Mazeedat Adeoye

Our ref: 

Mr G Irvine 
Senior Coroner 
East London Coroner’s Court 
Queens Road 
Walthamstow 
E17 8QP 

By email: 

Dear Mr Irvine,   

Minister of State for Care  

39 Victoria Street  
London  
SW1H 0EU 

30 January 2024 

Thank you for the Regulation 28 report of 5th December 2024 sent to the Secretary of State 
for Health and Social Care about the death of Mazeedat Opeyemi Adeoye. I am replying as 
the Minister with responsibility for adult social care.  
Firstly, I would like to say how saddened I was to read of the circumstances of Mazeedat’s 
tragic  death  and  I  offer  my  sincere  condolences  to  their  family  and  loved  ones.  The 
circumstances  your  report  describes  are  very  concerning  and  I  am  grateful  to  you  for 
bringing these matters to my attention.  

The report raises concerns over the local authority and child services team in the London 
Borough of Newham. The Department of Education (DfE) has oversight for child social care, 
and they are best placed to comment on the concerns raised. You may wish to reissue the 
report to DfE, so they are able to provide a formal response.  

Thank you for bringing these concerns to my attention.   

Yours sincerely, 

MINISTER OF STATE FOR CARE

Prevention of Future Deaths Report (Regulation 28) Response from the London Borough of 
Newham 

Contents 

1.  Foreword by the Director of Children’s Services 

2. 

Introduction 

a.  The Role of the No Recourse to Public Funds (NRPF) Team 

b.  Reviews carried out  

c.  Service wide Future Changes to be Made 

3.  London Borough of Newham's Response to the Coroner’s Concerns 

a.  The Coroner's Concern regarding the conduct of the Children's Services Team 

i.  The NRPF Team in 2021/2022 

ii.  Action taken following Mazeedat's Death 

iii.  Action Proposed to be Taken 

b.  The Coroner's Concern regarding the management of the NRPF Team 

i.  Action taken following Mazeedat's Death 

ii.  Action Proposed to be Taken 

c.  The Coroner's Concern regarding the standards of note-keeping and recording 

i.  Action taken following Mazeedat's Death 

ii.  Action Proposed to be Taken 

4.  Conclusions and Impact 

5.  Action Plan 

       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1. Foreword from the Director of Children’s Services  

I and the entire team at Newham Children's Services were deeply saddened to learn of the death 
of Mazeedat Adeoye.  I would like to express my deepest condolences to Mazeedat’s mother and 
her family. 

I will do everything in my power to help further ensure that the work of Newham’s Children’s 
Services department is carried out with professionalism, courtesy, empathy and respect and with 
consideration for the welfare of all the children, young people and families that we work with and 
support.  

We shall endeavour to do all we can to prevent such events in the future. 

We acknowledge the Coroner’s findings. We have re-evaluated our internal policies and 
procedures after this tragedy and significant changes and improvements have been made.  
However, in light of the Coroner's conclusions we commit again to reviewing the practices of the 
team, so that we can identify where further changes need to be made. In the months and years to 
come we will continue to listen to the many families we work with, to the professionals we work 
alongside and to the staff we employ, to ensure that we continually learn, take action where 
needed and improve. We have made a number of changes since Mazeedat’s tragic death, and 
further changes outlined in this report are planned. 

Below, we respond to each of the Coroner’s areas of concern, setting out what we have already 
done and what we intend to do in the future. We hope this response provides assurance that we 
have responded fully to every concern.  I am grateful to all the Voluntary and Community Sector 
Agencies who have liaised with me and have been so open, supportive and challenging of our 
services and will continue to work with them to best support families with No Recourse to Public 
Funds. 

Director Children’s Services 
29th January 2025 

       
 
 
 
 
 
 
 
 
 
 
 
 
 
 2. Introduction 

a) The Role of the No Recourse to Public Funds (NRPF) Team  

In providing our Response to the Coroner's Report, it is first necessary to set out the role and responsibility of the No 
Recourse to Public Funds (NRPF) team, which provided intervention to Mazeedat and her family. 

The Local Authority’s Children’s Services department have a duty to make enquiries prior to agreeing to offer intervention 
and support to families  under section 17 of the Children Act 1989.   We also have a duty to undertake proportionate 
checks  whilst  undertaking  assessments.  Working  Together  to  Safeguard  Children  2023  places  a  duty  on  Local 
Authorities  including  Children’s  Services  to  share  and  request  information  from  agencies.  When  families  first  seek 
support  from  the  London  Borough  of  Newham,  Social  Workers  must  undertake  these  duties  to  establish  the 
circumstances  of  the  family  and  the  types  of  support  the  children  could  need.  These  checks  are  conducted  during 
completing  a  Child  and  Family Assessment  within  a  timescale  of  45  days.  This  should  include  (for  example)  how 
someone came to be in the UK, the financial and other support they had been receiving, their identity and relationships 
to one another, any health and other specific needs, what services and intervention will assist and so on.  

Children  in  Newham  requiring  support  services  can  either  be  supported  by  Early  Help  Practitioners,  NRPF  Social 
Workers or Safeguarding Social Workers (where enquiries led to concerns about parenting capacity or a likelihood of 
concern about parenting capacity).  

In  2021,  parents  were  required  to  produce  documents  and  sign  relevant  forms  as  part  of  the  Child  and  Family 
Assessment process. However, the Local Authority can exercise a discretion to provide accommodation or offer support 
under  Section 17 of the  Children Act  1989  on  a without  prejudice  basis,  pending  further  information  being  obtained, 
including the gaining of documents and the signing of forms.  

Completing robust checks is necessary, including understanding the relationship and identity of any children. There is a 
need to balance the questions that must be asked with ensuring that our language is used carefully so that families do 
not feel stressed or offended, and that we engage families in the best way possible to gain the needed information. The 
best way to do this is by using a Relational Approach to build trust with families. Social Workers should compassionately 
hypothesise why information is not forthcoming or shared and curiously self-reflect and reflect with managers whether 
there are any barriers that parents are experiencing using a Relational Approach.  Any intervention or services should 
be offered to meet children’s needs and ensure they are not at risk with immediacy.  

b) Reviews carried out  

Immediately following Mazeedat's tragic death, a review was undertaken to investigate, explore and resolve any issues 
with the service.  The Quality Assurance team completed a review of the intervention with Mazeedat and her family.  

A complaint received by The Alternative Trust in March 2022 and was thoroughly investigated. 

A  deep  dive  audit  was  completed  in  December  2024  (upon  conclusion  of  the  Inquest)  to  immediately  re-review  the 
service’s practice focusing on service delivery, the experiences of families with No Recourse to Public Funds, the quality 
of management oversight and recording.  The reviewer analysed all Practice Learning Conversations (Audits) conducted 
within the NRPF service between 2022 to November 2024. In total, 24 files were reviewed. Feedback was successfully 
obtained from 19 of these families during the PLCs, accounting for 79% of the total, while for the remaining 5 families 
(21%), the auditor was unable to establish contact. The feedback, which sheds light on the service quality, highlighting 
strengths and areas for improvement from a family’s point of view, was largely positive. More details are included within 

       
 
 
 
 
 
 
 
 
 
 
 
 
 this report. 

c) Service wide Future Changes to be Made 

While  significant  and wide-ranging changes have  been made  since  2022, there is ongoing  learning, development in 
process  as  well  as  actions  to  be  carried  out. These  are  set  out  throughout  our  Response  in  respect  of  each  of  the 
Coroner's concerns.  We are also implementing the following: 

  Senior  Managers  spending  a  week,  twice  a  year,  in  practice  alongside  staff  in  all  teams.  This  will  include 

speaking to families, observing practice and auditing children’s case files. 

  A themed audit annually of children whose parents have No Recourse to Public Funds with a focus on single 

parents with limited network. 

  Peer Review of the NRPF Service by a London Authority with Good Ofsted rating. The peer review will consider 

leadership, quality of practice, quality of management oversight and quality of recording. 

  External Voluntary Sector Organisation with expertise in NRPF to be commissioned to gain Family Feedback. 
  An  offer  of  a  visit  by  the  Corporate  Director  of  Children's  Services  within  4  weeks  to  all  families  known  to 
Children’s Social Care who have lost children, to ensure the voice of the parents or carers is incorporated in 
learning. This has been offered to Mazeedat’s mother through the Voluntary and Community Sector agencies 
that  know  her.  Understandably she has advised that  she does not  feel  able  to  do  this. The offer  will always 
remain open. 

  All accidental deaths of children where abuse or neglect is not suspected will be reviewed independently to the 

Quality Assurance Unit. 

The implementation of the Action Plan and the impact of the actions once completed will be overseen by a Multi-Agency 
Task and Finish Group chaired by Director of Early Help and Safeguarding and CEO founder of The MAGPIE Project. 

       
 
 
 
 
 
 
 
 
 3. London Borough of Newham's Response to the Coroner's Concerns 

a) The Coroner's Concern regarding the conduct of the NRPF Team 

The Coroner set out the following Concern in his Report: 

The  Adeoye  family  interactions  with  the  local  authority,  child  services  team  were  characterised  by 
unprofessional  behaviour from social  workers. A  culture  existed within the  team  that tolerated  and therefore 
encouraged overtly antagonistic behaviour towards vulnerable people. Should this hostile environment continue 
to be enabled, sub-optimal care outcomes will result with an ongoing risk of fatal harm.  

(i) The NRPF Team in 2021/2022 

Mazeedat was deemed a Child in Need by the Local Authority by virtue of her parent’s lack of recourse to public funds, 
homelessness and destitution. The support provided by the NRPF Service was to meet these needs. There were no 
concerns about Ms Adeoye’s parenting capacity and her ability to meet all Mazeedat’s needs and therefore there was 
no need for a safeguarding Social Worker. This would have been unnecessarily intrusive and not proportionate.   

We recognise that there was a lack of empathy and understanding of Ms Adeoye’s situation on 14th October 2021. On 
this occasion, an appropriate questioning style or sufficient clarity was not used to explain the importance of the NRPF 
team requiring documentation and the need to understand the identity of Mazeedat and her relationship to Ms Adeoye. 
From all the information gathered, the Local Authority accept that a decision to support the family with accommodation 
on a without prejudice basis should have been made before the office closed. The focus should have been on meeting 
the homelessness need, not gaining the required documentation. 

(ii) Action Taken Following Mazeedat's death 

Quality Assurance 

The Local Authority introduced a Quality Assurance process whereby audits (Practice Learning Conversations – PLC's) 
were completed by managers, senior managers and the Quality Assurance Unit on a monthly basis across all services. 
A sample of which were then moderated by a more Senior Manager to ensure the quality of the audit as well as the 
accuracy of the finding. This brought about a constant, robust check on services and decision making with families. 

Focused Action for the NRPF team  

The Local Authority Quality Assurance Unit (who are independent from the NRPF Team) undertook an investigation into 
whether the NRPF staff followed due process on 1st February 2022. The Quality Assurance Unit are part of Children’s 
Services and are independent from the operational work that the department undertakes. They work to highlight areas 
of strength and areas of weakness within Children’s Services, with a focus on enforcing the maintenance of the quality 
of standard of practice across social care and early help services. They identify learning and ensure the implementation 
of  learning  throughout  Children’s  Services  and  the  partnership,  ensuring  the  workforce  training  and  development  is 
swiftly adapted to address concerns. This includes improving the quality of Social Work practice.  

The Head of Service, Director of Safeguarding and the Director of Children’s Services (at the time) met with the Director 
of Alternatives Trust  on 2nd  March  2022 to  discuss  the issues raised in their complaint.  Separate  meetings with the 
workers from the Alternatives Trust who had assisted  the family at the time and Social Workers and managers were 
held. The Social Workers who had been involved with the family were interviewed and discussions were had with their 

       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 supervisor and the NRPF Team Manager.  

Following the findings of the Quality Assurance Investigation and the findings from the complaint, Children’s Services 
made significant improvements to ensure that the support our families receive from the NRPF team was of good quality.  
This included: 

 

Instructing  all  staff  to  offer  accommodation  and  support  to  families  with  No  Recourse  to  Public  Funds  on  a 
without prejudice basis, to build trust, relationships and ensure the safety of children whether or not documents 
were produced and/or forms were signed.  

  Mandatory training to all NRPF, MASH and Assessment team staff on Family Shared Decision Making ensuring 

families are at the centre of co-produced plans and interventions.  

  Monthly practice improvement reflective supervision sessions for 9 months from March to December 2022. This 
was  completed  as  a  specific  development  plan  for  the  NRPF  Team  following  the  complaint  made  by  the 
Alternative Trust. These sessions used case examples to help workers think about language, the importance of 
the first contact and developing first impressions with families to ensure mutual  warmth and trust.  This was 
used to challenge practice and monitor staff’s practice improvement. The sessions were facilitated by a Family 
and Systemic Psychotherapist, and attended by Social Workers, Project Workers and the Team Managers in 
the NRPF Team.  

  Case  consultations  with  experienced  and  specialist  Practice  Development  Social  Workers  and  Family 
Psychotherapists to monitor and improve practice with a particular focus on balancing duties with compassion 
and working in partnership with parents.  

  One to one intensive reflective sessions with the social worker who worked with Mazeedat's family by a named 
Clinical Therapist to explore the findings of the complaint, test reflections and monitor practice given the findings 
of the complaint.  

In addition, The London Black Women’s Project conducted training with the NRPF Team. The aim was to further enhance 
their understanding of the journey of migrant families with No Recourse to Public Funds focussing on trauma-informed 
practice and domestic abuse. This has resulted in an improved awareness and knowledge in relation to trauma informed 
practice by the NRPF team and further enhanced working in partnership with the Voluntary and Community Sector, 

There is the continuation of a bi-monthly “Migrant Help Operational Group” meeting between senior management in the 
NRPF Service, Voluntary Community Services (VCS) and other council services, such as Housing, Adult’s Social Care, 
and Children’s Social Care. This originally began in September 2020, was rebranded and expanded in November 2023. 
The group enables regular collaboration to learn from each other and better jointly support families with No Recourse 
to Public Funds. These bi-monthly meetings have improved communication between the Local Authority and the VCS 
groups providing support for immigrant families.  

Improvements to the whole Children’s Services including the NRPF Team  

Newham  Children’s  Services  has  been  on  an  improvement  journey  since  2019,  recognising  that  improvements  in 
practice are crucial to positive outcomes for the children and families we work alongside. In light of this the service had 
developed  an  overarching  approach  to  the  practice  of  social  work,  that  is  informed  by  Systemic  Psychotherapy, 
Relational  and  Restorative  Practice.  We  have  built  this  into  an  approach  we  call  “Circles  of  Support”.  This  is 
characterised  by  the  idea  that  all  practice  is  held  by  Six  Key  components:  Compassion,  Curiosity,  Collaboration, 
Community, Confidence and Clarity. This work has directly improved the culture of the NRPF team by collaborative work 

       
 
 
 
 
 
 
 
 
 
 
 
 
 with families to deliver good quality interventions and provide the best packages of support to every child and young 
person who needs it.  

Since January 2022 there has been a focussed approach to improve the support and care offered to children and their 
families by Social Workers and managers in Newham. This support has been offered through a Purposeful, Planned 
and Focussed (PPF) approach.  

Training  around  the  use  of  language  and  the  impact  of  early  conversations  on  positive  outcomes  was  rolled  out  in 
February 2022 - “The power of the 1st Utterance”. “The Power of the 1st Utterance” is an approach developed within 
the Family and Systemic Psychotherapy field and adapted to social care contexts. It invites the worker (Social Workers 
in this case) to be mindful about how they start conversations  and  how  these conversational  starters construct what 
follows. The invitation is to start conversations in ways that are appreciative rather than starting from the point of concern. 
In this way relationships are more likely to be constructive, trusting, collaborative and enabling.  

Children’s  Services  Clinical  Family  Systemic  and  Psychotherapists Team  run  weekly  training  sessions  for  all  Social 
Workers, targeted at particular teams/or a particular Social Worker where specific issues or needs, such as concerns 
about language, relational practice and interventions with families are identified by managers, the Quality Assurance 
Unit or partners. 

Specialist training in Systemic and Relational Approaches by dual Qualified Family Systemic and Psychotherapists as 
well as Practice Development Social Workers (PDSWs) has been offered to staff. This has included a 5-day Systemic 
training offer (run three times a year), qualifying training up to a Masters level for a number of staff as well as individual 
focussed  workshops  on  subjects  such  as  Child  Sexual  Abuse,  Domestic  Violence,  Drug  and  Alcohol  Misuse, 
Neurodiversity  and  Mental  Ill  Health.  Weekly  sessions  also  run  throughout  the  year.  These  sessions  involve  staff 
exploring ‘language that cares’ and how we must have conversation with families, balancing rigour with compassion.  

Our named Court Manager trains Social Workers on a regular basis to explore and refresh staff regarding the legalities 
of Section  20 (foster care) matters. The focus of which  is to support workers better articulate  the legal framework to 
parents  and  young  people  so  that  they  are  fully  aware  of  their  rights  in  the  event  their  child(ren)  needs  to  be 
accommodated by the Local Authority under Section 20 of the Children Act 1989.  

Our  training  offer  is  constantly  under  review,  and  we  seek  feedback  from  families,  children,  staff,  communities  and 
partners with the aim of constantly improving  our service delivery. This is in  addition to producing and implementing 
action plans regarding the learning from any Local Practice Safeguarding Reviews to ensure we make improvements 
to service delivery as needed.  

“Welcome  Newham”  was  launched  on  11th  August  2022.  This  Council-led  weekly  one-stop  shop  offers  help  to 
immigrants, including refugees, asylum seekers and migrants with No Recourse to Public Funds. These include families 
and children who have recently arrived in the Borough, as well as hosts families. The Welcome Newham Team offers a 
plethora of support to migrant families by referring to appropriate services in the community such as access to education, 
health care, emergency support, assistance with food, clothing, finance, social connections and community inclusion. 
Over time, and because of effective partnership working with Voluntary, Community and Faith Sector, Welcome Newham 
has strengthened its services to vulnerable migrant children, adults and families who are new to the Borough. 

In a further demonstration of the improvements in our service to those who arrive in the borough with No Recourse to 
Public Funds in October 2024, Newham Council was awarded the ‘Borough of Sanctuary’ status by the National City of 
Sanctuary charity and the NRPF team were a central part of this. The City of Sanctuary awards recognise and celebrate 
the  organisations  which  go  above  and  beyond  to  welcome  people  seeking  sanctuary. The Award  acknowledges  the 
breadth of the Council’s and partners’ work in this area to create a culture of welcome which values the contribution and 

       
 
 
 
 
 
 
 
 
 
 
 strengths  of  refugees  and  other  sanctuary-seekers  arriving  in  the  borough.  As  part  of  the  award,  Newham  has 
demonstrated its commitment to the Sanctuary values of inclusivity, participation and integrity.  

A deep dive audit was completed in December 2024 as soon as the Coroner concluded the Inquest, to immediately re-
review the service’s practice focusing on service delivery, the experiences of families with No Recourse to Public Funds, 
the quality of management oversight and recording.  The reviewer analysed all PLCs conducted within the NRPF service 
between 2022 to November 2024. PLCs were conducted on a monthly basis. In total, 24 files were reviewed. Feedback 
was successfully obtained from 19 of these families during the PLCs, while the remaining 5 families, the auditor was 
unable to establish contact. Families rated  their experiences from  1 (inadequate) to 10  (outstanding),  providing both 
quantitative  ratings  and  detailed  qualitative  reflections.  This  feedback  sheds  light  on  the  service  quality,  highlighting 
strengths from a family’s point of view. 

The majority of families rated their experience positively:  

  26.3% (5 families) giving a score of 10, reflecting an outstanding experience. 
  68.4% (13 families) rated their experience between 8 and 9, indicating high satisfaction. 
  5.3% (1 family) rated their experience as 6, suggesting slight satisfaction.   

(iii) Action Proposed to be Taken 

Improvement to Practice 

We are committed to our programme of continually improving our practice standards, and embed an aspirational culture 
of learning, support and challenge with staff clear about what is expected of them including core practice such as the 
Voice of the Child, Visits, Assessments, Plans for children, Records and Supervision. 

Since the Coroner’s findings a further Training Plan for the NRPF team has been created to ensure staff have refresher 
training and that what occurred to Mazeedat will not occur again. 

The following refresher training courses have been identified and scheduled for the team: 

Training  
Completing Purposeful Child & Family Assessments (Single Assessments) 
and Planning 
Refresher of Relational Practice and application of Language that cares 
Section 20 Seminar - The seminar will concentrate on processes, language 
and working in partnership with parents.    
Language that Cares and Relational and  Compassionate Recording.  This 
will be conducted by a dual Qualified Family Systemic and Psychotherapists 
Human Rights Assessments 
Supervision Training for Managers 
Fortnightly seminars on varied subject matters related to practice conducted 
by the Newham Academy 

Date  
By 31/01/25 

By 28/02/25 
By 28/02/25 

By 28/02/25 

By 31/03/25 
By 30/04/25 
Fortnightly and 
ongoing 

A named Practice Development Social Worker (PDSW) has been aligned to the team, to further monitor and support 
ongoing  practice  development  in  the  service.  The  PDSW  will  follow  a  coaching  model  that  includes  the  delivery  of 
training  workshops  covering  the  above  topics  and  different  practice  subject  matters.  This  will  be  followed  by  1  to  1 
coaching  with  each  worker,  including  joint  visits,  practice  role  modelling,  observation  of  practice,  reviewing  written 
records  and  providing  feedback  and  reflective  spaces. We  consider  that  this  will  directly  impact  a  continuing 

       
 
 
 
 
 
 
 
 
 
 
 
 improvement in culture within the NRPF team. 

Working with Voluntary Organisations to further improve practice 

The council is committed to working in collaboration with voluntary organisations to offer better joined up support to our 
families and the following has been agreed:  

In  the  December  2024  audit  report,  it  was  recommended  that  Children’s  Services  annually  commission  an  external 
Voluntary  Organisation  with  expertise  in  NRPF  to  gain  Family  Feedback  in  addition  to  feedback  gained  within  the 
Practice  Learning  Conversations  that  take  place  as  part  of  Newham’s  Quality  Assurance  Process.  This  was  in 
recognition that  the  positive feedback  families gave to the  Newham employed  auditors (who  would have  introduced 
themselves  as  council  employees)  might  be  overly  positive  due  to  that  context and  that  an  external  agency  where 
families could remain anonymous would ensure more accuracy of feedback. 

A review of the Terms of Reference of the current Migrant Health Operational Group is to take place by April 2025 to 
enable  key  voluntary  organisations  working  with  NRPF  families  to  attend  and  offer  critical  reflection  on  systems, 
processes and decision making. The plan is for a voluntary organisation to co-chair the meeting. 

We plan to invite Voluntary Organisations to the NRPF Service Meeting to develop relationship, promote learning and 
enhance practice in April 2025, where the frequency of attendance and remit will be established. 

b) The Coroner's Concern regarding the management of the NRPF Team 

The Coroner has set out a further Concern in his Report as follows: 

The  NRPF team was poorly managed.  Social workers were not  adequately supervised, and  their caseloads 
were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very 
people the team were employed to support. The absence of proper management left inappropriate behaviour 
unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.  

We acknowledge the team had a high case load between 2020-2021 as a result of the Covid-19 pandemic, which led 
to a significant increase in the number of families we were supporting within the No Recourse to Public Funds Service. 
At  the  time  the  team  were  working  with  an  average  of  535  children.  We  acknowledge  this  impacted  on  consistent 
supervision and management oversight.  The caseload at the time of completing this report is 348 with the same number 
of staff that there was in 2021. Over time, there has been a gradual reduction in demand and assurance that practitioners 
are holding a more manageable caseload.   

Managers  across  the  Directorate  undertake  approximately  65  bi-monthly  Full  Case  File Audits,  as  well  as  sample  a 
number of case files dependent on a particular theme e.g. neglect, physical abuse. Alongside this, our Quality Assurance 
Unit  also  undertakes thematic and  multi-agency reviews.  Data is analysed and  compared to  neighbouring  boroughs 
which are considered statistical neighbours to assist with whether decision making in an area is consistent with other 
boroughs. An example of this is as follows; in 2020-2021 Newham placed 79 children into foster care, compared to the 
average of 77 of our statistical neighbours, in 2021-2022 this rose sharply in the borough, and we placed 141 children 
into  foster care, compared to 97  by our statistical neighbours. In 2022-2023  we placed 114 children  into foster care, 
compared to 98 of our statistical neighbours. We can conclude from these figures that Newham support more Section 
20 foster placements than other Local Authorities and that these placements have increased since 2020.  

       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (i) Action Taken Following Mazeedat's death 

In addition to the launch of our Practice Learning Conversations in 2022, which ensures heightened oversight of cases 
and practice by all managers including Senior Management, the Head of Service also chairs the NRPF panel twice a 
month, which allows for greater scrutiny of families’ situations. The purpose of the panel is to scrutinise the work with 
families and prevent any drift and delay in decision making for the children and families allocated to the service. The 
panel also ensure the oversight of the family’s circumstances such as their immigration journey, their accommodation 
needs and the level of support they are receiving. The panel consists of practitioners from Newham Children’s Social 
Care, Housing and the Legal department.  

A focused campaign was launched in 2022 to ensure that social workers and managers were recruited permanently and 
replaced agency staff who did not provide consistent Relational Practice to families.  These improvements can be seen 
in our staff retention and turnover rates since 2021. In 2021 we had 30% permanent staff (Social Workers and managers) 
in Children's Services and 70% agency staff. Currently we have 80% permanent staff (Social Workers and managers). 
Our  20%  agency  staff  receive  the  same  training  that  permanent  staff  do  as  we  can  invest  in  them  given  the  lower 
numbers of them. Many of these agency staff are longstanding. Our turnover rate is now very low and has been on a 
downward trajectory from 2019-20 where our turnover rate for social workers was 30.2%. In 2023-24 the turnover rate 
for social workers was 11%. An improved staff retention rate results in more experienced staff, and indicates a positive 
culture within the team where staff have appropriate caseloads and are able to give the time and energy needed to each 
individual child and their family. 

As part of our ongoing learning and practice development in 2022, a Family Therapist and Practice Development Social 
Worker held 1:1 reflective  supervision sessions with  named team managers  to  support with  improving the  quality  of 
supervision, recording and reflecting language that cares in management oversight and supervision records. We are 
continuing to strengthen and ensure compliance with supervision standards through monthly performance management 
meetings with the NRPF management team. These meetings are chaired by the Head of MASH, NRPF and Early Help 
Services. As  part  of  our  performance  management  schedule,  a  monthly  Practice  and  Outcome  Meeting  of  Head  of 
Services also takes place and is chaired by the Director of Early Help and Safeguarding. This meeting scrutinises the 
plethora of data  collated,  hypothesises the reason for the  data being  what  it is and directs  improvements. This data 
includes staff supervision timeliness and caseloads. 

Supervision Policy and Management Oversight Review 

The purpose of supervision is to ‘enable and support workers to build effective professional relationships, develop good 
practice, and  exercise both professional judgement and discretion in decision-making’. The frequency of supervision 
may vary depending on the supervisee's role, level of experience and the families they are supporting. However, the 
minimum standard expected is 4 weekly 1:1 meeting for one and a half hours for professional development and families 
that require additional support. This is monitored through monthly in depth data collection and if any concerns arise this 
is addressed with urgency.  

Access to Care & Resources Panel 

The purpose of the Access to Care and Resource Panel (ACRP) is to scrutinise and authorise all recommendations to 
look after children under Section 31 and 20 of the Children Act 1989. Newham Children’s Services recognises that the 
decision to look after a child or young person is a momentous and life changing event for them and their family and 
should only happen with due consideration of all the alternatives, with the needs of the child or young person at the 
forefront of our consideration. 

       
 
 
 
 
 
 
 
 
 
 
 
 The Panel are acutely aware of the disproportionality and disparity factors that are present within the Children’s Social 
Care and Education systems and strive to promote equity and inclusion, tackle racism and all forms of discrimination. 
The Panel require all aspects of Equity, Diversity and Inclusion to be explained and explored and strive to be culturally 
competent.  

The ACRP went live in July 2024 and is chaired by the Director of Children Services and the Director of Early Help and 
Safeguarding.  The  membership  of  the  panel  includes  senior  managers  from  Education,  Children  Social  Care, 
Independent Reviewing Service and Commissioning. Since going live in July 24, 138 children have been discussed at 
the ACRP, including those children whose parents have No Recourse to Public Funds. The introduction of the ACRP 
means that approvals for children to be looked after is no longer service led as it was in Mazeedat’s case. All requests 
will now need to be made to ACRP.  

Audit  

A deep dive audit was completed in December 2024 as soon as the Coroner concluded the Inquest to immediately re-
review the service’s practice focusing on service delivery, the experiences of families with No Recourse to Public Funds, 
the quality of management oversight and recording.  The reviewer analysed all PLCs conducted within the NRPF service 
between 2022 to November 2024. The December 2024 audit findings in relation to supervision found 15 cases (62.5%) 
were graded  as  Good, 1  case  (4.2%) as  Outstanding,  6  cases (25%)  were graded as Requires Improvement and  2 
cases (8.3%) as Inadequate. In cases graded as Inadequate or Requires Improvement the key concerns identified were 
that  managers  were  not  ensuring  swift  escalations  to  the  Home  Office  which  had  implications  for  families’  ability  to 
progress  with  their  immigration  status,  and  that  the  frequency  of  supervision  and  management  oversight  was  not 
consistently in line with the Supervision Policy. We note this aligns with the Coroner’s findings and therefore are taking 
further action to rectify the matter. 

(ii) Action Proposed to be Taken  

The  2024  audit  which  reviewed  all  PLCs  (audits)  undertaken  from  2022  to  2024  recommended  that  management 
oversight should be further strengthened and the supervision policy reviewed. We are in the process of reviewing our 
supervision policy to be more specific and clear regarding the frequency of supervision and management oversight for 
different types of children and family’s circumstances.  

The Service has a bi-monthly sample review schedule of case audits by the Service Manager. This is alongside Practice 
Learning  Conversations  undertaken  by  the  Quality Assurance  Service.  In  light  of  the  findings  made  by  the  Coroner, 
there will be a particular focus on the following areas in our audit schedule: 

  Supervision and management oversight 
  Recording 
  Plans 
  Voice of the child 

In response to the changes in government guidance “Stable Homes Built on Love” the directorate is ready to reimagine 
the service we offer to Children and Families, including families with No Recourse to Public Funds that will further embed 
our  Circles  of  Support  Practice  Model.  We  are  taking  the  opportunity  brought  about  by  these  changes  to  develop  a 
service which is aligned to the principles of “Stable Homes, Built on Love” and Working Together to Safeguard Children 
2023. As a result of these changes, the NRPF Team is going through structural changes, and going forward will be made 
up of mainly Family Support Project Workers instead of Social Workers. This new model ensures workers are able to 
spend  more  time  offering  effective  early  help  support  for  families  with  No  Recourse  to  Public  Funds.  This  more 
streamlined support will provide further relational, compassionate opportunities to work collaboratively with families and 

       
 
 
 
 
 
 
 
 
 
 
 voluntary organisations. It will continue to value all voices and reflect those voices in our records.  

With the launch of the new team on 20th January 2025, we have identified a quality assurance action plan (see below), 
to be undertaken over the course of the next 3 to 6 months. As part of the quality assurance programme for the newly 
reconfigured service, leadership, systems and processes in the NRPF Team will be monitored and reviewed. This will 
ensure further enhanced operational management and leadership oversight of the NRPF Team, including continuing to 
ensure manageable caseloads for workers. It will also support us to further review our performance, practice, conduct 
of staff, team culture, and any patterns of behaviours that may give cause for concern. 

Action 
Peer  Review  of  the  NRPF  Service  by  a  London Authority  with 
Good or Outstanding Ofsted rating. The peer review will consider 
leadership, quality of practice, quality of management oversight 
and quality of recording. 
Twice Yearly Practice Week – this will enable the leadership team 
in CYPS including the Director of Children’s Services to observe 
practice, audit children’s files and obtain feedback from families 
with No Recourse to Public Funds.  

As part of ensuring the ongoing improvement of the quality of the 
service  delivery  within  the  NRPF  Team,  our  Quality Assurance 
Unit shall undertake a review of any Complaints received in the 
service between 2022 – 2024. We will do this alongside the VCS 
organisations who may have raised concerns. 
Review and launch the new Supervision Policy  
Audit of adherence to the Supervision  Policy  
NRPF Policy to be reviewed alongside MAGPIE and Praxis 

Date 
By 30/04/25 

First  Practice  Week  will  be 
completed in February 2025 

Second  Practice  Week  will  be 
undertaken in May 2025 
By 31/03/2025 

By 30/04/25 
By 31/07/25 
By 30/06/25 

c) The Coroner's Concern regarding the standards of note-keeping and recording 

The Coroner has set a further concern as follows: 

Inadequate standards of note-keeping meant that the rationale for critical decisions made by the NRPF were 
not  properly  recorded.  The  absence  of  clear  records  diminished  both  communication  within  the  team  and 
accountability.  

We acknowledge the Coroner’s findings that record keeping was below the standard we expect and this has meant that 
crucial decisions made by the NRPF team were not clearly recorded on Mazeedat’s file.  Since 2022, we have set a 
very high standard on our recording to ensure it is purposeful, child focused and clearly reflects the actions and decisions 
we have taken to support the family.  

(i) Action Taken Following Mazeedat's death 

Significant improvements have already been made to note-keeping and the recording of actions and decisions.   

Appropriate and child centred recording is an area of practice that has been promoted, directed and embedded since 
2022. Appropriate and child centred recording is the practice that invites Social Workers to take jargon out of their written 
records and to use child focused recording on a child’s record. The aim is to avoid the use of acronyms and imagine 

       
 
 
 
 
 
 
 
 
 
 
  
 
 
 that the child will be reading, when they grow up, what is being written about them. Staff have been trained to do this by 
the roll out of the model of “Language That Cares”.  

Children’s Services now takes an approach to recording that is both non-pathologising and appreciative of the child and 
family’s contexts. A non-pathologising approach to recording is one where the Social Worker does not record in ways 
that construct the identity of a child through the use of diagnostic terminology or labels that imply the child is something, 
rather it invites a recording that says the child or parent is showing a behaviour at a particular time. An example would 
be  instead  of  saying  “X  is  aggressive”,  we  would  encourage  the  Social  Worker  to  record,  “X  due  to  his  traumatic 
experiences finds containing his feelings of distress hard”. Meaning as a parent he may speak aggressively or refuse to 
give information due to his past experiences of trauma. By using this approach, record keeping is clearly made, improves 
communication between staff, families and third parties, and improves the accountability of our staff. 

All quality assurance activity includes reviewing the quality and detail of recording on child’s files.  

The  December  2024  audit  findings  in  relation  to  recording  found  that  22  cases  were  graded  as  Good  and  1  as 
Outstanding and 1 as Requires Improvement. The case graded as Requires Improvement was due to the recording of 
the framing of the mother’s experiences of domestic abuse appeared to minimise the seriousness of the abuse. Other 
findings to further improve recording including workers ensuring chronologies were on file. 

Through the Newham Social Care Training Academy, we are continuing to offer training to staff including workers in the 
NRPF Team to ensure  that language that cares is used consistently when they are recording on the child’s file. The 
Academy is the vehicle for developing our workforce and improving outcomes through development and training, in turn 
helping them to support and empower the families they work with.  

(ii) Action Proposed to be Taken 

We are working closely with our IT support team to make further changes to our Integrated Children’s System (ICS) in 
order  to  support  with  further  strengthening  all  note-keeping  and  recording  including  the  recording  of  management 
decision making. 

The following system changes are planned: 

Proposed System Change 
Introduction of NRPF Plan template following the completion of a Child 
and  Family  Assessment.  This  will  ensure  regular  reviews  of  NRPF 
plans following the completion of Assessments. 
NRPF Panel Form to be embedded in our ICS system 

Date 
This went live on 14/01/25 

By 31/03/25 

       
 
 
 
 
 
 
 
 
 
 
 
 
 
 4. Conclusions and Impact 

In conclusion, we have re-evaluated our internal policies and procedures after this tragedy and significant changes and 
improvements  have  been  made  as  highlighted  in  this  report.  The  impact  for  children  and  families  as  found  through 
auditing  has  been  mainly  positive.  The  permanent  workforce  has  improved  dramatically  and  the  Regulator,  Ofsted 
concluded “Families with no recourse to public funds receive a responsive service from social workers who take into 
consideration the complexity of children’s circumstances and their needs”.  

Our service delivery has improved markedly from the Inadequate grading by Ofsted from 2019 until July 2022 where 
Children’s  Services  were  graded  as  Good  with  Outstanding  Leadership.  Since  the  launch  of  the  revised  Working 
Together to Safeguard Children 2023, we have reviewed the way we support families with No Recourse to Public Funds. 
We  are  in  the  process  of  making  systems  changes  in  line  with  the  principles  of  supporting  families  early  and  only 
allocating a family to a Social Worker for assessment and support if there are safeguarding concerns. This is also based 
on  the  feedback  we  have  received  from  Newham’s  families  which  was  similar  to  the  feedback  from  families  to  the 
National Review of Children’s Social Care- Stable Homes Built on Love.  

Importantly, feedback from the families themselves indicates that the service delivered by staff is compassionate, child 
focused  and  makes  a  difference  to  their  lives.  In  the  audit  conducted  in  December  2024  which  reviewed  children’s 
records between 2022 and 2024, the majority of families rated their experience very positively.  

Since 2022, families have written into the service offering thanks and compliments to the NRPF team. These have not 
been asked for but are collated, shared amongst the team and the whole service. Staff who receive such compliments 
in their practice get mentioned alongside the quote from the family (anonymously) in the Children’s Services newsletter 
which is distributed to over a 1000 staff. This all aims to share good practice and foster a positive culture. 

A sample of that feedback is included below: 

September 
2024 

Your team has done a great job in my life. More especially putting smiles on our 
faces when I thought there was no hope to survive with my children. During this 
sudden abandoned by their daddy, I was emotionally and socially deranged 
because I didn't know what to do due to my past statue until your team rescued 
me at the time of needy. You paved a very wide way for our future with a good 
channel with Praxis team.  I really appreciate all your supports as you all has 
created an impact in my heart. 
God bless you all. We love your team. 

February 2024 

I just want to say thanks to you and your humble office for the support given to 
my family, we are grateful! 

Thank you [social worker] for allowing God use you to support us especially at 
the moment when as a family we lost hope and had no means to survive, which 
was a moment we feared for what would become of our family as we had 
nowhere to go, or did not know what to do with our housing and financial 
situation. 

Each day we sleep and wake up in this house it is like a dream and each time "all 
we say is that may god bless you! beyond measures!!! yes, you only did your job 

       
 
 
 
 
 
 
 
 
 
 
 
 
 as a social worker, but little did you know that God was using you to help a family 
in need, if only u know how far we have come and what we went through you 
would understand why each time we see you or speak to you we cannot but 
keep thanking you and your humble office.  
Each time you speak from a place of concern and care for my daughter ‘F’and 
whenever you do it touches my heart!  
Thank you [social worker]! for doing your job diligently! 

Thank you [social worker]! for making our experience with you seamless! 

Thank you [social worker] for always reaching out to our family from a place of 
care without judging us or treating us differently because of our status! 

Thank you for listening when we needed clarity! 

Thank you [social worker] for making our experience with the social services no 
recourse to public funds team a good one! 

I wanted to express my heartfelt gratitude for your exceptional support throughout 
our visa processing journey. Your guidance and expertise played a pivotal role in 
making  this  intricate  process  more  manageable.  Your  dedication  to  ensuring  a 
smooth experience did not go unnoticed and I truly appreciate the time and effort 
you  invested  in  addressing  my  concerns,  no  matter  how  small  or  difficult  it 
sounded.  Your  professionalism  and  compassionate  approach  have  made  a 
significant impact, turning what could have been a stressful ordeal into a positive 
and successful outcome. Whenever you were not available, you ensured we had 
JB  who  was  always  at  hand  and  very  supportive. You  made  the  burden  lighter. 
Thank  you  once  again  for  your  unwavering  assistance.  Your  commitment  to 
helping  others  shines  through  and  I  am  genuinely  grateful  for  the  positive 
difference you have made in mine and W’s life. We will forever be indebted to you. 
God bless you and the entire NRPF Team. 

January 2024 

May 2023 

May I use this opportunity to commend your department for the prompt handling 
of  the  matter,  and  in  particular  Ms  “D”,  who  was  very  professional,  patient  and 
empathetic with me on the phone; I truly appreciated it.  

November 2022 

I want to thank you for having helped us to get the council's support! We are in a 
much better hotel, we can't cook yet and we can't even live like in a house, but we 
are happy to be well accommodated! I believe it is a temporary situation that soon 
we will follow a house! Even so, I want to thank you for helping us by filling out the 
form  and  calling  people  on  our  behalf!  May  your  life  be  more  than  blessed, 
magnificent and extraordinary! A big hug from our Family! 

November 2022  Thank you for being with us till the end. And support and guidance from you and 

team is amazing. Every will be there which is not belongs to us. Thank you  

September 
2022 

Thank you so much for your help, support, compassion and kindness. During our 
hard  time  you've  always  raised  a  hand  to  support  my  family.  I  really  appreciate 

       
 
 
  
 
 
  
 
 
 
 
 
 your hard  work, positive attitude  and kind  behaviour.  I would like to express my 
sincere gratitude for the service you've provided. 

We  acknowledge  that  more  needs  to  be  done  to  further  improve  practice,  and  have  therefore  devised  an  extensive 
action plan to further improve the service we offer to families with No Recourse to Public Funds. We are confident that 
the implementation of the action plan will further improve the practice already in place to ensure the NRPF Team can 
continue  to  deliver  intervention  that  is  compassionate  and  responsive  and  that  the  culture  of  the  team  and  service 
continues to be relational, child focused and collaborative. 

       
 
 
 
 
 
 
 
 
 5. Action Plan 

The implementation of the Action and the impact of the actions once completed will be overseen by a Multi-Agency Task 
and Finish Group chaired by Director of Early Help and Safeguarding and CEO founder of The MAGPIE Project.  

Action 
Terms of Reference for Task and Finish Group to be devised 
and agreed. 

Date  
By 19/02/25 

Lead 
Director of Early Help 
and Safeguarding 
with assistance from 
The Magpie Project 
and Praxis 

Review  the  Terms  of  Reference  of  the  current  Migrant 
Health  Operational  Group 
to  enable  key  voluntary 
organisations working with NRPF families to attend and offer 
critical  reflection  on  systems,  processes  and  decision 
making. The plan is for a voluntary organisation to co-chair 
the meeting 
Invite Voluntary Organisations to the NRPF Service Meeting 
to  develop  relationship,  promote  learning  and  enhance 
practice, where the frequency of attendance and remit will 
be established. 
Completing Purposeful Child & Family Assessments (Single 
Assessments) and Planning Training 
Refresher  Training  -  Language  that  Cares  and  Relational 
and Compassionate Recording.   

By April 2025  Migrant Health 

Operational Group 

By April 2025  Head of Service, 

NRPF 

By 31/01/25 

By 28/02/25 

Refresher  Training  –  Purposeful,  Planned  and  focused 
Planning.   

By 31/03/25 

Human Rights Assessments 

Supervision Training for Managers 

By 30/04/25 

By 30/04/25 

Section  20  Seminar  -  The  seminar  will  concentrate  on 
processes and compassionate relational language     

By 30/05/25 

Fortnightly  seminars  on  varied  subject  matters  related  to 
practice conducted by the Newham Social Care Academy 
Commission an external Voluntary Sector Organisation with 
expertise in NRPF to gain Family Feedback 
Practice Development Social Worker (PDSW) who has been 
aligned to the team will further monitor and support ongoing 
practice development in the service using a coaching model.  
1  to  1  coaching  with  each  worker,  including  joint  visits, 
practice  role  modelling,  observation  of  practice,  reviewing 
written  records,  providing  feedback  and  reflective  spaces 

Fortnightly 
and ongoing 
By 30/06/25 

By 31/01/25 

Social Care 
Academy 
Qualified Family 
Systemic and 
Psychotherapists 
Qualified Family 
Systemic and 
Psychotherapists 
Head of Service, 
NRPF 
Social Care 
Academy 
Social Care 
Academy and Care 
Proceedings 
Manager 
Social Care 
Academy 
Director of Early Help 
and Safeguarding 
Head of Quality 
Assurance and 
Improvement Service 

       
 
 
 
 
 
 By 30/04/25 

Director of Early Help 
and Safeguarding 

will be offered. 
Peer  Review  of  the  NRPF  Service  by  a  London Authority 
with Good or Outstanding Ofsted rating. The peer review will 
leadership,  quality  of  practice,  quality  of 
consider 
management oversight and quality of recording. 
Twice Yearly Practice Week – this will enable the leadership 
team in CYPS including the Director of Children’s Services 
to  observe  practice,  audit  children’s  files  and  obtain 
feedback from families with No Recourse to Public Funds.  

As part of ensuring the ongoing improvement of the quality 
of  the  service  delivery  within  the  NRPF Team,  our  Quality 
Assurance Unit shall undertake a review of any Complaints 
received in the service between 2022 – 2024. We will do this 
alongside  the  VCS  organisations  who  may  have  raised 
concerns. 
A themed audit annually of children whose parents have No 
Recourse  to  Public  Funds  with  a  focus  on  single  parents 
with limited network. 
Review and launch the new Supervision Policy  

First  Practice 
Week  will  be 
in 
completed 
February 
2025 

Second 
Practice 
Week  will  be 
undertaken  in 
May 2025 
By 
31/03/2025 

By 30/06/25 

By 30/04/25 

Audit of adherence to the Supervision  Policy  

By 31/07/25 

NRPF Policy to be reviewed alongside MAGPIE and Praxis  By 30/06/25 

Introduction of NRPF Plan template following the completion 
of a Child and Family Assessment. This will ensure regular 
reviews  of  NRPF  plans 
the  completion  of 
Assessments. 
NRPF Panel Form to be embedded in our ICS system 

following 

This  went  live 
on 14/01/25 

By 31/03/25 

Director of Children’s 
Services 

Head of Quality 
Assurance and 
Improvement Service 

Head of Quality 
Assurance and 
Improvement Service 
Director of Early Help 
and Safeguarding 
Head of Quality 
Assurance and 
Improvement Service 
Director of Early Help 
and Safeguarding 
Completed 

Head of Quality 
Assurance and 
Improvement Service

Mr G Irvine
Senior Coroner
East London Coroner’s Court
Queens Road
Walthamstow
E17 8QP

Dear Mr Irvine,

INQUEST TOUCHING THE DEATH OF MAZEEDAT OPEYEMI ADEOYE

I, 
, Head of the  National Police Air Service (NPAS), am writing in response to the Regulation
28:  Report  to  Prevent  Future  Deaths  in  the  matter  of  Mazeedat  Opeyemi  Adeoye  (reference
16975704).

Whilst acknowledging that the delay in locating Mazeedat did not contribute to her tragic death, I fully
accept that our training and operational practices require a review to ensure that future deaths are
prevented wherever possible. In coming to my decisions I have liaised with 
, Head
of  Flight  Operations, 
,  Tactical  Flight  Officer  and
,
technical SME, 
Regional Operations Manager. There is a large breadth of knowledge and experience between these
staff members, both in wider aviation and policing.

 , Training and Quality Standards Manager and

, 

Police decision making is based on the National Decision Model - a model that is trained via the College
of Policing.  The national decision  model  (NDM) is  suitable for all decisions  and should be used by
everyone in policing. It can be applied:

to spontaneous incidents or planned operations
by an individual or team of people
to both operational and non-operational situations




 Decision makers can use the NDM to structure a rationale of what they did during an incident

and why.

Everyone can use the NDM to review decisions and actions, and promote learning.

In a fast-moving incident, the police service recognises that it may not always be possible to segregate
thinking or response according to each phase of the model. In such cases, the main priority of decision
makers  is  to keep  in  mind  their overarching  mission to act  with  integrity to protect  and serve  the
public. This is in line with the ethical principle of 'public service'.

 The NDM has six key elements.



Code  of  Ethics; Ethical  policing  principles and Guidance  for  ethical  and  professional
behaviour in policing.

 Gather information and intelligence.





Assess threat and risk and develop a working strategy.
Consider powers and policy.
Identify options and contingencies.
Take action and review what happened.

In  this  particular  case  the  information  /  intelligence  was  that  the  house  and  gardens  had  been
thoroughly searched and with the rear gate locked the officers on the ground believed Mazeedat has
left the property via the front door. This then led to the Tactical Flight Officers determining the search
parameters.

Moving forwards, to investigate every heat source on every incident would not be practicable and
may be counter productive, leading to delays that could also contribute to future deaths. There will
always be a balance to be maintained.

The training our TFO's receive is to utilise the NDM, with the intelligence / information coming from a
variety of sources depending on the type of incident. It may be that NPAS are the only police resource
and are reliant on the contents of a police log, in other cases there will be officers on the ground and
their input forms part of the wider picture.

We have to rely on our staff applying their training correctly as well as using professional judgement
based  on  the  experience  they  have  in  police  aviation  and  how  the  different  cameras  detect  heat
sources. As technology progresses, potentially with new fleet, there may be opportunities to change
how we search.

I will however utilise this footage as a case study / training tool for NPAS that may give perspective to
search scenarios moving forward. Should a situation present itself in a similar way it may cause a TFO
to think beyond the info / intel where time and circumstances allow. This will be incorporated from
the next training course that commences on 14th February.

Yours sincerely

Head of NPAS

Social Work England 
Fitness to Practise Team 
1 North Bank 
Blonk Street 
Sheffield 
S3 8JY 

PRIVATE & CONFIDENTIAL 

Sent via email only to: 

21 January 2025 

Dear Mr Irvine, 

Re: Regulation 28 Report– Ref: 

I am writing further to the Regulation 28 Report to Prevent Future Deaths (1) sent to Dr 
Andrew McCulloch on 5 December 2024 in relation to the death of Mazeedat Adeoye.  I am 
writing on behalf of Social Work England to provide our response to the report. 

Thank you again for meeting with us on 3 January 2025. We found the meeting very helpful 
in allowing us to understand the case in more detail. We also appreciate that you have 
authorised the release of the documents bundle and the relevant recordings of the witness 
evidence. We have now received these documents and recordings. 

Our role as a regulator and the triage test 

As you are already aware Social Work England is the statutory regulator of social workers in 

England. We are a non-departmental public body, operating at arm’s length from 

government, and established by the Children and Social Work Act 2017. Our central focus is 

public protection. We do this by pursuing the following objectives: 

•  To protect, promote and maintain the health, safety and wellbeing of the public 

•  To promote and maintain public confidence in social workers in England 

•  To promote and maintain proper professional standards for social workers in 

England 

The achievement of our objectives is delivered through six key regulatory functions, one of 

which is the operation of a proportionate and efficient fitness to practise process to deal 

with concerns raised about those on our register. Our fitness to practise process is governed 

socialworkengland.org.uk 
1 North Bank, Blonk Street, Sheffield, S3 8JY 

1 

 
 
 
 
 
 
 
 
 by The Social Workers Regulations 2018 (as amended) (‘the regulations’) and the relevant 

Fitness to Practise Rules 2019 (as amended) (‘the rules’). 

When concerns are received about a social worker, we are required, in line with schedule 2, 
paragraph 1 of the regulations, to determine whether there are reasonable grounds for 
investigating whether the social worker’s fitness to practise is impaired. This is what we 
refer to as the triage test. We have legal powers that allow us to gather relevant 
information from a variety of stakeholders (schedule 2, paragraph 5(1) of the regulations). 
At the conclusion of the triage process, we produce a triage decision which sets out which 
concerns do or do not meet the threshold for investigation and provides reasoning to 
support that decision. 

Actions undertaken to date 

We can confirm we have already undertaken the following actions: 

1)  We have contacted the London  Borough of Newham to ask for the details of the 
social workers that were involved in the case and whether there are any ongoing 
employer investigations with respect to those social workers regarding their 
involvement with this case. The London Borough of Newham has responded  to us 
and provided  us with relevant information. 

2)  We have opened fitness to practise cases with respect to the following social 

workers, 
enquiries can be made. The social workers, in line with our current policies, will not 
be advised of the cases unless the triage test has been met and we have determined 
that an investigation must be undertaken.  

 so that further 

 and 

3)  We have started reviewing the documentation and recordings from the coronial 

inquest. We are in the process of identifying if further information/documentation 
may be required from the Local Authority and others. We may also return to you for 
further information. 

Next steps 

We will now be undertaking the following steps: 

1)  We will gather and assess any further information that we may require from relevant 

persons/organisations. 

2)  We will contact Mrs Adeoye and her legal representatives and advise her of our 

current involvement in these matters, to give her the opportunity to provide us with 
her perspective and/or further information. 

3)  Once we are satisfied we have all the relevant information we require to make a 
triage decision, we will then determine whether there are reasonable grounds  to 
investigate any of the individual social worker’s actions. 

socialworkengland.org.uk 
1 North Bank, Blonk Street, Sheffield, S3 8JY 

2 

 
 
 Updates as to fitness to practise process 

As you will appreciate the process of reviewing the documentation, gathering additional 
evidence and then assessing that evidence may take some time and we are unable to 
provide you with a specific timeframe in which this will be completed.  

As we understand  from our recent meeting, you do not require regular updates as to our 
progress. However, please let us know if you do want us to keep you updated as we 
undertake the above steps. Otherwise, we will provide you with an update once we have 
determined whether the triage test has been met with respect to any of the social workers. 

Thank you for your assistance in this matter. If you have any further queries in the 
meantime, please contact me through my email at      

 or by phone on

Kind regards,   

Triage Manager  

socialworkengland.org.uk 
1 North Bank, Blonk Street, Sheffield, S3 8JY 

3 

 
 
 
 
 
 
  
 socialworkengland.org.uk 
1 North Bank, Blonk Street, Sheffield, S3 8JY 

4