Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0268, written 8 May 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2026 |
|---|---|
| Reference | 2026-0268 |
| Deceased | Ollie Lee |
| Coroner | Hannah Berry |
| Coroner area | South Yorkshire (West) |
| Organisation named | South West Yorkshire Partnership Teaching NHS Foundation Trust |
| Source | judiciary.uk record |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1. 2. 3. 3. 4. REGULATION 28: REPORT TO PREVENT FUTURE DEATHS CORONER I am Hannah Berry, Assistant Coroner, for the coroner area of South Yorkshire (West) DATE OF REPORT 8 May 2026 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. THIS REPORT IS BEING SENT TO 1. 2. 3. , Chief Executive, Barnsley Metropolitan Borough Council , Chief Executive, South West Yorkshire Partnership NHS Trust , Headmaster, Barnsley Community Academy You are under a duty to respond to this report within 56 days of the date of this report, namely by 3 July 2026. I, the coroner, may extend the period if an appropriate application is made. YOUR RESPONSE Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 5. SUMMARY OF CORONER’S CONCERN There was poor communication and engagement between the agencies involved with supporting Ollie. This led to missed opportunities for Ollie to continue to receive the support of mental health services. 6. 7. ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action. INVESTIGATION AND INQUEST On 7 October 2024, I commenced an investigation into the death of Ollie Lee, aged 14 years. The inquest concluded on 8 May 2026 with a conclusion of suicide. The medical cause of death was 1a Compression to the neck. The record of inquest recorded that Ollie Lee died on 6 October 2024 at Barnsley District General Hospital from hanging . Ollie had complex needs with suspected neurodiversity, identity confusion and there were concerns she was being bullied at school. On 19 and 26 September 2023 Ollie self harmed at school, on 21 November 2023 she attempted to self ligature and on 4 December 2023 she attempted an overdose. Following these incidents Ollie was supported by the mental health services crisis team until her discharge on 11 March 2024 when it was assessed that she was no longer in crisis. On 4 October 2023 Ollie was put on the waiting list for psycho social intervention from mental health services and was eligible to start this intervention in June 2024. Due to poor communication between agencies Ollie was discharged from the service due to no contact and therefore no psycho social intervention occurred. This was a missed opportunity for Ollie to remain under the care of mental health services. There were additional missed opportunities due to lack of communication when additional self harm attempts were not reported to mental health services. It cannot be said whether the missed opportunity to receive additional support from mental health services caused or contributed to her death. 8. CIRCUMSTANCES OF DEATH Ollie Lee had complex needs. It was suspected that she was neurodiverse, there was suspicion of borderline personality disorder and at times it was reported that she struggled with body identity. She had changed her and pronouns at varying times in her life. She did not enjoy school and was bullied at times during her time at school. Ollie first voiced suicidal ideation on 9 November 2022 and had sessions with the school counsellor. On 19 September 2023 whilst in school she cut her wrist . A week later on 26 September she used Following the second incident she was taken to hospital and referred to the child and adolescent mental health service (CAMHS) within South West Yorkshire Partnership NHS Trust and on 4 October 2023 was put on the wait list for psychosocial intervention with CAMHS. On 23 November 2023 she admitted to the school counsellor that she had attempted to self ligature two days prior and on 4 December she was taken to hospital following an attempted overdose. Following this Ollie and her family were allocated a targeted early help support worker at Barnsley Metropolitan Borough Council. Ollie was supported from the crisis team within CAMHS until she was discharged on 15 February 2024 as it was assessed that she was no longer in crisis. Ollie had a period of absence from school as it was felt that school and bullying were a trigger for her and on 22 February 2024 she returned to education with a carefully managed integration. On 16 April Ollie reported to the deputy designated safeguarding lead at school that she had suicidal thoughts. Early help were notified but CAMHS were not. On 14 May Ollie’s early help support worker was notified by Ollie’s mother that Ollie was self harming. This was not notified to CAMHS. On 11 June, just over 9 months after Ollie had been put on the wait list for psycho social intervention she was allocated a psychologist. The psychologist was unable to make contact with Ollie’s mother by phone or post and so after making enquiries with the school that Ollie was in full time education she was discharged from CAMHS. Neither Ollie’s school nor early help were notified of this discharge and remained unaware that Ollie was closed to mental health services. Had early help have been made aware then they would have been able to inform CAMHS that Ollie’s mother was having problems with her telephone and of other issues that may have meant that contact could have been made. Ollie and her mother were also unaware that she had been discharged. On 6 June the early help support worker was notified that Ollie had been pulling her hair out. CAMHS were not notified. On 9 September the early help support worker contacted CAMHS to get an update on Ollie’s waiting list status and was advised that she had been discharged. On 6 October Ollie took her own life. During the inquest evidence was heard from Ollie’s school that Ollie had not asked to be known by anything other than her birth name of Willow at school. Evidence was also heard from early help that engagement had occurred with school on the importance of using Ollie’s chosen name and pronouns. There was no record of this being noted and actioned. 9. CORONER’S CONCERNS During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1) Poor communication and engagement between the agencies involved with Ollie including her school, CAMHS and targeted early help. 2) A lack of communication and engagement between targeted early help and CAMHS despite both agencies being aware that the other was involved. This led to a confusing picture and a missed opportunity for Ollie to remain open to CAMHS and receive psycho social intervention and continued support from CAMHS. 3) There was no record of important discussions that occurred between early help and the school and Ollie’s preference in relation to pronouns was not acted upon. 10. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. The family of Ollie Lee 2. Chief executive, United Learning I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. SIGNATURE
4 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Principal: Stephen Pitcher Re: Regulation 28 Report to Prevent Future Deaths – Ollie Lee (Deceased) Date of Report: 8 May 2026 Dear Assistant Coroner Berry, Thank you for your Regulation 28 Report dated 8 May 2026 concerning the tragic death of Ollie Lee. Firstly, I would like to express our sincere condolences to Ollie’s family and acknowledge the distressing circumstances outlined during the inquest. We have carefully considered the concerns raised within your report and recognise the importance of addressing these matters to reduce the risk of future harm. The death in October 2024 occurred during a period of change for the school; however, the focus since that time has been on ensuring sufficient capacity and consistency to sustain high-quality provision for all students. From September 2024, a new Principal has provided continuity of leadership and oversight, supporting the embedding of existing systems and expectations. Additional staffing, including the recruitment of a further safeguarding officer, has increased the capacity of the safeguarding team, enabling continued timely and effective responses. A Peer Conflict Resolution Officer role was also introduced to provide structured support for students in managing social interactions and resolving issues, with appropriate processes in place from September 2024 to monitor and track concerns. The Senior Leadership Team has been expanded to support clear leadership responsibility, including a focus on character and personal development through PSHE and behaviour. The school’s achievement of the UNICEF Rights Respecting Schools Gold Award and the Association for Character Education Quality Mark reflects the continuation of its established approach to promoting a respectful and supportive environment. Overall, these measures are intended to ensure that existing good practice is consistently maintained and supported with appropriate capacity. Following the receipt of the Regulation 28: Report to Prevent Future Deaths, meetings were convened on 22 May, , Service 4 June and 23 June 2026 between , Head of Quality, Children Services NHS, Director for Children’s Social Care Barnsley City Council, , Head of Service Barnsley City Council, , Principal at Barnsley Academy, , Regional Director United Learning and , General Manager CAMHs to ensure that we discussed each concern and our responses to these individually and collectively. We have reviewed the concerns identified within your report in detail and have set out below our response to each concern as a school, including the actions that have already been taken and those that we will be taking individually and collectively alongside other agencies as a response to findings. 1. Communication and Engagement Between Agencies We acknowledge the concerns regarding insufficient communication and coordination between agencies involved in supporting Ollie. Please find below the actions taken or proposed: In July 2024 Local Authority Partnership arrangements were adapted to support improved communication and effective working relationships with schools. Since this time, every school has been allocated a targeted Early Help link practitioner to support with communication and consistency in approach between schools and Principal: Stephen Pitcher agencies. This targeted support means regular connection between the school and the Local Authority Safeguarding Team’s Early Help Practitioner who offers advice, guidance and support where required. Following these changes in July 2024, the school has seen an improvement in communication linked to the reduction in referral only conversations. Since May 2023, Barnsley Academy has engaged with the Green Panel, an Early Intervention Panel that meets once per half-term and is designed to share resources and best practice around inclusion intervention, with the aim of reducing suspensions and exclusions. This is an example of multi-agency collaboration and communication to support vulnerable young people. Membership of the panel includes schools, education psychologists, Compass, Education Welfare Service, Targeted Early Help, Youth Justice, Targeted Youth Support, CSC, Early Help services. As a result of CAMHS sharing the crisis flowchart with schools, Barnsley Academy has adapted its protocols around escalating concerns for students who have self-harmed or are deemed to be at risk of harming themselves (including suicidal ideation). Whereas previously, parents or carers would have been advised to take their child to A&E to seek support, school now contacts the crisis team directly. Following the updated guidance from the Department for Education’s Working together to improve school attendance in August 2024 (Appendix 1), school safeguarding leaders updated their approach to ease identification of agencies involved with students via the use of ‘pinning’ on CPOMs profiles. Whilst we recognise that this action was taken prior to Ollie’s death in October 2024, this has supported the ease and efficiency of communication with agencies and has provided a clearer oversight of their involvement for school leaders. Barnsley Academy has completed regular professional development training with all safeguarding trained colleagues (DSLs/DDSLs) within the Academy, including most recently on Thursday 4 June 2026. The focus of the most recent training was around ensuring that where multi-agency support is in place for a student and their family, all relevant information is shared as routine with all agencies involved. Furthermore, particular emphasis was placed upon information sharing across agencies even when other stakeholders (e.g. a parent or Family Support Worker) state that they will share that information (Appendix 2). In addition to training colleagues, Barnsley Academy has formalised its Safeguarding Quality Assurance and Supervision process guidance (Appendix 3) to ensure that specific reference is made to quality assurance of relevant information sharing across multiple agencies. Within the guidance the Designated Safeguarding Lead completes routine quality assurance audits (Appendix 4) to ensure efficiency and compliance in relation to CPOMs logs and to monitor the effectiveness of multi-agency working. Within the guidance, there is also clear reference made to quality assuring multi-agency working as part of termly complex case file reviews. Whilst the working practices have been in place for much longer, the formal guidance was updated on 5 June 2026 and outlines training commitments as well as quality assurance processes to ensure routine practice and accountability. United Learning will be completing a routine Safeguarding Audit at Barnsley Academy on 8 July 2026 and will review the guidance document around safeguarding information sharing. As a part of the review the school will be requesting a specific focus on case sampling where students have multi-agency involvement to quality assure the effectiveness of the school’s work with external agencies. Through our working together and shared experiences, the Local Safeguarding Partnership Offer will be further developed to ensure a best practice template is available to schools where a Safety Plan is advised to be completed, for example in circumstances like self-harm. Ambition │ Determination │ Respect Barnsley Academy is part of United Learning. United Learning comprises: UCST (Registered in England No: 2780748. Charity No. 1016538) and ULT (Registered in England No. 4439859. An Exempt Charity). Companies limited by guarantee. VAT number 834 8515 12. Registered address: United Learning, Worldwide House, Thorpe Wood, Peterborough, PE3 6SB. Barnsley Academy Farm Road Barnsley South Yorkshire S70 3DL t: 01226 284606 e: admin@barnsley-academy.org w: barnsley-academy.org Principal: Stephen Pitcher 2. Communication Between Targeted Early Help and CAMHS We recognise the issues identified regarding the lack of effective communication between targeted early help services and CAMHS, which contributed to a missed opportunity for continued support. Whilst not specifically named within this concern, Barnsley Academy can note that improved working practices with both agencies have supported more proactive and timely communication, as well as strengthened working relationships. This seems to support the stated intention from both parties to look at how multi-agency communication and working can be improved and made more comprehensive and efficient. Targeted Early Help - Within school, an additional 7 members of staff have received central local authority training around Early Help processes since March 2025. As well as increased capacity to support referral processes, this has further enhanced staff understanding of how targeted early help services work and has made communication more efficient through a strengthening of cross-agency professional relationships and networks. As forementioned, from July 2024, Barnsley Academy has been allocated an Early Help Practitioner within targeted early help services who acts as a direct school liaison and primary point of contact. This has led to more proactive communication and support between early help and school. Mental Health Services - The school has continued to hold link meetings once per term with a school liaison from Compass Be. However, as well as discussing whole school support, these meetings have become more focused to address next steps for specific caseloads of identified students, where mental health concerns have been raised. 3. Record Keeping and Recognition of Individual Needs We acknowledge your third concern: ‘there was no record of important discussions that occurred between early help and the school and Ollie’s preference in relation to pronouns was not acted upon’. Whilst it remains unclear whether or not discussions around Ollie’s preference in relation to name and pronouns did take place between early help and school, actions have nevertheless been taken or are proposed in order to reduce the possibility of unrecorded discussions. A safeguarding colleague from United Learning investigated a complaint on behalf of Barnsley Academy which was received from Courtney Lee, mother of Ollie Lee, on 22 August 2025. The findings from this investigation identified aspects of record-keeping as an area for improvement. Either prior to the complaint being received, or since the outcome on 24 November 2025, Barnsley Academy has completed the following actions, all of which strengthen record keeping: Additional recruitment into the safeguarding team on 20 January 2025 has increased capacity allowing quality assurance to take place more regularly. The additional capacity has also ensured that preventative as well as reactive work has been further strengthened within the school. For example, the safeguarding officer has an allocated caseload of vulnerable students (Child Protection, Child in Need, others identified) and personally supports the attendance team with calls and home visits for these students as a priority when they are absent from school. In addition, the increased capacity has reduced the time taken to address lower-level concerns on CPOMs, resulting in earlier intervention. Ambition │ Determination │ Respect Barnsley Academy is part of United Learning. United Learning comprises: UCST (Registered in England No: 2780748. Charity No. 1016538) and ULT (Registered in England No. 4439859. An Exempt Charity). Companies limited by guarantee. VAT number 834 8515 12. Registered address: United Learning, Worldwide House, Thorpe Wood, Peterborough, PE3 6SB. Barnsley Academy Farm Road Barnsley South Yorkshire S70 3DL t: 01226 284606 e: admin@barnsley-academy.org w: barnsley-academy.org Principal: Stephen Pitcher As part of the annual safeguarding training which took place on 2 September 2025, a focus was given to logging incidents on CPOMs in order to ensure their timeliness and the provision of high-quality factual information within all logs. Training was also provided on ensuring consistent logging of follow-up actions to indicate how incidents have been addressed and to confirm that they have been fully resolved (Appendix 5). Following the findings in November 2025, the Designated Safeguarding Lead has been trained on auditing CPOMs logs and has been provided with an auditing template and guidance from United Learning (Appendix 4). Auditing is now in place as routine to ensure the quality of recording is consistent. Where any areas of inconsistency are identified, including around agency communication, it is followed up through training with individuals or wider groups of staff, as applicable. A formal auditing schedule is outlined in the Safeguarding Quality Assurance and Supervision process guidance (Appendix 3). Where a pronoun or name change request is made to Barnsley Academy, the school follows the Department for Education guidance: Gender questioning children and Keeping Children Safe in Education (Appendix 6). Safeguarding our children and young people is our highest priority. We believe that our role is to work in partnership with students and their parents/carers to support the best interests of each child’s wellbeing, safety and future. Whilst we recognise that Ollie did not expressly request a name or pronoun change, the name Ollie was identified on and in some school exercise books after her death. This suggests that there may have been potential missed opportunities to record concerns relating to identity questioning by some members of staff. As a result, during safeguarding training in September 2025 (Appendix 5), all members of staff were provided with further clarification around identification of concerns and low-level patterns of behaviour and expectations around information sharing, including around gender questioning. This was followed up again within the safeguarding update training for key colleagues on the 4 June 2026 (Appendix 2) and again with all staff on 26 June 2026 during a whole school Inset. Additional Measures In addition to the actions above, we have undertaken broader service improvements, which include the following: As previously noted, Barnsley Academy will be having a scheduled safeguarding audit on 8 July 2026. Whilst safeguarding audits are routine for all United Learning schools, we recognise the importance of this visit in ensuring that the actions taken as a result of the tragic loss of Ollie are being consistently applied across the school and wider services. All Barnsley Academy staff received a full day’s training from 14 professionals from a range of different agencies on 1 September 2025 (Appendix 7). This in-school training was aimed at further developing staff understanding of the challenges around emotional wellbeing and mental health for young people. This training also reflected our commitment to working effectively and proactively with external professionals. To further increase the impact of our mental health support within school, the Student Medical and Wellbeing Officer has attended a number of in-person and online mental health training events (both United Learning and others) to ensure we are engaging with best practice. We have also increased the number of mental health first aiders within school. Since the start of the academic year 2024-25, we have used the STEER Education platform to improve our early identification of students at risk of hidden social-emotional struggles. The research-led mental health Ambition │ Determination │ Respect Barnsley Academy is part of United Learning. United Learning comprises: UCST (Registered in England No: 2780748. Charity No. 1016538) and ULT (Registered in England No. 4439859. An Exempt Charity). Companies limited by guarantee. VAT number 834 8515 12. Registered address: United Learning, Worldwide House, Thorpe Wood, Peterborough, PE3 6SB. Barnsley Academy Farm Road Barnsley South Yorkshire S70 3DL t: 01226 284606 e: admin@barnsley-academy.org w: barnsley-academy.org Principal: Stephen Pitcher platform provides tools to measure, track and improve student wellbeing. In addition to this, we are also developing a “vulnerability tracker”, which will help us to better identify students whose wellbeing is at greater risk owing to contextual drivers within their lives. Conclusion We are fully committed to learning from this tragic case and will seek to continue strengthening our systems, processes, and partnership working arrangements wherever possible to ensure that individuals receive timely and appropriate support. We will continue to monitor the implementation and effectiveness of these actions and will ensure that lessons learned are embedded across Barnsley Academy. Please let us know if you require any further information or clarification regarding this response. Yours sincerely, Principal Barnsley Academy Ambition │ Determination │ Respect Barnsley Academy is part of United Learning. United Learning comprises: UCST (Registered in England No: 2780748. Charity No. 1016538) and ULT (Registered in England No. 4439859. An Exempt Charity). Companies limited by guarantee. VAT number 834 8515 12. Registered address: United Learning, Worldwide House, Thorpe Wood, Peterborough, PE3 6SB. Barnsley Academy Farm Road Barnsley South Yorkshire S70 3DL t: 01226 284606 e: admin@barnsley-academy.org w: barnsley-academy.org APPENDICES Appendix 1 - Department for Education’s Working together to improve school attendance in August 2024 Working together to improve school attendance (applies from 19 August 2024) Summary table of responsibilities for school attendance (applies from 19 August 2024) Appendix 2 – Safeguarding Professional Development Slides Appendix 3 - Safeguarding Quality Assurance and Supervision process guidance Appendix 4 – Safeguarding Quality assurance Audit Form Appendix 5 – Annual Safeguarding Training September 2025: Slides 65-68 referencing the importance of noticing / reporting small signs, including notes in books. Appendix 6 - Department for Education guidance: Gender questioning children and Keeping Children Safe in Education (Draft for consultation) Gender Questioning Children - non-statutory guidance Appendix 7 – Professional Development: Emotional Wellbeing and Mental Health for Young People (multi agency input). INSET Day Training – Monday, 1 September 2025 Appendix 8 – United Learning Mental Health Tiered Model
RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: The Senior Coroner, Mrs Tanyka Rawden for the Coroner Area South Yorkshire (West) in response to a REPORT TO PREVENT FUTURE DEATH REGULATION 28, made by Hannah Berry, Assistant Coroner following an inquest into the death of Willow Lee aka Ollie Lee that concluded on 8 May 2026. 1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Barnsley Metropolitan Borough Council Children’s Services provides this response within 56 days of the date of the Report to Prevent Future Deaths. 2. 3. DATE OF RESPONSE 22nd June 2026 CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN identified in the report are as follows: 1) Poor communication and engagement between the agencies involved with the child, including school, CAMHS and Targeted Early Help. 2) A lack of communication and engagement between Targeted Early Help and CAMHS despite both agencies being aware that the other was involved. This led to a confusing picture and a missed opportunity for the child to remain open to CAMHS and receive psychosocial intervention and continued support. 3) There was no record of important discussions between Early Help and the school, and relevant personal information, including the child’s preference in relation to pronouns, was not acted upon. 4. DETAILS OF ACTION TAKEN, how has the concern been addressed. Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. Response to Concern 1: Poor communication and engagement between the agencies involved with the child, including school, CAMHS and Targeted Early Help Since 2024, Children’s Social Care has continued to strengthen multi- agency working as part of our continuous approach to service development, with a clear focus on ensuring communication is proactive, purposeful and embedded in day-to-day practice rather than episodic or reactive. This is underpinned by an expectation that practitioners make early and active contact with partner agencies, including schools and CAMHS, to develop a shared and coherent understanding of children’s needs, risks and protective factors at the earliest opportunity. Within Targeted Early Help, communication with schools has been further strengthened through the introduction of named link workers for each school across the whole of Barnsley, which has created clear and accessible points of contact and a more consistent professional relationship. This has been complemented by more structured consultation opportunities, enabling school staff to routinely seek advice from Targeted Early Help practitioners at the earliest sign of concern. In practice, this means emerging issues relating to attendance, emotional wellbeing or family stressors are shared earlier, discussed jointly and responded to through coordinated planning, reducing delay and preventing escalation. In parallel, communication with CAMHS has developed through a more integrated and coordinated approach to emotional health and wellbeing. Targeted Early Help practitioners are now more consistently involved in multi-agency discussions where children present with mental health needs, ensuring that information from CAMHS is understood within the wider family and environmental context. This has been supported by clearer pathways between Early Help and CAMHS, including improved referral processes, more timely information sharing following assessments, and joint planning where children meet thresholds for both services. As a result, practitioners are better able to align interventions, reduce duplication and ensure that support provided to children and families is complementary rather than fragmented. improvements are reinforced through our updated practice These standards, which explicitly require practitioners to gather and triangulate information from across the professional network, including education and health partners, rather than relying on a single service perspective. This that expectation strengthens professional curiosity and ensures assessments reflect a comprehensive and multi-agency understanding of the child’s lived experience. Our practitioner supervision arrangements provide consistent management oversight of communication, managers routinely check that contact with key partners, including schools and CAMHS, has taken place, that information has been followed up and that actions are clearly recorded and progressed. This ensures that communication is not only expected but evidenced, and that any gaps or delay in information sharing are identified and addressed promptly. training Practitioner capability has also been strengthened through targeted training and development. Staff across Targeted Early Help and Children’s Social Care have undertaken focused on multi-agency working, information sharing, professional curiosity and contextual safeguarding. This includes reinforcing expectations around engaging with education and health partners, understanding thresholds for CAMHS involvement, and contributing effectively to multi-agency meetings. This training supports practitioners to communicate with confidence, understand the roles of partner agencies and ensure is shared clearly, that appropriately and in a timely way. information At a system level, Barnsley’s Multi-Agency Safeguarding Arrangements (MASA) (updated April 2026) provide the framework that underpins this practice, setting clear expectations for timely information sharing, joint working and collective decision-making across all partners. The MASA arrangements roles and responsibilities between agencies, including education and health, and by supporting effective escalation and professional challenge where communication is not timely or effective. strengthen accountability by defining In addition, service developments such as the move towards a more conversational Integrated Front Door and the alignment with the Families First Partnership model will continue to reinforce the importance of direct dialogue between practitioners across agencies. These developments prioritise real-time information sharing and joint problem-solving, ensuring that schools, CAMHS and Targeted Early Help are part of a coordinated response from the outset of involvement. Overall, these combined practice expectations, management oversight, system frameworks and workforce developments provide assurance that communication between Targeted Early Help, schools and CAMHS is more consistent, purposeful and effective. This reduces the risk of fragmented information, strengthens shared understanding and supports earlier, more coordinated intervention for children and families. Response to Concern 2: Lack of communication and engagement between Targeted Early Help and CAMHS, despite both agencies being aware of involvement Our current arrangements set a clear expectation that communication between practitioners is active, timely, and accountable. Practitioners are expected to make direct contact, be clear about why it is needed, and ensure that children known to more than one service are not supported through separate or disconnected activity. At the point involvement begins, where a Targeted Early Help practitioner identifies CAMHS involvement direct contact takes place at the earliest opportunity. This does not rely on records alone or on assumptions that another service already holds the full picture. In most cases, this means a same-day phone call or secure email to the practitioner who knows the child. That contact is used to confirm current involvement, understand the child’s presentation, clarify risk, and identify any active intervention. The outcome is recorded clearly, including agreed actions and any differences in professional view. Where CAMHS are actively involved with the child they are invited to family network meetings, child in need meetings, strategy discussions, child protection activity, or other relevant consultations The right practitioner is identified so that contributions are based on direct knowledge, and where this does not happen, practitioners are expected to follow up and escalate. Communication is not treated as a one-off event. It forms part of routine case coordination, with updates shared when risk changes, plans understood across services, and clarity maintained about who is leading each part of the response. This is particularly important where emotional wellbeing, safeguarding, and family support overlap. We recognise that supervision is central to ensuring this happens consistently. Managers check whether contact with CAMHS or other relevant agencies has been made, whether their current assessment and plan are understood, and whether this is properly reflected in the assessment of risk and need. Communication is therefore reviewed and challenged rather than assumed. Where there is drift, limited engagement, or lack of clarity, practitioners use escalation routes. This may include discussion between managers, use of professional resolution processes, or escalation through safeguarding partnership arrangements, with the aim of avoiding delay and resolving issues quickly. These expectations are reflected in current case management guidance. Practitioners are required to establish contact with key services at the start of involvement, clarify roles, gather information directly, and maintain communication throughout ongoing coordination. This reinforces active professional curiosity, clear information gathering, and purposeful oversight. Practice standards, supervision frameworks, and quality assurance activity reinforce the same expectations. Audit work tests whether there is clear evidence of multi-agency contact, role clarity, and recorded communication between services. Where this is not evident, the response includes management oversight, reflective supervision, and feedback into team learning and wider partnership discussion. Communication routes with CAMHS are including expectations about involvement in safeguarding processes, participation in professional discussions, and ensuring that the practitioner with direct knowledge of the child is involved. This reduces the risk of parallel working and makes it more likely that shared concerns are translated into shared action. therefore clear, Management oversight is equally explicit. Team managers check whether contact with relevant agencies has taken place, whether follow-up actions are recorded clearly, and whether safeguarding or wellbeing actions are progressing within the right timescales. Where multi-agency engagement is not evident, supervision records challenge and escalation. Where concerns are urgent, follow-up action happens quickly. High-priority actions are progressed within set timescales and with active management oversight. Compliance is monitored through case tracking and supervision so that critical safeguarding actions are not delayed. This will be strengthened further through planned CAMHS co-location within the Integrated Front Door during 2026 to 2027. This will support earlier shared discussion, faster information exchange, and better visibility of children whose needs sit across both emotional health and safeguarding systems. Taken together, this approach reduces parallel working, prevents partial understanding of a child’s circumstances, and supports earlier alignment of plans where mental health needs and safeguarding concerns exist at the same time. Expectations are clear, management oversight is explicit, audit activity tests practice directly, and wider system design supports agencies to work together earlier and more effectively. Response to Concern 3: No record of important discussions and relevant personal information, including pronoun preference, was not acted upon Our Practice Standards and case management guidance set clear expectations that all significant events—including professional discussions, key contacts, decisions, actions and the reasons for them—are recorded promptly, accurately and proportionately. This promotes more consistent recording and ensures that key information is clearly captured in the child’s record, accessible to managers and partners, and able to inform ongoing assessment and decision-making. Practice is not reliant on informal communication or individual recollection; there is a structured and transparent record that supports continuity, particularly in complex cases involving emotional distress, self-harm or changing risk. Management oversight is exercised through both formal supervision and day-to-day operational case discussions, providing regular scrutiny of the quality and timeliness of recording and decision-making. Managers review actions, address gaps and ensure that recording reflects the lived experience of the child. Actions arising from supervision or broader case oversight are specific, outcome-focused and linked to identified risks, with clear timescales for completion. Urgent actions are prioritised and progressed within 72 hours. Managers track these actions and escalate where necessary to maintain oversight and ensure that recording remains timely, accurate and complete. There has been a sustained focus on practice development, underpinned by training for all staff in Signs of Well-being, restorative practice and trauma-informed practice as core models within our practice framework. This reinforces the importance of understanding the whole child and ensuring that key aspects of their identity, lived experience and expressed wishes are accurately captured and consistently reflected in planning and intervention. Practitioners are clear about their responsibility to record relevant personal information that supports respectful and effective engagement, including how a child wishes to be addressed and understood. Within Targeted Early Help, this approach is embedded through direct work with children and young people that is relational, respectful and attuned to identity. Practitioners are expected to create safe, trusting environments where young people feel able to express their views about who they are, including any aspects of gender identity or how they wish to be addressed. Where a young person shares information about preferred pronouns or gender identity, practitioners respond sensitively and without assumption, recognising that this may be an important part of their sense of self and wellbeing. this information clearly within Practitioners record the Early Help assessment and ongoing case notes where it is relevant to supporting the young person effectively. This ensures that communication is respectful and consistent across professionals, reducing the risk of misunderstanding or disengagement. At the same time, practitioners are supported through supervision and guidance these conversations with to approach professional curiosity and care, recognising that identity can be fluid and that young people may be exploring or uncertain. The focus is therefore on listening, acknowledging and responding appropriately, rather than categorising or making premature conclusions. Where issues of gender identity intersect with other vulnerabilities such as mental health, emotional distress or family dynamics Targeted Early Help practitioners ensure that this is understood within the broader context of the young person’s lived experience. This informs proportionate planning, the identification of appropriate support, and, where necessary, liaison with specialist services. Supervision plays a key role in supporting practitioners to navigate these areas thoughtfully, ensuring that practice remains respectful, evidence-informed and centred on the young person’s welfare. Taken together, these developments mean that current practice is strong, consistent and child centred. Recording is clear and reliable, professional discussions are visible and inform decision-making, and the child’s identity including their expressed preferences is understood and incorporated into planning. Oversight arrangements provide greater assurance that standards are being applied consistently, and that any gaps are identified and addressed. 5. OF DETAILS PROPOSED Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. FURTHER ACTION Further action is planned through Barnsley’s social care reform and Families First programme. Barnsley has agreed the move towards a preventative, conversational Integrated Front Door model, developed with partners across health, police and education. The model will prioritise professional conversations as the main route for triage and decision-making, with MASH- style safeguarding checks retained where risk is high or unclear. Its purpose is to improve information sharing at first contact, reduce unnecessary hand- offs, support more proportionate decisions and create a clearer single pathway between Family Help, Targeted Early Help, CAMHS and statutory safeguarding. Implementation is planned through phased test-and-learn activity during 2026/27, with the model due to be operational by March 2027. There is a planned rollout of Mental Health First Aid training for all Targeted Early Help staff in August 2026 which is part of a wider service update and practice refresh, ensuring that workforce development keeps pace with the increasing complexity and prevalence of emotional wellbeing needs among children and families. This training will strengthen practitioners’ confidence, competence and consistency in recognising and responding to emotional distress, self-harm and suicide risk, providing them with a clear, evidence- informed framework for early identification and appropriate intervention. For practitioners, this offers practical tools, a shared language across the service, and greater assurance in decision-making, reducing uncertainty and reliance on escalation where earlier help may be more effective. In turn, families will benefit from more timely, skilled and compassionate responses, with practitioners better able to build trusting relationships, offer immediate support, and safely navigate pathways into specialist services where required. Collectively, this enhances the quality of early help, promotes resilience, and contributes to improved outcomes through earlier, more confident and coordinated responses to mental health need. 6. SIGNATURE Carly Speechley, Executive Director – Children’s Services
RESPONSE TO A REPORT TO PREVENT FUTURE DEATHS REGULATION 29 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). THIS RESPONSE IS BEING SENT TO: The Senior Coroner, Mrs Tanyka Rawden for the Coroner Area South Yorkshire (West) in response to a REPORT TO PREVENT FUTURE DEATH REGULATION 28, made by Hannah Berry, Assistant Coroner following an inquest into the death of Willow Lee aka Ollie Lee that concluded on 8 May 2026. 1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Barnsley Metropolitan Borough Council Children’s Services provides this response within 56 days of the date of the Report to Prevent Future Deaths. 2. 3. DATE OF RESPONSE 22nd June 2026 CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN identified in the report are as follows: 1) Poor communication and engagement between the agencies involved with the child, including school, CAMHS and Targeted Early Help. 2) A lack of communication and engagement between Targeted Early Help and CAMHS despite both agencies being aware that the other was involved. This led to a confusing picture and a missed opportunity for the child to remain open to CAMHS and receive psychosocial intervention and continued support. 3) There was no record of important discussions between Early Help and the school, and relevant personal information, including the child’s preference in relation to pronouns, was not acted upon. 4. DETAILS OF ACTION TAKEN, how has the concern been addressed. Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. Response to Concern 1: Poor communication and engagement between the agencies involved with the child, including school, CAMHS and Targeted Early Help Since 2024, Children’s Social Care has continued to strengthen multi- agency working as part of our continuous approach to service development, with a clear focus on ensuring communication is proactive, purposeful and embedded in day-to-day practice rather than episodic or reactive. This is underpinned by an expectation that practitioners make early and active contact with partner agencies, including schools and CAMHS, to develop a shared and coherent understanding of children’s needs, risks and protective factors at the earliest opportunity. Within Targeted Early Help, communication with schools has been further strengthened through the introduction of named link workers for each school across the whole of Barnsley, which has created clear and accessible points of contact and a more consistent professional relationship. This has been complemented by more structured consultation opportunities, enabling school staff to routinely seek advice from Targeted Early Help practitioners at the earliest sign of concern. In practice, this means emerging issues relating to attendance, emotional wellbeing or family stressors are shared earlier, discussed jointly and responded to through coordinated planning, reducing delay and preventing escalation. In parallel, communication with CAMHS has developed through a more integrated and coordinated approach to emotional health and wellbeing. Targeted Early Help practitioners are now more consistently involved in multi-agency discussions where children present with mental health needs, ensuring that information from CAMHS is understood within the wider family and environmental context. This has been supported by clearer pathways between Early Help and CAMHS, including improved referral processes, more timely information sharing following assessments, and joint planning where children meet thresholds for both services. As a result, practitioners are better able to align interventions, reduce duplication and ensure that support provided to children and families is complementary rather than fragmented. improvements are reinforced through our updated practice These standards, which explicitly require practitioners to gather and triangulate information from across the professional network, including education and health partners, rather than relying on a single service perspective. This expectation strengthens professional curiosity and ensures that assessments reflect a comprehensive and multi-agency understanding of the child’s lived experience. Our practitioner supervision arrangements provide consistent management oversight of communication, managers routinely check that contact with key partners, including schools and CAMHS, has taken place, that information has been followed up and that actions are clearly recorded and progressed. This ensures that communication is not only expected but evidenced, and that any gaps or delay in information sharing are identified and addressed promptly. training Practitioner capability has also been strengthened through targeted training and development. Staff across Targeted Early Help and Children’s Social Care have undertaken focused on multi-agency working, information sharing, professional curiosity and contextual safeguarding. This includes reinforcing expectations around engaging with education and health partners, understanding thresholds for CAMHS involvement, and contributing effectively to multi-agency meetings. This training supports practitioners to communicate with confidence, understand the roles of partner agencies and ensure is shared clearly, that appropriately and in a timely way. information At a system level, Barnsley’s Multi-Agency Safeguarding Arrangements (MASA) (updated April 2026) provide the framework that underpins this practice, setting clear expectations for timely information sharing, joint working and collective decision-making across all partners. The MASA arrangements roles and responsibilities between agencies, including education and health, and by supporting effective escalation and professional challenge where communication is not timely or effective. strengthen accountability by defining In addition, service developments such as the move towards a more conversational Integrated Front Door and the alignment with the Families First Partnership model will continue to reinforce the importance of direct dialogue between practitioners across agencies. These developments prioritise real-time information sharing and joint problem-solving, ensuring that schools, CAMHS and Targeted Early Help are part of a coordinated response from the outset of involvement. Overall, these combined practice expectations, management oversight, system frameworks and workforce developments provide assurance that communication between Targeted Early Help, schools and CAMHS is more consistent, purposeful and effective. This reduces the risk of fragmented information, strengthens shared understanding and supports earlier, more coordinated intervention for children and families. Response to Concern 2: Lack of communication and engagement between Targeted Early Help and CAMHS, despite both agencies being aware of involvement Our current arrangements set a clear expectation that communication between practitioners is active, timely, and accountable. Practitioners are expected to make direct contact, be clear about why it is needed, and ensure that children known to more than one service are not supported through separate or disconnected activity. At the point involvement begins, where a Targeted Early Help practitioner identifies CAMHS involvement direct contact takes place at the earliest opportunity. This does not rely on records alone or on assumptions that another service already holds the full picture. In most cases, this means a same-day phone call or secure email to the practitioner who knows the child. That contact is used to confirm current involvement, understand the child’s presentation, clarify risk, and identify any active intervention. The outcome is recorded clearly, including agreed actions and any differences in professional view. Where CAMHS are actively involved with the child they are invited to family network meetings, child in need meetings, strategy discussions, child protection activity, or other relevant consultations The right practitioner is identified so that contributions are based on direct knowledge, and where this does not happen, practitioners are expected to follow up and escalate. Communication is not treated as a one-off event. It forms part of routine case coordination, with updates shared when risk changes, plans understood across services, and clarity maintained about who is leading each part of the response. This is particularly important where emotional wellbeing, safeguarding, and family support overlap. We recognise that supervision is central to ensuring this happens consistently. Managers check whether contact with CAMHS or other relevant agencies has been made, whether their current assessment and plan are understood, and whether this is properly reflected in the assessment of risk and need. Communication is therefore reviewed and challenged rather than assumed. Where there is drift, limited engagement, or lack of clarity, practitioners use escalation routes. This may include discussion between managers, use of professional resolution processes, or escalation through safeguarding partnership arrangements, with the aim of avoiding delay and resolving issues quickly. These expectations are reflected in current case management guidance. Practitioners are required to establish contact with key services at the start of involvement, clarify roles, gather information directly, and maintain communication throughout ongoing coordination. This reinforces active professional curiosity, clear information gathering, and purposeful oversight. Practice standards, supervision frameworks, and quality assurance activity reinforce the same expectations. Audit work tests whether there is clear evidence of multi-agency contact, role clarity, and recorded communication between services. Where this is not evident, the response includes management oversight, reflective supervision, and feedback into team learning and wider partnership discussion. Communication routes with CAMHS are including expectations about involvement in safeguarding processes, participation in professional discussions, and ensuring that the practitioner with direct knowledge of the child is involved. This reduces the risk of parallel working and makes it more likely that shared concerns are translated into shared action. therefore clear, Management oversight is equally explicit. Team managers check whether contact with relevant agencies has taken place, whether follow-up actions are recorded clearly, and whether safeguarding or wellbeing actions are progressing within the right timescales. Where multi-agency engagement is not evident, supervision records challenge and escalation. Where concerns are urgent, follow-up action happens quickly. High-priority actions are progressed within set timescales and with active management oversight. Compliance is monitored through case tracking and supervision so that critical safeguarding actions are not delayed. This will be strengthened further through planned CAMHS co-location within the Integrated Front Door during 2026 to 2027. This will support earlier shared discussion, faster information exchange, and better visibility of children whose needs sit across both emotional health and safeguarding systems. Taken together, this approach reduces parallel working, prevents partial understanding of a child’s circumstances, and supports earlier alignment of plans where mental health needs and safeguarding concerns exist at the same time. Expectations are clear, management oversight is explicit, audit activity tests practice directly, and wider system design supports agencies to work together earlier and more effectively. Response to Concern 3: No record of important discussions and relevant personal information, including pronoun preference, was not acted upon Our Practice Standards and case management guidance set clear expectations that all significant events—including professional discussions, key contacts, decisions, actions and the reasons for them—are recorded promptly, accurately and proportionately. This promotes more consistent recording and ensures that key information is clearly captured in the child’s record, accessible to managers and partners, and able to inform ongoing assessment and decision-making. Practice is not reliant on informal communication or individual recollection; there is a structured and transparent record that supports continuity, particularly in complex cases involving emotional distress, self-harm or changing risk. Management oversight is exercised through both formal supervision and day-to-day operational case discussions, providing regular scrutiny of the quality and timeliness of recording and decision-making. Managers review actions, address gaps and ensure that recording reflects the lived experience of the child. Actions arising from supervision or broader case oversight are specific, outcome-focused and linked to identified risks, with clear timescales for completion. Urgent actions are prioritised and progressed within 72 hours. Managers track these actions and escalate where necessary to maintain oversight and ensure that recording remains timely, accurate and complete. There has been a sustained focus on practice development, underpinned by training for all staff in Signs of Well-being, restorative practice and trauma-informed practice as core models within our practice framework. This reinforces the importance of understanding the whole child and ensuring that key aspects of their identity, lived experience and expressed wishes are accurately captured and consistently reflected in planning and intervention. Practitioners are clear about their responsibility to record relevant personal information that supports respectful and effective engagement, including how a child wishes to be addressed and understood. Within Targeted Early Help, this approach is embedded through direct work with children and young people that is relational, respectful and attuned to identity. Practitioners are expected to create safe, trusting environments where young people feel able to express their views about who they are, including any aspects of gender identity or how they wish to be addressed. Where a young person shares information about preferred pronouns or gender identity, practitioners respond sensitively and without assumption, recognising that this may be an important part of their sense of self and wellbeing. this information clearly within Practitioners record the Early Help assessment and ongoing case notes where it is relevant to supporting the young person effectively. This ensures that communication is respectful and consistent across professionals, reducing the risk of misunderstanding or disengagement. At the same time, practitioners are supported through supervision and guidance these conversations with to approach professional curiosity and care, recognising that identity can be fluid and that young people may be exploring or uncertain. The focus is therefore on listening, acknowledging and responding appropriately, rather than categorising or making premature conclusions. Where issues of gender identity intersect with other vulnerabilities such as mental health, emotional distress or family dynamics Targeted Early Help practitioners ensure that this is understood within the broader context of the young person’s lived experience. This informs proportionate planning, the identification of appropriate support, and, where necessary, liaison with specialist services. Supervision plays a key role in supporting practitioners to navigate these areas thoughtfully, ensuring that practice remains respectful, evidence-informed and centred on the young person’s welfare. Taken together, these developments mean that current practice is strong, consistent and child centred. Recording is clear and reliable, professional discussions are visible and inform decision-making, and the child’s identity including their expressed preferences is understood and incorporated into planning. Oversight arrangements provide greater assurance that standards are being applied consistently, and that any gaps are identified and addressed. 5. OF DETAILS PROPOSED Please note that any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. FURTHER ACTION Further action is planned through Barnsley’s social care reform and Families First programme. Barnsley has agreed the move towards a preventative, conversational Integrated Front Door model, developed with partners across health, police and education. The model will prioritise professional conversations as the main route for triage and decision-making, with MASH- style safeguarding checks retained where risk is high or unclear. Its purpose is to improve information sharing at first contact, reduce unnecessary hand- offs, support more proportionate decisions and create a clearer single pathway between Family Help, Targeted Early Help, CAMHS and statutory safeguarding. Implementation is planned through phased test-and-learn activity during 2026/27, with the model due to be operational by March 2027. There is a planned rollout of Mental Health First Aid training for all Targeted Early Help staff in August 2026 which is part of a wider service update and practice refresh, ensuring that workforce development keeps pace with the increasing complexity and prevalence of emotional wellbeing needs among children and families. This training will strengthen practitioners’ confidence, competence and consistency in recognising and responding to emotional distress, self-harm and suicide risk, providing them with a clear, evidence- informed framework for early identification and appropriate intervention. For practitioners, this offers practical tools, a shared language across the service, and greater assurance in decision-making, reducing uncertainty and reliance on escalation where earlier help may be more effective. In turn, families will benefit from more timely, skilled and compassionate responses, with practitioners better able to build trusting relationships, offer immediate support, and safely navigate pathways into specialist services where required. Collectively, this enhances the quality of early help, promotes resilience, and contributes to improved outcomes through earlier, more confident and coordinated responses to mental health need. 6. SIGNATURE , Executive Director – Children’s Services
3rd July 2026 South West Yorkshire Partnership NHS
Teaching Foundation Trust
Fieldhead Hospital
Block 7
Ouchthorpe Lane
Wakefield
WF1 3SP
Ms Hannah Berry
HM Assistant Coroner, Yorkshire South West
Medico-Legal Centre
Watery Street
Sheffield
S3 7ES
Dear Ma’am,
Regulation 28 Response – Ollie Lee
We write in response to the Regulation 28 report following the inquest touching the death of
Ollie Lee. We would like to start this response by offering Ollie’s family our sincere
condolences for their loss.
We hope the information in this response provides assurance that the Trust has carefully
considered the concerns of relevance to the Trust. You heard oral evidence in respect of the
Trust’s learning following Ollie’s death, and this information is also repeated in our response
below.
The Trust has a Patient Safety Incident Response Framework (PSIRF) policy with
overarching systems and processes to learn and to improve care and services following
notifiable patient safety incidents. This includes a Trust Patient Safety Oversight Group
(PSOG) and a Children and Young Peoples Mental Health Service (CYMPHS) Patient
Safety Oversight Group (PSOG), which provide organisational and operational oversight of
the Trust’s response to incidents and any associated learning.
Following the death of Olllie, a review of Ollie’s electronic patient records, also known as a
case note review, was undertaken by the General Manager of the Barnsley Child and
Adolescent Mental Health Service (CAMHS). The case note review was presented to, and
subsequently approved by, the CYPMHS PSOG on 12 November 2024.
1
The case note review identified areas of learning local to Barnsley CAMHS, including
Information Sharing and Multi Agency Discharge Planning; the clinical quality of the Risk
Assessment for Non-Engagement form (RANE); and the associated discharge processes.
The local actions were completed by June 2025
A Patient Safety Improvement Plan to address the system-based learning was developed
and overseen by the CYPMHS PSOG. The Patient Safety Improvement Plan focused on
embedding the use of the clinical frameworks that are in place within the Trust to support
practice, including: Capturing the Childs Voice; the Consent to Care, Treatment &
Discharge tool and Engagement & Communication of Care; and Crisis, Discharge Planning
and Risk Assessment. The completion of the Patient Safety Improvement Plan actions was
approved by the CYPMHS PSOG in October 2025.
On receipt and review of the Regulation 28 report, it is noted that the concerns raised, as set
out below, were consistent with learning identified in the Trust’s case note review approved
by the CYPMHS PSOG in October 2025 and the learning presented at Ollie’s inquest. The
learning from the case note review, and other relevant systems or processes across
CAMHS, has been detailed below against the concerns raised in the Regulation 28 report.
Additionally, multi-agency communications have taken place since the conclusion of Ollie’s
inquest, and these too are detailed below.
1. Poor communication and engagement between the agencies involved with Ollie
including her school, CAMHS and targeted early help.
Branching Minds is the single point of contact for emotional help and wellbeing support
and is co-delivered by CAMHS and ‘Compass Be’ who are the Mental Health Support
Team in Schools (MHST) commissioned provider for Barnsley. CAMHS developed crisis
guidance for schools in June 2024 which described clinically appropriate approaches
when supporting children and young people in times of distress. School staff were
encouraged to utilise their ‘Compass Be’ senior practitioners for discussion and learning
in the once per term link sessions held at their schools. The crisis guidance specified
how to access support at the point of crisis and how children and young people and
parents/carers can self-refer to Branching Minds.
Having identified local learning from the case note review related to multi-agency
communication and engagement, on 4 April 2025, training was provided to Barnsley
CAMHS by the Trust Safeguarding Children Team on Information Sharing and Multi-
Agency Working. The purpose of the training was to reinforce the importance of multi-
agency working and information sharing to promote best practice. The Trust also has a
Safeguarding toolkit which supports clinical staff on a range of practice areas including
information sharing, and quality and accuracy of documentation.
2
The Trust’s ‘Did not attend/was not brought/no access visits policy’ reiterates that ‘Was
Not Brought’ is a term used instead of ‘Did Not Attend’ because it encourages
professionals to think about the situation from the child or patient perspective and
potentially take action, including the consideration of any safeguarding concerns. The
policy advises that communication with all relevant and involved agencies with the child
or young person must take place to ensure that information and decisions are shared in
a timely way, subject to considerations of patient confidentiality. Additionally, the policy
advises that clinicians should exercise professional curiosity, make reasonable attempts
to establish face to face contact, and consider reasonable adjustments to support
engagement.
As noted above, there are a range of clinical tools and frameworks in place within the
Trust to support communication and engagement including, for example the Consent to
Care, Treatment & Discharge tool that documents discussions related to confidentiality
and consent to share information during the child or young person’s care with CAMHS;
and the Risk Assessment for Non-Engagement form (RANE), which can be used when
children, young people and families have declined to engage with Trust CAMHS and
which documents a rationale regarding sharing of risks with and any follow up required
from other agencies.
2. A lack of communication and engagement between targeted early help and
CAMHS despite both agencies being aware that the other was involved. This led to
a confusing picture and a missed opportunity for Ollie to remain open to CAMHS
and receive psychosocial intervention and continued support from CAMHS.
Having identified learning related to multi agency communication and engagement in the
case note review, on 28 January 2025 the Branching Minds Clinical Lead delivered
training to Targeted Early Help Practitioners, who are children’s social care employees,
in relation to the CAMHS referral process and access to mental health support for
children and young people. The purpose of the training was to reinforce the multi-agency
arrangements and set a clear expectation that communication between practitioners is
active, timely, and accountable. This training is scheduled to be repeated in August
2026. In recognition of potential staff turnover within children’s social care, the Trust will
be providing these training sessions annually, supported by additional sessions to be
arranged at the request of social care services.
Additionally, and whilst not an action taken by the Trust, we are aware that on 12
February 2025 the Team Leaders for ‘Compass Be’ Mental Health Support Teams in
Schools – MHST) delivered training to Integrated Front Door staff (children’s social care
employees and first point of contact for children’s social care) in relation to referral
process and access to mental health support for children and young people. The
purpose of the training was to reinforce the multi-agency arrangements and set a clear
expectation that communication between practitioners is active, timely, and accountable.
The Trust are not responsible for the MHST training provision as this responsibility sits
with the commissioned provider of that service.
3
Future and on-going multi-agency communication and learning
Following Ollie’s inquest, on 4 June 2026, a multi-agency meeting was held between senior
leaders from the Trust, Barnsley Metropolitan Borough Council (BMBC) Children’s Social
Care, and Barnsley Academy. The purpose of the meeting was to hold an open discussion
regarding the concerns raised in the Regulation 28 report and to consider how the partners
could continue to work together towards developing shared improvement actions.
Subsequent to this meeting, a proposal was made and accepted by the Partnership Board
for the respective learning identified by the Trust, BMBC and Barnsley Academy to be
shared amongst the partner agencies in order to coordinate and formulate any multi-agency
pathway developments.
On 8 June 2026, the General Manager for Barnsley CAMHS met with the Service Manager
for the Targeted Early Help Service (TEHS) to explore opportunities for improving joint
working and strengthening timely and effective information sharing between services. To
further improve communication between CAMHS and TEHS, three key actions were agreed
for initial implementation:
• Daily briefing attendance
A representative from the Targeted Early Help Service will join the existing daily
briefing at Branching Minds. This will enable TEHS to share relevant information
about children and young people (CYP) known to their service and facilitate timely
consultation with the crisis team where required.
• Fortnightly case review meeting
An initial fortnightly meeting will be established between CAMHS and TEHS,
attended by a CAMHS Team Manager and a TEHS Team Manager, to review cases
awaiting allocation or intervention. This will support information sharing and identify
opportunities for coordinated or joint working.
• Bi-monthly strategic review
The TEHS Service Manager and the CAMHS General Manager will meet on a bi-
monthly basis to review progress, evaluate the effectiveness of joint working
arrangements, and consider the development of a Memorandum of Understanding
(MoU). This will be informed by learning from these initial actions.
All children’s services, including CAMHS, are involved in the broader Children’s Reform
Agenda, which is a comprehensive plan aimed at transforming children’s social care and
child protection policy, with a focus on improving multi-agency collaboration and enabling
earlier, more effective support for children and families. BMBC are the lead agency of the
wider Barnsley children’s services response to the Children’s Reform Agenda, and the Trust
are committed to supporting the multi-agency response to the Children’s Reform Agenda.
We understand BMBC have included a number of the initiatives, or proposed plans, in their
response to the Regulation 28 report.
4
Finally, in April 2026, the Children’s Wellbeing and Schools Act 2026 received royal assent,
and this includes the statutory duty for partner agencies to share information relevant to
safeguarding and promoting the wellbeing of children and young persons. This statutory duty
is intended to apply from September 2026 and national guidance to support its
implementation is in a consultation process. We are currently considering this within the
Trust and with partner agencies to ensure a collaborative and robust response to the
information sharing provisions of the Children’s Wellbeing and Schools Act 2026.
We hope that this response emphasise our continued commitments to learning and working
with partner agencies to ensure robust care and treatment for all children and young persons
that come into contact with our services.
We do hope the above information is of assistance and answers the concerns raised within
your Regulation 28 report following the sad death of Ollie Lee.
Yours sincerely,
Chief Medical Officer
Chief Nurse / Director of Quality & Professions
5
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