Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0425, written 29 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jul 2024 |
|---|---|
| Reference | 2024-0425 |
| Deceased | Lamarah Scarlett |
| Coroner | Katy Skerrett |
| Coroner area | Gloucestershire |
| Category | Child Death (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
His Majesty’s Senior Coroner for Gloucestershire Ms Katy Skerrett REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: HE Secretary of State for Education, Sanctuary Buildings, Great Smith Street, London, SW1P 3BT Director of Policy and Deputy Chief Executive at Local Government Association, 18 Smith Square, Westminster, London SW1P 3HZ eee Commissioner for West of England, Jubilee House, Croydon Street, ristol, CORONER lam Katy Skerrett, His Majesty's Senior Coroner for Gloucestershire. T CORON ER’S LEGAL POWERS | | 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 INVESTIGATION and INQUEST On the 28 November 2022 | commenced an investigation into the death of Lamarah Grace Scarlett. The investigation concluded at the end of the inquest on the 3 — 5" June 2024. The conclusion of the inquest was a narrative conclusion. The medical cause of death was 1A Unascertained. 4 CIRCUMSTANCES OF THE DEATH Lamarah Grace Scarlett “Lamarah” was a 12 year old girl who suffered with alternating hemiplegia of childhood (AHC) which is characterised by repeated episodes of weakness or paralysis. On the 24th September 2021 she had attended school. Lamarah had appeared happy and well during the day. At the end of the day Lamarah appeared to be tired. Staff did not feel she was presenting with any signs of a seizure or paralysis. At approximately 1500 hours she is secured in her wheelchair by staff and placed on a minibus to be transported to her home address. She is accompanied by a driver and a passenger assistant. During the journey Lamarah appears to be in distress, and is experiencing breathing difficulties. It is probable that Lamarah was suffering from a significant and profound episode of muscle weakness which made her unable to reposition her head to an upright position. Her head was in a hyper extended position, which caused her airway to become obstructed and led to her becoming acutely hypoxic. Neither the passenger assistant or the driver on the bus is aware of this. They do not raise the alarm or seek further assistance. if Lamarah’s head had been supported in an upright position and/ or if she had been placed in recovery position, it is likely that her airway would have opened up. However it remains unclear whether this. would have enabled sufficient airflow to her lungs as she had significant truncal weakness. At approximately 15.45 hours Lamarah arrives at her home address in an unresponsive state. Her mother commences resuscitation efforts, and emergency services soon thereafter arrive. Despite extensive resuscitation efforts, Lamarah is pronounced deceased at 16.45 hours. Gloucestershi a ini Barnwood, Gloucester, GL4 3D) 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. — Whether there is sufficient regulation of transport operators who provide category 1 home to school transport services to Special Educational Needs children? The following specific issues were identified: e The patient safety plans are not always read and understood by transport crew, e Home visits between passenger and transport crew often do not occur when contractually required, e The local authority are often not notified of personnel changes in the transport crew, e The need for proper handovers at drop off and pick up is not understood e There is no requirement for transport crew to be qualified first aiders, e The passenger assessment test requires further improvement, e There is no comprehensive schedule for inspection of transport operators, e There is no mandatory training or forums for operators to attend where information can be cascaded to them. e Operators have to approach multiple organisations which leads to confusion and inconsistency. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 4pm 23% September 2024. |, 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons (1) | Senior Associate, HCC Solicitors, New London House, 6 London Street, London, EC3R 7AD (2) DAC Beachcroft, Portwall Place, Portwall Lane, Bristol, BS1 9HS (3) (4) SE SENT team, Gloucestershire County Council, Block 5, 6" Floor, Shire Hall Westgate Street, Gloucester, GL1 2TG (6) a HCR Legal LLP, 62 Cornhill, London, EC3V 3NH 1am also under a duty to send the Chief Coroner a copy of your response. Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, GL4 3DJ The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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. Dated 29th Signature. Ms Katy SkerrettS His Majesty's Senior Coroner for Gloucesrs 4 Mi Coroner Gloucestershire Coroner's Court, Corinium Avenue, Barnwood, Gloucester, G14 3D)
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.
Minister for School Standards Sanctuary Buildings 20 Great Smith Street Westminster London SW1P 3BT tel: www.education.gov.uk/contactus/dfe Ms Katy Skerrett His Majesty’s Senior Coroner for Gloucestershire By email: 23 September 2024 Dear Ms Skerrett, I am writing on behalf of the Secretary of State for Education in response to the Regulation 28 Report to Prevent Future Deaths, issued on 29 July 2024, concerning the death of Lamarah Grace Scarlett on 24 September 2021. I am responsible for the government’s policy on home-to-school travel. I was deeply saddened to learn of Lamarah’s death. My heartfelt sympathy goes out to her family. The government’s home-to-school travel policy aims to make sure no child is prevented from accessing education by a lack of transport. Local authorities have a duty to arrange free travel for eligible children. To meet that duty, the travel they arrange must be suitable for the needs of the child concerned. I share your concern that, on this occasion, there do not seem to have been suitable arrangements in place to keep Lamarah safe on her journey home from school. Officials at the Department for Education have contacted Gloucestershire County Council about Lamarah’s case. I understand that the Council ensures children travelling on home-to-school transport have a ‘personal safety plan’ and that Lamarah’s plan included details of her condition, the signs and symptoms to watch out for, and how to respond to those symptoms. The Council makes it a condition of its contracts with transport operators that all members of the transport crew for each child have read their personal safety plan. At the time of Lamarah’s death, it was also a condition that at least one member of the crew had undertaken first aid training. It is now a condition that all members of the crew must undertake first aid training. The Council has advised that, in Lamarah’s case, the transport operator had failed to comply with both these conditions. The Council says it already had robust procedures in place for ensuring children’s safety and monitoring operators’ performance and that, since the inquest, they have enhanced their checks on transport operators and are reviewing their training for passenger assistants. They have also terminated all contracts with the operator responsible for Lamarah’s transport. The Department for Education publishes statutory guidance to assist local authorities in meeting their home-to-school transport duty. The latest version of the guidance was published in 2023 and includes much more comprehensive guidance about meeting a child’s needs than the version that was available at the time of Lamarah’s death. It is available here: www.gov.uk/government/publications/home-to-school- travel-and-transport-guidance. I believe it goes a long way to addressing the concerns you have raised in this case. In particular, it recommends that drivers and passenger assistants are trained in basic life support skills. It expects local authorities to conduct risk assessments, to consider how a child’s medical needs might affect them during their journey, and to put in place proportionate arrangements to manage those needs. It also requires them to ensure that a child’s driver and passenger assistant are aware of their needs and how to respond to them, that they have received any training they need to be able to do so, and that they are trained in (amongst other things) the handling of emergency situations. Further work is underway in the Department to support local authorities in arranging suitable travel for all children. For example, officials hold bi-monthly meetings to which all local authority school travel officers are invited to seek advice from one another and the Department and to share best practice. Officials are drafting non- statutory guidance to support better partnership working within local authorities (i.e. between SEND caseworkers and school travel officers) and beyond (i.e. between authorities and schools, parents and health professionals) to better meet children’s needs. I expect this piece of guidance to be available later this year or early next year. Officials will keep Lamarah’s case in mind as they continue to work on it. Thank you for bringing this important matter to my attention and for giving me the opportunity to respond. Yours, Minister for School Standards
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