Inquiry identifies ‘huge variation’ in quality of practice among personal advisers and lack of support for young people’s emotional needs, after finding care leavers were three to four times as likely to die in young adulthood as peers.
The care leaver workforce is “not fit for purpose” for those in greatest need, a government-commissioned review into the deaths of care experienced young people has found.
The review found a “huge variation” in the practice of personal advisers (PAs), with many lacking knowledge of the care leavers they were working with and focused on providing practical, rather than emotional, support.
The inquiry, carried out by care experienced journalist Ashley John-Baptiste and social work leader Clare Chamberlain, found care leavers were three to four times as likely to die in young adulthood as their peers.
In many of the cases, the young person’s death came in the immediate aftermath of leaving care, which the review said highlighted the “stark challenges and pressures” faced by young people in losing the support provided by the care system.
John-Baptiste and Chamberlain found that the workforce lacked a specialist knowledge and skills framework to support the complexity and isolation of young people leaving care.
They called on the Department for Education (DfE) to conduct a “major national review of the knowledge and skills required by the workforce”, including in areas such as systemic practice and mental health.
The DfE did not directly respond to this call in its press statement on the review, though did announce the start of a national rollout of Staying Close, which is designed to help care leavers find and maintain stable accommodation and to support them to access key services.
About the review
The DfE commissioned the review in April to examine the “unacceptably high” number of deaths of young care leavers and identify what more could have been done to help them.
Since December 2023, councils have been expected to report the deaths of care leavers aged up to 24 to the DfE and Ofsted through the child safeguarding incident notification system.
The review analysed notifications from 2025, and then looked at a sample of 16 cases that were representative of the total in further detail, including by talking to staff and, where possible, the family and friends of the young person.
It also held roundtable discussions with care experienced young people, loved-ones of young people who had died, government departments and sector bodies.
Young care leavers disproportionately likely to die
The review found that, in 2025, the DfE received 112 notifications of the deaths of care leavers aged 18-24, against a care leaver population of 86,620, implying a death rate of 130 per 100,000.
This was over four times the overall death rate for 15- to 19-year-olds (24.17 per 100,000) and more than three times the rate for 20- to 24-year-olds (35.05 per 100,000) in 2024.
By ethnicity, 68% were white, compared with 53% of the care leaver population aged 18-21, 12% black, compared with 15% of the population, 12% mixed ethnicity, as against 8% of the population, and 3% Asian, compared with 10% of the population.
Over a third (40) of care leavers whose deaths were reported in 2025 appeared to have taken their own lives. Though most of those who died overall (58%) were young men, most of those who died by suicide were young women (24, as opposed to 16 young men).
Fifteen of those who took their own lives had identified mental health needs, with six of this group living in specialist mental health accommodation at the time of their deaths. Six who died by suicide had had children removed, while three were experiencing or had undergone a transgender transition.
Twenty four died as a result of an drug or alcohol overdose, whether intentional or accidental, while six were living in adult prisons and died by overdose or suicide. Three of the 112 young people who died were murdered, the review found.
‘Huge drop off in levels of support’
The review found that 20% of the young people (22) died aged 18, more than at any other age and above the share of the care leaver population who was this age as of 2025 (17%).
The review stressed the figure should be treated with caution, given the possibility of notification numbers underestimating care leaver deaths at ages 21-24, given councils’ reduced contact with those of this age. However, it said the data was “strongly suggestive of the stark challenges and pressures faced by 18-year-olds when they leave care”.
It said young people faced “a huge drop in levels of support” at age 18, regardless of how well planned their transition was, with no equivalence in what was available for children in care and for adult care leavers.
Most of the young people studied were living in semi-independent or independent accommodation and some had been homeless for a period.
While independent living was often a choice made by young people, offering a freedom not afforded to children in care, it often led to isolation and loneliness.
The review found that the trauma care leavers had experienced made it difficult for them to make and maintain relationships. While this was supported in some areas by befriending services, such as the Family Rights Group’s Lifelong Links scheme, the review identified a lack of support for care leavers’ emotional needs.
The role of personal advisers
Councils must appoint a personal adviser for all care leavers they are required to support up to the age of 21, or up to 25, if requested by the young person.
Under care leaver regulations, PAs’ functions include providing care leavers with advice and support, participating, where applicable, in the assessment and preparation of their pathway plan – which sets out how the young person will be supported – participating in plan reviews, co-ordinating the provision of services and keeping informed about the young person’s progress.
Where a young person is provided with accommodation by the local authority, PAs must visit them after seven days, before the pathway plan review that must take place after 28 days and at least every two months, subsequently.
Statutory guidance on care leaver services under the Children Act 1989 states that PAs must consider if the accommodation continues to be suitable and how well the care leaver is managing in it.
Knowledge and skills required of PAs
The same guidance states that PAs should:
- Normally be working towards a professional qualification, though there is no prescribed qualification for the role.
- Possess a sound demonstrable understanding of human growth and development, particularly understanding the insecurities of looked-after children as they transition to adulthood.
- Have a working knowledge of the range of issues that care leavers might expect to face as they make their transition to adulthood and the legal framework affecting care leavers, including the Children Act 1989 and the Children (Leaving Care) Act 2000 and associated regulations.
- Work closely with doctors and nurses involved in health assessments and that it would be beneficial for them to have training in how to promote both physical and mental health.
- Be capable of understanding and acting upon relevant legislation concerned with housing and homelessness.
- Be able able to form a working relationship with the young person to carry forward their pathway plan.
The guidance states that councils “must be satisfied in every case that the person acting as a young person’s PA has the requisite skills and the necessary availability”.
PAs ‘focused on practicalities, not emotional needs’
While it was told of PAs who had developed strong relationships with care leavers and went “above and beyond” to support them, it met others who appeared to have “very low expectations” of their role, with “huge variation” in the quality of practice.
Many PAs seemed to “avoid the emotional side of the transition”, focusing instead on providing information or access to funding, and carrying out practical tasks.
Though caring and committed, the review found some PAs “hardly knew” the young person they were working with, being unaware of their history, childhood and what they may have experienced.
The review also found “a huge variation in quality of care” delivered to care leavers by accommodation providers, whose workforce it described as “unqualified”.
Workforce ‘not fit for purpose for those with greatest need’
It concluded that the care leaver workforce was “not fit for purpose for those with greatest need”, and lacked a “framework for the specialist knowledge and skills required to support the levels of complexity and the isolation of young people leaving care”.
“There is a need for a recognition of the complexity of the task of assisting young people through the transition to adulthood and we recommend a major national review of the knowledge and skills required by the workforce,” the review added
As well as considering the training and qualifications required of PAs, in relation to which there are currently no national requirements, John-Baptiste and Chamberlain said this review should ensure that the workforce has the requisite understanding of systemic practice, mental health and building relationships with young people.
They also called for more investment in the care leaver workforce.
What else did the review call for?
While the review said it was beyond its scope to make detailed policy recommendations, it also called for:
- Improved support for, and awareness of the needs of, care experienced people in custody, for example through councils appointing dedicated custody co-ordinators to support care leavers in prison.
- Councils to review their commissioning of supported accommodation for care leavers to examine whether it is providing the “sensitive, skilled, empathic support” young people need.
- A national initiative to ensure care leavers with medical conditions receive the same level of support from the NHS as they did when receiving children’s health services.
- Consideration to be given for there to be mandatory reviews of cases when young care leavers die, and for local authorities to be routinely involved in inquests into their deaths.
‘These young lives ended too soon’
“It is a national tragedy that so many care-experienced young people are dying so early in life and that, resultantly, a report like this is required,” said John-Baptiste, in a foreword to the report.
“These young lives ended far too soon. Although we have heard about young people who were in devastating situations – we have also come to learn how loved and missed they are by those who knew them. Their lives truly mattered.”
Children’s minister Josh MacAlister thanked John-Baptiste and Chamberlain for carrying out the review, adding: “The tragic stories they have captured must galvanise us to make sure that no one leaving care is left isolated and alone.”
Extending Staying Close scheme
Through the Children’s Wellbeing and Schools Act 2026, the government introduced a duty on councils to consider whether care leavers aged up to 25 should receive “staying close” support and, where their welfare requires it, to offer that to them.
This will involve providing advice, information or representation to help care leavers find and keep suitable accommodation and to access services relating to health and wellbeing, relationships, education and training, employment and participating in society.
According to the DfE, this will constitute a “sharper version” and a national rollout of the existing Staying Close scheme for care leavers, which it funds in 47 of the 153 councils.
Though the duty will be implemented in spring 2029, the DfE said the national rollout would start this year, with £25m allocated to the scheme in 2026-27. This includes the £21.1m allocated to the 47 authorities already delivering Staying Close, suggesting there will only be limited funding for other councils this year.
The care leaver local offer
The 2026 act also introduces a duty on public organisations, such as NHS bodies, government departments and educational institutions, to promote opportunities for looked-after children and care leavers to enhance their wellbeing and employment prospects. This comes into force in autumn 2027.
From 30 September 2026, councils will come under a duty to publish their arrangements for supporting care leavers in their transition to adulthood and independent living.
DfE guidance, published recently, states that these “local offers” should “clearly explain the housing support available to care experienced young people and how they can access it”.
Councils should also set out details of what support is available to help care leavers develop and maintain relationships, including one-to-one mentoring or befriending support and help to reconnect with former carers or important adults.
Rollout of schemes to support relationships
At the same time, the DfE has allocated £8.4m from October 2026 to March 2028 to fund a national rollout of schemes, such as Lifelong Links, to support children in care and care leavers build and maintain relationships with important people in their lives.
The department also plans to introduce a measure in relation to enduring relationships against which local authorities will be judged, and to make the issue a focus of Ofsted’s inspections of councils and social care providers.
In relation to PAs, the local offer guidance states their “interest should be in the overall wellbeing and development of the young person”, and they should be empowered to make care leavers “feel that they belong and are cared for and supported”.
However, in its response to the review into care leaver deaths, the DfE did not address its conclusions on the workforce or its call for a national review of staff skills and knowledge.
Source: Community Care
