Ministers have rejected a coroner’s recommendation to introduce a standard safeguarding information management tool across all schools after the death of a 16-year-old girl. Georgia Scarff from Bury St Edmunds in Suffolk died from a severe head injury after she was hit in April 2024 by a lorry close to her home. Coroner Darren Stewart concluded in October last year that Scarff had intended to take her own life after developing in the year leading up to her death “anxiety in relation to her academic performance, future options and how she would manage these”. Stewart said Royal Hospital School, a private school she attended in Holbrook, was “not in any way causative” in her death. But “not all staff were familiar or proficient” with their safeguarding platform, which led to important information not being recorded. The coroner wrote to the Department for Education warning that the absence of a single standard safeguarding management tool in schools “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”. Responding to the prevention of future deaths report, Josh MacAlister, the minister for children and families, said that while the government “agrees that information sharing needs to be improved, we do not think this is best achieved through the creation of a national system or database”. ‘Some appropriate action’ The coroner said Scarff first confided in her mother in January 2024. Her mother then sought help from the school, which arranged for Georgia to receive counselling. She had three sessions before her death. While the school took “some appropriate action”, the coroner’s report said that “not all staff members were familiar or proficient” with a child protection online management system that had been introduced. Although “not causative of Georgia’s death”, it “led to important information not being recorded in Georgia’s record”, Stewart said. Georgia Scarff, image supplied by Suffolk Constabulary Because there was no standard system, “teachers moving between schools and colleges must familiarise themselves with different processes and tools”. He told the education secretary: “I am concerned that the absence of a single standard safeguarding management tool for schools and colleges 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”. But in the DfE’s response, MacAlister said keeping children safe in education guidance was “very clear” that all concerns, discussions and decisions made “should be recorded in writing”. “I was deeply saddened to learn of Georgia’s death and would like to offer my heartfelt sympathy to her family and friends. “Whilst we agree that information sharing needs to be improved, we do not think this is best achieved through the creation of a national system or database.” Unique identifier The children’s wellbeing and schools act, which has gained royal assent, will require relevant individuals to share information relating to safeguarding and wellbeing, MacAllister said. The act would also create a single unique identifier which would “help join–up systems and improve speed and accuracy of information sharing”. Dai Durbridge, a partner in safeguarding at Browne Jacobson, said the “vast majority” of schools already used a child protection online management system so “there is no clear rationale for government to develop its own national system”. “Instead, what is required here is high-quality staff training, record management and categorisation of issues as they arise. Josh MacAlister “One of the biggest challenges we see is a misrepresentation of safeguarding records due to inconsistency and a lack of completeness in data input from staff. Addressing this would help to identify safeguarding concerns more proactively.” In its response to the coroner, Royal Hospital School said that it had appointed a new designated safeguarding lead in January 2025 and had expanded its safeguarding team from two to four. It also said the dedicated safeguarding lead team issued safeguarding updates to all staff every two to three weeks that included “explicit reminders” on the use of the safeguarding management system. In-person training All staff have also attended in-person training on the use of the system. The school has also joined the Inspired Learning Group, which runs more than 30 schools and nurseries, “which provides an additional layer of rigour, oversight and expertise at head office level”. A DfE spokesperson said: “Georgia Scarff’s death is a tragedy, and our thoughts remain with her family, friends and loved ones. “All schools and colleges must have regard to our statutory safeguarding guidance, keeping children safe in education, which we strengthened this September, including clearer expectations on information sharing and the transfer of child protection files when a child moves between schools. “We’ve also strengthened our guidance on the link between mental health and safeguarding, so schools can better identify and support children at risk, while accelerating the roll out of mental health support teams across the country to cover every school and college by 2029.” A Royal Hospital School spokesperson said: “We would like to thank the coroner for his thorough and sensitive consideration throughout this hearing and for his ongoing work in supporting the school to ensure consistent records are maintained within the school’s safeguarding management IT system, something we are fully committed to.” Samaritans are available 365 days a year. 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