Coroner criticises ‘Working Together 2018’

A further report by Richard Travers, the Senior Coroner for Surrey has been published concerning the death of Oskar Miles Nash.  The report focuses on action that is necessary to help ‘Prevent Future Deaths’.  It identifies 12 ‘concerns’ – ten of which relate to local issues and two of which are considered to require action at the national level.  The report ‘Oskar Nash: Prevention of future deaths’ (2022) can be accessed by clicking here.

In his earlier report[1] the Coroner categorically rejected suggestions made by statutory agencies that Oskar’s mother’s parenting ability was responsible for his difficulties – the Coroner stating:

Oskar was undoubtedly a child with extremely complex needs who, by reason of his autism exhibited very challenging behaviour … . Oskar was a child in need of skilled, professional support, which he did not receive and, for the avoidance of doubt, I will say expressly that I do not consider that his problems, or his death, were caused or contributed to by any failure on the part of his mother to meet her parental responsibilities .…


The ‘National Issues’ identified in the Coroner’s most recent report echo the findings of the 2021 ‘Institutionalising Parent Carer Blame’ research report by highlighting the inadequacy of the Department for Education’s 2018 Guidance ‘Working Together’. The Coroner’s report states (concern 11):

From the evidence I heard at the inquest and the prevention of future deaths hearing, it was apparent that the national “Working Together” guidance focuses on children who are in need of safeguarding by reason of risks within the home or from other parental failures to keep the child safe. It was apparent that the consequential approach tends to look critically at the child’s family and parent(s) and their parenting skills, and that this is likely to be inappropriate if the child is in need through disability. I consider that this had a detrimental impact on the approach of agencies to Oskar and his family. I am concerned that “Working Together” does not provide clearer guidance specifically for the safeguarding of children with disabilities, including Autism, and the approach to be taken by agencies to parents and families.

Four of the 12 ‘concerns’ in the Coroner’s report refer to the lack of autism awareness by those involved in Oskar’s care.  This problem was (again) highlighted in the 2021 ‘Institutionalising Parent Carer Blame’ research report (para 5.25) which referred to:

The almost total lack of statutory guidance[2] concerning the importance of ensuring that disabled children are assessed by assessors with the training, skills, knowledge and competence in undertaking disabled children’s assessments is in stark contrast to that relating to the assessment of disabled adults.

In this context the Coroner’s report (‘concern 12’) states:

I was told that the National Autism Strategy does not currently include a timetabled commitment for relevant mandatory Autism training to be provided to all state agencies working directly with autistic adults and children. I am concerned that this poses an ongoing risk to autistic children and their ability to access the services they require for their support, welfare, and safeguarding

‘Concern 9’ of the Coroner’s report also echoes a finding in the ‘Institutionalising Parent Carer Blame’ research report,[3] namely the barriers created by complex local authority ‘threshold criteria’: the Coroner stating:

… I found that following Oskar Nash’s final referral to [the council’s] Children’s Services Department, … there was a failure to appreciate the seriousness of his situation and the risks arising, and a consequential failure to allocate his case appropriately. I found that this contributed to his death. The inappropriate allocation resulted, in part, from the application of [the council’s] then “threshold of needs” document, which was used to inform the level at which support should be provided. At the prevention of future deaths hearing, I heard evidence about [the council’s] revised “threshold of needs” document, as well as the recent guidance …  in relation to suicidality, which has been introduced since Oskar’s death. Despite these changes, I remain concerned that the “threshold of needs” document does not adequately and clearly reflect the known risks of mental health difficulties, self-harm, and suicidal ideation for autistic children (given their prevalence in this group of children) and that, consequentially, there is an ongoing risk that an autistic child in these circumstances will be allocated an insufficient level of support, as was the case for Oskar.


[1] This is referred to in a posting ‘Blamed and criticised for her parenting’ (2021).
[2] Department of Health Care and Support for Deafblind Children and Adults Policy Guidance (2014) is the only guidance we have been able to identify that require such expertise.
[3] See paras 5.01 – 5.12.


Posted 11 February 2022