The Work of Ofsted - Children, Schools and Families Committee Contents

Further supplementary memorandum submitted by Ofsted


  I write in response to the queries that you raised during my appearance at the Children, Schools and Families Select Committee on 9 February 2009. You asked about the child death figures included in my recent Annual Report.

  As was discussed in the Committee hearing, there has been some confusion regarding these matters over recent months. At the centre of the debate has been the different ways in which various organisations collect these figures.

  Ofsted collects its figures from a specific source and for a specific purpose. This information is based on detailed and individually matched data, which is provided by local authorities, as notifications of serious incidents resulting in deaths or serious injuries to children where abuse or neglect is, or is suspected to be, a factor. It also includes figures relating to the deaths of looked after children in the care of local authorities.

  Ofsted records details of these serious incidents at the point of notification. Local authorities are required to notify Ofsted at an early stage, so that we can brief government departments and ministers, and track progress where circumstances indicate that a serious case review may be convened. As Ofsted receives more information about each individual case, for example, following notification of the outcome of a post mortem or criminal proceedings, we update our records. In many cases, in particular where there are complex medical issues, these investigations take a long time to reach a conclusion. However, as more information becomes available, it may become clear that abuse or neglect was not a factor in a death, even if it was suspected at the initial point of contact. As such, the information on Ofsted's record is subject to change over time. My Annual Report 2007-08 stated that there had been 282 notifications of deaths of children to Ofsted from local authorities between 1 April 2007 and 31 August 2008. This information was up-to-date and correct at the time it was quoted.

  An examination of our records relating to each of these tragic deaths showed that, as of 24 November 2008, 72 of the 282 notified deaths had been found not to have abuse or neglect as a factor. In each of the remaining 210 deaths, abuse or neglect was either a factor or still a suspected factor. This includes those tragic cases where a parent or carer murdered their child, but also other circumstances where neglect or abuse played a part, including a worrying number of suicides.

  Ofsted takes this widest possible definition of where abuse may be a factor, as we believe this is the only way to ensure we capture the full picture. We have included violent deaths of children arising from homicide and those that can be hidden, including death by poisoning, drowning, or fatal accidents and adverse events caused by neglect. Examples of such cases may include a child who dies in a car accident, because their parents or carers were driving under the influence of drugs; or a young child left unsupervised, who runs out onto a road through an open gate and suffers permanent brain damage. Clearly, the boundary between abuse and accidents is sometimes a matter of judgement.

  The following table gives a breakdown of the 210 deaths. The table contains additional comments giving some further information about the types of circumstances included. Please note that, where there are small numbers, these have been either not quoted or have been aggregated to ensure anonymity.


Circumstances surrounding the deaths
Number of
Additional comments
Suicide28Young people aged 12-17 years; identified factors include domestic violence and mental health concerns; includes young people in care or custodial settings.

Murder by parent or carer
25 A parent or carer was subsequently charged with murder.
Physical abuse23Medical opinion states that the injuries were non-accidental; or where a parent or carer was subsequently charged with offences directly linked to the injuries.

Substance misuse identified as a factor
19Substance misuse was evident at time of death; poisoning by parent or carer including administration of prescribed medication; deaths arising from harm and harm suffered by babies born to parents with a history of substance misuse.

Unexplained causes
16 Outcomes of police or coroners' enquiries are inconclusive but abuse or neglect suspected.

14Neglect identified as factor in the death. Malnourishment identified as cause of death; neglect identified as factors in the death includes children left unattended, failure to seek medical attention, and known neglect by parent or carer.

Killed by parent when sleeping
11 Child died as a result of suffocation sharing bed with a parent when there were concurrent concerns of alcohol, substance misuse or domestic violence.

Domestic violence identified as a factor
11Circumstances of death are inconclusive but known domestic violence between parents or carers is recorded.

Parenting concerns—teenage parents
10Factors of poor parenting practice, such as feeding, and where one or more parent was a teenager.

Killing by another young person
9 Deaths through shootings or stabbings inflicted by a young person where abuse or neglect is a contributory factor.

Death by accident where neglect occurred
8Accidents on roads or in homes where neglect is a factor; includes illegal handling of guns; and accidents where the explanation is not consistent with the injuries sustained by the child.

House fire—arson
7 House fires deliberately caused by a member of the immediate family.

Shaken baby syndrome
7 Based on stated medical opinion.
Concealed birth6Questions posed whether or not the babies were still-born.
Other16Aggregation of factors where the small numbers could lead to the children concerned being identified; included are children on the child protection register at the time of death, concerns about agency practice, concerns about the mental health of parents or carers and history of sexual abuse.

  Of the original 210 cases, a serious case review has been completed or is on-going in 149. We are aware that a serious case review is not taking place in 58 cases, although in a number of these, the local safeguarding children board has informed Ofsted that single agency reviews will be conducted. A decision is still awaited in three cases.

  As explained above, the number of these cases where neglect and abuse are still suspected will continue to drop as more information becomes available. Current breakdowns of the circumstances surrounding the deaths can only be obtained through a detailed examination at a given point in time. The 210 figure was produced through such a one-off examination. However, given the degree of interest in this area, Ofsted is at present investigating how we might introduce a system to highlight new information on an ongoing basis.

  As you can see, these are complex matters which inevitably involve an element of judgement. I do hope the detailed background information that I have provided is helpful and explains how Ofsted reached thefigures quoted in my Annual Report. As I have said, I stand by these figures and firmly believe that it is vital and appropriate for Ofsted to take this widest possible definition of where abuse or neglect may contribute to child deaths or serious injuries.

Christine Gilbert

Her Majesty's Chief Inspector

February 2009

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