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.