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Oskar Nash: Prevention of Future Deaths Report says Working Together guidance is not working for children with disabilities

A Coroner’s report following the inquest into the death of 14-year-old Oskar Nash says national guidance used by agencies when supporting children is not working for children with disabilities because it is focused on the safeguarding needs of children at risk of harm from their parents or in the home.

Posted on 20 February 2022

Oskar’s mother and her solicitor say the concern raised by Surrey Coroner Richard Travers could have a significant impact nationally and the Secretary of State for Education must now respond because the guidance urgently needs amending.

Mr Travers’ concern, one of 12 raised in a Prevention of Future Deaths report following Oskar’s inquest in 2021, says the national Working Together guidance, with its focus on children who need protection from parental failures or risks at home, results in agencies taking a critical view of a child’s family and parenting skills, likely to be inappropriate for a child in need through disability.

Mr Travers said he considered this had had a detrimental impact on the approach of agencies to Oskar and his family and added: “I am concerned that “Working Together” does not provide clearer guidance specifically for the safeguarding of children with disabilities, including Autism, and the approach to be taken by agencies to parents and families.”

Oskar’s death in 2020 was contributed to by neglect by Surrey and Borders Partnership NHS Foundation Trust’s Child and Adolescent Mental Health Service, Mr Travers concluded at the inquest.

Oskar was well known to the Child and Adolescent Mental Health Service (CAMHS) and to Children’s Services, having been the subject of a number of referrals to both. All state agencies concerned with Oskar knew about his history of suicidal ideation. Yet there were repeated failures to answer his mother Natalia’s pleas for help for her son.

Significantly, when Oskar was moved from a special school to a mainstream school in 2019, there was a failure to ensure that there was a sufficient sharing of information about Oskar’s history, special needs and current situation. The coroner said he is concerned that there is no system in place, locally or nationally, to ensure information sharing is achieved by the relevant SEN department for every child with an Education, Health and Care Plan.

Oskar never received the clinical assessment he needed and Mr Travers said he is concerned that there is an ongoing risk that some referrals may be inappropriately closed.

The Coroner raised concerns about a lack of mandatory training on autism within Surrey and Borders Partnership NHS Foundation Trust, Surrey County Council, its children’s services department, its Education and Special Educational Needs Department, plus a widespread lack of knowledge and understanding of Autism and morbid mental health conditions across all the state agencies from which he heard while investigating Oskar’s death. The National Autism Strategy does not currently include a timetabled commitment for relevant mandatory Autism training to be provided to all state agencies working directly with autistic adults and children.

Leigh Day solicitor Anna Moore said:

“Following the evidence heard at Oskar’s inquest, the Senior Coroner for Surrey has made a number of reports identifying areas of concern, where change is required.

“We particularly welcome the concerns the coroner has raised with the statutory guidance used by various authorities to support children, including social services, the police and the NHS. It has long been a concern that the guidance does not adequately serve the needs of children with disabilities and instead focuses solely on children who are in need due to safeguarding issues from their parents. The Coroner found that, in Oskar’s case this had a detrimental impact on the approach taken to support him and his family. The guidance urgently needs amending to address the specific requirements of children with disabilities as well as children whose needs arise from safeguarding concerns. On behalf of Oskar’s family and many others who have been failed by this guidance, I hope that the Secretary of State for Education gives this careful consideration.

“The Coroner also highlighted concerns that training in autism is still not mandatory for those working in health and social care in Surrey and more widely. He raised a number of specific concerns about how referrals to Surrey mental health services are dealt with, confirming that some might still be closed inappropriately or not categorised with the correct level of urgency. Concerns also remain with the Surrey County Council’s procedures for assessing and supporting children.

“The reports show that the state agencies have not yet done enough to ensure that children in their care are adequately protected and they will now have to tell the Coroner what steps have been taken in response to minimise the risks still present of further preventable deaths.”

Oskar’s mother Natalia Nash said:

“I am very pleased with the very comprehensive report that the Coroner produced, pointing to all very relevant issues that still need to be addressed on local and most importantly on a national level. I hope that his concerns will be taken seriously and all the necessary improvements implemented as soon as possible so that no other child like Oskar will have to face the same difficulties without meaningful support and no other family has to experience the pain of loss as we did.”

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Anna Moore
Court of Protection Inquests

Anna Moore

Anna Moore is an associate solicitor in the human rights department.

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