Coroner warns about lack of national safeguarding guidance after pupil, 16, who died when struck by lorry was 'struggling' at £50,000-a-year boarding school

A coroner has warned about the lack of national safeguarding guidance after a 'kind and generous' pupil at a £50,000-a-year boarding school was hit by a lorry the day before she was due to return for a new term. Georgia Scarff, 16, was worried about her academic performance in her upcoming GCSEs as well as her future plans, a three-day inquest heard last week. The 'compassionate' teenager had been placed on a watchlist at the exclusive Royal Hospital School (RHS) in Holbrook, Suffolk, due to the death of her father. The family had moved to Bury St Edmunds from Shelland, near Stowmarket, in 2010 following Mr Scarff's death, the inquest was told. Georgia joined Royal Hospital School, which was founded by Royal Charter in 1712, in 2022 when she entered Year 10 and boarded there. Three-night boarding at the 200-acre campus currently costs £39,735, while weekly boarding is £45,774 and full boarding is £49,851. Her mother, Jennifer Scarff, said her daughter complained about boarding and in Year 11 began suffering panic attacks and saw the school nurse, followed by three sessions with the school counsellor.She later changed from boarding three nights a week to five, which senior staff interpreted as a sign she was coping with school life. Georgia Scarff, 16, was described by her family as a 'keen sports person, excelling in hockey, tchoukball, fitness training and more recently rugby' The teenager died after being hit by a lorry on the A14 near her home in Bury St Edmunds, Suffolk, the night before she was due to return to historic Royal Hospital School in Holbrook for the start of the summer term when she was due to sit her GCSEsBut the inquest heard Mrs Scarff was woken by a phone call from Georgia at 1.20am on April 15, 2024, the day she was due to return to Holbrook for the summer term. Mrs Scarff then called 999.Just 40 minutes later, she learned that Georgia had died on the westbound section of the A14 dual carriageway after being hit by a truck a short distance from her home. The inquest heard her anxiety led her to act impulsively in taking her own life. Her cause of death was recorded as a severe head injury sustained in a traffic collision.A senior coroner has now published a prevention of future deaths report where he warned about the lack of a universal guidance system for students and staff who move schools. He also noted that not all staff at RHS were proficient in using their child protection software and that some information about Georgia was missing from her records. During the inquest at Suffolk coroner's court, Georgia was described by her family as a 'caring, compassionate, thoughtful, kind and generous person who exuded warmth and a self-assured charisma'.She was called a 'private person whose company was uplifting' and had a 'genuine desire to see the lives of those around her enhanced'.Mrs Scarff told the inquest her daughter had been 'my best friend, my right-hand woman, my little helper and comforter'. She added Georgia was 'wise beyond her years' and 'gave off a very tough and resilient persona'. The teenager was weeks away from sitting her GCSEs, was on her way to completing her Duke of Edinburgh Gold Award before she diedThe teenager excelled in sport, including hockey and rugby, and was on her way to completing her Duke of Edinburgh Gold Award.But she developed anxiety during her GCSE year and confided her concerns to her mother, who sought assistance from the school. Mrs Scarff wrote to her form tutor, Tereza Shopova Mireva, in January 2024, saying that Georgia was suffering from anxiety which left her feeling sick and made it difficult for her to board, the inquest was told.She included comments her daughter had made, including 'How will I cope with the bigger stresses of life?' and 'My friends at school are not my best friends. No-one is really close to me'.But Ms Shopova Mireva said it wasn't enough for her to raise formal safeguarding concerns as lots of children suffered anxiety in their GCSE year.She also didn't raise the matter with Georgia, telling the inquest: 'I did not necessarily feel that is my expertise. I suggested they go to the health centre.'Ms Shopova Mireva added: 'It's quite common for GCSE students to feel physically sick because of the exams, especially with students with a hard-working profile because they want to do well.'The school arranged for Georgia to receive counselling and at the time of her death on April 15, 2024, she had been to three sessions.On April 14, the last day of the Easter holidays, she returned to her bedroom with the expectation that she would return to Holbrook the following morning. Family members said she appeared relaxed and to have had 'an enjoyable break'.At some point between 10pm and 1.20am the following morning, Georgia left home and walked around Bury St Edmunds.She sent several messages to her mother and sister expressing thoughts of a concerning nature. At around 1.30am, she stepped into the path of a lorry driving westbound on the A14 which caused her immediate death.A subsequent police investigation established that no defect with the lorry or conduct on the part of the driver were causative of Georgia's death.Area Coroner for Suffolk Darren Stewart has now raised concerns that not all staff at the school were proficient in using their Child Protection Online Management System. This led to important information not being noted in Georgia's school records. She attended Royal Hospital School in Holbrook, Suffolk, which was founded in 1712 and where full-time boarders pay £49,851 Georgia seen playing tchoukball, an indoor team sport, played with a ball by teams of 7 playersMr Stewart said: 'During the course of the Inquest the Court heard evidence of national statutory guidance to schools in relation to safeguarding of children in the form of the DfE document 'Keeping children safe in education 2025, Statutory guidance for schools and colleges' dated September 2025.'This statutory guidance includes reference to record keeping and information sharing. However, the Court also heard evidence that there is no single standard safeguarding information management tool for schools and colleges.'Teachers moving between schools and colleges must familiarise themselves with different processes and tools depending on that used by an individual school or college.'I am concerned that the absence of a single standard safeguarding information management tool for schools and colleges may result in a risk to life due to teachers being unfamiliar with different management tools and as a consequence important information relating to safeguarding not being recorded in children's safeguarding records.'Mr Stewart sent the report to the headmaster of Royal Hospital School and the Secretary of State for Education.A spokesperson for Royal Hospital School said: 'I would like to express, on behalf of the Royal Hospital School (RHS), our deep condolences to Georgia's family. 'Our community remain saddened by her loss.'As part of our ongoing development of safeguarding practice, a number of changes were implemented in the period between Georgia's death and the inquest.'RHS is fully committed to maintaining a safeguarding culture in which information is recorded accurately and consistently, and in which all staff understand the importance of effective documentation in keeping pupils safe.'A Department for Education spokesperson said: 'I was deeply saddened to learn of Georgia's death and would like to offer my heartfelt sympathy to her family and friends. Whilst we agree that information sharing needs to be improved, we do not think this is best achieved through the creation of a national system or database.'Notable alumni at the Holbrook school, which is nicknamed 'The Cradle of the Navy', include Antarctic explorer Ernest Joyce (1875–1940), a member of Sir Ernest Shackleton's ill-fated Imperial Trans-Antarctic Expedition and John Deane (1800–1884) and Charles Deane, who discovered the wreck of the Mary Rose in 1839.Among other notable alumni are Admiral Arthur Phillip (1738–1814), founder of Sydney, Australia and the Governor of the first European colony on the continent, and marksman Malcolm Cooper (1947–2001), who won Olympic gold medals at Los Angeles and Seoul and beat or equalled 15 world records.For confidential support, call Samaritans on 116 123, visit samaritans.org.