Jacob Shorter

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Date: 

JJ/KH  

1 July 2024 

Confidential – Addressee Only  
Sheffield Coroners Court 
Medico Legal Centre  
Watery Street 
Sheffield 
South Yorkshire 
S3 7ES 

FAO of HMAC M.Whittle 
By Email: 

Dear Coroner  

Re: Jacob Lee Shorter (deceased)  
Ref: 27618356 

Children and Young People’s Services 
Town Hall 
 Crossley Street 
Halifax 
HX1 1UJ 

This  response  is  provided  by  Calderdale  Council  in  relation  to  the  Regulation  28:  Report  to 
Prevent  Future  Deaths  dated  18  June  2024  issued  by  Assistant  Coroner  Marilyn  Whittle, 
Coroner area of South Yorkshire (West) following the conclusion of the inquest on the 18 th June 
2024. 

Representations  in  relation  to  matters  arising  from  the  Inquest  hearing  which  gave  rise  to  the 
coroner’s concern: 

1. It  is  a  pre-condition  to  making  a  report  that  the  ‘coroner  has  considered  all  the  documents, 
evidence  and  information  that  in  the  opinion  of  the  coroner  is  relevant  to  the  investigation’ 

(Regulation 28(3)). The concern raised by the coroner related to the Independent Visitor service 
and there was no witness evidence or opportunity for that service to provide witness evidence to 
the coroner to fully set out matters addressing the concerns now raised by the coroner.  Had that 
opportunity  been  provided  then  we  do  not  consider  that  a  regulation  28  PFD  would  have  been 
issued as the coroner would have been satisfied that the procedures in place were satisfactory as 
set out comprehensively below.  

2. The  Council  submit  that  in  the  absence  of  direct  evidence  at  the  inquest  hearing  to  address  the 
concern  raised  by  the  coroner,  it  was  reasonable  and  appropriate  for  a  letter  expressing  that 
concern to have been made instead of a regulation 28 PFD report in accordance with paragraph 
37 of Guidance No.5 Reports to Prevent Future Deaths issued by the Chief Coroner.  

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 3. The concern raised by the coroner in the absence of  hearing any evidence from the independent 
visitor service is likely to hinder future recruitment and retention of Independent Visitor volunteers 
by  the  Council.  The  service  provides  an  important  statutory  role  to  visit,  befriend  and  advise  a 
child/young  person.    There  is  a  real  risk  volunteers  may  deem  that  they  are  being  unfairly 
criticised for non-disclosure of confidential information when that is not the case as set out below. 
Independent visitor volunteers adhere to both Council and National standards including the need 
to  ensure  confidentiality  and  to  identify  the  circumstances  of  when  it  is  appropriate  to  disclose 
relevant information. 

Preliminary Matters: 

In  relation  to  the  Regulation 28  Report,  box  3  appears to  contain a  typographical error in  that 
the date of the inquest opening pre-dates the tragic death of Jacob. 

At the inquest hearing, the Council’s Pathways Leaving Care Team Manager was summonsed 
to give oral evidence.  This witness gave evidence and explained he could only provide 
evidence on behalf of the Pathways Team based on records held by that service. His evidence 
was set out in a written report to the coroner dated 8 March 2024.  

At the inquest the witness addressed the coroner that he could not give evidence or answer 
questions on behalf of other departments within the Council upon which he had no knowledge.  

It is regrettable that there was no evidence from the other departments who were actively 
engaged in the care and support for Jacob resulting in the coroner deciding that there was a 
need to raise a Regulation 28 report.  

The Council would also like to point out a misunderstanding of the evidence as set out in box 4 
of the Report.  The summary states that following the visit by the independent visitor on the 3 
December 2023, “This information was not passed onto the… pathways team.”  That is 
incorrect.  Information was passed onto the Pathways team by the Independent Visitor team 
and that evidence is set out in the Pathways Team manager’s report (page A19 of the inquest 
bundle).  This was also the witness’s evidence at the inquest.  

The Council will also take this opportunity to clarify that the Independent Visitor volunteer met 
with Jacob on the 30 December 2023 and not 31 December 2023 as stated in box 4.  

Response to Coroner’s Concerns set out in Box 5 of the Report  

The matters of concern identified within the Report giving rise to concern was as follows: 

(1) Whilst the Independent Visitor was made aware of previous suicidal ideation this was not 
passed on to the foster carer or anyone else. Calderdale were unable to tell me of the 
training they receive or the escalation route for concerns or disclosures of this type. 

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 There is a clear risk that if this type of information is not passed on and adequate training 
is not provided in terms of metal health then this could cause future deaths.  

Firstly, in order to address the above matter of concern, it is important to state at this juncture 
that there was no evidence before the coroner from the independent visitor service on their 
policy and procedures which is regrettable.  The evidence provided to the coroner was from the 
Pathways Leaving care team who was unable to address a specific question when asked about 
the Independent Visitor service.   There was no request for the Council to specifically provide 
information relating to the Independent Visitor service and neither was there any previous 
concern raised to the issue which arose at the inquest hearing.   

Therefore, we take this opportunity of setting out the role and responsibility of the Independent 
Visitor service and will then address the specific matters of concerns of the coroner.   

Calderdale Council has a specialised service for the provision of Independent Visitors.  This is a 
statutory service for looked after children when a local authority has to appoint an Independent 
Visitor if they feel it would be in the young person’s best interests to do so.  

This was introduced under section 23ZB Children Act 1989 as amended by the Children and 
Young Persons Act 2008.  The Act confirms that “A person appointed under this section must 
visit, befriend and advise the child.” 

Calderdale Council adhere to guidance and standards issued by the National Independent 
Visitor Network dated January 2016 - link to guidance National IV Standards.pdf 
(barnardos.org.uk).  

The standards set out expectations that Independent Visitor services have to work to and to 
maintain a high level of confidentiality between the young person, Independent Visitor and 
service coordinator which is necessary to foster and establish a relationship of trust between the 
young person and Independent Visitor.   

Independent Visitor roles are undertaken by unpaid volunteers independent of the Council’s 
social services department.  Independence of service is important and is in accordance with 
Department for Education guidance 3.262 The Children Act 1989 guidance and regulations 
(publishing.service.gov.uk).   

It should be noted that an Independent Visitor would not have access to a young person’s case 
file in accordance with the guidance. However, information from the Independent Visitor 
volunteers following visits with young persons are fed back to the Independent Visitor team with 
a brief description of the visit, unless there are any concerns or queries arising from the visit.  All 
volunteers are trained to understand the types of issues which would need passing onto the 
team including for example concerns regarding the young person’s welfare or safeguarding.   It 
is for the Independent Visitor Team to pass relevant information onto other services (if 
appropriate) within the Council.  

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 The Council has a vigorous recruitment, selection and training process for volunteer 
Independent Visitors where they learn and understand their role and what is expected of them 
and develop the knowledge, skills and the circumstances of when confidential disclosed 
information needs to be shared with others, for example when there is a safeguarding issue.    

To address the coroner’s specific concerns, the Council can confirm the following matters: 

-  Disclosure of Confidential Information from Jacob to the Independent Visitor Volunteer 

All Independent Visitors Volunteers adhere to the Council’s “Safeguarding Code of Conduct for 
Independent Visitors.” The Code forms part of the agreement for Independent Visitors to work 
as a volunteer.   The Safeguarding Code is specific and sets out the circumstances in which 
disclosure should take place by stating: 

“Volunteers must: 

▪  Report any incidents or concerns that cause them to believe that a child, young person or 

vulnerable adult is, or is likely to be, at risk of harm…” 

This procedure is also set out in the Council’s “IV & Volunteer Health & Safety Guidance.” 

Jacob was a 19 year old adult. The Independent Visitor assigned to Jacob visited him once a 
month and this was increased to two visits a month following the Professional Meeting that took 
place on the 15 November 2023.   

The Independent Visitor volunteer visited Jacob on Sunday 3 December 2023 when during the 
course of the visit there was a discussion about his mental wellbeing.  Jacob disclosed that he 
had felt suicidal in the past but not at this moment.  Jacob also disclosed that he had been to 
the doctors with his foster carer, and they had spoken about anti-depressants but he had 
chosen to try other things before medication like walking which he was going to try.   Jacob also 
confirmed that he felt love and supported and knew that he could speak to his foster carer and 
the independent visitor if he needed to.   

The Independent Visitor volunteer called the Independent Visitor team on Monday 4th December 
2023 and reported in detail what Jacob had disclosed.   

On Tuesday 5 December 2023, the team spoke with the Pathways Team by telephone relaying 
the information that Jacob had disclosed to the Independent Visitor volunteer.  

As the confidential disclosure of Jacob’s feeling related to how he felt in the past and there was   
no imminent signs of risk of self-harm or safeguarding concerns and that he had recently been 
seen by his GP when his mental wellbeing was discussed, the confidential disclosure was not 
discussed with the foster carer and it would not have been appropriate to do so at that time.  

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 On the 30 December 2023, the Independent Visitor volunteer visited Jacob and no concerns 
were raised.   

The action taken by the Independent Visitor volunteer was in accordance with the Council’s and 
National guidance whereby they passed relevant information to the Independent Visitor team 
who in turn passed this information to the Pathways team.  This was done promptly.  

The Council accept there are circumstances where information may be passed onto a foster 
carer which may arise as follows: 

a.  When the Independent Visitor volunteer reports concern to the Independent Visitor team 

who then opts to pass information onto the foster carer; or  

b.  If there was an imminent risk to the young person, then the Independent Visitor volunteer 
is trained to approach the foster carer directly and/or the Social Services Emergency Duty 
team and/or the police to ensure that they are acting in the young person’s best interest. 

It should be noted that Independent Visitor volunteers are not specialists in mental health.  Their 
statutory remit is to visit, befriend and advise the young person.   

-  Training  

Thorough and comprehensive training is delivered to all Independent Visitor volunteers as part 
of the recruitment process.  The training programme is conducted over a period of 8-12 weeks 
(undertaken once a week for approximately 2 hours each session).   

Training topics include:  introduction to the Independent Visitor service, Equality Act topics, 
detailed introduction to safeguarding/risk of harm and managing disclosure and confidentiality, 
health & safety and risk assessments, welfare of children and general mental health risks to 
children in addition to understanding their role and responsibility in accordance with National 
standard guidance.     

Once the Independent Visitor volunteer has completed their training programme and 
assessment, the Independent Visitor Manager prepares a report on the recruitment of 
Independent Visitor volunteer.  A panel of professionals is convened including other external 
parties such as the Youth Justice Service, where the panel would review the report and decide 
whether to approve the Independent Visitor volunteer for the post.   

Independent Visitor volunteers’ performance is reviewed every 6 months by the Independent 
Visitor team and if there are any further training needs these are identified during that review 
process and addressed.   

The Council can assure the coroner that there is extensive training delivered to Independent 
Visitor volunteers whereby they understand their role and responsibility and the circumstances 
in which disclosure of confidential information may be necessary to the Independent Visitor 
team.   

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 -  Lessons Learnt 

The Independent Visitor service is always looking to provide enhanced training to their 
volunteers to increase their knowledge, skills and awareness on mental wellbeing matters 
concerning young person’s.   

As such, the service plans the following additional training needs directly as a result of this 
tragic incident: 

a.  Providing Independent Visitor volunteers (where necessary) Mental Health First Aid Training.  
b.  Induction Training programme to include a specific topic relating to suicide prevention and signs.  

Conclusion 

This response sets out in detail the statutory role of the Independent Visitor Service, the extent 
of their statutory remit, their adherence to Council and National guidance and standards on the 
issue of disclosure of confidential information.  

The response sets out and addresses the specific concerns of the coroner in relation to the care 
of Jacob and the steps taken by the independent visitor volunteer following disclosure of a 
confidential nature in accordance with both Council and National guidance on safeguarding. 

While the Independent Visitor service are not mental health specialists, the Council recognise 
that specific suicide prevention training would be helpful for the volunteers to increase their 
knowledge and skills on the subject when they are carrying out their statutory role to befriend 
and advise a young person.   

If there is any further information that you require, then please contact me.  

Yours faithfully 

Director – Children and Young People’s Services 

For and on behalf of Calderdale Council 

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