Melsadie Parris

Directorate for Children’s Services 

Buckinghamshire Council 
The Gateway 
Gatehouse Road 
Aylesbury 
Buckinghamshire HP19 8FF 

www.buckinghamshire.gov.uk 

24 January 2023 

Dear Mr Wade KC 

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 
In the matter of the Inquest re Leighane Redmond and Melsadie Parris   

This is a response by Buckinghamshire Children’s Social Care (“BCSC”) response to HMAC Wade KC Report 
to Prevent Future Deaths made under Regulation 28 of the Coroners (Investigations) Regulations 2013 
dated 12 February 2021. That report arose from an Inquest held between 14th to 30th November 2022 into 
the deaths of Melsadie Parris and her mother Leighane Redmond  

I would like to take this opportunity to add my condolences to both Leighane and Melsadie’s families and 
acknowledge the extremely tragic nature of this case. I would also like to thank the Coroner for his report. 

The Report to Prevent Future Deaths identified one matter of concern to the Coroner, namely: 
‘that the social work staff in the children’s services were informed on 9th January 2019 by two separate 
persons, Melsadie’s father (directly) and Melsadie’s grandmother (indirectly by means of written report 
produced by the 111 NHS non-emergency service, noting the information) that the adult with daily care of 
Melsadie had spoken to Melsadie in terms of describing her as evil. On checking with the adult carer, that 
person admitted to the social worker that the reports were true. The social work team knew that the adult 
carer had previously been referred to them by emergency services as a result of genuine and valid concerns 
about  the  carer’s  mental  health  such  that  the  carer  suffering  from  psychosis.  The  team  had  removed 
Melsadie  appropriately  while  awaiting  a  mental  health  assessment,  which  was  completed  without 
knowledge  of  the  carer’s  remark  and  before  the  remark  was  known  to  children’s  services.  The  mental 
health assessment found that the carer was not psychotic, an opinion which was appropriate on the day 
of assessment. The social work team had earlier conducted an investigation around an older matter of 
concern involving Melsadie, but this was unrelated to the mental health of her adult carer, and it had 
arisen two calendar months before the mental health crisis. In respect of that initial concern the social 
worker  had  concluded  reasonably  that  there  was  no  evidence  to  justify  the  removal  of  Melsadie  nor 
continuing concern for her safety, but for logistical reasons their file remained open at the time of the new 
concerns around the carer’s metal health. 

However the team based their review on investigations conducted some months before the mental health 
concerns arose and before the remark about evil was made. The team did not conduct a renewed visit to 
the home, nor seek up to date information from the family, nor liaise with the mental health team. It is 
likely that if they had done so they would have discovered more detail of the extent of the carer’s mental 
illness  which  was  indicative  of  paranoia  with  depression,  linked  to  concealment  of  ongoing  episodic 
psychosis.  It  is  possible  that  a  further  mental  health  assessment  would  have  been  sought,  and 
arrangements made to remove Melsadie from the custody of the carer. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 I found that existing guidance and policy recognised and encouraged the need to engage with family to 
gather information, to make home visits, to liaise with mental health and to treat assessment decisions 
and verification of file closure as dynamic processes requiring rigorous scrutiny. 

However, despite the existence of this guidance, the team placed undue reliance on the opinion of the 
mental health professionals and on old irrelevant investigations. Furthermore, although the department 
commissioned an independent review of the case, this found that the death could not have been predicted 
(which I accept), but tended to emphasise perceived shortcomings in the mental health professionals work, 
without acknowledging the above concerns. In addition it contained factual inaccuracies, such as a failure 
to identify the revelations of 9th January 2019. The review report was withheld, following complaints by 
the family as to matters of  fact, but the  council decided nonetheless to publish  an executive summary 
which maintained the partial reflection of the review conclusions. I am concerned that by so doing the 
department will persist in a view that its team did not fail to adhere to its own guidance and good practice.’ 

This response therefore covers actions that BCSC intend to take in respect of file closures.  

Preamble  
Before dealing with my response however I do wish to respectfully clarify one key factual point: 

The report states that: 
Furthermore, although the department commissioned an independent review of the case, …(and)…. but 
the council decided nonetheless to publish an executive summary which maintained the partial reflection 
of the review conclusions.’  

The  independent  review  was  commissioned  by,  and  the  executive  summary  published  by,  the 
Buckinghamshire Safeguarding Children’s Partnership Home - Buckinghamshire Safeguarding Children 
Partnership  (buckssafeguarding.org.uk)  which  is  a  wholly  independent  and  separate  legal  entity  to 
Buckinghamshire  Council,  and  for  the  avoidance  of  any  doubt,  also  completely  separate  to 
Buckinghamshire  County  Council.    This  is  a  very  important  distinction  which  has  been  clearly  stated 
already within the evidence and previous correspondence.   

Therefore, it would be more accurate for the final paragraph of the reg 28 report to read: 
Furthermore,  although  Buckinghamshire  Safeguarding  Children’s  Partnership  commissioned  an 
independent review of the case, this found that the death could not have been predicted (which I accept) 
but  tended  to  emphasise  perceived  shortcomings  in  the  mental  health  professionals  work,  without 
acknowledging  the  above  concerns.  In  addition  it  contained  factual  inaccuracies,  such  as  a  failure  to 
identify the revelations of 9th January 2019. The review report was withheld, following complaints by the 
family  as  to  matters  of  fact,  but  Buckinghamshire  Safeguarding  Children’s  Partnership  decided 
nonetheless  to  publish  an  executive  summary  which  maintained  the  partial  reflection  of  the  review 
conclusions. I am concerned that by so doing Buckinghamshire Council Children’s Services will persist in a 
view that its team did not fail to adhere to its own guidance and good practice.’ 

Given  Buckinghamshire  Council  Children’s  Services  were  not  responsible  for  either  the  independent 
report,  or  the  publication  of  the  executive  summary,  it  is  difficult  to  see  how  the  conclusion  in  the 
underlined  sentence  could  logically  therefore  be  drawn  and  would  ask  for  this  to  please  be  amended 
within the Prevention of Future Deaths Report.  

File Closure 
I am pleased to note that it is recognised by the Assistant Coroner that our existing policies and guidance 
are deemed sufficiently robust. We do not therefore propose to re-visit those policies and guidance as a 
result of this PFD, as this does not appear to be the Assistant Coroner’s requirement.  

Buckinghamshire  Council  accepts  the  Assistant  Coroner’s  view  that  best  practice  in  employing  those 
policies was not followed when this file was closed and intends to learn from this deeply tragic case and 
the concern identified by the Coroner.  

 
 
 
 
 
 
 
 
 
 
 As a statutory children services department, Buckinghamshire Council are fully focussed upon the safety 
and well-being of all the children and young people who are referred to us. Given the complexity of this 
work, the fact that every case is different, and that the Assistant Coroner has confirmed the policies and 
procedures we have are the right ones, our focus will be on ensuring that our staff properly evidence the 
rationale and decision-making process that informs their professional judgment resulting in the closure 
of cases going forward.  

Closing a piece of work will remain the action and task of line managers, as this is an appropriate exercise 
of their professional judgement however, going forward the closing reasons will need to be specifically 
recorded by that manager and will include an analysis addressing the following matters: 

a)  confirmation  that  there  are  no  outstanding  tasks,  including  informing  family  members  and  other 

professionals of this decision, and  

b)  a commentary on the merits of another visit to the family home,  
c)  why it is therefore appropriate and safe to close the file  

The closure of casework and adherence to the above standard will form part of our Quality Assurance 
activity which will give senior managers oversight of this area of practice enabling them to monitor future 
adherence to our guidance and to good practice.  

We do consider it important to note for the purposes of our response to the PFD, that in this particular 
case, the Local Authority consider that the legal test (Threshold) for any further statutory intervention 
was no longer evidenced and that this is what prompted the closure decision.  

The legal Threshold to allow statutory intervention by a Local Authority is set out in s47(1) (b) Children 
Act 1989, namely that: 
47.  Local authority’s duty to investigate. 
(1) Where a local authority— 
(b) have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely 
to suffer, significant harm, the authority shall make, or cause to be made, such enquiries as they consider 
necessary to enable them to  decide  whether they should take any action to safeguard or promote the 
child’s welfare. 

It is respectfully noted at this juncture that the Assistant Coroner himself confirmed within his Findings 
that ‘Melsadie was not a child in need and was not at risk. In January 2019 Melsadie was well cared for. 
She was loved. Her mother was in good jobs. Her mother was taking appropriate steps to deal with her 
debts. Her mother was inter-acting with doctors, employers, a landlord, her neighbours, her ex-partner, 
her friends, her child’s nursery, the child social work team…… in ways which were reasonable, appropriate, 
reassuring – even impressive. She was in fact interacting with her mother.’  

Finally, we would also take the opportunity to respectfully note that in the event that a manager instructs 
a further visit to take place in the future and either a) the family do not make themselves available to the 
social worker or b) refuse such a visit, in the absence of any other new evidence identifying a current 
safeguarding concern, the threshold to insist upon a further visit will not be met and the case will close in 
any event as the Local Authority would then have no legal right to be able to investigate any further.  

Other  
The recommendations from the independent SCR will also be actioned, although the accountable body 
regarding this will be the Safeguarding Partnership Board.  

 
 
 
 
 
 
 
 
 
 
 In conclusion, Buckinghamshire Children’s Social Care are determined to learn from this deeply tragic case 
and do take the Coroner’s concerns very seriously. We are focused on continuously improving the service 
we  provide  to  families  and  are  committed  to  improving  this  for  all  children  and  young  people  in 
Buckinghamshire.  

Yours sincerely 

Corporate Director Children’s Services