Ella Murray

From 
Parliamentary Under-Secretary of State for    
Patient Safety, Women’s Health and Mental Health  

39 Victoria Street   
London  SW1H 0EU   

Our ref: PFD – 25-02-07 - MURRAY  

HM Coroner Catherine Wood  
Kent and Medway Coroners Service  
Oakwood House  
Oakwood Park  
Maidstone  
Kent ME16 8AE  

By email: Kentandmedwaycoroners@kent.gov.uk   

21st August 2025  

Dear Mrs Wood,   

Thank you for the Regulation 28 report of 7 February 2025 sent to the Secretary of State 
about the death of Ella Louise Murray. I am replying as the Minister with responsibility for 
Patient Safety, Women's Health and Mental Health.  

Firstly, I would like to say how saddened I was to read of the circumstances of Ella’s death, 
and I offer my sincere condolences to her 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.   

I  understand  that  NHS  England  and  Kent  and  Medway  Integrated  Care  Board  have  also 
received this report and I trust that they will adequately address your concerns at the local 
level.  I  look  forward  to  reading  their  responses  and  working  with  them  on  any  proposed 
changes.  

For matters that  fall  outside  of  this Department’s  direct  responsibility,  I  would  respectfully 
signpost you to the Department for Education (DfE), which leads on child safeguarding policy 
and related legislation and is better placed to respond to these elements of your report. I 
understand that they are preparing a separate response addressing those elements and my 
response references DfE policy where relevant.  

Your report raises concerns that, if a multiagency meeting had been convened under section 
47 of the Children Act 1989, Ella’s death may have been prevented, and such action may 
reduce the risk of death for other children in a similar position. I would like to assure you that 
the expectation is that a section 47 enquiry will normally be initiated to determine any action 
required to safeguard and promote the welfare of a child who is suspected to be suffering or 
is likely to suffer significant harm. Local authority social workers should lead assessments 
under section 47 of the Children Act 1989.   

Similarly, the expectation is that the police, health practitioners, teachers and school staff 
and other relevant practitioners should help the local authority in undertaking its enquiries.  

  
    
  
  
  
  
  
  
  
   
    
  
  
  
 Health  practitioners  should  provide  appropriate  specialist  assessments.  The  lead  health 
practitioner may need to request and co-ordinate these assessments. Health practitioners 
should also ensure appropriate treatment and follow up health concerns. The police should 
help other organisations and agencies understand the reasons for concerns about the child’s 
safety and welfare by sharing information and make available to other practitioners any other 
relevant information gathered or known to inform discussions about the child’s welfare.  

The  DfE’s  Children's  Wellbeing  and  Schools  Bill,  which  is  currently  being  considered  by 
Parliament, aims to strengthen these arrangements by placing a duty on local safeguarding 
partners  (local  authorities,  police  forces,  and  integrated  care  boards)  to  establish 
multiagency  child  protection  teams  (MACPTs)  with  a  minimum  membership  to  include  a 
social  worker,  police  officer,  registered  health  practitioner,  and  person  with  education 
experience.  

As  part  of  this,  the  Government’s  Families  First  Partnership  programme  is  delivering  the 
national  rollout  of  reforms  to  family  help,  multi-agency  child  protection  and  family  group 
decision-making,  including  delivery  of  MACPTs.  The  programme  guide  sets  out  the 
responsibilities  of  the  MACPT  members,  including  to  facilitate  better  communication  and 
information  sharing  among  practitioners  and  agencies. This  is available  at:  Families  First 
Partnership programme - GOV.UK  

I trust that the responses from NHS England or Kent and Medway Integrated Care Board 
will address why this may not have happened in Ella’s case and what mitigations have been 
put in place.  

Your  report  also  raises  concerns about  information  sharing. To  share  information  lawfully, 
NHS organisations must comply with the principles set out in data protection legislation, the 
General Data Protection Regulations (GDPR) and the common law duty of confidence. They 
should also apply the Caldicott Principles which have been established by the National Data 
Guardian  for  Health  and  Social  Care  to  govern  how  data  is  shared  by  health  and  care 
organisations.  

The Caldicott Principles make clear that the duty to share information can be as important 
as  the  duty  to  protect  patient  confidentiality.  Healthcare  professionals  should  have  the 
confidence to share information in the best interests of their patients, within the framework 
set out by the Principles, and be supported by the policies of their employers, regulators and 
professional bodies to do so.  

All NHS organisations, as part of their information governance arrangements, are required 
to have in place Caldicott Guardians who have responsibilities to safeguard and govern the 
use  of  patient  information  and  can  provide  advice  in  circumstances  where  there  may  be 
uncertainty about disclosure.   

Finally, and more widely, the Government is committed to tackling suicide as one the biggest 
killers in this country. The Suicide Prevention Strategy for England sets out priority areas for 
action to prevent suicides.  This includes the need to provide tailored, targeted support to 
priority groups, which includes children and young people, people who have self-harmed and 
people in contact with mental health services, providing effective crisis support within and 
outside of the NHS.   

  
  
  
  
  
  
  
  
  
  
 We recognise that too many children and young people like Ella are not getting the support 
that they need with their mental health. That is why we are investing an extra £688 million 
this  year  to  transform  mental  health  services  by  hiring  more  staff,  delivering  more  early 
interventions, and getting waiting lists down so young people can have the best possible start 
in life.  

We want to intervene much earlier to support better outcomes for children and young people. 
That is why our 10 Year Health Plan sets out how we will work with schools and colleges to 
better identify and meet children's mental health needs by expanding mental health support 
teams  in  schools  to  cover  100%  of  pupils  by  2029/30,  and  by  embedding  mental  health 
support in the new Young Futures hubs, to ensure there is no 'wrong front door' for young 
people seeking help.    

I hope this response is helpful. Thank you for bringing these concerns to my attention.    

All good wishes,

Chief Nursing Officer’s Directorate
NHS Kent and Medway
Floor, Gail House
Lower Stone Street
Maidstone
ME15 6NB

 2

nd

Mrs Catherine Wood
Area Coroner,
Mid Kent and Medway

Sent via email

Dear Mrs Wood,

Inquest into the death of Ella Louise MURRAY

I write in reference to the Prevention of Future Death Report made on 7th February 2025 to

 Chief Executive NHS England and the Kent and Medway Integrated Care

, Secretary of State for Health and Social Care,

Board (ICB).

Thank you for sharing your concerns with us.  We have liaised with Medway Foundation
Trust (MFT) and North East London Foundation Trust (NELFT - who are the provider for
children’s and young people’s mental health services in Kent & Medway) in the compilation
of this response.

NHS Kent and Medway is a commissioner of health services and the health lead statutory
safeguarding partner for both children and adults. Please note that neither the ICB Safeguarding
team or the Child Death Review team had direct contact with Ella or her family.

Ella was known to North East London Foundation Trust’s Children and Young People (NELFT)
services who are commissioned by NHS Kent and Medway to provide child and adolescent
mental health services.

I outline below the chronology of events following notification of Ella’s death, from a Child Death
Review perspective, which the ICB Safeguarding Team participates in.

The Kent and Medway Child Death Review Service (CDR) were notified on 16/11/23, within 24
hours of Ella’s death, by both Police and Kings College Hospital, in line with statutory guidance.
The Initial CDR standard operating processes were followed; a notification of death was sent out
to all known involved partners, and involvement summaries requested.

     
 A Joint Agency Response (JAR) meeting was scheduled for 20/11/23 (delayed only by the
weekend). A patient summary was received from her general practitioner (GP) on 16/11/23, as
well as information from social care, stating that Ella was known to Kent Integrated Children’s
Services, and with contact details for the relevant team. Social care informed the Child Death
Review team that an initial strategy meeting had already taken place and details from the
meeting were shared.

‘With You’ charity identified to the Child Death Review (CDR) team on 16/11/23, a summary of
their involvement, and Kent Community Health Foundation Trust (KCHFT) shared that Ella was
not open to any KCHFT services at the time of her passing, but that she had recent school
health involvement for counselling. From KCHFT records they believed Ella was also known to
mental health services.  It has been confirmed that Ella was known to North East London
Foundation Trust (NELFT) who provide mental health services.

On 20/11/23 the named nurse for safeguarding at Maidstone & Tunbridge Wells Trust (MTW)
informed the Child Death Review team that Ella had not been seen by this Trust in any capacity.

The Joint Agency Response was well attended on 20/11/23 and chaired by the Designated
Doctor, supported by the Child Death Review team, including specialist nurse and family liaison
team. There was representation at the Joint Agency Response from NELFT; Primary Care;
Kings College London NHS Hospitals Trust (King’s College Hospital); Education - Safeguarding;
Designated Nurse for Safeguarding Children, South East Coast Ambulance Service (SECAmb);
Kent Children’s Social Care; Police and Schools. Actions from the Joint Agency Response were
that there would be a further strategy meeting on 23/11/23; that NELFT would send chronology
reports to CDR team; that there was a Section 47 (A Section 47 Enquiry is initiated to decide
whether, and what type of, action is required to safeguard and promote the welfare of a child
who is suspected of, or likely to be, suffering significant harm) now in place for all children; and
a request for clarity on the location of Ella’s death.

At the Joint Agency Review the link to Ella potentially knowing two other young people through
school/ the local rugby club, who sadly died by suspected suicide, were identified by Police/
school. Joint Agency Review attendees were informed that the school were already seeking
support for students and staff, and Police were going to reach out to the rugby club to ensure
they had access to support for other rugby club members.

For all suspected child death by suicides, the Child Death Review team routinely links with the
Kent and Medway Integrated Children’s Services Suicide Prevention Programme Manager,
based in Kent County Council’s Public Health Team, for the purpose of monitoring, prevalence,
and intelligence across Kent.  Ella’s case was shared and the suspected link with two other
recent deaths also noted.

The Child Death Review team were notified by Kent Safeguarding Children Multiagency
Partnership (KSCMP) on 27/11/23 that a notification for a Local Children Safeguarding Practice
Review (LSCPR) had been received and that a Rapid Review would be convened.

On 01/02/24 the coroner’s office confirmed that Ella did not have a post-mortem; the cause of
her death had been confirmed as asphyxia due to hanging and that the coroner would bring
Ella’s case to inquest.

06/02/25 Child Death Review team informed by Designated Nurse that Local Children
Safeguarding Practice Review had been published on the Kent Safeguarding Children
Partnership Board (KSCPB) and link to the report.

 25/03/25 – Ella’s case was presented at a Child Death Review Meeting, which convened and
was chaired by Kings College Hospital for the purpose of review and analysis, and identified
matters relating to the death, contributory and modifiable factors.  Kent and Medway Child
Death Review team and Designated Doctor attended, alongside representation from Kent
Safeguarding Children Multi-Agency Partnership, North East London Foundation Trust, and
Education. Matters of concern from the Preventing Future Deaths (Regulation 28), were
discussed and reviewed, and details from the published Local Safeguarding Children’s Practice
Review were shared and action updates given. Following the Child Death Review Meeting,
Ella’s case review will be presented at Kent & Medway Child Death Overview Panel.

The specific action for the Child Death Review Team from the published Local Safeguarding
Child Practice Review (LSCPR) for Ella and her older sibling was as follows:
The Kent and Medway Child Death Review team will ensure any groups e.g. any sports teams/
etc. are routinely considered as part of the Child Death Review process to meet this
recommendation.

In response to this, the Kent and Medway Child Death Review team have confirmed that it is
already routine practice to involve known organisations in child death processes as soon as they
are identified following a death, as per the Child Death Statutory Guidance. In order to evidence
this further, the Child Death Review Team will be undertaking an audit within this cohort of
children.

Work has commenced a system wide Child Death Review process, to ensure appropriate gap
analysis is mapped to the new NHS England Child Death Protocol and in preparation for the
soon to be published Independent Review into Kent & Medway’s Child Death arrangements.

Feedback from the Rapid Review following notification for a formal Local Safeguarding
Child Practice Review (12/12/23)

Following the Joint Agency Review on 20/11/2023, NHS Kent and Medway Designated Nurse
for Safeguarding Children made a Serious Incident referral for Ella’s death, as per the local Kent
Safeguarding Children’s Partnership process. As a statutory safeguarding partner, NHS Kent
and Medway, have a responsibility to inform the other safeguarding partners of serious incidents
they think should be considered for a practice review.

Following notification to Kent Safeguarding Children Multi-Agency Partnership (KSCMP) of
Ella’s suspected death by suicide, where neglect may have been a feature, a decision to notify
the Child Safeguarding Practice Review Panel was made. Requests for agency information
were sent on 27/11/2023. This included requests to NHS Kent and Medway (for GP information)
and Health Providers across Kent and Medway. Summaries were presented to a virtual Rapid
Review Group on 13/12/2023 and the Groups recommendation was sent to the Child
Safeguarding Practice Review Panel. Single agency summaries from health identified learning
and actions, such as practitioners to employ professional curiosity during assessments and,
where there is disparity between the voice of the child and parent wishes, that practitioners
should make a conscious effort to explore and explain the potential impact of non-engagement
of the child to the parent.

A Local Child Safeguarding Practice Review (LSCPR) was undertaken. The period under review
and scope was June 2019 and November 2023. The Local Child Safeguarding Practice Review
considered Ella and her sister, it focused on multi-agency safeguarding practice and the factors
that support good practice, as well as identifying what areas of safeguarding practice might have
been different to enhance future practice. Four themes were identified that the analysis draws
upon.  Within theme one there is a section on including making referrals or requests for support
and decision making as well as identified learning.

 The Local Child Safeguarding Practice Review overview report was published on 30th January
2025.Recommendations within the report are being actioned and monitored via the multi-agency
safeguarding arrangements in place within the Child Death Overview Panel and via the Learning
Implementation Group.

Kent and Medway safeguarding team have been supporting NELFT in response to an
outstanding recommendation for a related Rapid Review which may support the Regulation 28
response for Ella.

NELFT held a multi-agency meeting and have agreed to formulate a child focussed safety plan,
this will be shared with the child’s school (and social worker, if identified) for every child who has
a safety plan. Alongside this, NELFT have agreed to develop an escalation flow chart for
professionals, to include a Single Point of Access contact and Multi-Disciplinary Team meeting
escalation process. This would include the sharing of the safety plan with other necessary
agencies and points, in which referrals to social care for escalation should be completed. Once
rolled out an audit will be completed, which will meet the recommendation outlined in another
Local Child Safeguarding Practice Review.

As part of the ICBs response to a number of suicides of children and young people during
2023, a series of learning events have taken place. The first focused on North East London
Foundation Trust (NELFT - our children and young people mental health services provider)
and their learning as an organisation. The second focused on the patients’ and their families’
perspective to ensure their voices were engaged as part of wider learning. The third focused
on system wide/inter agency working in November 2024. This event will culminate in a
system wide improvement plan that will include a focus on agency information sharing, risk
assessments and decision making among others. Work on a shared risk protocol across
system partners has already commenced.

The work undertaken by NELFT as part of the system wide action plan is summarised below
and relates specifically to how they are enhancing information sharing processes: -

  A Professional Consultation line is now operational in their Single Point of Access
  Raising staff awareness of the need to share information with other agencies as per risk

management and safeguarding principles

  Delivery of training around Consent, GDPR, Mental Capacity Act and Gillick Competence
  Gathering consent (from young people and their families) to share information with other

agencies at point of referral (through our single point of access)

  Training programme for Risk Formulation developed for rollout across the organisation

for children and young people, moving away from risk stratification

  Safety planning advice sheet developed and shared with partner agencies to enhance

access to NELFT services for consultation regarding cases of concern

  Safety planning advice developed for young people, their families and carers to highlight

the support NELFT offer and how to access other suitable agencies

  Work with Kent and Medway Care Records colleagues to enhance the information

available on this platform to other healthcare providers

In addition, Kent & Medway ICB has implemented the Kent and Medway Care Record
(KMCR), which supports inter agency access to health and social care records. The level of
visibility recommended is largely in place, although continued work to support use of the
system is ongoing.  There are no current plans to have a direct interface between education
and the KMCR, but Kent County Council front door teams, who act as a single point of
contact for requests for support at an intensive level or above for children, young people and
families, ensuring these requests are directed to the appropriate service for ongoing support

 and intervention all have access and can communicate information, where applicable to
colleagues

I hope this letter provides you with assurance that actions have been taken to address the
concerns raised.

Yours sincerely

Signed on behalf of

Chief Nursing Officer

NHS Kent and Medway ICB

Chair | 
Chief Executive | 

Page 4 of 4

Mrs Catherine Wood 
HM Area Coroner 
Mid Kent and Medway 
Coroner Service Team 
Cantium Houe 
Sandling Road 
Maidstone 
ME14 1XD  

Dear Coroner, 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

28 March 2025  

Re: Regulation 28 Report to Prevent Future Deaths – Ella Louise Murray who 
died on 15 November 2023  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  7 
February 2025 concerning the death of Ella Louise Murray on 15 November 2023. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Ella’s family and all those who loved and cared for 
her. NHS England are keen to assure the Coroner and Ella’s family that the concerns 
raised about Ella’s care have been listened to and reflected upon.   

My response to the Coroner focuses on those areas of concern that sit within NHS 
England’s  national  policy  or  programme  remit.  It  would  not  be  appropriate  at  this 
juncture for NHS England to provide comment on actions taken by Kent & Medway 
Integrated Care Board, Kent Social Services or the Local Authority involved in Ella’s 
care.  

You have raised various concerns in your Report, including that there was a failure to 
undertake an adequate, or any, risk assessment and take any further steps to ensure 
Ella's  safety,  including  urgently  removing  Ella  either  to  a  hospital  bed  or  otherwise 
liaising with social services. You have also raised the concern that there was no shared 
access  to  records  for  all  agencies  and  no  way  to  convene  an  urgent  multi-agency 
meeting. 

Your Report echoes recommendations made from previous reviews into suicides of 
children and young people (CYP). The 2020 Kent Safeguarding Children Multi-Agency 
Partnership Review of Suicide in Children and Young People noted concerns about 
the  risk  assessment  process  and  warned  against  using  short-cuts  or  abridged 
assessments  in  place  of  more  thorough  processes.  The  review  also  recommended 
that  school  teaching  staff  were  better  integrated  into  interprofessional  safeguarding 
networks, a change that HM Coroner’s Report suggests would have better supported 
Ella.  

Both the Kent Safeguarding Review and the 2021 National Child Mortality Database 
(NCMD)  Suicide  Report,  published  in  October  2021,  recommended  improved 
information sharing between agencies. Across the 108 deaths included in the NCMD 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
 Report, the most  common  issue  reported  was  poor  communication  and  information 
sharing  between  professionals.  The  second  most  common  issue  was  poor  quality 
referrals.  

As your Report raises, the 2024-25 Children’s Wellbeing and School’s Bill will address 
these  concerns.  The  Bill  strengthens  the  role  of  education  in  multi-agency 
safeguarding arrangements as well as creating a clearer legal basis for information 
sharing. This is facilitated by the inclusion of a common identifier.  

Ella’s case includes learnings for teams across NHS England and local organisations, 
as well as more broadly. It is NHS England’s understanding that Kent and Medway 
Integrated  Care Board  will  be  responding  to the  Coroner  separately  with  a  system-
level response detailing the local actions taken. NHS England will consider the ICB’s 
response in due course. My colleagues from national NHS England teams have also 
provided the below input.  

National CYP Mental Health Team 

Integrated Care Systems (ICSs) are a vehicle for integrated planning, to ensure that 
those  who  need  it  have  access  to  comprehensive  mental  health  support  which  is 
integrated across health, social care, education, and the voluntary sector. The vision 
for greater local system integration and autonomy is being implemented for specialised 
mental  health,  learning  disability  and  autism  services,  by  giving  responsibility  for  a 
given population to Provider Collaboratives. Provider Collaboratives will improve links 
to other care settings, to improve the whole pathway and reduce reliance on the most 
specialised services by reinvesting in community provision.   

National Safeguarding Team 

The  NHS  England South  East  regional  safeguarding  team  will,  through  established 
governance  arrangements,  have  oversight  of  Kent  and  Medway  Integrated  Care 
Board’s actions to implement the learning to improve safeguarding at both the Local 
Safeguarding Children Partnership and within all commissioned services. 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Ella, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

 
  
 
 National Medical Director