The incident every special school headteacher hopes will never occur almost happened at my school in Bradford. A child entrusted to my care nearly died.

The pupil, who has complex needs, was rushed to hospital in an ambulance, where she spent two nights in a coma while her mother sat praying at her bedside, with staff from the school sitting on the other side of the bed.

It was a few years ago and I can tell this story now because the student survived the overdose of epilepsy medication and made a full recovery; her mother has given me permission to share what happened in the hope it might help prevent a tragedy in the future.

I know better now but then, despite having been a headteacher for over 10 years, I had never done any training or preparation for taking responsibility for this whole area of work, and naively presumed all NHS services delivered in specialist schools and settings were consistently planned, delivered and managed for quality, according to a commissioning framework or protocol set out by central government.

However, in the aftermath of this incident, I discovered there wasn’t even a standard reporting system or mechanism for accountability when medicine and health treatment is delivered in special schools in England.

Lessons needed to be learned.

A widespread issue

After speaking about this incident and the concerns it had raised at my regional headteachers’ network in Yorks & Humber, I discovered I wasn’t alone in wondering why medical services that are so essential to children who have complex health needs as part of their package of SEND, are so variable from school to school and between local authority areas.

Colleagues approached me during the break and spoke quietly of near misses and also of events where children had come to harm while health care was carried out in their special schools.

Furthermore, when we used the Special Schools Voice website to ask headteacher colleagues ‘‘What keeps you awake at night?” the clear answer was: “Problems with the delivery of health care and services.”

It came to light that in England we have a classic “postcode lottery” because the commissioning and delivery of these services that provide medical and health care in special schools is entirely delegated to local authorities and their partner clinical commissioning groups.

Not only does the Department for Education not direct local authorities about how this should be done, but they don’t gather data about it either.

This was not a great situation to uncover.

Acting rapidly 

However, one great habit of special school headteachers is that we maintain support groups in every part of the country.

Calling on these regional networks and finding like-minded colleagues concerned about this situation meant that in 2019 we formed our own single agenda lobby group, Medicine in Specialist Schools (MiSS).

This was set up to “give a voice to school leaders in specialist provision, who want to ensure that their pupils receive high-quality health and medical support while they are in school”.

We moved quickly to start doing this and by February 2020, weeks before the outbreak of Covid, Special Schools Voice arranged for a MiSS delegation to visit the DfE to outline our concerns around medicine and health care provision in special schools.

The civil servants tasked with meeting the group listened to what we had to say and responded: “We do hear these accounts [of a postcode lottery] from around the country, but it is all very anecdotal; do you have any data?”

The networks responded energetically to our call, and a fortnight later, 179 schools - just short of 20 per cent of all the special schools in England - had submitted their data to us.

Last year, this data was presented back to the civil servants, this time from CQC, DfE, NHS England and Ofsted, in the form of a report from ESC Management Services’ experts in health and SEND law, that points out the gaps across the country and makes six key recommendations for the long-awaited national SEND review to consider.

To their credit, the colleagues from Sanctuary Buildings thanked us for the work undertaken, took the findings on board, and came back later with further queries that showed they were dissecting and digesting the contents.

If there was a straightforward “booster jab” solution available I have no doubt the DfE would have taken action already.

The impact of Covid 

The truth is this problem is as complex as the health needs of children who now, thanks to fantastic advances in medical treatment and technology, survive longer and in greater numbers than in the decades when I was new to the profession.

However, the system architecture we are working with for SEND in England is still stuck in the 20th century.

An attempt to bring it up to speed was made with the Children and Families Act in 2014, and a suite of new guidance on SEND that emerged in 2015 to try to make this a reality.

But the hashtag #SENDcrisis that trended in 2018 drove record numbers of parents to submit their horror stories as evidence to the Commons Education Select Committee, along with headteachers in the SSV and MiSS networks who wrote lengthy essays explaining why the hashtag was so dominant on EduTwitter.

The select committee’s excoriating report on SEND, published in the autumn of 2019, was preempted by the announcement of the national SEND review, but Covid smothered the work of this team and the sector instead had to fight the fire of school closures.

Alongside the issues of school closures and Covid risk assessments for children yet to be deemed “clinically vulnerable”, another concern emerged as Covid took hold in 2020 - the wholesale withdrawal of paediatric health and therapy services, not just in special schools, but everywhere.

The pressure to staff the “red wards” drew all clinical staff away from “elective” work, and many children with complex health needs are still waiting for them to return.

Now we wait for the SEND review’s final product at the fourth time of asking - the education secretary has nailed his colours to the mast, and the DfE seems to be galvanised for action, with a SEND Green Paper widely expected.

There is much it needs to solve: mainstream failure and exclusion, long waits for EHCP assessment, the postcode lottery funding problem and lack of specialist school places.

What needs to change 

Meanwhile, with regards to ensuring that the health needs of our most vulnerable children are met, there is also much that must change.

The MiSS group has six clear asks from the SEND review:

1. A NHS commissioning framework is required for children and young people with additional and complex health needs and disabilities when they are attending specialist education settings because of the cumulative clinical risk that is being managed there.

2. Annual nursing needs assessments should be mandatory in specialist education settings to inform commissioning and workforce planning by both NHS Trusts and schools.

3. Clarification of the legal status of clinical nursing care in specialist education settings is needed when it is outside the framework of NHS commissioning and funded directly from the school’s budget.

4. Delegation of clinical tasks by healthcare professionals to “support workers” in schools should require LAs to provide a robust delegation framework in line with forthcoming NICE guidelines.

5. Training provided to special school staff to carry out these “delegated clinical tasks” must fit with the Nursing and Midwifery Council’s professional standards and establish consistent expectations for this care across the country.

6. Ofsted and the Care Quality Commission (CQC) should explore how delivery of clinical nursing and paediatric therapy services in specialist education settings could be incorporated into the joint local area SEND inspection framework, so that commissioners of services and professionals working with the most vulnerable children can be held to account for the quality of care provided in these schools and settings.

Currently, the CQC has a duty in law to inspect health services when they are provided in residential special schools, but when those services are offered to children with the same needs in neighbouring day special schools, they do not have a remit.

The gap is because neither Ofsted nor the CQC is tasked to review health and medical services when they are provided in these special schools.

In fact, in some cases where children have come to harm in schools as a result of failures in their medical care, school staff have been held to account by the Teaching Regulation Agency, who do not have a remit for this role either.

It seems the TRA has become the “room of requirement” when gross failures have to be held to account.

It doesn’t have to be like this. In Wales, these arrangements are delegated, and the Welsh government has developed clear policy frameworks for medical and health care when it is delivered in specialist schools.

Things still go wrong, but the protocols exist to find out why, hold professionals to account, learn lessons and put things right. Let’s hope that the forthcoming national SEND review can do the same job for England.

Dominic Wall is a headteacher in Bradford and Co-ordinator of the Medicine in Specialist Schools regional leaders network