Coroner says school record gaps pose risk to lives

A coroner has raised concerns that disparities in the way that pupil records are kept could lead to future deaths.

Darren Stewart, coroner for Suffolk, said different schools using different safeguarding information management tools "may result in a risk to life due to teachers being unfamiliar" with new systems when they changed jobs.

The issue was raised in a prevention of future deaths report (PFDR) after Georgia Scarff, 16, died near her home in Bury St Edmunds in 2024. She had been a boarding pupil at the Royal Hospital School, but an inquest concluded the school's record-keeping was not deemed to be causative.

The Department for Education has been contacted for comment about the PFDR.

Georgia died in the early hours of 15 April 2024, when she had returned home during the Easter holidays.

The coroner concluded the girl, who was a boarder at the private school in Holbrook, intended to take her own life.

The PFDR said that RHS had used the Child Protection Online Management System (CPOMS) as a safeguarding system.

It said the inquest had heard about "appropriate action being taken when concerns relating to Georgia were raised by her mother to school authorities".

However, the report said that evidence was shown that "not all staff were familiar with or proficient in the use of CPOMS which, although not causative of Georgia's death, led to important information not being recorded in Georgia's CPOMS record".

The coroner said: "I am concerned that in another case the failure to record important safeguarding detail may result in a risk to life."

A statement from RHS said: "Georgia was a beacon of kindness and joy to her peers, and her loss continues to be felt deeply across our community. She was admired for her creativity, determination and warmth of character.

"Since the conclusion of the inquest, we have delivered further in-person training and published additional guidance relating to CPOMS, enhanced user access and alert systems within the software, and established a programme of ongoing and refresher training for staff.

"Georgia remains very much in our thoughts, as do those closest to her."

In the PFDR, Stewart said he was "concerned" there was not a single safeguarding system used across all education settings.

"Teachers moving between schools and colleges must familiarise themselves with different processes and tools depending on that used by an individual school or college," he said.

"[That] may result in a risk to life due to teachers being unfamiliar with different management tools and as a consequence important information relating to safeguarding not being recorded in children's safeguarding records."

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