Lucy-Anne Dyson

HHJ ALEXIA DURRAN 

Secretary of State for Education 

Dear Ms Phillipson 

Prevention of Future Deaths Report – Lucy-Anne Dyson nee Rushton 

24 December 2025 

Thank you for copying to me your response dated 19 November 2025 to the Prevention of Future Deaths 
Report (PFD) relating to the inquest into the death of Lucy-Anne Dyson. I fully support the desire to tackle 
violence against women and girls, and I understand that the Government’s strategy to do this includes 
involving communities in the push for change, so publicising brutality when it occurs is important, 
politically. However, a PFD report is not a political tool. A PFD report is a decision by a judge that action 
should be taken to prevent future deaths. 

The purpose of the coroner’s investigation into a death is to provide answers to four statutory questions, 
namely who the deceased was and when, where and how the deceased came by his or her death. ‘How’ is 
usually confined to meaning 'by what means', but where the enhanced duty of investigation arises under 
Article 2 of the European Convention on Human Rights, the coroner or jury must examine the wider 
circumstances in which the death occurred. However, in both types of inquest, the coroner or jury cannot 
express an opinion on any topic other than the four statutory matters to be ascertained, and the 
attribution of blame forms no part of the coroner's role. The 2009 Act expressly prevents inquest 
determinations from being framed in such a way as to appear to determine any question of civil liability or 
any question of criminal liability on the part of a named person. A coroner or jury’s determination will 
therefore never state that a particular person brutally beat and killed the deceased. Such findings are 
made in criminal proceedings, not in coronial ones. It may also be useful to note that a medical cause of 
death, such a ‘multiple blunt force injuries’ is a narrow statement of the medical reason the person died. It 
is not appropriate as part of the medical cause of death to include a wider statement about how the 
injuries were caused.  

The PFD Report in Lucy-Anne Dyson’s case states that she died ‘as a result of a prolonged, severe and 
brutal attack’ and that she was unlawfully killed, these were the findings of the jury as boxes 3 and 4 of the 
PFD report make clear. ‘Unlawful killing’ is a shortform conclusion that can be used in coronial cases where 
the coroner or jury is satisfied that a death was caused by murder, manslaughter or infanticide.   

I am disappointed that you decided to include in your PFD response a criticism of the wording used in the 
PFD Report. As I have explained, coroners and their juries cannot attribute violence to a named person and 

The Royal Courts of Justice, Strand, London, WC2A 2LL 
Website: https://www.judiciary.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 there is a framework within which their findings and conclusions must be expressed. In addition, it is not 
appropriate for a member of the Government to criticise a judicial decision. Coroners are judges, and 
criticising their decisions in this way is incompatible with judicial independence.  

I note your concern about the email address used by the coroner to contact you. Coroners do what they 
can to establish the correct addresses to which PFD Reports should be sent, but there is chronic under-
resourcing across the service, and the correct contact details are not always easy to determine, particularly 
when a recipient of a report has not had prior involvement in the proceedings. To assist with this, I am 
intending to create a list of contact details of the organisations that often receive PFD reports. That will 
enable those organisations to specify where they would like PFD Reports to be sent. When the list is 
published, I will circulate the details to all Government departments, so that information can be added or 
amended, as appropriate.  

I have decided to publish your full response to the PFD Report, on open justice grounds. However, I will 
also be publishing this letter alongside it, to enable the public to understand more fully how coroner’s and 
their jury’s decisions are reached, and the limits to how those decisions can be expressed.  

Yours sincerely, 

HHJ ALEXIA DURRAN  
CHIEF CORONER OF ENGLAND AND WALES  

2

Department for Education 

Secretary of State for Education 

Darren Stewart OBE 

Dear Darren Stewart OBE, 

19 November 2025 

Prevention of Future Death Report – Lucy-Anne Dyson née Rushton 
(03/09/2025) 

I would like to express my deepest sympathies to the family and friends of  
Lucy-Anne Dyson née Rushton. 

I am grateful that you have raised these important concerns, which highlight the 
critical importance of effective multi-agency communication and consistent 
safeguarding standards in preventing harm and protecting both adults and children 
from abuse and neglect.  

But before I respond on the specific matters of concern you raised, I want to express 
very clearly my concern and disappointment that the Prevention of Future Death 
report which you sent to me did not accurately or sensitively reflect the appalling 
brutality with which Lucy-Anne’s estranged husband murdered her.  

It is extremely disappointing to see your language in section 4 of your report (the 
narrative conclusion) describing, euphemistically, a “dysfunctional and toxic” 
relationship in which “the nature of the relationship between both parties was 
abusive”, which was “a material contribution to [her] death”; furthermore you describe 
the cause of death as being “multiple blunt force injuries”, as if these injuries fell from 
the sky or were of unknown origin, the manner of her death was a sickeningly violent 
murder by her estranged husband, as the sentencing remarks by Judge Akhlaq 
Choudhury KC made very clear. I have raised my concerns on this point with the 
Parliamentary Under-Secretary of State for Victims and Tackling Violence Against 
Women and Girls.  

On the concerns you have raised in the report, the Department is committed to 
ensuring that all agencies with safeguarding responsibilities can share information 
effectively, make informed decisions, and take timely action to protect individuals at 
risk of harm. We recognise that poor information sharing and inconsistent 
approaches to referrals have been recurring challenges in serious safeguarding 
incidents, and we are taking significant steps to address these issues through 
legislative reform, updated national guidance, and system-wide practice 
improvements. 

I will address the two concerns you have raised and set out the actions the 
Department is taking in response. 

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

 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern 1: Lack of a national interface to enable reporting and communication 
between schools and safeguarding agencies 

We recognise that fragmented systems and inconsistent data-sharing processes can 
create barriers to effective safeguarding. To address this, the Department is leading 
a programme of reform to strengthen multi-agency information sharing through the 
following measures: 

  Single unique identifier 

The Children’s Wellbeing and Schools Bill, introduced in Parliament on 17th 
December will protect children at risk of abuse, stopping vulnerable children 
falling through cracks in services, and deliver a core guarantee of high standards 
with space for innovation in every child’s education.  

The Bill, which is currently being scrutinised in Parliament, will introduce 
provisions for a consistent child identifier, enabling professionals to securely and 
accurately match records across different systems and agencies. This will  
support schools, police, children’s social care, and health services to share 
information more effectively and identify children at risk earlier. 

  New Information Sharing Duty 

The Bill will also establish a new legal obligation on relevant organisations 
(including education, health, police, and social care) to share information for the 
purpose of safeguarding and promoting the welfare of children. This will ensure 
all key agencies have a shared legal foundation for timely and appropriate 
information exchange. 

  Pilots and Implementation Planning 

The Department has initiated a series of local pilots to test the implementation of 
the consistent child identifier and its interoperability with existing safeguarding 
systems (such as CPOMS) and local authority databases. Learning from these 
pilots will inform national standards for interoperability between systems. 

  System and Process Reform 

Alongside legislative changes, the Department is convening education, local 
authority, and technology partners to develop national data standards to enable 
secure, accurate connections between school safeguarding systems and partner 
agencies. 

  Statutory Guidance and Sector Engagement 

The updated Working Together to Safeguard Children (2023) guidance 
emphasises the importance of proactive information sharing to assess and 
respond to concerns about a child’s safety. Further statutory guidance will be 
issued, co-produced with the sector, to support practitioners in applying the new 
Information Sharing Duty and consistent identifier in practice. 

  Operation Encompass 

The Department has worked closely with the Home Office to prepare statutory 
guidance for the implementation of the Operation Encompass duty. This will 
require police forces to notify educational settings of domestic abuse incidents 

 
 
 
 
 
 
 
 
 affecting pupils. The duty, currently voluntary, will become mandatory under the 
Victims and Prisoners Act 2024 from November 2025. 

Concern 2: Lack of national guidance/standards mean agencies are receiving 
referrals that rely too heavily on individual judgement or where no referral is 
made at all 

The Department recognises that inconsistent referral quality and variable thresholds 
for action can lead to risks being missed or misunderstood. To strengthen national 
consistency, build practitioner confidence and expertise, and ensure every agency is 
taking coordinated decisive action, we are implementing reforms and have 
strengthened the statutory framework; this includes: 

  Families First Partnership Programme 

Through this programme, we are delivering national reforms to Family Help, 
multi-agency child protection, and Family Group Decision Making. The reforms 
include establishing multi-agency child protection teams that bring together 
education, police, health, and social care professionals to take decisive action 
where significant harm is identified. The programme also promotes integrated 
‘front door’ models for triaging contacts and referrals, ensuring concerns are 
directed appropriately and consistently. 

 

Improving Professional Practice and Training 
The Department, alongside Social Work England, is investing in training for child 
and family social workers to strengthen identification and response to violence, 
abuse, and coercive control. Domestic abuse awareness is being embedded in 
social work education and training standards, as well as across education and 
health sectors. This includes updating safeguarding training and reinforcing 
expectations within statutory guidance and school safeguarding policies. 

  Multi-Agency Safeguarding Arrangements (MASAs) 

Local authorities, police forces, and health services share joint responsibility for 
safeguarding and promoting the welfare of children through MASAs. We 
strengthened Working Together guidance in 2023 to be clearer on roles and 
responsibilities of safeguarding partners, accountability structures and the role of 
education. Local published arrangements provide a framework for effective 
partnership working and ensure clear understanding of referral routes, 
thresholds, and local processes for raising concerns. Robust arrangements 
support timely decision-making and coordinated support for families. The 
Children's Wellbeing and Schools Bill includes a new requirement for education 
to play a strategic role in the partnership, given the crucial role these providers 
and settings have in a child’s life. 

  Working Together to Safeguard Children (2023) 

We updated this guidance in 2023, with a sharp focus on strengthening multi-
agency working across the whole system of help, support and protection. 
Importantly, we introduced new national multi-agency child protection standards 
setting out what every individual, at every level, in every agency should do to 
work together and understand their role, to improve child protection practice and 
outcomes for children. We also strengthened expectations about the role of other 
agencies, including police and health, in child protection processes.  This 
guidance sets clear expectations for all safeguarding partners to share 
information early and work collaboratively in assessing and responding to risk. It 

 
 
 
 
 
 
 clarifies that local authorities must consider a wide range of evidence from across 
agencies when making decisions under section 47 of the Children Act 1989. In 
2023 we committed to reviewing Working Together every year to ensure it 
reflects best evidence. 

  Ofsted Inspection and Oversight 

Through the Inspection of Local Authority Children’s Services (ILACS) 
framework, Ofsted evaluates how effectively local authorities identify, assess, 
and manage risk in line with Working Together. This includes assessing the 
quality of referrals, thresholds for intervention, and the effectiveness of multi-
agency working. Findings inform policy development, including the 2023 update 
of Working Together to Safeguard Children, and enable targeted support or 
intervention where systemic weaknesses are identified.  

  Keeping Children Safe in Education (KCSIE) (2024) 

Schools and colleges have a critical role to play in protecting children and 
keeping them safe. The Department publishes the statutory safeguarding 
guidance Keeping Children Safe in Education (KCSIE) to support schools and 
colleges in carrying out their duties to safeguard and promote the welfare of 
children. KCSIE makes clear that every school must have a Designated 
Safeguarding Lead who takes lead responsibility for safeguarding and child 
protection. Part 1 of the guidance, which should be read by all staff who work 
directly with children, sets out that all staff should know what to do if they have 
concerns about a child and should be aware of the process for making referrals 
to local authority children’s social care and for statutory assessments under the 
Children Act 1989. This ensures a consistent understanding across all education 
settings of how to recognise, report and respond to concerns about a child’s 
safety or welfare. This guidance was last updated in September 2025. 

Conclusion 
The Department for Education is committed to taking forward these reforms to 
ensure that: 

  practitioners across all safeguarding agencies can share information swiftly 

 

 

and securely; 
referrals and responses are based on consistent national standards rather 
than individual interpretation; and 
families affected by domestic abuse receive timely, coordinated, and effective 
support. 

We will continue to monitor implementation of these measures and engage closely 
with safeguarding partners to ensure that lessons learned lead to lasting 
improvements in practice and outcomes. 

Please ensure that any future reports for action by my department are submitted to 
my Department for Education address, 
, and 
not the Parliamentary offices of individual ministers. I am concerned that a proper 
process to establish the correct address to which to send a report to the Secretary of 
State for Education was not followed. 

 
 
 
 
 
 
 
 
 I hope that this response is useful for addressing the concerns raised in the 
Prevention of Future Death report. In view of my wider concerns about the lack of 
understanding of violence against women evidenced by the report, and the process 
followed (or not followed) in drawing the conclusions in your report to the attention of 
government ministers, I am copying this letter to the Chief Coroner, and to the 
Deputy Prime Minister, the Lord Chancellor and the Secretary of State for Justice, 

.  

Secretary of State for Education