Dear Coroner

Re: Jacob Lee Shorter (deceased) Ref: 27618356

This response is provided by Calderdale Council in relation to the Regulation 28: Report to Prevent Future Deaths dated 18 June 2024 issued by Assistant Coroner Marilyn Whittle, Coroner area of South Yorkshire (West) following the conclusion of the inquest on the 18th June
2024.

Representations in relation to matters arising from the Inquest hearing which gave rise to the coroner’s concern:

1. It is a pre-condition to making a report that the ‘coroner has considered all the documents, evidence and information that in the opinion of the coroner is relevant to the investigation’ (Regulation 28(3)). The concern raised by the coroner related to the Independent Visitor service and there was no witness evidence or opportunity for that service to provide witness evidence to the coroner to fully set out matters addressing the concerns now raised by the coroner. Had that opportunity been provided then we do not consider that a regulation 28 PFD would have been issued as the coroner would have been satisfied that the procedures in place were satisfactory as set out comprehensively below.

2. The Council submit that in the absence of direct evidence at the inquest hearing to address the concern raised by the coroner, it was reasonable and appropriate for a letter expressing that concern to have been made instead of a regulation 28 PFD report in accordance with paragraph 37 of Guidance No.5 Reports to Prevent Future Deaths issued by the Chief Coroner.

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3. The concern raised by the coroner in the absence of hearing any evidence from the independent visitor service is likely to hinder future recruitment and retention of Independent Visitor volunteers by the Council. The service provides an important statutory role to visit, befriend and advise a child/young person. There is a real risk volunteers may deem that they are being unfairly criticised for non-disclosure of confidential information when that is not the case as set out below. Independent visitor volunteers adhere to both Council and National standards including the need to ensure confidentiality and to identify the circumstances of when it is appropriate to disclose relevant information.

Preliminary Matters:

In relation to the Regulation 28 Report, box 3 appears to contain a typographical error in that the date of the inquest opening pre-dates the tragic death of Jacob.

At the inquest hearing, the Council’s Pathways Leaving Care Team Manager was summonsed to give oral evidence. This witness gave evidence and explained he could only provide evidence on behalf of the Pathways Team based on records held by that service. His evidence was set out in a written report to the coroner dated 8 March 2024.

At the inquest the witness addressed the coroner that he could not give evidence or answer questions on behalf of other departments within the Council upon which he had no knowledge.

It is regrettable that there was no evidence from the other departments who were actively engaged in the care and support for Jacob resulting in the coroner deciding that there was a need to raise a Regulation 28 report.

The Council would also like to point out a misunderstanding of the evidence as set out in box 4 of the Report. The summary states that following the visit by the independent visitor on the 3 December 2023, “This information was not passed onto the… pathways team.” That is incorrect. Information was passed onto the Pathways team by the Independent Visitor team and that evidence is set out in the Pathways Team manager’s report (page A19 of the inquest bundle). This was also the witness’s evidence at the inquest.

The Council will also take this opportunity to clarify that the Independent Visitor volunteer met with Jacob on the 30 December 2023 and not 31 December 2023 as stated in box 4.

Response to Coroner’s Concerns set out in Box 5 of the Report

The matters of concern identified within the Report giving rise to concern was as follows:

(1) Whilst the Independent Visitor was made aware of previous suicidal ideation this was not passed on to the foster carer or anyone else. Calderdale were unable to tell me of the training they receive or the escalation route for concerns or disclosures of this type.

2 There is a clear risk that if this type of information is not passed on and adequate training is not provided in terms of metal health then this could cause future deaths.

Firstly, in order to address the above matter of concern, it is important to state at this juncture that there was no evidence before the coroner from the independent visitor service on their policy and procedures which is regrettable. The evidence provided to the coroner was from the Pathways Leaving care team who was unable to address a specific question when asked about the Independent Visitor service. There was no request for the Council to specifically provide information relating to the Independent Visitor service and neither was there any previous concern raised to the issue which arose at the inquest hearing.

Therefore, we take this opportunity of setting out the role and responsibility of the Independent Visitor service and will then address the specific matters of concerns of the coroner.

Calderdale Council has a specialised service for the provision of Independent Visitors. This is a statutory service for looked after children when a local authority has to appoint an Independent Visitor if they feel it would be in the young person’s best interests to do so.

This was introduced under section 23ZB Children Act 1989 as amended by the Children and Young Persons Act 2008. The Act confirms that “A person appointed under this section must visit, befriend and advise the child.”

Calderdale Council adhere to guidance and standards issued by the National Independent Visitor Network dated January 2016 - link to guidance National IV Standards.pdf (barnardos.org.uk).

The standards set out expectations that Independent Visitor services have to work to and to maintain a high level of confidentiality between the young person, Independent Visitor and service coordinator which is necessary to foster and establish a relationship of trust between the young person and Independent Visitor.

Independent Visitor roles are undertaken by unpaid volunteers independent of the Council’s social services department. Independence of service is important and is in accordance with Department for Education guidance 3.262 The Children Act 1989 guidance and regulations (publishing.service.gov.uk).

It should be noted that an Independent Visitor would not have access to a young person’s case file in accordance with the guidance. However, information from the Independent Visitor volunteers following visits with young persons are fed back to the Independent Visitor team with a brief description of the visit, unless there are any concerns or queries arising from the visit. All volunteers are trained to understand the types of issues which would need passing onto the team including for example concerns regarding the young person’s welfare or safeguarding. It is for the Independent Visitor Team to pass relevant information onto other services (if appropriate) within the Council.

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The Council has a vigorous recruitment, selection and training process for volunteer Independent Visitors where they learn and understand their role and what is expected of them and develop the knowledge, skills and the circumstances of when confidential disclosed information needs to be shared with others, for example when there is a safeguarding issue.

To address the coroner’s specific concerns, the Council can confirm the following matters:

- Disclosure of Confidential Information from Jacob to the Independent Visitor Volunteer

All Independent Visitors Volunteers adhere to the Council’s “Safeguarding Code of Conduct for Independent Visitors.” The Code forms part of the agreement for Independent Visitors to work as a volunteer. The Safeguarding Code is specific and sets out the circumstances in which disclosure should take place by stating:

“Volunteers must: ▪ Report any incidents or concerns that cause them to believe that a child, young person or vulnerable adult is, or is likely to be, at risk of harm…”

This procedure is also set out in the Council’s “IV & Volunteer Health & Safety Guidance.”

Jacob was a 19 year old adult. The Independent Visitor assigned to Jacob visited him once a month and this was increased to two visits a month following the Professional Meeting that took place on the 15 November 2023.

The Independent Visitor volunteer visited Jacob on Sunday 3 December 2023 when during the course of the visit there was a discussion about his mental wellbeing. Jacob disclosed that he had felt suicidal in the past but not at this moment. Jacob also disclosed that he had been to the doctors with his foster carer, and they had spoken about anti-depressants but he had chosen to try other things before medication like walking which he was going to try. Jacob also confirmed that he felt love and supported and knew that he could speak to his foster carer and the independent visitor if he needed to.

The Independent Visitor volunteer called the Independent Visitor team on Monday 4th December 2023 and reported in detail what Jacob had disclosed.

On Tuesday 5 December 2023, the team spoke with the Pathways Team by telephone relaying the information that Jacob had disclosed to the Independent Visitor volunteer.

As the confidential disclosure of Jacob’s feeling related to how he felt in the past and there was no imminent signs of risk of self-harm or safeguarding concerns and that he had recently been seen by his GP when his mental wellbeing was discussed, the confidential disclosure was not discussed with the foster carer and it would not have been appropriate to do so at that time.

2 On the 30 December 2023, the Independent Visitor volunteer visited Jacob and no concerns were raised.

The action taken by the Independent Visitor volunteer was in accordance with the Council’s and National guidance whereby they passed relevant information to the Independent Visitor team who in turn passed this information to the Pathways team. This was done promptly.

The Council accept there are circumstances where information may be passed onto a foster carer which may arise as follows:
a. When the Independent Visitor volunteer reports concern to the Independent Visitor team who then opts to pass information onto the foster carer; or
b. If there was an imminent risk to the young person, then the Independent Visitor volunteer is trained to approach the foster carer directly and/or the Social Services Emergency Duty team and/or the police to ensure that they are acting in the young person’s best interest.

It should be noted that Independent Visitor volunteers are not specialists in mental health. Their statutory remit is to visit, befriend and advise the young person.

- Training

Thorough and comprehensive training is delivered to all Independent Visitor volunteers as part of the recruitment process. The training programme is conducted over a period of 8-12 weeks (undertaken once a week for approximately 2 hours each session).

Training topics include: introduction to the Independent Visitor service, Equality Act topics, detailed introduction to safeguarding/risk of harm and managing disclosure and confidentiality, health & safety and risk assessments, welfare of children and general mental health risks to children in addition to understanding their role and responsibility in accordance with National standard guidance.

Once the Independent Visitor volunteer has completed their training programme and assessment, the Independent Visitor Manager prepares a report on the recruitment of Independent Visitor volunteer. A panel of professionals is convened including other external parties such as the Youth Justice Service, where the panel would review the report and decide whether to approve the Independent Visitor volunteer for the post.

Independent Visitor volunteers’ performance is reviewed every 6 months by the Independent Visitor team and if there are any further training needs these are identified during that review process and addressed.

The Council can assure the coroner that there is extensive training delivered to Independent Visitor volunteers whereby they understand their role and responsibility and the circumstances in which disclosure of confidential information may be necessary to the Independent Visitor team.

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- Lessons Learnt

The Independent Visitor service is always looking to provide enhanced training to their volunteers to increase their knowledge, skills and awareness on mental wellbeing matters concerning young person’s.

As such, the service plans the following additional training needs directly as a result of this tragic incident:
a. Providing Independent Visitor volunteers (where necessary) Mental Health First Aid Training.
b. Induction Training programme to include a specific topic relating to suicide prevention and signs.

Conclusion

This response sets out in detail the statutory role of the Independent Visitor Service, the extent of their statutory remit, their adherence to Council and National guidance and standards on the issue of disclosure of confidential information.

The response sets out and addresses the specific concerns of the coroner in relation to the care of Jacob and the steps taken by the independent visitor volunteer following disclosure of a confidential nature in accordance with both Council and National guidance on safeguarding.

While the Independent Visitor service are not mental health specialists, the Council recognise that specific suicide prevention training would be helpful for the volunteers to increase their knowledge and skills on the subject when they are carrying out their statutory role to befriend and advise a young person.

If there is any further information that you require, then please contact me.