Source · Prevention of Future Deaths

Ben Walmsley

Ref: 2018-0363 Date: 21 Nov 2018 Coroner: Joanne Kearsley Area: Manchester (North) Responses identified: 0 / 1 View PDF

The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking missed safeguarding opportunities.

Date 21 Nov 2018
56-day deadline 21 Jun 2019 est.
Responses identified 0 of 1
Child Death (from 2015) Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary
The school's IT system lacked a mechanism to alert staff when students attempted to access blocked self-harm content, relying solely on teacher monitoring and risking missed safeguarding opportunities.
View full coroner's concerns
the evidence revealed matters giving rise to concern ; In my opinion there is During the course of the inquest is taken: In the circumstances it is my statutory duty to a risk that future deaths will occur unless action report to you into Bens death it emerged that on a number %f davs in the month prior During the course of the investigation Phillips Secondary school) computers "how to kill myself to his death he had searched on the school (St "how to tie a noose' why shouldn't commit suicide" the Court that the school filters are accessed via Smoothwall which provides age It was explained to Ben could not access these pages as they were blocked there was no appropriate filtered content Whilst school tO be made aware that a pupil may have attempted to search mechanism in place at the time for the for such pages that at the time of Ben's death the only monitoring was in lessons andWas solelr The Court heard evidence students were doing: The school has 900 pupils and the Court reliant on the teacher trying to watch what to access blocked content Not all of these heard in any one day there can be 12,000 attemptsi bv pupils relate to social media pages would be as concerning as the content Ben was trying to access, some may which the school does not allow. provided to the Court that since Ben's death_Smoothwallhave now upgraded functionality Evidence was and aged set and and blocked high Tisk safeguarding categories are attempting to be staffnow receive notifications when accessed. identified members of staff. Since this installation These alerts are "real time notifications and go to three similar sites to Ben and have taken action staefhave been notified of two other children attempting t0 acceort to aspeakeo €herand also to speak to their parents to offer support is mandatory for all schools or indeed whether other software However it is not known if this functionality providers who are used by schools have this consider disseminating this information; this is of course a If schools do not have this facility you may wish to matter for yourself.

Report sections

Investigation and inquest
concluded an Inquest into the death of Ben Walmsley date of birth 21.09.2002 On the 19"h November 2018 who died on the 04.02.2018 15 years old:
Circumstances of the death
of the death are that on the 4" February 2018 Ben Walmsley committed suicide The circumstances at his home address by hanging: involvement with any services at the time of his death: Bury Safeguarding Childrens Ben had little review into previous contact and a number of learning Board have undertaken Serious Case points arise from this of the Inquest evidence was heard on one specific issue which am of However during the course order to prevent future deaths. Details of this are out the opinion needs to be addressed in below.
Action should be taken
be taken to prevent future deaths and believe each of you respectively In my opinion action should have the power to take such action.

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Report details

Reference
2018-0363
Date of report
21 November 2018
Coroner
Joanne Kearsley
Coroner area
Manchester (North)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Jun 2019 (estimated).

Sent to

Department for Education

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