Oskar Nash

Dear Mr Travers Inquest touching the death of the late Oskar Nash I write in response to your Regulation 28 Report dated 31 January 2022 and thank you for the same. Each of the concerns directed to Surrey County Council has been fully considered. I set out below the response to each concern in turn. Concern 6 The evidence at the inquest revealed that the staff in the Education / SEN Department, including SEN caseworkers, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm, and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis. Response: On 30 November 2021 the Executive Director for Children Families, Lifelong Learning and Culture wrote to all staff in the Directorate setting out the Autism Awareness Training offer available for all staff in the Directorate. The training is now mandatory for all staff working directly with children and young people and must be completed by 31 March 2022. The uptake of the training is being monitored for each individual. The awareness training must also be completed by all new starters as they join as a part of their mandatory training. The training captures:
• information on autism diagnoses, how the condition impacts the individual and the challenges for people who work with or care for people with autism.
• key issues such as the autistic spectrum, the causes of autism, autism and social communication issues, autism and body language, facial expressions and tone of voice, mind blindness, sensory issues, coping methods and the positives of autism.
• the different effects of the condition for those on the autistic spectrum and how to support someone with dealing with those effects. Richard Travers HM Senior Coroner for Surrey Sent via email Leadership Office Woodhatch Place 11 Cockshot Hill Reigate, Surrey RH2 8EF 25 March 2022

• the potential link to mental health issues, anxiety, and self-harming. The training does not currently capture fully the link between autism and self harm or suicidal ideation, and the associated risks. The SCC Children’s Academy is currently in the process of reviewing the training required in order to equip all frontline workers to recognise this risk and is in the process of identifying the most appropriate further training package for relevant staff to broaden understanding around this. SCC is committed to rolling out this further training package at the very earliest opportunity.

As part of the SCC All Age Autism strategy, significant additional funding has been secured to raise awareness and understanding of staff around autism generally.

Concern 7 The evidence at the inquest showed that, in the months before his death, Oskar Nash was moved from a special needs school and placed into a mainstream school which did not have the facilities or expertise sufficiently to meet his complex needs. I found that the inappropriate placement, by SCC, of Oskar into the mainstream school contributed to his death.

Prior to the placement, the mainstream school had been provided with Oskar’s Educational, Health and Care Plan, but this failed adequately to identify and record his mental and emotional health concerns, his risk of suicidal ideation, his consequential needs, and the provision required to meet those needs, and it had not been updated to reflect a series of subsequent reviews of the Plan and significant subsequent events. The mainstream school was not provided with any of the extensive and informative records from the special needs school from which he was being moved.

I was told by the mainstream school that, had they seen the records held by his special needs school, they would have recognised their inability to meet his needs and informed the SEN Department accordingly.

At the prevention of future deaths hearing, I was told that it continues to be the case that a prospective school will usually be provided by the SEN Department with the child’s EHCP only. Further, it was apparent that there is a lack of clarity as to the extent to which a current school may or should provide records or information to a prospective school.

I am concerned that there is an ongoing risk that placements of children with EHCPs are being made on the basis of inadequate information and record sharing. On the evidence before me, it was clear that, even if an EHCP were comprehensive and fully updated (which may not be the case), it is unlikely to contain all matters of relevance to the question of a prospective school’s ability to meet the child’s needs.

I was given no good reason why fuller information and record sharing, sufficient to ensure that the prospective school can properly assess its ability to meet the child’s needs, should not take place before any child with an EHCP is placed in a new school. I am concerned that there is no system in place, locally or nationally, to ensure this is achieved by the relevant SEN department for every child with an EHCP. I am also concerned that there is an ongoing lack of clarity as to schools’ powers and duties to share information and documents, and any data protection ramifications this may have.

Response: When a change of school placement is being considered, the Council’s SEND department is required to share a comprehensive and accurate up to date EHCP

(including, where relevant, supporting information that is considered important) for the prospective school to consider. This could include supporting assessments and information resulting from the most recent annual review. These documents combined should provide a clear picture of the current needs of the child or young person and the arrangements needed to support their learning, meet their needs, and secure the planned outcomes.

SEND Code of Practice para 9.82 states that advice from schools, colleges and other education or training providers will contribute to the development of an EHCP to ensure that it meets the child or young person’s needs, the outcomes they want to achieve and the aspirations they are aiming for. SCC complies with this national requirement. The intention is for the EHCP to contain all necessary information.

Steps have been taken to better train SEND officers with a view to ensuring EHCPs are drawn properly with advice from the wide range of professionals named. Significant improvements in the quality of EHCPs have resulted. These EHCPs can then be relied upon to share all necessary information.

There is no national requirement for the local authority to share child protection files or to require schools to do so.

Keeping Children Safe in Education (DfE) 2021 paragraphs 105-113 sets out guidance to education providers on the subject of information sharing.

At 110. KCSiE states:
110. The Data Protection Act 2018 and UK GDPR do not prevent the sharing of information for the purposes of keeping children safe. Fears about sharing information must not be allowed to stand in the way of the need to safeguard and promote the welfare and protect the safety of children.

To this end, any school wishing to seek further information from the current/prior school can request such information and the school receiving that request can make a decision about whether it is suitable to share such information in line with the guidance. This is a matter of professional judgment on a case by case basis.

Given the sensitive nature of safeguarding files and child protection information, SCC does not consider that a blanket system of sharing such information for all children with an EHCP is necessary or appropriate in relation to the placement of a child in school. However, where a school considers that they require further information they can make this request by exception.

Safeguarding concerns and/or child protection concerns should not form the basis of a decision of an educational provider as to its suitability to meet a child's need. It is a national expectation that all educational providers will be able to support children with concerns around self-harm and/or suicidal ideation including where this is co-morbid with other conditions, including autism. Any child or young person could experience or develop suicidal ideation or self-harm at any time. This is, very sadly, a common occurrence and systems of support should be in place in every educational provider to support children in school with, where appropriate, the help of partners eg. mental health services. This national expectation and approach is set out in the Department for Education publication Promoting Children and Young People’s Mental Health and Well Being published 21 September 2021 (first published in 2015) and the referenced Public Health England Guidance published September 2021.

SCC is in the process of reviewing its guidance to educational providers and has committed to incorporating in that guidance clearer information around the parameters within which information can be shared between educational providers and to highlight

that schools can, where considered appropriate, request additional information from a current/previous school. SCC is committed to concluding the review by May 2022.

The SEND Code of Practice paragraph 9.89 states that mainstream education cannot be refused by a local authority on the grounds that it is not suitable. A local authority can rely on the exception of incompatibility with the efficient education of others in relation to maintained nursery schools, mainstream schools or mainstream post-16 institutions taken as a whole only if it can show that there are no reasonable steps it could take to prevent that incompatibility.

In paragraph 9.90 the Code of Practice further sets out that, where the local authority considers a particular mainstream place to be incompatible with the efficient education of others, it must demonstrate, in relation to maintained nursery schools, mainstream schools or mainstream post-16 institutions in its area taken as a whole, that there are no reasonable steps that it, or the school or college, could take to prevent that incompatibility. Efficient education means providing for each child or young person a suitable, appropriate education in terms of their age, ability, aptitude and any special educational needs they may have. Where a local authority is considering whether mainstream education is appropriate (as opposed to considering the appropriateness of an individual institution) the term ‘others’ means the children or young people with whom the child or young person with an EHCP would be likely to come into contact on a regular day-to-day basis. Where a parent or young person has expressed a preference for mainstream education and it would not be incompatible with the efficient education of others, the local authority has a duty to secure that provision.

Concern 8 The evidence at the inquest revealed that the staff in SCC’s Children’s Services Department, including Social Workers and other Team members, had insufficient understanding of Autism, its links to co-morbid mental health conditions, self-harm and suicidal ideation, and how to communicate with an autistic child. I am concerned that there continues to be no requirement for the staff to undertake relevant Autism training on a mandatory basis.

Response: The Coroner is respectfully referred to the response to Concern 6 above. The communication from the Executive Director for Children, Families, Lifelong Learning and Culture of 30 November 2021 was sent to all staff within the Directorate. This includes both staff within the Education department and those within the Children's Services Department.

Equally, the further training to be offered addressing more specifically the link between autism and self-harm or suicidal ideation and the associated risks, will be rolled out to all relevant staff within both the Education department and the Children's Services Department. SCC is fully committed to ensuring that all relevant staff receive appropriate training around autism and the associated risks.

Concern 9 At the inquest I found that following Oskar Nash’s final referral to SCC’s Children’s Services Department, which was made approximately two months before his death, there was a failure to appreciate the seriousness of his situation and the risks arising, and a consequential failure to allocate his case appropriately. I found that this contributed to his death. The inappropriate allocation resulted, in part, from the application of SCC’s then “threshold of needs” document, which was used to inform the level at which support should be provided.

At the prevention of future deaths hearing, I heard evidence about SCC’s revised “threshold of needs” document, as well as the recent guidance (including a “toolbox”) in relation to suicidality, which has been introduced since Oskar’s death.

Despite these changes, I remain concerned that the “threshold of needs” document does not adequately and clearly reflect the known risks of mental health difficulties, self-harm, and suicidal ideation for autistic children (given their prevalence in this group of children) and that, consequentially, there is an ongoing risk that an autistic child in these circumstances will be allocated an insufficient level of support, as was the case for Oskar.

Response: In light of the concern raised, there has been a further review of the current ‘Effective Family Resilience’ document undertaken and careful consideration of the need to make changes to that document. At the current time, we do not believe there is a need to update the document in the level of need descriptions with additional definitions or criteria. However, we have reflected that adding some wording within the section on page 8 (as outlined below) draws attention to the need to consider aggravating factors of mental health, suicidal ideation and autism which should weigh more on the assessment and need / risk grading rather than simply the initial referral trigger.

‘The windscreen cannot replace professional curiosity, judgement or decision making and should not be used as a checklist or an assessment of need. The indicators of need are suggestions of the types of need a child and family may have. Sometimes their needs may include indicators from each of the levels, however combined, they may cause additional strain on the family (for example the impact of additional factors related to emotional wellbeing, mental health and or self-harm upon a child who has a diagnosis of autism) and following discussion with the family may indicate a higher level of support needed. Equally, there may be family strengths that are mitigating factors for the indicators’

We intend to update the 'Effective Family Resilience' document to expand this paragraph and include the wording above in red. This change cannot be unilaterally made but will be subject to the agreement of the Surrey Safeguarding Children Partnership and will need the approval of the Surrey Safeguarding Children's Board. We anticipate that agreement will be forthcoming and the document will then be amended accordingly.

Concern 10 At the prevention of future deaths hearing, I heard evidence concerning the post-death reviews conducted into Oskar Nash’s death by the Surrey Child Death Review Partnership Team and the Surrey Safeguarding Children Partnership. The evidence showed that neither process resulted in a sufficient or effective investigation of the death; I consider that the evidence shows that fact finding was superficial, there was no meaningful analysis of the part played by statutory agencies in the causation of his death, and only very limited learning was identified.

Ineffective review by the child death review processes results in the risk of further deaths in similar circumstances and I am concerned that the local and/or national process, guidance and oversight are insufficient to ensure that an effective post-death investigation, which should not be dependent on the inquest process, is achieved in all cases.

Response: The Coroner's concern is respectfully noted. In terms of post-death reviews, SCC follows the national guidance set out in Working Together 2018. This gives flexibility for the local

safeguarding partnership to decide how learning may be best generated and disseminated. Even if the criteria are met, it is not an automatic requirement to hold a Local Children’s Safeguarding Practice Review “It is for them to determine whether a review is appropriate, taking into account that the overall purpose of a review is to identify improvements to practice” (HM Government 2028:87). It is ultimately most important that local safeguarding partners respond to any death in a proportionate and appropriate way.

In respect of the post-death review into Oskar's death, SCC followed national guidance and took appropriate steps by way of a Thematic Review which was accepted by the National Panel.

SCC is aware that the Chair of the National Panel is also considering the Coroner's concern and will be providing a response to the same. SCC remains committed to following national guidance and will readily adopt changes in practice, if any, recommended by the National Panel.

Dear Mr Travers, Thank you for your Regulation 28 Report to prevent future deaths dated 31 January 2022 concerning the death of Oskar Nash on 10 January 2020. On behalf of Surrey Heartlands Clinical Commissioning Group (CCG), I want to express our deepest condolences to Oskar’s family. Following the prevention of future death hearing you raised a concern in your Regulation 28 report to prevent future deaths to the Chief Executive Officer of Surrey Heartlands CCG regarding the post death review process: Concern 10: At the prevention of future deaths hearing, I heard evidence concerning the post-death reviews conducted into Oskar Nash’s death by the Surrey Child Death Review Partnership Team and the Surrey Safeguarding Children Partnership. The evidence showed that neither process resulted in a sufficient or effective investigation of the death; I consider that the evidence shows that the fact finding was superficial, there was no meaningful analysis of the part played by statutory agencies in the causation of his death, and only very limited learning was identified. Ineffective review by the child death review process results in the risk of further deaths in similar circumstances and I am concerned that the local and/or national process, guidance and oversight are insufficient to ensure that an effective post-death investigation, which should not be dependent on the inquest process, is achieved in all cases. I would like to assure HM Coroner and the family that we have taken the issues raised in the report very seriously, they have been carefully and thoroughly considered at every level of the organisation and we have begun taking steps to address the issues raised. On 17 March 2022, the Surrey CDR team met with Professor , Professor of Infant Health & Developmental Physiology, University of Bristol and an academic at

the National Childhood Mortality Database (NCMD) to discuss the CDR process in Surrey. NCMD are currently undertaking a review of Joint Agency responses nationally (which include Surrey cases) to improve, strengthen and review the process. Any recommendations from this review will be fully implemented in Surrey.

Additionally, we are asking the National Team to undertake a review of the Surrey CDR process. This will provide an independent view of our CDR process, identifying any areas of improvement and/or assurance. We would be pleased to share this, and any resultant action plan for improvement with you.

The Child Death Review (CDR) following Oskar’s death is still open and is being completed in line with Statutory Process as outlined within the National Statutory Guidelines: Child death review: statutory and operational guidance (England). The review at the Child Death Overview Panel (CDOP) has not yet taken place, as CDOP do not consider any case until all investigations are completed, including the Coroner’s Inquest and any further investigations, like a PFD hearing, as these are an integral part of the CDR process. This is to ensure that every opportunity to capture learning is taken up before the CDOP review.

The CDR is the process to be followed when responding to, investigating, and reviewing the death of any child under the age of 18, from any cause. It runs from the moment of a child’s death to the completion of the review by the CDOP.

This is intended to be the final, independent scrutiny of a child’s death by professionals who have had no responsibility for the child during their life. It is at this point in the process that all learning from Oskar’s death is collated and includes information from parallel investigations, such as Coronial Investigation/Inquest, Joint Agency Response, Criminal Investigation, Serious Incident (SI) Investigation) into the final standardised report to NCMD to allow our local learning to influence national learning and future direction.

The CDR Team accept that the reporting forms (Form B’s) received were minimally completed. The CDR Team do not have direct access to any agency records and rely on professional accountability and integrity when completing the Reporting Form B. However, we will take forward this learning to ensure when forms are received providing minimal information, we go back and request greater detail from agencies to ensure we have a complete account of their involvement in that child’s life. In addition, a learning event has been arranged to support and provide guidance to professionals when completing a Form B.

Surrey CDR team have arranged a meeting with national colleagues in the NCMD to discuss the learning identified in relation to the completion of reporting form B’s and improvements needed to the Child Death Review processes.

Working Together to Safeguard Children (2018 p.103) states – “All practitioners participating in the child death review process should notify, report, and scrutinise child deaths using the standardised templates”. The templates are nationally agreed and available from the website www.gov.uk/government/publications/child-death-reviews- forms-for-reporting-child-deaths. The NCMD have replicated these templates for use within the electronic reporting system used in most areas across England, including Surrey (eCDOP). The majority of the boxes are direct questions with multiple choice answers, some provide free text. The format of the forms is nationally agreed, therefore, Surrey CDR team are not able to amend these forms at a local level. However, we will raise the issues identified with the NCMD to identify future improvements in processes.

In addition to the CDR process, to identify learning from a number of deaths from probable suicide and to help prevent future deaths, the CDR and the SSCP team undertook a thematic review in 2020. In response to concerns raised by parents, who reported that they had struggled to find information of where to access help and support, a Suicide Prevention Toolbox was developed. This is designed to be a living document which will be reviewed and updated as required. The Thematic Review was well received both locally and nationally and was used to challenge and influence the development of the design and offer of the new services in Mindworks Surrey. The action taken to date to prevent future similar deaths is as follows:

Dissemination of learning from the thematic review:
• In October 2020, over 200 participants attended one of four online sessions on ‘Probable Suicide by Children and Young People in Surrey Thematic Review Learning Event’ which was accredited for CPD by the Faculty of Public Health.
• The Learning from the Thematic Review and Suicide Prevention Toolbox was presented at dedicated webinars (Awareness of Autistic Spectrum Disorder (ASD); Management of self-harm; Prevention of alcohol and substance misuse; Parent support; Work across the County to mitigate Adverse Childhood Experiences (ACEs); Timely support for children and young people in crisis, Support for completing effective referrals; Implementing a Surrey Healthy Schools Approach)
• The Thematic Review and the Suicide Prevention Toolbox were published and shared at a national level with the National Safeguarding Panel and presented regionally at NHS England (NHSEI) and National Child Mortality Database meetings.
• Learning from thematic review and development of Suicide Prevention Toolbox has also been presented locally at:  monthly lunch & learn sessions which are attended by practitioners from all agencies across Surrey  GP safeguarding sessions  Incorporated in Surrey Children Services’ academy training

An Action Plan was developed in response to learning from the Thematic review

• A multi-agency Task & Finish Group was established to develop an action plan based on the learning and opportunities not to be missed that were identified in the thematic review.
• It was identified that as part of the Surrey Suicide Prevention Partnership, while there is an established adult subgroup (with a delivery workplan to monitor progress of actions to meet the priorities outlined in the Surrey Suicide Prevention Strategy) there was not a specific children and young person subgroup.
• Following the completion of the Task and Finish group, a children and young person subgroup of the Surrey Suicide Prevention Partnership was established in September 2021 to develop a delivery work plan and continue the monitoring and progression of the action plan developed by the Task and Finish Group.

Oskar’s death, including all information gathered throughout the CDR process, will be presented at the next suicide themed CDOP meeting; any additional learning and action required from Oskar’s death will be shared across services/multi-professionals in Surrey and nationally via NCMD. We have transitioned to holding themed panels on a repeating cycle which allows for better identification of themes. This will also allow an opportunity to review whether prior learning has been embedded in practice and identify any ongoing areas of concern.

While there is still ongoing work to be done, I hope this response provides assurance that the CDR Team at Surrey Heartlands CCG are committed to working with national colleagues to address concerns related to CDR processes highlighted in the Regulation 28 Report to prevent future deaths and we thank you for the opportunity to further reflect on learning following the sad death of Oskar.

Dear Mr Travers, Oskar Miles Nash, Deceased - Regulation 28 report to prevent future deaths I am writing further to your Regulation 28 report in relation to Oskar Miles Nash. We note with concern your conclusion that Oskar died as a result of Suicide contributed to by neglect on the part of Surrey and Borders Partnership NHS Foundation Trust’s Child and Adolescent Mental Health Service, and that his death was more than minimally contributed to by the various failures of: Surrey and Borders Partnership NHS Foundation Trust’s Child and Adolescent Mental Health Service; Surrey County Council’s Special Educational Needs Department; Surrey County Council’s Children’s Services Department and Targeted Youth Support Team; and St Dominic’s School and Cobham Free School, as outlined in your report. We note your finding in Concern 10 that neither of the post-death reviews conducted into Oscar Nash's death by the Surrey Child Death Review Partnership Team and the Surrey Safeguarding Children Partnership resulted in a sufficient or effective investigation of the death; that fact finding was superficial, there was no meaningful analysis of the part played by statutory agencies in the causation of his death, and only very limited learning was identified. We agree with your conclusion that ‘ineffective review by the child death review processes results in the risk of further deaths in similar circumstances’, and note your concern that ‘the local and/or national process, guidance and oversight are insufficient to ensure that an effective post-death investigation, which should not be dependent on the inquest process, is achieved in all cases’. In our response to your report, we will outline the steps we have taken and continue to take, in conjunction with the Department for Education, local Safeguarding Partners and with other national and local stakeholders to improve the quality and effectiveness of the child safeguarding practice review process. We restrict our response to those areas which come within our purview as the National Child Safeguarding Practice Review Panel. We note the finding expressed within Concern 10 in relation to the child death review process, and note that responsibility for those processes rests with the Department for Health and Social Care, the National Child Mortality Database 25 March 2022

team, and with the local Child Death Review Partners. While this is outside our remit, we recognise there are nevertheless considerable areas of overlap and we seek to work in collaboration with those responsible on areas of mutual interest so as to improve learning and reduce the risks of future death or harm to children.

The purpose and remit of the National Child Safeguarding Practice Review Panel

The National Child Safeguarding Practice Review Panel (hereafter the Panel) was established in 2018 as part of wider reforms to interagency working to safeguard children, as specified in the Children Act 2004 and amended by the Children and Social Work Act 2017. The purpose and remit of the Panel and the wider processes of local and national reviews are outlined in Chapter 4 of Working Together 2018.

The purpose of reviews of serious child safeguarding cases is ‘to identify improvements to be made to safeguard and promote the welfare of children’. Working Together 2018 stipulates that ‘Reviews should seek to prevent or reduce the risk of recurrence of similar incidents’. It goes on to state that they ‘are not conducted to hold individuals, organisations or agencies to account, as there are other processes for that purpose’. As such, these reviews are not intended to be investigations into the cause or circumstances of the death or serious harm, nor to determine whether any individual, organisation or agency was culpable. Nevertheless, at all stages of the safeguarding practice review process, both the local Safeguarding Partners, and we as a national Panel, seek to identify and learn lessons with a view to improving practice and better safeguarding and promoting the welfare of children.

Working Together 2018 specifies that the responsibility for how the system learns the lessons from serious child safeguarding incidents lies at a national level with the Panel and at a local level with the Safeguarding Partners. As a Panel, we are responsible for identifying and overseeing the review of serious child safeguarding cases which raise issues that are complex or of national importance, and to maintain oversight of the system of national and local reviews and how effectively it is operating.

The remit of the Panel and of the safeguarding practice review system is limited to reviewing serious child safeguarding cases which are defined as those in which:

• abuse or neglect of a child is known or suspected and
• the child has died or been seriously harmed. The death of a child in which abuse or neglect is not known or suspected would therefore not come within the Panel’s remit, and responsibility for any review of such deaths sits with the child death review partners. Such cases may at times come to the notice of the Panel when, for example, it is not clear whether abuse or neglect may have contributed, or where there is nevertheless potential for learning in relation to safeguarding children.

Where a local authority in England is aware of a serious child safeguarding case that meets the above criteria, they must notify the Panel and the local safeguarding partners within five working days. On receiving notification of a serious child safeguarding case, the safeguarding partners should promptly undertake a rapid review of the case. The aim of this rapid review is to:

• gather the facts about the case, as far as they can be readily established at the time;
• discuss whether there is any immediate action needed to ensure children’s safety and share any learning appropriately;
• consider the potential for identifying improvements to safeguard and promote the welfare of children; and
• decide what steps to take next, including whether or not to undertake a child safeguarding practice review. The Panel’s expectation is that these rapid reviews will be completed and submitted to the Panel within 15 working days. It is important to note that the timeframes for these rapid reviews are tight, so as to ensure that any learning coming out of the review process is not delayed and that the system of learning proceeds promptly and efficiently. This means, however, that any fact finding will, necessarily, be limited and the rapid review is geared towards identifying immediate learning. Should the rapid review identify the potential for further learning, then the expectation is that this will be explored through a Local Child Safeguarding Practice Review (LCSPR).

The LCSPR is a more in-depth review, commissioned by the safeguarding partners, where they determine that there is potential for further learning to identify improvements to practice. These reviews should take a thorough and systematic approach to learning from the case, and should seek to involve the family as well as relevant practitioners and managers. They should be completed within six months, published and submitted to the Panel. The reviews should be carried out by an independent reviewer, using principles of systems methodology and in a way that enables the review to look at and analyse frontline practice as well as organisational structures and learning. The reviews should be proportionate to the circumstances of the case, focus on potential learning, and establish and explain the reasons why the events occurred as they did.

Local Safeguarding Partners have a duty to ensure that the review is of satisfactory quality. The Safeguarding Partners also have a responsibility to disseminate learning from the review and to take appropriate action in response to the findings.

As part of its remit to maintain oversight of the system and how effectively it is operating, the Panel receives and appraises all rapid reviews and LCSPRs. We provide feedback to the local Safeguarding Partners on the quality of both rapid reviews and LCSPRs, and identify, collate and disseminate learning arising from these reviews.

Actions taken to date to improve learning Since its inception, the Panel has been sent over 1500 rapid reviews and we have seen the publication of more than 100 LCSPRs. In 2021 there were a total of 398 rapid reviews, of which 156 related to fatal cases and 242 to non- fatal serious harm. In 125 cases (31%), the local Safeguarding Partners decided to commission an LCSPR.

As a Panel we have had significant concerns about both the quality and timeliness of both the rapid reviews and the LCSPRs. While we have seen some excellent examples of high-quality review and learning submitted within the specified timeframes, we have also seen rapid reviews and LCSPRs that are tardy, unfocused and insufficiently analytic. We recognise that some of this has been due to Safeguarding Partners and reviewers getting used to the new system of reviews. In addition, the Covid-19 pandemic and consequent lockdowns had a particular impact on the ability of Safeguarding Partners to complete both rapid reviews and LCSPRs in a timely manner. Nevertheless, we remain concerned that, too often, the reviews are not of sufficient rigour and quality to identify meaningful learning and to drive relevant improvements to children’s safeguarding.

In 2018 the Panel produced detailed practice guidance which outlined the process of reviews and our expectations for what makes for good quality reviews. We are in the process of updating this guidance in light of our learning since 2018.

In response to each rapid review and LCSPR which we receive as a Panel, we write to the Safeguarding Partners, providing feedback on the content and quality of the review, any learning arising from it, and actions we are taking as a Panel in response to any national issues identified. While initially much of this feedback was focused on the process and criteria for reviews, we have increasingly been more detailed and focused on issues of quality and learning. In cases which are particularly complex, or where we as a Panel have particular concerns about the quality of the review, we will often engage directly with the Safeguarding Partners through telephone calls or online or face-to-face meetings, offering advice, guidance and support. Where we deem a review to be of insufficient quality, we may ask the Safeguarding Partners to amend the report, or take further action to achieve more meaningful learning, or ask for evidence of implementation and impact of action in response to any recommendations.

Over the past two years we have sought to improve our communication with Safeguarding Partners in order to improve the quality of and learning from the review process. We have instituted a system of regional working with individual Panel members assigned as leads to each of the nine government regions. This has been backed up by a series of regional webinars, in which we have explored learning coming from both local and national reviews as well as issues of quality and process.

In addition to our oversight of the system of local reviews, as a Panel we are

responsible for commissioning national reviews into cases which raise issues of national importance. To date we have completed and published three national reviews, each of which has been a thematic review, drawing on a number of cases relating to a particular theme: sudden unexpected death in infancy (SUDI); child criminal exploitation; and non-accidental injury in infants aged under one. Each of these thematic national reviews has sought to identify relevant learning to inform practice and system improvement within the relevant area. While the Panel has no immediate plans to announce a national review into suicide it remains a theme in which we have a very keen interest and we will continue to analyse the cases which we see to consider if a practice briefing or more detailed piece of thematic work in this space would aid system learning.

Ongoing and planned actions to improve learning

As a Panel we have noted improvements in both the timeliness and quality of rapid reviews over the past year. We continue to feedback to local Safeguarding Partners on the content and quality of their rapid reviews. We are now also receiving significant numbers of completed LCSPRs. To date, very few of these have been completed within the required timeframe of six months, and many have been delayed by a year or more. We consider this unacceptable and are working with Safeguarding Partners to ensure that they take a more streamlined and focused approach to learning through the LCSPRs, but we are aware that there is still a long way to go.

In recognition of the ongoing issues around timeliness and quality, and taking note of your expressed concerns regarding the Oskar Nash rapid review, we are currently updating our practice guidance, with a much greater focus on issues of quality and learning in the reviews. We are planning also to publish some anonymised examples of good quality rapid reviews as exemplars of good practice.

We continue to monitor the learning from all rapid reviews and LCSPRs and are in the process of developing an observatory function to provide up-to-date data and information on all serious safeguarding cases, along with a case tracking system to enable us to monitor and report on the progress of reviews. We have, to date, and will continue to commission national analyses of the learning from rapid reviews and LCSPRs, and both of these pieces of work include some analysis of the quality of those reviews. We publish the findings of these analyses as part of our annual report.

We continue to commission national thematic reviews and currently are undertaking a review of domestic abuse which we intend to publish shortly. In addition, we are carrying out two case-specific national reviews – one into the deaths of Arthur Labinjo-Hughes and Star Hobson, and one into safeguarding children with disabilities and complex health needs in residential settings - both of which will report later this year.

Conclusion We note that the rapid review on Oskar Nash was undertaken in January
2020. A lot has happened since then, and it is our impression that there have been significant improvements in the quality of both rapid reviews and LCSPRs over that time. We recognise, however, that there is still a lot to be done to ensure that the system of safeguarding practice reviews is more fit for purpose. We welcome this Regulation 28 report as a stimulus both for us as a Panel and for all local Safeguarding Partners to improve the quality of reviews and the overall learning coming from them.

I hope that this letter provides you with relevant and helpful information about the national system of reviews of the circumstances around the deaths of children as a result of abuse or neglect.