Dear Mr Irvine, Thank you for the Regulation 28 report of 5th December 2024 sent to the Secretary of State for Health and Social Care about the death of Mazeedat Opeyemi Adeoye. I am replying as the Minister with responsibility for adult social care. Firstly, I would like to say how saddened I was to read of the circumstances of Mazeedat’s tragic death and I offer my sincere condolences to their 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. The report raises concerns over the local authority and child services team in the London Borough of Newham. The Department of Education (DfE) has oversight for child social care, and they are best placed to comment on the concerns raised. You may wish to reissue the report to DfE, so they are able to provide a formal response. Thank you for bringing these concerns to my attention.

Dear Mr Irvine,

Re: Regulation 28 Report– Ref: I am writing further to the Regulation 28 Report to Prevent Future Deaths (1) sent to Dr Andrew McCulloch on 5 December 2024 in relation to the death of Mazeedat Adeoye. I am writing on behalf of Social Work England to provide our response to the report. Thank you again for meeting with us on 3 January 2025. We found the meeting very helpful in allowing us to understand the case in more detail. We also appreciate that you have authorised the release of the documents bundle and the relevant recordings of the witness evidence. We have now received these documents and recordings. Our role as a regulator and the triage test As you are already aware Social Work England is the statutory regulator of social workers in England. We are a non-departmental public body, operating at arm’s length from government, and established by the Children and Social Work Act 2017. Our central focus is public protection. We do this by pursuing the following objectives:
• To protect, promote and maintain the health, safety and wellbeing of the public
• To promote and maintain public confidence in social workers in England
• To promote and maintain proper professional standards for social workers in England The achievement of our objectives is delivered through six key regulatory functions, one of which is the operation of a proportionate and efficient fitness to practise process to deal with concerns raised about those on our register. Our fitness to practise process is governed PRIVATE & CONFIDENTIAL

socialworkengland.org.uk 1 North Bank, Blonk Street, Sheffield, S3 8JY 2 by The Social Workers Regulations 2018 (as amended) (‘the regulations’) and the relevant Fitness to Practise Rules 2019 (as amended) (‘the rules’). When concerns are received about a social worker, we are required, in line with schedule 2, paragraph 1 of the regulations, to determine whether there are reasonable grounds for investigating whether the social worker’s fitness to practise is impaired. This is what we refer to as the triage test. We have legal powers that allow us to gather relevant information from a variety of stakeholders (schedule 2, paragraph 5(1) of the regulations). At the conclusion of the triage process, we produce a triage decision which sets out which concerns do or do not meet the threshold for investigation and provides reasoning to support that decision. Actions undertaken to date We can confirm we have already undertaken the following actions:
1) We have contacted the London Borough of Newham to ask for the details of the social workers that were involved in the case and whether there are any ongoing employer investigations with respect to those social workers regarding their involvement with this case. The London Borough of Newham has responded to us and provided us with relevant information.
2) We have opened fitness to practise cases with respect to the following social workers,

and so that further enquiries can be made. The social workers, in line with our current policies, will not be advised of the cases unless the triage test has been met and we have determined that an investigation must be undertaken.
3) We have started reviewing the documentation and recordings from the coronial inquest. We are in the process of identifying if further information/documentation may be required from the Local Authority and others. We may also return to you for further information. Next steps We will now be undertaking the following steps:
1) We will gather and assess any further information that we may require from relevant persons/organisations.
2) We will contact Mrs Adeoye and her legal representatives and advise her of our current involvement in these matters, to give her the opportunity to provide us with her perspective and/or further information.
3) Once we are satisfied we have all the relevant information we require to make a triage decision, we will then determine whether there are reasonable grounds to investigate any of the individual social worker’s actions.

socialworkengland.org.uk 1 North Bank, Blonk Street, Sheffield, S3 8JY 3

Updates as to fitness to practise process As you will appreciate the process of reviewing the documentation, gathering additional evidence and then assessing that evidence may take some time and we are unable to provide you with a specific timeframe in which this will be completed. As we understand from our recent meeting, you do not require regular updates as to our progress. However, please let us know if you do want us to keep you updated as we undertake the above steps. Otherwise, we will provide you with an update once we have determined whether the triage test has been met with respect to any of the social workers. Thank you for your assistance in this matter. If you have any further queries in the meantime, please contact me through my email at or by phone on

Kind regards, 

Triage Manager

socialworkengland.org.uk 1 North Bank, Blonk Street, Sheffield, S3 8JY 4

Prevention of Future Deaths Report (Regulation 28) Response from the London Borough of Newham

Contents

1. Foreword by the Director of Children’s Services

2. Introduction

a. The Role of the No Recourse to Public Funds (NRPF) Team

b. Reviews carried out

c. Service wide Future Changes to be Made

3. London Borough of Newham's Response to the Coroner’s Concerns

a. The Coroner's Concern regarding the conduct of the Children's Services Team

i. The NRPF Team in 2021/2022

ii. Action taken following Mazeedat's Death

iii. Action Proposed to be Taken

b. The Coroner's Concern regarding the management of the NRPF Team

i. Action taken following Mazeedat's Death

ii. Action Proposed to be Taken

c. The Coroner's Concern regarding the standards of note-keeping and recording

i. Action taken following Mazeedat's Death

ii. Action Proposed to be Taken

4. Conclusions and Impact

5. Action Plan

1. Foreword from the Director of Children’s Services

I and the entire team at Newham Children's Services were deeply saddened to learn of the death of Mazeedat Adeoye. I would like to express my deepest condolences to Mazeedat’s mother and her family.

I will do everything in my power to help further ensure that the work of Newham’s Children’s Services department is carried out with professionalism, courtesy, empathy and respect and with consideration for the welfare of all the children, young people and families that we work with and support.

We shall endeavour to do all we can to prevent such events in the future.

We acknowledge the Coroner’s findings. We have re-evaluated our internal policies and procedures after this tragedy and significant changes and improvements have been made. However, in light of the Coroner's conclusions we commit again to reviewing the practices of the team, so that we can identify where further changes need to be made. In the months and years to come we will continue to listen to the many families we work with, to the professionals we work alongside and to the staff we employ, to ensure that we continually learn, take action where needed and improve. We have made a number of changes since Mazeedat’s tragic death, and further changes outlined in this report are planned.

Below, we respond to each of the Coroner’s areas of concern, setting out what we have already done and what we intend to do in the future. We hope this response provides assurance that we have responded fully to every concern. I am grateful to all the Voluntary and Community Sector Agencies who have liaised with me and have been so open, supportive and challenging of our services and will continue to work with them to best support families with No Recourse to Public Funds.

Director Children’s Services 29th January 2025

2. Introduction

a) The Role of the No Recourse to Public Funds (NRPF) Team

In providing our Response to the Coroner's Report, it is first necessary to set out the role and responsibility of the No Recourse to Public Funds (NRPF) team, which provided intervention to Mazeedat and her family.

The Local Authority’s Children’s Services department have a duty to make enquiries prior to agreeing to offer intervention and support to families under section 17 of the Children Act 1989. We also have a duty to undertake proportionate checks whilst undertaking assessments. Working Together to Safeguard Children 2023 places a duty on Local Authorities including Children’s Services to share and request information from agencies. When families first seek support from the London Borough of Newham, Social Workers must undertake these duties to establish the circumstances of the family and the types of support the children could need. These checks are conducted during completing a Child and Family Assessment within a timescale of 45 days. This should include (for example) how someone came to be in the UK, the financial and other support they had been receiving, their identity and relationships to one another, any health and other specific needs, what services and intervention will assist and so on.

Children in Newham requiring support services can either be supported by Early Help Practitioners, NRPF Social Workers or Safeguarding Social Workers (where enquiries led to concerns about parenting capacity or a likelihood of concern about parenting capacity).

In 2021, parents were required to produce documents and sign relevant forms as part of the Child and Family Assessment process. However, the Local Authority can exercise a discretion to provide accommodation or offer support under Section 17 of the Children Act 1989 on a without prejudice basis, pending further information being obtained, including the gaining of documents and the signing of forms.

Completing robust checks is necessary, including understanding the relationship and identity of any children. There is a need to balance the questions that must be asked with ensuring that our language is used carefully so that families do not feel stressed or offended, and that we engage families in the best way possible to gain the needed information. The best way to do this is by using a Relational Approach to build trust with families. Social Workers should compassionately hypothesise why information is not forthcoming or shared and curiously self-reflect and reflect with managers whether there are any barriers that parents are experiencing using a Relational Approach. Any intervention or services should be offered to meet children’s needs and ensure they are not at risk with immediacy. b) Reviews carried out

Immediately following Mazeedat's tragic death, a review was undertaken to investigate, explore and resolve any issues with the service. The Quality Assurance team completed a review of the intervention with Mazeedat and her family.

A complaint received by The Alternative Trust in March 2022 and was thoroughly investigated.

A deep dive audit was completed in December 2024 (upon conclusion of the Inquest) to immediately re-review the service’s practice focusing on service delivery, the experiences of families with No Recourse to Public Funds, the quality of management oversight and recording. The reviewer analysed all Practice Learning Conversations (Audits) conducted within the NRPF service between 2022 to November 2024. In total, 24 files were reviewed. Feedback was successfully obtained from 19 of these families during the PLCs, accounting for 79% of the total, while for the remaining 5 families (21%), the auditor was unable to establish contact. The feedback, which sheds light on the service quality, highlighting strengths and areas for improvement from a family’s point of view, was largely positive. More details are included within

this report.

c) Service wide Future Changes to be Made

While significant and wide-ranging changes have been made since 2022, there is ongoing learning, development in process as well as actions to be carried out. These are set out throughout our Response in respect of each of the Coroner's concerns. We are also implementing the following:

 Senior Managers spending a week, twice a year, in practice alongside staff in all teams. This will include speaking to families, observing practice and auditing children’s case files.  A themed audit annually of children whose parents have No Recourse to Public Funds with a focus on single parents with limited network.  Peer Review of the NRPF Service by a London Authority with Good Ofsted rating. The peer review will consider leadership, quality of practice, quality of management oversight and quality of recording.  External Voluntary Sector Organisation with expertise in NRPF to be commissioned to gain Family Feedback.  An offer of a visit by the Corporate Director of Children's Services within 4 weeks to all families known to Children’s Social Care who have lost children, to ensure the voice of the parents or carers is incorporated in learning. This has been offered to Mazeedat’s mother through the Voluntary and Community Sector agencies that know her. Understandably she has advised that she does not feel able to do this. The offer will always remain open.  All accidental deaths of children where abuse or neglect is not suspected will be reviewed independently to the Quality Assurance Unit.

The implementation of the Action Plan and the impact of the actions once completed will be overseen by a Multi-Agency Task and Finish Group chaired by Director of Early Help and Safeguarding and CEO founder of The MAGPIE Project.

3. London Borough of Newham's Response to the Coroner's Concerns

a) The Coroner's Concern regarding the conduct of the NRPF Team

The Coroner set out the following Concern in his Report:

The Adeoye family interactions with the local authority, child services team were characterised by unprofessional behaviour from social workers. A culture existed within the team that tolerated and therefore encouraged overtly antagonistic behaviour towards vulnerable people. Should this hostile environment continue to be enabled, sub-optimal care outcomes will result with an ongoing risk of fatal harm.

(i) The NRPF Team in 2021/2022

Mazeedat was deemed a Child in Need by the Local Authority by virtue of her parent’s lack of recourse to public funds, homelessness and destitution. The support provided by the NRPF Service was to meet these needs. There were no concerns about Ms Adeoye’s parenting capacity and her ability to meet all Mazeedat’s needs and therefore there was no need for a safeguarding Social Worker. This would have been unnecessarily intrusive and not proportionate.

We recognise that there was a lack of empathy and understanding of Ms Adeoye’s situation on 14th October 2021. On this occasion, an appropriate questioning style or sufficient clarity was not used to explain the importance of the NRPF team requiring documentation and the need to understand the identity of Mazeedat and her relationship to Ms Adeoye. From all the information gathered, the Local Authority accept that a decision to support the family with accommodation on a without prejudice basis should have been made before the office closed. The focus should have been on meeting the homelessness need, not gaining the required documentation.

(ii) Action Taken Following Mazeedat's death

Quality Assurance

The Local Authority introduced a Quality Assurance process whereby audits (Practice Learning Conversations – PLC's) were completed by managers, senior managers and the Quality Assurance Unit on a monthly basis across all services. A sample of which were then moderated by a more Senior Manager to ensure the quality of the audit as well as the accuracy of the finding. This brought about a constant, robust check on services and decision making with families.

Focused Action for the NRPF team

The Local Authority Quality Assurance Unit (who are independent from the NRPF Team) undertook an investigation into whether the NRPF staff followed due process on 1st February 2022. The Quality Assurance Unit are part of Children’s Services and are independent from the operational work that the department undertakes. They work to highlight areas of strength and areas of weakness within Children’s Services, with a focus on enforcing the maintenance of the quality of standard of practice across social care and early help services. They identify learning and ensure the implementation of learning throughout Children’s Services and the partnership, ensuring the workforce training and development is swiftly adapted to address concerns. This includes improving the quality of Social Work practice.

The Head of Service, Director of Safeguarding and the Director of Children’s Services (at the time) met with the Director of Alternatives Trust on 2nd March 2022 to discuss the issues raised in their complaint. Separate meetings with the workers from the Alternatives Trust who had assisted the family at the time and Social Workers and managers were held. The Social Workers who had been involved with the family were interviewed and discussions were had with their

supervisor and the NRPF Team Manager.

Following the findings of the Quality Assurance Investigation and the findings from the complaint, Children’s Services made significant improvements to ensure that the support our families receive from the NRPF team was of good quality. This included:

 Instructing all staff to offer accommodation and support to families with No Recourse to Public Funds on a without prejudice basis, to build trust, relationships and ensure the safety of children whether or not documents were produced and/or forms were signed.

 Mandatory training to all NRPF, MASH and Assessment team staff on Family Shared Decision Making ensuring families are at the centre of co-produced plans and interventions.

 Monthly practice improvement reflective supervision sessions for 9 months from March to December 2022. This was completed as a specific development plan for the NRPF Team following the complaint made by the Alternative Trust. These sessions used case examples to help workers think about language, the importance of the first contact and developing first impressions with families to ensure mutual warmth and trust. This was used to challenge practice and monitor staff’s practice improvement. The sessions were facilitated by a Family and Systemic Psychotherapist, and attended by Social Workers, Project Workers and the Team Managers in the NRPF Team.

 Case consultations with experienced and specialist Practice Development Social Workers and Family Psychotherapists to monitor and improve practice with a particular focus on balancing duties with compassion and working in partnership with parents.

 One to one intensive reflective sessions with the social worker who worked with Mazeedat's family by a named Clinical Therapist to explore the findings of the complaint, test reflections and monitor practice given the findings of the complaint.

In addition, The London Black Women’s Project conducted training with the NRPF Team. The aim was to further enhance their understanding of the journey of migrant families with No Recourse to Public Funds focussing on trauma-informed practice and domestic abuse. This has resulted in an improved awareness and knowledge in relation to trauma informed practice by the NRPF team and further enhanced working in partnership with the Voluntary and Community Sector,

There is the continuation of a bi-monthly “Migrant Help Operational Group” meeting between senior management in the NRPF Service, Voluntary Community Services (VCS) and other council services, such as Housing, Adult’s Social Care, and Children’s Social Care. This originally began in September 2020, was rebranded and expanded in November 2023. The group enables regular collaboration to learn from each other and better jointly support families with No Recourse to Public Funds. These bi-monthly meetings have improved communication between the Local Authority and the VCS groups providing support for immigrant families.

Improvements to the whole Children’s Services including the NRPF Team

Newham Children’s Services has been on an improvement journey since 2019, recognising that improvements in practice are crucial to positive outcomes for the children and families we work alongside. In light of this the service had developed an overarching approach to the practice of social work, that is informed by Systemic Psychotherapy, Relational and Restorative Practice. We have built this into an approach we call “Circles of Support”. This is characterised by the idea that all practice is held by Six Key components: Compassion, Curiosity, Collaboration, Community, Confidence and Clarity. This work has directly improved the culture of the NRPF team by collaborative work

with families to deliver good quality interventions and provide the best packages of support to every child and young person who needs it.

Since January 2022 there has been a focussed approach to improve the support and care offered to children and their families by Social Workers and managers in Newham. This support has been offered through a Purposeful, Planned and Focussed (PPF) approach.

Training around the use of language and the impact of early conversations on positive outcomes was rolled out in February 2022 - “The power of the 1st Utterance”. “The Power of the 1st Utterance” is an approach developed within the Family and Systemic Psychotherapy field and adapted to social care contexts. It invites the worker (Social Workers in this case) to be mindful about how they start conversations and how these conversational starters construct what follows. The invitation is to start conversations in ways that are appreciative rather than starting from the point of concern. In this way relationships are more likely to be constructive, trusting, collaborative and enabling.

Children’s Services Clinical Family Systemic and Psychotherapists Team run weekly training sessions for all Social Workers, targeted at particular teams/or a particular Social Worker where specific issues or needs, such as concerns about language, relational practice and interventions with families are identified by managers, the Quality Assurance Unit or partners.

Specialist training in Systemic and Relational Approaches by dual Qualified Family Systemic and Psychotherapists as well as Practice Development Social Workers (PDSWs) has been offered to staff. This has included a 5-day Systemic training offer (run three times a year), qualifying training up to a Masters level for a number of staff as well as individual focussed workshops on subjects such as Child Sexual Abuse, Domestic Violence, Drug and Alcohol Misuse, Neurodiversity and Mental Ill Health. Weekly sessions also run throughout the year. These sessions involve staff exploring ‘language that cares’ and how we must have conversation with families, balancing rigour with compassion.

Our named Court Manager trains Social Workers on a regular basis to explore and refresh staff regarding the legalities of Section 20 (foster care) matters. The focus of which is to support workers better articulate the legal framework to parents and young people so that they are fully aware of their rights in the event their child(ren) needs to be accommodated by the Local Authority under Section 20 of the Children Act 1989.

Our training offer is constantly under review, and we seek feedback from families, children, staff, communities and partners with the aim of constantly improving our service delivery. This is in addition to producing and implementing action plans regarding the learning from any Local Practice Safeguarding Reviews to ensure we make improvements to service delivery as needed.

“Welcome Newham” was launched on 11th August 2022. This Council-led weekly one-stop shop offers help to immigrants, including refugees, asylum seekers and migrants with No Recourse to Public Funds. These include families and children who have recently arrived in the Borough, as well as hosts families. The Welcome Newham Team offers a plethora of support to migrant families by referring to appropriate services in the community such as access to education, health care, emergency support, assistance with food, clothing, finance, social connections and community inclusion. Over time, and because of effective partnership working with Voluntary, Community and Faith Sector, Welcome Newham has strengthened its services to vulnerable migrant children, adults and families who are new to the Borough.

In a further demonstration of the improvements in our service to those who arrive in the borough with No Recourse to Public Funds in October 2024, Newham Council was awarded the ‘Borough of Sanctuary’ status by the National City of Sanctuary charity and the NRPF team were a central part of this. The City of Sanctuary awards recognise and celebrate the organisations which go above and beyond to welcome people seeking sanctuary. The Award acknowledges the breadth of the Council’s and partners’ work in this area to create a culture of welcome which values the contribution and

strengths of refugees and other sanctuary-seekers arriving in the borough. As part of the award, Newham has demonstrated its commitment to the Sanctuary values of inclusivity, participation and integrity.

A deep dive audit was completed in December 2024 as soon as the Coroner concluded the Inquest, to immediately re- review the service’s practice focusing on service delivery, the experiences of families with No Recourse to Public Funds, the quality of management oversight and recording. The reviewer analysed all PLCs conducted within the NRPF service between 2022 to November 2024. PLCs were conducted on a monthly basis. In total, 24 files were reviewed. Feedback was successfully obtained from 19 of these families during the PLCs, while the remaining 5 families, the auditor was unable to establish contact. Families rated their experiences from 1 (inadequate) to 10 (outstanding), providing both quantitative ratings and detailed qualitative reflections. This feedback sheds light on the service quality, highlighting strengths from a family’s point of view.

The majority of families rated their experience positively: 
26.3% (5 families) giving a score of 10, reflecting an outstanding experience. 
68.4% (13 families) rated their experience between 8 and 9, indicating high satisfaction. 
5.3% (1 family) rated their experience as 6, suggesting slight satisfaction.

(iii) Action Proposed to be Taken

Improvement to Practice

We are committed to our programme of continually improving our practice standards, and embed an aspirational culture of learning, support and challenge with staff clear about what is expected of them including core practice such as the Voice of the Child, Visits, Assessments, Plans for children, Records and Supervision.

Since the Coroner’s findings a further Training Plan for the NRPF team has been created to ensure staff have refresher training and that what occurred to Mazeedat will not occur again.

The following refresher training courses have been identified and scheduled for the team:

Training Date Completing Purposeful Child & Family Assessments (Single Assessments) and Planning By 31/01/25 Refresher of Relational Practice and application of Language that cares By 28/02/25 Section 20 Seminar - The seminar will concentrate on processes, language and working in partnership with parents. By 28/02/25 Language that Cares and Relational and Compassionate Recording. This will be conducted by a dual Qualified Family Systemic and Psychotherapists By 28/02/25 Human Rights Assessments By 31/03/25 Supervision Training for Managers By 30/04/25 Fortnightly seminars on varied subject matters related to practice conducted by the Newham Academy Fortnightly and ongoing

A named Practice Development Social Worker (PDSW) has been aligned to the team, to further monitor and support ongoing practice development in the service. The PDSW will follow a coaching model that includes the delivery of training workshops covering the above topics and different practice subject matters. This will be followed by 1 to 1 coaching with each worker, including joint visits, practice role modelling, observation of practice, reviewing written records and providing feedback and reflective spaces. We consider that this will directly impact a continuing

improvement in culture within the NRPF team.

Working with Voluntary Organisations to further improve practice

The council is committed to working in collaboration with voluntary organisations to offer better joined up support to our families and the following has been agreed:

In the December 2024 audit report, it was recommended that Children’s Services annually commission an external Voluntary Organisation with expertise in NRPF to gain Family Feedback in addition to feedback gained within the Practice Learning Conversations that take place as part of Newham’s Quality Assurance Process. This was in recognition that the positive feedback families gave to the Newham employed auditors (who would have introduced themselves as council employees) might be overly positive due to that context and that an external agency where families could remain anonymous would ensure more accuracy of feedback.

A review of the Terms of Reference of the current Migrant Health Operational Group is to take place by April 2025 to enable key voluntary organisations working with NRPF families to attend and offer critical reflection on systems, processes and decision making. The plan is for a voluntary organisation to co-chair the meeting.

We plan to invite Voluntary Organisations to the NRPF Service Meeting to develop relationship, promote learning and enhance practice in April 2025, where the frequency of attendance and remit will be established.

b) The Coroner's Concern regarding the management of the NRPF Team

The Coroner has set out a further Concern in his Report as follows:

The NRPF team was poorly managed. Social workers were not adequately supervised, and their caseloads were not periodically reviewed. The absence of leadership allowed a gradual erosion of empathy for the very people the team were employed to support. The absence of proper management left inappropriate behaviour unconstrained and allowed irrational decisions made arbitrarily by junior staff, to stand unchecked.

We acknowledge the team had a high case load between 2020-2021 as a result of the Covid-19 pandemic, which led to a significant increase in the number of families we were supporting within the No Recourse to Public Funds Service. At the time the team were working with an average of 535 children. We acknowledge this impacted on consistent supervision and management oversight. The caseload at the time of completing this report is 348 with the same number of staff that there was in 2021. Over time, there has been a gradual reduction in demand and assurance that practitioners are holding a more manageable caseload.

Managers across the Directorate undertake approximately 65 bi-monthly Full Case File Audits, as well as sample a number of case files dependent on a particular theme e.g. neglect, physical abuse. Alongside this, our Quality Assurance Unit also undertakes thematic and multi-agency reviews. Data is analysed and compared to neighbouring boroughs which are considered statistical neighbours to assist with whether decision making in an area is consistent with other boroughs. An example of this is as follows; in 2020-2021 Newham placed 79 children into foster care, compared to the average of 77 of our statistical neighbours, in 2021-2022 this rose sharply in the borough, and we placed 141 children into foster care, compared to 97 by our statistical neighbours. In 2022-2023 we placed 114 children into foster care, compared to 98 of our statistical neighbours. We can conclude from these figures that Newham support more Section 20 foster placements than other Local Authorities and that these placements have increased since 2020.

(i) Action Taken Following Mazeedat's death

In addition to the launch of our Practice Learning Conversations in 2022, which ensures heightened oversight of cases and practice by all managers including Senior Management, the Head of Service also chairs the NRPF panel twice a month, which allows for greater scrutiny of families’ situations. The purpose of the panel is to scrutinise the work with families and prevent any drift and delay in decision making for the children and families allocated to the service. The panel also ensure the oversight of the family’s circumstances such as their immigration journey, their accommodation needs and the level of support they are receiving. The panel consists of practitioners from Newham Children’s Social Care, Housing and the Legal department.

A focused campaign was launched in 2022 to ensure that social workers and managers were recruited permanently and replaced agency staff who did not provide consistent Relational Practice to families. These improvements can be seen in our staff retention and turnover rates since 2021. In 2021 we had 30% permanent staff (Social Workers and managers) in Children's Services and 70% agency staff. Currently we have 80% permanent staff (Social Workers and managers). Our 20% agency staff receive the same training that permanent staff do as we can invest in them given the lower numbers of them. Many of these agency staff are longstanding. Our turnover rate is now very low and has been on a downward trajectory from 2019-20 where our turnover rate for social workers was 30.2%. In 2023-24 the turnover rate for social workers was 11%. An improved staff retention rate results in more experienced staff, and indicates a positive culture within the team where staff have appropriate caseloads and are able to give the time and energy needed to each individual child and their family.

As part of our ongoing learning and practice development in 2022, a Family Therapist and Practice Development Social Worker held 1:1 reflective supervision sessions with named team managers to support with improving the quality of supervision, recording and reflecting language that cares in management oversight and supervision records. We are continuing to strengthen and ensure compliance with supervision standards through monthly performance management meetings with the NRPF management team. These meetings are chaired by the Head of MASH, NRPF and Early Help Services. As part of our performance management schedule, a monthly Practice and Outcome Meeting of Head of Services also takes place and is chaired by the Director of Early Help and Safeguarding. This meeting scrutinises the plethora of data collated, hypothesises the reason for the data being what it is and directs improvements. This data includes staff supervision timeliness and caseloads.

Supervision Policy and Management Oversight Review

The purpose of supervision is to ‘enable and support workers to build effective professional relationships, develop good practice, and exercise both professional judgement and discretion in decision-making’. The frequency of supervision may vary depending on the supervisee's role, level of experience and the families they are supporting. However, the minimum standard expected is 4 weekly 1:1 meeting for one and a half hours for professional development and families that require additional support. This is monitored through monthly in depth data collection and if any concerns arise this is addressed with urgency.

Access to Care & Resources Panel

The purpose of the Access to Care and Resource Panel (ACRP) is to scrutinise and authorise all recommendations to look after children under Section 31 and 20 of the Children Act 1989. Newham Children’s Services recognises that the decision to look after a child or young person is a momentous and life changing event for them and their family and should only happen with due consideration of all the alternatives, with the needs of the child or young person at the forefront of our consideration.

The Panel are acutely aware of the disproportionality and disparity factors that are present within the Children’s Social Care and Education systems and strive to promote equity and inclusion, tackle racism and all forms of discrimination. The Panel require all aspects of Equity, Diversity and Inclusion to be explained and explored and strive to be culturally competent.

The ACRP went live in July 2024 and is chaired by the Director of Children Services and the Director of Early Help and Safeguarding. The membership of the panel includes senior managers from Education, Children Social Care, Independent Reviewing Service and Commissioning. Since going live in July 24, 138 children have been discussed at the ACRP, including those children whose parents have No Recourse to Public Funds. The introduction of the ACRP means that approvals for children to be looked after is no longer service led as it was in Mazeedat’s case. All requests will now need to be made to ACRP.

Audit

A deep dive audit was completed in December 2024 as soon as the Coroner concluded the Inquest to immediately re- review the service’s practice focusing on service delivery, the experiences of families with No Recourse to Public Funds, the quality of management oversight and recording. The reviewer analysed all PLCs conducted within the NRPF service between 2022 to November 2024. The December 2024 audit findings in relation to supervision found 15 cases (62.5%) were graded as Good, 1 case (4.2%) as Outstanding, 6 cases (25%) were graded as Requires Improvement and 2 cases (8.3%) as Inadequate. In cases graded as Inadequate or Requires Improvement the key concerns identified were that managers were not ensuring swift escalations to the Home Office which had implications for families’ ability to progress with their immigration status, and that the frequency of supervision and management oversight was not consistently in line with the Supervision Policy. We note this aligns with the Coroner’s findings and therefore are taking further action to rectify the matter.

(ii) Action Proposed to be Taken

The 2024 audit which reviewed all PLCs (audits) undertaken from 2022 to 2024 recommended that management oversight should be further strengthened and the supervision policy reviewed. We are in the process of reviewing our supervision policy to be more specific and clear regarding the frequency of supervision and management oversight for different types of children and family’s circumstances.

The Service has a bi-monthly sample review schedule of case audits by the Service Manager. This is alongside Practice Learning Conversations undertaken by the Quality Assurance Service. In light of the findings made by the Coroner, there will be a particular focus on the following areas in our audit schedule:

 Supervision and management oversight  Recording  Plans  Voice of the child

In response to the changes in government guidance “Stable Homes Built on Love” the directorate is ready to reimagine the service we offer to Children and Families, including families with No Recourse to Public Funds that will further embed our Circles of Support Practice Model. We are taking the opportunity brought about by these changes to develop a service which is aligned to the principles of “Stable Homes, Built on Love” and Working Together to Safeguard Children
2023. As a result of these changes, the NRPF Team is going through structural changes, and going forward will be made up of mainly Family Support Project Workers instead of Social Workers. This new model ensures workers are able to spend more time offering effective early help support for families with No Recourse to Public Funds. This more streamlined support will provide further relational, compassionate opportunities to work collaboratively with families and

voluntary organisations. It will continue to value all voices and reflect those voices in our records.

With the launch of the new team on 20th January 2025, we have identified a quality assurance action plan (see below), to be undertaken over the course of the next 3 to 6 months. As part of the quality assurance programme for the newly reconfigured service, leadership, systems and processes in the NRPF Team will be monitored and reviewed. This will ensure further enhanced operational management and leadership oversight of the NRPF Team, including continuing to ensure manageable caseloads for workers. It will also support us to further review our performance, practice, conduct of staff, team culture, and any patterns of behaviours that may give cause for concern.

Action Date Peer Review of the NRPF Service by a London Authority with Good or Outstanding Ofsted rating. The peer review will consider leadership, quality of practice, quality of management oversight and quality of recording. By 30/04/25 Twice Yearly Practice Week – this will enable the leadership team in CYPS including the Director of Children’s Services to observe practice, audit children’s files and obtain feedback from families with No Recourse to Public Funds. First Practice Week will be completed in February 2025

Second Practice Week will be undertaken in May 2025 As part of ensuring the ongoing improvement of the quality of the service delivery within the NRPF Team, our Quality Assurance Unit shall undertake a review of any Complaints received in the service between 2022 – 2024. We will do this alongside the VCS organisations who may have raised concerns. By 31/03/2025 Review and launch the new Supervision Policy By 30/04/25 Audit of adherence to the Supervision Policy By 31/07/25 NRPF Policy to be reviewed alongside MAGPIE and Praxis By 30/06/25

c) The Coroner's Concern regarding the standards of note-keeping and recording

The Coroner has set a further concern as follows:

Inadequate standards of note-keeping meant that the rationale for critical decisions made by the NRPF were not properly recorded. The absence of clear records diminished both communication within the team and accountability.

We acknowledge the Coroner’s findings that record keeping was below the standard we expect and this has meant that crucial decisions made by the NRPF team were not clearly recorded on Mazeedat’s file. Since 2022, we have set a very high standard on our recording to ensure it is purposeful, child focused and clearly reflects the actions and decisions we have taken to support the family.

(i) Action Taken Following Mazeedat's death

Significant improvements have already been made to note-keeping and the recording of actions and decisions.

Appropriate and child centred recording is an area of practice that has been promoted, directed and embedded since
2022. Appropriate and child centred recording is the practice that invites Social Workers to take jargon out of their written records and to use child focused recording on a child’s record. The aim is to avoid the use of acronyms and imagine

that the child will be reading, when they grow up, what is being written about them. Staff have been trained to do this by the roll out of the model of “Language That Cares”.

Children’s Services now takes an approach to recording that is both non-pathologising and appreciative of the child and family’s contexts. A non-pathologising approach to recording is one where the Social Worker does not record in ways that construct the identity of a child through the use of diagnostic terminology or labels that imply the child is something, rather it invites a recording that says the child or parent is showing a behaviour at a particular time. An example would be instead of saying “X is aggressive”, we would encourage the Social Worker to record, “X due to his traumatic experiences finds containing his feelings of distress hard”. Meaning as a parent he may speak aggressively or refuse to give information due to his past experiences of trauma. By using this approach, record keeping is clearly made, improves communication between staff, families and third parties, and improves the accountability of our staff.

All quality assurance activity includes reviewing the quality and detail of recording on child’s files.

The December 2024 audit findings in relation to recording found that 22 cases were graded as Good and 1 as Outstanding and 1 as Requires Improvement. The case graded as Requires Improvement was due to the recording of the framing of the mother’s experiences of domestic abuse appeared to minimise the seriousness of the abuse. Other findings to further improve recording including workers ensuring chronologies were on file.

Through the Newham Social Care Training Academy, we are continuing to offer training to staff including workers in the NRPF Team to ensure that language that cares is used consistently when they are recording on the child’s file. The Academy is the vehicle for developing our workforce and improving outcomes through development and training, in turn helping them to support and empower the families they work with.

(ii) Action Proposed to be Taken

We are working closely with our IT support team to make further changes to our Integrated Children’s System (ICS) in order to support with further strengthening all note-keeping and recording including the recording of management decision making.

The following system changes are planned:

Proposed System Change Date Introduction of NRPF Plan template following the completion of a Child and Family Assessment. This will ensure regular reviews of NRPF plans following the completion of Assessments. This went live on 14/01/25 NRPF Panel Form to be embedded in our ICS system By 31/03/25

4. Conclusions and Impact

In conclusion, we have re-evaluated our internal policies and procedures after this tragedy and significant changes and improvements have been made as highlighted in this report. The impact for children and families as found through auditing has been mainly positive. The permanent workforce has improved dramatically and the Regulator, Ofsted concluded “Families with no recourse to public funds receive a responsive service from social workers who take into consideration the complexity of children’s circumstances and their needs”.

Our service delivery has improved markedly from the Inadequate grading by Ofsted from 2019 until July 2022 where Children’s Services were graded as Good with Outstanding Leadership. Since the launch of the revised Working Together to Safeguard Children 2023, we have reviewed the way we support families with No Recourse to Public Funds. We are in the process of making systems changes in line with the principles of supporting families early and only allocating a family to a Social Worker for assessment and support if there are safeguarding concerns. This is also based on the feedback we have received from Newham’s families which was similar to the feedback from families to the National Review of Children’s Social Care- Stable Homes Built on Love.

Importantly, feedback from the families themselves indicates that the service delivered by staff is compassionate, child focused and makes a difference to their lives. In the audit conducted in December 2024 which reviewed children’s records between 2022 and 2024, the majority of families rated their experience very positively.

Since 2022, families have written into the service offering thanks and compliments to the NRPF team. These have not been asked for but are collated, shared amongst the team and the whole service. Staff who receive such compliments in their practice get mentioned alongside the quote from the family (anonymously) in the Children’s Services newsletter which is distributed to over a 1000 staff. This all aims to share good practice and foster a positive culture.

A sample of that feedback is included below:

September 2024 Your team has done a great job in my life. More especially putting smiles on our faces when I thought there was no hope to survive with my children. During this sudden abandoned by their daddy, I was emotionally and socially deranged because I didn't know what to do due to my past statue until your team rescued me at the time of needy. You paved a very wide way for our future with a good channel with Praxis team. I really appreciate all your supports as you all has created an impact in my heart. God bless you all. We love your team.

February 2024 I just want to say thanks to you and your humble office for the support given to my family, we are grateful!

Thank you [social worker] for allowing God use you to support us especially at the moment when as a family we lost hope and had no means to survive, which was a moment we feared for what would become of our family as we had nowhere to go, or did not know what to do with our housing and financial situation.

Each day we sleep and wake up in this house it is like a dream and each time "all we say is that may god bless you! beyond measures!!! yes, you only did your job

as a social worker, but little did you know that God was using you to help a family in need, if only u know how far we have come and what we went through you would understand why each time we see you or speak to you we cannot but keep thanking you and your humble office. Each time you speak from a place of concern and care for my daughter ‘F’and whenever you do it touches my heart! Thank you [social worker]! for doing your job diligently!

Thank you [social worker]! for making our experience with you seamless!

Thank you [social worker] for always reaching out to our family from a place of care without judging us or treating us differently because of our status!

Thank you for listening when we needed clarity!

Thank you [social worker] for making our experience with the social services no recourse to public funds team a good one!

January 2024 I wanted to express my heartfelt gratitude for your exceptional support throughout our visa processing journey. Your guidance and expertise played a pivotal role in making this intricate process more manageable. Your dedication to ensuring a smooth experience did not go unnoticed and I truly appreciate the time and effort you invested in addressing my concerns, no matter how small or difficult it sounded. Your professionalism and compassionate approach have made a significant impact, turning what could have been a stressful ordeal into a positive and successful outcome. Whenever you were not available, you ensured we had JB who was always at hand and very supportive. You made the burden lighter. Thank you once again for your unwavering assistance. Your commitment to helping others shines through and I am genuinely grateful for the positive difference you have made in mine and W’s life. We will forever be indebted to you. God bless you and the entire NRPF Team.

May 2023 May I use this opportunity to commend your department for the prompt handling of the matter, and in particular Ms “D”, who was very professional, patient and empathetic with me on the phone; I truly appreciated it.

November 2022 I want to thank you for having helped us to get the council's support! We are in a much better hotel, we can't cook yet and we can't even live like in a house, but we are happy to be well accommodated! I believe it is a temporary situation that soon we will follow a house! Even so, I want to thank you for helping us by filling out the form and calling people on our behalf! May your life be more than blessed, magnificent and extraordinary! A big hug from our Family!

November 2022 Thank you for being with us till the end. And support and guidance from you and team is amazing. Every will be there which is not belongs to us. Thank you

September 2022 Thank you so much for your help, support, compassion and kindness. During our hard time you've always raised a hand to support my family. I really appreciate

your hard work, positive attitude and kind behaviour. I would like to express my sincere gratitude for the service you've provided.

We acknowledge that more needs to be done to further improve practice, and have therefore devised an extensive action plan to further improve the service we offer to families with No Recourse to Public Funds. We are confident that the implementation of the action plan will further improve the practice already in place to ensure the NRPF Team can continue to deliver intervention that is compassionate and responsive and that the culture of the team and service continues to be relational, child focused and collaborative.

5. Action Plan

The implementation of the Action and the impact of the actions once completed will be overseen by a Multi-Agency Task and Finish Group chaired by Director of Early Help and Safeguarding and CEO founder of The MAGPIE Project.

Action Date Lead Terms of Reference for Task and Finish Group to be devised and agreed. By 19/02/25 Director of Early Help and Safeguarding with assistance from The Magpie Project and Praxis Review the Terms of Reference of the current Migrant Health Operational Group to enable key voluntary organisations working with NRPF families to attend and offer critical reflection on systems, processes and decision making. The plan is for a voluntary organisation to co-chair the meeting By April 2025 Migrant Health Operational Group Invite Voluntary Organisations to the NRPF Service Meeting to develop relationship, promote learning and enhance practice, where the frequency of attendance and remit will be established. By April 2025 Head of Service, NRPF Completing Purposeful Child & Family Assessments (Single Assessments) and Planning Training By 31/01/25 Social Care Academy Refresher Training - Language that Cares and Relational and Compassionate Recording. By 28/02/25 Qualified Family Systemic and Psychotherapists Refresher Training – Purposeful, Planned and focused Planning. By 31/03/25 Qualified Family Systemic and Psychotherapists Human Rights Assessments By 30/04/25 Head of Service, NRPF Supervision Training for Managers By 30/04/25 Social Care Academy Section 20 Seminar - The seminar will concentrate on processes and compassionate relational language By 30/05/25 Social Care Academy and Care Proceedings Manager Fortnightly seminars on varied subject matters related to practice conducted by the Newham Social Care Academy Fortnightly and ongoing Social Care Academy Commission an external Voluntary Sector Organisation with expertise in NRPF to gain Family Feedback By 30/06/25 Director of Early Help and Safeguarding Practice Development Social Worker (PDSW) who has been aligned to the team will further monitor and support ongoing practice development in the service using a coaching model. 1 to 1 coaching with each worker, including joint visits, practice role modelling, observation of practice, reviewing written records, providing feedback and reflective spaces By 31/01/25 Head of Quality Assurance and Improvement Service

will be offered. Peer Review of the NRPF Service by a London Authority with Good or Outstanding Ofsted rating. The peer review will consider leadership, quality of practice, quality of management oversight and quality of recording. By 30/04/25 Director of Early Help and Safeguarding Twice Yearly Practice Week – this will enable the leadership team in CYPS including the Director of Children’s Services to observe practice, audit children’s files and obtain feedback from families with No Recourse to Public Funds. First Practice Week will be completed in February 2025

Second Practice Week will be undertaken in May 2025 Director of Children’s Services As part of ensuring the ongoing improvement of the quality of the service delivery within the NRPF Team, our Quality Assurance Unit shall undertake a review of any Complaints received in the service between 2022 – 2024. We will do this alongside the VCS organisations who may have raised concerns. By 31/03/2025 Head of Quality Assurance and Improvement Service A themed audit annually of children whose parents have No Recourse to Public Funds with a focus on single parents with limited network. By 30/06/25 Head of Quality Assurance and Improvement Service Review and launch the new Supervision Policy By 30/04/25 Director of Early Help and Safeguarding Audit of adherence to the Supervision Policy By 31/07/25 Head of Quality Assurance and Improvement Service NRPF Policy to be reviewed alongside MAGPIE and Praxis By 30/06/25 Director of Early Help and Safeguarding Introduction of NRPF Plan template following the completion of a Child and Family Assessment. This will ensure regular reviews of NRPF plans following the completion of Assessments. This went live on 14/01/25 Completed NRPF Panel Form to be embedded in our ICS system By 31/03/25 Head of Quality Assurance and Improvement Service

Dear Mr Irvine, INQUEST TOUCHING THE DEATH OF MAZEEDAT OPEYEMI ADEOYE I, , Head of the National Police Air Service (NPAS), am writing in response to the Regulation 28: Report to Prevent Future Deaths in the matter of Mazeedat Opeyemi Adeoye (reference
16975704). Whilst acknowledging that the delay in locating Mazeedat did not contribute to her tragic death, I fully accept that our training and operational practices require a review to ensure that future deaths are prevented wherever possible. In coming to my decisions I have liaised with , Head of Flight Operations, , , Tactical Flight Officer and technical SME, , Training and Quality Standards Manager and , Regional Operations Manager. There is a large breadth of knowledge and experience between these staff members, both in wider aviation and policing. Police decision making is based on the National Decision Model - a model that is trained via the College of Policing. The national decision model (NDM) is suitable for all decisions and should be used by everyone in policing. It can be applied:  to spontaneous incidents or planned operations  by an individual or team of people  to both operational and non-operational situations  Decision makers can use the NDM to structure a rationale of what they did during an incident and why. Everyone can use the NDM to review decisions and actions, and promote learning. In a fast-moving incident, the police service recognises that it may not always be possible to segregate thinking or response according to each phase of the model. In such cases, the main priority of decision makers is to keep in mind their overarching mission to act with integrity to protect and serve the public. This is in line with the ethical principle of 'public service'.

The NDM has six key elements.  Code of Ethics; Ethical policing principles and Guidance for ethical and professional behaviour in policing.  Gather information and intelligence.  Assess threat and risk and develop a working strategy.  Consider powers and policy.  Identify options and contingencies.  Take action and review what happened. In this particular case the information / intelligence was that the house and gardens had been thoroughly searched and with the rear gate locked the officers on the ground believed Mazeedat has left the property via the front door. This then led to the Tactical Flight Officers determining the search parameters. Moving forwards, to investigate every heat source on every incident would not be practicable and may be counter productive, leading to delays that could also contribute to future deaths. There will always be a balance to be maintained. The training our TFO's receive is to utilise the NDM, with the intelligence / information coming from a variety of sources depending on the type of incident. It may be that NPAS are the only police resource and are reliant on the contents of a police log, in other cases there will be officers on the ground and their input forms part of the wider picture. We have to rely on our staff applying their training correctly as well as using professional judgement based on the experience they have in police aviation and how the different cameras detect heat sources. As technology progresses, potentially with new fleet, there may be opportunities to change how we search. I will however utilise this footage as a case study / training tool for NPAS that may give perspective to search scenarios moving forward. Should a situation present itself in a similar way it may cause a TFO to think beyond the info / intel where time and circumstances allow. This will be incorporated from the next training course that commences on 14th February.