Source · Prevention of Future Deaths

Jacob Bates

Ref: 2019-0456 Date: 31 Dec 2019 Coroner: Peter Nieto Area: Derby & Derbyshire Responses identified: 1 / 1 View PDF

Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due to resource constraints.

Date 31 Dec 2019

56-day deadline 25 Feb 2020 est.

Responses identified 1 of 1

Community health care and emergency services related deaths Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

As have stated did not find that the evidence established a causal or contributory connection between the unregulated placement and Jacob's death: found this to be So on the applicable civil iaw test; the balance of probabilities. However in my summing-up did express my serious concerns that Jacob had been placed in an unregulated placement despite his history, needs, and risks_ Evidence was given at the inquest hearing by two former employees at the placement that had no prior experience of working with young people (indeed no experience . of working in any form of care-related work) and were left in charge of the unit where Jacob was placed after a very short period of commencing employment (one former staff member said that he had only completed two shadowing sessions before being asked to be in sole charge of the unit overnight). The evidence of the responsible local authority was that it had not sought evidence from the placement provider as to staff competency and training, or that suitable policies and procedures were in place; it" effectively accepted the assurances of the provider prior they

The local authority stated that it now has systems providing for greater scrutiny and diligence but it was explained that where residentiallsupported provision is solely for young people aged 16 to 18 that provision: falls outside or the statutory regime of inspection , and regulatory compliance as enforced by Ofsted. My understanding is that the issue of unregulated placements for 16 to 18 year olds has been widely highlighted as a cause for concern but the evidence of a senior local authority manager at inquest was that she was unaware of any plans nationally to address the issue despite concerns having been very widely raised. 1. Vulnerable young people, aged 16 to 18 , are being placed in unregulated placements_ Any young person under the age of 18 placed in an unregulated placement is likely to have very significant vulnerabilities, and it is Iikely that young people with complex needs and at significant risk are being placed in such placements; indeed this was the case for Jacob_ 3_ As the placements are unregulated there are no statutory regulations to comply with relating to competency and appropriate policies and procedures by the provider and there is no regulatory body to check and assess those providers_ This is clearly a concerning situation given the very high level needs that some of the young people will have The lack of statutory regulation then places an onus on local authorities to check that a provider is competent and safe_ Whilst in making individual placements it must be the duty of a local authority to satisfy itself as best as it is able that placements are 'safe' , given the pressures on local authorities it cannot be the case that are in a position to mirror the type and nature of inspection arid oversight that might be provided by regulator such as Ofsted .
5. In view of the points made above the lack of statutory regulation is placing vulnerable young people at risk, and:' there is a realistic possibility that deaths may occur

Responses

1 respondent

the Secretary of State for Education Central Government

27 Feb 2020 PDF

Action Planned

The Department for Education launched a consultation on proposals to ensure unregulated provision is used appropriately, including introducing new national standards and enforcement mechanisms, with the consultation open until April 8, 2020. (AI summary)

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Dear Mr Peter Nieto, Thank you for your correspondence of 31 December 2019 about the death of Jacob Andrew Bates_ would like to take this opportunity to say how deeply saddened am about Jacob's death. His loss, at such a young age and in such circumstances is deeply upsetting and offer my condolences to those who knew; loved and supported Jacob. report raises several matters of concern surrounding the use of unregulated provision. believe every child and young person should have access to a stable and secure placement in accommodation that can meet their needs and, most importantly, keep them safe. It is unacceptable for any child or young person's placement to not meet their needs or keep them safe, for any amount of time. share your concerns that unregulated settings are not always good enough, and that some children are being placed at risk or in settings that cannot meet their needs. It is clear that reform is urgently needed, and this is why on 12 February 2020 | launched a consultation on a range of proposals to ensure that unregulated provision is being used appropriately and meets the needs of young people placed there: Depa EDucATION 'ArTMeNT Your the

will not tolerate poor provision that fails our most vulnerable children. This is these proposals include introducing new checks and balances in the system, including the introduction of new national standards for providers of independent and semi-independent provision. The proposals aim to improve provision and make it easier for local authorities to assess the quality of what is on offer. We are also consulting on how these standards should be enforced either by mandating local authorities to only use providers that meet the standards, or by introducing a new quality and inspection regime , overseen by Ofsted, similar to the regime already in place for children's homes. This consultation is an opportunity to shape our proposals and next steps in terms of what and how we might implement the proposals. It is open for response until 8 April 2020 and can be accessed at https Ilconsulteducation %ov uklunrequlated-provision/unregulated-provision: children-in-carel would welcome your views, and those of all interested persons, on the detailed proposals_ It is a priority for this Government that children and young people in care have the support; protection and care they deserve_ The independently led Care Review will also take a fundamental look across children's social care with the aim of better supporting, protecting and improving the outcomes of vulnerable children and young people. However; am clear that the issue of unregulated provision cannot wait and requires immediate and decisive action to be taken. Following the consultation we will consider the responses received and publish a response which will include a timetable for any reforms that will be taken forward Once again, was sorry to of this tragedy and hope our proposed reforms will prevent children and young people being placed in provision that does not need their needs_

Report sections

Investigation and inquest

On 17 July 2017 commenced an investigation into the death of Jacob Andrew Bates (dob: January 2000; dod: 2017). The investigation concluded by way of an inquest hearing from to December 2019 (a copy of the record of inquest is enclosed with the covering letter to this report). My findings at inquest were as follows: Medical cause of death: 1a Ligature around the neck 1b Mental health issues and autism: Summary of circumstances: Jacob died as a result of placing plastic ties around his neck as ligatures. Although he had not given any immediate indication to anyone that he was contemplating taking his own life he was assessed as being at on-going risk of serious self-harm_ Due to the nature of the act; his self-harm history, the on-going assessed risk, and his leaving of a 'suicide' note found that he had undertaken a deliberate act with the intention of taking his own life. Just prior to his death a six month unregulated placement had recently been ended, and to that placement he had spent over two and half years in a succession of secure placements July prior

On the evidence did not find that factors associated with the unregulated placement had directly contributed to Jacob's death: My conclusion as to Jacob's death was a short form conclusion of suicide

Circumstances of the death

Jacob had diagnoses of autism and mental health problems. Following serious overdose in February 2014 he was thereafter placed in succession of secure placements under the provisions of the Mental Health Act 1983 and the Children Act 1989 until he returned to his home area of Chesterfield around Christmas 2016 when he was placed, under the provisions of s.20 Children Act 1989; in an unregulated placement for young people aged between 16 .and years of age and was also supported by local authority social care and child and adolescent mental health services: The Chesterfield placement was not specialist placement for young people with autism or mental health problems and the placement had 'been made in the context of specialist placement having given very short notice of termination of placement_ There had been many episodes of self-harm following the overdose in February, some serious, including just two months to his death and he was assessed at on-going risk of serious self-harm:" The Chesterfield placement came to an end following Jacob's decision to move in to live with his father where he received on-going support from the agencies

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_

Inquest conclusion

Medical cause of death: 1a Ligature around the neck 1b Mental health issues and autism: Summary of circumstances: Jacob died as a result of placing plastic ties around his neck as ligatures. Although he had not given any immediate indication to anyone that he was contemplating taking his own life he was assessed as being at on-going risk of serious self-harm_ Due to the nature of the act; his self-harm history, the on-going assessed risk, and his leaving of a 'suicide' note found that he had undertaken a deliberate act with the intention of taking his own life. Just prior to his death a six month unregulated placement had recently been ended, and to that placement he had spent over two and half years in a succession of secure placements July prior

On the evidence did not find that factors associated with the unregulated placement had directly contributed to Jacob's death: My conclusion as to Jacob's death was a short form conclusion of suicide

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Shared signals

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Report details

Reference: 2019-0456
Date of report: 31 December 2019
Coroner: Peter Nieto
Coroner area: Derby & Derbyshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 25 Feb 2020 (estimated).

Sent to

Department for Education

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.