Mia Janin

PFD Report All Responded Ref: 2024-0103
Date of Report 22 February 2024
Coroner Tony Murphy
Coroner Area North London
Response Deadline ✓ from report 18 April 2024
All 1 response received · Deadline: 18 Apr 2024
Response Status
Responses 1 of 1
56-Day Deadline 18 Apr 2024
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroners Concerns
(1) Any ongoing gender based bullying at JFS gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future; and (2) The initiatives introduced by JFS to address gender based bullying following Mias death do not appear to have gained the confidence of some JFS female students, which gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future.
Responses
The Jewish Free School
22 Feb 2024
Response received
View full response
HM Area Coroner for North District of Greater London Mr P. A. Murphy

In the matter of an inquest touching the death of Mia Janin

Jewish Free School response to a report on action to prevent future deaths pursuant to paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013

Introduction I am witing in response to the 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 22nd February 2024 in respect of the death of Mia Janin, and I respond as the Headteacher of the Jewish Free School (JFS).

On behalf of JFS I would like to continue to extend condolences to Mia’s family.

Concerns The Prevention of Future Death Report identifies the below matters of concern that I address with reference to details of actions already taken and that we plan to undertake.

(1) Any ongoing gender-based bullying at JFS gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in future; and (2) The initiatives introduced by JFS to address gender based bullying following Mia’s death do not appear to have gained the confidence of some female students, which gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist in future.

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The prevention of future deaths report notes:

“The current head teacher of Mia’s secondary school- the Jewish Free School (JFS) - gave evidence at the final inquest hearing concerning systemic changes introduced at JFS following Mia’s death. This included a complete overhaul of safeguarding practices, increased behaviour management, improved information, staff surveys and externally delivered sessions by charities including Norwoord, Streetwise, Jewish Womens Aid and Keshet”

“Evidence provided by some JFS students after Mia’s death to the police and Ofsted described regular incidents of gender based bullying by some male JFS students of some female JFS students. Some of those child witnesses have not experienced a change in culture at JFS since Mia’s death and did not describe being consulted or surveyed about the changes introduced by JFS”.

Although JFS considers that much of the evidence referred to in the Regulations 28 Report that was provided by some JFS students after Mia’s death to the police and Ofsted pre-dates the changes implemented following Mia’s death, JFS nevertheless takes your concerns very seriously and has carefully reviewed and considered the matters within the Regulation 28 Report.

It is hoped that this response assures you and Mia’s family that JFS is committed to continuous improvement in relation to initiatives to address gender-based bullying and all forms of bullying.

Response In summary relevant changes introduced at JFS since Mia’s death, include but are not limited to:
a. The appointment of a full-time safeguarding lead.
b. The appointment of 5 full time Safeguarding Officers, who report to the Designated Safeguarding lead.
c. The appointment of a Director of Behaviour, Head of Key Stage 3 and Head of Key Stage 4 all of whom are Assistant Principals and sit on the Senior Leadership Team.

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d. The appointment of four Pastoral Officers, reporting to the Behavioural Lead.
e. The appointment of a Mental Health Lead, who leads a wellbeing team consisting of 2 counsellors and on average 5 trainee counsellors.
f. The redrafting of the Safeguarding and Child Protection Policy, the Anti-Bullying Policy and the Behaviour and Discipline Policy.
g. The delivery of formal Personal, Social and Health Education (PSHE) teaching in the curriculum to address all aspects of personal development, during which expectations of appropriate behaviour regarding all aspects of student conduct are made clear.
h. The introduction of ‘Child Protection Online Management System’ (CPOMS) as a centralised reporting tool used by all staff across the school.
i. The introduction of an ‘Investigation and Reporting’ room to which students who are disrupting lessons are sent and where any students can report any problems or concerns, they are experiencing.
j. The introduction of an anonymous reporting system on the school website.
k. The introduction of a Peer Buddy programme involving annual training of 30 Year 10 students to work with Year 7 through weekly sessions with tutor groups.
l. The introduction of ‘Time to Talk’ which runs every lunchtime and is staffed by two experienced members of staff. This is a forum for students to relax and talk about anything that is on their mind.
m. Weekly safeguarding updates for staff.
n. Monthly safeguarding newsletter for parents.

The below elaborates further on the above changes.

In the most recent OFSTED report following an inspection in April 2022, OFSTED noted that: “Pupils know to whom and where they can turn if they have any worries. Pupils felt confident to report any concerns because staff help them. Staff are vigilant to any incidents of bullying and act swiftly to resolve any bullying issues”.

Serious consideration has been given by JFS to the school’s programme of personal, social and health education (PSHE), which includes education in respect of relationships and sex education. In April 2022 in relation to JFS’s PHSE programme, OFSTED noted: “Dedicated sessions for all year groups are delivered by trained staff. These sessions are supplemented with specially organised workshops in response to identified and specific risks to pupils’ well-

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being or requests and suggestions from pupils, including the school’s LGBTQ+ group.”. It is hoped that the specific reference by OFSTED to ‘requests and suggestions from pupils’ being reflected in the PHSE programme reassures the court that student concerns are gathered, listened to, and acted upon.

CPOMS is a centralised behaviour system. Staff submit entries on CPOMS based on any concerns, including gender-based bullying, they themselves may witness or any concerns reported to them by any student. CPOMS entries are reviewed on an ongoing basis by the Safeguarding team and allocated to a member of the safeguarding team for appropriate action. Entries on CPOMS include what may appear as low-level concerns to ensure effective aggregate data collection, which in turn ensures all concerns relating to each student are centrally available. CPOMS therefore enables the safeguarding team to have an overview of any issues taking place, as well as consider and take appropriate action in respect of any emerging patterns, which include any issues relating to gender-based bullying.

All students at JFS are known and supported. JFS now has multiple coordinated systems that work to protect children, and staff work to ensure safeguarding is effective. To ensure there are no communication gaps between the Safeguarding and Behaviour teams, fortnightly review meetings are attended by the Designated Safeguarding Lead, Mental Health and Wellbeing Lead, Special Educational Needs Coordinator, Safeguarding Officer and Director of Key Stage. All students in JFS have a safeguarding rating between 1 and 4, 4 representing the highest level of risk and 1 representing no known risk. Students receive personal check-ins from the Safeguarding Officers to understand each individual’s circumstances. This means that all students irrespective of risk rating, receive detailed check-ins to review any issues that they may have alongside any changes or concerns that may have been logged on CPOMS. All actions from these reviews are logged on CPOMS for follow-up. Such data review provides a further opportunity for year group changes and trends to be identified and appropriate action to be taken. By way of further safeguard, once a month our Safeguarding Governor meets with the Designated Safeguarding Lead to review the top-10 most significant concerns.

In respect of your concerns in relation to ongoing issues in respect of, or initiatives in relation to gender-based bullying, JFS has an anti-bullying policy that is reviewed annually. The current version of the anti-bullying policy was published in January 2024, a copy of which has already been provided to the Court, which clearly states that “Bullying of any sort will not be

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tolerated…”. The anti-bullying policy expressly recognises that bullying behaviour may be sexist. As set out in the anti-bullying policy, all concerns in respect of any bullying, which includes sexists or gender-based bullying will be seriously and thoroughly investigated.

In the first instance JFS seeks to dissuade students from negative behaviours, including gender- based bullying, through various approaches including: reinforcing expectations at the start of each half term, regular reminders during assemblies, PSHE sessions, anti-bullying week, visiting speakers, incorporating an ‘anti-bullying’ message into lessons, and peer to peer buddies.

Staff receive training in school policies and are trained to be alert and responsive to signs of bullying. JFS also seeks to enable and encourage students and parents who are aware of bullying to report any concerns to a member of staff. Staff will record any concerns on CPOMS and concerns will then be investigated and appropriate action taken.

JFS has a Behaviour and Discipline Policy, this was also last reviewed in January 2024 and a copy has been provided to the Court. The Behaviour Policy and Discipline Policy specifically sets out that JFS aims to “promote tolerance and consideration for others regardless of race, creed, gender, perceived ability, age, appearance of disability and develop appropriate strategies to eradicate bullying”. Through this policy JFS seeks to impose clear and consistent sanctions to clearly communicate that gender-based bullying or indeed bullying of any kind, will not be tolerated.

JFS is pro-active in educating students about the gender-based bullying and equality. The school has implemented a mix of student-led, teacher-led and externally-led sessions including:
• The organisation ‘Everyone’s Invited’ addressing all staff and students over the course of two days about sexual harassment both online and in person including the signs of abuse and how to report malicious content.
• Presentations to all year groups from the Metropolitan Police Service on appropriate use of social technology and the consequences of gender-based bullying and the creation or distribution of Youth Produced Sexual Imagery (YPSI).

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• Presentations to all year groups from Streetwise, and separately by

(counselling psychologist and Community Rebbetzin at Golders Green United Synagogue) on consent and assertiveness of the female voice.
• Delivery of year group assemblies by ‘Education Child Protection Ltd’ on understanding abuse and how to deal with it.
• Parental webinar by the same company to all parents on working together to safeguard their children.
• Creation of a 160-strong student voice group, 40 students of which champion equality in the school.
• Creation of a Student Digital Leaders group which has presented to year groups on positive communication between peers.
• Delivery of a ‘Relationships’ and ‘Celebrating Differences’ strand in PHSE looking at a range of topics from managing control in interaction, coercion in relationships, assertiveness and saying no, boundaries within intimate and romantic relationships, prejudice and discrimination, and violence against women

JFS is constantly seeking ways to improve its provision and, going forward, will be working with the Jewish Women’s Aid group to build a series of drop-down days to further embed cultural change.

I hope I have provided reassurance surrounding the steps that JFS has taken, and continues to take, to address the issues of concern contained within your report.

Please do not hesitate to contact me should you require any further information.
Report Sections
Investigation and Inquest
Mia Janin was born on 7 June 2006. On 12 March 2021 Mia was found deceased at home aged 14 years old. On the 18 March 2021 an investigation was opened into her death and an inquest was opened on 31 March 2021. Following a lengthy police investigation a final inquest hearing concluded before me on 26 January 2024 as follows: "Mia Janin took her life while still a child and while still in the process of maturing into adulthood".
Circumstances of the Death
Mia was last seen alive around 10pm on 11 March 2021 when saying goodnight to her parents in their family home. Mia was found deceased at home by her parents around 6.50am on 12 March 2021 suspended from from a ligature. Two undated notes in Mias handwrit ing were found on her bed on 12 March 2021 addressed to her family and friends, which explained that Mia had decided to end her life. Mias death was entirely unexpected by her family, friends and teachers. She had felt low self-esteem at times but had not been diagnosed with any mental illness nor presented a risk of taking her own life. Mia had close friends including at her secondary school but she also experienced bullying behaviour from some male students. Neither Mias family nor teachers was aware of that behaviour before her death. On 10 March 2021 Mia posted a video on social media asking two of these male students not to mock her and criticising their music and fashion. This video received a large number of hostile responses, which Mia found stressful. On the evening of 1 1 March 2021 Mia said to her parents that she had had a difficult week and asked to move to a different secondary school, which they agreed to explore. Toxicological examination confirmed the absence of any illicit substances in Mias system. The post-mortem examination found marks of self-harm (recent and old) of which Mias family was not aware. Mia is much missed by her loving family, friends and wider community who describe her as creative, kind, entrepreneurial and highly intelligent, amongst many other things. The current head teacher of Mias secondary school - the Jewish Free School (JFS) - gave evidence at the final inquest hearing concerning systemic changes introduced at JFS following Mias death. This included a co mplete overhaul of safeguarding practices, increased behaviour management, improved information, staff surveys and externally delivered sessions by charities including Norwood, Streetwise, Jewish Womens Aid and Keshet. Evidence provided by some JFS students after Mias death to the police and Ofsted described regular incidents of gender based bullying by some male JFS students of some female JFS students. Some of those child witnesses had not experienced a change in culture at JFS since Mias death and did not describe being consulted or surveyed about the changes introduced by JFS.
Copies Sent To
email: (ibid) (ibid) , Child Death Overview Panel, North Central London Date 22 February 2024

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.