Chadrack Mulo
PFD Report
All Responded
Ref: 2017-0120
All 1 response received
· Deadline: 28 Jul 2017
Coroner's Concerns (AI summary)
School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a need for wider adoption of immediate welfare checks.
View full coroner's concerns
1. The school had a telephone number for Chadrack’s mother, but not for any other family member or friend. Now, they insist that for every child in the school they have the telephone number of three different adults.
2. If a child unexpectedly fails to attend and no relevant adult can be contacted via phone, staff at the school do not now wait three to five days as they did then, but instead immediately send a member of staff to the family home.
They now make a distinction between an attendance issue that may warrant a penalty (not the case for Chadrack because he was under the age of five years) and a potential welfare issue.
3. If there is no answer at the family home when staff members attend, they now immediately contact the police, who in most cases are likely to force entry. This protocol seems very sensible, but is clearly driven by the appalling tragedy of Chadrack’s death. It seems unlikely that other schools in Hackney, elsewhere in London, or indeed in the rest of England & Wales, have such a system in place.
2. If a child unexpectedly fails to attend and no relevant adult can be contacted via phone, staff at the school do not now wait three to five days as they did then, but instead immediately send a member of staff to the family home.
They now make a distinction between an attendance issue that may warrant a penalty (not the case for Chadrack because he was under the age of five years) and a potential welfare issue.
3. If there is no answer at the family home when staff members attend, they now immediately contact the police, who in most cases are likely to force entry. This protocol seems very sensible, but is clearly driven by the appalling tragedy of Chadrack’s death. It seems unlikely that other schools in Hackney, elsewhere in London, or indeed in the rest of England & Wales, have such a system in place.
Responses
Action Planned
The Department for Education will update the 'Keeping Children Safe in Education' and 'School Attendance' guidance to recommend schools hold multiple contact numbers and clarify the link between attendance and welfare issues. Changes will be made at the earliest opportunity, subject to formal consultation on the safeguarding guidance. (AI summary)
The Department for Education will update the 'Keeping Children Safe in Education' and 'School Attendance' guidance to recommend schools hold multiple contact numbers and clarify the link between attendance and welfare issues. Changes will be made at the earliest opportunity, subject to formal consultation on the safeguarding guidance. (AI summary)
View full response
%6p FOR Robert Goodwill MP Minister of State Sanctuary Buildings 20 Great Smilh Street Westminster London SWIP 38T tel: 0370 000 2288 wwW. education gov uklhelplcontactus Coroner ME Hassell Senior Coroner, Inner North London St Pancras Coroner's Court Camley St London N1C 4PP 19h June 2017 ea1 Ms Hassel , My predecessor; Edward Timpson, received your Prevention of Future Death report, regarding the tragic death of Chadrack Mbala Mulo, on 20 April 2017 . This is a heart- breaking case and my thoughts are with all those who knew Chadrack and his mother: would Iike to stress that the Department takes the issues raised in the report seriously and will take action in light of your recommendations The school only held a single number for Chadrack's mother and no contact number for any other family member or friend. have asked Departmental officials to examine how we can best update the statutory 'Keeping Children Safe in Education' guidance and the 'School Attendance' guidance so that reflect best practice and recommend that schools hold more than one contact number_ You make an important distinction in your report between attendance issues and welfare issues and underline that school staff should be considering welfare when managing attendance. In this area too, the Department will examine how best we can update attendance and safeguarding guidance to make this Iink clearer: would anticipate that guidance will continue to make clear that professional judgement should be used in deciding when child safety or welfare concerns should be escalated to children's social care services andlor the police. have also asked the Department to identify the best way to reinforce this point further in the attendance and safeguarding guidance. will ensure that changes to strengthen the guidance will be made at the earliest opportunity, subject to formal consultation on the safeguarding guidance: have asked Departmental officials to forward your report to Her Majesty's Chief Inspector of Education, Children's Services and Skills forher consideration:
Sent To
- Department for Education
Response Status
Linked responses
1 of 1
56-Day Deadline
28 Jul 2017
All responses received
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 26 October 2016, one of my assistant coroners, William Dolman, commenced an investigation into the death of Chadrack Mbala Mulo, aged 4 years. The investigation concluded at the end of the inquest on 10 April 2017. At inquest, I made a determination as follows.
Chadrack had learning difficulties and, when his mother died unexpectedly at home on 1 or 2 October 2016, he did not know how to call for help or feed himself properly. He died a fortnight later of dehydration and starvation. He was then found within approximately 48 hours. His medical cause of death was: 1a dehydration and acute protein-energy malnutrition 2 autism spectrum disorder (ASD)
Chadrack had learning difficulties and, when his mother died unexpectedly at home on 1 or 2 October 2016, he did not know how to call for help or feed himself properly. He died a fortnight later of dehydration and starvation. He was then found within approximately 48 hours. His medical cause of death was: 1a dehydration and acute protein-energy malnutrition 2 autism spectrum disorder (ASD)
Circumstances of the Death
Chadrack’s mother suffered a sudden death in epilepsy, probably on 1 or 2 October 2016. Chadrack was not seen in school after 30 September 2016.
The staff at Morningside Primary School were concerned and rang his mother on several occasions. They also visited the home twice, but could not gain access to the block of flats where Chadrack and his mother lived.
The likelihood is that Chadrack lived alone in the family home for over a fortnight after his mother’s death. He was found a couple of days after his own death, with his arms around her body. She was by then very decomposed.
The staff at Morningside Primary School were concerned and rang his mother on several occasions. They also visited the home twice, but could not gain access to the block of flats where Chadrack and his mother lived.
The likelihood is that Chadrack lived alone in the family home for over a fortnight after his mother’s death. He was found a couple of days after his own death, with his arms around her body. She was by then very decomposed.
Copies Sent To
City & Hackney Safeguarding Children Board
, headteacher, Morningside Primary School
, Chadrack’s auntie
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Taxi company and school safeguarding arrangements
Southport Inquiry
Missed Child Safeguarding Referrals
Audit of safeguarding information transfer between schools
Southport Inquiry
Missed Child Safeguarding Referrals
Guidance on LEA and police visits to absent children
Southport Inquiry
Missed Child Safeguarding Referrals
Guidance for parents of children found with weapons
Southport Inquiry
Missed Child Safeguarding Referrals
School-to-college records on radicalisation vulnerability
Manchester Arena Inquiry
Missed Child Safeguarding Referrals
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.