Source · Prevention of Future Deaths

Georgia Scarff

Ref: 2026-0378 Date: 4 Feb 2026 Coroner: Darren Stewart Area: Suffolk 2 responses identified · 2 indexed addressees View PDF

Response deadline: 23 November 2026 (estimated from the Judiciary.uk publication date).

Date 4 Feb 2026
56-day deadline 23 Nov 2026 est. estimated from the Judiciary.uk publication date
Responses identified 2 of 2

Coroner's concerns

Coroner’s Concerns (source excerpt)
Royal Hospital School (RHS) During the course of the Inquest the Court received evidence of the introduction and use of the Child Protection Online Management System (CPOMS) as a safeguarding system to ensure the safety of children attending RHS. In addition, the Court heard evidence of appropriate action being taken when concerns relating to Georgia...
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Royal Hospital School (RHS) During the course of the Inquest the Court received evidence of the introduction and use of the Child Protection Online Management System (CPOMS) as a safeguarding system to ensure the safety of children attending RHS. In addition, the Court heard evidence of appropriate action being taken when concerns relating to Georgia were raised by her mother to school authorities.

However, the Court also heard evidence that not all staff were familiar with or proficient in the use of CPOMS which, although not causative of Georgia’s death, led to important information not being recorded in Georgia’s CPOMS record.

I am concerned that in another case the failure to record important safeguarding detail may result in a risk to life.

Department for Education (DfE) During the course of the Inquest the Court heard evidence of national statutory guidance to schools in relation to safeguarding of children in the form of the DfE document ‘Keeping children safe in education 2025, Statutory guidance for schools and colleges’ dated September 2025.  This statutory guidance includes reference to record keeping and information sharing.

However, the Court also heard evidence that there is no single standard safeguarding information management tool for schools and colleges.  Teachers moving between schools and colleges must familiarise themselves with different processes and tools depending on that used by an individual school or college.

I am concerned that the absence of a single standard safeguarding information management tool for schools and colleges may result in a risk to life due to teachers being unfamiliar with different management tools and as a consequence important information relating to safeguarding not being recorded in children’s safeguarding records.

Responses

2 respondents

Department for Education

Central Government
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AI-classified response stance Action Planned
AI-generated response summary

The Department for Education plans to introduce an information sharing duty and a Single Unique Identifier via the Children’s Wellbeing and Schools Bill to improve safeguarding information sharing, though it does not support creating a national system or database. It also highlighted existing statutory guidance (KCSIE) for schools on record keeping and information sharing.

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Dear Darren Stewart OBE, I am writing on behalf of the Secretary of State for Education in response to the Regulation 28 Report to Prevent Future Deaths issued on 4 February 2026 concerning the tragic death of Georgia Charlotte Scarff on 15 April 2024. I am responding in my role as the Minister for Children and Families. I was deeply saddened to learn of Georgia’s death and would like to offer my heartfelt sympathy to her family and friends. Your report identified two key areas where action might prevent future deaths:
• One action related to your concern that not all staff at the RHS were familiar with or proficient in the use of CPOMS which, although not causative of Georgia’s death, led to important information not being recorded in Georgia’s CPOMS record. You were concerned that in another case the failure of staff to record important safeguarding detail may result in a risk to life.
• You were also concerned that the absence of a single standard national safeguarding information management tool for schools and colleges may result in a risk to life, due to teachers being unfamiliar with different management tools and consequently, important information relating to safeguarding not being recorded in children’s safeguarding records. Schools and colleges play an incredibly important role in safeguarding and promoting the welfare of children. They have daily contact with most children and are uniquely placed to identify concerns and address them early. We support schools and colleges to do this through our statutory safeguarding guidance, Keeping children safe in education (KCSIE), which all schools and colleges must have regard to when safeguarding and promoting the welfare of children, including independent schools. KCSIE is very clear that all concerns, discussions and decisions made, and the reasons for those decisions, should be recorded in writing. Information should be kept confidential and stored securely. It is good practice to keep concerns and referrals in a separate child protection file for each child. Records should include:
• a clear and comprehensive summary of the concern. Sanctuary Buildings 20 Great Smith Street London SW1P 3BT tel: 0370 000 2288 www.education.gov.uk/contactus/dfe

[Page 2]
• details of how the concern was followed up and resolved; and
• a note of any action taken, decisions reached and the outcome. If in doubt about recording requirements, staff should discuss with the designated safeguarding lead (or a deputy). KCSIE also makes very clear that information sharing, amongst other things, is vital in promoting children’s welfare, including in relation to their educational outcomes. Schools and colleges have clear powers to share, hold and use information for these purposes. As part of meeting a child’s needs, it is important for governing bodies and proprietors to recognise the importance of information sharing between practitioners and local agencies. This should include ensuring arrangements are in place that set out clearly the processes and principles for sharing information within the school or college and with local authority children’s social care, the safeguarding partners and other organisations, agencies, and practitioners as required. Part one of KCSIE is clear that the school’s designated safeguarding lead (or a deputy) should always be available to discuss safeguarding concerns. If in exceptional circumstances, the designated safeguarding lead (or a deputy) is not available, this should not delay appropriate action being taken. Staff should consider speaking to a member of the senior leadership team and/or take advice from local authority children’s social care. We know that CPOMS is heavily used in many schools, but it is not a requirement for schools to use CPOMS. Instead, schools must have regard to KCSIE, which sets out expectations in relation to record keeping and the sharing of information, as well as that all staff receive safeguarding training and know what to do if they have a concern about a child. Independent schools in England, like RHS, are also regulated by this Department and must comply with the Independent School Standards (ISS) at all times. Schools are inspected against these standards by the relevant inspectorate. Compliance with safeguarding requirements is assessed through the ISS, which require schools to have regard to KCSIE. Where schools are found not to comply with the ISS, the Department may take regulatory or enforcement action in line with its regulatory and enforcement policy statement. Whilst we agree that information sharing needs to be improved, we do not think this is best achieved through the creation of a national system or database. Instead, through the Children’s Wellbeing and Schools Bill we are introducing an information sharing duty, requiring relevant persons to share information relating to safeguarding and wellbeing, and making provision for a Single Unique Identifier, or consistent identifier, which will help join up systems and improve speed and accuracy of information sharing. We are currently piloting how this works and intend to introduce it by the end of this Parliament.

[Page 3] Thank you for bringing this important matter to my attention and giving me the opportunity to respond.

Royal Hospital School

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AI-classified response stance Action Taken
AI-generated response summary

The Royal Hospital School introduced a new assessment template, strengthened its safeguarding leadership, and implemented regular safeguarding updates and meetings. Following the inquest, all staff attended in-person CPOMS training, were issued a guide, and CPOMS user access was enhanced, with ongoing refresher training established.

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Dear Mr Stewart, Re: Response relating to Regulation 28 Report into the death of Georgia Scarff Thank you for your Report to Prevent Future Deaths regarding the very sad death of Georgia. Before addressing the specific matters of concern raised, I would like to express, on behalf of the Royal Hospital School (RHS), our deep condolences to Georgia’s family. Our community remain saddened by her loss. Your Report highlights concern regarding our Child Protection Online Management System (CPOMS), that not all staff were familiar or proficient in the use of CPOMS. While this was not found to be causative in Georgia’s death, the school has reflected carefully on this concern. As part of our ongoing development of safeguarding practice, a number of changes were implemented in the period between Georgia’s death and the inquest. In September 2024, we introduced a new assessment template for pupils on the watch list, ensuring their needs and support arrangements are clearly documented and reviewed at least termly. In January 2025, we strengthened our safeguarding leadership structure by appointing a new Designated Safeguarding Lead (DSL) and expanded the Deputy DSL team from one member of staff to four, increasing both expertise and capacity. From January 2025, the DSL also began issuing safeguarding updates to all staff every two to three weeks. These communications include explicit reminders on the use of CPOMS and expectations around recording. The DSL team commenced twice-per-half-term meetings to review safeguarding matters and work through scenarios designed to support consistent decision-making. In September 2025, we introduced a further measure ensuring that all pupils on the watch list are raised in every fortnightly DSL–House Parent 1:1 meeting; these observations are subsequently entered on CPOMS. During this time, the DSL also engaged in additional professional development, including training on suicide prevention and safety planning. Following the inquest, we implemented additional actions directly related to the concern you raised. On 5 January 2026, all staff attended in-person CPOMS training supported by contextualised examples drawn from our own school environment. Staff were also issued with the RHS Guide to Using CPOMS, including all new staff on starting RHS. We have Royal Hospital School, Holbrook, Ipswich, Suffolk, IP9 2RX t +44(0)1473 326200 e reception@royalhospitalschool.org www.royalhospitalschool.org

[Page 2] enhanced CPOMS user access and alert settings to support improved oversight and responsiveness. A programme of ongoing refresher training has been established, supported by checking exercises designed to monitor staff confidence and identify where further development is needed. Any areas for improvement will be addressed through targeted training. Finally, in November 2025, RHS has joined the Inspired Learning Group which provides an additional layer of rigour, oversight and expertise at Head Office level. RHS is fully committed to maintaining a safeguarding culture in which information is recorded accurately and consistently, and in which all staff understand the importance of effective documentation in keeping pupils safe. We are confident that the actions outlined above address the concerns raised in your Report and demonstrate our ongoing commitment to strengthening safeguarding practice.

Report sections

Investigation and inquest
On 17 April 2024 I commenced an investigation into the death of Georgia Charlotte SCARFF aged 16.

The investigation concluded at the end of the inquest on 10 October 2025. The conclusion of the inquest was: Narrative Conclusion – Georgia Charlotte SCARFF was described by her family and friends as a caring, compassionate, thoughtful, kind and generous person who exuded warmth and a self-assured charisma.  A private person whose company was uplifting, who deeply loved and cherished her family and who had a genuine desire to see the lives of those around her enhanced.

At school, Georgia had been an accomplished and talented athlete who was known for her conscientiousness and commitment to her studies.  During her GCSE year Georgia started to develop anxiety in relation to her academic performance, future options and how she would manage these.  She confided her concerns to her mother who sought assistance from Georgia’s school in January 2024.  Georgia had not confided to anyone at her school about her concerns and had appeared to behave normally to both fellow students and staff throughout this time.  Notwithstanding this, the school arranged for Georgia to receive counselling and at the time of her death she had undertaken three sessions with a Counsellor.

Sunday, the 14th April 2024 was the last day of the Easter break and Georgia retired to bed that evening with the expectation being that she would return to school the following morning.  She appeared to be normal and her family recalled her having had an enjoyable break and that evening seemed to be her usual self.

At some point between 10.00 pm during the evening of the 14th and 01.20 am in the early morning of the 15th April 2024, Georgia left her home and proceeded to walk around Bury Saint Edmunds.  She sent several messages to her mother and sister expressing thoughts of a concerning nature.  At around 01.30 am on the 15th April 2024 Georgia stepped into the path of a lorry driving westbound on the A14 in the vicinity of Bury Saint Edmunds.  The impact with the lorry caused injuries which led to Georgia’s immediate death.  A subsequent Police investigation established that no defect with the lorry or conduct on the part of the driver were causative of Georgia’s death.

At the time of her death, Georgia was experiencing anxiety associated with her ruminating about what she perceived to be concerns relating to her studies and future life choices.  This led to Georgia acting impulsively in taking her own life by stepping into the path of a lorry and which caused her death.

The medical cause of death was confirmed as: 1a Severe Head Injury 1b Road Traffic Collision CIRCUMSTANCES OF THE DEATH Narrative Conclusion see part 4.

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Report details

Reference
2026-0378
Date of report
4 February 2026
Coroner
Darren Stewart
Coroner area
Suffolk

Responses identified

Responses identified 2 of 2
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Nov 2026 (estimated from the Judiciary.uk publication date).

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Department for Education
Royal Hospital School

Part of a series

2 reports
2026-0057 0 responses identified

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