[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child (2) the preplanning of the visit was deficient in that there was no indication that the four potential episodes of known to OFSTED were a key line of enquiry (3) the safeguarding documentation, which was entirely relevant, was not considered by the inspector (4) other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector (5) in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that

Coroner's Court, 2 Faraday Court, Faraday Drive, Fulwood, Preston, Lancashire, PR2 9NB

none of the breaches of the Regulations could be sustained against the Home. (6) on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was "outstanding" and no concerns were raised in the Regulation 44 reports (7) there is a discretion not to publish an OFSTED if there are "exceptional circumstances" which was relied upon by the senior manager in not publishing this report. OFSTED has provided no guidance to senior managers as to what constitutes "exceptional circumstances" which in this instance was taken to include the death of a child: in almost all other looked after child deaths, the death of the child was not sufficient to constitute "exceptional circumstances". A lack of guidance leaves senior managers to apply arbitrary criteria as to whether or not a report should be published (8) following an unannounced monitoring visit where the manager of the Home and the Responsible Individual were not present, no attempt was made to clarify any matters of concern with such individuals