_ 1, The inquest was told that GMP followed their own guidance which accorded with that of the College of Policing into the level of expertise of the officer allocated to investigate Katie's allegations As a result of this the case was not dealt with by an experienced Public Protection or specialist sexual offences trained officer. It was allocated to a probationary police constable with approximately 6 months experience officer did not seize the phone which contained social media contents until her third visit on the initial evening the offence was disclosed: The allocated officer was not experienced in joint working with social services or familiar with the concept of the voice of the child and what it would mean in such a case. At the time the decision was made by police to NFA matters there was no discussion about whether there could her day day The key be a victimless prosecution; it was not established if the initial account was recorded on body worn footage or the extent of the social media contact by the suspect and the nature of any offences that could be revealed by those messages. No attempt was made to have a further face to face conversation with Katie; The Local Authority at the time were using a substantial number of agency social workers. As a result the Child and Family Assessment was not completed in accordance with best practice and not shared in accordance with expectations around best practice. The Local Authority has since made significant progress in moving away from a reliance on agency staff to fill gaps in social work cover: The inquest was told that agency social workers are still used extensively in other Local Authorities creating a risk that similar situation could arise; At the safeguarding strategy meeting an officer allocated to attend such meetings on behalf of GMP attended rather than an officer allocated to the case_ As a result the quality of information sharing and understanding of the allegation was more limited. On the particular police division in question this practice has stopped. It was unclear how common the approach is on a wider basis;
4. It was accepted by witnesses for both the Local Authority and GMP that the voice of the child was not fully heard throughout their investigations. They via the safeguarding board commissioned an independent report whose findings and recommendations have been fully adopted by the safeguarding board. It was unclear what if any steps would be taken t0 disseminate the lessons pan GM or nationally;
5. A further concern identified was that there was no mechanism for the school to be formally be aware of information within the Child and Family Assessment. As a result there was no formal follow-Up procedure set out in the best practice national guidance the school was working within: The inquest heard that Katie's school recognising this gap has built on the working together guidance to develop guidance that ensures there is a proactive approach to engaging with a child and their family the writing of a Child and Family Assessment;
6. On the day Katie committed suicide she had attended a GCSE English class: The exam board required poetry syllabus was being studied that The lesson included a poem where the contextualisation of it included the use of suicide. The teacher delivering the lesson had no way of understanding the history of self-harm of Katie and her particular vulnerability when delivering a post day: set text in accordance with the exam board requirements It was unclear what if any guidance is given by the exam board t0 assist teachers minimising risk to pupils in this scenario_