Marcia Grant

Department for Education 

Minister for Children and Families 

Marilyn Whittle 
Assistant Coroner for the Coroner Area of South Yorkshire (West) 
South Yorkshire (West) Coroner’s Service 
Medico-Legal Centre 
Watery Street 
Sheffield  
S3 7ES 

25 November 2025 

Dear Ms Whittle,  

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

This is the Department for Education’s (the Department) response to your report 
made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and 
Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 2 
September 2025, following the tragic death of Marcia Grant on 5 April 2023. I am 
responding as the Minister for Children and Families, and have responsibility for 
foster care.  

Thank you for your conduct of the inquest and for your identification of matters of 
concern, which are set out in the Report.  

Marcia’s passing deeply shocked and saddened everyone across the Department 
and our thoughts are with her family and friends. I recently met with Marcia’s family 
to discuss their experience, alongside 
, their MP. As a dedicated and 
skilled foster carer, Marcia was a pillar of the fostering community. Her compassion, 
commitment, and tireless efforts transformed the lives of countless children and 
young people. She was deeply respected and will be remembered with warmth and 
admiration by all who had the privilege of knowing her.  

I want to set out my heartfelt admiration more broadly for the huge contribution made 
by foster carers. Foster carers provide loving homes to most children in care and 
form the backbone of the children’s social care system. Fostering is an incredibly 
challenging role which requires skills and unwavering dedication from those who 
volunteer to give vulnerable children a home.  

We will shortly be announcing comprehensive measures to reform the fostering 
system, and are considering the voices and experiences raised that Marcia’s family 
raised as part of these reforms.   

Sanctuary Buildings 20 Great Smith Street London SW1P 3BT 
tel: 0370 000 2288  www.education.gov.uk/contactus/dfe 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 These reforms will significantly increase the number of foster carers and improve the 
experience of fostering. The Department remains committed to improving 
recruitment and retention to ensure that every child in care is able to have a stable, 
loving foster home, where this is the most appropriate option. Our goal is for local 
authorities to have improved placement sufficiency, enabling better matching where 
children can have a choice of placement. We believe that this will help to avoid 
issues such as those identified in Marcia’s case.  

While our response focuses on the lack of placements, as requested, I will briefly set 
out our position on the wider themes you raised about this tragic case. Our statutory 
guidance sets that fostering services must provide carers with the information 
necessary to fulfil their role effectively. In emergency placements, where full 
information may not be immediately available, local authorities must make the most 
appropriate decision based on the information at hand and in the child’s best 
interests. Any outstanding information should be provided to the foster carer at the 
earliest opportunity. 

The National Minimum Standards for fostering services, which inform Ofsted 
inspections, affirm that foster carers are entitled to full and timely disclosure of a 
child’s circumstances, including recent significant events. This enables carers to 
understand and respond appropriately to the child’s needs and behaviours. Data 
protection legislation does not prevent the sharing of such information where there is 
a valid legal basis and a risk of serious harm.  

The National Minimum Standards also set out that children should only be matched 
to places that can meet their needs. These standards also set out that the impact of 
the placement on household members should be considered before placements are 
made. This type of activity is central to any effective matching practice.  

Matter of concern 1 – Lack of placements 

The lack of foster placements placed significant strain on the Local Authority to 
consider creative solutions to try and avoid an unauthorised placement. This led to 
an unsuitable placement being accepted. I was informed the shortage of placements 
is a both a local and a national issue and therefore both Rotherham Metropolitan 
Borough Council and the Minister for the Department for Education are asked to 
consider this concern. 

We recognise there are too few fostering placements, causing sufficiency challenges 
for local authorities across the country. This places pressure on local authorities and 
results in a lack of choice on placements, which can lead to unsuitable matches, as 
well as placement instability and children being placed out-of-area.  

We have already made progress on this issue through our investments in 
recruitment and retention within local authorities. The Department has been 
supporting over 60% of local authorities across England in 10 regional recruitment 
support hubs, most of which launched in the spring and summer of 2024. These 
hubs, backed by regional communications campaigns in each area, support 

 
 
 
 
 prospective foster carers from their first enquiry to ensure that they carers are 
properly supported through the application process. Most recruitment support hubs 
are surpassing the Department’s expectations for foster carer approvals, compared 
to what we expect they would have achieved without the programme. These 
highlight the impact of collaborative working in driving recruitment success. 

We have also invested in rolling out a foster care retention model called Mockingbird, 
an innovative evidence-based approach involving six to ten families grouped into a 
constellation around a hub home carer. Mockingbird includes peer support, respite 
and training. It was found to substantially improve retention by an independent 
evaluation, which showed that participating households were 82% less likely to 
deregister than households who did not participate. 

Despite this progress, we know we need to go further and faster in significantly 
increasing foster care numbers. We will set out our plans for doing this in 
comprehensive new measures over the coming months.  

This work is being backed by the Chancellor’s Transformation Fund, announced in 
the Spring Statement, which will provide an additional £25m over 2 years (beginning 
in 2026/27 and 2027/28). This is additional to the £15m of fostering investment that 
was announced in the Autumn Budget, to cover investment taking place in 2025/26. 
The Spending Review also set out funding to renovate and expand foster carer 
homes, so that approved carers can look after more children.  

Once again, we would like to take the opportunity to thank you for highlighting these 
matters of concern, and for giving us the opportunity to respond.  

Yours sincerely 

Minister for Children and Families

Regulation 28: Report to Prevent Future Deaths Response by 
Rotherham Metropolitan Borough Council into the Matters of 
Concern in respect of the death of: 

 Marcia Grant 

Introduction 

Rotherham Metropolitan Borough Council (RMBC) wishes to express condolences to 
Mrs Grant’s family and acknowledge the important matters raised in the Prevention of 
Future Deaths Report. We are committed to ensuring that action is taken to mitigate 
future risks when placing our children and to support decision making by the dedicated 
carers, who ensure that some of the most vulnerable children and young people in our 
society have a loving home where their needs can be met.  

RMBC acknowledges its responsibilities to children and to foster carers and strives to 
achieve  the  highest  standards  when placing  children  outside  of  their  family  homes. 
RMBC  takes  the  matters  raised  in  the  Regulation  28  Report  seriously  and  offers 
assurance that processes are continually developed to ensure that they are robust, 
identify  and  mitigate  risk  and  ensure  that  children  are  placed  in  appropriate 
placements and provisions.  

1.  Matter of Concern: 

Lack  of  placements.  The  lack  of  foster  placements  placed  significant 
strain  on  the  Local  Authority  to  consider  creative  solutions  to  try  and 
avoid  an  unauthorised  placement.  This  led  to  an  unsuitable  placement 
being accepted. I was informed the shortage of placements is both a local 
and a national issue and therefore both Rotherham Metropolitan Borough 
Council and the Minister for the Department for Education are asked to 
consider this concern.   

Current Situation 

The Local Authority recognises the challenges set out by the Assistant Coroner and 
agrees that the picture both nationally and consequently in Rotherham is that the “lack 
of  foster  placements  placed  significant  strain  on  the  Local  Authority  to  consider 
creative solutions to try and avoid an unauthorised placement.”  

 
 
 
 
 
 
 
 
 The Inquest noted in the evidence provided that consideration of this issue has been 
subject to discussion by sector leaders nationally. The challenges have led to children 
with particular needs being placed in ways which are outside of the relevant legislation 
and placements that are sub-optimal, including placements far from the local area.  

The  Local Authority  has  repeatedly  made  the  point  in  regional  and  national  forums 
about  the  difficulty  that  this  creates  in  managing  such  cases  and  in  managing  the 
associated  risks.  This  burden  falls  across  the  entire  system  and  creates  scenarios 
where children can be placed in provisions which do not always meet their needs.  

Sufficiency Strategies and Development 

In 2020 Cabinet confirmed Rotherham’s strategic intention to ensure more Rotherham 
Children in Care are placed within the Borough, close to their family and community 
networks.  

Development of new children’s residential provision, along with foster care, third party 
placements, semi-independent provisions, and other family-based placements, aims 
to  provide  a  mixed  economy  of  arrangements,  which  will  seek  to  effectively  meet 
Rotherham’s statutory duties, outlined in the Sufficiency Strategy. 

The  Looked After  Children  and  Care  Leavers  Sufficiency  Strategy  2023-2028  was 
approved by Cabinet in October 2022. The Strategy was developed in line with the 
duty to provide or procure placements for the Local Authority’s Children in Care.  

Action:  

The Fostering Rotherham In-House Plan 2023-2028 details the plans to develop the 
Fostering  Service  to  increase  sufficiency,  focusing  on  marketing  and  recruitment, 
valuing  our  foster  carers,  service  developments  and  innovation,  training,  quality 
assurance and performance and family and friends as foster carers.   

The Children in Care Sufficiency Board was established in January 2023 to deliver the 
Sufficiency Strategy.   

The  children’s  residential  development  programme  responds  directly  to  Rotherham 
Children  and  Young  People’s  Services’  (CYPS)  strategic  intention  to  reduce  the 
number of external residential placements for children and ensure more Rotherham 
Children  in  Care  are  placed  within  Borough,  close  to  their  family  and  community 
networks. The Council has demonstrated their commitment with a multi-million pound 
capital programme as well as a more recent increase in the revenue budget to ensure 
an enhanced offer to children and young people.  

The  four  phases  of  residential  development  will  deliver  20  residential  beds  and  2 
emergency beds across 11 registered settings by March 2027. So far, the programme 
has delivered 13 residential beds and 1 emergency bed across 7 registered settings.  

In August 2024  a 16+  Sufficiency Transformation Board  was  established  to  provide 
overall  direction  to  the  project  setting  out  what  is  required,  authorising  work  and 

 
 
 monitoring progress against the delivery of the proposals approved by  the Children 
and Young People’s Services’ Directorate Leadership Team in relation to the needs of 
older children in care and care leavers. This led to a clear and agreed cross Council 
working protocol to support developing further sufficiency in the system.   

In November 2024 Cabinet approved an addendum to the Children in Care Sufficiency 
Strategy  detailing  the  needs  analysis,  commissioning  intentions  and  development 
programme for supported accommodation for care leavers.   

Fostering Current Position 

RMBC has successfully sustained a positive recruitment and retention rate with foster 
carers in the Borough and comparatively with local and national statistics have been 
very  successful  in  this  area.  Despite  a  national  reduction  of  LA  approvals  of 
approximately 32% since 2021, Rotherham’s performance shows a 54.44% increase 
from  11  approvals  in  22/23  to  17  approvals  in  2023/2024.   In  2023/24  the  average 
number of approvals for all LAs returning data in England was 12.3, an increase of 9% 
year  on  year.  As  such,  Rotherham  performed  well  above  the  average  approvals 
according to the Office of National Statistics (ONS) data.   

When  comparing  performance  between  LAs  nationally  expressing  number  of 
approvals  as  a  percentage  of  the  total  population  size  of  their  areas,  Rotherham 
ranked 22nd (of 152 LAs) in 2022/2023 and were 5th out of 152 LAs based on the 
ONS rounded up figures. 

Regionally,  Rotherham’s  approval  performance  (based  on  rounded-up  numbers) 
increased from Rotherham having the 3rd highest number of approvals to having the 
second  highest  numbers in  the  region. This  reflects  a  sharp  decline  across  2 other 
Local Authorities. Rotherham is the highest performing LA in the region when it comes 
to approvals as a percentage of population, for both actuals and rounded figures. 

RMBC  have  maintained  a  cohort  of  experienced  foster  carers  in  the  Borough  and 
continue to recruit new foster carers with a range of skills.  

RMBC seek continual feedback from foster carers and utilise this to improve services 
and support for the fostering community. 

Action:   

Foster carers have been consulted in response to the inquest findings and asked for 
feedback  about  what  improvements  could  be  made.  This  was  constructive  and 
proposed: a structure chart of the organisation; graduated information sharing about 
children at the stage foster carers have expressed an interest in offering a placement; 
and a contribution to the structure of placement referral forms.  

RMBC  have  invested  in  creative  marketing  strategies  to  target  a  range  of  local 
prospective  foster  carers.  The  assessment  and  review  process  for  foster  carers  is 

 
 
 stringent, ensuring that RMBC foster carers have the necessary knowledge, skills and 
experience to undertake the role.  

Following a report to the Children in Care Sufficiency Board in May 2025 reviewing the 
current  fostering  recruitment  strategy,  it  was  agreed  a  time  limited  Placements 
(Fostering) Transformation Board should be established.  

The purpose of the Placements (Fostering) Transformation Board is to provide a forum 
for enhanced scrutiny around the Sufficiency Strategy, to ensure a continued focus on 
recruitment  and  retention  of  foster  carers  and  to  adopt  recommendations  from  the 
national agenda, with a specific focus on Fostering. This will now include the response 
to  the  recommendations  from  the  Regulation  28  Report.  It  is  anticipated  that  this 
bespoke Board will have completed its work by May 2026. 

Placements for Young People 

Young  people  over  primary  school  age  are  particularly  challenging  to  find  suitable 
foster  placements  for;  the  DfE  reporting  figures  for  2023  highlight  that  64%  of  all 
children in care were over the age of 10 years old and 57% of children in care at that 
time  were  male.  The  Children’s  Commissioner  analyses  research  into  adolescents 
entering care and emphasises that these children are more likely to have experienced 
instability and adversity for sustained periods, to have additional special educational 
needs  and  are  less  likely  to  get  the  support  they  need.  This  leaves  young  people 
vulnerable to abuse and exploitation and at higher risk of developing social, emotional 
and mental health needs. This then results in young people not being considered for 
foster placements, which would actually be the best, most stable option for most. 

Action: 

It is for this reason that RMBC works tirelessly to recruit and train foster carers with a 
variety  of  skills  and  from  diverse  backgrounds.  It  is  almost  always  preferable  for 
children and young people to be placed in appropriate, family-based settings where 
possible and we will continue to focus on this destination for our children in care.  

Kinship Placement Options  

Kinship care has been a continuing focus for the Local Authority, to support placement 
sufficiency and to ensure that children can live with family members where possible. 

Action: 

RMBC, in response to the  DfE’s Families First Programme, has appointed a senior 
leader  as  a  Kinship  Lead  for  the  local  authority  and  has  also  recruited  Kinship 
Navigators to focus on the support offered to Kinship Carers. RMBC has also reviewed 
and updated Kinship Practice Guidance and financial support to Kinship carers. This 
has been in place since January 2025 and the fully updated Kinship Local offer was 
launched in October 2025. 

 
 
 
 2.  Matter of Concern: 

Documentation and communication. Both the lack of documentation 
recording all the relevant risks, failure to complete forms and the lack of 
adequate communication of the risks in this matter led to a child being 
placed with a family where numerous individuals considered this was an 
inappropriate placement. Senior decision making was not based on all 
the appropriate information identifying there are inadequate systems 
and processes. 

At the time of the initial placement being required for Child X, limited information was 
known about his background and needs. The initial placement referral form was brief 
and  did  not  contain  all  relevant  information.  While  the  placement  referral  form  was 
repeatedly updated over the short period Child X was in care with RMBC, we could 
not determine which placement referral form had been shared with Mrs Grant during 
the initial matching discussions due to the version control of documents. There were 
however a number of conversations with Mrs Grant about Child X. Mrs Grant had also 
taken steps to ensure that she knew where Child X was at all times and that she had 
locked away knives to ensure he could not access these. RMBC acknowledge that the 
storage  and  version  control  of  documents  required  improvement  and  had  already 
taken steps to address this. Further immediate changes were made during the course 
of the Inquest, and we are satisfied that the correct version of the placement referral 
form  is  now  used.  This  ensures  that  the  most  relevant  and  up  to  date  information, 
including on risks, is shared with foster carers during matching discussions.  

Action: 

In  2023,  a  dedicated  fostering  duty  worker  was  appointed  to  manage  and  share 
information  with  in-house  foster  carers  about  children  needing  a  placement.  This 
process ensures that information is held in one place and the duty worker has in depth 
knowledge of available carers and their skill set, to promote effective matching with 
children.  The  duty  role  co-ordinates  matching  discussions  and  information  sharing 
between fostering supervising social workers, foster carers themselves and allocated 
social workers for children to ensure a comprehensive overview of each child requiring 
a placement. RMBC has ensured that all social workers within the service understand 
and follow the process.   

Schemes  of  delegation  and  approval  processes  were  also  revised  during  2023  to 
ensure that information about children requiring a placement is approved by a senior 
manager to ensure quality and consistency. Mitigation of risk and relevant history is 
considered  and  shared  with  prospective  carers  and  providers  prior  to  matching 
discussions taking place.  

 
 
 
 
 The Commissioning and Placements Service has also implemented a process, which 
ensures that placement approvals are given at the correct senior management level, 
depending  on  the  child  and  the  nature  of  the  placement.  Placement  referral  forms, 
which contain all relevant information, are signed by decision makers and saved to the 
child’s file prior to placements commencing.  

There have been challenges around pre-populated forms, within the children’s case 
management system, which RMBC acknowledge can be lengthy and cumbersome. 
Sections within certain forms were repetitive and led to social workers only completing 
relevant sections of forms, which leaves many sections blank. A dedicated Systems 
User  Group  within  RMBC  meets  monthly  to  focus  on  work  required  to  update  and 
revise forms within the children’s case management system.  

3.  Matter of Concern: 

Risk Assessment. Evidence was heard about the risks posed by the 
Child but no evidence that the risk to the foster carers or the other child 
in their care had been considered or assessed. Again, there was lack of 
documentation and no formal risk assessment document or collated risk 
profile for all individuals to allow proper consideration of risks.  

RMBC  acknowledge  the  importance  of  a  coordinated  and  risk-based  approach  to 
identifying and mitigating foreseeable risks in caring for children, both for their carers’ 
and their own benefit.  

At the time of Child X’s placement, the Local Authority had worked on the premise that 
risks, when these are determined to be high, are considered within a more in-depth 
assessment. When placed, Child X was not deemed to pose a high risk of harm to 
himself,  or  others  and  no  evidence  was  presented  which  indicated  that  the  risks 
identified  would  increase  and  so  a  stand-alone  risk  assessment  had  not  been 
completed. As acknowledged above, the initial placement referral form did not contain 
all  the  known  risks  about  Child  X. As  concerns  developed  about  the  other  young 
person  in  placement,  this  was  considered  and  acted  upon  by  RMBC,  including  the 
provision  of  a  significant  support  package  to  help  mitigate  risk  to  him  and  an 
acceptance by the whole professional network that Child X’s placement could only be 
of very short duration. 

Action 

Following  Mrs  Grant’s  tragic  death,  various  specific  changes  have  been  made  to 
ensure that the Council delivers the best possible services to foster carers and children 
and young people. 

Since 2023, explicit sections for risk analysis have been populated within Placement 
Referral  Forms  and  Matching  Approval  documents  to  ensure  that  this  is  routinely 

 
 
 
 
 considered for every child requiring a placement. Risk is also considered within child 
and family assessments.  

The  authorisation  levels  of  placement  referral  forms  and  placement  agreements 
ensure that Senior Managers are responsible for ensuring all matters of risk have been 
considered, alongside mitigation of these risks.  

Standalone risk assessment forms have been maintained and refined for children and 
young people who may present with high risks, and guidance has been revisited since 
the inquest to ensure that the threshold for standalone risk assessments is clear and 
that this practice is routinely implemented where children are deemed to pose a risk 
to themselves or others. 

It  is  important  to  note  that  risk  management  is  incorporated  into  everyday  practice 
within  children’s  social  care.  It  remains  impossible  to  anticipate  all  potential  future 
risks, particularly for children who are not known well to the service.  

Foster carers will also continue to be consulted around their experience of risk when 
children  have  been  placed  to  ensure  that  the  Local  Authority  learns  via  the  lived 
experience  of  carers  and  children.  RMBC  has  recently  revised  the  foster  carer 
communication plan to ensure that this is embedded within practice. 

Conclusion  

RMBC  is  a  reflective  organisation  and  continually  strives  to  improve  practice, 
processes and procedures. It is recognised that improvement is a continual process 
and RMBC takes its corporate parenting responsibilities seriously. In summary of the 
points above, we will: 

•  Continue  to  pursue  our  Looked After  Children  and  Care  Leavers  Sufficiency 
Strategy  2023-2028  with  its  emphasis  on  residential,  fostering  and  kinship 
provision 

•  Continue  to  make  improvements  to  documentation,  recording  and  approval 

processes and co-produce matching guidance with our foster carers 

•  Continue  to  enhance  risk  assessment  processes  and  ensure  criteria  for 

standalone risk assessments for placements are clear to all involved. 

The Council trusts that the above addresses the matters of concern raised during the 
course of the Inquest. As stated at the outset, the Council is committed to ensuring 
that action  is taken  to  mitigate  risks  in  placing  our  children and to  support decision 
making  by  the  dedicated  foster  carers  who  ensure  that  children  and  young  people 
have a loving home that can care for them and meet their needs.  

The complexity of these placements remains one of the most difficult decision-making 
processes  that  the  Council  is  involved  in.  We  will  continue  to  work  with  our  staff, 
children and foster carers to deliver these services as effectively as possible to meet 
the needs of all involved. We will also continue to advocate for appropriate national 

 
 
 placement sufficiency that meets the needs of all our children and young people and 
will continue to engage with Government around this critical issue. 

Strategic Director of Children and Young People’s Services 
Rotherham Metropolitan Borough Council  
11.11.25.