Joshua Allcock

BIRCHILLS HEALTH CENTRE 
23-37 Old Birchills 

Walsall 

West Midlands 

Dear Mr Zafar Siddique, 

I am writing today on behalf of Birchills Health Centre in response to the PFD reports following the sad 
death of J.A. 

We wanted to firstly express our deepest condolences to J.A’s family and his foster guardians as this 
will be an extremely difficult time for them. 

We have reviewed J.A’s case in our clinical meeting on 19.01.2023 and more recently on 02.02.2026 
as part of our child protection meeting. This later meeting was attended by our practice clinicians. The 
clinician who assessed J.A on 28.12.2022 no longer works at our surgery but he was a salaried doctor 
with us at the time. We reviewed the records we had available including record keeping and telephone 
calls (all which have been previously submitted).  

Specific points that we identified for learning are; 

1. 

2. 

3. 

4. 

5. 

After reviewing the  notes we  had available to us, we felt that more comprehensive record 
keeping including clearer details of fluid intake should be recorded in assessing any child with 
risk of dehydration. 

Your report highlighted the insensitivity of CRP as a way to identify dehydration. We have had 
a presentation on identification of dehydration in children to help remind clinicians on most 
effective ways of assessing hydration status. The presentation highlighted that a clear record 
of  fluid  intake  and  output  is  required  as  well  as  considering  recording  weight  as  a  more 
accurate clinical indicator to help identify dehydration- useful if there are other readings to 
compare  to.  Other  things  to  consider  include  a  urine  dipstick  if  possible.  This  child  was 
reviewed  at  the  local  accident  and  emergency  department  on  25.12.22.  The  discharge 
summary  had  no  information  about  the  clinical  assessment  of  this  child.  It  may  have  been 
useful to have this information for comparison although in this case its unlikely it would have 
made a difference to the clinical management as this was based on the assessment on the day. 
If it was deemed necessary we would have made attempts to chase this information, but this 
process can take days to week to receive.  

We have discussed the links between autism and ARFID. In addition, we have also discussed 
ARFID in other risk groups. If there is a suspicion or a formal diagnosis of neurodevelopmental 
disorders and ARFID, we discussed the need for lower suspicion of dehydration in these cases 
despite normal clinical findings and having a lower threshold for secondary care assessment.  

We have reviewed our equipment in the surgery to ensure we all items are relevant, working 
and  calibrated  annually.  Additionally,  we  have  purchased  specific  paediatric  assessment 
equipment such as infant & child BP cuffs, and new paediatric sats probes in addition to the 
current ones in the surgery. 

This child was registered with our surgery on 23.12.22 by his foster carers. We received his full 
records on 29.12.22. The foster parents contacted our surgery on 28.12.22  at 13:28 requesting 
a review with a clinician as  the child was unwell. They were given an appointment at 17:00 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 and the GP did an assessment of their acute illness. We reviewed our policy with regarding 
new patients with complicated histories without full records being available. We usually do 
contact other providers if we feel more information is needed to help clinical management. In 
this  case  it  would  not  be  relevant,  but  we  will  continue  to  consider  to  chase  relevant 
information if needed.  

We would like to thank Mr Siddique for his detailed report, and any further ongoing recommendations 
would be gratefully received. 

Yours Sincerely, 

GP Partner 
(On behalf of GP Partners)

Birmingham, Black Country and Solihull Integrated Care Board 
Civic Centre 
St Peters Square 
Wolverhampton 
West Midlands 
WV1 1SH 

T

9th March 2026 

Mr Zafar Siddique 
Senior Coroner for the Black Country  

Dear Mr Siddique, 

Consolidated Response to Regulation 28 Report - In the Matter of the Death of 
Joshua Lee Allcock 

Following the inquest into the death of Joshua Lee Allcock and the subsequent Regulation 28 
Prevention of Future Deaths Report, this submission provides a coordinated summary of the 
actions taken and learning implemented by partner agencies across the Walsall system. 

This response incorporates the attached detailed submissions from: 

•  Birchills Health Centre 
•  Walsall Healthcare NHS Trust 
•  Walsall Metropolitan Borough Council 

These responses collectively outline the actions already taken and the further measures being 
implemented to strengthen safeguarding, clinical assessment, and multi-agency oversight for 
children with complex needs. 

First and foremost, all organisations wish to reiterate their deepest condolences to Joshua’s family 
and carers following this tragic loss. 

Key Areas of Learning Identified 

Across the inquest findings and subsequent reviews, several themes for improvement were 
identified: 

1. 

Recognition and Assessment of Complex Neurodevelopmental Needs 

The inquest highlighted the challenges that can arise when a child presents with developmental 
delay, possible autism, and complex dietary behaviours, particularly when a formal diagnosis has 
not yet been established. 

Evidence heard during the inquest also raised awareness of Avoidant Restrictive Food Intake 
Disorder (ARFID) and the potential risks associated with restrictive diets and dehydration in 
children with neurodevelopmental conditions. 

 
                                                  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.   Multi-agency Understanding of Health and Developmental Needs 

There was learning across the system regarding the need for stronger multi-disciplinary 
coordination, particularly where multiple services are involved in supporting a child. 

3.   Recognition and Escalation where Children with Complex Needs may be at Risk 

Learning was identified in relation to professional escalation where concerns exist about a child's 
health, diet, or development, even when a clear medical diagnosis has not yet been confirmed. 

4.   Clinical Assessment and Documentation 

The importance of clear documentation and structured clinical assessment, particularly in relation 
to hydration status and dietary intake in young children, was highlighted. 

Actions Taken by Individual Organisations: 

1.   Birchills Health Centre 

The Practice would have welcomed the opportunity to attend the Inquest to give them an insight 
into the case and wider learning. Following the PFD notice Birchills Health Centre has undertaken 
internal clinical review and learning following Joshua’s death. 

Key actions include: 

•  Review of the case within clinical governance meetings and safeguarding discussions. 
•  Reinforcement of enhanced documentation standards, particularly around hydration 

assessment and fluid intake recording. 

•  Education for clinicians regarding assessment of dehydration in children, including 

• 

recognition of early signs and use of appropriate clinical indicators. 
Increased awareness of ARFID and its association with autism and other 
neurodevelopmental conditions, with emphasis on maintaining a lower threshold for 
escalation to secondary care where concerns arise. 

•  Review and improvement of paediatric assessment equipment, including the purchase of 

additional paediatric blood pressure cuffs and oxygen saturation probes. 

•  Reinforcement of processes for obtaining additional clinical information when children 

newly register with the practice and historical records are not yet available. 

These measures aim to strengthen the early identification of clinical risk and improve 
documentation and decision-making in primary care settings.  

2.   Walsall Healthcare NHS Trust 

Walsall Healthcare NHS Trust outlined the existing pathways used to assess children with 
developmental and neurodevelopmental concerns. 

Key points include: 

•  The Trust has long-standing Under-5 clinical pathways designed to guide the assessment 

of young children presenting with developmental or behavioural concerns. 

•  A specialised autism assessment pathway, in place since 2016 and updated in 2023 and 
2025, supports multi-disciplinary assessment of children suspected of having autism. 

 
                                                  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  The Trust recognises the wider concern raised regarding national guidance about the age 

at which autism can be reliably diagnosed and continues to operate local clinical 
pathways alongside national standards. 

•  The Trust is working collaboratively with partners across the Black Country Integrated 

Care System to ensure that learning from this case informs system-wide improvements. 

3.   Walsall Metropolitan Borough Council 

Walsall Council undertook a comprehensive review following the both the Child Safeguarding 
Practice Review and the inquest findings. 

A number of system improvements have been implemented within Children’s Services and as part 
of the Multiagency learning identified from the Child Safeguarding Practice review 

Key actions include: 

Multi-Disciplinary Team (MDT) model 

A new process has been introduced whereby Multi-Disciplinary Team meetings are convened for 
children with complex needs. These meetings provide a forum for shared professional analysis of 
a child’s developmental, health and care needs and ensure coordinated planning across agencies. 

MDTs are now standard practice and are particularly required: 

•  When children have complex health or developmental needs 
•  When there is uncertainty about diagnosis or support requirements 
•  Prior to children entering care to ensure carers receive appropriate information. 

Strengthening safeguarding oversight 

Due to Walsall being a Families First for Children Pathfinder pilot site, a Multi-Agency Child 
Protection Team has been established. 

The scope and focus of these teams are to improve child protection practice, with a focus on: 

•  Developing  a  consistent  network  of  professionals  leading  child  protection  practice,  and 

knowledge of how to access advice and guidance 
Improved information-sharing and communication between agencies 

• 
•  Shared reflective and analytical thinking  
•  Multi-agency decision-making throughout child protection processes 
• 

Increasing expertise where this is needed 

Improved information sharing 

New protocols have been introduced to strengthen coordination between health services and 
social care where multiple professionals are involved with a child. 

“Was Not Brought” safeguarding policy 

A multi-agency policy is being developed to provide clear expectations and escalation pathways 
when children are not brought to health appointments which will align with local Safeguarding 
threshold documents. 

 
                                                  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Training and workforce development 

Training programmes for foster carers and social workers are being updated in 2026 to include: 

•  Understanding of ARFID 
•  Supporting children with autism and complex needs 
•  Enhanced safeguarding and neglect recognition. 

Safeguarding partnership response  

In addition to the learning identified as part of the Coroner’s Inquest it is also significant to note that 
a Child Safeguarding Practice Review was undertaken. The review is now published and identified 
learning for a number of agencies. Governance arrangements through the Walsall Safeguarding 
Children Partnership provide ongoing oversight of both the Multiagency Child Safeguarding 
Review action plan and individual agency action plans through performance monitoring and 
auditing. 

These measures are intended to ensure that children with complex needs are safeguarded and 
receive coordinated and responsive support across agencies.  

System-Wide Learning 

Across all organisations, the following key areas of learning have been recognised: 

•  Greater awareness of ARFID and restrictive eating behaviours 
•  The case has highlighted the importance of recognising restrictive eating behaviours 

associated with neurodevelopmental conditions and the associated risk of dehydration 
and malnutrition. 
Importance of multi-agency collaboration 

• 
•  All agencies recognise that complex cases require earlier and stronger multi-disciplinary 

coordination, particularly where diagnosis remains uncertain. 

•  Strengthening escalation processes 
•  There is now greater emphasis on ensuring professionals escalate concerns where a 

child’s presentation or needs are not fully understood. 
Improved communication between health and safeguarding partners 

• 
•  New protocols and MDT processes aim to ensure that all professionals involved with a 
child share information effectively and develop a common understanding of risks. 

Assurance Regarding Prevention of Future Deaths 

Partner organisations across the Walsall system are committed to learning from Joshua’s death 
and ensuring that the changes described above reduce the risk of similar events occurring in the 
future. 

Collectively, the actions undertaken provide assurance that: 

•  Clinicians are better supported to assess dehydration and complex feeding issues in 

children 

•  Professionals have improved understanding of ARFID and neurodevelopmental 

conditions 

•  Multi-agency decision-making structures are now strengthened 
•  Safeguarding systems provide stronger oversight of children with complex needs 
•  Training and policy improvements are being implemented across the workforce. 

 
                                                  
 
 
 
 
 
 
 
 
 
 
 
 
 These changes are subject to ongoing governance, quality assurance, and audit through the 
Safeguarding Partnership and organisational governance structures to ensure sustained 
improvement. 

Conclusion 

Joshua’s death was a deeply tragic event. All agencies involved remain committed to learning from 
this case and to strengthening partnership working so that children with complex needs are 
recognised earlier, supported appropriately, and protected from harm. 

We trust that this consolidated response provides assurance regarding the actions taken and the 
system-wide learning that has occurred following the inquest. 

Should the Court require any further information or clarification, we would be pleased to provide it. 

Yours sincerely, 

Chief Nurse/Clinical & Quality Officer  
Birmingham, Black Country and Solihull (Cluster) Integrated Care Board 
SRO for Black Country Local Maternity and Neonatal System 

On behalf of the Walsall Safeguarding Partnership Organisations 

Attachments 

•  Birchills Health Centre – Regulation 28 Response (5 March 2026) 
•  Walsall Healthcare NHS Trust – Regulation 28 Response (23 February 2026) – 
includes Under 5’s multiagency ASD assessment process and Walsall Child 
Development service autism diagnostic pathway. 

•  Walsall Metropolitan Borough Council – Regulation 28 Response (3 March 2026) 

CC:  

 Chief Nursing Officer, Walsall Healthcare NHS Trust 

, Director of Children’s Services, Walsall Metropolitan Borough Council

Mr Zafar Siddique 
Senior Coroner for the Black Country 
The Coroner’s Court 
Jack Judge House 
Halesowen Street 
Oldbury 
B69 2AJ 

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

4th March 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Joshua Lee Allcock who 
died on 3rd January 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  7th 
January  2026  concerning  the  death  of  Joshua  Lee  Allcock  on  3rd  January  2023.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my  deep condolences to  Joshua’s  family  and  loved ones.  NHS England  is 
keen to assure the family and yourself that the concerns raised about Joshua’s care 
have been listened to and reflected upon.   

Your Report raised the following concerns: 

1.  There  is  no  clear  national  guidance  on  autism  assessments,  leading  to  a 
variation  in  practice  for  when  an  assessment  for  autism  can  be  made,  with 
some areas specifying children need to be at least 3 years of age. 

2.  Without a formal diagnosis of autism being made, there was no onward referral 
to dieticians with experience of autism and therefore an understanding of the 
link between autism and avoidant restrictive food intake disorder (ARFID). 
3.  The Capillary Refill Time (CRT) test used to assess dehydration by checking 
peripheral  blood  flow  is  a  very  insensitive  test  and  can  provide  misleading 
reassurance. Therefore, young children with similar circumstances to Joshua 
may be at risk when assessing levels of dehydration. NHS England may wish 
to consider reviewing their guidance for health professionals. 

Autism Assessments Guidance 

NHS England has produced a national framework and operational guidance for autism 
assessments.  Whilst  the  national  framework  states  that  “the  traits  that  characterise 
autism emerge during the pre-school years, yet diagnoses given before 2 years of age 
are less stable than those given after this age”, the operational guidance suggests that 
Integrated  Care  Boards  (ICBs)  should  ensure  that  all  ages  can  access  autism 
assessments: “check that people of all ages can access an autism assessment in the 
area”. 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 The  National  Institute  for  Health  and  Care  Excellence  (NICE)  guidance  for  autism 
spectrum  disorder  in  under  19s  (CG128)  at  section  1.5  provides  details  on  how  to 
conduct autism assessments for children and young people. The guidance does not 
specify the minimum age for an autism assessment, but it does advise: “be aware that 
in some children and young people there may be uncertainty about the diagnosis of 
autism, particularly in: children younger than 24 months…”. 

Referral for ARFID 

Not  having  a  diagnosis  of  autism  should  not  have  significantly  affected  the 
management of Joshua’s ARFID. The Royal College of Psychiatrists has produced an 
ARFID factsheet which states clearly that ARFID doesn't just occur in autistic people, 
but that it is more common in autistic people (and in boys, and ages 4-14 years).   

In January 2026, NHS England published guidance for commissioners and providers 
on eating disorder services for Children and Young People (CYP) including those with 
ARFID.  

Staff working in CYP’s mental health services (CYPMHs, sometimes known as Child 
and Adolescent Mental Health Services or CAMHS) and community eating disorder 
services  (CEDS)  should  have  the  skills  and  confidence  to  treat  CYP  with 
neurodevelopmental  conditions  and  those  with  chronic  physical  ailments,  when  an 
additional  mental  health  issue  arises.  The  necessary  adjustments  and  adaptions 
should be made to support those with additional needs. All pathways must also ensure 
that reasonable adjustments are made in line with the Equality Act 2010. 

Treatment  and  support  adaptations  will  be  made  for  those  with  additional  needs  or 
requiring  reasonable  adjustments,  for  example,  CYP  who  are  autistic  or  have  a 
learning disability.  

ICBs should develop and deliver ARFID care pathways, which might include provision 
outside  of  dedicated  CEDS  (for  example,  for  under  5s),  as  specialist  CEDS 
intervention may not always address the primary presenting need for CYP presenting 
with ARFID. 

As  part  of  their  biopsychosocial  assessment  which  involves  the  CYP  and 
parent/carers,  the  CEDS  team  should  determine  whether  a  CEDS  intervention  or 
shared  care  arrangements  are  most  appropriate  to  support  the  primary  presenting 
need  of  the  CYP.  For  example,  CYP  with  neurodevelopmental  conditions  may  be 
receiving input for disordered eating that might meet the diagnostic criteria for ARFID 
from  community  paediatricians,  speech  and  language  therapists,  occupational 
therapists and community children’s dieticians. Where there is doubt about whether 
CEDS  is  appropriate,  discussion  at  a  CYP  neighbourhood  multidisciplinary  team 
meeting, involving primary care and paediatric expertise, should be considered.  

There  are  increasing  examples  of  innovative  practice  for  CYP  requiring  intensive 
support. For example, in the West Midlands, the Eating Disorder Intensive In reach 
Team (EDIIT) at Toucan offers specialist support enabling collaborative care for young 
people with disordered eating, neurodiversity and learning disabilities.  

 Capillary Refill Time 

Capillary  Refill  Time  (CRT)  is  a  moderately  effective  but  imperfect  clinical  sign  for 
diagnosing dehydration in a child. A prolonged CRT (>2 seconds) is a strong indicator 
of dehydration, but its sensitivity is variable, so a normal CRT does not reliably exclude 
dehydration. It is one of the most useful individual signs, but a combination of signs 
(such  as  skin  turgor,  respiratory  pattern,  and  capillary  refill  considered  together)  is 
more accurate than any single sign alone.  

In summary, CRT is best used as a “red flag” for dehydration, but should not be relied 
upon in isolation for diagnosis. Clinical dehydration scales and a combination of signs 
are preferred for greater diagnostic accuracy.  

It  is  important  for  all  clinicians  to  know  when  and  how  to  assess  for  signs  of 
dehydration. Assessment for dehydration would be guided by the history and context 
given for each individual patient. For example, the NICE guidance on diarrhoea and 
vomiting caused by gastroenteritis in under 5’s (CG84) gives guidance on assessing 
children for dehydration: 

1.2.1.1 During remote or face-to-face assessment ask whether the child: 

•  appears unwell 
•  has altered responsiveness, for example is irritable or lethargic 
•  has decreased urine output 
•  has pale or mottled skin 
•  has cold extremities 

The NHS website also offers information for patients and carers on dehydration: 

Symptoms of dehydration in adults and children include: 

feeling thirsty 

• 
•  dark yellow, strong-smelling pee 
•  peeing less often than usual 
feeling dizzy or lightheaded 
• 
feeling tired 
• 
•  a dry mouth, lips and tongue 
•  sunken eyes 

Assessment  of  dehydration  is  on  the  curriculum  of  undergraduate  and  relevant 
postgraduate  medical  courses  and  the  emphasis  is  not  on  reliance  on  a  single 
indicator. NHS England does not publish guidance on the assessment of dehydration 
as it is in the basic domain of medical professionals to know this. Publication of further 
guidance is unlikely to result in increased recognition. However, I note that your Report 
has been addressed to other health organisations, including Walsall Healthcare NHS 
Trust and Birchill’s Medical Centre. They may be able to provide further information 
around the local guidance on assessing dehydration and the use of CRT tests.  

 
 
 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 
Joshua, 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  
NHS England

23 February 2026 

PRIVATE AND CONFIDENTIAL – 
TO BE OPENED BY ADDRESSEE ONLY 

Mr Zafar Siddique 
Senior Coroner for The Black Country 

Dear Mr Siddique  

Trust Headquarters 
Wilbraham Court 
Walsall Manor Hospital 
Moat Road 
Walsall 
WS2 9PS 

Re: 

In the matter of Regulation 28, Prevention of Future Deaths Report – Joshua Lee Allcock – 
Response Due 6 March 2026 

Following the inquest on 05/12/2025, you issued the Regulation 28, Prevention of Future Deaths report 
to the following organisations: 

1.  Chief Executive, Walsall Healthcare NHS Trust 
2.  Chief Executive, Walsall Local Authority 
3.  NHS England (Reg 28 Reports) -email address England.coroners28@nhs.net 
4.  Practice Manager, Birchill’s Health Centre 

This response is provided only for respondent 1, the Chief Executive, Walsall Healthcare NHS Trust.  

Walsall Healthcare NHS Trust has in place an under 5’s pathway which has been in existence for many 
years.  Archive records indicate that the under 5’s pathway was developed as early as 1991, this 
progressed to introduce a unique autism pathway from 2016.  It is noted from the inquest records that 
your concerns are primarily with unclear national guidelines for the age at which autism can be reliably 
diagnosed.  The pathways in use are attached for information.  

•  Multiagency Autism Assessment Pathway for Under 5’s – February 2023 
•  Walsall Child development service (WCDS) Autism Diagnostic pathway 24.09.2025 

Your concerns regarding national guidance are recognised, however Walsall Healthcare NHS Trust does 
not solely rely on this national guidance.  

A co-ordinated response will also be provided on behalf of respondents 1-4 by the Black Country 
Integrated Care Board. 

Yours sincerely 

Group Chief Executive

Walsall MBC - PFD (JA) response to Coroner  

1.  Walsall Metropolitan Borough Council (the local authority) acknowledges the 

concerns identified by the coroner and the Regulation 28 Report of the coroner 
following the inquest for Joshua Allcock. 

2.  These concerns relate specifically to a lack of formal diagnosis of autism for Joshua, 
and that this meant there was a subsequent lack of specialist understanding of his 
needs, and the likelihood that he experienced a condition known as Avoidant 
Restrictive Food Intake Disorder (ARFID). The coroner invites all agencies to review 
guidance and approaches to assessing the needs of children with complex medical 
needs. 

3.  The local authority accepts these points and consistently strives to develop learning 

and practices. 

4.  An Action Plan was provided to the inquest setting out the learning and actions from 
the local authority undertaken following the Child Safeguarding Practice Review for 
Joshua (WS15 Children’s Services Action Plan). This document is provided 
alongside this response to offer a detailed overview of learning and changes made 
(Appendix A). 

5.  With regards to the diagnosis of autism, Joshua had been assessed by the Walsall 
Child Development Centre when he was 3 years old. That assessment concluded 
that Joshua had Global Developmental Delay, and showed traits of autism, but a 
diagnosis was not given at this time. 

6.  Joshua’s needs and dietary intake required specialist assessment and oversight. 
Joshua was not diagnosed nor understood to have the condition ARFID. This 
understanding was provided by medical experts after his death.  

7.  It is recognised that all professionals should have had a greater focus on 

understanding Joshua’s complex health and dietary needs. There should have been 
an escalation of professional oversight where it was considered there were gaps in 
understanding a child’s needs, and/or providing appropriate support to them. 

8.  A new process of Multi-Disciplinary Team (MDT) meetings has been put in place for 
children with complex needs. These meetings should be held to identify a shared 
professional analysis of children’s needs, and progress actions required for 
assessment and support. MDTs occur in addition to multi-agency monthly Child in 
Need and Child Protection meetings. They are focused on understanding health and 
developmental needs, especially when there are specific complexities and/or 
challenges. An MDT policy and toolkit has been developed and launched with 
partners, with refresher training provided to local authority practitioners last year. All 
Team Managers and more experienced social workers who would work with a child 
with Joshua’s needs have undertaken this training. MDTs should be held as 
frequently as required, but with clear outcomes and expectations on professional 
networks of actions to assess children’s needs and enhance support as required.  

9.  MDTs for Joshua would have enabled a specific focus on his health and 

development, and on what the developmental delay he experienced meant for him in 
respect of his everyday care, assessments and specific interventions or actions 
required. This would include multi-agency consideration of any advice or support that 

1 

 
 
 
 
 
 
 
 
 
 
 Walsall MBC - PFD (JA) response to Coroner  

had been provided. This serves as a more focused consideration of developmental 
needs and delay, and strategies to support a child and their family, which sits 
alongside a more holistic consideration of a Child in Need Meeting or Child 
Protection Core Group. An MDT would have helped to highlight the need for a 
diagnosis of autism given this was the condition his family and professionals felt he 
had, given his presentation and the actions required to achieve this.  

10. It is now standard practice that an MDT should be convened by the local authority 

prior to a child entering care. This is significant for Home Finding Referrals to find the 
right home for a child when they enter care, and the Placement Planning process, 
where a meeting held to make sure carers have the right information to care for a 
child. The use of MDTs was identified as part of the WS15 Children’s Social Care 
Action Plan, and this is now in place and consistently used. 

11. Quality assurance activity is undertaken to understand and improve practice, and to 
monitor the use and impact of policy and practice changes. The support for children 
with complex needs has been subject to multi-agency auditing through the Walsall 
Safeguarding Children’s Partnership, and internal local authority practice learning. 
This has shown that MDTs are now consistently used.  

12. Children’s services have reinforced expectations that placement planning for children 
with known or suspected complex health or dietary needs must include clear, written 
information for carers with explicit guidance on escalation should concerns arise. 
This oversight is applied to all children who enter care from senior managers through 
the local authority Legal Gateway Panel where these decisions are made, and 
locality area managers then oversee the implementation of these recommendations.  

13. A key challenge for Joshua was that he often was not brought to health 

appointments. This was a part of the pattern of neglectful care he experienced, and 
the significant harm that resulted from this. This impacted on understanding and 
assessing his health and development needs. The local authority has shared 
information across the workforce about existing Was Not Brought health policies. A 
Multi Agency task and finish group was stood up following the recommendations of 
the Safeguarding Practice Review in order to develop a Was Not Bought Policy a 
draft has been developed.  

14. The neglectful care that Joshua experienced was subject to oversight and review, 

and this continues to be an area of focus. Neglect is one for the key priorities for the 
Walsall Safeguarding Children’s Partnership. The WS15 Children’s Social Care 
Action Plan sets out key areas for training and development to continue to enhance 
social care practice where children experience neglect. 

15. Walsall Council has been a Pathfinder for national Children’s Social Care reform in 

the Families First for Children programme. There is an emphasis in these reforms on 
multi-agency working and identifying and meeting children’s needs at the earliest 
opportunity. New processes and ways of working have been introduced and are 
subject to ongoing evaluation. This has demonstrated a positive impact to date, 
including external oversight from industry regulator Ofsted. This work includes 
children with the most complex of needs and their families. There has been strong 
partnership involvement in this reform programme at a strategic and operational 
level. 

2 

 
 
 
 
 
 
 
 
 Walsall MBC - PFD (JA) response to Coroner  

16. A key strand of these reforms has been the establishment of a Multi-Agency Child 

Protection Team. This is to further enhance practice where there are child protection 
concerns for a child. The Multi-Agency Child Protection Team includes additional 
oversight of experienced professionals, mechanisms for improved information-
sharing and professional collaboration, and a process to provide swift escalation and 
multi-agency oversight for decision-making.  

17. The local authority supports early diagnosis of autism where this is appropriate and is 
committed to multi-agency working to identify and assess health needs early for 
children, especially those with complex needs. An understanding of Joshua’s autism 
and the likelihood that he experienced ARFID, would have brought to the fore a 
different understanding of how to support his dietary needs. In particular, this would 
have meant understanding his highly restrictive diet and working with this condition, 
and professionals would have been attentive to the importance of consistency when 
he came into care at a point when everything in his life changed. The local authority 
will continue to work with safeguarding partners to ensure that learning regarding 
autism, ARFID and the risk of dehydration is shared across agencies.  

18. The Safeguarding Partnership hosted a reflective discussion with strategic 

safeguarding leaders to consider the learning from the Safeguarding Practice Review 
alongside the findings from the Inquest. This was to consider how to further 
incorporate learning in the Safeguarding Practice learning review following what was 
further understood from the Inquest.  

19. The significance of ARFID was brought out in the inquest for Joshua, this condition 
and its impact is being incorporated into mandatory training for social workers and 
foster carers on working with disabled children and those with complex needs. 
Mandatory service workshops will also be used to share learning about ARFID and 
autism, so all social workers and carers understand this condition. These workshops 
will cover all practitioners working in Children’s Social Care and will be completed by 
May 2026. 

20. The training provided to foster carers has also been reviewed, with a specific focus 
on supporting children with autism and special educational needs. This training is 
being updated to include ARFID and will be rolled out as a part of the mandatory 
training for all foster carers, to cover all local authority carers across 2026. 

21. Joshua’s death was a tragedy of the greatest magnitude. Walsall Council is 

committed to working with our partners to learn and continue to improve our practice 
and responses to children with complex needs and their families. Further work is 
being undertaken specifically focused on developing multi-agency practice and 
specialist knowledge for these children. Joshua’s needs were complex and unique, 
however it is the responsibility of professional systems to work together to assess, 
meet children’s needs as early as possible, and to navigate challenging 
circumstances such as in child protection contexts.  

22. The local authority is committed to learning from this tragic death and to working 

collaboratively with partner agencies to reduce the risks of similar death in the future. 
The Walsall Safeguarding Children’s Partnership has robust governance 
arrangements in place in respect of all Action Plans, incorporating the WS15 Child 
Safeguarding Practice Review Action Plan. This includes reporting to the 

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 Walsall MBC - PFD (JA) response to Coroner  

Performance and Quality Assurance Group who audit and sample work with children 
and families, and actions to improve practice and systems. This work is then 
subsequently overseen by the Safeguarding Partnership Leadership Group, and any 
issues are reported to the Safeguarding Partnership Executive Leadership Team. 

23. We trust that this response addresses the matters raised within the Regulation 28 

report and remain open to providing any further clarification the coroner may require. 

Date: 03/03/2026 

Director Children’s Social Care  
Walsall Council 

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 Walsall MBC - PFD (JA) response to Coroner  

Identified Learning 

Action 

1. 

The partnership should seek 
assurance that the GCP2 tool is 
understood and used by 
professionals where neglect is 
considered to be a feature 

Neglect is one of 4 Safeguarding 
Partnership priorities and 
Neglect Steering Group to 
provide oversight of use of 
NSPCC GCP2 tool across the 
Safeguarding Partnership 

Neglect Lead role established to 
drive GCP2 training and neglect 
practice improvement and 
training 

Appendix A 

Responsible 
Lead 

Completion 
Date  

Progress/update 

April 2024 

Director for 
Partnerships – 
Neglect Steering 
Group  

Neglect Steering Group 
established, meets monthly, and 
oversees uptake GCP2 training 

Director for 
Partnerships 

April 2024 

Neglect Lead post established and 
recruited to – LC  

GCP2 training delivered across 
Children’s Social Care managers 
and practitioners 

LC and Principal 
SW 

April 2025 

114 staff trained in GCP2 

Group Manager 
for MACPT 

January 2025 

Multi-Agency Child Protection 
Team and Lead Child Protection 
Practitioners to oversee practice 
working with families where 
neglect occurs (inc. all CP 
enquiries and Plans) 

5 

Continued rollout of training – all 
staff to be trained by end of March 
2026 

MACPT pilot operational. Lead 
Child Protection Practitioner role 
established and now used 3 of 4 
localities 

Full rollout due by April 2026 

 
 
 
 
 
 
 
 
 
 
 
 
 Walsall MBC - PFD (JA) response to Coroner  

Contribute to development of 
“Was Not Brought” policy, and 
ensure this is shared to all 
managers and practitioners in 
CSC 

Head of 
Safeguarding 
Partnership 
Business Unit 

In progress 

Policy in development developed 
by Safeguarding Partnership, 
including representatives from 
Children’s Social Care 

Multi-disciplinary Team Meetings 
to be held in addition to Core 
Group Meetings where there are 
identified specific health and 
developmental needs. 

Head of Service 
Family 
Safeguarding 

April 2023 

Multi-agency protocol in place. 
This is now standard practice, it is 
reviewed through monthly audits 
and now subject to the enhanced 
oversight of the Multi-Agency Child 
Protection Team 

2. 

3. 

The partnership should 
consider the development of a 
multi-agency “Was Not 
Brought” policy which makes 
clear the roles and 
responsibilities of all 
professionals in the 
safeguarding system when a 
child is not brought to a 
medical appointment and 
includes consideration of how 
this corresponds to the 
thresholds for social care 
intervention 

The partnership should 
facilitate a discussion between 
children’s services and health 
leads to identify the most 
appropriate way to coordinate 
the sharing of information 
across the health system and 
into a child’s plan. This is 
particularly important when 
multiple health professionals 
are involved in supporting a 
child with complex needs 

4. 

The partnership should seek 
assurance from children’s 
social care that there are 

Additional training provided to 
Team Managers and Child 
Protection Conference Chairs on 

Principal SW 

September 2025  Programme of management 

training delivered through the 
Practice Leadership Programme 

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 Walsall MBC - PFD (JA) response to Coroner  

Supervision and oversight of CP 
Plans 

appropriate mechanisms in 
place to scrutinise the length of 
time a child is subject to a child 
protection plan to avoid delays 
in taking prompt action to 
address the concerns 

and during Service Development 
Days. Programme of training 
completed in September 2025  

Midway Review process reviewed 
and development work with CP 
Chairs 

Group Manager 
for Safeguarding 
and Review 

September 2025  Process reviewed and updated, 

shared to all CP Chairs  

Safeguarding Partnership FAST 
Escalation process reviewed and 
shared across to all managers 
and practitioners in CSC 

Multi-Agency Child Protection 
Team pilot established to 
enhance information-sharing and 
escalation where there are gaps 
in information 

Multi-Agency Child Protection 
Team and Lead Child Protection 
Practitioners to oversee CP Plans, 
with multi-agency review after 12 
months of a CP Plan. The Neglect 
Lead joins all reviews where 
neglect is a feature 

Principal SW 

February 2024 

Process reviewed and updated, 
shared across communication 
channels by February 2024 

Group Manager 
for MACPT 

January 2025 

MACPT pilot operational 

Full rollout due by April 2026 

Group Manager 
for MACPT 

January 2025 

MACPT pilot operational 

Full rollout due by April 2026 

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 Walsall MBC - PFD (JA) response to Coroner  

Strats – LCPPs to oversee and 
stay involved 

5. 

Multi-agency chronologies 
should be used where children 
experience neglect to develop a 
holistic analysis of their needs 
and any gaps in accessing 
support and services 

6. 

Enhance direct work skills to 
capture the voice of disabled 
children and children with 
developmental delay 

Chronologies training delivered 
across CSC 

Principal SW 

March 2025 

Chronology training delivered to all 
practitioners in the Family 
Safeguarding Service 

Multi-agency chronologies to be 
used for all children where there 
are CP enquiries 

Head of Service 
Family 
Safeguarding 

March 2025 

Head of Service 
Family 
Safeguarding 

April 2023 

Principal SW 

January 2024 

This is now a practice standard, it 
is reviewed through monthly audits 
and the oversight of the Multi-
Agency Child Protection Team 

This is now a practice standard, it 
is reviewed through monthly audits 
and now subject to the enhanced 
oversight of the Multi-Agency Child 
Protection Team 

Role established and all CSW post 
recruited to 

The Disabled Children and Young 
Person’s Team will co-work with 
the Family Safeguarding Team 
where a child has significant 
developmental delay 

Consultant Social Worker role 
established – 1 per locality – to 
provide guidance and guidance to 
practitioners including direct 
work skills 

Direct work training is delivered to 
all practitioners in Children’s 
Social Care, including training on 

Principal SW 

September 2023  Ongoing rolling programme for all 

practitioners, and this is 

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 Walsall MBC - PFD (JA) response to Coroner  

communicating with disabled 
children and children 
experiencing developmental 
delay 

mandatory requirement for all 
practitioners 

7. 

Ensure that all health 
professionals are invited to Child 
Protection Core Groups 

Communication to all managers 
and practitioners, reinforced in 
service and team meetings 

Head of Service 
Family 
Safeguarding 

April 2023 

Briefings held and information 
shared through all communication 
channels 

8. 

When placing children in foster 
care with developmental delay 
needs, there should be additional 
support provided to understand 
and meet needs 

New protocol implemented with 
0-19 Health Service to provide 
overview of children’s health 
needs 

Multi-disciplinary Team Meetings 
to be held where a child is 
experiencing developmental 
delay. If there is not sufficient 
clarity on a child’s needs the 
escalation processes outlined 
elsewhere here 

The Disabled Children and Young 
Person’s Team will co-work with 
the Family Safeguarding Team 
where a child has significant 
developmental delay 

Head of Service 
Family 
Safeguarding 

April 2025, 
reviewed August 
2025 

Protocol in place. This has been 
reviewed to enhance coordination 
and streamline process 

Further review due January 2026 

Multi-agency protocol in place. 
This is now standard practice, it is 
reviewed through monthly audits 
and now subject to the enhanced 
oversight of the Multi-Agency Child 
Protection Team 

This is now standard practice, it is 
reviewed through monthly audits 
and now subject to the enhanced 
oversight of the Multi-Agency Child 
Protection Team 

Head of Service 
Family 
Safeguarding 

April 2023 

Head of Service 
Family 
Safeguarding 

April 2023 

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 Walsall MBC - PFD (JA) response to Coroner  

9. 

Make sure that parent’s voices 
are heard and respected  

A new Parental Advocacy Service 
has been established, with 
parents to be offered support 
from a representative from a local 
community organisation 

Head of Service 
Family 
Safeguarding 

September 2025  Offer established and available to 

all families – to be considered prior 
to all CP Conferences 

10