The death of Jordan Burling shook the nation when a court found his mother, Dawn Cranston, and grandmother, Denise Cranston, guilty of manslaughter two years after paramedics found the 18-year-old's emaciated body on a mattress in his living room at their home in Farnley, weighing less than six stone back in June 2016. His sister Abigail Burling, aged 25 at the 2018 trial, was cleared of manslaughter but found guilty of causing or enabling the death of a vulnerable adult.
An independent review has now found that no council or health agencies were directly involved in his death, but added authorities should "urgently" be given more powers to scrutinise home education settings, warning that some not attending school could be at risk of becoming "isolated".
The report paints a grim picture of the life of Jordan, referred to as "Jake" in the report, in the years up to his death, adding that his neighbours barely saw him outside the house since his younger years.
It stated: "Although there had been a number of concerns about his welfare during his early years, and a series of referrals, assessments and interventions, he had been almost invisible as a young man growing up in Leeds, with limited contacts and opportunities beyond his immediate family after he finished primary education.
"[He] had no identifiable experience of social life outside his family or of employment or training after the age of 11 when he was educated at home.
"His opportunities appeared to have been extremely limited."
The report continued to outline early developmental problems with Jake, as well as an unwillingness from his immediate family to engage with health professionals and social services.
An elective home education visit by Leeds City Council when Jake was still of school age stated that he often worked from a laptop balanced on his knees, and that it was not clear if he had a private place to study or anywhere to keep books.
Today's report stated: "Within the limited remit to monitor and enforce standards within home education, it is clear that the EHE officers continued to have some doubts about the efficacy and appropriateness of the schooling that Jake was receiving over this period of three years.
"They continued to recommend that Jake should return to school. It was recorded that the skills required for Jake to sit GCSEs and progress to college had not been developed by the time of the March 2012 visit."
One of the council's EHE managers commented in March 2012: "There was a long way to travel between the armchair and further education college. The opportunity to do this was explored – I gave the example of getting a Saturday job, to meet new people and develop new skills."
Jake did not do this and was not apparently encouraged by this family to do so.
In a section of the report looking into the care he received up until his death, it stated: "Although a degree of self‐neglect cannot be ruled out, there is no apparent reason why Jake should have chosen to starve himself. His period of homeschooling had perhaps intensified his dependence on his mother and had left him emotionally and physiologically ill equipped for adulthood.
"This built on the experience of his early years when he had significant developmental needs, difficulty in integrating into school and persistent health and hygiene concerns.
"There are few occasions when his voice, wishes and feelings can be established – they are consistently brokered through the perspectives and concerns of his mother and family."
In a section of the report looking at "learning points" and "agency-specific learning", it called on several health, education and social work agencies should have looked into to Jake's case further at the time.
Under the section referring to Leeds City Council's Children's Social Work service, it stated that a lack of specific protection concerns when he and his sister went to live with their grandma led to social services deciding there was no reason for further involvement.
The report's author added: "I believe that this did not help a comprehensive evaluation of the cumulative and persistent risks of neglect for Jake and (his sister), shared by all the agencies working with the family.
"When assessments were completed, they relied on the self‐reporting of Daphne (his mother) and Dorothy (grandmother), they focused in working with Daphne to improve her parenting but in reality she was not able to maintain improvement, and to provide consistent care and to actually complete the tasks that had been agreed.
"There was a lack of challenge or follow‐up as to assess how things had actually changed for Jake and Annie. There is little evidence of the children’s own voices in the recording available to this review.
"There was a worrying picture of neglect and delayed development for Jake which would now result in a better co-ordinated early help offer, building on the positive work that the school undertook."
The report went on to state that school nursing was currently "reviewing the support" it offered to homeschooled children, adding that there is a "need to establish how all agencies ensure that these children remain visible to services".
On homeschooling generally, the report stated that his mother felt it was unfair that she got no financial support from the council to help with Jake's schooling, and that she had to pay for his exams.
It added: "This case illustrates the rudimentary nature of the scrutiny available for supporting homeschooling through national policy and guidance, and how as a result young people can be at risk of becoming isolated from the services and support they may require."
Following the report's publication, James Rogers, chairman of the Safer Leeds executive, said: “Due to the tragic, complex and disturbing context of Jordan’s death, a Joint Statutory Review (JSR) was commissioned on behalf of Safer Leeds, Leeds Safeguarding Children Partnership and Leeds Safeguarding Adults Board.
“Extensive work has taken place to identify where improvements could be made, address the question of how Jordan could have died in such distressing circumstances and what, if anything, could be done by agencies in Leeds to prevent such an outcome in the future.
“The independent review concluded that no agencies or practitioners in Leeds had any direct involvement in the circumstances surrounding Jordan’s death or were responsible in any way for the treatment he received from his family.
“However, there were several occurrences in Jordan’s life where, if they were to be repeated today, interventions and outcomes would almost certainly be different because of changing and constantly improving practices in Leeds.
“The council, along with its partner agencies, remains committed to continually auditing, updating and improving policies to ensure the safeguarding of children, young people and vulnerable adults, and minimise the potential for a tragedy like this to be repeated.”
At the trial, a nurse described ulcers on Jordan Burling's body as the worse she had ever seen, and his condition was described as being akin to a concentration camp victim.