Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Ella Louise Murray who died on 15 November 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 7 February 2025 concerning the death of Ella Louise Murray on 15 November 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Ella’s family and all those who loved and cared for her. NHS England are keen to assure the Coroner and Ella’s family that the concerns raised about Ella’s care have been listened to and reflected upon.

My response to the Coroner focuses on those areas of concern that sit within NHS England’s national policy or programme remit. It would not be appropriate at this juncture for NHS England to provide comment on actions taken by Kent & Medway Integrated Care Board, Kent Social Services or the Local Authority involved in Ella’s care.

You have raised various concerns in your Report, including that there was a failure to undertake an adequate, or any, risk assessment and take any further steps to ensure Ella's safety, including urgently removing Ella either to a hospital bed or otherwise liaising with social services. You have also raised the concern that there was no shared access to records for all agencies and no way to convene an urgent multi-agency meeting.

Your Report echoes recommendations made from previous reviews into suicides of children and young people (CYP). The 2020 Kent Safeguarding Children Multi-Agency Partnership Review of Suicide in Children and Young People noted concerns about the risk assessment process and warned against using short-cuts or abridged assessments in place of more thorough processes. The review also recommended that school teaching staff were better integrated into interprofessional safeguarding networks, a change that HM Coroner’s Report suggests would have better supported Ella. Both the Kent Safeguarding Review and the 2021 National Child Mortality Database (NCMD) Suicide Report, published in October 2021, recommended improved information sharing between agencies. Across the 108 deaths included in the NCMD National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

28 March 2025

Report, the most common issue reported was poor communication and information sharing between professionals. The second most common issue was poor quality referrals. As your Report raises, the 2024-25 Children’s Wellbeing and School’s Bill will address these concerns. The Bill strengthens the role of education in multi-agency safeguarding arrangements as well as creating a clearer legal basis for information sharing. This is facilitated by the inclusion of a common identifier. Ella’s case includes learnings for teams across NHS England and local organisations, as well as more broadly. It is NHS England’s understanding that Kent and Medway Integrated Care Board will be responding to the Coroner separately with a system- level response detailing the local actions taken. NHS England will consider the ICB’s response in due course. My colleagues from national NHS England teams have also provided the below input. National CYP Mental Health Team Integrated Care Systems (ICSs) are a vehicle for integrated planning, to ensure that those who need it have access to comprehensive mental health support which is integrated across health, social care, education, and the voluntary sector. The vision for greater local system integration and autonomy is being implemented for specialised mental health, learning disability and autism services, by giving responsibility for a given population to Provider Collaboratives. Provider Collaboratives will improve links to other care settings, to improve the whole pathway and reduce reliance on the most specialised services by reinvesting in community provision. National Safeguarding Team The NHS England South East regional safeguarding team will, through established governance arrangements, have oversight of Kent and Medway Integrated Care Board’s actions to implement the learning to improve safeguarding at both the Local Safeguarding Children Partnership and within all commissioned services. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Ella, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Mrs Wood,

Thank you for the Regulation 28 report of 7 February 2025 sent to the Secretary of State about the death of Ella Louise Murray. I am replying as the Minister with responsibility for Patient Safety, Women's Health and Mental Health.

Firstly, I would like to say how saddened I was to read of the circumstances of Ella’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

I understand that NHS England and Kent and Medway Integrated Care Board have also received this report and I trust that they will adequately address your concerns at the local level. I look forward to reading their responses and working with them on any proposed changes.

For matters that fall outside of this Department’s direct responsibility, I would respectfully signpost you to the Department for Education (DfE), which leads on child safeguarding policy and related legislation and is better placed to respond to these elements of your report. I understand that they are preparing a separate response addressing those elements and my response references DfE policy where relevant.

Your report raises concerns that, if a multiagency meeting had been convened under section 47 of the Children Act 1989, Ella’s death may have been prevented, and such action may reduce the risk of death for other children in a similar position. I would like to assure you that the expectation is that a section 47 enquiry will normally be initiated to determine any action required to safeguard and promote the welfare of a child who is suspected to be suffering or is likely to suffer significant harm. Local authority social workers should lead assessments under section 47 of the Children Act 1989.

Similarly, the expectation is that the police, health practitioners, teachers and school staff and other relevant practitioners should help the local authority in undertaking its enquiries.

Health practitioners should provide appropriate specialist assessments. The lead health practitioner may need to request and co-ordinate these assessments. Health practitioners should also ensure appropriate treatment and follow up health concerns. The police should help other organisations and agencies understand the reasons for concerns about the child’s safety and welfare by sharing information and make available to other practitioners any other relevant information gathered or known to inform discussions about the child’s welfare.

The DfE’s Children's Wellbeing and Schools Bill, which is currently being considered by Parliament, aims to strengthen these arrangements by placing a duty on local safeguarding partners (local authorities, police forces, and integrated care boards) to establish multiagency child protection teams (MACPTs) with a minimum membership to include a social worker, police officer, registered health practitioner, and person with education experience.

As part of this, the Government’s Families First Partnership programme is delivering the national rollout of reforms to family help, multi-agency child protection and family group decision-making, including delivery of MACPTs. The programme guide sets out the responsibilities of the MACPT members, including to facilitate better communication and information sharing among practitioners and agencies. This is available at: Families First Partnership programme - GOV.UK

I trust that the responses from NHS England or Kent and Medway Integrated Care Board will address why this may not have happened in Ella’s case and what mitigations have been put in place.

Your report also raises concerns about information sharing. To share information lawfully, NHS organisations must comply with the principles set out in data protection legislation, the General Data Protection Regulations (GDPR) and the common law duty of confidence. They should also apply the Caldicott Principles which have been established by the National Data Guardian for Health and Social Care to govern how data is shared by health and care organisations.

The Caldicott Principles make clear that the duty to share information can be as important as the duty to protect patient confidentiality. Healthcare professionals should have the confidence to share information in the best interests of their patients, within the framework set out by the Principles, and be supported by the policies of their employers, regulators and professional bodies to do so.

All NHS organisations, as part of their information governance arrangements, are required to have in place Caldicott Guardians who have responsibilities to safeguard and govern the use of patient information and can provide advice in circumstances where there may be uncertainty about disclosure.

Finally, and more widely, the Government is committed to tackling suicide as one the biggest killers in this country. The Suicide Prevention Strategy for England sets out priority areas for action to prevent suicides. This includes the need to provide tailored, targeted support to priority groups, which includes children and young people, people who have self-harmed and people in contact with mental health services, providing effective crisis support within and outside of the NHS.

We recognise that too many children and young people like Ella are not getting the support that they need with their mental health. That is why we are investing an extra £688 million this year to transform mental health services by hiring more staff, delivering more early interventions, and getting waiting lists down so young people can have the best possible start in life.

We want to intervene much earlier to support better outcomes for children and young people. That is why our 10 Year Health Plan sets out how we will work with schools and colleges to better identify and meet children's mental health needs by expanding mental health support teams in schools to cover 100% of pupils by 2029/30, and by embedding mental health support in the new Young Futures hubs, to ensure there is no 'wrong front door' for young people seeking help.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

All good wishes,