Marcia Grant

Dear Ms Whittle,

RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

This is the Department for Education’s (the Department) response to your report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 2 September 2025, following the tragic death of Marcia Grant on 5 April 2023. I am responding as the Minister for Children and Families, and have responsibility for foster care.

Thank you for your conduct of the inquest and for your identification of matters of concern, which are set out in the Report.

Marcia’s passing deeply shocked and saddened everyone across the Department and our thoughts are with her family and friends. I recently met with Marcia’s family to discuss their experience, alongside , their MP. As a dedicated and skilled foster carer, Marcia was a pillar of the fostering community. Her compassion, commitment, and tireless efforts transformed the lives of countless children and young people. She was deeply respected and will be remembered with warmth and admiration by all who had the privilege of knowing her.

I want to set out my heartfelt admiration more broadly for the huge contribution made by foster carers. Foster carers provide loving homes to most children in care and form the backbone of the children’s social care system. Fostering is an incredibly challenging role which requires skills and unwavering dedication from those who volunteer to give vulnerable children a home.

We will shortly be announcing comprehensive measures to reform the fostering system, and are considering the voices and experiences raised that Marcia’s family raised as part of these reforms.

These reforms will significantly increase the number of foster carers and improve the experience of fostering. The Department remains committed to improving recruitment and retention to ensure that every child in care is able to have a stable, loving foster home, where this is the most appropriate option. Our goal is for local authorities to have improved placement sufficiency, enabling better matching where children can have a choice of placement. We believe that this will help to avoid issues such as those identified in Marcia’s case.

While our response focuses on the lack of placements, as requested, I will briefly set out our position on the wider themes you raised about this tragic case. Our statutory guidance sets that fostering services must provide carers with the information necessary to fulfil their role effectively. In emergency placements, where full information may not be immediately available, local authorities must make the most appropriate decision based on the information at hand and in the child’s best interests. Any outstanding information should be provided to the foster carer at the earliest opportunity.

The National Minimum Standards for fostering services, which inform Ofsted inspections, affirm that foster carers are entitled to full and timely disclosure of a child’s circumstances, including recent significant events. This enables carers to understand and respond appropriately to the child’s needs and behaviours. Data protection legislation does not prevent the sharing of such information where there is a valid legal basis and a risk of serious harm.

The National Minimum Standards also set out that children should only be matched to places that can meet their needs. These standards also set out that the impact of the placement on household members should be considered before placements are made. This type of activity is central to any effective matching practice.

Matter of concern 1 – Lack of placements The lack of foster placements placed significant strain on the Local Authority to consider creative solutions to try and avoid an unauthorised placement. This led to an unsuitable placement being accepted. I was informed the shortage of placements is a both a local and a national issue and therefore both Rotherham Metropolitan Borough Council and the Minister for the Department for Education are asked to consider this concern. We recognise there are too few fostering placements, causing sufficiency challenges for local authorities across the country. This places pressure on local authorities and results in a lack of choice on placements, which can lead to unsuitable matches, as well as placement instability and children being placed out-of-area. We have already made progress on this issue through our investments in recruitment and retention within local authorities. The Department has been supporting over 60% of local authorities across England in 10 regional recruitment support hubs, most of which launched in the spring and summer of 2024. These hubs, backed by regional communications campaigns in each area, support

prospective foster carers from their first enquiry to ensure that they carers are properly supported through the application process. Most recruitment support hubs are surpassing the Department’s expectations for foster carer approvals, compared to what we expect they would have achieved without the programme. These highlight the impact of collaborative working in driving recruitment success. We have also invested in rolling out a foster care retention model called Mockingbird, an innovative evidence-based approach involving six to ten families grouped into a constellation around a hub home carer. Mockingbird includes peer support, respite and training. It was found to substantially improve retention by an independent evaluation, which showed that participating households were 82% less likely to deregister than households who did not participate. Despite this progress, we know we need to go further and faster in significantly increasing foster care numbers. We will set out our plans for doing this in comprehensive new measures over the coming months. This work is being backed by the Chancellor’s Transformation Fund, announced in the Spring Statement, which will provide an additional £25m over 2 years (beginning in 2026/27 and 2027/28). This is additional to the £15m of fostering investment that was announced in the Autumn Budget, to cover investment taking place in 2025/26. The Spending Review also set out funding to renovate and expand foster carer homes, so that approved carers can look after more children. Once again, we would like to take the opportunity to thank you for highlighting these matters of concern, and for giving us the opportunity to respond.

Regulation 28: Report to Prevent Future Deaths Response by Rotherham Metropolitan Borough Council into the Matters of Concern in respect of the death of: Marcia Grant

Introduction Rotherham Metropolitan Borough Council (RMBC) wishes to express condolences to Mrs Grant’s family and acknowledge the important matters raised in the Prevention of Future Deaths Report. We are committed to ensuring that action is taken to mitigate future risks when placing our children and to support decision making by the dedicated carers, who ensure that some of the most vulnerable children and young people in our society have a loving home where their needs can be met. RMBC acknowledges its responsibilities to children and to foster carers and strives to achieve the highest standards when placing children outside of their family homes. RMBC takes the matters raised in the Regulation 28 Report seriously and offers assurance that processes are continually developed to ensure that they are robust, identify and mitigate risk and ensure that children are placed in appropriate placements and provisions.

1. Matter of Concern:

Lack of placements. The lack of foster placements placed significant strain on the Local Authority to consider creative solutions to try and avoid an unauthorised placement. This led to an unsuitable placement being accepted. I was informed the shortage of placements is both a local and a national issue and therefore both Rotherham Metropolitan Borough Council and the Minister for the Department for Education are asked to consider this concern.

Current Situation The Local Authority recognises the challenges set out by the Assistant Coroner and agrees that the picture both nationally and consequently in Rotherham is that the “lack of foster placements placed significant strain on the Local Authority to consider creative solutions to try and avoid an unauthorised placement.”

The Inquest noted in the evidence provided that consideration of this issue has been subject to discussion by sector leaders nationally. The challenges have led to children with particular needs being placed in ways which are outside of the relevant legislation and placements that are sub-optimal, including placements far from the local area. The Local Authority has repeatedly made the point in regional and national forums about the difficulty that this creates in managing such cases and in managing the associated risks. This burden falls across the entire system and creates scenarios where children can be placed in provisions which do not always meet their needs. Sufficiency Strategies and Development In 2020 Cabinet confirmed Rotherham’s strategic intention to ensure more Rotherham Children in Care are placed within the Borough, close to their family and community networks. Development of new children’s residential provision, along with foster care, third party placements, semi-independent provisions, and other family-based placements, aims to provide a mixed economy of arrangements, which will seek to effectively meet Rotherham’s statutory duties, outlined in the Sufficiency Strategy. The Looked After Children and Care Leavers Sufficiency Strategy 2023-2028 was approved by Cabinet in October 2022. The Strategy was developed in line with the duty to provide or procure placements for the Local Authority’s Children in Care. Action: The Fostering Rotherham In-House Plan 2023-2028 details the plans to develop the Fostering Service to increase sufficiency, focusing on marketing and recruitment, valuing our foster carers, service developments and innovation, training, quality assurance and performance and family and friends as foster carers. The Children in Care Sufficiency Board was established in January 2023 to deliver the Sufficiency Strategy. The children’s residential development programme responds directly to Rotherham Children and Young People’s Services’ (CYPS) strategic intention to reduce the number of external residential placements for children and ensure more Rotherham Children in Care are placed within Borough, close to their family and community networks. The Council has demonstrated their commitment with a multi-million pound capital programme as well as a more recent increase in the revenue budget to ensure an enhanced offer to children and young people. The four phases of residential development will deliver 20 residential beds and 2 emergency beds across 11 registered settings by March 2027. So far, the programme has delivered 13 residential beds and 1 emergency bed across 7 registered settings. In August 2024 a 16+ Sufficiency Transformation Board was established to provide overall direction to the project setting out what is required, authorising work and

monitoring progress against the delivery of the proposals approved by the Children and Young People’s Services’ Directorate Leadership Team in relation to the needs of older children in care and care leavers. This led to a clear and agreed cross Council working protocol to support developing further sufficiency in the system. In November 2024 Cabinet approved an addendum to the Children in Care Sufficiency Strategy detailing the needs analysis, commissioning intentions and development programme for supported accommodation for care leavers. Fostering Current Position RMBC has successfully sustained a positive recruitment and retention rate with foster carers in the Borough and comparatively with local and national statistics have been very successful in this area. Despite a national reduction of LA approvals of approximately 32% since 2021, Rotherham’s performance shows a 54.44% increase from 11 approvals in 22/23 to 17 approvals in 2023/2024. In 2023/24 the average number of approvals for all LAs returning data in England was 12.3, an increase of 9% year on year. As such, Rotherham performed well above the average approvals according to the Office of National Statistics (ONS) data. When comparing performance between LAs nationally expressing number of approvals as a percentage of the total population size of their areas, Rotherham ranked 22nd (of 152 LAs) in 2022/2023 and were 5th out of 152 LAs based on the ONS rounded up figures. Regionally, Rotherham’s approval performance (based on rounded-up numbers) increased from Rotherham having the 3rd highest number of approvals to having the second highest numbers in the region. This reflects a sharp decline across 2 other Local Authorities. Rotherham is the highest performing LA in the region when it comes to approvals as a percentage of population, for both actuals and rounded figures. RMBC have maintained a cohort of experienced foster carers in the Borough and continue to recruit new foster carers with a range of skills. RMBC seek continual feedback from foster carers and utilise this to improve services and support for the fostering community. Action: Foster carers have been consulted in response to the inquest findings and asked for feedback about what improvements could be made. This was constructive and proposed: a structure chart of the organisation; graduated information sharing about children at the stage foster carers have expressed an interest in offering a placement; and a contribution to the structure of placement referral forms. RMBC have invested in creative marketing strategies to target a range of local prospective foster carers. The assessment and review process for foster carers is

stringent, ensuring that RMBC foster carers have the necessary knowledge, skills and experience to undertake the role. Following a report to the Children in Care Sufficiency Board in May 2025 reviewing the current fostering recruitment strategy, it was agreed a time limited Placements (Fostering) Transformation Board should be established. The purpose of the Placements (Fostering) Transformation Board is to provide a forum for enhanced scrutiny around the Sufficiency Strategy, to ensure a continued focus on recruitment and retention of foster carers and to adopt recommendations from the national agenda, with a specific focus on Fostering. This will now include the response to the recommendations from the Regulation 28 Report. It is anticipated that this bespoke Board will have completed its work by May 2026. Placements for Young People Young people over primary school age are particularly challenging to find suitable foster placements for; the DfE reporting figures for 2023 highlight that 64% of all children in care were over the age of 10 years old and 57% of children in care at that time were male. The Children’s Commissioner analyses research into adolescents entering care and emphasises that these children are more likely to have experienced instability and adversity for sustained periods, to have additional special educational needs and are less likely to get the support they need. This leaves young people vulnerable to abuse and exploitation and at higher risk of developing social, emotional and mental health needs. This then results in young people not being considered for foster placements, which would actually be the best, most stable option for most. Action: It is for this reason that RMBC works tirelessly to recruit and train foster carers with a variety of skills and from diverse backgrounds. It is almost always preferable for children and young people to be placed in appropriate, family-based settings where possible and we will continue to focus on this destination for our children in care. Kinship Placement Options Kinship care has been a continuing focus for the Local Authority, to support placement sufficiency and to ensure that children can live with family members where possible. Action: RMBC, in response to the DfE’s Families First Programme, has appointed a senior leader as a Kinship Lead for the local authority and has also recruited Kinship Navigators to focus on the support offered to Kinship Carers. RMBC has also reviewed and updated Kinship Practice Guidance and financial support to Kinship carers. This has been in place since January 2025 and the fully updated Kinship Local offer was launched in October 2025.

2. Matter of Concern:

Documentation and communication. Both the lack of documentation recording all the relevant risks, failure to complete forms and the lack of adequate communication of the risks in this matter led to a child being placed with a family where numerous individuals considered this was an inappropriate placement. Senior decision making was not based on all the appropriate information identifying there are inadequate systems and processes. At the time of the initial placement being required for Child X, limited information was known about his background and needs. The initial placement referral form was brief and did not contain all relevant information. While the placement referral form was repeatedly updated over the short period Child X was in care with RMBC, we could not determine which placement referral form had been shared with Mrs Grant during the initial matching discussions due to the version control of documents. There were however a number of conversations with Mrs Grant about Child X. Mrs Grant had also taken steps to ensure that she knew where Child X was at all times and that she had locked away knives to ensure he could not access these. RMBC acknowledge that the storage and version control of documents required improvement and had already taken steps to address this. Further immediate changes were made during the course of the Inquest, and we are satisfied that the correct version of the placement referral form is now used. This ensures that the most relevant and up to date information, including on risks, is shared with foster carers during matching discussions. Action: In 2023, a dedicated fostering duty worker was appointed to manage and share information with in-house foster carers about children needing a placement. This process ensures that information is held in one place and the duty worker has in depth knowledge of available carers and their skill set, to promote effective matching with children. The duty role co-ordinates matching discussions and information sharing between fostering supervising social workers, foster carers themselves and allocated social workers for children to ensure a comprehensive overview of each child requiring a placement. RMBC has ensured that all social workers within the service understand and follow the process. Schemes of delegation and approval processes were also revised during 2023 to ensure that information about children requiring a placement is approved by a senior manager to ensure quality and consistency. Mitigation of risk and relevant history is considered and shared with prospective carers and providers prior to matching discussions taking place.

The Commissioning and Placements Service has also implemented a process, which ensures that placement approvals are given at the correct senior management level, depending on the child and the nature of the placement. Placement referral forms, which contain all relevant information, are signed by decision makers and saved to the child’s file prior to placements commencing. There have been challenges around pre-populated forms, within the children’s case management system, which RMBC acknowledge can be lengthy and cumbersome. Sections within certain forms were repetitive and led to social workers only completing relevant sections of forms, which leaves many sections blank. A dedicated Systems User Group within RMBC meets monthly to focus on work required to update and revise forms within the children’s case management system.

3. Matter of Concern:

Risk Assessment. Evidence was heard about the risks posed by the Child but no evidence that the risk to the foster carers or the other child in their care had been considered or assessed. Again, there was lack of documentation and no formal risk assessment document or collated risk profile for all individuals to allow proper consideration of risks. RMBC acknowledge the importance of a coordinated and risk-based approach to identifying and mitigating foreseeable risks in caring for children, both for their carers’ and their own benefit. At the time of Child X’s placement, the Local Authority had worked on the premise that risks, when these are determined to be high, are considered within a more in-depth assessment. When placed, Child X was not deemed to pose a high risk of harm to himself, or others and no evidence was presented which indicated that the risks identified would increase and so a stand-alone risk assessment had not been completed. As acknowledged above, the initial placement referral form did not contain all the known risks about Child X. As concerns developed about the other young person in placement, this was considered and acted upon by RMBC, including the provision of a significant support package to help mitigate risk to him and an acceptance by the whole professional network that Child X’s placement could only be of very short duration. Action Following Mrs Grant’s tragic death, various specific changes have been made to ensure that the Council delivers the best possible services to foster carers and children and young people. Since 2023, explicit sections for risk analysis have been populated within Placement Referral Forms and Matching Approval documents to ensure that this is routinely

considered for every child requiring a placement. Risk is also considered within child and family assessments. The authorisation levels of placement referral forms and placement agreements ensure that Senior Managers are responsible for ensuring all matters of risk have been considered, alongside mitigation of these risks. Standalone risk assessment forms have been maintained and refined for children and young people who may present with high risks, and guidance has been revisited since the inquest to ensure that the threshold for standalone risk assessments is clear and that this practice is routinely implemented where children are deemed to pose a risk to themselves or others. It is important to note that risk management is incorporated into everyday practice within children’s social care. It remains impossible to anticipate all potential future risks, particularly for children who are not known well to the service. Foster carers will also continue to be consulted around their experience of risk when children have been placed to ensure that the Local Authority learns via the lived experience of carers and children. RMBC has recently revised the foster carer communication plan to ensure that this is embedded within practice. Conclusion RMBC is a reflective organisation and continually strives to improve practice, processes and procedures. It is recognised that improvement is a continual process and RMBC takes its corporate parenting responsibilities seriously. In summary of the points above, we will:
• Continue to pursue our Looked After Children and Care Leavers Sufficiency Strategy 2023-2028 with its emphasis on residential, fostering and kinship provision
• Continue to make improvements to documentation, recording and approval processes and co-produce matching guidance with our foster carers
• Continue to enhance risk assessment processes and ensure criteria for standalone risk assessments for placements are clear to all involved. The Council trusts that the above addresses the matters of concern raised during the course of the Inquest. As stated at the outset, the Council is committed to ensuring that action is taken to mitigate risks in placing our children and to support decision making by the dedicated foster carers who ensure that children and young people have a loving home that can care for them and meet their needs. The complexity of these placements remains one of the most difficult decision-making processes that the Council is involved in. We will continue to work with our staff, children and foster carers to deliver these services as effectively as possible to meet the needs of all involved. We will also continue to advocate for appropriate national

placement sufficiency that meets the needs of all our children and young people and will continue to engage with Government around this critical issue.

Strategic Director of Children and Young People’s Services Rotherham Metropolitan Borough Council
11.11.25.