Joshua Allcock

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

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

Your Report raised the following concerns:

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

Autism Assessments Guidance

NHS England has produced a national framework and operational guidance for autism assessments. Whilst the national framework states that “the traits that characterise autism emerge during the pre-school years, yet diagnoses given before 2 years of age are less stable than those given after this age”, the operational guidance suggests that Integrated Care Boards (ICBs) should ensure that all ages can access autism assessments: “check that people of all ages can access an autism assessment in the area”. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

4th March 2026

The National Institute for Health and Care Excellence (NICE) guidance for autism spectrum disorder in under 19s (CG128) at section 1.5 provides details on how to conduct autism assessments for children and young people. The guidance does not specify the minimum age for an autism assessment, but it does advise: “be aware that in some children and young people there may be uncertainty about the diagnosis of autism, particularly in: children younger than 24 months…”. Referral for ARFID Not having a diagnosis of autism should not have significantly affected the management of Joshua’s ARFID. The Royal College of Psychiatrists has produced an ARFID factsheet which states clearly that ARFID doesn't just occur in autistic people, but that it is more common in autistic people (and in boys, and ages 4-14 years). In January 2026, NHS England published guidance for commissioners and providers on eating disorder services for Children and Young People (CYP) including those with ARFID. Staff working in CYP’s mental health services (CYPMHs, sometimes known as Child and Adolescent Mental Health Services or CAMHS) and community eating disorder services (CEDS) should have the skills and confidence to treat CYP with neurodevelopmental conditions and those with chronic physical ailments, when an additional mental health issue arises. The necessary adjustments and adaptions should be made to support those with additional needs. All pathways must also ensure that reasonable adjustments are made in line with the Equality Act 2010. Treatment and support adaptations will be made for those with additional needs or requiring reasonable adjustments, for example, CYP who are autistic or have a learning disability. ICBs should develop and deliver ARFID care pathways, which might include provision outside of dedicated CEDS (for example, for under 5s), as specialist CEDS intervention may not always address the primary presenting need for CYP presenting with ARFID. As part of their biopsychosocial assessment which involves the CYP and parent/carers, the CEDS team should determine whether a CEDS intervention or shared care arrangements are most appropriate to support the primary presenting need of the CYP. For example, CYP with neurodevelopmental conditions may be receiving input for disordered eating that might meet the diagnostic criteria for ARFID from community paediatricians, speech and language therapists, occupational therapists and community children’s dieticians. Where there is doubt about whether CEDS is appropriate, discussion at a CYP neighbourhood multidisciplinary team meeting, involving primary care and paediatric expertise, should be considered. There are increasing examples of innovative practice for CYP requiring intensive support. For example, in the West Midlands, the Eating Disorder Intensive In reach Team (EDIIT) at Toucan offers specialist support enabling collaborative care for young people with disordered eating, neurodiversity and learning disabilities.

Capillary Refill Time Capillary Refill Time (CRT) is a moderately effective but imperfect clinical sign for diagnosing dehydration in a child. A prolonged CRT (>2 seconds) is a strong indicator of dehydration, but its sensitivity is variable, so a normal CRT does not reliably exclude dehydration. It is one of the most useful individual signs, but a combination of signs (such as skin turgor, respiratory pattern, and capillary refill considered together) is more accurate than any single sign alone. In summary, CRT is best used as a “red flag” for dehydration, but should not be relied upon in isolation for diagnosis. Clinical dehydration scales and a combination of signs are preferred for greater diagnostic accuracy. It is important for all clinicians to know when and how to assess for signs of dehydration. Assessment for dehydration would be guided by the history and context given for each individual patient. For example, the NICE guidance on diarrhoea and vomiting caused by gastroenteritis in under 5’s (CG84) gives guidance on assessing children for dehydration:
1.2.1.1 During remote or face-to-face assessment ask whether the child:
• appears unwell
• has altered responsiveness, for example is irritable or lethargic
• has decreased urine output
• has pale or mottled skin
• has cold extremities The NHS website also offers information for patients and carers on dehydration: Symptoms of dehydration in adults and children include:
• feeling thirsty
• dark yellow, strong-smelling pee
• peeing less often than usual
• feeling dizzy or lightheaded
• feeling tired
• a dry mouth, lips and tongue
• sunken eyes

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

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Joshua, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mr Zafar Siddique,

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

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

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

Specific points that we identified for learning are;

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

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

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

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

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

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

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

Dear Mr Siddique

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

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

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

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

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

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

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

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

Dear Mr Siddique,

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

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

This response incorporates the attached detailed submissions from:
• Birchills Health Centre
• Walsall Healthcare NHS Trust
• Walsall Metropolitan Borough Council

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

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

Key Areas of Learning Identified

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

1. Recognition and Assessment of Complex Neurodevelopmental Needs

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

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

2. Multi-agency Understanding of Health and Developmental Needs

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

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

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

4. Clinical Assessment and Documentation

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

Actions Taken by Individual Organisations:

1. Birchills Health Centre

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

Key actions include:
• Review of the case within clinical governance meetings and safeguarding discussions.
• Reinforcement of enhanced documentation standards, particularly around hydration assessment and fluid intake recording.
• Education for clinicians regarding assessment of dehydration in children, including recognition of early signs and use of appropriate clinical indicators.
• Increased awareness of ARFID and its association with autism and other neurodevelopmental conditions, with emphasis on maintaining a lower threshold for escalation to secondary care where concerns arise.
• Review and improvement of paediatric assessment equipment, including the purchase of additional paediatric blood pressure cuffs and oxygen saturation probes.
• Reinforcement of processes for obtaining additional clinical information when children newly register with the practice and historical records are not yet available.

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

2. Walsall Healthcare NHS Trust

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

Key points include:
• The Trust has long-standing Under-5 clinical pathways designed to guide the assessment of young children presenting with developmental or behavioural concerns.
• A specialised autism assessment pathway, in place since 2016 and updated in 2023 and 2025, supports multi-disciplinary assessment of children suspected of having autism.

• The Trust recognises the wider concern raised regarding national guidance about the age at which autism can be reliably diagnosed and continues to operate local clinical pathways alongside national standards.
• The Trust is working collaboratively with partners across the Black Country Integrated Care System to ensure that learning from this case informs system-wide improvements.

3. Walsall Metropolitan Borough Council

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

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

Key actions include:

Multi-Disciplinary Team (MDT) model

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

MDTs are now standard practice and are particularly required:
• When children have complex health or developmental needs
• When there is uncertainty about diagnosis or support requirements
• Prior to children entering care to ensure carers receive appropriate information.

Strengthening safeguarding oversight

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

The scope and focus of these teams are to improve child protection practice, with a focus on:
• Developing a consistent network of professionals leading child protection practice, and knowledge of how to access advice and guidance
• Improved information-sharing and communication between agencies
• Shared reflective and analytical thinking
• Multi-agency decision-making throughout child protection processes
• Increasing expertise where this is needed

Improved information sharing

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

“Was Not Brought” safeguarding policy

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

Training and workforce development

Training programmes for foster carers and social workers are being updated in 2026 to include:
• Understanding of ARFID
• Supporting children with autism and complex needs
• Enhanced safeguarding and neglect recognition.

Safeguarding partnership response

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

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

System-Wide Learning

Across all organisations, the following key areas of learning have been recognised:
• Greater awareness of ARFID and restrictive eating behaviours
• The case has highlighted the importance of recognising restrictive eating behaviours associated with neurodevelopmental conditions and the associated risk of dehydration and malnutrition.
• Importance of multi-agency collaboration
• All agencies recognise that complex cases require earlier and stronger multi-disciplinary coordination, particularly where diagnosis remains uncertain.
• Strengthening escalation processes
• There is now greater emphasis on ensuring professionals escalate concerns where a child’s presentation or needs are not fully understood.
• Improved communication between health and safeguarding partners
• New protocols and MDT processes aim to ensure that all professionals involved with a child share information effectively and develop a common understanding of risks.

Assurance Regarding Prevention of Future Deaths

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

Collectively, the actions undertaken provide assurance that:
• Clinicians are better supported to assess dehydration and complex feeding issues in children
• Professionals have improved understanding of ARFID and neurodevelopmental conditions
• Multi-agency decision-making structures are now strengthened
• Safeguarding systems provide stronger oversight of children with complex needs
• Training and policy improvements are being implemented across the workforce.

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

Conclusion

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

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

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

Walsall MBC - PFD (JA) response to Coroner

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1. Walsall Metropolitan Borough Council (the local authority) acknowledges the concerns identified by the coroner and the Regulation 28 Report of the coroner following the inquest for Joshua Allcock.

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

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

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

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

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

7. It is recognised that all professionals should have had a greater focus on understanding Joshua’s complex health and dietary needs. There should have been an escalation of professional oversight where it was considered there were gaps in understanding a child’s needs, and/or providing appropriate support to them.

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

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

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

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

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

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

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

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

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

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

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

18. The Safeguarding Partnership hosted a reflective discussion with strategic safeguarding leaders to consider the learning from the Safeguarding Practice Review alongside the findings from the Inquest. This was to consider how to further incorporate learning in the Safeguarding Practice learning review following what was further understood from the Inquest.

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

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

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

22. The local authority is committed to learning from this tragic death and to working collaboratively with partner agencies to reduce the risks of similar death in the future. The Walsall Safeguarding Children’s Partnership has robust governance arrangements in place in respect of all Action Plans, incorporating the WS15 Child Safeguarding Practice Review Action Plan. This includes reporting to the

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

23. We trust that this response addresses the matters raised within the Regulation 28 report and remain open to providing any further clarification the coroner may require.

Date: 03/03/2026 Director Children’s Social Care Walsall Council

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Appendix A

Identified Learning Action Responsible Lead Completion Date Progress/update
1. The partnership should seek assurance that the GCP2 tool is understood and used by professionals where neglect is considered to be a feature Neglect is one of 4 Safeguarding Partnership priorities and Neglect Steering Group to provide oversight of use of NSPCC GCP2 tool across the Safeguarding Partnership Director for Partnerships – Neglect Steering Group April 2024 Neglect Steering Group established, meets monthly, and oversees uptake GCP2 training

Neglect Lead role established to drive GCP2 training and neglect practice improvement and training Director for Partnerships April 2024 Neglect Lead post established and recruited to – LC

GCP2 training delivered across Children’s Social Care managers and practitioners LC and Principal SW April 2025 114 staff trained in GCP2

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

Multi-Agency Child Protection Team and Lead Child Protection Practitioners to oversee practice working with families where neglect occurs (inc. all CP enquiries and Plans) Group Manager for MACPT January 2025 MACPT pilot operational. Lead Child Protection Practitioner role established and now used 3 of 4 localities

Full rollout due by April 2026

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2. The partnership should consider the development of a multi-agency “Was Not Brought” policy which makes clear the roles and responsibilities of all professionals in the safeguarding system when a child is not brought to a medical appointment and includes consideration of how this corresponds to the thresholds for social care intervention Contribute to development of “Was Not Brought” policy, and ensure this is shared to all managers and practitioners in CSC Head of Safeguarding Partnership Business Unit In progress Policy in development developed by Safeguarding Partnership, including representatives from Children’s Social Care
3. The partnership should facilitate a discussion between children’s services and health leads to identify the most appropriate way to coordinate the sharing of information across the health system and into a child’s plan. This is particularly important when multiple health professionals are involved in supporting a child with complex needs Multi-disciplinary Team Meetings to be held in addition to Core Group Meetings where there are identified specific health and developmental needs. Head of Service Family Safeguarding April 2023 Multi-agency protocol in place. This is now standard practice, it is reviewed through monthly audits and now subject to the enhanced oversight of the Multi-Agency Child Protection Team

4. The partnership should seek assurance from children’s social care that there are Additional training provided to Team Managers and Child Protection Conference Chairs on Principal SW September 2025 Programme of management training delivered through the Practice Leadership Programme

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appropriate mechanisms in place to scrutinise the length of time a child is subject to a child protection plan to avoid delays in taking prompt action to address the concerns Supervision and oversight of CP Plans and during Service Development Days. Programme of training completed in September 2025

Midway Review process reviewed and development work with CP Chairs Group Manager for Safeguarding and Review September 2025 Process reviewed and updated, shared to all CP Chairs

Safeguarding Partnership FAST Escalation process reviewed and shared across to all managers and practitioners in CSC Principal SW February 2024 Process reviewed and updated, shared across communication channels by February 2024

Multi-Agency Child Protection Team pilot established to enhance information-sharing and escalation where there are gaps in information Group Manager for MACPT January 2025 MACPT pilot operational

Full rollout due by April 2026

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

Group Manager for MACPT January 2025 MACPT pilot operational

Full rollout due by April 2026

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Strats – LCPPs to oversee and stay involved
5. Multi-agency chronologies should be used where children experience neglect to develop a holistic analysis of their needs and any gaps in accessing support and services Chronologies training delivered across CSC

Principal SW March 2025

Chronology training delivered to all practitioners in the Family Safeguarding Service

Multi-agency chronologies to be used for all children where there are CP enquiries Head of Service Family Safeguarding March 2025 This is now a practice standard, it is reviewed through monthly audits and the oversight of the Multi- Agency Child Protection Team
6. Enhance direct work skills to capture the voice of disabled children and children with developmental delay The Disabled Children and Young Person’s Team will co-work with the Family Safeguarding Team where a child has significant developmental delay Head of Service Family Safeguarding April 2023 This is now a practice standard, it is reviewed through monthly audits and now subject to the enhanced oversight of the Multi-Agency Child Protection Team

Consultant Social Worker role established – 1 per locality – to provide guidance and guidance to practitioners including direct work skills Principal SW January 2024 Role established and all CSW post recruited to

Direct work training is delivered to all practitioners in Children’s Social Care, including training on Principal SW September 2023 Ongoing rolling programme for all practitioners, and this is

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communicating with disabled children and children experiencing developmental delay mandatory requirement for all practitioners
7. Ensure that all health professionals are invited to Child Protection Core Groups Communication to all managers and practitioners, reinforced in service and team meetings Head of Service Family Safeguarding April 2023 Briefings held and information shared through all communication channels

New protocol implemented with 0-19 Health Service to provide overview of children’s health needs Head of Service Family Safeguarding April 2025, reviewed August 2025 Protocol in place. This has been reviewed to enhance coordination and streamline process

Further review due January 2026
8. When placing children in foster care with developmental delay needs, there should be additional support provided to understand and meet needs Multi-disciplinary Team Meetings to be held where a child is experiencing developmental delay. If there is not sufficient clarity on a child’s needs the escalation processes outlined elsewhere here Head of Service Family Safeguarding April 2023 Multi-agency protocol in place. This is now standard practice, it is reviewed through monthly audits and now subject to the enhanced oversight of the Multi-Agency Child Protection Team

The Disabled Children and Young Person’s Team will co-work with the Family Safeguarding Team where a child has significant developmental delay Head of Service Family Safeguarding April 2023 This is now standard practice, it is reviewed through monthly audits and now subject to the enhanced oversight of the Multi-Agency Child Protection Team

Walsall MBC - PFD (JA) response to Coroner

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9. Make sure that parent’s voices are heard and respected A new Parental Advocacy Service has been established, with parents to be offered support from a representative from a local community organisation Head of Service Family Safeguarding September 2025 Offer established and available to all families – to be considered prior to all CP Conferences