A coroner has told ministers to take action on the systems schools use to deal with unexpected absences, following the death of a four-year-old boy who was left alone in his family flat for two weeks after his mother died.
Coroner Mary Hassell insisted that action “should be taken” to avoid deaths in the future, after an inquest found that Chadrack Mbala Mulo died of malnutrition and dehydration in Hackney, east London.
Officials say that he died on on October 18 last year and was subsequently found in the flat with the body of his mother, Esther Eketi-Mulo, approximately 48 hours after his death. It is believed that he is likely to have survived alone in the flat for “over a fortnight”.
In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action
The inquest, by assistant coroner William Dolman, found that concerned staff at Morningside Primary School, Hackney, had not been able to contact Chadrack’s mother or gain access to the block of flats where they lived after he failed to turn up at school.
Now Hassell, the senior coroner at St Pancras Coroner’s Court, has written to the children’s minister Edward Timpson about the procedures followed by schools when pupils do not turn up.
The inquest found that Chadrack’s mother, who had suffered from epilepsy, died suddenly on October 1 or 2 , and that he was not seen in school after September 30.
School staff had attempted to call his mother on several occasions and visited the family home twice but could not gain access to the block of flats where they lived, the inquest found.
Janet Taylor, the headteacher at Morningside, said the school had at the time followed its procedure for checking on children missing from school, and had “worked closely with the authorities” since his death to consider “what more schools can do in situations like this”.
“Chadrack’s tragic death has devastated all those who knew him at our school,” she said. “We will remember him as a happy little boy and the circumstances of his death are heartbreaking.”
Hassell raised concerns that the school only held a single telephone number for Chadrack’s mother and not for any other family member or friend. Staff at the school also waited three to five days before sending someone to the family home, she said.
The school has since changed its protocols: it now holds contact numbers for three adults on each child’s file, and sends staff to family homes immediately in cases where they can’t reach someone by phone and calling the police if they cannot gain entry.
However, although she described the new approach as “very sensible”, Hassell says it “seems unlikely” that other schools in Hackney, London or in the rest of England and Wales would have such a system in place.
A spokesperson for the Department for Education described the case as “heartbreaking and tragic”, and said it would be responding “in due course”.
“The department is in receipt of the coroner’s report and takes the issues it raises very seriously,” he said.
Jim Gamble, who chairs the City and Hackney Safeguarding Children Board, has also written to Timpson, calling for DfE guidance to be updated.
He said that the main finding of a local review into the case aligned with an issue identified by the coroner about the distinction between attendance and welfare issues.
“This is a key learning point and having reviewed the non-statutory guidance for maintained schools, academies, independent schools and local authorities issued by the DfE in November 2016, I believe that this could be strengthened in response.”
Timpson has until June 19 to respond.
Why are people so afraid to act any more. Every action has to be an ‘official procedure’. If you are unable to make contact with a parent and then visit their home and can not make contact would you not peek through the letterbox, notice something amiss then call the police to breakdown the door? This is just so sad.
Absolutely tragic. You don’t even think about situations like these when you consider the consequences of not closely tracking the school attendance of vulnerable children.
What about the holidays. This is not something schools can solve it is a community issue and we all are responsible.
This is tragic but not something that would normally happen to a mother and child. People are not usually so isolated that nobody missed the lady after 2 weeks. It isn’t down to the school, they did more than I would expect they phoned and went to the house. Usually people have a job, neighbours, friends or family. You hear of elderly people laying on the floor injured/died and schools wouldn’t be held responsible for that. It is not a schools role to play the sole support network and it wouldn’t help a preschooler who could have equally been put in this situation. We all have a responsibility to look after each other.