The report from the first phase of the Southport Inquiry has now been made available. A well-considered, thoughtful and detailed piece, we summarise the inquiry's recommendations and observations as outlined in the first volume of the first phase.
The full 267 page volume can be read here. Some may find it a difficult and distressing read.
A summary of the second volume of phase one of the report will be available on our website next week.
The recommendations
The inquiry outlined its recommendations in Phase 1, Volume 1 as follows:
- Recommendation 1: Phase 2 should consider what single agency or structure should be appointed or established to record, monitor and coordinate interventions for children and young people who present a high risk of serious harm. This must be matched with cultural change so that agencies are prepared to own and manage risk appropriately not just refer it on to others.
- Recommendation 2: Phase 2 should consider the development of a multi-agency risk assessment tool that is clear, accessible and suitable for use across public sector services.
- Recommendation 3: Phase 2 should consider whether there should be a further ability to restrict or monitor access to the internet on the part of children and young people, if a significant threshold is passed concerning the risk they pose to others.
- Recommendation 4: The Department for Transport should require local authorities to ensure that all licensed taxi drivers have a clear duty to promptly report any significant criminal activity they witness while working. This duty should perform part of mandatory training, and a failure to report such activity, subject to individual circumstances, should place the driver's licence at risk. Local authorities should implement practical measures to ensure that drivers have read, understood and acknowledged this requirement.
- Recommendation 5: The Department for Transport should ensure that local authorities establish effective arrangements between licensed taxi companies and schools. These should enable school safeguarding teams to access taxi booking information where relevant to a legitimate safeguarding or risk concern relating to a child who should be at school.
- Recommendation 6: All police forces should ensure that their policies, guidance and training address taking on a calculated degree of risk in recognition of the immediate need to protect the public from an obvious risk to life. This may involve the decision to deploy unarmed officers with caution.
- Recommendation 7: All police forces that have not implemented a model providing immediate and direct support to Force Incident Managers, ideally through a second Force Incident Manager, should consider adopting such arrangements to strengthen decision-making during critical incidents.
- Recommendation 8: NHS England should review funding, and consider providing additional resources, to enable all emergency response ambulance staff to participate in appropriate training exercises.
- Recommendation 9: North West Ambulance Service should review its procedures for declaring a Major Incident or Major Incident (Standby) to ensure clarity in how declarations are made and how they are communicated internally and to other emergency services.
- Recommendation 10: Merseyside Police and North West Ambulance Service should review the terminology used in their systems and procedures to ensure shared understanding and interoperability. The College of Policing and the National Ambulance Resilience Unit should undertake a national review to ensure that police and ambulance services across the country operate with consistent terminology and mutual understanding.
- Recommendation 11: The Department for Education should update the out of school settings guidance by reviewing the health and safety section to ensure terminology is clear and consistent, particularly regarding emergency plans and fire/evacuation plans for smaller providers. The guidance should also be updated to include a non-binding cross-reference to school entrance security guidance, emphasising that while out of school settings may differ from schools in terms of what is necessary, appropriate or proportionate, providers should still consider appropriate entrance and exit security measures.
- Recommendation 12: Phase 2 should consider systems to detect and report concerning online behaviour and suspicious combinations of purchases.
- Recommendation 13: The Home Office's ongoing review of the sale of castor beans should consider regulation of the number of castor beans that can be sold in a single transaction.
- Recommendation 14: Phase 2 should consider whether conventional archery bows should be subject to age verification prior to sale, delivery restrictions including ID checks, mandatory labelling for deliveries, and industry or trading standards to prevent the use of military-style imagery in marketing.
- Recommendation 15: Phase 2 should consider, in parallel with the government's consultation where possible, a prohibition on the sale of crossbows, a licensing scheme similar to firearms, higher controls on purchasing such as restricting sales to age-verified in store transactions, and Trading Standards measures to prevent military-style marketing.
- Recommendation 16: The Home Office should provide clear guidance to all UK retailers of archery bows and crossbows on identifying and reporting suspicious behaviour, including underage purchasers or those who appear to be interested in criminal use of the equipment, and should consider placing retailers under defined obligations to report material suspicions.
- Recommendation 17: The Commissioner of Police of the Metropolis should consider an investigation, with input from the Crown Prosecution Service if appropriate, as to whether Ageo Wholesale UK Ltd committed criminal offences in relation to how it marketed knives/machetes or sold them without required age verification or labelling.
- Recommendation 18: The Home Office should take immediate action to ensure that online knife retailers are complying with the Knives Act 1997, particularly regarding the marketing of knives, machetes, swords and similar bladed articles.
- Recommendation 19: Amazon should improve its measures to prevent children from making purchases, including making the conditions of use and sale more prominent; improve the labelling on packaging of bladed articles so that the warning is more prominent; ensure drivers inform recipients whenever deliveries contain a bladed article; review its systems for recording details of the recipient to ensure that an accurate record of the recipient is obtained; audit its training of age-verified deliveries for drivers.
- Recommendation 20: Phase 2 should consider further measures relating to knives/bladed items sales.
- Recommendation 21: The Department for Education should review and strengthen its guidance to schools on monitoring and filtering systems, including ensuring that the systems used are appropriate and adequate from a technical perspective. The department should ensure schools understand these requirements and consider whether inspections by Ofsted should play a greater role in monitoring compliance.
- Recommendation 22: Lancashire County Council should undertake a comprehensive review of how its children's services and Early Help teams assess and manage risk and online harms to children. This review should ensure that all frontline staff have a consistent and up to date understanding of online risks, and that they have access to effective tools and guidance to identify and respond to these risks. It should specifically include consideration of the risks associated with the use of Virtual Private Networks, which can enable children to bypass safeguards. The Department of Health and Social Care should consider whether reforms to national guidance, policy or training are required.
- Recommendation 23: The Department for Science, Innovation and Technology should consider extending the powers under the Online Safety Act 2023 to enable senior coroners to make a notification to Ofcom to obtain access to social media accounts of perpetrators (not just of a child who has died), and for statutory inquiries to be able to make a notification to Ofcom to obtain access to the social media accounts of both a child who has died and also a perpetrator.
- Recommendation 24: Phase 2 should consider age verification for the use of Virtual Private Network (VPN) software and other options to avoid VPNs being used to circumvent the age-related protections in the Online Safety Act 2023.
The observations
The inquiry additionally made a number of observations:
- Observation A: It should be incumbent on all Force Incident Managers to consider whether the criteria for a major incident are met and to declare one at the earliest opportunity.
- Observation B: This was linked to Recommendation 5. The balance of risks around parents being able to access information concerning the destination of taxis booked directly by their children might also warrant consideration.
- Observation C: The relevant bodies and agencies (North West Ambulance Service, Merseyside Police, the College of Policing and the National Ambulance Resilience Unit (NARU)) may wish to consider Professor Lyon's observation when considering any improvements to the ways in which major tragedies of this kind are handled and in their training exercises. Professor Richard Lyon was the inquiry's independent expert in emergency medicine and pre-hospital care. He was complimentary of the care provided, and there were no practical steps identified which would have improved what the inquiry described as a highly successful reaction by the emergency services. When specifically asked if there were any lessons to be learned, the improvement suggested by Professor Lyon was that there may be a need to secure a greater degree of situational awareness of a complex scene when multiple 999 calls are placed.
- Observation D: The efforts which the inquiry were told was presently underway to place chest seals and bleed control kits in high risk locations for penetrating trauma (e.g. pubs and night clubs) are important and should be prioritised. It would be unrealistic to suggest that such a kit should be located in a building such as the Hart Space. This would be a disproportionate expectation, given the low likelihood of an event of this kind occurring.
- Observation E: The capacity for getting blood products to the scene in response to major and critical incidents is worthy of ongoing consideration by ambulance trusts and helicopter emergency medical services nationwide.
- Observations F and G: Amazon may wish to take note of [some of] their sellers' apparent lack of cooperation in this inquiry's investigation.
- Observation H: The inquiry was critical of a French-based retailer which failed to respond to the inquiry's requests for assistance.
- Observation I: There is a need for better clarity and accessibility regarding what the law requires in the sphere of controls on bladed items. The best way to achieve this will be conisidered in Phase 2. In the meantime, it is important that the Home Office and police forces maximise the visibility of existing guidance and that retailers and delivery companies familiarise themselves with it (see pages 198-199 of the report at the link above for full details of the available guidance).
Best practice
Our summary of Phase 1, Volume 2 will follow next week. It would be best practice to attempt to embed the inquiry's recommendations where possible and where relevant to your organisation.
How we can help
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The information in this article is correct at the time of writing. It is intended as general guidance and should not be treated as legal advice. Every situation turns on its own facts, and tailored advice should be sought before taking any action.
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