Lamarah Scarlett
PFD Report
Partially Responded
Ref: 2024-0425
Coroner's Concerns (AI summary)
Inadequate regulation of transport for Special Educational Needs children led to issues including crew unfamiliarity with safety plans, poor handovers, insufficient personnel change notifications, and a lack of mandatory training or oversight.
View full coroner's concerns
Whether there is sufficient regulation of transport operators who provide category home to school transport services to Special Educational Needs children? The following specific issues were identified: The patient safety plans are not always read and understood by transport crew, Home visits between passenger and transport crew often do not occur when contractually required, The local authority are often not notified of personnel changes in the transport crew, The need for proper handovers at drop off and pick up is not understood There is no requirement for transport crew to be qualified first aiders, The passenger assessment test requires further improvement; There is no comprehensive schedule for inspection of transport operators; There is no mandatory training or forums for operators to attend where information can be cascaded to them: Operators have to approach multiple organisations which leads to confusion and inconsistency:
Responses
Action Planned
The Department for Education has contacted Gloucestershire County Council, who now require all members of transport crews to undertake first aid training. The Department is drafting non-statutory guidance to support better partnership working to meet children’s needs, expected later this year or early next year. (AI summary)
The Department for Education has contacted Gloucestershire County Council, who now require all members of transport crews to undertake first aid training. The Department is drafting non-statutory guidance to support better partnership working to meet children’s needs, expected later this year or early next year. (AI summary)
View full response
Dear Ms Skerrett,
I am writing on behalf of the Secretary of State for Education in response to the Regulation 28 Report to Prevent Future Deaths, issued on 29 July 2024, concerning the death of Lamarah Grace Scarlett on 24 September 2021. I am responsible for the government’s policy on home-to-school travel.
I was deeply saddened to learn of Lamarah’s death. My heartfelt sympathy goes out to her family. The government’s home-to-school travel policy aims to make sure no child is prevented from accessing education by a lack of transport. Local authorities have a duty to arrange free travel for eligible children. To meet that duty, the travel they arrange must be suitable for the needs of the child concerned. I share your concern that, on this occasion, there do not seem to have been suitable arrangements in place to keep Lamarah safe on her journey home from school.
Officials at the Department for Education have contacted Gloucestershire County Council about Lamarah’s case. I understand that the Council ensures children travelling on home-to-school transport have a ‘personal safety plan’ and that Lamarah’s plan included details of her condition, the signs and symptoms to watch out for, and how to respond to those symptoms. The Council makes it a condition of its contracts with transport operators that all members of the transport crew for each child have read their personal safety plan. At the time of Lamarah’s death, it was also a condition that at least one member of the crew had undertaken first aid training. It is now a condition that all members of the crew must undertake first aid training.
The Council has advised that, in Lamarah’s case, the transport operator had failed to comply with both these conditions. The Council says it already had robust procedures in place for ensuring children’s safety and monitoring operators’ performance and that, since the inquest, they have enhanced their checks on transport operators and are reviewing their training for passenger assistants. They
have also terminated all contracts with the operator responsible for Lamarah’s transport.
The Department for Education publishes statutory guidance to assist local authorities in meeting their home-to-school transport duty. The latest version of the guidance was published in 2023 and includes much more comprehensive guidance about meeting a child’s needs than the version that was available at the time of Lamarah’s death. It is available here: www.gov.uk/government/publications/home-to-school- travel-and-transport-guidance. I believe it goes a long way to addressing the concerns you have raised in this case. In particular, it recommends that drivers and passenger assistants are trained in basic life support skills. It expects local authorities to conduct risk assessments, to consider how a child’s medical needs might affect them during their journey, and to put in place proportionate arrangements to manage those needs. It also requires them to ensure that a child’s driver and passenger assistant are aware of their needs and how to respond to them, that they have received any training they need to be able to do so, and that they are trained in (amongst other things) the handling of emergency situations.
Further work is underway in the Department to support local authorities in arranging suitable travel for all children. For example, officials hold bi-monthly meetings to which all local authority school travel officers are invited to seek advice from one another and the Department and to share best practice. Officials are drafting non- statutory guidance to support better partnership working within local authorities (i.e. between SEND caseworkers and school travel officers) and beyond (i.e. between authorities and schools, parents and health professionals) to better meet children’s needs. I expect this piece of guidance to be available later this year or early next year. Officials will keep Lamarah’s case in mind as they continue to work on it.
Thank you for bringing this important matter to my attention and for giving me the opportunity to respond.
Yours,
Minister for School Standards
I am writing on behalf of the Secretary of State for Education in response to the Regulation 28 Report to Prevent Future Deaths, issued on 29 July 2024, concerning the death of Lamarah Grace Scarlett on 24 September 2021. I am responsible for the government’s policy on home-to-school travel.
I was deeply saddened to learn of Lamarah’s death. My heartfelt sympathy goes out to her family. The government’s home-to-school travel policy aims to make sure no child is prevented from accessing education by a lack of transport. Local authorities have a duty to arrange free travel for eligible children. To meet that duty, the travel they arrange must be suitable for the needs of the child concerned. I share your concern that, on this occasion, there do not seem to have been suitable arrangements in place to keep Lamarah safe on her journey home from school.
Officials at the Department for Education have contacted Gloucestershire County Council about Lamarah’s case. I understand that the Council ensures children travelling on home-to-school transport have a ‘personal safety plan’ and that Lamarah’s plan included details of her condition, the signs and symptoms to watch out for, and how to respond to those symptoms. The Council makes it a condition of its contracts with transport operators that all members of the transport crew for each child have read their personal safety plan. At the time of Lamarah’s death, it was also a condition that at least one member of the crew had undertaken first aid training. It is now a condition that all members of the crew must undertake first aid training.
The Council has advised that, in Lamarah’s case, the transport operator had failed to comply with both these conditions. The Council says it already had robust procedures in place for ensuring children’s safety and monitoring operators’ performance and that, since the inquest, they have enhanced their checks on transport operators and are reviewing their training for passenger assistants. They
have also terminated all contracts with the operator responsible for Lamarah’s transport.
The Department for Education publishes statutory guidance to assist local authorities in meeting their home-to-school transport duty. The latest version of the guidance was published in 2023 and includes much more comprehensive guidance about meeting a child’s needs than the version that was available at the time of Lamarah’s death. It is available here: www.gov.uk/government/publications/home-to-school- travel-and-transport-guidance. I believe it goes a long way to addressing the concerns you have raised in this case. In particular, it recommends that drivers and passenger assistants are trained in basic life support skills. It expects local authorities to conduct risk assessments, to consider how a child’s medical needs might affect them during their journey, and to put in place proportionate arrangements to manage those needs. It also requires them to ensure that a child’s driver and passenger assistant are aware of their needs and how to respond to them, that they have received any training they need to be able to do so, and that they are trained in (amongst other things) the handling of emergency situations.
Further work is underway in the Department to support local authorities in arranging suitable travel for all children. For example, officials hold bi-monthly meetings to which all local authority school travel officers are invited to seek advice from one another and the Department and to share best practice. Officials are drafting non- statutory guidance to support better partnership working within local authorities (i.e. between SEND caseworkers and school travel officers) and beyond (i.e. between authorities and schools, parents and health professionals) to better meet children’s needs. I expect this piece of guidance to be available later this year or early next year. Officials will keep Lamarah’s case in mind as they continue to work on it.
Thank you for bringing this important matter to my attention and for giving me the opportunity to respond.
Yours,
Minister for School Standards
Sent To
- Department for Education
- Local Government Association
Response Status
Linked responses
1 of 3
56-Day Deadline
23 Sep 2024
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 the 28th November 2022 | commenced an investigation into the death of Lamarah Grace Scarlett. The investigation concluded at the end of the inquest on the 3 5th June 2024_ The conclusion of the inquest was a narrative conclusion: The medical cause of death was 1A Unascertained.
Circumstances of the Death
Lamarah Grace Scarlett "Lamarah" was a 12 year old girl who suffered with alternating hemiplegia of childhood (AHC) which is characterised by repeated episodes of weakness or paralysis. On the September 2021 she had attended school. Lamarah had appeared happy and well during the At the end of the day Lamarah appeared to be tired: Staff did not feel she was presenting with any signs of a seizure Or paralysis. At approximately 1500 hours she is secured in her wheelchair by staff and placed on minibus to be transported to her home address. She is accompanied by a driver and a passenger assistant During the journey Lamarah appears to be incdistress,eand is experiencing breathing difficulties It is probable that Lamarah was suffering from a significant and profound episode of muscle weakness which made her unable to reposition her head to an upright position: Her head was in a hyper extended position, which caused her airway to become obstructed and led to her becoming acutely hypoxic Neither the passenger assistant Or the driver on the bus is aware of this. They do not raise the alarm %r seek further assistance_ If Lamarah's head had been supported in an upright position andl or if she had been placed in recovery position, it is likely that her airway would have opened up. However it remains unclear whether this would have enabled sufficient airflow to her lungs a she had significant truncal weakness_ At approximately 15.45 hours Lamarah arrives at her home address in a unresponsive state Her mother commences resuscitation efforts and emergency services soon thereafter arrive. Despite extensive resuscitation efforts, Lamarah is pronounced deceased at 16.45 hours_ Gloucestershire Coronerk CourtCorinium Avenue Barnwood Gloucester, GL4 3DJ Katy and 24th day:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.