's death by the Surrey Child Death Review 
Partnership Team and the Surrey Safeguarding Children Partnership resulted 
in a sufficient or effective investigation of the death; that fact finding was 
superficial, there was no meaningful analysis of the part played by statutory 
agencies in the causation of his death, and only very limited learning was 
identified. 

We agree with your conclusion that ‘ineffective review by the child death 
review processes results in the risk of further deaths in similar circumstances’, 
and note your concern that ‘the local and/or national process, guidance and 
oversight are insufficient to ensure that an effective post-death investigation, 
which should not be dependent on the inquest process, is achieved in all 
cases’. 

In our response to your report, we will outline the steps we have taken and 
continue to take, in conjunction with the Department for Education, local 
Safeguarding Partners and with other national and local stakeholders to 
improve the quality and effectiveness of the child safeguarding practice review 
process. We restrict our response to those areas which come within our 
purview as the National Child Safeguarding Practice Review Panel.  

We note the finding expressed within Concern 10 in relation to the child death 
review process, and note that responsibility for those processes rests with the 
Department for Health and Social Care, the National Child Mortality Database 

 team, and with the local Child Death Review Partners. While this is outside 
our remit, we recognise there are nevertheless considerable areas of overlap 
and we seek to work in collaboration with those responsible on areas of 
mutual interest so as to improve learning and reduce the risks of future death 
or harm to children. 

The purpose and remit of the National Child Safeguarding Practice 
Review Panel 

The National Child Safeguarding Practice Review Panel (hereafter the Panel) 
was established in 2018 as part of wider reforms to interagency working to 
safeguard children, as specified in the Children Act 2004 and amended by the 
Children and Social Work Act 2017. The purpose and remit of the Panel and 
the wider processes of local and national reviews are outlined in Chapter 4 of 
Working Together 2018.  

The purpose of reviews of serious child safeguarding cases is ‘to identify 
improvements to be made to safeguard and promote the welfare of children’. 
Working Together 2018 stipulates that ‘Reviews should seek to prevent or 
reduce the risk of recurrence of similar incidents’. It goes on to state that they 
‘are not conducted to hold individuals, organisations or agencies to account, 
as there are other processes for that purpose’. As such, these reviews are not 
intended to be investigations into the cause or circumstances of the death or 
serious harm, nor to determine whether any individual, organisation or agency 
was culpable. Nevertheless, at all stages of the safeguarding practice review 
process, both the local Safeguarding Partners, and we as a national Panel, 
seek to identify and learn lessons with a view to improving practice and better 
safeguarding and promoting the welfare of children. 

Working Together 2018 specifies that the responsibility for how the system 
learns the lessons from serious child safeguarding incidents lies at a national 
level with the Panel and at a local level with the Safeguarding Partners. As a 
Panel, we are responsible for identifying and overseeing the review of serious 
child safeguarding cases which raise issues that are complex or of national 
importance, and to maintain oversight of the system of national and local 
reviews and how effectively it is operating. 

The remit of the Panel and of the safeguarding practice review system is 
limited to reviewing serious child safeguarding cases which are defined as 
those in which: 

•  abuse or neglect of a child is known or suspected and 
• 

the child has died or been seriously harmed. 

The death of a child in which abuse or neglect is not known or suspected 
would therefore not come within the Panel’s remit, and responsibility for any 
review of such deaths sits with the child death review partners. Such cases 
may at times come to the notice of the Panel when, for example, it is not clear 
whether abuse or neglect may have contributed, or where there is 
nevertheless potential for learning in relation to safeguarding children. 

 
 
 
 
 
 
 Where a local authority in England is aware of a serious child safeguarding 
case that meets the above criteria, they must notify the Panel and the local 
safeguarding partners within five working days. On receiving notification of a 
serious child safeguarding case, the safeguarding partners should promptly 
undertake a rapid review of the case. The aim of this rapid review is to: 

•  gather the facts about the case, as far as they can be readily 

established at the time; 

•  discuss whether there is any immediate action needed to ensure 

children’s safety and share any learning appropriately; 

•  consider the potential for identifying improvements to safeguard and 

promote the welfare of children; and  

•  decide what steps to take next, including whether or not to undertake a 

child safeguarding practice review. 

The Panel’s expectation is that these rapid reviews will be completed and 
submitted to the Panel within 15 working days. It is important to note that the 
timeframes for these rapid reviews are tight, so as to ensure that any learning 
coming out of the review process is not delayed and that the system of 
learning proceeds promptly and efficiently. This means, however, that any fact 
finding will, necessarily, be limited and the rapid review is geared towards 
identifying immediate learning. Should the rapid review identify the potential 
for further learning, then the expectation is that this will be explored through a 
Local Child Safeguarding Practice Review (LCSPR).  

The LCSPR is a more in-depth review, commissioned by the safeguarding 
partners, where they determine that there is potential for further learning to 
identify improvements to practice. These reviews should take a thorough and 
systematic approach to learning from the case, and should seek to involve the 
family as well as relevant practitioners and managers. They should be 
completed within six months, published and submitted to the Panel. The 
reviews should be carried out by an independent reviewer, using principles of 
systems methodology and in a way that enables the review to look at and 
analyse frontline practice as well as organisational structures and learning. 
The reviews should be proportionate to the circumstances of the case, focus 
on potential learning, and establish and explain the reasons why the events 
occurred as they did.  

Local Safeguarding Partners have a duty to ensure that the review is of 
satisfactory quality. The Safeguarding Partners also have a responsibility to 
disseminate learning from the review and to take appropriate action in 
response to the findings.  

As part of its remit to maintain oversight of the system and how effectively it is 
operating, the Panel receives and appraises all rapid reviews and LCSPRs. 
We provide feedback to the local Safeguarding Partners on the quality of both 
rapid reviews and LCSPRs, and identify, collate and disseminate learning 
arising from these reviews. 

 
 
 
 
 
 Actions taken to date to improve learning 

Since its inception, the Panel has been sent over 1500 rapid reviews and we 
have seen the publication of more than 100 LCSPRs. In 2021 there were a 
total of 398 rapid reviews, of which 156 related to fatal cases and 242 to non-
fatal serious harm. In 125 cases (31%), the local Safeguarding Partners 
decided to commission an LCSPR. 

As a Panel we have had significant concerns about both the quality and 
timeliness of both the rapid reviews and the LCSPRs. While we have seen 
some excellent examples of high-quality review and learning submitted within 
the specified timeframes, we have also seen rapid reviews and LCSPRs that 
are tardy, unfocused and insufficiently analytic. We recognise that some of 
this has been due to Safeguarding Partners and reviewers getting used to the 
new system of reviews. In addition, the Covid-19 pandemic and consequent 
lockdowns had a particular impact on the ability of Safeguarding Partners to 
complete both rapid reviews and LCSPRs in a timely manner. Nevertheless, 
we remain concerned that, too often, the reviews are not of sufficient rigour 
and quality to identify meaningful learning and to drive relevant improvements 
to children’s safeguarding. 

In 2018 the Panel produced detailed practice guidance which outlined the 
process of reviews and our expectations for what makes for good quality 
reviews. We are in the process of updating this guidance in light of our 
learning since 2018.  

In response to each rapid review and LCSPR which we receive as a Panel, 
we write to the Safeguarding Partners, providing feedback on the content and 
quality of the review, any learning arising from it, and actions we are taking as 
a Panel in response to any national issues identified. While initially much of 
this feedback was focused on the process and criteria for reviews, we have 
increasingly been more detailed and focused on issues of quality and 
learning. In cases which are particularly complex, or where we as a Panel 
have particular concerns about the quality of the review, we will often engage 
directly with the Safeguarding Partners through telephone calls or online or 
face-to-face meetings, offering advice, guidance and support. Where we 
deem a review to be of insufficient quality, we may ask the Safeguarding 
Partners to amend the report, or take further action to achieve more 
meaningful learning, or ask for evidence of implementation and impact of 
action in response to any recommendations. 

Over the past two years we have sought to improve our communication with 
Safeguarding Partners in order to improve the quality of and learning from the 
review process. We have instituted a system of regional working with 
individual Panel members assigned as leads to each of the nine government 
regions. This has been backed up by a series of regional webinars, in which 
we have explored learning coming from both local and national reviews as 
well as issues of quality and process.  

In addition to our oversight of the system of local reviews, as a Panel we are 

 
 
 
 
 
 responsible for commissioning national reviews into cases which raise issues 
of national importance. To date we have completed and published three 
national reviews, each of which has been a thematic review, drawing on a 
number of cases relating to a particular theme: sudden unexpected death in 
infancy (SUDI); child criminal exploitation; and non-accidental injury in infants 
aged under one. Each of these thematic national reviews has sought to 
identify relevant learning to inform practice and system improvement within 
the relevant area. While the Panel has no immediate plans to announce a 
national review into suicide it remains a theme in which we have a very keen 
interest and we will continue to analyse the cases which we see to consider if 
a practice briefing or more detailed piece of thematic work in this space would 
aid system learning. 

Ongoing and planned actions to improve learning 

As a Panel we have noted improvements in both the timeliness and quality of 
rapid reviews over the past year. We continue to feedback to local 
Safeguarding Partners on the content and quality of their rapid reviews.  
We are now also receiving significant numbers of completed LCSPRs. To 
date, very few of these have been completed within the required timeframe of 
six months, and many have been delayed by a year or more. We consider this 
unacceptable and are working with Safeguarding Partners to ensure that they 
take a more streamlined and focused approach to learning through the 
LCSPRs, but we are aware that there is still a long way to go. 

In recognition of the ongoing issues around timeliness and quality, and taking 
note of your expressed concerns regarding the Oskar Nash rapid review, we 
are currently updating our practice guidance, with a much greater focus on 
issues of quality and learning in the reviews. We are planning also to publish 
some anonymised examples of good quality rapid reviews as exemplars of 
good practice.  

We continue to monitor the learning from all rapid reviews and LCSPRs and 
are in the process of developing an observatory function to provide up-to-date 
data and information on all serious safeguarding cases, along with a case 
tracking system to enable us to monitor and report on the progress of reviews. 
We have, to date, and will continue to commission national analyses of the 
learning from rapid reviews and LCSPRs, and both of these pieces of work 
include some analysis of the quality of those reviews. We publish the findings 
of these analyses as part of our annual report. 

We continue to commission national thematic reviews and currently are 
undertaking a review of domestic abuse which we intend to publish shortly. In 
addition, we are carrying out two case-specific national reviews – one into the 
deaths of Arthur Labinjo-Hughes and Star Hobson, and one into safeguarding 
children with disabilities and complex health needs in residential settings - 
both of which will report later this year. 

 
 
 
 
 
 Conclusion 

We note that the rapid review on Oskar Nash was undertaken in January 
2020. A lot has happened since then, and it is our impression that there have 
been significant improvements in the quality of both rapid reviews and 
LCSPRs over that time. We recognise, however, that there is still a lot to be 
done to ensure that the system of safeguarding practice reviews is more fit for 
purpose. We welcome this Regulation 28 report as a stimulus both for us as a 
Panel and for all local Safeguarding Partners to improve the quality of reviews 
and the overall learning coming from them. 

I hope that this letter provides you with relevant and helpful information about 
the national system of reviews of the circumstances around the deaths of 
children as a result of abuse or neglect.   

Yours sincerely, 

, Chair – Child Safeguarding Practice Review Panel

Rt Hon Nadhim Zahawi MP 
Secretary of State 

Sanctuary Buildings   Great Smith Street   Westminster   London   SW1P 3BT 

   www.education.gov.uk/contactus/dfe 

Mr Richard Travers 
H.M. Senior Coroner for the County of Surrey
Surrey Coroner’s Service
HM Coroner's Court
Station Approach
Woking
Surrey
GU22 7AP

Dear Mr Travers, 

28 March 2022 

I am writing in response to your Regulation 28 report concerning the death of 
Oskar Nash. This is a truly tragic case. I am grateful for the expertise and rigor 
you brought to the inquest and I wish to express here my sincere condolences to 
Oskar’s family and friends. 

I have noted the matters of concern you have listed for the Department for 
Education. In response I have set out information relating to two substantive 
reviews, of special educational needs and disability and of the children’s social 
care system, that will lead to significant reform of the support available for the 
most vulnerable of children and young people. 

Further, I can confirm that the Child Safeguarding Practice Review Panel has 
received your notice and will be responding to you (in relation to Concern 10) in 
due course. The national panel is responsible for identifying and overseeing the 
review of serious child safeguarding cases which, in its view, raise issues that are 
complex or of national importance and maintains oversight of the system of 
national and local reviews and how effectively it is operating.  

Review of support for children with special educational needs 

We note the points in your report (under Concern 7) about the system for 
preparing statutory Education, Health and Care (EHC) plans and for deciding 
which school a local authority should name in a plan. We agree the importance of 
identifying the wider lessons to be learnt from the events leading up to Oskar’s 
death. We recognise that it is crucial that any EHC plan in place for a child is 
aligned with, and supported by, wider plans put in place by health, children’s 

 social care or other agencies, including those which can respond in a crisis 
situation.  

There were clearly failings in Oskar’s case. We recognise that the current special 
education and disability system, established through the Children and Families 
Act 2014, does not consistently deliver the services needed by children and 
young people and their families. That is why we have undertaken a 
comprehensive review of how the system has evolved since 2014 and how it can 
be made to work best for all families, ensuring quality of provision is the same 
across the country. In doing so we have placed a clear focus on the importance 
of joined-up support, working in collaboration with the Department of Health and 
Social Care (and the Secretary of State for Health and Social Care, will be writing 
to you with regard to mandatory training in learning disability and autism 
(Concern 12)).  

The SEND review will be published in the form of a Green Paper that will be 
made available imminently.  It is critical that our proposals are tested publicly to 
get invaluable feedback and expertise from a wide range of perspectives, 
including sector professionals, children, young people and parents, before final 
decisions are made, and so the publication will launch a full public consultation of 
at least 12 weeks. The consultation will be hosted on citizen space, as with all 
government consultations, and will give ample opportunity for everyone to have 
their say.  

Independent Review of Children’s Social Care 

We are clear that nothing is more important than children’s welfare, and those 
who need help and protection deserve high quality and effective support as soon 
as a need is identified.  We recognise the need to make significant change to the 
current system to improve the lives and outcomes of those supported by 
children’s social care. That is why we have launched a bold, broad and 
independently led review that is looking at the needs, experiences and outcomes 
of the children and families it supports and what is required to make a real 
difference to their lives. In doing so, the review will contribute to ambitious and 
deliverable reforms, taking into account the sustainability of local services and 
effective use of resources and considering how the social care system responds 
to the needs of all children who are referred. It will address major challenges, 
including inconsistencies in nationwide practices and outcomes. 

The Review published its Case for Change in June 2021, setting out the key 
issues and inviting feedback from parties with an interest in the Review. The 
Case For Change: Your Feedback was published in October 2021 and Review’s 
full report is due to be published this Spring.   

 
 
 
 
 The Department will consider any necessary changes to statutory guidance, 
including revisions to Working Together to Safeguard Children (Concern 11), as 
part of that wider programme of reform, once it has received the full and final 
report and recommendations of the Review. Substantive revisions to guidance 
will be subject to full consultation. 

Thank you once again for highlighting your concerns surrounding Oskar’s death.  

Yours sincerely,    

Rt Hon Nadhim Zahawi MP 
Secretary of State for Education

Richard Travers 
HM Senior Coroner for Surrey 
Sent via email 

Leadership Office 
Woodhatch Place 
11 Cockshot Hill 
Reigate, Surrey 
RH2 8EF 

25 March 2022 

Dear Mr Travers  

Inquest touching the death of the late Oskar Nash 

I write in response to your Regulation 28 Report dated 31 January 2022 and thank you for the 
same. 

Each of the concerns directed to Surrey County Council has been fully considered. I set out 
below the response to each concern in turn. 

Concern 6 
The evidence at the inquest revealed that the staff in the Education / SEN Department, including 
SEN caseworkers, had insufficient understanding of Autism, its links to co-morbid mental health 
conditions, self-harm, and suicidal ideation, and how to communicate with an autistic child. I am 
concerned that there continues to be no requirement for the staff to undertake relevant Autism 
training on a mandatory basis. 

Response: 
On 30 November 2021 the Executive Director for Children Families, Lifelong Learning and 
Culture wrote to all staff in the Directorate setting out the Autism Awareness Training 
offer available for all staff in the Directorate. 

The training is now mandatory for all staff working directly with children and young 
people and must be completed by 31 March 2022.  The uptake of the training is being 
monitored for each individual. The awareness training must also be completed by all new 
starters as they join as a part of their mandatory training.  

The training captures: 

•

•

•

information on autism diagnoses, how the condition impacts the individual and
the challenges for people who work with or care for people with autism.

key issues such as the autistic spectrum, the causes of autism, autism and social
communication issues, autism and body language, facial expressions and tone of
voice, mind blindness, sensory issues, coping methods and the positives of
autism.

the different effects of the condition for those on the autistic spectrum and how to
support someone with dealing with those effects.

 • 

the potential link to mental health issues, anxiety, and self-harming.  

The training does not currently capture fully the link between autism and self harm or 
suicidal ideation, and the associated risks. The SCC Children’s Academy is currently in 
the process of reviewing the training required in order to equip all frontline workers to 
recognise this risk and is in the process of identifying the most appropriate further 
training package for relevant staff to broaden understanding around this. SCC is 
committed to rolling out this further training package at the very earliest opportunity. 

As part of the SCC All Age Autism strategy, significant additional funding has been 
secured to raise awareness and understanding of staff around autism generally.  

Concern 7 
The evidence at the inquest showed that, in the months before his death, Oskar Nash was 
moved from a special needs school and placed into a mainstream school which did not have the 
facilities or expertise sufficiently to meet his complex needs. I found that the inappropriate 
placement, by SCC, of Oskar into the mainstream school contributed to his death. 

Prior to the placement, the mainstream school had been provided with Oskar’s Educational, 
Health and Care Plan, but this failed adequately to identify and record his mental and emotional 
health concerns, his risk of suicidal ideation, his consequential needs, and the provision 
required to meet those needs, and it had not been updated to reflect a series of subsequent 
reviews of the Plan and significant subsequent events. The mainstream school was not 
provided with any of the extensive and informative records from the special needs school from 
which he was being moved.   

I was told by the mainstream school that, had they seen the records held by his special needs 
school, they would have recognised their inability to meet his needs and informed the SEN 
Department accordingly. 

At the prevention of future deaths hearing, I was told that it continues to be the case that a 
prospective school will usually be provided by the SEN Department with the child’s EHCP only. 
Further, it was apparent that there is a lack of clarity as to the extent to which a current school 
may or should provide records or information to a prospective school. 

I am concerned that there is an ongoing risk that placements of children with EHCPs are being 
made on the basis of inadequate information and record sharing. 
On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully 
updated (which may not be the case), it is unlikely to contain all matters of relevance to the 
question of a prospective school’s ability to meet the child’s needs. 

I was given no good reason why fuller information and record sharing, sufficient to ensure that 
the prospective school can properly assess its ability to meet the child’s needs, should not take 
place before any child with an EHCP is placed in a new school. I am concerned that there is no 
system in place, locally or nationally, to ensure this is achieved by the relevant SEN department 
for every child with an EHCP. I am also concerned that there is an ongoing lack of clarity as to 
schools’ powers and duties to share information and documents, and any data protection 
ramifications this may have. 

Response: 
When a change of school placement is being considered, the Council’s SEND 
department is required to share a comprehensive and accurate up to date EHCP 

 
 
 
 
 
 
 
 
 (including, where relevant, supporting information that is considered important) for the 
prospective school to consider. This could include supporting assessments and 
information resulting from the most recent annual review. These documents combined 
should provide a clear picture of the current needs of the child or young person and the 
arrangements needed to support their learning, meet their needs, and secure the planned 
outcomes.   

SEND Code of Practice para 9.82 states that advice from schools, colleges and other 
education or training providers will contribute to the development of an EHCP to ensure 
that it meets the child or young person’s needs, the outcomes they want to achieve and 
the aspirations they are aiming for.  SCC complies with this national requirement.  The 
intention is for the EHCP to contain all necessary information. 

Steps have been taken to better train SEND officers with a view to ensuring EHCPs are 
drawn properly with advice from the wide range of professionals named. Significant 
improvements in the quality of EHCPs have resulted. These EHCPs can then be relied 
upon to share all necessary information.   

There is no national requirement for the local authority to share child protection files or 
to require schools to do so.  

Keeping Children Safe in Education (DfE) 2021 paragraphs 105-113 sets out guidance to 
education providers on the subject of information sharing.  

At 110. KCSiE states: 
110. The Data Protection Act 2018 and UK GDPR do not prevent the sharing 
of information for the purposes of keeping children safe. Fears about sharing information 
must not be allowed to stand in the way of the need to safeguard and promote the 
welfare and protect the safety of children. 

To this end, any school wishing to seek further information from the current/prior school 
can request such information and the school receiving that request can make a decision 
about whether it is suitable to share such information in line with the guidance. This is a 
matter of professional judgment on a case by case basis.  

Given the sensitive nature of safeguarding files and child protection information, SCC 
does not consider that a blanket system of sharing such information for all children with 
an EHCP is necessary or appropriate in relation to the placement of a child in school. 
However, where a school considers that they require further information they can make 
this request by exception.    

Safeguarding concerns and/or child protection concerns should not form the basis of a 
decision of an educational provider as to its suitability to meet a child's need. It is a 
national expectation that all educational providers will be able to support children with 
concerns around self-harm and/or suicidal ideation including where this is co-morbid 
with other conditions, including autism.  Any child or young person could experience or 
develop suicidal ideation or self-harm at any time. This is, very sadly, a common 
occurrence and systems of support should be in place in every educational provider to 
support children in school with, where appropriate, the help of partners eg. mental health 
services. This national expectation and approach is set out in the Department for 
Education publication Promoting Children and Young People’s Mental Health and Well 
Being published 21 September 2021 (first published in 2015) and the referenced Public 
Health England Guidance published September 2021.  

SCC is in the process of reviewing its guidance to educational providers and has 
committed to incorporating in that guidance clearer information around the parameters 
within which information can be shared between educational providers and to highlight 

 
 
 
 
 
 
 
 
 
 that schools can, where considered appropriate, request additional information from a 
current/previous school. SCC is committed to concluding the review by May 2022. 

The SEND Code of Practice paragraph 9.89 states that mainstream education cannot be 
refused by a local authority on the grounds that it is not suitable. A local authority can 
rely on the exception of incompatibility with the efficient education of others in relation 
to maintained nursery schools, mainstream schools or mainstream post-16 institutions 
taken as a whole only if it can show that there are no reasonable steps it could take to 
prevent that incompatibility.  

In paragraph 9.90 the Code of Practice further sets out that, where the local authority 
considers a particular mainstream place to be incompatible with the efficient education 
of others, it must demonstrate, in relation to maintained nursery schools, mainstream 
schools or mainstream post-16 institutions in its area taken as a whole, that there are no 
reasonable steps that it, or the school or college, could take to prevent that 
incompatibility. Efficient education means providing for each child or young person a 
suitable, appropriate education in terms of their age, ability, aptitude and any special 
educational needs they may have. Where a local authority is considering whether 
mainstream education is appropriate (as opposed to considering the appropriateness of 
an individual institution) the term ‘others’ means the children or young people with 
whom the child or young person with an EHCP would be likely to come into contact on a 
regular day-to-day basis. Where a parent or young person has expressed a preference 
for mainstream education and it would not be incompatible with the efficient education of 
others, the local authority has a duty to secure that provision. 

Concern 8 
The evidence at the inquest revealed that the staff in SCC’s Children’s Services Department, 
including Social Workers and other Team members, had insufficient understanding of Autism, 
its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to 
communicate with an autistic child. I am concerned that there continues to be no requirement 
for the staff to undertake relevant Autism training on a mandatory basis. 

Response: 
The Coroner is respectfully referred to the response to Concern 6 above. The 
communication from the Executive Director for Children, Families, Lifelong Learning and 
Culture of 30 November 2021 was sent to all staff within the Directorate. This includes 
both staff within the Education department and those within the Children's Services 
Department. 

Equally, the further training to be offered addressing more specifically the link between 
autism and self-harm or suicidal ideation and the associated risks, will be rolled out to all 
relevant staff within both the Education department and the Children's Services 
Department. SCC is fully committed to ensuring that all relevant staff receive appropriate 
training around autism and the associated risks. 

Concern 9 
At the inquest I found that following Oskar Nash’s final referral to SCC’s Children’s Services 
Department, which was made approximately two months before his death, there was a failure to 
appreciate the seriousness of his situation and the risks arising, and a consequential failure to 
allocate his case appropriately. I found that this contributed to his death. The inappropriate 
allocation resulted, in part, from the application of SCC’s then “threshold of needs” document, 
which was used to inform the level at which support should be provided. 

 
 
 
 
 
 
 
 At the prevention of future deaths hearing, I heard evidence about SCC’s revised “threshold of 
needs” document, as well as the recent guidance (including a “toolbox”) in relation to suicidality, 
which has been introduced since Oskar’s death.  

Despite these changes, I remain concerned that the “threshold of needs” document does not 
adequately and clearly reflect the known risks of mental health difficulties, self-harm, and 
suicidal ideation for autistic children (given their prevalence in this group of children) and that, 
consequentially, there is an ongoing risk that an autistic child in these circumstances will be 
allocated an insufficient level of support, as was the case for Oskar. 

Response: 
In light of the concern raised, there has been a further review of the current ‘Effective 
Family Resilience’ document undertaken and careful consideration of the need to make 
changes to that document. At the current time, we do not believe there is a need to 
update the document in the level of need descriptions with additional definitions or 
criteria. However, we have reflected that adding some wording within the section on page 
8 (as outlined below) draws attention to the need to consider aggravating factors of 
mental health, suicidal ideation and autism which should weigh more on the assessment 
and need / risk grading rather than simply the initial referral trigger. 

‘The windscreen cannot replace professional curiosity, judgement or decision making 
and should not be used as a checklist or an assessment of need. The indicators of need 
are suggestions of the types of need a child and family may have. Sometimes their needs 
may include indicators from each of the levels, however combined, they may cause 
additional strain on the family (for example the impact of additional factors related to 
emotional wellbeing, mental health and or self-harm upon a child who has a diagnosis of 
autism) and following discussion with the family may indicate a higher level of support 
needed. Equally, there may be family strengths that are mitigating factors for the 
indicators’ 

We intend to update the 'Effective Family Resilience' document to expand this paragraph 
and include the wording above in red. This change cannot be unilaterally made but will 
be subject to the agreement of the Surrey Safeguarding Children Partnership and will 
need the approval of the Surrey Safeguarding Children's Board. We anticipate that 
agreement will be forthcoming and the document will then be amended accordingly.  

Concern 10 
At the prevention of future deaths hearing, I heard evidence concerning the post-death reviews 
conducted into Oskar Nash’s death by the Surrey Child Death Review Partnership Team and 
the Surrey Safeguarding Children Partnership. The evidence showed that neither process 
resulted in a sufficient or effective investigation of the death; I consider that the evidence shows 
that fact finding was superficial, there was no meaningful analysis of the part played by statutory 
agencies in the causation of his death, and only very limited learning was identified.  

Ineffective review by the child death review processes results in the risk of further deaths in 
similar circumstances and I am concerned that the local and/or national process, guidance and 
oversight are insufficient to ensure that an effective post-death investigation, which should not 
be dependent on the inquest process, is achieved in all cases.  

Response: 
The Coroner's concern is respectfully noted. In terms of post-death reviews, SCC follows 
the national guidance set out in Working Together 2018. This gives flexibility for the local 

 
 
 
 
 
 
 
 
 
 safeguarding partnership to decide how learning may be best generated and 
disseminated. Even if the criteria are met, it is not an automatic requirement to hold a 
Local Children’s Safeguarding Practice Review “It is for them to determine whether a 
review is appropriate, taking into account that the overall purpose of a review is to 
identify improvements to practice” (HM Government 2028:87).  It is ultimately most 
important that local safeguarding partners respond to any death in a proportionate and 
appropriate way. 

In respect of the post-death review into Oskar's death, SCC followed national guidance 
and took appropriate steps by way of a Thematic Review which was accepted by the 
National Panel.  

SCC is aware that the Chair of the National Panel is also considering the Coroner's 
concern and will be providing a response to the same. SCC remains committed to 
following national guidance and will readily adopt changes in practice, if any, 
recommended by the National Panel.  

Yours sincerely 

Chief Executive 
Surrey County Council

Mr Richard Travers 
Senior Coroner 
HM Coroner’s Court 
Station Approach, Woking 
Surrey GU22 7AP 

58 Church Street 
Weybridge 
Surrey 
KT13 8DP 

28 March 2022 

Re: Regulation 28 Report- Prevention of Future deaths- Oskar Nash 

Dear Mr Travers, 

Thank you for your Regulation 28 Report to prevent future deaths dated 31 January 
2022 concerning the death of Oskar Nash on 10 January 2020. On behalf of Surrey 
Heartlands  Clinical  Commissioning  Group  (CCG),  I  want  to  express  our  deepest 
condolences to Oskar’s family. 

Following  the  prevention  of  future  death  hearing  you  raised  a  concern  in  your 
Regulation 28 report to prevent future deaths to the Chief Executive Officer of Surrey 
Heartlands CCG regarding the post death review process: 

Concern 10: At the prevention of future deaths hearing, I heard evidence concerning 
the post-death reviews conducted into Oskar Nash’s death by the Surrey Child Death 
Review  Partnership  Team  and  the  Surrey  Safeguarding  Children  Partnership.  The 
evidence showed that neither process resulted in a sufficient or effective investigation 
of the death; I consider that the evidence shows that the fact finding was superficial, 
there  was  no  meaningful  analysis  of  the  part  played  by  statutory  agencies  in  the 
causation of his death, and only very limited learning was identified. 

Ineffective review by the child death review process results in the risk of further deaths 
in similar circumstances and I am concerned that the local and/or national process, 
guidance  and  oversight  are  insufficient  to  ensure  that  an  effective  post-death 
investigation, which should not be dependent on the inquest process, is achieved in 
all cases. 

I would like to assure HM Coroner and the family that we have taken the issues raised 
in  the  report  very  seriously,  they  have  been  carefully  and  thoroughly  considered  at 
every level of the organisation and we have begun taking steps to address the issues 
raised. 

On 17 March 2022, the Surrey CDR team met with Professor 
, Professor 
of Infant Health & Developmental Physiology, University of Bristol and an academic at 

 
 
 
 the  National  Childhood  Mortality  Database  (NCMD)  to  discuss  the  CDR  process  in 
Surrey.  NCMD  are  currently  undertaking  a  review  of  Joint  Agency  responses 
nationally  (which  include  Surrey  cases)  to  improve,  strengthen  and  review  the 
process. Any recommendations from this review will be fully implemented in Surrey. 

Additionally,  we  are  asking  the  National  Team  to  undertake  a  review  of  the  Surrey 
CDR process.  This will provide an independent view of our CDR process, identifying 
any areas of improvement and/or assurance. We would be pleased to share this, and 
any resultant action plan for improvement with you. 

The  Child  Death  Review  (CDR)  following  Oskar’s  death  is  still  open  and  is  being 
completed  in  line  with  Statutory  Process  as  outlined  within  the  National  Statutory 
Guidelines:  Child  death  review:  statutory  and  operational  guidance  (England).  The 
review at the Child Death Overview Panel (CDOP) has not yet taken place, as CDOP 
do not consider any case until all investigations are completed, including the Coroner’s 
Inquest and any further investigations, like a PFD hearing, as these are an integral 
part of the CDR process. This is to ensure that every opportunity to capture learning 
is taken up before the CDOP review. 

The  CDR  is  the  process  to  be  followed  when  responding  to,  investigating,  and 
reviewing the death of any child under the age of 18, from any cause. It runs from the 
moment of a child’s death to the completion of the review by the CDOP.  

This is intended to be the final, independent scrutiny of a child’s death by professionals 
who have had no responsibility for the child during their life. It is at this point in the 
process that all learning from Oskar’s death is collated and includes information from 
parallel 
Investigation/Inquest,  Joint  Agency 
Response,  Criminal  Investigation,  Serious  Incident  (SI)  Investigation)  into  the  final 
standardised report to NCMD to allow our local learning to influence national learning 
and future direction. 

investigations,  such  as  Coronial 

The CDR Team accept that the reporting forms (Form B’s) received were minimally 
completed. The CDR Team do not have direct access to any agency records and rely 
on professional accountability and integrity when completing the Reporting Form B. 
However,  we  will  take  forward  this  learning  to  ensure  when  forms  are  received 
providing minimal information, we go back and request greater detail from agencies to 
ensure we have a complete account of their involvement in that child’s life. In addition, 
a learning event has been arranged to support and provide guidance to professionals 
when completing a Form B. 

Surrey CDR team have arranged a meeting with national colleagues in the NCMD to 
discuss the learning identified in relation to the completion of reporting form B’s and 
improvements needed to the Child Death Review processes.  

Page 2 of 4 

 
  
 
 
 
 
 
 Working  Together  to  Safeguard  Children  (2018  p.103)  states  –  “All  practitioners 
participating in the child death review process should notify, report, and scrutinise child 
deaths using the standardised templates”. The templates are nationally agreed and 
available from the website www.gov.uk/government/publications/child-death-reviews-
forms-for-reporting-child-deaths. The NCMD have replicated these templates for use 
within the electronic reporting system used in most areas across England, including 
Surrey (eCDOP). The majority of the boxes are direct questions with multiple choice 
answers,  some  provide  free  text.  The  format  of  the  forms  is  nationally  agreed, 
therefore,  Surrey  CDR  team  are  not  able  to  amend  these  forms  at  a  local  level. 
However,  we  will  raise  the  issues  identified  with  the  NCMD  to  identify  future 
improvements in processes. 

In  addition  to  the  CDR  process,  to  identify  learning  from  a  number  of  deaths  from 
probable  suicide  and  to  help  prevent  future  deaths,  the  CDR  and  the  SSCP  team 
undertook a thematic review in 2020. In response to concerns raised by parents, who 
reported  that    they  had  struggled  to  find  information  of  where  to  access  help  and 
support, a Suicide Prevention Toolbox was developed. This is designed to be a living 
document which will be reviewed and updated as required. The Thematic Review was 
well received both locally and nationally and was used to challenge and influence the 
development of the design and offer of the new services in Mindworks Surrey. The 
action taken to date to prevent future similar deaths is as follows: 

Dissemination of learning from the thematic review:  

•  In  October  2020,  over  200  participants  attended  one  of  four  online  sessions  on 
‘Probable  Suicide  by  Children  and  Young  People  in  Surrey  Thematic  Review 
Learning Event’ which was accredited for CPD by the Faculty of Public Health. 
•  The  Learning  from  the  Thematic  Review  and  Suicide  Prevention  Toolbox  was 
presented at dedicated webinars (Awareness of Autistic Spectrum Disorder (ASD); 
Management  of  self-harm;  Prevention  of  alcohol  and  substance  misuse;  Parent 
support;  Work  across  the  County  to  mitigate  Adverse  Childhood  Experiences 
(ACEs);  Timely  support  for  children  and  young  people  in  crisis,  Support  for 
completing effective referrals; Implementing a Surrey Healthy Schools Approach) 
•  The  Thematic  Review  and  the  Suicide  Prevention  Toolbox  were  published  and 
shared  at  a  national  level  with  the  National  Safeguarding  Panel  and  presented 
regionally  at  NHS  England  (NHSEI)  and  National  Child  Mortality  Database 
meetings. 

•  Learning from thematic review and development of Suicide Prevention Toolbox has 

also been presented locally at: 
  monthly  lunch  &  learn  sessions  which  are  attended  by  practitioners  from  all 

agencies across Surrey 
  GP safeguarding sessions 
  Incorporated in Surrey Children Services’ academy training  

Page 3 of 4 

 
 
 
 
 
 An Action Plan was developed in response to learning from the Thematic review 

•  A  multi-agency  Task  &  Finish  Group  was  established  to  develop  an  action  plan 
based on the learning and opportunities not to be missed that were identified in the 
thematic review.  

•  It  was  identified  that  as  part  of  the  Surrey  Suicide  Prevention  Partnership,  while 
there is an established adult subgroup (with a delivery workplan to monitor progress 
of actions to meet the priorities outlined in the Surrey Suicide Prevention Strategy) 
there was not a specific children and young person subgroup. 

•  Following the completion of the Task and Finish group, a children and young person 
subgroup  of  the  Surrey  Suicide  Prevention  Partnership  was  established  in 
September 2021 to develop a delivery work plan and continue the monitoring and 
progression of the action plan developed by the Task and Finish Group.   

Oskar’s death, including all information gathered throughout the CDR process, will be 
presented  at  the  next  suicide  themed  CDOP  meeting;  any  additional  learning  and 
action required from Oskar’s death will be shared across services/multi-professionals 
in Surrey and nationally via NCMD. We have transitioned to holding themed panels on 
a repeating cycle which allows for better identification of themes. This will also allow 
an opportunity to review whether prior learning has been embedded in practice and 
identify any ongoing areas of concern. 

While there is still ongoing work to be done, I hope this response provides assurance 
that the CDR Team at Surrey Heartlands CCG are committed to working with national 
colleagues  to  address  concerns  related  to  CDR  processes  highlighted  in  the 
Regulation 28 Report to prevent future deaths and we thank you for the opportunity to 
further reflect on learning following the sad death of Oskar. 

Yours sincerely, 

Professor 
Interim Accountable Officer 

Page 4 of 4