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The safeguarding file that did not arrive before she started college

Autistic, seventeen, and at known risk of suicide, she began a new college without the file that would have told staff so.

School · 2020s · Method: None information handover

What happened

The coroner’s Regulation 28 report of 14 October 2024 records diagnoses of ADHD at ten and autism at eleven, with “associated excessive anxiety, low mood, and emotional dysregulation” and a risk of suicide that persisted and fluctuated.

Her council issued an Education, Health and Care Plan at fifteen. Mainstream school was a struggle and placements broke down. In September 2021 she began a course at a new college. Within weeks she was low in mood and speaking of suicide. She died at home on 12 October 2021.

The outcome

The inquest concluded on 1 May 2024. The coroner found suicide, more than minimally contributed to by three failures: her mental health service’s failure to assess, diagnose and treat her; her council’s failure to ensure the plan said enough about her mental health and suicide risk for the college to meet her needs; and a multi-agency failure to share information from June 2021.

The coroner’s Regulation 28 report raised two concerns. Per that report, schools and colleges believed they must spend an extra £6,000 a year on a pupil before applying for a statutory assessment, which delayed hers. It is a funding threshold, not a condition of applying, as the council’s response of 13 November 2024 told every provider in its area. The second was the file.

The Department for Education replied on 14 February 2025: a reminder to local authorities, an acceptance that what happened was “not in line with the duties and responsibilities placed on schools and colleges”, and a promise to keep the guidance under review. No transfer system was created.

What went wrong

Knowledge held in one building did not move to the next. Keeping Children Safe in Education, as the coroner quotes it, requires the child protection file within five days for an in-year transfer, or the first five days of a new term. What that permits: a young person at risk of suicide can start at a college holding nothing about her while the file is in the post. There is no centralised system; each institution sends its own, with “variable levels of efficiency and reliability”.

The plan was thin where it mattered: not unwritten, but incomplete.

What it teaches

A file is not paperwork. It is the difference between a college that knows and one that guesses, and it should arrive before the child does.

A plan that records attainment but not risk gives the new setting everything except what it needs.

And check the folklore: “we have to spend six thousand first” is not law.

Questions for the room

Evidence and limits

Confidence: confirmed. The Regulation 28 report and both responses were read in full from judiciary.uk on 7 November 2026; BBC News, 3 May 2024, was read live.

She is not named at any age, nor are her school or either college: the report lists the establishments sent copies, and any of them alongside the date would identify her. Her mother is withheld for the same reason. The council appears in the citations, not the text. No staff is named.

The inquest’s findings document is not published on the page read, so the months before her death are known only at the report’s level.

Our positive handling training for schools starts with knowing a pupil’s risks before anyone has to manage them.

Sources

Reviewed 7 November 2026.

All school cases  ·  Education Casebook

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