Prevention of Future Deaths reports · 2024

Jennifer Chalkley

Regulation 28 report to prevent future deaths, reference 2024-0542, written 14 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report14 Oct 2024
Reference2024-0542
DeceasedJennifer Chalkley
CoronerRichard Travers
Coroner areaSurrey
CategoryChild Death (from 2015) · Suicide (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Re : Jennifer Sharren Chalkley, Deceased  

Regulation 28 Report to Prevent Future Deaths 

Regulation 28 Report to Prevent Future Deaths 

This Report is being sent to: 

1. 

2. 

Department for Education (in relation to Concerns 1 and 2) 

, Secretary of State for Education, The 

Council (in relation to Concern 1) 

, The Chief Executive Officer of Surrey County 

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 Jennifer Sharren Chalkley. The 
inquest concluded on the 1st May 2024 when I found that the medical cause of 
death was:   

Ia  Suspension 

and my conclusion as to the death was that: 

Jennifer Chalkley died as a result of Suicide. 

Her death was more than minimally contributed to by : 

(i) 

A failure by Surrey and Borders Partnership NHS Foundation 
Trust’s Child and Adolescent Mental Health Service properly to 
assess, diagnose and treat Jennifer following referrals made in May 
2018 and January 2021 in order to manage her conditions and 
minimise her risk of suicide, 

(ii) 

A failure by Surrey County Council’s Special Educational Needs 
Department to ensure that Jennifer’s Education, Health and Care 
Plan contained sufficient and updated information about her mental 

1 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 and emotional health needs and her risk of suicide, such as to 
enable the college she attended from September 2021 to understand 
and meet her consequential needs and manage the consequential 
risk, and 

(iii)  A multi-agency failure to share information and work together to 

ensure that Jennifer was supported effectively to manage her 
neurodevelopmental and mental and emotional health needs, and 
her risk of suicide, especially from June 2021 onwards. 

I subsequently held a hearing to receive evidence relating to the prevention of 
future deaths and this was concluded on the 26th July 2024. I then allowed time for 
submissions by Interested Persons. 

4  CIRCUMSTANCES OF THE DEATH 

When she died, aged 17 years, Jennifer Chalkley was a girl with complex special 
needs. She had been diagnosed with Attention Deficit Hyperactivity Disorder 
when she was 10 years of age and Autistic Spectrum Disorder when she was aged 
11 years.  

These two neurodevelopmental conditions, together with associated excessive 
anxiety, low mood, and emotional dysregulation from which she suffered 
periodically, resulted in a persisting but fluctuating risk of suicide. 

Jennifer was known to the Child and Adolescent Mental Health Service and to 
Children’s Services, having been the subject of a number of referrals arising from 
her suicidal ideation and behaviour and her other vulnerabilities. She was also 
monitored under the Paediatric Team at a local hospital. An Education, Health and 
Care Plan was issued to Jennifer by the Special Educational Needs Department of 
her local authority when she was 15 years old, but she struggled to cope in 
mainstream school and experienced the breakdown of school and college 
placements. Jennifer also struggled to cope with personal relationships. 

In September 2021, Jennifer enrolled in a course at a new college. Within weeks 
she experienced low mood and was expressing suicidal ideation. Late on the 
evening of the 11th October 2021, Jennifer returned to her mother’s home, having 
separated from the boyfriend with whom she had been living.  

On the 12th October 2021, Jennifer’s mother feared that she was suffering a 
mental health crisis and arranged an emergency telephone consultation with the 
General Practitioner for later that day. However, at 16.20 hours, Jennifer was  
found hanging 
 in her bedroom. Despite resuscitation efforts from 
attending paramedics, she could not be revived and her death was pronounced at 
16.40 hours on the 12th October 2021. 

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

2 

 
 
 
 
 
 
 
 
 
 
 
 5  CORONER’S CONCERNS 

The evidence received at the prevention of future deaths hearing showed that a 
number of the issues and concerns raised at and following the inquest hearing 
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: 

Concern 1  

The “Special Educational Needs and Disability Code of Practice: 0 to 25 years”, 
which was issued by the Department for Education and the Department of Health 
and Social Care, provides statutory guidance for organisations which work with 
and support children and young people who have special educational needs or 
disabilities. The Code indicates that Local Authorities must carry out their 
functions with a view to identifying all the children and young people in their area 
who have or may have SEN or who have or may have a disability (Section 22 of 
the Children and Families Act 2014). At the inquest hearing, I heard that such 
children and young people must be identified as soon as possible so that their 
needs can be assessed and met as soon as possible. This is because the early 
provision of support increases its effectiveness and the meeting of need at the 
earliest stage may prevent, and is likely to reduce the risk of, mental health 
difficulties and suicidality developing. 

The evidence at the inquest revealed that there was some delay in an application 
being made for Jennifer to be assessed for an Education, Health and Care Plan 
because the mainstream school she attended believed that, before making such 
application, it must first have spent an additional £6,000 per annum in meeting her 
needs. The evidence suggested that this belief was wide-spread amongst schools, 
colleges and others, both in and beyond Surrey. 

At the prevention of future deaths hearing, it was confirmed that there is no 
statutory or other requirement for a school to have to spend an additional £6,000 
per annum in meeting a child’s SEN needs before applying for a statutory 
assessment. I am concerned that the misunderstanding by schools and colleges is 
delaying or preventing applications for statutory assessments being made in some 
cases and thereby acting as a barrier to ensuring all children and young people 
with additional needs are receiving effective support as soon as possible. I am 
concerned that this creates or increases the risk of avoidable suicidality 
developing. 

I heard that, in response to this misconception, Surrey County Council has, since 
Jennifer’s death, updated its guidance on the criteria that will be considered to 
determine when a statutory assessment will be conducted and that the new 
guidance seeks to make it clear that there is no requirement for £6,000 to be spent 
before an application for assessment can be made. However, the evidence I 

3 

 
 
 
 
 
 
 
 
 
 received from a local college showed that the misunderstanding persists, despite 
the updated guidance. It seems therefore that further action is needed to ensure 
that all Surrey schools and colleges understand, clearly, that spending an 
additional £6,000 on a child is not a pre-requisite to applying for a statutory 
assessment. 

I heard too that this misunderstanding probably originates from the School and 
Early Years Finance (England) Regulations 2023 (and their previous iterations), 
which set the high needs costs threshold at £6,000; it seems that the confusion 
may also stem from information issued by the Education and Skills Funding 
Agency. 

I am concerned that the misconception persists nationally and that, for the reasons 
set out above, action is needed to ensure that all schools and colleges understand, 
clearly, that spending an additional £6,000 on a child is not a pre-requisite to 
applying for a statutory assessment. 

Concern 2  

At the inquest hearing the evidence showed that in September 2021, shortly before 
her death, Jennifer commenced a course at a new college. I heard that the new 
college did not receive her safeguarding file from her previous educational 
establishment prior to her death on the 12th October 2021; as a result the new 
college’s ability to recognise and manage Jennifer’s needs and risks, including her 
risk of suicide, was undermined.  

I heard that the Keeping Children Safe in Education 2024 statutory guidance for 
schools and colleges, and its previous iterations, state that where children leave a 
school or college, the designated safeguarding lead should ensure that their child 
protection file is transferred to the new school or college as soon as possible, and 
within 5 days for an in-year transfer, or otherwise within the first 5 days of the 
start of a new term, to allow the new school or college to have support in place for 
when the child arrives. 

I am concerned that the requirement to transfer safeguarding information “within 
the first 5 days of the start of a new term” means that a child who is at risk of self-
harm or suicide may start at a new school or college without that establishment 
having all or any of the information in the safeguarding file. As that information is 
likely to be relevant to their management of the risk, I am concerned that 
permitting transfer up to five days after the start of term undermines the stated 
intention that the new school or college should “have support in place for when 
the child arrives”.  

I also heard that there is no centralised system that stores and transfers learning 
support and safeguarding information between schools and colleges, or other 
agencies who are supporting young people. Rather, the transfer of documents is 
undertaken by the individual schools and colleges concerned, with, I heard, 
variable levels of efficiency and reliability. 

4 

 
 
 
 
 
 
 
 
 
 
 In the circumstances, I am concerned that there is not a national system in place to 
require and facilitate the guaranteed transfer of safeguarding information in 
advance of a child or young person starting a new school or college at the start of 
a new term or academic year, and that this exposes a suicidal child or young 
person to additional and avoidable risk. 

6 

ACTION SHOULD BE TAKEN 
In my opinion action should be taken to prevent future deaths by addressing the 
concerns set out above and I believe your organisation has 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 9th December 2024.  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 and to the following: 

Surrey and Borders Partnership NHS Foundation Trust 

(i) 
(ii) 
(iii) 
(iv)  Guildford College 
(v) 
(vi)  Howard of Effingham School and the Howard Partnership. 

Nescot College 

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 

14th October 2024                                                                       Richard Travers 

5

Responses

2 responses 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.

Response from Department for Education (PDF)
Minister for School Standards 
Sanctuary Buildings 20 Great Smith Street Westminster London SW1P 3BT 
tel: 0370 000 2288  www.education.gov.uk/contactus/dfe 

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

14 February 2025  

Dear Mr Travers,  

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 14 October 2024 concerning the tragic 
death of Jennifer Chalkley on 12 October 2021. I am responsible for the government’s 

policy on special educational needs and safeguarding.   

I was deeply saddened to learn of Jennifer’s death. I would like to offer my heartfelt 

sympathy to her family.   

Your report identified two key areas where action might prevent future deaths: potential 

delays in seeking and securing Education, Health and Care (EHC) plans because of 

misunderstandings of the law by schools and colleges, and issues with the timely transfer 

of safeguarding information between schools and colleges.   

Schools and colleges have a fundamental responsibility to keep children and young people 

safe.  Under section 3 of the Children Act 1989, any person with the care of a child who 

does not have parental responsibility for them is subject to a duty to do all that is 

reasonable in all the circumstances for the purposes of safeguarding or promoting the 

welfare of the child.  Supporting children and young people with mental health needs is of 

the first importance. This government works closely with the further education sector to 

promote and support providers to embed a whole college approach to mental health and 

wellbeing. This includes supporting sign-up to the Association of Colleges mental health 

charter. Mental Health Support Teams (MHSTs), delivering evidence-based early support 

for mental health issues and supporting senior mental health leads, are being rolled out to 

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 all schools and colleges. 

Concern 1 – the test for an Education, Health and Care needs assessment 
You are concerned that “misunderstanding by schools and colleges is delaying or 

preventing applications for statutory assessments being made in some cases and thereby 

acting as a barrier to ensuring all children and young people with additional needs are 

receiving effective support as soon as possible. I am concerned that this creates or 
increases the risk of avoidable suicidality developing.”   

An EHC plan is intended to meet a child or young person’s special educational needs, 
together with any relevant health and care needs. In cases such as Jennifer’s, an EHC 

plan provides an opportunity to bring together the support provided by a child or young 
person’s school or college with that of other agencies such as health providers.  The core 

purpose of an EHC plan is to meet special educational needs: children and young people 

frequently receive support for health or social care needs without an EHC plan.  Indeed, a 

child or young person who has health and/or social care needs but no special educational 

needs, would not meet the criteria in the Children and Families Act 2014 to be issued with 

an EHC plan.   

Section 36(1) of the Children and Families Act 2014 sets out that “A request for a local 

authority in England to secure an EHC needs assessment for a child or young person may 
be made to the authority by the child’s parent, the young person or a person acting on 

behalf of a school or post-16 institution”.  The associated statutory guidance (the SEND 

code of practice) is clear that: 

9.9 “In addition, anyone else can bring a child or young person who has (or may 

have) SEN to the attention of the local authority, particularly where they think an 

EHC needs assessment may be necessary. This could include, for example, foster 

carers, health and social care professionals, early years practitioners, youth 

offending teams or probation services, those responsible for education in custody, 

school or college staff or a family friend. Bringing a child or young person to the 

attention of the local authority will be undertaken on an individual basis where there 

are specific concerns. This should be done with the knowledge and, where 
possible, agreement of the child’s parent or the young person.” 

Section 37(1) provides that the local authority must issue an EHC plan “Where, in the light 

of an EHC needs assessment, it is necessary for special educational provision to be made 
for a child or young person in accordance with an EHC plan”.   

2 

 
 
 
 
 
 The SEND Code of Practice notes (at para 9.14) that, in deciding whether an EHC needs 

assessment is necessary, the local authority should consider a range of evidence, 
including “evidence of the action already being taken by the early years provider, school or 
post-16 institution to meet the child or young person’s SEN”. At para 9.55 the Code notes 

that a relevant factor in deciding whether to issue an EHC plan might be:  

“whether the special educational provision required to meet the child or young 
person’s needs can reasonably be provided from within the resources normally 

available to mainstream early years providers, schools and post-16 institutions, or 

whether it may be necessary for the local authority to make special educational 
provision in accordance with an EHC plan”. 

However, the Code states clearly at para 9.16 that: 

“Local authorities may develop criteria as guidelines to help them decide when it is 

necessary to carry out an EHC needs assessment (and following assessment, to 

decide whether it is necessary to issue an EHC plan). However, local authorities 

must be prepared to depart from those criteria where there is a compelling reason 

to do so in any particular case and demonstrate their willingness to do so where 

individual circumstances warrant such a departure. Local authorities must not 
apply a ‘blanket’ policy to particular groups of children or certain types of need, as 
this would prevent the consideration of a child’s or young person’s needs 

individually and on their merits.” 

The Children and Families Act 2014 and its statutory guidance are therefore clear that a 

request for an EHC needs assessment may be made at any time by a school or college, or 
by the child’s parents or the young person themselves. There is a further safeguard that, in 
the event a request for assessment is refused, the child’s parents (or, from age 16, the 

young person) have the right to appeal the decision to the First-tier Tribunal (Special 

Educational Needs and Disability). 

The arrangements relating to funding are distinct from the statutory tests for an EHC needs 

assessment set out above. Regulation 11(3) of the School and Early Years Finance and 

Childcare (Provision of Information About Young Children) (Amendment) (England) 

Regulations 2024 (and the predecessor regulations relating to previous years) require local 

authorities to identify for each mainstream school an amount within its overall budget, 

calculated by reference to relevant factors in the local schools funding formula, and using a 

threshold sum of £6,000 per pupil below which the school will be expected to meet the 

3 

 
 
 
 
 
 additional costs of pupils with special educational needs (SEN). This amount is often 

referred to as the notional SEN budget. Guidance for local authorities on the purpose and 

calculation of this notional SEN budget is published here: Pre-16 schools funding: local 

authority guidance for 2024 to 2025 - GOV.UK. This notional SEN budget amount is 

intended to assist mainstream schools in fulfilling their duty under section 66(2) of the 
Children and Families Act 2014 to “use [their] best endeavours to secure that the special 
educational provision called for by the pupil’s or student’s special educational needs is 

made”.  This duty applies to all pupils with SEN in mainstream schools and all students in 
institutions within the further education (FE) sector – not just those with EHC plans. 

Although there is no notional SEN budget identified for FE institutions, the funding 

arrangements are similar to those for schools in that, for additional SEN support costs in 

excess of the £6,000 per student threshold, colleges can request access to high needs 
funding from the relevant local authority’s high needs budget.  

Additional guidance concerns the way funding is allocated to support schools and colleges 

meet special educational needs, for example High needs funding: 2025 to 2026 

operational guide and on the notional SEN budget for mainstream schools: operational 

guidance 2025 to 2026.  These documents are careful not to assume that children and 
young people who require top-up funding from a local authority’s high needs budget will 

automatically have an EHC plan. We will keep this point under review as the guidance 

documents are updated.   

In the light of your concerns, we have reviewed the relevant guidance from the DfE and the 

Education, Skills and Funding Agency (ESF). We have not identified any ambiguity in that 

guidance, but in view of the concerns raised we have written to local authorities to remind 

them that the threshold to be considered for an EHC plan is as set out in the Children and 

Families Act 2014. The expectation on mainstream schools and colleges of meeting the 

costs of additional SEN support up to £6,000 does not prevent a child or young person 
being brought to the local authority’s attention as potentially having special educational 

needs which require provision according to an EHC plan, thereby requiring the local 

authority to decide whether to conduct an EHC needs assessment.    

Concern 2 – transferring safeguarding information  
I also note your concern that “there is not a national system in place to require and 

facilitate the guaranteed transfer of safeguarding information in advance of a child or 
young person starting a new school or college… and that this exposes a suicidal child or 

young person to additional and avoidable risk”.   

4 

 
 
 
 
 As you are aware, the Department publishes statutory safeguarding guidance, Keeping 

children safe in education (KCSIE), which all schools and colleges must have regard to 

when safeguarding and promoting the welfare of children.  

We take the view that KCSIE is very clear that where children leave the school or college, 

the designated safeguarding lead should ensure their child protection file is transferred to 

the new school or college as soon as possible, and within 5 days for an in-year transfer or 

within the first 5 days of the start of a new term to allow the new school or college to have 

support in place for when the child arrives. The guidance also makes clear that receiving 

schools and colleges should ensure key staff such as designated safeguarding leads and 

special educational needs co-ordinators (SENCOs) or the named persons with oversight 

for special educational needs and disabilities in a college, are aware as required.  

Paragraph 122 makes it clear that in addition to the child protection file, the designated 

safeguarding lead should also consider if it would be appropriate to share any information 

with the new school or college in advance of a child leaving.  

There is therefore a national process for sharing information between schools and 

colleges, and the guidance on the timing of the sharing of relevant information is clear. We 

are very saddened to hear that, in Jennifer's case, her new college had not received the 

information within the specified time to ensure continuity of support for Jennifer. This was 

not in line with the duties and responsibilities placed on schools and colleges. We do 

regularly review the statutory safeguarding guidance to see where it could be strengthened 

or further clarification is needed, which is subject to public consultation. In view of this very 

tragic case, we will keep this section under review.  

SEND provision arranged by Surrey County Council  

You may be aware that, in September 2023, Ofsted and CQC undertook a Local Area 

SEND inspection in Surrey under the new SEND inspection framework. The report, 
published on 24 November, found “inconsistent experiences and outcomes for 
children and young people with SEND” and identified four areas for improvement.   

Following the inspection, in line with our SEND intervention approach for LAs with an 
inconsistent outcome, the Department began formal monitoring of the local area’s SEND 

arrangements. The Department has also commissioned an independent SEND Advisor to 
provide expertise and challenge.  We are monitoring Surrey CC’s progress in improving its 

5 

 
 
 
 
 
 
 
 SEND services, including through 6-month review meetings.  

Thank you for bringing this important matter to my attention and giving me the opportunity 

to respond. 

I am copying this letter to 

, Executive Director of Children, Families and 

Lifelong Learning at Surrey County Council.   

Sincerely, 

Minister for School Standards 

6
Response from Surrey County Council (PDF)
Email: 

                                                                                                             13th November 2024 

Sent via email 

Dear Senior Coroner Richard Travers, 

Re: Response to Prevention of Future Deaths (PFD) Report Concern 

I am writing on behalf of Surrey County Council in response to the concern raised in your 
recent Prevention of Future Deaths report, published on 14th October 2024.  

We have noted the issue regarding the perceived requirement for schools and further 
education providers to allocate £6,000 of support to a pupil or learner with Special 
Educational Needs and Disabilities (SEND) before they are eligible to apply for an 
Education, Health, and Care Needs Assessment (EHCNA). 

In response, we have prepared a communication to be sent to all Surrey education 
providers, including schools, non-maintained independent sector providers, and further 
education institutions, to address and clarify this misunderstanding.  

This communication reinforces the statutory position as set forth under the Children and 
Families Act 2014, which does not stipulate a financial threshold as a prerequisite for 
requesting an EHCNA. Our aim is to provide clear guidance to prevent any further confusion 
on this matter. 

The full wording of this communication is attached for your information, and we will be 
disseminating it via our established channels to ensure that it reaches all relevant Surrey 
education providers. 

Please feel free to contact my office if you require any further clarification or additional 
information regarding our response. 

Yours sincerely, 

Chief Executive 
Surrey County Council 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Attachment: Communication to Surrey Education Providers 

Further to the concern raised by the coroner in a recent Prevention of Future Deaths 
hearing published on 14th October 2024, we wish to reiterate and reinforce the following 
information to all Surrey education providers who support children and young people from 
statutory school age to 25 years old. This includes all non-maintained independent sector 
and further education providers in addition to schools. 

The Concern: 

Some schools and further education providers believe it is necessary to provide £6,000 of 
support to a pupil or learner with SEND before being able to apply for an EHC Needs 
Assessment. 

Statutory Position as Upheld by Surrey County Council: 

Under the Children and Families Act 2014, local authorities are required to consider an EHC 
needs assessment if the child has or may have SEN, and if the provision may need to be 
made through an EHCP. There is no mention in the law or in the SEND Code of Practice of 
a requirement for the school to spend a specific amount before initiating an assessment.  

The focus remains on the educational progress of the child and the sufficiency of the 
support provided through SEN support plans; it does not require schools to exhaust a fixed 
budget before requesting an EHC assessment. The decision to request an assessment is 
based on individual needs and the inability of current support to sufficiently meet those 
needs, not on a financial spending threshold. 

The expectation set out in the School and Early Years Finance (England) Regulations 
2023 sets a high needs cost threshold of £6,000 which we, and the coroner, recognise 
may lead to some confusion. 

The £6,000 threshold refers to element 2 of the schools’ SEND funding system from 
which schools are expected to support pupils with additional needs, in line with what should 
be ordinarily available. However, these funding regulations are not a barrier to requesting 
an EHCNA where it is required. 

Guidance to Education Providers: 

All education providers are expected to make a decision whether to request an EHC Needs 
Assessment based on their professional judgment and taking into account the guidance 
published on the Surrey SEND Local Offer website.

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