Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0056, written 23 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 23 Feb 2022 |
|---|---|
| Reference | 2022-0056 |
| Deceased | Adrian Balog |
| Coroner | Zak Golombeck |
| Coroner area | Manchester City |
| Category | Child Death (from 2015) · Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: • The Rt Hon Nadhim Zahawi MP, Secretary of State for Education Copied for interest to: • Chief Coroner • The Rt Hon Sajid Javid MP, Secretary of State for Health and Social Care • • Dr • Dr • Dr • Manchester City Council • Salford City Council • Manchester Safeguarding Partnership • Loreto High School • Manchester University NHS Foundation Trust • The Newcastle upon Tyne Hospital NHS Foundation Trust 1 CORONER I am Mr Zak Golombeck, Area Coroner for Manchester (City) Area 2 CORONER’S LEGAL POWERS 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. 3 INQUEST I concluded the inquest into the death of Adrian Vincent Balog on 21st February 2022. I recorded the following medical cause of death: 1a. Multiorgan failure 1b. Dilated cardiomyopathy 2. Morbid obesity; Heparin induced thrombocytopenia I returned the following narrative conclusion: The Deceased died from natural causes contributed to by his longstanding morbid obesity, which itself significantly contributed to his death in that it rendered him ineligible to receive appropriate treatment. Those parentally responsible for him did not educate the Deceased on the correct foods to eat nor on how to live a healthy 1 lifestyle, and did not take him to (or access support from) weight management services. Throughout his childhood he was fed an unhealthy diet and allowed to continue with this diet into his early teenage years. 4 CIRCUMSTANCES OF THE DEATH The Deceased was 13 years of age at the time of his death. He had suffered from morbid obesity from the age of 3. In February 2015 he was diagnosed with dilated cardiomyopathy. As a result of his morbid obesity, the Deceased was not eligible to undergo heart transplantation, or any interim measures pending transplantation for his weight to reduce to a transplantable level. The Deceased was hospitalised in February 2015 and was diagnosed with heparin induced thrombocytopenia which was a further factor in the Deceased not being eligible for interim measures, including mechanical support of his heart. The Deceased was transferred from Royal Manchester Children’s Hospital (RMCH) to Freeman Hospital, Newcastle, on 15th March 2015 for consideration of treatment options. No treatment options were viable, and therefore the Deceased returned to RMCH on 18th March 2015 and a decision was made for him to receive palliative care. The Deceased died on 2nd April 2015 at RMCH. The Inquest explored evidence in relation to the Deceased’s clinical care, and also matters relating to public health concerns in view of the Deceased’s morbid obesity, and whether this should have led to a referral to children’s services by clinicians in primary care and/or staff at the Deceased’s school. Evidence was admitted which pointed to a change in societal attitudes and mores towards childhood obesity since 2015, although it was accepted by the public health witnesses that there is progress to be made for obesity to be afforded the same level of concern as malnourishment in children. It was accepted that an obese child – and particularly a morbidly obese child – may be a child at risk, even in the absence of other signs of neglect. 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: Two Department for Education documents referred to in evidence, namely ‘Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children’ (July 2018) and ‘Keeping children safe in education 2021: Statutory guidance for schools and colleges’ (September 2021) were referred to in evidence. I admitted oral evidence from the current Headteacher of Loreto High School (the school the Deceased attended), , who told the court 2 that the school’s recent policies on safeguarding adopted the information from these government documents. In the two government documents there is no reference to ‘obesity’ relating to signs and symptoms of neglect in children. The absence of such a reference is a matter of concern as to how obesity in children is viewed as a public health issue in comparison to malnourished or underweight children (which are both referenced as signs and symptoms of neglect). The consensus from the public health witnesses was that obesity should be included within national guidance as a sign of symptom of neglect in order to protect children at risk. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and 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 20 April 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 Interested Persons. I have also sent it to organisations who may find it useful or of interest. 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 DATE: NAME OF CORONER: 23 February 2022 Signed: Zak Golombeck HM Area Coroner for Manchester City Area 3
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 Mr Zak Golombeck, HM Area Coroner for Manchester City Area HM Coroners Service Manchester City Area The Exchange Floor The Royal Exchange Building Cross Street Manchester M2 7EF 20 June 2022 Dear Mr Golombeck, I am writing in response to your Regulation 28 report concerning the death of Adrian Vincent Balog. This is a tragic case. I am grateful for the expertise and rigor you brought to the inquest and I wish to express my sincere condolences to Adrian’s family and friends. I also want to apologise for the delay in replying to your original correspondence. I have noted the matters of concern you have listed for the Department for Education in relation to the Working Together to Safeguard Children statutory guidance (2018) and to the Keeping Children Safe in Education statutory guidance for schools and colleges (2021), specifically your request to include ‘obesity’ as an indicator of abuse and neglect in both sets of guidance. Working Together to Safeguard Children Statutory Guidance We are clear that everyone looking after or working with a child has a role to play in safeguarding and promoting their welfare, including their physical health. Working Together to Safeguard Children (2018) is statutory guidance which safeguarding partners (the local authority, the police and clinical commissioning groups/integrated care boards from 1 July 2022) and other agencies involved in safeguarding and promoting the welfare of children must have regard to. Raising concerns about a child’s weight is a sensitive subject. However, where there are concerns that the child’s weight indicate that the child may be at risk of significant harm including through neglect, the matter should be addressed to prevent any further escalation of risk. Concerns of this type should be raised with the local authority’s children’s social care service. Local authorities and their partners, including health and education, have a range of mechanisms, including outside of the safeguarding system through which they might provide help to a family including through universal, early help and targeted services. Keeping Children Safe in Education Statutory Guidance Keeping Children Safe in Education Statutory Guidance (KCSIE) is clear that causing physical harm to a child and the persistent failure to meet a child’s basic physical needs are indicators of neglect and abuse. The guidance sets out how schools should protect children from harm and what to do if they have concerns about a child. KCSIE is clear that governing bodies and proprietors must ensure that policies, procedures and training in their schools are effective and comply with the law at all times and that all staff should receive appropriate safeguarding and child protection training which is regularly updated. In addition, to support staff KCSIE is clear that all schools should have a designated safeguarding lead (DSL). Amongst other things the DSL should always be available to support staff and discuss any safeguarding concerns. Government’s Childhood Obesity strategy The Government has a national ambition to halve childhood obesity and significantly reduce the gap in obesity between children from the most and least deprived areas by 2030. We want to achieve this by ensuring that we are supporting parents, schools and local authorities, particularly in the most deprived areas. The Government’s Childhood Obesity: A Plan for Action (launched in 2016) included the introduction of the Soft Drinks Industry Levy which came into effect in 2018 and the sugar reduction programme challenged all sectors of the food industry to reduce by 20% by 2020 the level of sugar in the categories that contribute most to the intakes of children up to 18 years. As part of the healthy weight investment in 2021/22, 11 Local Authorities were awarded funding to test the expansion of tier 2 behavioural weight management services for children and families and pilot interventions to improve access to local services for children identified as living with overweight or obesity through the National Child Measurement Programme. Although Manchester was not one of the funded 11 Local Authorities, they currently offer multi-component tier 2 weight management services for children and families. Manchester Children’s Hospital is one of the areas developing what a holistic offer for children and young people living with complications from excess weight (link) looks like. The healthy weight investment in 2021/22 also included a series of research around early years obesity and a package of proposals to establish the evidence base and the framework to support interventions in the early years to prevent obesity, support healthy growth and improve wider health and development outcomes. The findings of these reports will be published in due course. Independent Review of Children’s Social Care I would also like to bring to your attention the Independent Review of Children’s Social Care which published its final report on 23 May 2022. The review makes a number of recommendations to strengthen early help provision for vulnerable families, as well as improving the child protection system for the most vulnerable children in society, including through more effective and joined up working between partners such health, the police and education. We will need to consider the detail of the recommendations and we will work with experts in the sector to develop our response to the report with a view to publish a detailed and ambitious implementation strategy later this year. I will ensure that the matters you have raised in your report are considered in the context of the recommendations made in the Review and I hope that my response provides the reassurance you need that this matter will be looked at soon. Yours sincerely, Rt Hon Nadhim Zahawi MP Secretary of State for Education
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