Skip to content
recurance

Oliver Weston

20 Dec 2021 · Coroner Dr James Adeley · Lancashire & Blackburn with Darwen

The coroner's concerns

  1. 1. lack of documented monitoring or inspection visit following death of looked after child

    “there was no documented evidence as to whether a monitoring or inspection visit was required following the death of a looked after child”
  2. 2. deficient preplanning of inspection

    “the preplanning of the visit was deficient in that there was no indication that the four potential episodes of known to OFSTED were a key line of enquiry”
  3. 3. safeguarding documentation ignored

    “the safeguarding documentation, which was entirely relevant, was not considered by the inspector”
  4. 4. relevant information ignored

    “other significant information indexed in the file, such as an annual psychological review, was not considered by the inspector”
  5. 5. OFSTED conclusions unsupported

    “in almost every instance where OFSTED was critical of the Home it was either found to be based on insufficiency of enquiry, misinterpretation of the available evidence or drawing unsupportable conclusions from the available documentation resulting in OFSTED accepting that”
  6. 6. lack of critical appraisal

    “on review by an inspector familiar with the home and a senior manager, a lack of critical appraisal failed to detect any of the deficiencies in the inspection. A critical appraisal might have been expected as the previous OFSTED rating of the Home was”

Responses

No published response was found on judiciary.uk.

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error