Natasha Hill

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THIS RESPONSE IS BEING SENT TO: 

The Senior Coroner, Dr Julian Morris, for the Coroner Area of London Inner 
South in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ 
following an inquest into the death of Natasha Hill that concluded on Friday 1 May, 
2026. 

1. 

RESPONDENT 

In line with our duty under Regulation 29 of the Coroners (Investigations) 
Regulations 2013, The Secretary of State for Education provides this 
response within 56 days (plus any extension granted) of the date of the 
Report to Prevent Future Deaths. 

2. 

 17 July 2026 

3.  CONFIRMATION OF CORONER’S MATTERS OF CONCERN 

The MATTERS OF CONCERN identified in the report are as follows: 

1.  Anyone requiring/ needing/suffering 

o  Safeguarding 
o  Domestic violence 
o  Controlling/ coercive behaviour 

         And incurring the consequential risks, as a teenager approaching 18  

should be formally reviewed by an adult safeguarding team and the 
independent reviewing officer. 

2.  Thought should be given to creating a young person’s team covering the 
transition from under 18 (MACE) to adult safeguarding teams e.g. For 
the period 18-22. 

3.  Thought should be given to a young person's protection by way of 

creation of an extension to the CAWN for the young person, against the 
adult creating that safeguarding risk e.g. young person's abuse warning 
notice.  

4.  The creation of one single national policy for policing and child sexual 
exploitation following the groundwork laid down by Operation Hydrant 
and local Forces. 

5.  Re safeguarding offender management, the use of VOO's and the 

creation of POETs/ DAPST and RMUs: Consideration should be given to 
the creation of one set of criteria with one name whose role it is to cover 
and create a central guidance. 

6.  To consider the wider dissemination of existing local protocols nationally, 

for example the London Exploitation Protocol. 

7.  The provision of guidance in respect of missing persons/ runaways and 
the return to home interviews to assist the actions of the police and local 
councils. 

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DETAILS OF ACTIONS TAKEN, CURRENT ACTIONS, AND PLANNED 
ACTIONS: 

3. 

Matter of Concern 1: 
•  This government is supporting vulnerable children and their families, 

including those where domestic abuse is a factor, by intervening at the 
earliest opportunity through the Families First Partnership programme. 
Through this programme, which is supported by £2.4bn over the next three 
years, community based multi-disciplinary Family Help and multi-agency 
child protection teams are being introduced to  help, support and protect 
children and their families.  

•  For young people approaching adulthood who are experiencing, or are at 
risk of, harm, including domestic abuse and/or controlling or coercive 
behaviour, their ongoing needs and risks should be formally reviewed 
before they reach 18, in line with statutory safeguarding guidance Working 
Together to Safeguard Children and the principles of transitional 
safeguarding. 

•  This review should include both children’s and adult services, the child, 
parents/carers, and family network as appropriate, and the Independent 
Reviewing Officer for children who are looked after.   

•  This will support a coordinated transition to adult services, ensure that 

identified risks are appropriately managed, and young people are able to 
move safely into adulthood. 

Actions taken: 

•  The Department for Health and Social Care (DHSC) published an 

independent Bridging the Gap briefing setting out the importance of 
transitional safeguarding within adult social work in 2021. This briefing 
focuses on safeguarding young people journeying from adolescence into 
adulthood, particularly on sexual and criminal exploitation, to help 
prevent instances of sexual exploitation in adulthood.  

Current Actions: 

•  The National Adult Safeguarding Board will be conducting an urgent review 
of adult safeguarding powers and duties.  The first part of that work will be 
to consult on updating the safeguarding chapter of Care and support 
statutory guidance (CASSG). As part of this update, we will consider what 
guidance can be provided to strengthen safeguarding in the context of the 
transition of young people to adult services. In that process we will take the 
learning from this PFD report and consider the recommendation that when 
a teenager with care and support needs approaches 18 they should be 
reviewed formally by an adult safeguarding team and the independent 
reviewing officer.   
In March 2026, DHSC launched an 11-month project, with the Department 
for Education (DfE), Social Care Institute for Excellence (SCIE) and Skills 
for Care (SfC) to develop practical materials to improve transitions into 
adult social care. The project will deliver a set of best practice principles for 
good transitions, together with bespoke training materials for social workers 
and social care leaders to help ensure they have the knowledge and tools 

• 

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to provide high-quality support to young people as they transition into 
adulthood. Evidence to support best practice in relation to transitional 
safeguarding will be considered as part of this project, as well as the 
actions that we can take to make tangible improvements in this area. 

DETAILS OF ACTIONS TAKEN, CURRENT ACTIONS, AND PLANNED 
ACTIONS: 

Matter of Concern 2: 

•  The Families First Partnership (FFP) programme guide details expectations 
of local areas and safeguarding partners. This includes the expectation that 
local areas have an operational integrated front door, where contacts and 
referrals can be triaged to the right level of service; ensure front door 
alignment with multi-agency child protection teams (MACPTs) and wider 
local arrangements; and consider and set out the MACPT’s role in 
supporting transitions out of child protection. This can include interactions 
with Multi-Agency Child Exploitation (MACE) and transitions into adult 
safeguarding teams. 

•  As government continues to make significant reforms to children’s social 

care, including through the Children’s Wellbeing and Schools Act 2026, we 
are consulting on updating the statutory framework for help, support and 
protection for children and their families. This will inform revisions to 
Working Together to Safeguard Children 2026 (Working Together), the 
Children’s Social Care National Framework 2026 (the National Framework) 
statutory guidance, and policy that will underpin the development of the 
MACPT regulations.  

•  The consultation launched on 22 June and will run until 4 September. We 

propose substantive changes to Working Together, including on: 
accountability of multi-agency safeguarding arrangements and the role of 
the Local Authority Designated Officer (LADO); MACPTs; the delivery of 
Family Help and earlier, more joined-up support for families; family 
networks and family group decision making; a strengthened response to 
extra-familial harm; child protection for looked-after children; and 
responding to potential for extreme violence.  

•  MACPTs oversee the development, review, and closure of Child Protection 

Plans and transitions out of child protection for children at risk of or 
suffering significant harm. We are also further clarifying how these 
processes apply to looked after children. 

Care leavers  

•  The Department is currently undertaking a review of care leaver deaths, as 
announced in Spring 2026, which is expected to consider safeguarding-
related issues and identify any relevant themes or lessons. We will use the 
findings from this work to inform future policy development and operational 
practice, including consideration of whether additional safeguarding 
arrangements or dedicated structures for adults should be introduced. 

•  More broadly, we are already strengthening support for care leavers 

through the Children’s Wellbeing and Schools Act (2026), including a new 
duty on local authorities to provide Staying Close support up to age 25. 

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Insights from the review will help inform how we continue to develop and 
improve support for care leavers’ safety, wellbeing and access to services. 

DETAILS OF ACTIONS TAKEN, CURRENT ACTIONS, AND PLANNED 
ACTIONS: 

Matter of Concern 6: 

•  Keeping children safe, both inside and outside the home, is a key pillar in 
this government’s mission to break down barriers to opportunity. This is 
reflected in the Children’s Social Care National Framework.  

•  Our Families First Partnership Programme, backed by over £2.4 billion 

funding, and Children’s Wellbeing and Schools Act 2026 are rolling out the 
biggest reforms in a generation to family help and multi-agency child 
protection. 

•  Children who are experiencing, or likely to experience, significant harm 
outside the home should receive a child protection response, as set out 
in Working Together to Safeguard Children 2026. 

•  Working Together 2026 is also clear that known transition points for a child 
should be planned for in advance, including where children are likely to 
transition between child and adult services. 

•  There is further work to update Working Together to ensure consistent 

identification of and responses to significant harm under section 47 of the 
Children Act 1989 (inside and outside the home, and online); and for 
MACPTs to oversee the development, review, and closure of Child 
Protection Plans and transitions out of child protection for children at risk of 
or suffering significant harm. This includes further clarification of how these 
processes are applied for looked after children.  

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DETAILS OF ACTIONS TAKEN, CURRENT ACTIONS, AND PLANNED 
ACTIONS: 

Matter of Concern 7: 

•  DfE's Statutory guidance on children who run away or go missing from 

home or care' (2014) outlines local authorities' responsibilities to all missing 
children, including their duty to report all incidences of children going 
missing from care to the DfE in annual data collections. 

•  The statutory guidance requires local authorities to share that information 
locally in a multi-agency forum to prevent all children from going missing.  
•  We expect statutory safeguarding partners to work together to reduce the 

chances of children going missing, to respond effectively when they do and 
understand why. 

•  When a child is found, they must be offered an independent return 

interview (Return Home Interview - RHI) and local authorities, police and 
voluntary services should also work together to build a comprehensive 
picture of why the child went missing and to understand what support they 
may need in the future to prevent them from going missing again. 

•  As government continues to make significant reforms to children’s social 

care, including through the Children’s Wellbeing and Schools Act 2026, we 
are consulting on updating the statutory framework for help, support and 
protection for children and their families. This will inform revisions to 
Working Together to Safeguard Children 2026 (Working Together), the 
Children’s Social Care National Framework 2026 (the National Framework) 
statutory guidance, and policy that will underpin the development of the 
Multi-Agency Child Protection Team regulations (MACPT regulations).  
•  The consultation launched on 22 June and will run until 4 September. We 

propose substantive changes to Working Together, including on: 
accountability of multi-agency safeguarding arrangements and the role of 
the LADO; multi-agency child protection teams (MACPTs); the delivery of 
Family Help and earlier more joined up support for families; family networks 
and family group decision making; a strengthened response to extra-familial 
harm; child protection for looked-after children; and, responding to potential 
for extreme violence.  

•  MACPTs oversee the development, review, and closure of Child Protection 

Plans and transitions out of child protection for children at risk of or 
suffering significant harm. 

•  The Department for Education, working with colleagues across government, 
will be updating the content of the guidance for children who go missing 
from home or care. We will be working closely with a wide range of 
operational partners and sector stakeholders as part of this process, 
including on the format for this guidance, to ensure a robust multi-agency 
response to missing children. 

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4.  DETAILS OF FURTHER ACTION PROPOSED 

See responses above. 

Signed: 

  Secretary of State for Education   

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Minister of State for Policing and 
Crime 

2 Marsham Street 
London SW1P 4DF 
www.gov.uk/home-office 

July 2026 

His Majesty’s Coroner Dr Julian Morris 
London Inner South Coroner’s Court  
London 
SE1 1YD 

Dear Dr Morris,  

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

Thank you for your Report to Prevent Future Deaths on 1 May 2026 regarding the unlawful 
killing of Natasha Hill. I would like to start by extending my deepest condolences to 
Natasha Hill’s family and loved ones for their devastating loss. 

Tackling domestic abuse, child sexual exploitation and abuse and violence against women 
and girls (VAWG) is a top priority for this government and we will treat it as the national 
emergency that it is. We are working to deliver a cross-government transformative 
approach to halve VAWG in a decade, underpinned by the new VAWG Strategy. 

Thank you for your conduct of the inquest, and your identification of a number of matters of 
concern, which are set out in the Report. The safeguarding gaps you have identified are 
important and I am clear that lessons must be learned across Government and beyond. 

The Home Office’s response to your Report focuses on three matters of concern raised, 
specifically concerns 3, 4 and 5.  

Matter of concern 3 
Thought should be given to the creation of a young person's protection by way of creation 
of an extension to the CAWN for the young person, against the adult creating that 
safeguarding risk e.g. young person's abuse warning notice.  

Child Abduction Warning Notices (CAWNs) are a non-statutory tool available to the police 
to warn suspects that they may be prosecuted, if they persist, for a child abduction offence 
when there is not enough evidence that a criminal offence is being committed.  

CAWNs can be issued by the police to disrupt contact between any potential abductor 
over the criminal age of responsibility and a child under the age of 16 (the Child Abduction 
Act 1984), or under 18 years if they are under local authority care (the Children Act 1989). 
College of Policing guidance requires forces to keep CAWNs under regular review, with a 
review process scheduled no later than six months after the notice is issued, and decisions 
on retention or removal taken in line with the Authorised Professional Practice. 

Police have a number of powers and tools at their disposal to prevent, disrupt and 
prosecute child exploitation. CAWNs are one of these tools, but a range of other powers 
are available to officers, depending on the circumstances in the case, and they are set out 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 in the Home Office’s Child Exploitation Disruption Toolkit [See more here: 
https://www.gov.uk/government/publications/child-exploitation-disruption-toolkit]. 

The Child Exploitation Disruption Toolkit supports police, social care and other frontline 
partners to use a suite of disruption tools to safeguard children and stop offenders. It 
makes clear that child exploitation cannot be addressed by a single agency working alone, 
and that effective collaboration, particularly around information sharing, is essential to 
protecting children and disrupting offending. We continue to keep this framework under 
review. 

Matter of concern 4 
The creation of one single national policy for policing and child sexual exploitation 
following the groundwork laid down by Operation Hydrant and local Forces. 

The Home Office is working to create a consistent, victim-centred response to child sexual 
exploitation, building on progress to date in strengthening the policing response including 
by the Child Sexual Exploitation (CSE) Taskforce (part of the Hydrant Programme). Below 
is a list of activity underway which seeks to ensure that police are equipped to respond to 
CSE in a consistent manner. 

We are working with national policing partners to strengthen the response to child sexual 
exploitation, including group-based child sexual abuse and exploitation, by supporting 
programmes that improve the policing response across England and Wales. The 
Government has established the national police operation into group-based child sexual 
exploitation and abuse, Operation Beaconport, backed by almost £38 million, to improve 
policing’s ability to investigate group-based offending, ensuring a consistent response 
wherever abuse is reported and better, trauma-informed support for victims and survivors.  

The Government also works closely with the College of Policing to develop and maintain 
its Authorised Professional Practice (APP), which sets out national guidance and clear 
expectations for how forces identify risk, safeguard victims and pursue offenders.  

This year the Home Office is providing £6.1 million in funding to the CSE Taskforce, part of 
the Hydrant Programme, which was established in 2023 to strengthen the policing 
response to child sexual exploitation, including group-based child sexual exploitation and 
abuse. The Taskforce supports police forces through complex investigations, peer 
reviews, training and operational advice, helping to build capability and improve 
investigative practice. It also contributes to the development of national policing guidance 
and training products, including the Authorised Professional Practice (APP). 

In addition, the Taskforce helps to share learning and promote effective multi-agency 
working. Through force reviews, practitioner networks and engagement with safeguarding 
partners, it supports local areas to improve the identification of risk, information sharing, 
offender disruption and the safeguarding of children, recognising that tackling CSE 
requires a coordinated response across agencies. 

The Taskforce works closely with the Home Office funded Tackling Organised Exploitation 
(TOEX) Programme, which uses data and analytics to identify patterns of exploitation, link 
offending across force boundaries, and help police better connect intelligence so that risks 
to children are recognised and acted on more effectively. The Home Office is investing 
£10.7 million in the TOEX Programme in 2026/27. 

The Home Office also funds the National Centre for Violence Against Women and Girls 
and Public Protection (NCVPP), launched in April 2025, to provide national leadership and 
improve professional practice in the policing response to violence against women and 
girls, child sexual abuse and wider public protection offences. The Centre is intended to 
place victims’ experiences at the heart of police investigations, deliver improved training 

 
 
 
 
 
 
 
 
 
 for officers, professionalise public protection work and drive up investigative and 
operational standards across all police forces. 

The Department for Education, in collaboration with the Home Office, are currently 
consulting on whether to amend the government definition and guidance on child sexual 
exploitation, working closely with partners including law enforcement, children’s 
safeguarding and policing. 

Matter of concern 5 
Re safeguarding offender management, the use of VOO's and the creation of POETs/ 
DAPST and RMUs: Consideration should be given to the creation of one set of criteria with 
one name whose role it is to cover and create a central guidance. 

While Protective Order Enforcement Teams (POETs), Domestic Abuse Problem Solving 
Teams (DAPSTs) and Risk Management Units (RMUs) are all distinct operational teams 
within policing and Violent Offender Orders (VOOs) are an important tool, we recognise 
that they should operate as part of a coherent system. The NCVPP helps bring together 
learning, guidance and best practice to improve the consistency and quality of the policing 
response to VAWG and public protection harms. As part of this, the NCVPP is taking 
forward work in a number of areas linked to risk assessment, offender management, 
safeguarding and protection orders including: 

•  Developing updated national guidance on all VAWG protection orders, including 

offender management, breach response and escalation pathways 

•  Supporting work to establish Stalking Protection Order (SPO) intensification sites in 

• 

select police forces 
Improving risk assessment practice by publishing guidance on secondary risk 
assessments and strengthening information sharing arrangements 
•  Strengthening the recording and quality of protection order data by clear 

instructions on entering and maintaining data to police forces 

•  Supporting more joined-up multi-agency working by developing consistent, 

improved and evidence-led MARAC and MATAC arrangements 

Thank you for raising these important issues in your report. I hope this response has been 
helpful in setting out our plans to better safeguard victims and prevent devastating cases 
like this from occurring. 

Very best wishes, 

Minister of State for Policing and Crime

National Police Chiefs’ Council
   50 Broadway
London
SW1H 0BL

HM Senior Coroner Dr Julian Morris
London Inner South
Southwark Coroners Court
1 Tennis Street
London
SE1 1YD

By email to John Thompson, Clerk to the Senior Coroner
(john.thompson@southwark.gov.uk)

27th July 2026

Dear Senior Coroner Morris,

I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 5 of
the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013, in relation to the prevention of future deaths report (dated 01.05.2026) sent via email
for my attention as the NPCC Chair (dated 05.06.2026).

The notice sets out concerns that arose from the information received during the inquest into the death
of Natasha Hill. I am very sorry to read of the circumstances of Natasha’s death. My sympathies are
with her family, friends and colleagues.

Matters of concern have been highlighted below:

 Anyone requiring / needing / suffering

o Safeguarding
o Domestic violence / abuse
o Controlling/ coercive behaviour
And incurring the consequential risks, as a teenager approaching 18 should be formally
reviewed by an adult safeguarding team and the independent reviewing officer.

 Thought should be given to creating a young person’s team covering the transition from under

18 (MACE) to adult safeguarding teams e.g. For the period 18-22.

 Thought should be given to the creation of a young person's protection by way of creation of an
extension to the CAWN for the young person, against the adult creating that safeguarding risk
e.g. young person's abuse warning notice.

 The creation of one single national policy for policing and child sexual exploitation following the

groundwork laid down by Operation Hydrant and local Forces.

 Re safeguarding offender management, the use of VOO's and the creation of POETs/ DAPST
and RMUs: Consideration should be given to the creation of one set of criteria with one name
whose role it is to cover and create a central guidance.

  To consider the wider dissemination of existing local protocols nationally, for example the

London Exploitation Protocol.

 The provision of guidance in respect of missing persons / runaways and the return to home

interviews to assist the actions of the police and local councils.

In formulating this response, the NPCC Hydrant Programme, The Child Sexual Exploitation Taskforce,
and National Centre for Violence Against Women & Girls and Public Protection have been extensively
consulted.

Initially, I thought it would be beneficial to highlight the national Child Protection Framework at the time
of Natasha’s death, before covering more recent developments. During the relevant period, agencies
were operating within the statutory framework established by Working Together to Safeguard Children
2015, which was subsequently revised in July 2018. These arrangements required effective multi-
agency information sharing, coordinated safeguarding planning, child-centred decision making, and
collaborative responses between children's social care, policing, health and education services where
concerns about significant harm existed.

In parallel, the Department for Education's 2017 guidance on Child Sexual Exploitation reinforced that
exploitation is a form of child sexual abuse and highlighted the need to recognise coercion, grooming,
power imbalances and the reality that children may continue to associate with those who are exploiting
them. The guidance also emphasised the importance of professional curiosity, offender disruption and
coordinated multi-agency safeguarding responses.

The circumstances identified within the DHR demonstrate that many nationally recognised indicators of
child sexual exploitation and abuse were present, including a substantial age disparity, repeated
missing episodes, physical injuries, controlling behaviour, isolation from support networks and
continued association with a known violent offender.

The review found that extensive safeguarding activity was undertaken and that agencies recognised
both Natasha's vulnerability and the risk posed by the perpetrator. However, the evidence suggests that
safeguarding arrangements were fragmented rather than integrated. While MACE, MARAC and
MAPPA processes were all engaged, there was limited coordination between these forums and no
single mechanism that retained oversight of the cumulative and escalating risk presented to Natasha.
Viewed against the statutory expectations operating at the time, the principal issue therefore does not
appear to be the absence of safeguarding structures, but rather the effectiveness with which those
structures were connected. The review identifies missed opportunities to share intelligence, coordinate
disruption activity, manage cumulative risk and maintain a unified safeguarding plan around both the
victim and the perpetrator.

The findings also highlight challenges associated with cross-border safeguarding, as Natasha moved
between local authority and policing areas. Existing guidance required cooperation between agencies
where children crossed geographical boundaries, but the review found that these arrangements did not
always operate effectively in practice.

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 Contextual Safeguarding

Although Contextual Safeguarding was not yet fully embedded within statutory guidance during much of
the relevant period, it was already emerging as a significant framework for understanding adolescent
risk. The 2018 revision of Working Together subsequently incorporated references to contextual
safeguarding, recognising that harm may arise in relationships and environments beyond the family
home.

Natasha's experience reflects many features now associated with extra-familial harm: exploitation by an
older adult, abuse within an intimate relationship, repeated missing episodes linked to risk, movement
across geographical locations and overlapping indicators of domestic abuse and child sexual
exploitation. The review therefore provides a powerful example of the type of adolescent vulnerability
that has subsequently informed developments in contextual safeguarding practice.

Transitional Safeguarding

Perhaps the most significant strategic learning from the review relates to transitional safeguarding.
The DHR demonstrates that Natasha's vulnerability did not diminish when she turned 18. Her
experiences of trauma, exploitation, coercive control and domestic abuse continued, yet key child-
focused safeguarding mechanisms reduced or ceased at the point she became an adult. The Child
Abduction Warning Notice expired, children's safeguarding arrangements diminished, and no
equivalent safeguarding framework existed to provide continuity of oversight.

However, it is important to recognise that there was no established statutory framework for transitional
safeguarding in 2017–2018. There was no national requirement for MACE arrangements to continue
beyond 18, no expectation that children's safeguarding processes should automatically extend into
adulthood, and no dedicated transitional safeguarding model for vulnerable young adults. During this
period, transitional safeguarding was still an emerging concept rather than an embedded feature of
policy and practice.

Reflection: If this happened today

If a case with the same horrific circumstances experienced by Natasha presented today, safeguarding
partners would be expected to adopt a fundamentally different approach, recognising that vulnerability,
exploitation and coercive control do not cease when a young person reaches adulthood. Although
transitional safeguarding remains an area of practice development rather than a statutory framework, it
is now widely recognised that safeguarding responses should be driven by vulnerability and risk, not
solely by age.

From a strategic perspective, a young person experiencing child sexual exploitation, domestic abuse,
trauma, repeated missing episodes and care experience would not be expected to simply "age out" of
safeguarding arrangements at 18. Instead, there should be planned continuity of protection, with
transition arrangements commencing well before adulthood and involving children's services,
exploitation specialists, police, health, adult safeguarding and leaving care services. The focus should
be on maintaining oversight of risk, preserving protective relationships and ensuring clear ownership of
safeguarding concerns beyond the child's eighteenth birthday.  However, whilst these arrangements
are expected, there is limited direction within the current statutory guidance Working Together to
Safeguard Children 2026.  Transition is limited to “Known transition points for the child should be

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 planned for in advance. This includes where children are likely to transition between child and adult
services”.   In short, there is no single statutory national transitional safeguarding framework for children
who continue to experience exploitation into early adulthood.

Research in Practice, the Department of Health and Social Care, Social Care Institute for Excellence,
ADASS (Directors of adult social services), Local Government Association and others have collectively
advanced Transitional Safeguarding as an approach to safeguarding young people into adulthood.
Importantly, these organisations describe Transitional Safeguarding as a whole-system approach rather
than a specific service, panel or statutory process.

Current safeguarding practice would also place much greater emphasis on the management and
disruption of perpetrators. Rather than focusing primarily on the behaviour of the victim, agencies would
be expected to coordinate intelligence, utilise available disruption tactics, consider civil and criminal
powers and ensure that offender management and safeguarding arrangements operate as part of a
coherent strategy.

CSE Taskforce Response

Many of the themes identified in the DHR have subsequently informed national improvements in child
exploitation policy and practice. In particular, there has been a sustained shift towards child-centred,
trauma-informed and perpetrator-focused responses, stronger multi-agency coordination, and greater
recognition of contextual safeguarding.

There exists the Tackling Child Exploitation Support Programme and Department for Education’s Multi-
Agency Practice Principles for responding to child exploitation and extra-familial risk and harm (2026)
which promotes a shared partnership understanding of risk, improved information sharing, a welfare-led
approach to children affected by exploitation, and recognition of the need for agencies to work across
age-related boundaries when exploitation continues into adulthood.

Successive editions of Investigating Child Sexual Abuse and Exploitation (CSAE) Practice Advice
(2020, 2023 and 2025) have strengthened national expectations around child-centred investigations,
trauma-informed practice, contextual safeguarding, multi-agency working, victim engagement and
perpetrator disruption. Collectively, these developments have reinforced that exploitation should be
understood as abuse, that vulnerability may persist beyond childhood, and that safeguarding responses
should be informed by cumulative risk rather than individual incidents in isolation.

Alongside this, national disruption guidance and learning produced through the CSE Taskforce, Hydrant
Programme and partners has sought to address one of the key findings of the DHR: the need to move
beyond managing victims alone and place greater emphasis on identifying, disrupting and managing
perpetrators and exploitation networks. National learning has promoted disruption as a safeguarding
intervention, strengthened multi-agency approaches to exploitation through MACE arrangements, and
reinforced the importance of linking missing person activity, contextual safeguarding and perpetrator
management to achieve earlier intervention and improved safeguarding outcomes. National self-
assessment activity has also supported forces and safeguarding partners to evaluate their response to
child sexual exploitation and identify areas for improvement.

Current national activity has also focused on strengthening the strategic management of exploitation
and extra-familial harm through improved multi-agency disruption approaches. National disruption

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 conferences and learning events have promoted the use of disruption as a safeguarding intervention,
encouraging agencies to move beyond reactive measures and develop coordinated, preventative
responses to perpetrators and exploitation networks.

The CSE Taskforce and Hydrant Programme have supported forces through national self-assessment
activity, enabling policing and safeguarding partners to evaluate their response to child sexual
exploitation, identify areas for development and inform future national guidance. Learning from major
inquiries, inspection findings and independent reviews has been incorporated into successive iterations
of national practice advice and guidance products.

Alongside developments in contextual safeguarding, increasing attention has been given to Transitional
Safeguarding, recognising that young people affected by exploitation, abuse and extra-familial harm
often remain vulnerable beyond their eighteenth birthday. National partners across policing,
safeguarding and health sectors continue to advance policy and practice in this area to support greater
continuity of protection and risk management through the transition to adulthood.

National work has also highlighted the importance of effective Multi-Agency Child Exploitation (MACE)
arrangements, stronger links between missing person activity and exploitation risk, and improved
oversight of children who experience harm across geographical boundaries or are placed away from
their home area. These developments reinforce the need for coordinated intelligence sharing, disruption
activity and safeguarding responses that recognise cumulative vulnerability and exploitation risk.
Emphasis has been placed on understanding repeated missing episodes as indicators of exploitation
and harm. Work continues to ensure information gathered through missing person investigations
informs both safeguarding planning and perpetrator disruption activity. National initiatives have also
strengthened engagement with sectors such as hospitality, transport and accommodation providers in
recognising and responding to indicators of child exploitation.

Taken together, these developments provide a more coherent framework for responding to the risks
highlighted by the review, and the concerns raised, including exploitation, extra-familial harm, domestic
abuse, cross-boundary offending and the continuing vulnerability of young people transitioning into
adulthood. Whilst transitional safeguarding remains an area of developing practice rather than a
statutory framework, there is now far greater recognition that safeguarding responses should be driven
by vulnerability, harm and need, rather than ending at an arbitrary age threshold.

Child Abduction Warning Notice

Child Abduction Warning Notice (CAWN) is, by design, a child protection tool and ceases to apply once
the young person reaches 18. The DHR demonstrates how this created a significant safeguarding gap:
the risk posed by the perpetrator remained unchanged, but one of the key disruption mechanisms
available to agencies fell away when Natasha became an adult.

The concern highlighted the absence of any equivalent protection despite ongoing exploitation,
domestic abuse and coercive control risks. There is currently no direct equivalent of a CAWN for adults
and no nationally adopted "young person's abuse warning notice" or similar mechanism. The legal
framework remains largely divided between child safeguarding powers and adult safeguarding
arrangements.

Page 5 of 7

 However, there is growing recognition within Transitional Safeguarding practice that care-experienced
young adults and those affected by exploitation may continue to require targeted protection and
disruption activity beyond their eighteenth birthday. This has contributed to wider discussions about
how safeguarding systems, contextual disruption and civil powers can be adapted to better protect
children and young people by being vulnerability led rather than age led.

Missing Persons and Transitional Safeguarding

Current policing guidance recognises that missing episodes are often indicators of vulnerability,
exploitation and harm rather than standalone incidents. Police are expected to view repeated missing
episodes as part of a wider safeguarding picture, assess cumulative risk, share information with
partners and consider the role of perpetrators and exploiters. Missing episodes should not be managed
in isolation but used to build an understanding of escalating risk and vulnerability.

For children, Return Home Interviews (RHIs) are a key safeguarding intervention. They provide an
opportunity to understand why a child went missing, whether exploitation or abuse has occurred, what
support is required and what action should be taken to prevent further harm. The information gathered
should inform safeguarding planning, disruption activity and multi-agency risk management.

From a transitional safeguarding perspective, Natasha's case highlights a continuing challenge. Whilst
there are well-established statutory arrangements for children who go missing, there is no equivalent
statutory Return Home Interview requirement or exploitation framework that automatically continues
into adulthood. As recognised within transitional safeguarding guidance, abuse and exploitation
frequently continue beyond 18 even though statutory safeguarding systems change significantly at that
point.

The key strategic learning is that where a young person has a history of exploitation, repeated missing
episodes, domestic abuse, grooming or coercive control, agencies should ensure that intelligence from
missing episodes continues to inform safeguarding and disruption activity beyond the age of 18. Risk
management should be driven by vulnerability and harm rather than chronological age, with continuity
of oversight through multi-agency partnership arrangements, care leaver support and exploitation risk
management.

We have taken an urgent review of the Child Abuse Authorised Professional Practice that is currently
out for consultation through the College of Policing. There is much within the draft APP that aligns with
transitional safeguarding principles, particularly its emphasis on vulnerability, exploitation, coercion and
control, trauma informed practice, professional curiosity, information sharing and avoiding victim
blaming. However a gap has been identified relating to transition to adulthood, and we have requested
that additional wording is included. You can find the consultation here until 4th August 2026: Child
abuse APP – have your say | College of Policing.

Whilst guidance and statutory arrangements exist to support transition into adult services, not all young
people meet the high eligibility thresholds for adult social care. As a result, agencies must remain alert
to young adults who continue to experience vulnerability, exploitation, trauma, or harm and ensure they
are not viewed solely through a crime or incident-based lens. A holistic assessment of risk, need and
lived experience remains essential.

Page 6 of 7

 I hope the information provided will go some way to address your concerns. Please do not hesitate to
contact me if you require further action or information in relation to my response.

Yours sincerely,

CC Gavin Stephens QPM
Chair
National Police Chiefs’ Council

Page 7 of 7

National Police Chiefs’ Council
   50 Broadway
London
SW1H 0BL

HM Senior Coroner Dr Julian Morris
London Inner South
Southwark Coroners Court
1 Tennis Street
London
SE1 1YD

27th July 2026

Dear Senior Coroner Morris,

I write on behalf of the National Police Chiefs Council (NPCC) in relation to paragraph 7, Schedule 5 of
the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013, in relation to the prevention of future deaths report (dated 01.05.2026) sent via email
for my attention as the NPCC Chair (dated 05.06.2026).

The notice sets out concerns that arose from the information received during the inquest into the death
of Natasha Hill. I am very sorry to read of the circumstances of Natasha’s death. My sympathies are
with her family, friends and colleagues.

Matters of concern have been highlighted below:

 Anyone requiring / needing / suffering

o Safeguarding
o Domestic violence / abuse
o Controlling/ coercive behaviour
And incurring the consequential risks, as a teenager approaching 18 should be formally
reviewed by an adult safeguarding team and the independent reviewing officer.

 Thought should be given to creating a young person’s team covering the transition from under

18 (MACE) to adult safeguarding teams e.g. For the period 18-22.

 Thought should be given to the creation of a young person's protection by way of creation of an
extension to the CAWN for the young person, against the adult creating that safeguarding risk
e.g. young person's abuse warning notice.

 The creation of one single national policy for policing and child sexual exploitation following the

groundwork laid down by Operation Hydrant and local Forces.

 Re safeguarding offender management, the use of VOO's and the creation of POETs/ DAPST
and RMUs: Consideration should be given to the creation of one set of criteria with one name
whose role it is to cover and create a central guidance.

  To consider the wider dissemination of existing local protocols nationally, for example the

London Exploitation Protocol.

 The provision of guidance in respect of missing persons / runaways and the return to home

interviews to assist the actions of the police and local councils.

In formulating this response, the NPCC Hydrant Programme, The Child Sexual Exploitation Taskforce,
and National Centre for Violence Against Women & Girls and Public Protection have been extensively
consulted.

Initially, I thought it would be beneficial to highlight the national Child Protection Framework at the time
of Natasha’s death, before covering more recent developments. During the relevant period, agencies
were operating within the statutory framework established by Working Together to Safeguard Children
2015, which was subsequently revised in July 2018. These arrangements required effective multi-
agency information sharing, coordinated safeguarding planning, child-centred decision making, and
collaborative responses between children's social care, policing, health and education services where
concerns about significant harm existed.

In parallel, the Department for Education's 2017 guidance on Child Sexual Exploitation reinforced that
exploitation is a form of child sexual abuse and highlighted the need to recognise coercion, grooming,
power imbalances and the reality that children may continue to associate with those who are exploiting
them. The guidance also emphasised the importance of professional curiosity, offender disruption and
coordinated multi-agency safeguarding responses.

The circumstances identified within the DHR demonstrate that many nationally recognised indicators of
child sexual exploitation and abuse were present, including a substantial age disparity, repeated
missing episodes, physical injuries, controlling behaviour, isolation from support networks and
continued association with a known violent offender.

The review found that extensive safeguarding activity was undertaken and that agencies recognised
both Natasha's vulnerability and the risk posed by the perpetrator. However, the evidence suggests that
safeguarding arrangements were fragmented rather than integrated. While MACE, MARAC and
MAPPA processes were all engaged, there was limited coordination between these forums and no
single mechanism that retained oversight of the cumulative and escalating risk presented to Natasha.
Viewed against the statutory expectations operating at the time, the principal issue therefore does not
appear to be the absence of safeguarding structures, but rather the effectiveness with which those
structures were connected. The review identifies missed opportunities to share intelligence, coordinate
disruption activity, manage cumulative risk and maintain a unified safeguarding plan around both the
victim and the perpetrator.

The findings also highlight challenges associated with cross-border safeguarding, as Natasha moved
between local authority and policing areas. Existing guidance required cooperation between agencies
where children crossed geographical boundaries, but the review found that these arrangements did not
always operate effectively in practice.

Page 2 of 7

 Contextual Safeguarding

Although Contextual Safeguarding was not yet fully embedded within statutory guidance during much of
the relevant period, it was already emerging as a significant framework for understanding adolescent
risk. The 2018 revision of Working Together subsequently incorporated references to contextual
safeguarding, recognising that harm may arise in relationships and environments beyond the family
home.

Natasha's experience reflects many features now associated with extra-familial harm: exploitation by an
older adult, abuse within an intimate relationship, repeated missing episodes linked to risk, movement
across geographical locations and overlapping indicators of domestic abuse and child sexual
exploitation. The review therefore provides a powerful example of the type of adolescent vulnerability
that has subsequently informed developments in contextual safeguarding practice.

Transitional Safeguarding

Perhaps the most significant strategic learning from the review relates to transitional safeguarding.
The DHR demonstrates that Natasha's vulnerability did not diminish when she turned 18. Her
experiences of trauma, exploitation, coercive control and domestic abuse continued, yet key child-
focused safeguarding mechanisms reduced or ceased at the point she became an adult. The Child
Abduction Warning Notice expired, children's safeguarding arrangements diminished, and no
equivalent safeguarding framework existed to provide continuity of oversight.

However, it is important to recognise that there was no established statutory framework for transitional
safeguarding in 2017–2018. There was no national requirement for MACE arrangements to continue
beyond 18, no expectation that children's safeguarding processes should automatically extend into
adulthood, and no dedicated transitional safeguarding model for vulnerable young adults. During this
period, transitional safeguarding was still an emerging concept rather than an embedded feature of
policy and practice.

Reflection: If this happened today

If a case with the same horrific circumstances experienced by Natasha presented today, safeguarding
partners would be expected to adopt a fundamentally different approach, recognising that vulnerability,
exploitation and coercive control do not cease when a young person reaches adulthood. Although
transitional safeguarding remains an area of practice development rather than a statutory framework, it
is now widely recognised that safeguarding responses should be driven by vulnerability and risk, not
solely by age.

From a strategic perspective, a young person experiencing child sexual exploitation, domestic abuse,
trauma, repeated missing episodes and care experience would not be expected to simply "age out" of
safeguarding arrangements at 18. Instead, there should be planned continuity of protection, with
transition arrangements commencing well before adulthood and involving children's services,
exploitation specialists, police, health, adult safeguarding and leaving care services. The focus should
be on maintaining oversight of risk, preserving protective relationships and ensuring clear ownership of
safeguarding concerns beyond the child's eighteenth birthday.  However, whilst these arrangements
are expected, there is limited direction within the current statutory guidance Working Together to
Safeguard Children 2026.  Transition is limited to “Known transition points for the child should be

Page 3 of 7

 planned for in advance. This includes where children are likely to transition between child and adult
services”.   In short, there is no single statutory national transitional safeguarding framework for children
who continue to experience exploitation into early adulthood.

Research in Practice, the Department of Health and Social Care, Social Care Institute for Excellence,
ADASS (Directors of adult social services), Local Government Association and others have collectively
advanced Transitional Safeguarding as an approach to safeguarding young people into adulthood.
Importantly, these organisations describe Transitional Safeguarding as a whole-system approach rather
than a specific service, panel or statutory process.

Current safeguarding practice would also place much greater emphasis on the management and
disruption of perpetrators. Rather than focusing primarily on the behaviour of the victim, agencies would
be expected to coordinate intelligence, utilise available disruption tactics, consider civil and criminal
powers and ensure that offender management and safeguarding arrangements operate as part of a
coherent strategy.

CSE Taskforce Response

Many of the themes identified in the DHR have subsequently informed national improvements in child
exploitation policy and practice. In particular, there has been a sustained shift towards child-centred,
trauma-informed and perpetrator-focused responses, stronger multi-agency coordination, and greater
recognition of contextual safeguarding.

There exists the Tackling Child Exploitation Support Programme and Department for Education’s Multi-
Agency Practice Principles for responding to child exploitation and extra-familial risk and harm (2026)
which promotes a shared partnership understanding of risk, improved information sharing, a welfare-led
approach to children affected by exploitation, and recognition of the need for agencies to work across
age-related boundaries when exploitation continues into adulthood.

Successive editions of Investigating Child Sexual Abuse and Exploitation (CSAE) Practice Advice
(2020, 2023 and 2025) have strengthened national expectations around child-centred investigations,
trauma-informed practice, contextual safeguarding, multi-agency working, victim engagement and
perpetrator disruption. Collectively, these developments have reinforced that exploitation should be
understood as abuse, that vulnerability may persist beyond childhood, and that safeguarding responses
should be informed by cumulative risk rather than individual incidents in isolation.

Alongside this, national disruption guidance and learning produced through the CSE Taskforce, Hydrant
Programme and partners has sought to address one of the key findings of the DHR: the need to move
beyond managing victims alone and place greater emphasis on identifying, disrupting and managing
perpetrators and exploitation networks. National learning has promoted disruption as a safeguarding
intervention, strengthened multi-agency approaches to exploitation through MACE arrangements, and
reinforced the importance of linking missing person activity, contextual safeguarding and perpetrator
management to achieve earlier intervention and improved safeguarding outcomes. National self-
assessment activity has also supported forces and safeguarding partners to evaluate their response to
child sexual exploitation and identify areas for improvement.

Current national activity has also focused on strengthening the strategic management of exploitation
and extra-familial harm through improved multi-agency disruption approaches. National disruption

Page 4 of 7

 conferences and learning events have promoted the use of disruption as a safeguarding intervention,
encouraging agencies to move beyond reactive measures and develop coordinated, preventative
responses to perpetrators and exploitation networks.

The CSE Taskforce and Hydrant Programme have supported forces through national self-assessment
activity, enabling policing and safeguarding partners to evaluate their response to child sexual
exploitation, identify areas for development and inform future national guidance. Learning from major
inquiries, inspection findings and independent reviews has been incorporated into successive iterations
of national practice advice and guidance products.

Alongside developments in contextual safeguarding, increasing attention has been given to Transitional
Safeguarding, recognising that young people affected by exploitation, abuse and extra-familial harm
often remain vulnerable beyond their eighteenth birthday. National partners across policing,
safeguarding and health sectors continue to advance policy and practice in this area to support greater
continuity of protection and risk management through the transition to adulthood.

National work has also highlighted the importance of effective Multi-Agency Child Exploitation (MACE)
arrangements, stronger links between missing person activity and exploitation risk, and improved
oversight of children who experience harm across geographical boundaries or are placed away from
their home area. These developments reinforce the need for coordinated intelligence sharing, disruption
activity and safeguarding responses that recognise cumulative vulnerability and exploitation risk.
Emphasis has been placed on understanding repeated missing episodes as indicators of exploitation
and harm. Work continues to ensure information gathered through missing person investigations
informs both safeguarding planning and perpetrator disruption activity. National initiatives have also
strengthened engagement with sectors such as hospitality, transport and accommodation providers in
recognising and responding to indicators of child exploitation.

Taken together, these developments provide a more coherent framework for responding to the risks
highlighted by the review, and the concerns raised, including exploitation, extra-familial harm, domestic
abuse, cross-boundary offending and the continuing vulnerability of young people transitioning into
adulthood. Whilst transitional safeguarding remains an area of developing practice rather than a
statutory framework, there is now far greater recognition that safeguarding responses should be driven
by vulnerability, harm and need, rather than ending at an arbitrary age threshold.

Child Abduction Warning Notice

Child Abduction Warning Notice (CAWN) is, by design, a child protection tool and ceases to apply once
the young person reaches 18. The DHR demonstrates how this created a significant safeguarding gap:
the risk posed by the perpetrator remained unchanged, but one of the key disruption mechanisms
available to agencies fell away when Natasha became an adult.

The concern highlighted the absence of any equivalent protection despite ongoing exploitation,
domestic abuse and coercive control risks. There is currently no direct equivalent of a CAWN for adults
and no nationally adopted "young person's abuse warning notice" or similar mechanism. The legal
framework remains largely divided between child safeguarding powers and adult safeguarding
arrangements.

Page 5 of 7

 However, there is growing recognition within Transitional Safeguarding practice that care-experienced
young adults and those affected by exploitation may continue to require targeted protection and
disruption activity beyond their eighteenth birthday. This has contributed to wider discussions about
how safeguarding systems, contextual disruption and civil powers can be adapted to better protect
children and young people by being vulnerability led rather than age led.

Missing Persons and Transitional Safeguarding

Current policing guidance recognises that missing episodes are often indicators of vulnerability,
exploitation and harm rather than standalone incidents. Police are expected to view repeated missing
episodes as part of a wider safeguarding picture, assess cumulative risk, share information with
partners and consider the role of perpetrators and exploiters. Missing episodes should not be managed
in isolation but used to build an understanding of escalating risk and vulnerability.

For children, Return Home Interviews (RHIs) are a key safeguarding intervention. They provide an
opportunity to understand why a child went missing, whether exploitation or abuse has occurred, what
support is required and what action should be taken to prevent further harm. The information gathered
should inform safeguarding planning, disruption activity and multi-agency risk management.

From a transitional safeguarding perspective, Natasha's case highlights a continuing challenge. Whilst
there are well-established statutory arrangements for children who go missing, there is no equivalent
statutory Return Home Interview requirement or exploitation framework that automatically continues
into adulthood. As recognised within transitional safeguarding guidance, abuse and exploitation
frequently continue beyond 18 even though statutory safeguarding systems change significantly at that
point.

The key strategic learning is that where a young person has a history of exploitation, repeated missing
episodes, domestic abuse, grooming or coercive control, agencies should ensure that intelligence from
missing episodes continues to inform safeguarding and disruption activity beyond the age of 18. Risk
management should be driven by vulnerability and harm rather than chronological age, with continuity
of oversight through multi-agency partnership arrangements, care leaver support and exploitation risk
management.

We have taken an urgent review of the Child Abuse Authorised Professional Practice that is currently
out for consultation through the College of Policing. There is much within the draft APP that aligns with
transitional safeguarding principles, particularly its emphasis on vulnerability, exploitation, coercion and
control, trauma informed practice, professional curiosity, information sharing and avoiding victim
blaming. However a gap has been identified relating to transition to adulthood, and we have requested
that additional wording is included. You can find the consultation here until 4th August 2026: Child
abuse APP – have your say | College of Policing.

Whilst guidance and statutory arrangements exist to support transition into adult services, not all young
people meet the high eligibility thresholds for adult social care. As a result, agencies must remain alert
to young adults who continue to experience vulnerability, exploitation, trauma, or harm and ensure they
are not viewed solely through a crime or incident-based lens. A holistic assessment of risk, need and
lived experience remains essential.

Page 6 of 7

 I hope the information provided will go some way to address your concerns. Please do not hesitate to
contact me if you require further action or information in relation to my response.

Yours sincerely,

Chair
National Police Chiefs’ Council

Page 7 of 7