Two years on from her death, what lessons have been learnt?
7 August 2023. Natasha Jade Ashby, known as Tasha, was found lifeless in a tent at Hereford Bus Station, where she’d been living for months, despite being a vulnerable care leaver in the care of Herefordshire Council.
Herefordshire Council were not sufficiently alarmed by her death aged just 21 to trigger a serious case review. It’s not the first time a vulnerable care leaver has died in a tent in Hereford so perhaps the Herefordshire Safeguarding Partnership thought this was pretty run of the mill stuff for Herefordshire.
There was no sign of any independent review until after the first hearing at the Coroner’s Court in November 2024. At this hearing the family’s barrister pointed out the catalogue of safeguarding referrals made in the run up to Tasha’s death, and the coroner broadened the scope of the inquest to include questions about whether Herefordshire Council had failed to safeguard Tasha. 10 days have now been set aside for the full inquest in March 2026.
With egg on their faces, the Herefordshire Safeguarding Partnership (HSP) somewhat belatedly announced there would be an independent review into Tasha’s death. The family were notified of this in February 2025. They were reassured that they would be kept informed about the review’s progress and invited to participate. It’s now August 2025, and on the eve of the second anniversary of their child’s death, the family are still waiting to hear anything further.
At the pre-inquest hearing in June 2025, the coroner asked Herefordshire Council’s barrister for an update on the progress of the promised independent review. The Council’s barrister seemed a bit befuddled by the question, then suggested that this might be the “Ingram” review. When asked by the coroner to say more, he couldn’t give much detail and said he thought the Ingram review was an independent investigation into Tasha’s case and some other cases. The coroner asked for clarification to be provided. Shortly after the hearing, the family’s solicitor received confirmation that it was not the “Ingram” review but the “Ingson” review. There was no further information.
In the absence of meaningful communication from the Council about the “Ingson” review, a family friend put in a Freedom of Information request. It revealed that as of 11th July 2025 there was no Ingson review. (see Appendix 1).
It is cruel to promise a grieving family an independent review, and then not to deliver on that promise in a timely fashion. But it would be a relief if Susan Teresa Ingram, director of Ingson Ltd, has not been chosen to run the independent review into Tasha’s death. She may be a capable woman, but there are serious question marks about how independent she could be in this case. The first two testimonials on her company website reveal a closeness of connection to those in senior positions at Herefordshire Council which would be alarming if she were appointed.
As of 5 August 2025, the first testimonial on her website is from Eleanor Brazil, the Children’s Commissioner for Herefordshire from Sept 2022 to Dec 2024. The second testimonial is from Gladys Rhodes White, the Improvement Adviser to Herefordshire Council from April 2021 to Mar 2024. (see Appendix 2). Both Eleanor Brazil and Glady Rhodes White were in post advising Herefordshire Council when Tasha died. Their actions and inactions should be part of any independent review. Gladys Rhodes White was already in post in March 2022 when a report was published into the premature deaths of six other vulnerable adults. There were 12 clear recommendations for action to prevent future avoidable deaths. How vigorously did Gladys Rhodes White and Eleanor Brazil pursue the implementation of those recommendations? That is a relevant question which needs to be looked at.
One of the reasons why Herefordshire Children’s Services has been mired for so long in failure and scandal is that it routinely dodges proper external scrutiny and prefers to mark its own homework or pay trusted consultants to mark its homework. If the family are to have any faith in the independent review into their child’s death they should be consulted about who undertakes the review.
Clarity about the independent review is needed in the first instance for the family, but also for the public watching more chaos unfold. Is there to be a review or not? Why was a review only called after the first hearing with the coroner? Why has there been a further six month delay since the review was announced? Why the confusion over Ingram and Ingson? Who has been appointed to do the review? How independent are they? Has the review started? What will be the scope of the review? What does participation in this review look like for the family?
The confusion and the delays are unforgivable. This council talks about dealing with families in a trauma informed way but it still repeatedly compounds the trauma of families with what looks like callous indifference or casual incompetence.
It’s two years since Tasha died. There is no evidence that lessons have been learned by Herefordshire Council from her case. The family want and deserve answers. They want to know what really happened in their daughter’s case, but they also want to ensure that no more young lives are needlessly wasted.
Six weeks before Tasha died, the coroner issued a prevention of future deaths notice in connection with the death of a homeless care leaver who died in a tent in Hereford. When lessons are not learned, history repeats itself. How long do the people of Herefordshire need to wait for change? How many more avoidable deaths are there going to be?
Appendix 1
Can you please confirm when the "Ingson" Review started?
Answer: This was not a review but a Management Development Programme for Permanent and Aspiring Managers as part of our first Phase Improvement Plan, alongside the work undertaken with Leeds City Council our Improvement Partner. This programme was undertaken from April 23- November 2023. The programme included direct observations of managers undertaking key tasks e.g. supervision, strategy discussions, or any other suitable meetings. Feedback via 1:1 mentoring meetings to enable managers to learn, reflect and grow.
This training was over 5 months to enhance and develop skills of the management group in supporting staff in front line practice.
The developmental workshops provide an opportunity for TMs to refresh and improve their knowledge and skills in various areas including :
(1) Managing Expectations and Confident Decision Making.
(2) Management Styles (Situational Leadership Based).
(3) Assuring Best Practice
(4) A Collaborative Evaluation
(5) Supervision and Managing Poor Performance
(6) Confident Presentation Skills.
(7) Strategic Thinking and the Management of Change.
(8) Effective Report Writing.
Can you confirm who is undertaking the review and the purpose of the review?
Answer: This is not a current piece of work and was part of our Initial Improvement Plan. There is more information on the purpose of this work above.
Appendix 2
https://ingson.co.uk/testimonials/
Eleanor Brazil
Former DCS and current DfE Children's Services Commissioner
I have worked with INGSON in a number of authorities during quite challenging times, including Dudley, Lambeth and Stoke on Trent. Their absolute focus on improving the quality of social work practice to secure better outcomes for children has without doubt helped front-line staff and managers to make significant improvements. They help practitioners understand what needs to change and to benefit from their support to help them do so. Both John and Suzi bring extensive knowledge and experience, and use that in a positive and enabling way. They provide continuous analysis and feedback to senior managers to help inform them on wider changes needed to enable practice to improve. I am always happy to recommend them.
Gladys Rhodes White OBE
Director of Children
As an experienced Director of Children (DCS), I have worked in a number of Authorities ranging from those rated ‘Inadequate Ofsted’ to ‘Outstanding’. This has involved working with many consultants and improvement partners. It is refreshing to come across people like Suzi and John (INGSON) who deliver consultancy services that are of the highest quality. They work well as a team and offer advice, support, and practical solutions to a range of social care challenges.
I worked with INGSON on a project in an Authority that was subject to a statutory notice to improve. They helped to design an innovative, bespoke programme of improvement involving front-line social workers and managers. It was a huge task that required clear planning, well-orchestrated interventions and effective communication with front-line staff, senior managers and external scrutineers. The programme was intensive and required INGSON to audit, quality assure, assess, and coach social workers to deliver good quality case work and supervision on a monthly scrutinised programme of intense improvement. They developed constructive working relationships to help staff to understand what ‘good’ looks like and how to achieve it, either as a front-line practitioner or a manager. In addition to individual and team coaching they provided examples of best practice, training videos and expertise on what constitutes good and outstanding work with children and families.
INGSON’s approach is methodical and reliable, but they are also flexible and responsive to changing requirements and demands. I found them an absolute pleasure to work with. They demonstrated a real empathy for workers and children and families – wanting the best outcomes for the staff and the children. Their passion for good social work is at the heart of what they do. I can highly recommend them.