Lucy-Anne Dyson
PFD Report
Partially Responded
Ref: 2025-0451
Coroner's Concerns (AI summary)
A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate child protection actions.
View full coroner's concerns
1. The lack of a national interface to enable reporting/communication between schools using safeguarding record keeping systems (e.g. CPOMS) and relevant agencies, including Police and Children’s Services.
2. The lack of national guidance/standards means agencies with safeguarding duties for children are receiving referrals that either rely too heavily on the individual referrer’s judgement about what should be included, or where no referral is made at all.
2. The lack of national guidance/standards means agencies with safeguarding duties for children are receiving referrals that either rely too heavily on the individual referrer’s judgement about what should be included, or where no referral is made at all.
Responses
Action Taken
The Department for Education highlights the work being done across government to protect women and girls from violence, including the Tackling Domestic Abuse Plan, the Domestic Abuse Act 2021, and updated statutory safeguarding guidance 'Working Together to Safeguard Children'. (AI summary)
The Department for Education highlights the work being done across government to protect women and girls from violence, including the Tackling Domestic Abuse Plan, the Domestic Abuse Act 2021, and updated statutory safeguarding guidance 'Working Together to Safeguard Children'. (AI summary)
View full response
Dear Darren Stewart OBE,
Prevention of Future Death Report – Lucy-Anne Dyson née Rushton (03/09/2025)
I would like to express my deepest sympathies to the family and friends of Lucy-Anne Dyson née Rushton.
I am grateful that you have raised these important concerns, which highlight the critical importance of effective multi-agency communication and consistent safeguarding standards in preventing harm and protecting both adults and children from abuse and neglect.
But before I respond on the specific matters of concern you raised, I want to express very clearly my concern and disappointment that the Prevention of Future Death report which you sent to me did not accurately or sensitively reflect the appalling brutality with which Lucy-Anne’s estranged husband murdered her.
It is extremely disappointing to see your language in section 4 of your report (the narrative conclusion) describing, euphemistically, a “dysfunctional and toxic” relationship in which “the nature of the relationship between both parties was abusive”, which was “a material contribution to [her] death”; furthermore you describe the cause of death as being “multiple blunt force injuries”, as if these injuries fell from the sky or were of unknown origin, the manner of her death was a sickeningly violent murder by her estranged husband, as the sentencing remarks by Judge Akhlaq Choudhury KC made very clear. I have raised my concerns on this point with the Parliamentary Under-Secretary of State for Victims and Tackling Violence Against Women and Girls.
On the concerns you have raised in the report, the Department is committed to ensuring that all agencies with safeguarding responsibilities can share information effectively, make informed decisions, and take timely action to protect individuals at risk of harm. We recognise that poor information sharing and inconsistent approaches to referrals have been recurring challenges in serious safeguarding incidents, and we are taking significant steps to address these issues through legislative reform, updated national guidance, and system-wide practice improvements.
I will address the two concerns you have raised and set out the actions the Department is taking in response.
Concern 1: Lack of a national interface to enable reporting and communication between schools and safeguarding agencies
We recognise that fragmented systems and inconsistent data-sharing processes can create barriers to effective safeguarding. To address this, the Department is leading a programme of reform to strengthen multi-agency information sharing through the following measures:
Single unique identifier The Children’s Wellbeing and Schools Bill, introduced in Parliament on 17th December will protect children at risk of abuse, stopping vulnerable children falling through cracks in services, and deliver a core guarantee of high standards with space for innovation in every child’s education.
The Bill, which is currently being scrutinised in Parliament, will introduce provisions for a consistent child identifier, enabling professionals to securely and accurately match records across different systems and agencies. This will support schools, police, children’s social care, and health services to share information more effectively and identify children at risk earlier.
New Information Sharing Duty The Bill will also establish a new legal obligation on relevant organisations (including education, health, police, and social care) to share information for the purpose of safeguarding and promoting the welfare of children. This will ensure all key agencies have a shared legal foundation for timely and appropriate information exchange.
Pilots and Implementation Planning The Department has initiated a series of local pilots to test the implementation of the consistent child identifier and its interoperability with existing safeguarding systems (such as CPOMS) and local authority databases. Learning from these pilots will inform national standards for interoperability between systems.
System and Process Reform Alongside legislative changes, the Department is convening education, local authority, and technology partners to develop national data standards to enable secure, accurate connections between school safeguarding systems and partner agencies.
Statutory Guidance and Sector Engagement The updated Working Together to Safeguard Children (2023) guidance emphasises the importance of proactive information sharing to assess and respond to concerns about a child’s safety. Further statutory guidance will be issued, co-produced with the sector, to support practitioners in applying the new Information Sharing Duty and consistent identifier in practice.
Operation Encompass The Department has worked closely with the Home Office to prepare statutory guidance for the implementation of the Operation Encompass duty. This will require police forces to notify educational settings of domestic abuse incidents
affecting pupils. The duty, currently voluntary, will become mandatory under the Victims and Prisoners Act 2024 from November 2025.
Concern 2: Lack of national guidance/standards mean agencies are receiving referrals that rely too heavily on individual judgement or where no referral is made at all
The Department recognises that inconsistent referral quality and variable thresholds for action can lead to risks being missed or misunderstood. To strengthen national consistency, build practitioner confidence and expertise, and ensure every agency is taking coordinated decisive action, we are implementing reforms and have strengthened the statutory framework; this includes:
Families First Partnership Programme Through this programme, we are delivering national reforms to Family Help, multi-agency child protection, and Family Group Decision Making. The reforms include establishing multi-agency child protection teams that bring together education, police, health, and social care professionals to take decisive action where significant harm is identified. The programme also promotes integrated ‘front door’ models for triaging contacts and referrals, ensuring concerns are directed appropriately and consistently.
Improving Professional Practice and Training The Department, alongside Social Work England, is investing in training for child and family social workers to strengthen identification and response to violence, abuse, and coercive control. Domestic abuse awareness is being embedded in social work education and training standards, as well as across education and health sectors. This includes updating safeguarding training and reinforcing expectations within statutory guidance and school safeguarding policies.
Multi-Agency Safeguarding Arrangements (MASAs) Local authorities, police forces, and health services share joint responsibility for safeguarding and promoting the welfare of children through MASAs. We strengthened Working Together guidance in 2023 to be clearer on roles and responsibilities of safeguarding partners, accountability structures and the role of education. Local published arrangements provide a framework for effective partnership working and ensure clear understanding of referral routes, thresholds, and local processes for raising concerns. Robust arrangements support timely decision-making and coordinated support for families. The Children's Wellbeing and Schools Bill includes a new requirement for education to play a strategic role in the partnership, given the crucial role these providers and settings have in a child’s life.
Working Together to Safeguard Children (2023) We updated this guidance in 2023, with a sharp focus on strengthening multi- agency working across the whole system of help, support and protection. Importantly, we introduced new national multi-agency child protection standards setting out what every individual, at every level, in every agency should do to work together and understand their role, to improve child protection practice and outcomes for children. We also strengthened expectations about the role of other agencies, including police and health, in child protection processes. This guidance sets clear expectations for all safeguarding partners to share information early and work collaboratively in assessing and responding to risk. It
clarifies that local authorities must consider a wide range of evidence from across agencies when making decisions under section 47 of the Children Act 1989. In 2023 we committed to reviewing Working Together every year to ensure it reflects best evidence.
Ofsted Inspection and Oversight Through the Inspection of Local Authority Children’s Services (ILACS) framework, Ofsted evaluates how effectively local authorities identify, assess, and manage risk in line with Working Together. This includes assessing the quality of referrals, thresholds for intervention, and the effectiveness of multi- agency working. Findings inform policy development, including the 2023 update of Working Together to Safeguard Children, and enable targeted support or intervention where systemic weaknesses are identified.
Keeping Children Safe in Education (KCSIE) (2024) Schools and colleges have a critical role to play in protecting children and keeping them safe. The Department publishes the statutory safeguarding guidance Keeping Children Safe in Education (KCSIE) to support schools and colleges in carrying out their duties to safeguard and promote the welfare of children. KCSIE makes clear that every school must have a Designated Safeguarding Lead who takes lead responsibility for safeguarding and child protection. Part 1 of the guidance, which should be read by all staff who work directly with children, sets out that all staff should know what to do if they have concerns about a child and should be aware of the process for making referrals to local authority children’s social care and for statutory assessments under the Children Act 1989. This ensures a consistent understanding across all education settings of how to recognise, report and respond to concerns about a child’s safety or welfare. This guidance was last updated in September 2025.
Conclusion The Department for Education is committed to taking forward these reforms to ensure that:
practitioners across all safeguarding agencies can share information swiftly and securely; referrals and responses are based on consistent national standards rather than individual interpretation; and families affected by domestic abuse receive timely, coordinated, and effective support.
We will continue to monitor implementation of these measures and engage closely with safeguarding partners to ensure that lessons learned lead to lasting improvements in practice and outcomes.
Please ensure that any future reports for action by my department are submitted to my Department for Education address, , and not the Parliamentary offices of individual ministers. I am concerned that a proper process to establish the correct address to which to send a report to the Secretary of State for Education was not followed.
I hope that this response is useful for addressing the concerns raised in the Prevention of Future Death report. In view of my wider concerns about the lack of understanding of violence against women evidenced by the report, and the process followed (or not followed) in drawing the conclusions in your report to the attention of government ministers, I am copying this letter to the Chief Coroner, and to the Deputy Prime Minister, the Lord Chancellor and the Secretary of State for Justice, .
Secretary of State for Education
Prevention of Future Death Report – Lucy-Anne Dyson née Rushton (03/09/2025)
I would like to express my deepest sympathies to the family and friends of Lucy-Anne Dyson née Rushton.
I am grateful that you have raised these important concerns, which highlight the critical importance of effective multi-agency communication and consistent safeguarding standards in preventing harm and protecting both adults and children from abuse and neglect.
But before I respond on the specific matters of concern you raised, I want to express very clearly my concern and disappointment that the Prevention of Future Death report which you sent to me did not accurately or sensitively reflect the appalling brutality with which Lucy-Anne’s estranged husband murdered her.
It is extremely disappointing to see your language in section 4 of your report (the narrative conclusion) describing, euphemistically, a “dysfunctional and toxic” relationship in which “the nature of the relationship between both parties was abusive”, which was “a material contribution to [her] death”; furthermore you describe the cause of death as being “multiple blunt force injuries”, as if these injuries fell from the sky or were of unknown origin, the manner of her death was a sickeningly violent murder by her estranged husband, as the sentencing remarks by Judge Akhlaq Choudhury KC made very clear. I have raised my concerns on this point with the Parliamentary Under-Secretary of State for Victims and Tackling Violence Against Women and Girls.
On the concerns you have raised in the report, the Department is committed to ensuring that all agencies with safeguarding responsibilities can share information effectively, make informed decisions, and take timely action to protect individuals at risk of harm. We recognise that poor information sharing and inconsistent approaches to referrals have been recurring challenges in serious safeguarding incidents, and we are taking significant steps to address these issues through legislative reform, updated national guidance, and system-wide practice improvements.
I will address the two concerns you have raised and set out the actions the Department is taking in response.
Concern 1: Lack of a national interface to enable reporting and communication between schools and safeguarding agencies
We recognise that fragmented systems and inconsistent data-sharing processes can create barriers to effective safeguarding. To address this, the Department is leading a programme of reform to strengthen multi-agency information sharing through the following measures:
Single unique identifier The Children’s Wellbeing and Schools Bill, introduced in Parliament on 17th December will protect children at risk of abuse, stopping vulnerable children falling through cracks in services, and deliver a core guarantee of high standards with space for innovation in every child’s education.
The Bill, which is currently being scrutinised in Parliament, will introduce provisions for a consistent child identifier, enabling professionals to securely and accurately match records across different systems and agencies. This will support schools, police, children’s social care, and health services to share information more effectively and identify children at risk earlier.
New Information Sharing Duty The Bill will also establish a new legal obligation on relevant organisations (including education, health, police, and social care) to share information for the purpose of safeguarding and promoting the welfare of children. This will ensure all key agencies have a shared legal foundation for timely and appropriate information exchange.
Pilots and Implementation Planning The Department has initiated a series of local pilots to test the implementation of the consistent child identifier and its interoperability with existing safeguarding systems (such as CPOMS) and local authority databases. Learning from these pilots will inform national standards for interoperability between systems.
System and Process Reform Alongside legislative changes, the Department is convening education, local authority, and technology partners to develop national data standards to enable secure, accurate connections between school safeguarding systems and partner agencies.
Statutory Guidance and Sector Engagement The updated Working Together to Safeguard Children (2023) guidance emphasises the importance of proactive information sharing to assess and respond to concerns about a child’s safety. Further statutory guidance will be issued, co-produced with the sector, to support practitioners in applying the new Information Sharing Duty and consistent identifier in practice.
Operation Encompass The Department has worked closely with the Home Office to prepare statutory guidance for the implementation of the Operation Encompass duty. This will require police forces to notify educational settings of domestic abuse incidents
affecting pupils. The duty, currently voluntary, will become mandatory under the Victims and Prisoners Act 2024 from November 2025.
Concern 2: Lack of national guidance/standards mean agencies are receiving referrals that rely too heavily on individual judgement or where no referral is made at all
The Department recognises that inconsistent referral quality and variable thresholds for action can lead to risks being missed or misunderstood. To strengthen national consistency, build practitioner confidence and expertise, and ensure every agency is taking coordinated decisive action, we are implementing reforms and have strengthened the statutory framework; this includes:
Families First Partnership Programme Through this programme, we are delivering national reforms to Family Help, multi-agency child protection, and Family Group Decision Making. The reforms include establishing multi-agency child protection teams that bring together education, police, health, and social care professionals to take decisive action where significant harm is identified. The programme also promotes integrated ‘front door’ models for triaging contacts and referrals, ensuring concerns are directed appropriately and consistently.
Improving Professional Practice and Training The Department, alongside Social Work England, is investing in training for child and family social workers to strengthen identification and response to violence, abuse, and coercive control. Domestic abuse awareness is being embedded in social work education and training standards, as well as across education and health sectors. This includes updating safeguarding training and reinforcing expectations within statutory guidance and school safeguarding policies.
Multi-Agency Safeguarding Arrangements (MASAs) Local authorities, police forces, and health services share joint responsibility for safeguarding and promoting the welfare of children through MASAs. We strengthened Working Together guidance in 2023 to be clearer on roles and responsibilities of safeguarding partners, accountability structures and the role of education. Local published arrangements provide a framework for effective partnership working and ensure clear understanding of referral routes, thresholds, and local processes for raising concerns. Robust arrangements support timely decision-making and coordinated support for families. The Children's Wellbeing and Schools Bill includes a new requirement for education to play a strategic role in the partnership, given the crucial role these providers and settings have in a child’s life.
Working Together to Safeguard Children (2023) We updated this guidance in 2023, with a sharp focus on strengthening multi- agency working across the whole system of help, support and protection. Importantly, we introduced new national multi-agency child protection standards setting out what every individual, at every level, in every agency should do to work together and understand their role, to improve child protection practice and outcomes for children. We also strengthened expectations about the role of other agencies, including police and health, in child protection processes. This guidance sets clear expectations for all safeguarding partners to share information early and work collaboratively in assessing and responding to risk. It
clarifies that local authorities must consider a wide range of evidence from across agencies when making decisions under section 47 of the Children Act 1989. In 2023 we committed to reviewing Working Together every year to ensure it reflects best evidence.
Ofsted Inspection and Oversight Through the Inspection of Local Authority Children’s Services (ILACS) framework, Ofsted evaluates how effectively local authorities identify, assess, and manage risk in line with Working Together. This includes assessing the quality of referrals, thresholds for intervention, and the effectiveness of multi- agency working. Findings inform policy development, including the 2023 update of Working Together to Safeguard Children, and enable targeted support or intervention where systemic weaknesses are identified.
Keeping Children Safe in Education (KCSIE) (2024) Schools and colleges have a critical role to play in protecting children and keeping them safe. The Department publishes the statutory safeguarding guidance Keeping Children Safe in Education (KCSIE) to support schools and colleges in carrying out their duties to safeguard and promote the welfare of children. KCSIE makes clear that every school must have a Designated Safeguarding Lead who takes lead responsibility for safeguarding and child protection. Part 1 of the guidance, which should be read by all staff who work directly with children, sets out that all staff should know what to do if they have concerns about a child and should be aware of the process for making referrals to local authority children’s social care and for statutory assessments under the Children Act 1989. This ensures a consistent understanding across all education settings of how to recognise, report and respond to concerns about a child’s safety or welfare. This guidance was last updated in September 2025.
Conclusion The Department for Education is committed to taking forward these reforms to ensure that:
practitioners across all safeguarding agencies can share information swiftly and securely; referrals and responses are based on consistent national standards rather than individual interpretation; and families affected by domestic abuse receive timely, coordinated, and effective support.
We will continue to monitor implementation of these measures and engage closely with safeguarding partners to ensure that lessons learned lead to lasting improvements in practice and outcomes.
Please ensure that any future reports for action by my department are submitted to my Department for Education address, , and not the Parliamentary offices of individual ministers. I am concerned that a proper process to establish the correct address to which to send a report to the Secretary of State for Education was not followed.
I hope that this response is useful for addressing the concerns raised in the Prevention of Future Death report. In view of my wider concerns about the lack of understanding of violence against women evidenced by the report, and the process followed (or not followed) in drawing the conclusions in your report to the attention of government ministers, I am copying this letter to the Chief Coroner, and to the Deputy Prime Minister, the Lord Chancellor and the Secretary of State for Justice, .
Secretary of State for Education
Sent To
- Department for Education
- Women and Equalities
Response Status
Linked responses
1 of 2
56-Day Deadline
16 Mar 2026
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 12 July 2019 I commenced an investigation into the death of Lucy-Anne DYSON aged
30. The investigation concluded at the end of the inquest on 18 December 2024. A Narrative Conclusion was recorded by the Jury.
30. The investigation concluded at the end of the inquest on 18 December 2024. A Narrative Conclusion was recorded by the Jury.
Circumstances of the Death
Narrative conclusion Lucy Ann Rushton was in a relationship with her husband for 9 years until they separated at the beginning of 2019. They were married in 2014, after which the relationship became dysfunctional and toxic. They had two children together and the father still maintained regular contact with the children and Ms. Rushton at the home. Whilst this was ongoing, the nature of the relationship between both parties was abusive and at times violent. The relationship made a material contribution to Lucy Rushton’s death. On the 9th of September 2018 Lucy Rushton and her husband were spending a weekend away from their children at a hotel in Bournemouth. At 0300 am on the 9th September 2019 a 999 call was received by Police in relation to reports of an altercation at the hotel. Police responded and questioned Ms. Rushton in her hotel room, her husband having been asked to step outside the hotel room accompanied by a Police Officer. When questioned by Police Ms. Rushton denied any altercation having taken place or having been assaulted by her husband. CCTV evidence which existed at the time and showed a physical confrontation between Ms. Rushton and her husband was not secured by Police as part of their enquiries in relation to the incident. A Public Protection Notice (PPN) issued by Police following this incident was submitted 3 weeks after the event. At the time this was received by the home local authority for Ms. Rushton the PPN was not actioned due to it being confused as a duplicate of another, unrelated PPN concerning one of Ms. Rushton’s children. The two children of Ms. Rushton and her husband attended a local primary school. In March 2019 one of the children of Ms. Rushton and her husband reported violence they witnessed between their parents to school staff. The school did not refer the matter following investigation to children’s services. A further incident where similar comments were made again by Ms. Rushton’s children was not referred to children’s services when it should have been. Both incidents revealed a toxic relationship in existence between Ms. Rushton and the children’s father. A referral to children’s services was made on the 7th June 2019 following a safeguarding concern for the children due to Ms. Rushton’s conduct. The referral was declined by children’s services. On the 30th May 2019 a complaint was made to Police in relation to allegations concerning images taken of Ms. Rushton by her estranged husband on his mobile telephone. Following receipt of the complaint several lines of enquiry were not followed up by Police. When spoken to by Police Ms. Rushton confirmed that the images taken were of consensual activity between her and her husband. A formal risk assessment by way of a DASH Form was not completed and no Public Protection Notice in relation to the incident raised, the matter being closed following Ms. Rushton denying any offence having been committed when she was spoken to by Police. Lucy Rushton died on the 23rd June 2019 in the early hours of the morning as a result of a prolonged, severe and brutal attack with the cause of death being multiple blunt force injuries. Lucy Ann Rushton was unlawfully killed.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.