Further supplementary memorandum submitted
REPORT 2007-08: FIGURES
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
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 OF CHILDREN
NOTIFIED TO OFSTED BETWEEN 1 APRIL 2007 AND 31 MARCH 2008, WHERE
NEGLECT OR ABUSE IS A FACTOR OR A SUSPECTED FACTOR
Circumstances surrounding the deaths
|Suicide||28||Young 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
||A parent or carer was subsequently charged with murder.
|Physical abuse||23||Medical 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
|19||Substance 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.
||Outcomes of police or coroners' enquiries are inconclusive but abuse or neglect suspected.
|14||Neglect 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
||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
|11||Circumstances of death are inconclusive but known domestic violence between parents or carers is recorded.
Parenting concernsteenage parents
|10||Factors of poor parenting practice, such as feeding, and where one or more parent was a teenager.
Killing by another young person
||Deaths through shootings or stabbings inflicted by a young person where abuse or neglect is a contributory factor.
Death by accident where neglect occurred
|8||Accidents 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 fires deliberately caused by a member of the immediate family.
Shaken baby syndrome
||Based on stated medical opinion.|
|Concealed birth||6||Questions posed whether or not the babies were still-born.
|Other||16||Aggregation 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
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
Her Majesty's Chief Inspector