Lauren Barfoot

PFD Report All Responded Ref: 2014-0385
Date of Report 28 August 2014
Coroner Lorna Tagliavini
Response Deadline ✓ from report 23 October 2014
All 4 responses received · Deadline: 23 Oct 2014
Coroner's Concerns (AI summary)
Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification and an ineffective search for the deceased. Social Services also failed to maintain comprehensive contact lists and hold timely strategy meetings.
View full coroner's concerns
and July day

_ (1) There was a failure by the London Borough of Bexley Social Services to record make accessible, a comprehensive list of Lauren's friends, family and acquaintances and their addresses and contact numbers, with whom contact could be made in order to assist professionals in an effective search for Lauren (2) There was a failure by Ethelbert's Children's Services to relay full and detailed information to the Missing Person's Unit (Greenwich) as to the level of risk classified as "high" in relation to Lauren's misuse of solvent abuse and vulnerabllity of sexual exploitalion: (3) There was a failure by the MPS Missing Person's Unit (Greenwich) to carry out an effective search for Lauren as a consequence of the lack of information not shared with the Unit by those responsible for looking after and searching for Lauren, and therefore a missed opportunity for the Missing Person's Unit to classify Lauren as a "high risk missing person (4) There was a failure by The London Borough of Bexley to hold a timely "strategy meeting" by those concerned in the care for Lauren after she had been missing for several in order to pool information and resources in order to catty out an effective search for Lauren_
Responses
Bexley Borough Council Local Authority / Fire Service
23 Oct 2014
Action Taken
Bexley Children's Services have implemented lessons learned into social work practice, and a triage system is in place for when looked after children go missing. A risk assessment report is required in preparation for strategy meetings for missing looked after children, and strategy meetings are held within three days of a child going missing. (AI summary)
View full response
Dear Ms Tagliavini Re: Inquest concluded on August 2014, into the death of Lauren Barfoot (aged 14) Bexley's Children's Services take its responsibility to looked after children very seriously and have ensured that lessons have been learnt and implemented in social work practice following this case; Bexley children's social care services were inspected by the external regulator Ofsted, under the Single Inspection Framework during March 2014_ The Inspection independently reviewed practice regarding looked after children who went missing and the following is an extract from the Ofsted report published in May 2014: 'When looked after children go missing an established triage system is used to determine the action to be taken including whether a child protection enquiry is necessary. Robust systems are in place to track and identify individual looked after children who go missing and those who are at risk of sexual exploitation. These children are regularly considered at multi-agency meetings and suitable contingency plans are agreed. Sensitive interviews are undertaken with looked after children when they return to their placements_ In response to the regulation 28 report to prevent future deaths and the recommended actions to be taken: full and regularly updated Ilst of persons by both the London Borough of Bexley Social Services and Ethelbert's Children's Services wlth whom a "looked after" child is connected in order to be able to make meaningful searches after abscondinglmissing: This list to be kept centrally or is readily accessible; whether electronically or in another format Bexley Children's Social Care sends a letter and proforma document recording the associations of young people to all residential providers. Previously, Bexley relied on the residential providers own protocols in respect of missing children. It was identified that these varied across the country. The letter and proforma also sets out expectations regarding having an up to date list available. By Bexley giving providers the process and pro-forma documents, we can be confident that when a child goes missing they are aware of our expectations in collecting information on Listening to YOU, working tor you Fax

persons the young person is connected to_ All information will now be returned to, and held centrally by, Bexley's Placements Service_ The sharing of details of any relevant risk assessment carried out In respect of the missing child should be passed to the police in order they can make a properly and informed decision as t0 the level of resources needed in order to carry out an effective search risk assessment report is required in preparation for any strategy meetings for missing looked after children strategy meeting is held within three days of a child going missing- The social worker will provide a risk assessment report to the meeting in accordance with the Bexley Practico Guidanco_pro-forma for assessing risk: The meeting is chaired by the Independent Reviewing Officer for child_ The risk assessment report requires comprehensive information about all possible contacts and locations where the child may be found, including any information known about risks presenting to the young person: The risk assessment report will be passed to the police at the strategy meeting in order that they can assess the level of risk and resources required s0 that they can out an effective search for the missing young person_ Subsequent strategy meetings are held at 5 days and weekly thereafter iii) The holding of a timely strategy meeting at which information can be pooled and resources allocated and utilised effectively Strategy meetings for missing looked after children are held within the timescales set out in the "Children who go missing Home or Care Practice Guidance" implemented in May 2013_ The holding of the strategy meetings aro overseen by the manager for the "looked after" Independent Reviewing Officer service The timeliness of 'missing' strategy meetings is tracked monthly performance reports and meetings, to ensure good practice is maintained, Relates to the Greenwich Police Missing Person's Unit hope the information contained in this letter assures the Coroner that Bexley's Children's Services has responded appropriately to the concerns raised in the Inquest.
Metropolitan Police Service Police / Law Enforcement
23 Oct 2014
Action Taken
Greenwich Police enclosed a report detailing their actions, addressing information sharing and risk assessment, as well as their broader response to the serious case review that followed the death. Their response has been reviewed to ensure that measures introduced following the serious case review account for issues raised in the report and are fully embedded in current practice. (AI summary)
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Dear Assistant Coroner Tagliavini, Thank you for writing to me with a copy of your report in relation to the death of Lauren Barfoot You have asked that write to you detailing the response Greenwich Police. have included the relevant quotation from your report below "There was a failure by the MPS Missing Persons Unit (Greenwich) to carry out an effective search for Lauren as a consequence of the lack of information not shared with the Unit by those responsible for looking after and searching for Lauren, and therefore missed opportunity for the Missing Person's Unit to classify Lauren as a "high risk missing person' Action identified by the Assistant Coroner which should be taken in relation to this matter "The means by which the Missing Persons Unit (Greenwich) is able to access essential information in respect of a missing person, in order to carry out an effective prioritisation of resources required for any search". enclose a report detailing our actions, addressing the specific issues of information sharing and risk assessment; but also our broader response to the serious case review that followed Lauren's death have caused our response to be reviewed in light of the inquest to ensure that those measures introduced following the serious case review account for the issues raised in your report and are fully embedded in current practice_ If you require any further information please do not hesitate to contact me
Ethelbert Childrens Services1
Action Taken
Ethelbert Childrens Services has implemented steps to address concerns regarding the collation of information, risk assessment, and contact details. They now complete a Met Police Missing Person Reporting Form upon a child's arrival and provide details by phone when reporting a child missing. (AI summary)
View full response
Dear Madam Inquest Touching upon the deathot Lquren Barfoot Heard 3L July _ LAugust 2014 Further in the above matter we acknowledge recelpt of the Regulation 28 Report that you kindly sent to Ethelbert Children's Services Having reviewed the same we attach for your kind attention copies of the following INVESTORS IN PEOPLE documents: - List of actions related to the collation and sharing of information re the placed child ISO9I KktiTFFFD F1rY Vulnerability Assessment Met Police Missing Person Reporting Form OCRY Caene. Once you have had an opportunity to review the action list we trust that you will find the steps that we have implemented, address concerns in respect of City&e collation of information as to risk assessment of child and contact details Guilds which can be shared with other agencles; The missing persons reporting form is a document that the Metropolitan Police now issue and require us to complete on the arrival of a child, We understand that this Is retalned centrally by them and is cross referenced by them when reports are recelved that the chlld has gone missing; In addltion at the time of reporting that a chlld is mlssing; a telephone call would be made by the care manager providing the current circumstances and any additional details in relation to clothing; times and other relevant information: Thls information wlll enable the Pollce to undertake full assessment, We continue to explore the possibillty of sending an updated missing person form Reglstered Ollce by emall, to the police as outlined in action list, although to date our conversations Jncecut uth Miafinan 6nFm ise with the Met have not proved successful; Leinne 4833nta itj6 Lra- Ra {t UP,621 On a separate note and for the sake of completeness we would advise that there is Keuaedafn?: ~' slightly different system In place within Kent Police (and potentlally in other police force areas): In Kent we complete a vulnerablllty assessment on each child at the Exceedlng Oulcomes Page of 2 Websile; wwv ethelbertonline.co.Uk E-mail: heaclolfice elhelberlhomes co.uk Oul of Hours: 01843 820030 pierise tole: @u inbr; Mion | o dterf" Iitis % llc;' e8 oimf (Ieft nvixbethchaser}{uness mIcoled oi;ne cmil fic; M0mamm 1*3: i 9i 'aon# Tol; the the

Ethelbert Childrens Services 1neim [v017 ETHELBERT ftu rclt Htf % time of placement which Is passed to the Pollce and each child is then given unlque reference number (PID number): It Is cross referenced to at the time of any subsequent missing person reports being made. Regrettably they currently do not have facility for recelving information by emall; copy of the vulnerablllty assessment Is attached
Ethelbert Childrens Services
Action Taken
Ethelbert Childrens Services has implemented steps to address concerns regarding the collation of information, risk assessment, and contact details. They now complete a Met Police Missing Person Reporting Form upon a child's arrival and provide details by phone when reporting a child missing. (AI summary)
View full response
Dear Madam Inquest Touching upon the deathot Lquren Barfoot Heard 3L July _ LAugust 2014 Further in the above matter we acknowledge recelpt of the Regulation 28 Report that you kindly sent to Ethelbert Children's Services Having reviewed the same we attach for your kind attention copies of the following INVESTORS IN PEOPLE documents: - List of actions related to the collation and sharing of information re the placed child ISO9I KktiTFFFD F1rY Vulnerability Assessment Met Police Missing Person Reporting Form OCRY Caene. Once you have had an opportunity to review the action list we trust that you will find the steps that we have implemented, address concerns in respect of City&e collation of information as to risk assessment of child and contact details Guilds which can be shared with other agencles; The missing persons reporting form is a document that the Metropolitan Police now issue and require us to complete on the arrival of a child, We understand that this Is retalned centrally by them and is cross referenced by them when reports are recelved that the chlld has gone missing; In addltion at the time of reporting that a chlld is mlssing; a telephone call would be made by the care manager providing the current circumstances and any additional details in relation to clothing; times and other relevant information: Thls information wlll enable the Pollce to undertake full assessment, We continue to explore the possibillty of sending an updated missing person form Reglstered Ollce by emall, to the police as outlined in action list, although to date our conversations Jncecut uth Miafinan 6nFm ise with the Met have not proved successful; Leinne 4833nta itj6 Lra- Ra {t UP,621 On a separate note and for the sake of completeness we would advise that there is Keuaedafn?: ~' slightly different system In place within Kent Police (and potentlally in other police force areas): In Kent we complete a vulnerablllty assessment on each child at the Exceedlng Oulcomes Page of 2 Websile; wwv ethelbertonline.co.Uk E-mail: heaclolfice elhelberlhomes co.uk Oul of Hours: 01843 820030 pierise tole: @u inbr; Mion | o dterf" Iitis % llc;' e8 oimf (Ieft nvixbethchaser}{uness mIcoled oi;ne cmil fic; M0mamm 1*3: i 9i 'aon# Tol; the the

Ethelbert Childrens Services 1neim [v017 ETHELBERT ftu rclt Htf % time of placement which Is passed to the Pollce and each child is then given unlque reference number (PID number): It Is cross referenced to at the time of any subsequent missing person reports being made. Regrettably they currently do not have facility for recelving information by emall; copy of the vulnerablllty assessment Is attached
Sent To
  • Bexley Social Services
  • Ethelbert’s Children’s Services
  • Metropolitan Police Service
Response Status
Linked responses 4 of 3
56-Day Deadline 23 Oct 2014
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 4th July 2012 an inquest was opened into the death of Lauren Barfoot aged 14 years. The inquest concluded on 1st August 2014 after an inquest held on 31st and 1st August 2014. The conclusion of the inquest was: Accidental death contributed to by failures in the sharing of Information and pooling and use of resources by those in whose care Lauren was in at the time of her death_
Circumstances of the Death
On 22md April 2012 Lauren became a "looked after child" pursuant to section 20 of the Children's Act 1989 and was placed in Micawber House ("the home' by the London Borough of Bexley Social Services, a home run by Ethelbert's Children Services. From the outset; Lauren was frequently missing from Micawber House although would most often return the following at the latest. On 22" June 2012 Lauren went missing from the home and was reported by the staff at the Home to the MPS, and (reated as a missing person by the Missing Person's Unit (Greenwich Borough) from that date until her discovery in the porch of her putative father's home address in the Plumstead, London SE18 area
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe your organisations have the power to ake such action. For example: A full and regularly updated list of persons by both the London Borough of Bexley Social Services and Ethelbert's Children's Services with whom a "looked after" child is connected in order; to be able to make meaningful searches after abscondinglmissing: This list to be kept centrally or is readily accessible, whether electronically or in another format, The sharing of details of any relevant risk assessment carried out in respect of the missing child should be passed to the police in order can make a properly and fully informed decision as to the level of resources needed In order to carry out an effective search: The holding of a timely strategy meeting at which information can be pooled and resources allocated and utilised effeclively. (iv) The means by which the Missing Persons Unit (Greenwich) is able to access essential information in respect of a missing person; in order to carry out n effective prioritisation of resources required for any search:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.