Jada Bailey, R (on the application of) v HM Senior Coroner for East London [2025] EWHC 1637 (Admin)

[2025] EWHC 1637 (Admin)Case No AC-2024-LON-002105
IN THE HIGH COURT OF JUSTICE
KING’S BENCH DIVISION
ADMINISTRATIVE COURT
Venue Royal Courts of Justice, Strand, London, WC2A 2LLDate 30/06/2025
Before
MR JUSTICE SWIFT
Between
JADA BAILEYClaimantHM SENIOR CORONER FOR EAST LONDONDefendant
Between
LONDON BOROUGH OF WALTHAM FORESTInterested PartiesCOMMISSIONER OF POLICE OF THE METROPOLISInterested PartiesCHIEF CONSTABLE OF DOREST POLICEInterested PartiesCHIEF CONSTABLE OF NOTTINGHAMSHIRE POLICEInterested PartiesYOUTH OFFENDING SERVICEInterested Parties
Jesse Nicholls (instructed by Hodge Jones and Allen) for ClaimantBridget Dolan KC (instructed by London Borough of Waltham Forest Legal Services) for DefendantHearing dates 13 February and 17 June 2025
Approved JudgmentThis judgment was handed down remotely at 2 pm on 30 June 2025 by circulation to the parties or their representatives by e-mail and by release to the National Archives..............................

Introduction

[1]Jada Bailey (“the Claimant”) challenges the decision of HM Senior Coroner for East London (“the Coroner”) not to resume the inquest into the death of her son, Jaden. In the serious case review report, prepared on behalf of the Safeguarding Children’s Board for Waltham Forest, which was the subject of the bulk of the submissions in this case, Jaden was referred to as “C”. In this judgment, I refer extensively to that serious case review report so, for sake of consistency, I will also refer to Jaden as “C”. C died on 8 January 2019. He had been riding a moped in Leyton in East London and was hit by a car. Those inside the car then got out and stabbed him. He died at the scene. He was 14 years old.[2]The inquest into his death was formally opened on 18 January 2019. However, on 19 January 2019, Ayoub Majdouline was charged with C’s murder. On 2 April 2019 the Coroner adjourned the inquest pending the criminal trial, a decision required by paragraph 2 of Schedule 1 to the Coroners and Justice Act 2009 (“the 2009 Act”). On 11 December 2019 Ayoub Majdouline was convicted of C’s murder, and on 18 December 2019 he was sentenced to life imprisonment with a minimum term of 21 years.[3]On 24 December 2019 the Coroner issued a certificate that the inquest was not to be resumed. On 14 June 2023 the Claimant applied to the Coroner to resume the inquest. On 27 November 2023 written submissions, settled by counsel acting on behalf of the Claimant (who continues to act for her in these proceedings), were made in support of the application. The Coroner’s decision not to resume the inquest is set out in a document dated 18 March 2024. The material part of that decision is as follows. “28. I accept the family’s submission that the State’s investigative obligation under Article 2 ECHR was engaged on the basis of potential breach by the police of their operational duty to safeguard Jaden's life. The low threshold of arguability is made out here by the admitted failings of the MPS combined with the findings of the SCR. 29. I reject the argument that the investigatory obligation was engaged on the basis of potential breach by the police and other agencies of the systemic duty to safeguard Jaden's life. Such a duty operates at a high level, the “duty to put in place a legislative and administrative framework to protect the right to life, involving effective deterrence against threats to life, including criminal law provisions to deter the commission of offences, backed up by a law enforcement machinery for the prevention, suppression and sanctioning of breaches of such provisions” (Van Colle v Chief Constable of the Hertfordshire Police [2009] 1 AC 225 at para 28. In this case numerous systems were in place during the material time. The argument that the systems in place can be assessed as insufficient due to the fatal outcome for Jaden is a syllogism. 30. I now turn to the question of whether the state has satisfied the enhanced procedural obligation under Article two? Here the question I must pose is whether all the other investigative procedures of the state have collectively satisfied the requirements of the procedural obligation (see Goodson v HM Coroner for Bedfordshire [2004] EWHC 2931 (Admin) at paragraph 59 (iv) and (vi)). I remind myself that it is necessary for the Coroner to consider “the totality of available procedures”, including public investigations and any potential for a civil claim: R(AP) v HM Coroner for Worcestershire [2011] EWHC 1453 (Admin), [95]. 31. The decision of a Coroner on whether or not to resume an inquest has been described as one “of a highly discretionary character”. I remind myself of the guidance provided by the Chief Coroner in Law Sheet No.5 which asserts that the wide discretion a Coroner has in making decisions, “emanates from the inquisitorial nature of the coroner’s inquiry.” (R v South London Coroner, ex parte Thompson (1982) 126 SJ 625). There must be a good reason for me to exercise my discretion in a particular way, both in fact and in law. As Lord Greene MR said in the Wednesbury case “… a person entrusted with a discretion must, so to speak, direct himself properly in law. He must call his own attention to the matters which he is bound to consider. He must exclude from his consideration matters which are irrelevant.’.” 32. There is no prescriptive approach to the form of an Article 2 investigation and, although its precise constituents will vary from case to case, the minimum requirements were set out in Jordan v United Kingdom (24746/94) (2003) 37 EHRR 2, [2001] 5 WLUK 158. 33. I have considered and adopt the ratio of Garnham J in R (Sharon Grice) v Her Majesty’s Senior Coroner of Brighton and Hove v The Chief Constable of Sussex Police, Sussex Partnership NHS Foundation Trust [2020] EWHC 3581 (Admin) [84-85].a. No particular procedure had to be adopted in order to fulfil the Jordan requirements. The requirements can be satisfied by a set of separate investigations, rather than by a single, unified procedure.b. The requirement for the family of the deceased to be involved in the investigation did not mean the investigating authorities had to satisfy every request for a particular step to be taken.c. The requirement for public scrutiny did not invariably require a public hearing nor did it mean that the family had to be able directly to test the evidence.d. There was no requirement that each element of the investigative procedure met each one of the tests. 34. I have sought and secured disclosure to allow me to properly assess the nature and scope of; the criminal trial, the SCR, the PCIR and the PCAR, having considered that material I find that the state has: acted of their own motion to investigate; the cumulative investigation process was independent, effective and reasonably prompt; the investigations did have a sufficient element of public scrutiny of its processes and results to secure accountability; and that there was involvement of the next of kin to the extent necessary to safeguard their legitimate interests. As such, I do find that the state fulfilled its obligation under the enhanced investigative obligation through the totality of the investigations set out above. In simple terms I pose myself the question, have the cumulative investigations covered the likely scope of an inquest and my answer is that that they have and indeed have gone beyond the remit of the type of inquest described by the Lord Chief Justice in R(Morahan) v HM Assistant Coroner for West London [2022] EWCA Civ 1410 “an inquisitorial and relatively summary process. It is not a surrogate public inquiry.”. 35. I go on to ask myself whether the conclusions of any inquest could provide valuable conclusions (primary conclusions and a Regulation 28 report) that would go beyond the conclusions reached in the other investigations? Firstly, the limitations placed upon me mean that any primary conclusion at inquest could not be inconsistent with the result of the criminal trial and therefore “Unlawful killing” would be the most appropriate conclusion. 36. Secondly, a Regulation 28 report is simply a report not a ruling, it is toothless to the extent that a coroner cannot proscribe a solution to the concern identified, require specific performance of remediation or even demand that the report is responded to. Other inquiries into Jaden's death have been able to make recommendations and require action. 37. I ask myself is this submission intended to lead to an inquest that would relitigate the criminal trial? I do not find that to be the case. 38. Finally, I ask myself what are the family wishes? There clear wish is that a Middleton inquest is heard into the death. I value their submissions and understand their depth of feeling but I note that the family wishes are not the determinative issue. I am not satisfied, for the reasons set out above, that there is sufficient reason to resume the inquest into Jaden’s death pursuant to para 8(1) Sch 1 CJA 2009.”[4]The reference in paragraph 38 of the Coroner’s reasons to paragraph 8(1) of Schedule 1 to the 2009 Act is to the provision that an investigation that has been suspended “… may not be resumed unless … the senior coroner thinks there is sufficient reason for resuming it”. The reference in his reasons to “the SCR” is to the serious case review commissioned by the Safeguarding Children’s Board for Waltham Forest. That review was undertaken by John Drew. Mr Drew was Director of Social Services at the London Borough of Redbridge from 2000 to 2009 and, between 2009 and 2013, was the Chief Executive of the Youth Justice Board for England and Wales. He conducted the serious case review from early 2019. His report (“the SCR report”) was published in May 2020. The reference in the Coroner’s reasons to the PCIR and PCAR are to two reports prepared by the Metropolitan Police into a complaint made by the Claimant. The Claimant first complained to the Independent Office for Police Conduct (“the IOPC”) by letter dated 12 November 2019. The complaint was that the Metropolitan Police had failed to take reasonable steps to prevent C’s death. The IOPC referred the complaint to the Metropolitan Police for investigation. The Metropolitan Police responded to the complaint by letter dated 6 July 2021. The Claimant was dissatisfied with the outcome and wrote to the IOPC contending that the matters raised in the complaint had not been adequately investigated. The IOPC agreed in respect of 7 of the 9 matters that had been considered by the Metropolitan Police, and sent those matters back to the Metropolitan Police for further investigation. The further report on the investigation was sent by letter dated 13 April 2023. That report upheld 2 of the Claimant’s complaints but rejected the remaining 5 complaints.[5]In this claim for judicial review, the Claimant’s first ground of challenge is that the decision not to resume the inquest gives rise to a breach of the procedural obligation under ECHR article 2. The second ground of challenge is that the Coroner’s conclusion not to resume the inquest rested on two errors of law as to the likely utility of the resumed inquest. The third ground of challenge, as pleaded, was that the decision was contrary to a duty to investigate arising at common law. In the course of submissions, the Claimant abandoned her pleaded case on Ground 3. She accepted that the Coroner’s obligations to investigate are those contained in the 2009 Act. There is no separate common law source of either power or obligation. The 2009 Act covers all relevant ground. Instead, the Claimant contends that the decision not to resume the inquest was made by the Coroner without regard to three relevant considerations.

Decision

[6]The Coroner’s decision accepted the premise of the Claimant’s submission that the obligation to investigate under ECHR article 2 arose on the facts of this case. There has been no argument to the contrary before me, and I will therefore proceed on that premise. ECHR article 2 imposes an obligation on signatory States not to take life without justification and also to “… establish a framework of laws, precautions, procedures and means of enforcement which will to the greatest extent reasonably practicable protect life”: see R(Middleton)v West Somerset Coroner [2004] 2 AC 182, per Lord Bingham at paragraph 2. It has also been decided that article 2 gives rise to what is referred to as an “operational” duty that, when it arises, requires a State to take steps within its power to protect an individual from particular risks of death: see Osman vUnited Kingdom (1998) 29 EHRR 245 at paragraph 116. It is further well-established that article 2 can give rise to an investigative (also referred to as procedural) obligation. The investigative duty is parasitic on the article 2 substantive duty and is directed to a State’s performance of those substantive obligations to ensure practical effect is given to them. An investigative obligation will arise if “it appears that one or other of the … substantive obligations has been, or may have been, violated and it appears that the agents of the state are, or may be, in some way implicated” (also per Lord Bingham in Middleton, most recently restated by Lord Burnett CJ in R(Morahan) v WestLondon Assistant Coroner [2023] KB 81).[7]In all instances, the investigation that is required must be “an effective public investigation by an independent official body” (again, per Lord Bingham in Middleton). In R(Smith) v Oxfordshire Assistant Deputy Coroner [2011] 1 AC 1 Lord Phillips explained the generality of the obligation in this way (at paragraph 64). “64. The procedural obligation requires a state, of its own motion, to carry out an investigation into a death that has the following features:(i) It must have a sufficient element of public scrutiny of the investigation or its results.(ii) It must be conducted by a tribunal that is independent of the state agents who may bear some responsibility for the death.(iii) The relatives of the deceased must be able to play an appropriate part in it.(iv) It must be prompt and effective. This means that it must perform its essential purposes. These are to secure the effective implementation of the domestic laws which protect the right to life and to ensure the accountability of state agents or bodies for deaths occurring under their responsibility. These features are derived from the Strasbourg jurisprudence, as analysed in the Middleton case and R(L, a patient) v Secretary of State for Justice [2009] AC 588. I shall describe an investigation that has these features as an “article 2 investigation”.” The purpose of the investigation is to secure effective implementation of the laws, precautions and proceedings that exist to protect the right to life. This can mean any or all of: holding state agents to account; or exposing culpable conduct; or identifying deficient practices or approaches to learn lessons for the future. What is required in any particular case will depend on the circumstances of that case and the way in which those circumstances give rise to the possibility that a breach of one of the substantive article 2 obligations may have occurred.[8]Most often when it arises, the investigative duty is discharged by an inquest held under the provisions of the 2009 Act. The substance of the Coroner’s decision challenged in these proceedings (which was part of his final conclusion, pursuant to paragraph 8 of Schedule 1 to the 2009 Act, that there was no sufficient reason to resume the inquest into C’s death) was that the steps already taken by the time of his decision had been sufficient to satisfy the article 2 requirement for investigation. The Claimant’s submission is that the Coroner’s conclusion on article 2 was wrong, and that on the facts of this case the article 2 obligation to investigate has not yet been discharged. For the reasons that follow I do not accept that submission.[9]C’s history and the sequence of events that led to his death were set out at length in the SCR report. What follows is a summary of the narrative in that report. C was born in Leicester in 2004. He lived with his mother. In 2010, his father was deported to Jamaica after serving a prison sentence in England. In 2015, C started secondary school. In his first year he seemed to settle well. During his second year at secondary school (Year 8) C’s behaviour deteriorated resulting in three, short, fixed-term exclusions from school. There was some suggestion that the police had told his school of an allegation that C had threatened another child and that the handle of a gun had been shown, but no formal action was taken on the matter. Nevertheless, in April 2017, before the end of Year 8, the Claimant withdrew C from the school fearing that otherwise he might be excluded permanently. From that time C was home-schooled by the Claimant. In July 2017 C admitted that he had stolen a bicycle. When the complaint was made to the police there was a suggestion that one of the children involved in the theft had a gun but that was not substantiated. Ultimately, the police dealt with the complaint by “informal resolution”. The police did not notify the Youth Offending Service either of the complaint or the suggestion that a gun had been present.[10]By the time the next school year (Year 9) started, in September 2017, C remained out of school. A conversation between the Claimant and Nottinghamshire Council’s Home Education Advisor led to a misunderstanding. The advisor believed the Claimant’s intention was to apply for a school place for C to start the next school year (i.e. September 2018). In fact, the Claimant wanted C to be back in school as soon as possible, as her work commitments made it very difficult for her to home-school C and properly supervise him during the days. In January 2018 the Claimant did apply to a school for a place for C but that application was unsuccessful and Nottinghamshire Council was unaware that the application had been made.[11]By early 2018 there was evidence that C was being drawn into criminal activity. This included his arrest in January 2018 for possession of a “Rambo-style” knife and a small amount of cannabis. This resulted in a caution and referral to the Youth Offending Service. However, the Home Education Service was not informed of this, and the Youth Offender Service was not made aware of the report of gun possession from 2017.[12]In April 2018 the Claimant moved C to London to live with her mother in London. At the same time the Claimant applied to the London Borough of Waltham Forest (“LBWF”, the relevant local authority) to be rehoused. That application was not properly dealt with by the housing officer at LBWF. By the time that that housing officer left employment with LBWF in October 2018 no offer of accommodation had been made to the Claimant. At the end of October 2018, the Claimant made a second application to LBWF. This application was dealt with by a different housing officer. An offer of accommodation was made to the Claimant in early January 2019, albeit of accommodation out of borough, in Tilbury.[13]When the Claimant moved C to live with her mother in April 2018 she also made an application to LBWF for a school place for C. Although LBWF passed that application to a relevant school, the school failed to act on the application until the end of June 2018. C was admitted to the school, but not until 3 July 2018. C’s move from Nottinghamshire did not disrupt completion of the sessions with the Youth Offending Service. The three remaining sessions were successfully transferred from Nottinghamshire to London, and completed.[14]On 25 October 2018, during the half term holiday week, C was found with another child (also from the Waltham Forest area) at a “cuckoo house” in Bournemouth. They were found by the police in possession of cocaine (some in wraps, some in packages), a mobile phone, and £325 in cash. Both were arrested on suspicion of possession of a class A drug with intent to supply. C was interviewed under caution by the Dorset police. He gave “no comment” replies. He was then released, very early in the morning of 26 October 2018, pending further investigation. He was brought back to London by the Metropolitan Police. Later the same day there was a meeting of the Waltham Forest “Multi-Agency Safeguarding Hub” (“MASH”). This led to preparation of a four-point action plan by a social worker from the Children’s Social Care Department. However, that work was not completed until the end of the first week in January 2019.[15]On 12 November 2018 C was permanently excluded from school. This was because of a Snapchat video that showed him in possession of an imitation handgun. C was arrested and charged with possession of the imitation gun. He pleaded guilty to that charge on 28 November 2018. The LBWF Behaviour, Attendance and Children Missing Service allocated C a place at a pupil referral unit and then, at the request of the Claimant, arranged an interview for C in a school in Hackney (the Boxing Academy). C failed to attend that interview on 20 December 2018, but it was rearranged for 10 January 2019. C was killed on 8 January 2019.[16]Drawing these matters together, the possible breach of the substantive article 2 obligation concerned the obligations “… to establish a framework of laws, precautions, procedures and means of enforcement which will to the greatest extent reasonably practicable, protect life”, and the operation duty to protect an individual from a specific risk of death. In this instance both concerned the arrangements put in place by the local authorities, the police and other agencies that had come into contact with C and the Claimant, to safeguard C against the risk of falling victim to criminal exploitation. That included preventive measures such as ensuring C’s participation in education, taking steps (in this case through provision of accommodation and appropriate social services support) to promote the Claimant’s ability to provide a settled home life for C and influence his behaviour. It also included consideration of how the various public authorities went about working collaboratively, for example by providing information to one another.[17]The SCR report contained various criticisms of failures and shortcomings on the part of the local authorities and police forces involved with the Claimant and C in Nottinghamshire, London, and Dorset, and explained the ways in which they had failed to work together effectively. Under the heading “Did Child C get the help he needed, when he needed it”, Mr Drew, the report’s author wrote the following. “Did Child C get the help he needed, when he needed it? The tragedy described in this Serious Case Review concludes in the murder of a 14-year [old] child. These circumstances might make it easy to answer this question with a resounding ‘No’. Such help as was provided to Child C and his family could be dismissed as a failure since he was killed. But I believe to answer this question in such a way is to miss a more fundamental point and that is that no-one, and in this I believe I am right to include Child C’s mother, imagined that Child C was at risk of being murdered (though I accept that something in his mood on the 7th January 2019 alarmed her). The question that was being asked of Waltham Forest Council and its partners in the autumn of 2018 was never ‘how can we prevent Child C from being attacked and possibly killed? Instead it was the less dramatic question ‘how can we reduce or eliminate the criminal exploitation to which this child is being exposed?’ This is a very different matter. I have set out in some detail in the narrative of this report how Child C’s needs gradually came into focus. There is no doubt in my mind that some of this work could have been given greater priority. I am thinking here in particular of the response to the family’s housing needs, where as I have calculated, settlement could have been reached two months earlier. In addition, at least one reachable moment could have been seized. The complex tapestry of the work being undertaken with Child C and his family could have been better coordinated. Information exchange was not always good, a fact exacerbated by his living in Nottinghamshire and then Waltham Forest. I have identified the weaknesses in these areas as I see them in the main body of this report. But none of these issues on their own appear to be decisive and by November 2019 there was clear engagement by a number of branches of the Council and its partners to support Child C’s family and to protect Child C. By mid-December all the key elements of this plan were in place and being implemented. What no one knew was how little time was available to try to reach Child C and turn his thinking, as well as the circumstances around his life. I believe that the particular tragedy that overtook Child C could not have been anticipated on the basis of what was known about Child C’s life at that time. So, while it is clear that Child C was not protected either by the Council, or its partners, or by any other person, from the ultimate danger that engulfed him, I do not find any major fault in the response to his circumstances. It is possible to criticise the speed of the response of some bodies, but even if, for example, Child C and his family had been housed in November 2018, it is a giant leap from this possibility to be able to say this would have eliminated the danger that he faced. For example, had he been rehoused in Waltham Forest, as his family wanted, I doubt it would have had any real impact on his day to day activities. Equally we can speculate as to whether there was a reachable moment on the 25th October that could have been exploited, or whether if an adult had ensured he attended the Boxing Academy interview on the 20th December this would have been a turning point. But in the end, this is just that, speculation. It is certainly possible to criticise the absence of full coordination and a ‘guiding hand’ to oversee the whole operation, and it is easy to see the weaknesses in the exchange of information. But the plan or plans themselves were coming together in what in any normal circumstances would be considered a reasonable fashion. Tragically what none of those involved knew was that there were other forces at work.”[18]The Claimant’s first submission in support of the article 2 ground concerns the scope and content of the SCR report. The Claimant’s further submissions criticise the form of the investigation. So far as concerns the latter, the Claimant contends that Mr Drew lacked independence; that there was no sufficient opportunity for her to be involved in the SCR exercise; and that the SCR did not meet the requirement for public scrutiny. The Claimant further submits that the shortcomings in the SCR process were not, for the purpose of compliance with article 2, addressed by the investigation of her complaint to the IOPC about the conduct of the Metropolitan Police. That investigation was not independent as it was undertaken by the Metropolitan Police; nor did it take place in public; nor did it provide adequate or any opportunity for the Claimant to be involved.[19]As to the scope of the SCR investigation and the report the Claimant’s submission is to the effect that it did not address matters that an article 2- compliant investigation should. The scope of the SCR investigation may be seen from the part of the report headed “Summary of Findings and Recommendations.” This section is lengthy but merits consideration in full. “Summary of findings and recommendations I identified eight findings from this review for the Local Safeguarding Children Board to consider. At the request of the SCR Panel I have split these into broader, systemic, findings that may have relevance beyond Waltham Forest or Nottinghamshire and more local practice-based findings that appear to be of more restricted relevance. Systemic findings FINDING OF FACT: Child C spent all but 3 of his last 22 months out of school and for much of this there was limited adult guidance or supervision in regard to how he spent his time. Child C was only 12 years old when his mother withdrew him from school in order to educate him at home. Her account is that this went well particularly at first, a view shared by the Elective Home Education Advisor who visited twice. However, DE’s need to return to work to support her family in the autumn of 2017 may have reduced the supervision and guidance he received. On his arrival in Waltham Forest a school place was not found in late April, as it should have been, adding a further two months to the number of months that Child C was out of school. He was still only 13 for much of this time. The systemic issue here is that the national education policy contains a presumption that only very limited supervision of home education arrangements is required. No one in authority was aware that the home education arrangements that had been agreed no longer involved significant reliable supervision of Child C’s activities. In particular, there was no consequent requirement that the Elective Home Education service in Nottinghamshire should have been alerted when signs of Child C’s lack of supervision first appeared in January 2018 or that a more comprehensive review of his circumstances should have taken place at that time. IMPLICATIONS FROM THIS FOR THE RELIABILITY OF THE CHILD PROTECTION SYSTEM: Time spent out of school, for whatever reason, is recognised to constitute a significant risk to children who are vulnerable to criminal exploitation. The current arrangements governing home education contribute to this risk. The approach that underpins the current government guidance in respect of Elective Home Education, an approach of minimum intervention or supervision, does not seem to be compatible with safeguarding children who are vulnerable to criminal exploitation. RECOMMENDATION: Recommendation No. 1 The WFSCB will be referring this report to the Department for Education, and in so doing should formally ask the Department to clarify whether (and how) it intends to review the current guidance of home education in the light of this finding of fact. 2 FINDING OF FACT: The response to Child C while detained in Bournemouth and then on his return from there in October 2018 did not capitalise on a ‘reachable’ moment for a child who was clearly being criminally exploited, and nor was all the information available from the authorities in Bournemouth transferred to their counterparts in Waltham Forest. Reachable moments There is a clear indication from Child C’s conversation with the Appropriate Adult he met in Bournemouth (see page 25) that the crisis of his arrest there constituted a ‘reachable’ moment. However, this opportunity was not taken. Work could have begun at this moment of crisis on the broad issues of Child C’s vulnerability as well as the obvious specific issue of debt bondage. The current system for collecting and returning London children to their homes in such circumstances has only relatively recently been extended as far as Bournemouth despite this being an obvious area for ‘county lines’ operations to target. My understanding is that some other authorities whose children are found in Bournemouth may not have any such arrangements in place. Transfer of information Communication at this time between the authorities in Bournemouth and Waltham Forest was incomplete and frustrating to all involved. Very little information was transmitted back to Waltham Forest from Bournemouth and at least one key element of the contact with Child C, his request to speak to the Samaritans from his police station cell, did not re-emerge until uncovered by this review. The Pan-Dorset Safeguarding Children Partnership is keen to act on the learning from this review. The incident occurred prior to the new Local Authority of Bournemouth, Christchurch and Poole Council being established and the formation of the Pan-Dorset Safeguarding Children Partnership. The Partnership have, in year one, named child exploitation as a priority and have commissioned, with the Community Safety Partnership, a Home Office and the Office of the Dorset Police and Crime Commissioner sponsored local review using the Home office methodology which will be conducted in March 2020. The areas of multiagency learning from this SCR of Child C will be captured in these activities. The National Police Chiefs Council’s sponsored ‘County Lines Vulnerability Tracker’ has also been designed to improve the flow of information (see page 26 and footnote 70). In summary Working Together 2018 provides no guidance on the issues of reachable moments and the transfer of information between areas in these circumstances, although, as already mentioned, the Ministry of Justice has recently issued practice guidance on County Lines Exploitation that does cover the issue of who should return children to their home area – guidance with parts of which I disagree (see Appendix 3). IMPLICATIONS FROM THIS FOR THE RELIABILITY OF THE CHILD PROTECTION SYSTEM: The importance of maximising the potential of reachable moments in working with children is beginning to be recognised. However, there is no satisfactory approach to covering the whole country when a child who is exposed to ‘county lines’ style operations is found a distance away from their home. There were also difficulties in communication between the authorities in Bournemouth and Waltham Forest, and there was an incomplete transfer of information between them. The absence of a national approach to guide all concerned at such moments serves children like Child C poorly. RECOMMENDATIONS: Recommendation No. 2 The WFSCB should revise its procedures, guidance and training to embed the concept of ‘reachable moments’ in the safeguarding of adolescents in Waltham Forest. Recommendation No. 3 Waltham Forest Council should review the current arrangements for recovering children from outside of the borough in order to satisfy itself there are comprehensive arrangements that can reach any part of the United Kingdom. Recommendation No. 4 The WFSCB should ensure that children who are returned to the borough are brought back by adults with skills relevant to working with children who are being criminally exploited. The WFSCB should also ensure that these adults are then able to continue in personal contact with the children they return, when such contact is identified as being of importance as part of an intervention plan with the child. Recommendation No. 5 Waltham Forest Council should refer this report to the London Mayor’s Office for Police and Crime and request that the current uncertainties about the catchment area of the ‘Rescue and Response County Lines’ are rectified by a clear and unambiguous statement made to each Police Force in England and Wales (and their relevant partners), as well as a revised statement sent to each London Borough. Recommendation No. 6 Waltham Forest Council should raise the issue of the absence of a national system for responding to children who are arrested and detained away from their home areas with the Department for Education (children’s issues), the Home Office (policing issues) and the Ministry of Justice (youth offending team and other frontline practitioner issues). The Council should include at this time a request that the Ministry of Justice review its guidance on the arrangements for returning children to home areas in the light of the findings of this review. The Ministry should be asked to seek other evidence of effectiveness and what works best for children from agencies and authorities who are active in this field including the MOPAC’s ‘Rescue and Response service’. The Ministry of Justice guidance does cover the issue of transferring information from the authorities where the child is found to the ‘home’ MASH. In the light of this I have no further recommendations to make on this particular point. 3 FINDING OF FACT: By early January 2019 there were considerable numbers of professional involved with Child C and his family, creating obvious risks of duplication and confusion. Adolescents live complex lives outside of their families, lives that bring them into contact with a great variety of people, situations and agencies. ‘Contextual safeguarding’ requires guidance that reflects this. Even though the children’s social worker held discussions with the other caseworkers involved with Child C and his family there appears to have been a compelling case for bringing together, under strong leadership, all those who had information and insight to contribute to developing a unified response to Child C’s vulnerability. The case of Child C also highlights the importance of Housing Services being fully integrated into such an approach. There may be good practical reasons why discussions within the MASH do not involve all possible parties, but I believe Child C’s case provides a clear example of an occasion where Housing Services not only controlled access to a service that was highly relevant to keeping him safe, but also where they held information that was not known to any other agency, these being the twin drivers for holding multi-agency case planning meetings. IMPLICATIONS FROM THIS FOR THE RELIABILITY OF THE CHILD PROTECTION SYSTEM: When children are exposed to child criminal exploitation there is a strong argument for case discussion involving all agencies engaged with the child and family to be held in every case and for this principal to be stated clearly in national and local guidance. RECOMMENDATIONS: Recommendation No. 7 WFSCB should audit the use made of case discussions (however named) so as to satisfy itself that multi-agency discussion always takes place in cases where a safeguarding plan is being developed. Recommendation No. 8 In the light of the outcome of this audit WFSCB should review its current arrangements for multi-agency case discussion in safeguarding cases, in particular those arrangements applying to adolescents, in order to satisfy itself that all agencies with a contribution to make either to the knowledge base of such a discussion or the plan of action to improve safeguarding for the child are invited and involved. See also Recommendation No. 10 Recommendation No. 9 The WFSCB will also be referring this report to the Department for Education, and in so doing should formally ask the Department to clarify whether (and how) it intends to review the current guidance on multi-agency case discussion in the light of this finding of fact. N.B. This reference appears consistent with the recommendation of the Child Safeguarding Practice Review Panel 134 that the government should move at pace to review Working Together in the light of its own review of the issue of criminal exploitation. Local practice-based findings Findings 4 FINDING OF FACT: Information about the first two gun-related incidents involving Child C. (in 2016 and 2017) was not shared by the Nottinghamshire Police with other agencies, and nor did Nottinghamshire Police share information about the threats made against Child C in the summer of 2018. Gun-related incidents: The failure to share this information with the Nottinghamshire Youth Offending Service meant that not only were they unaware of this background when assessing Child C for a caution after the episode in January 2018 but also the information about the first two incidents never became part of the background knowledge passed on to Waltham Forest agencies after Child C’s move from Nottinghamshire. Threats made against Child C: The failure to share this information with either the Waltham Forest MASH or the Metropolitan Police Service meant that Waltham Forest Council was not aware of this when they began to assess Child C’s vulnerability to criminal exploitation in November 2019. Nottinghamshire Police has now amended this information sharing protocol to the effect that such information is now shared. In the light of this I have no further recommendations to make on this point. 5 FINDING OF FACT: There was a delay in processing DE’s application for a place for Child C at the Waltham Forest High School in May 2018. This contributed a further two months to the 20 months in which Child C did not receive adequate supervision or guidance. The School Admissions Service did not spot this delay. Both the School and the Admissions Service have revised their arrangements to attempt to ensure this does not reoccur. In the light of this I have no further recommendations to make on this point. 6 FINDINGS OF FACT:a. The initial response to DE’s application for housing in Waltham Forest was slow and no new action was taken following DE’s request that her application for rehousing be reopened by Waltham Forest in August up until the end of October 2018.b. The Housing Service was not engaged in multi-agency discussions about how to respond to the criminal exploitation of Childc. C. Slow response This delayed the establishment of adequate housing for Child C’s family and restricted DE’s ability to supervise her son. It is my opinion that this could have had an impact on DE’s ability to exercise parental control and supervision over Child C. The Waltham Forest Housing Service accept my finding of fact but do not accept my opinion that this could impacted on DE’s parental control. The Waltham Forest Housing Service have made a series of changes to their monitoring arrangements in relation to applications for rehousing in response to this case. These have been described to me as:• ‘we monitor cases that are overdue in ‘Approach or Application Triggered’ when they remain in this status beyond 28 days’;• ‘we monitor cases that are overdue in ‘Prevention’ beyond 56 days in this status’;• ‘we monitor cases that are overdue in ‘Relief’ beyond 56 days in this status’; and• ‘we began monitoring overdue cases in ‘Approach’ from September 2019’. In the light of this I have no further recommendations to make on this point. Involvement of the Housing Service in planning to reduce Child C’s vulnerability to exploitation Despite the Housing Service holding information not known to any other agency, and also controlling resources that were an important component of the plan to protect Child C from future criminal exploitation, they were not involved in discussions about protecting Child C. Any meeting considering Child C’s vulnerability to exploitation without the Housing Service would have been an inadequate forum. IMPLICATIONS FROM THIS FOR THE RELIABILITY OF THE CHILD PROTECTION SYSTEM: In this case any meeting considering Child C’s vulnerability to exploitation without Housing would have been an inadequate forum. RECOMMENDATION Recommendation No. 10 WFSCB should review the references to the involvement of Housing Services in case discussions and meetings in their procedures and either broaden the invitation list to strategy meetings/discussions or create provision for case discussions that do involve Housing where this is needed. 7 FINDING OF FACT: The initial gathering of background information about Child C carried out by the MASH in October 2018 was incomplete and the Waltham Forest High School should have been alerted to the involvement of one of their pupils in these events. Only limited checks were made when Child C was first drawn to the attention of the Waltham Forest MASH after his arrest in Bournemouth. The MASH has reinforced with its staff the need for them to comply with the MASH’s standard procedures to require a wide trawl of sources, while acknowledging, reasonably in my view, that a full intelligence check on every referral that it receives would be disproportionate in all cases. In the light of this I have no further recommendations to make on this point. 8 FINDING OF FACT: While the overarching approach of the partnership’s response to children who are criminally exploited is sound, and, in particular, contextualised safeguarding is well described in the Waltham Forest safeguarding partnerships’ Adolescents Practice Guide (‘Safeguarding Adolescents: A Practice Guide’) there may be learning for the partnership from a number of specific features of Child C’s case in respect to speed of initial response, assessment and response to contextual safeguarding issues, and awareness of the threat of drug debt bondage.[20]The Claimant’s overall contention is that the failings and errors identified in the SCR report ought to be investigated in further detail. Thus, it is submitted, there should be exploration of why the “reachable moment”, the opportunity that arose in October 2018 when C was returned to London from Bournemouth was not grasped; why the various public authorities failed to provide information to each other; why a formal multi-agency discussion of C’s case did not occur; how it was that C was allowed to be out of school for an extended period; and what lessons could be learned from the failure by LBWF properly to address the Claimant’s first application for housing made in April 2018. In submissions at the hearing further points were identified as follows.(1) Which authorities were aware in 2016 and 2017 that C was excluded or absent from school?(2) Nottinghamshire Police’s awareness of C in 2018, and who they shared information with to identify the risk to him?(3) Who knew and what did Nottinghamshire Police do about the Claimant’s concerns about C and the threats made to her in July 2018?(4) What did Waltham Forest Multi-Agency Safeguarding Hub, LBWF, the Young Offending Service and the police know about C in April 2017-2018 and what did they do or not do?(5) Who was told about C arrest in Bournemouth in October 2018 at an alleged ‘cuckoo house’, and what action was taken in consequence?(6) When C was found to be in possession of a gun at school in November 2018 and was arrested, what were the consequences and what awareness did the public services have of this?(7) Who knew about C going missing in November 2018 and what was done about it?(8) In December 2018 what was the extent of recognition of the risk by the Bronze Panel meeting that C would be exploited by organised gangs and have access to firearms?(9) Why was contact not made with C between 14 December 2018 and 8 January 2019, particularly when the Claimant telephoned the Children’s Social Care social worker on 7 January 2019?(10) Why did the Metropolitan Police not ask Nottinghamshire Police for information about C when they had an opportunity to do so?(11) In the months immediately prior to C’s death, which authority was aware of the threats to him and what had each done?[21]In her written submissions for the Coroner, Ms Dolan KC addressed matters raised at the hearing, point by point to the effect that each had been considered in the course of the SCR report. I accept her written submissions on these matters. In his submission in reply for the Claimant, Mr Jesse Nicholls raised supplementary questions. I do not consider the approach taken by the Claimant on this issue assists. It is readily apparent from the SCR report that it is a thorough and thoughtful consideration of all relevant matters. To my mind the SCR report is a highly impressive piece of work that should provide valuable assistance to all public authorities concerned. By identifying very clearly things they did and things they failed to do the SCR report ought both to promote accountability for what happened and to provide valuable guidance to those public authorities as regard their future conduct. Whenever considering a document such as this SCR report it will always be possible to point to further questions that could have been considered or further detail that could have been looked for. But that is not the test of whether the investigation that has been undertaken meets the requirement arising under article 2. In the circumstances of this case the investigation needed to consider the actions of the public authorities in Nottinghamshire and in London that had responsibilities that, if performed, would have served to safeguard C against the risk of falling victim to criminal exploitation. The SCR report, as written, evidences an effective investigation of the actions and omissions of those public authorities. It is not to the point that other matters might also have been considered in the course of the report.[22]The Claimant’s further submission on the scope of the SCR report was that the requirements of the article 2 obligation were not met because the report did not identify what the relevant public authorities “should have done”. This submission does not assist the Claimant. The purpose of an article 2 investigation is to consider what did happen; to establish a picture of past events. Often it will be readily apparent from findings on what did happen, what other steps should have been taken. That is so in the present case since it is clear from the SCR report that certain steps that were not taken should have been taken. But that is a by-product of the investigation. It is also clear from provisions in the 2009 Act that the purpose of an inquest investigation is to establish what did happen. By section 5 of the 2009 Act the purpose of the inquest is (in a case such as the present) to establish how, when, where, and in what circumstances the deceased came by his death. The focus is on the investigation of past events, and conclusions on what took place. This purpose is underlined by section 10 of the 2009 Act. That requires the coroner (or jury) to reach decisions on the matters specified in section 5 but then provides that those decisions:
“…may not be framed in such a way as to appear to determine any question of …civil liability…”
Thus, the findings at an inquest are not intended to decide what should have happened only what did happen.[23]The Claimant’s remaining submissions concern the process that was followed to produce the SCR report. The Claimant first contends that as a matter of principle, an exercise such as the SCR is incapable on its own of discharging the article 2 investigative duty. She further contends that the process was not independent of the public authorities concerned; that the process was inadequate because Mr Drew lacked the power to compel witnesses to provide information or documents; that the investigation was not conducted in public such that it will be insufficient to ensure accountability; and that she was insufficiently involved with the investigation process.[24]Article 2 does not prescribe the form of investigation that must take place. The position has been crisply summarised in the judgment R(Grice) v HM SeniorCoroner for Brighton and Hove [2020] EWHC 3581 (Admin) per Garnham J. “64. The minimum requirements were set out in Jordan v United Kingdom (2001) E.H.R.R. 52 at [106] – [109], Edwards at [69] – [73] and in Amin at [25]. They are commonly referred to as the Jordan requirements: a) the authorities must act of their own motion; b) the investigation must be independent; c) the investigation must be effective in the sense that it must be conducted in a manner that does not undermine its ability to establish the relevant facts; this is, as it was described in Jordan “an obligation of means rather than results”; d) the investigation must be reasonably prompt; e) there must be a “sufficient element of public scrutiny of the investigation or its results to secure accountability in practice as well as in theory; the degree of public scrutiny required may well vary from case to case”; and f) there must be involvement of the next of kin “to the extent necessary to safeguard his or her legitimate interests”. 65. Citing Goodson v HM Coroner for Bedfordshire [2004]EWHC Admin 2931 at [68], it was accepted in D that “even the minimum requirements involve a degree of flexibility”. ... 84. I have set out at [64] above the positive requirements (the Jordan requirements) of an Article 2-compliant investigation. It is important also to record what is not required:(i) It is not a requirement of the ECHR that any particular procedure be adopted to fulfil the Jordan requirements. The form of the investigation may vary according to the circumstances and those requirements can be satisfied by a set of separate investigations, rather than by a single, unified procedure (see Jordan v UK (2003)37 EHRR 2; Amin, at [20]; and R(Goodson) v HM Coroner for Bedfordshire [2004] EWHC 2931 (Admin), at [59]).(ii) The requirement for the family of the deceased to be involved in an investigation to the extent necessary to safeguard their interests does not mean that the investigating authorities must satisfy every request for a particular step to be taken in the investigation: see Giuliani and Gaggio v Italy (2012) 54 EHRR 10, [304].(iii) The requirement of public scrutiny does not invariably require a public hearing: see Ramsahai v Netherlands (2008) 46 EHRR 43, [353]. And neither requirement means that the family of the deceased must be able directly to test evidence: see R(D) v SSHD [39]-[42].”[25]Given this summary of the principles, the first part of the Claimant’s submission must fail. There is no in principle reason why an investigation of the kind conducted by Mr Drew is incapable of satisfying the article 2 duty to investigate. The Claimant relies on two authorities: R(Silvera) v HM Senior Coroner for Oxfordshire [2017] EWHC 2499 (Admin); and R(Mullane) v West BerkshireSafer Communities Partnership [2006] EWHC 2499. In Silvera, a mother had been killed by her daughter. The daughter had been a detained psychiatric patient but had absconded from hospital shortly after a doctor had decided she no longer met the criteria for sectioning under section 3 of the Mental Health Act 1983. The police had been told that the daughter had absconded and also told that she might be holding her mother hostage. But the police took no action. Some days later the mother was found dead at her home. The daughter was there and was arrested. An inquest had commenced but then been adjourned pending the criminal proceedings. Later, the coroner decided not to resume the inquest on the basis that the article 2 investigative obligation had been met by the criminal trial together with a “Domestic Homicide Review” undertaken by the local Safer Communities Partnership pursuant to the obligation at section 9 of the Domestic Violence, Crime and Victims Act 2004, and a “Route Cause Analysis Investigation Report” undertaken by the relevant NHS Trust. In fact, there had been no trial as a plea had been entered as to the other investigations, the court observed:
“35. The Senior Coroner refers in his letter of February 2016 to the “Crown Court Trial” together with the two reports as being sufficient to satisfy Article 2 of the Convention. There was, in fact, no Crown Court trial. At an early hearing an acceptable plea was tendered and “K” was made the subject of a hospital order. The two other investigations comprised an internal NHS Trust investigation that was carried out in private and the DHR was expressed to be private and confidential.”
The court’s conclusion (in full) was as follows. “39. In my judgment, the Senior Coroner should have taken a decision to resume the inquest. His decision not to do so, was unlawful and in breach of both the obligations under article 2 of the Convention and the common law obligations to do so. Taken together the Crown Court proceedings and the two internal investigations did not satisfy the requirements in this case. In all the circumstances, this claim for judicial review should be allowed.” The judgment in Silvera is a conclusion on its facts and does not purport to be otherwise. It establishes no issue of principle.[26]In Mullane an estranged husband shot and killed his wife and son. During the incident the wife had called the police and asked for help. It took more than 20 minutes for the police to leave to help the wife. The defendant decided to establish a Domestic Violence Homicide Review. That decision was challenged by the wife’s next of kin. The court’s decision in that case also turns on its facts. It establishes no issue of principle.[27]The Claimant is also wrong to submit that Mr Drew who conducted the SCR and prepared the SCR report did not act independently. Mr Drew’s credentials clearly indicate his independence both from the Waltham Forrest Safeguarding Children’s Board that appointed him and from the public authorities who actions were considered in the course of the investigation. Mr Nicholls’ submission that there was a lack of independence rests on two matters. The first is a passage in the introduction to the SCR report:
“Throughout all of this I am indebted to DE’s solicitor Alice Hardy and her associates at Hodge Jones & Allen for their help. This has meant that some parts of Child C’s mother’s account could be included in this review, although this is not the full participation that would have been ideal. I have also included material published by the Daily Telegraph from an interview with DE. I have been greatly assisted throughout my review by Suzanne Elwick for the Safeguarding Partnership and by Daniel Phelps, the Senior Responsible Officer for this review. They have put up with my countless enquiries with patience and good humour and have allowed me a virtually free hand in pursuing my enquiries. A large number of people, too many to mention here individually, in Waltham Forest, in London more generally, in Nottinghamshire, and in Dorset have also played a significant part in the review.”
Mr Nicholls submitted that because Mr Drew referred to having been “greatly assisted” by Ms Elwick and Mr Phelps, he was not independent. That submission rests on an obvious misunderstanding of the passage set out above. Mr Drew is doing no more than thanking those who have ensured information was available to him, including the solicitor who represented the Claimant both then and in these proceedings.[28]The second passage relied on is a passage in a letter written by Mr Drew to the Claimant’s solicitor dated 27 April 2020 (just before the SCR report was published). By this stage an issue had arisen as to whether certain documents should be provided to the Claimant pursuant to a subject access request which he had made under the Data Protection Act 2018. Mr Drew’s letter was in response to that request and referred to advice he had taken on whether he was a data controller for the purposes of the 2018 Act. Towards the end of the letter Mr Drew wrote this:
“Bringing this Serious Case Review to completion The Safeguarding Partnership has asked me to avoid entering into further dialogue on any of the issues in your letter, and to bring the process of my review to a conclusion.”
This is no suggestion that Mr Drew’s investigation was not conducted or the SCR report was not prepared entirely independently. No such inference reasonably arises from a desire by April 2020, to conclude an investigation that had commenced over a year earlier.[29]The Claimant’s next point is that the SCR was ineffective because it lacked the power to compel witnesses or compel the provision of documents. This submission is without foundation. No such requirement arises from article 2. The issue concerns the sufficiency of the investigation. Moreover, here, there is no suggestion either in the report or elsewhere, that relevant evidence or material was withheld from or otherwise unavailable to Mr Drew.[30]The Claimant further submits that the SCR failed the requirement for sufficient public scrutiny both because Mr Drew did not conduct his investigation by holding public hearings and because the SCR report does not identify the relevant local government and other officers by name. I also reject this submission. The requirement arising from article 2 for sufficient public scrutiny of either the investigation or its results or both, exists to ensure accountability, to promote public confidence in adherence to the substantive obligations arising under article 2, and to prevent any appearance of collusion or tolerance of unlawful acts. What is appropriate to meet these objectives is not fixed. There is no requirement that an investigation must be conducted through public hearings. I do not consider that the investigation that Mr Drew undertook was impaired by the absence of such hearings. Considered in the round, the SCR report identifies and then scrutinises the acts and omissions of the relevant public authorities. C murder was tragic, causing the Claimant and others who knew him profound grief. But in terms of the public interests that the article 2 obligation to investigate serves to protect, public scrutiny by way of publication of this SCR report is sufficient. My conclusion on this matter is not altered by the fact that relevant local government officers and police officers and others are not named in the SCR report. In the circumstance of this case the absence of their names from the report does not affect the report’s intelligibility or public understanding of what went wrong. In this case, the relevant accountability is the accountability of the public authorities involved. In this case individual accountability is not needed to meet the requirements of article 2. In any event, none of the names of the public employees who acted is a secret. The Claimant had direct dealing with many of them. If she wished to publicise their names she would be free to do so.[31]The Claimant’s final submission on the article 2 ground of challenge is that she had no sufficient opportunity to participate in the SCR process. The submission includes the contention that she could not properly participate because documents were not provided to her.[32]The Claimant did have a sufficient opportunity for involvement in the SCR. Mr Drew was commissioned to undertake the SCR by the Waltham Forest Safeguarding Children Board in early 2019. In the period March 2019 to May 2020 there was a lot of correspondence between Mr Drew and Messrs. Hodge, Jones and Allen, the solicitors representing the Claimant. Throughout this period Mr Drew was, politely, persistent in his attempt to meet the Claimant. For example, in an email of 15 April 2019 he said:
“Very simply I am extremely keen to meet Ms. Bailey (and anyone else she would like to have with her) in the first instance both to introduce myself, to explain what a Serious Case Review (SCR), and to set up further meetings in which I can explore her perspective on this tragedy. There is no absolute requirement that this should happen but past experience, both my own and from other SCRs, is that parental (and family in some instances) accounts are critical to maximising the learning from a Review. No professionals will know a child or their story as well as will their parent. I can arrange to visit Ms. Bailey wherever she wishes, at any time of her choosing (this includes evenings or weekends if that is her wish). If she wishes I can arrange access to a suitable and acceptable (to her) office setting for her, those who accompany her, and for me. I am entirely happy for a member of your firm to accompany her if this is what you and she would like. We could meet in your office if that is what you and she would like, although these are not easy meetings for obvious reasons and you and Ms. Bailey may favour a more informal setting.”
The Claimant’s solicitors replied on her behalf by letter dated 25 April 2019:
“Thank you for your email dated 15 April 2019 suggesting a meeting with Ms Bailey to hear her perspective regarding the death of her son. I have discussed the proposal with Ms Bailey and I have explained the potential benefits of such a meeting. Understandably, Ms Bailey does not want to meet anyone herself to relive the day in question and the months that led up to it. Nevertheless, she does understand the utility of such a meeting and so she has decided that she would like me, as the solicitor with conduct of her case, to meet you in her stead.”
In consequence of this Mr Drew met the Claimant’s solicitors. During May and June 2019, he provided them with lists of what were referred to as “prompts” for the Claimant to encourage her to provide information. After responses were provided (towards the end of June 2019) Mr Drew offered again to meet the Claimant. However, the Claimant’s preference remained to communicate through her solicitors. In July 2019 Mr Drew raised further matters for the Claimant to consider.[33]On 19 December 2019, following of the end of the criminal trial, Mr Drew wrote again to the Claimant’s solicitors asking if she would meet him. The email enclosed a letter for the Claimant. The material part of that letter was as follows:
“May I start by expressing my deepest condolences to you and your family for the loss of your dearly loved son. I never met Jaden, obviously, but I feel I have come to know something about him as I have conducted this review. He was clearly a very special boy. I tried to contact you this spring, via your solicitor, Alice Hardy, and I believe she discussed this with you. At that stage you did not feel able to meet me although you did answer a number of questions that I passed on to Alice. This was very helpful. I wonder whether you would now be prepared to meet me. I am very near the end of my Review and I would like to learn more about Jaden and his life from you, as well as to listen to your views about how future tragedies can be avoided. I will need to finish my Review soon but I would very much like to meet you before the final report is written so that it can include as many of your views as possible, and so you can influence the learning that needs to come from this tragedy. I live in the same part of London as you and would be prepared to meet either at your house or at a convenient location. I will be on my own but you should feel able to invite anyone with you as you think best.”
The Claimant’s solicitors replied on 20 January 2020 saying that they were due to meet the Claimant shortly. The same day Mr Drew wrote as follows: “It is obvious from the media that Jada has been doing that she is in a much better place than she was nine months ago and I can really not emphasise too much the opportunity that is available to her in respect of the review. It is a real pity that we have had to progress so far without her. I am conscious from comments that she had made in the press that there are issues she wishes to cover. Meeting me is her chance to do this. I am currently working on an assumption that there will be a full draft of the report, including recommendations, available at the beginning of March, with publication following during the spring. However, I would like to have a number of conversations with her around key issues before I finalise that draft for sending to you and her. I look forward to hearing from you after Wednesday. As I’ve said before I am happy to meet her anywhere, at any time, and with any number of people. I will be on my own. The Claimant’s solicitors replied asking if a list of questions could be sent. Mr Drew sent the questions in an email later the same day (20 January 2020).[34]On 6 February 2020 the Claimant’s solicitors wrote to Mr Drew explaining that the Claimant had decided not to meet him: “I am sorry for the delay in updating you since seeing my client. I did discuss your letter with her and explain that you would like to meet before finalising your report, and why. I am afraid she would prefer not to meet you. There is no discourtesy intended, but she is struggling with her mental health and finds the prospect of discussing Jaden with someone in authority very difficult. I take your point that she was willing to talk to press after the trial, but you will appreciate that the press represent an opportunity for her to express her frustration publicly, which is quite different. Answers to the questions Mr Drew had sent on 20 January 2020 were provided on 11 February 2020.[35]Thereafter, there was correspondence between the Claimant’s solicitors and Mr Drew concerning provision to the Claimant of the draft report. The draft report was provided to the Claimant on 3 March 2020. Mr Drew gave an opportunity for the Claimant to comment on the draft report. Initially he asked for comments by 21 March 202 but that period was extended, by agreement, and the Claimant’s comments were provided in a letter from her solicitors dated 6 April 2020.[36]The first request by the Claimant for information and documents was made in a letter from her solicitors dated 27 March 2020. The letter was written by reference to the draft report. In total, 24 points were raised, relating to 14 separate passages in the draft report. (The final version of the report, without appendices, ran to 66 pages). Most of the requests asked for further particulars of information contained in the report, and asked for the source of information to be provided. This accounted for 20 of the points raised. There were four requests for documents referred to in the draft report:(1) “a local Safeguarding Board’s thresholds document”;(2) a “Children and Family Assessment”;(3) an assessment dating from January 2019 made by the Youth Offending Service; and(4) copy documents from a school in Nottingham concerning one of the temporary exclusions that had occurred in 2017.[37]Mr Drew responded to the requests, save for the requests for documents, by letter of 1 April 2020 (mis-dated as 1 March 2020). So far as concerned the request for documents, Mr Drew said that the Claimant should ask the four organisations concerned for copies, because they had provided the documents to him on the basis that he would not disclose them further.[38]On 6 April 2020 the Claimant’s solicitors wrote to Mr Drew making a subject access request under the Data Protection Act 2018. This request was not limited to the documents previously sought but concerned 13 identified documents. Mr Drew replied the same day. So far as concerned the subject access request, he wrote as follows:
“The most pressing issue concerns the documents you have requested. I have no desire to stand between Jada Bailey (and you) and these documents, but had received advice that it was not my place to release them to you. Since you dispute this, and since I am not lawyer myself, I have requested authority to seek independent legal advice on this matter. It’s unusual for an SCR author to need independent legal advice but this seems right in all these circumstances. I will let you know when I have authority to proceed, and it may be that a solicitor to solicitor conversation will help expedite things. I agree with you that it is not desirable that this take 40 days to resolve, and I will do everything in my power to expedite matters.”
Mr Drew returned to this point in a letter dated 27 April 2020:
“Data request As I explained I wanted to take independent legal advice on the data issues you raised. I needed to do this as in the normal course of things an Independent Reviewer takes advice from one of the Safeguarding Partnership’s solicitors but in the circumstances that we are in, that is with the possibility of legal action between Jada Bailey and at least two of the three partners, it seemed best to go outside of that circle. The Waltham Forest Safeguarding Partners were fully supportive of this request. I have now had advice provided to me by a QC who is also a head of chambers. His advice is that I am not a ‘data controller’ (s45 of the 2018 Data Protection Act) but simply process data on behalf of different controllers “and therefore cannot [his emphasis] provide the documents to the mother, as requested”
. This means that I am not able to send you documents as requested, and so suggest that you contact the individual agencies directly. If you are in any doubt about their provenance don’t hesitate to come back to me and I will do my best to assist you. He added that he thought it prudent that I also contact the Information Commissioner’s Office directly to seek their advice, and this I did yesterday. I will contact you if their advice is any different to that that I have already received.”[39]Also, on 27 April 2020, the London Borough of Waltham Forest wrote to the Claimant directly. One point made in that letter was that if the Claimant wanted the documents requested in the 6 April 2020 letter she should contact the relevant public authorities herself.[40]Drawing these matters together, the investigation did provide sufficient opportunity for the Claimant to participate. Mr Drew offered that opportunity at the beginning of the investigation and then again, from time to time, as the investigation progressed. The Claimant’s participation was limited to providing responses to written questions. But that was the Claimant’s choice. Had she felt able to meet Mr Drew I expect her involvement in the process would have increased. The information the Claimant did provide was considered and contained within the SCR report. The final version of the report also took account of the Claimant’s comments on the draft version of the report that was provided to her at the beginning of March 2020.[41]The request for documents was made very late in the day: first on 27 March 2020; and then in an expanded form on 6 April 2020. By the time the SCR report was published, the subject access request remained outstanding. However, since that request was raised so late in the day that possibility was unavoidable. I do not consider any of this shows that the Claimant was insufficiently involved in the investigation or lacked an effective opportunity to participate in and comment on the formulation of the SCR report. Rather, opportunities to participate were available from the outset of the investigation in early 2019 and, given the assistance available to the Claimant from the experienced and able solicitors who advised her, the opportunities to participate were real and substantial.[42]Since I have rejected the Claimant’s contention that the SCR report failed to meet the requirements of the article 2 investigative obligation, it is unnecessary for me to consider the further points made that concerned the investigation of the Claimant’s complaint to the IOPC. In the premises, Ground 1 of the Claimant’s challenge fails.[43]This ground of challenge is directed to paragraphs 35 and 36 of the Coroner’s reasons, the paragraphs that follow the conclusion at paragraph 34 that the investigation already undertaken had met the article 2 obligation to investigate and had in fact “gone beyond” an article 2-compliant investigation. At paragraph 35 to 36 the Coroner considered whether there was, to use the language of paragraph 8 of the Schedule 1 to the 2009 Act, any further “sufficient reason” to resume the inquest, by asking whether conclusions the inquest might provide would go beyond those already reached in the investigations to date. The Coroner concluded that the answer to this was no for two reasons:
“... Firstly, the limitations placed upon me mean that any primary conclusion at inquest could not be inconsistent with the result of the criminal trial and therefore “Unlawful killing” would be the most appropriate conclusion. ... Secondly, a Regulation 28 report is simply a report not a ruling, it is toothless to the extent that a coroner cannot proscribe a solution to the concern identified, require specific performance of remediation or even demand that the report is responded to. Other inquiries into Jaden's death have been able to make recommendations and require action.”
[44]As to the first reason, the Claimant submits this shows the Coroner failed to consider the possibility that an inquest might lead to a “narrative conclusion”. This submission relies on “Form 2”, the document at Schedule 1 to the Coroner’s (Inquest) Rules 2013. Rule 34 of the 2013 Rules provides that a Coroner, or as appropriate, a jury “must make a determination and any findings required under section 10 using Form 2”. Section 10 of the 2009 Act requires decisions on the questions set out at section 5(1)(a) and (b) of the 2009 (i.e. who the deceased was and how, when, where and in what circumstances he came by his death), and a finding on the particulars required in the Births and Deaths Registration Act 1953. Form 2 provides a template to meet the requirements of section 10 of the 2009 Act by setting out 5 questions. Question 4 reads. “Conclusion of the coroner/jury as to the death: (see notes (i) and (ii)” Note(i) states that any of 9 “short-form conclusions may be adopted” these include “accident or misadventure”, “lawful/unlawful killing”, “natural causes”, “open” etc. Note(ii) then states “as an alternative, or in addition to one of the short-form conclusions listed under Note (i) the coroner or where applicable the jury, may make a brief narrative conclusion.” The Claimant’s submission is that when reaching his decision, the Coroner did not consider the possibility of a “narrative conclusion”.[45]I do not accept that submission. The suggested distinction between “short-form” and “narrative” conclusions that is the premise of this submission is a distinction without a difference. There is no material difference between a conclusion expressed using any of the terms listed in Note (i) and one that is in the “brief narrative” form anticipated by Note (ii). Each is intended to be descriptive: to describe the outcome of the inquest. For example, a conclusion of “unlawful killing” could be given either by simply using those words or through a narrative to the same effect. In the present case the point made by the Coroner in his reasons was only to the effect that the conclusion reached at an inquest, however expressed, would have to be consistent with a conclusion of unlawful killing because that conclusion was the only one that could be consistent with the outcome of the criminal trial that had taken place. Therefore, the Coroner did not disregard the possibility that the conclusion at any resumed inquest might take the form of a narrative. Rather, his point was that because the conclusion (however expressed) would have to be consistent with the verdict in the criminal proceedings that C had been murdered, it was unlikely that anything in the conclusion would go beyond the conclusions already reached, for example, in the SCR report.[46]In relation to the Coroner’s second reason the report referred to – “the regulation 28 report” – is one made pursuant to paragraph 7 of Schedule 5 of the 2009 Act. That provides:
“7 (1) Where— (a) a senior coroner has been conducting an investigation under this Part into a person’s death, (b) anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and (c) in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action. (2) A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it. (3) A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner.”
This is the report then referred to in regulation 28 of the Coroner’s (Investigations) Regulations 2013. Among other matters, regulation 28 specifies to whom the report must or may be sent. (a) a senior coroner has been conducting an investigation under this Part into a person’s death, (b) anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and (c) in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances,[47]The Claimant takes issue with the description of a regulation 28 report as “toothless”. But if the whole sentence is read, it is clear that the Coroner’s use of this word discloses no material misdirection or error of law. It is correct that the contents of a 28 report are not prescriptive; the Coroner’s turn of phrase was colourful but not wrong.[48]In the premises, there is no error in this part of the Coroner’s decision. The second ground of challenge therefore fails. Ground 3. Failure to have regard to relevant considerations.[49]The Claimant’s submission is that when reaching his decision not to resume the inquest the Coroner failed to have regard to relevant considerations, namely:(a) the public interest in holding an inquest;(b) the purpose pursued by sections 5(1) and (2) of the 2009 Act;(c) that an inquest can serve to allay any public concern arising from a death; and(d) the possibility of making a regulation 28 report.[50]So far as concerns the possibility of a regulation 28 report, it is clear from paragraph 36 of his decision that the Coroner did have that possibility well in mind. So far as concerns the remaining points, each was a matter raised with the Coroner in the Claimant’s written submissions to him dated 27 November 2023. Further, it is readily apparent from the Coroner’s decision, read in the round, that he took these matters into account since each is integral to the notion of the investigation required under the provisions of the 2009 Act (regardless of whether or not that investigation is required to meet the obligation arising under ECHR article 2). This ground of challenge therefore also fails.

Disposal

[51]For the reasons above, the Claimant’s application for judicial review is dismissed. ________________________________________