Themes | Child Protection & Education | The Accountability Index

Care leaver transition to adult services

High number of deaths among care leavers highlighting poor transition coordination from children's social care to adult services.

457 items 18 sources 2 inquiries
Source spread

Where this theme appears

This theme appears across 18 independent accountability sources, so the source mix matters as much as the headline total.

3 inquiry recs 15 PFD reports 57 committee recs 14 HSSIB recs 3 CQC actions 2 ICIBI recs 2 PPO recs 44 IMB recs 11 IMB reports 32 DHR recs 2 PHSO decisions 207 LGO/SPSO decisions 1 CJINI report

Browse by source

Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.

18 sources
Inquiry recommendations(3)
WATE-(38) — Extend local authority duty to provide parental-level support for care leavers
Waterhouse Inquiry
Recommendation: The duty upon local authorities under section 24(1) of the Children Act 1989 to advise, assist and befriend a child with a view to promoting his welfare when he ceases to be looked after by them should be extended so …
Unknown
WATE-(37) — Prepare and periodically review leaving care plans for all looked after children
Waterhouse Inquiry
Recommendation: A leaving care plan should be prepared for each looked after child, in consultation with that child, a year in advance of the event and should be reviewed periodically thereafter until the child ceases to require or be eligible for …
Unknown
SP49 — Audit of Young Adults Team transition assessments
Southport Inquiry
Recommendation: Lancashire County Council, with the Care Quality Commission, should commission an independent audit of the Young Adults Team to ensure assessments for transition to adult care are timely, properly reasoned and take full account of the individual’s history. This should …

Words of: HM Government, Government Response to Phase 1 of the Southport Inquiry (CP 1623), presented to Parliament by the Home Secretary, 2 July 2026

Gov response: There are a further 27 recommendations that require delivery by organisations that sit outside central government. The government has written to all national, regional and local organisations responsible for delivering recommendations to highlight the findings …
Accepted
Prevention of Future Deaths reports(15)
Ryan Chapman
31 Jan 2014 · West Sussex
Concerns: The coroner identified staff's lack of understanding regarding the patient leave policy and the role of support workers as escorts. Concerns were also raised about overdue risk assessments, insufficient information provided to families, and inconsistent visitor security on the ward.
Overdue
Derrick Plater
21 Mar 2014 · Norfolk
Concerns: The coroner raised concerns that care home visits were not standard practice before placing individuals with complex needs, relying instead on the home's assurances. There was also uncertainty regarding guidelines or protocols for undertaking such visits during the assessment and placement process.
Response: • The organisation stated that a pre-placement visit by a social worker would not be introduced as part of the assessment and placement process. • It explained that social workers … (AI summary)
Responded
Sean Morley
24 Mar 2014 · Warwickshire
Concerns: The coroner noted concerns regarding the A444, where pedestrians and cyclists frequently use the carriageway verge, yet there are no warning signs, street lights, or protective barriers despite a 70mph speed limit. This situation poses a risk of further fatal collisions.
Response (Warwickshire County Council): • A CCTV survey was commissioned to determine pedestrian and cyclist use, with analysis of the footage pending. • A feasibility study will be carried out to investigate introducing a … (AI summary)
Responded
Elaine Giles
05 Dec 2014 · South Lincolnshire
Concerns: The coroner raises concerns regarding the need for detailed assessments of a patient's functional performance in their home circumstances post-discharge and the importance of adequate home support.
Overdue
Lee Boden
29 Sep 2015 · Milton Keynes
Concerns: The coroner raised concerns that the deceased was not informed of his placement until the day before release, which may have increased his risk of drug use. There was also no protocol for continuing monitoring of vulnerable new arrivals at the hostel, leading to a significant delay in his discovery.
Response (HM Prison and Probation Service): • The service stated it would address timeliness in developing release plans and ensuring service users are informed of changes with managers and staff. • The service stated it would … (AI summary)
Responded
Amy El-Keria
03 Oct 2016 · East Sussex
Concerns: Hounslow Social Services had a misapprehension regarding their ongoing welfare role for a child placed at a facility. They also did not assess the need for support regarding family contact, despite the mother raising difficulties.
Response (Department of Health and Social Care): • NHS England commissioned guidance on staffing for mental health care, with completion expected by December 2017. • An additional 56 CAMHS inpatient beds have been commissioned, and £400 million … (AI summary)
Response (Department of Health): • NHS England and Health Education England are working to improve the capacity and capability of the workforce delivering mental health care for children and young people. • This work … (AI summary)
Response (London Borough of Hounslow): • The London Borough of Hounslow re-drafted and updated its Thresholds Guidance & Assessment Protocols. • The updated protocols include specific references to local authority duties for children placed away … (AI summary)
Response (Priory Group): • An enhanced Risk Assessment Tool was launched on 28 November 2016, and staff briefings on its use are underway. • Observation recording forms have been enhanced, and the policy … (AI summary)
Response (Priory Group): • An enhanced Risk Assessment Tool was launched on 28 November 2016, and staff briefings on its use are underway. • Observation recording forms have been enhanced, and the policy … (AI summary)
Responded
John Jaundoo
29 Mar 2017 · Liverpool and Wirral
Concerns: The Probation Trust placed high-risk offenders in unsuitable supported living accommodation, lacked dynamic risk assessments, and did not provide timely information. Liverpool City Council missed opportunities for oversight and validation visits of the accommodation provider and the Probation Trust.
Overdue
Owen Williams
25 Jul 2019 · West Yorkshire (West)
Concerns: The coroner raises concerns about the absence of a national agreement on A-level results release timing, which can lead to delays between students receiving electronic results and support, and a lack of communication with parents about the process.
Response (Department for Education): • The Department for Education will jointly host a roundtable with UCAS and other education sector organisations to agree on support for students receiving exam results. • The Joint Council … (AI summary)
Response (UCAS): • UCAS contacted the Department for Education (DfE) and the Joint Council for Qualifications (JCQ) to discuss concerns regarding the time students access results and inconsistencies in approach. • UCAS … (AI summary)
Overdue
Miriam Smith-Cox
24 Jul 2015 · Cornwall and the Isles of Scilly
Concerns: The coroner noted that a safeguarding concern regarding Ms Smith-Cox's accommodation and living conditions was raised, but the support stakeholder did not receive or act upon it prior to her death.
Response (PLUSS): • The organisation stated it would reinforce understanding of the Safeguarding policy and responsibilities. • The organisation stated it would conduct additional Safeguarding, Alerters, and Lone Working training for the … (AI summary)
Response (the Department of Work and Pensions): • The Department of Work and Pensions stated it had prepared and enclosed its response to the Prevention of Future Deaths Report. (AI summary)
Responded
Marshall Metcalfe and Jane Ireland
25 Nov 2021 · Blackpool & Fylde
Concerns: The coroner raises concerns about Children's Social Care closing cases for young people during mental health inpatient admissions, leading to a lack of social worker input into discharge planning, which may impede therapeutic relationships and increase risks post-discharge.
Overdue
Samuel Pearson
10 Nov 2022 · South London
Concerns: The coroner noted a lack of multi-agency working and information sharing during an emergency housing move, and a 2-3 week backlog in an NHS referral service where GPs were not informed of capacity issues.
Response (Oxleas NHS Foundation Trust): • The Trust completed an updated ADAPT Operational Policy. • The new policy details the information referrers will receive regarding waiting times and urgent referral procedures. • All teams maintain … (AI summary)
Response (Response London Borough of Bromley Council): • The Local Authority's Housing Department senior management contacted Clarion to request a review of their Emergency Decant Policy regarding notification of vulnerable household members. • The Local Authority provided … (AI summary)
Response (Clarion Housing Group): • Clarion Housing Group is reviewing its alternative accommodation and related assessment process. • The review is considering how interagency working can be further embedded into processes for providing alternative … (AI summary)
Responded
Lance Walker
19 Jan 2023 · West London
Concerns: The coroner raised concerns about the lack of regulation for supported accommodation for 18-21 year olds, which means some providers lack adequate training and resources for complex needs. Additionally, there is no standard referral form for 16-25 year olds entering supported housing, which can lead to vital information being missed.
Overdue
Jake Baker
08 Feb 2024 · Surrey
Concerns: Surrey County Council has not rigorously reviewed the death, with the coroner identifying ongoing gaps in care leaver support processes, adviser training, and risk assessment protocols. Concerns also relate to opaque processes for obtaining diagnoses and accessing adult social care.
Response (CQC): • CQC has commenced an assessment process for Surrey County Council, sharing the PFD report's concerns with its local authority assessment team. • CQC successfully prosecuted Transform Residential Limited for … (AI summary)
Response (Surrey County Council): • Surrey County Council is developing a Multi-Agency Transition Protocol to provide direction to frontline staff on steps to take when a person's diagnosis is unclear. • A pilot is … (AI summary)
Responded
Barrie Forster
05 Nov 2024 · Cornwall and the Isles of Scilly
Concerns: The coroner identified a lack of suitable accommodation for prisoners released from custody, including Approved Premises and local authority housing, which can lead to homelessness or unsuitable placements and increased difficulties in supervision.
Response (HMPPS MOJ and MHCLG): • His Majesty’s Prison & Probation Service operates a three-tier Community Accommodation Service (CAS) and has expanded Approved Premises and CAS2 bed spaces. • Homelessness Prevention Teams and Strategic Housing … (AI summary)
Responded
Caroline and Bernard Cleall
09 May 2025 · South London
Concerns: LB Croydon Adult Social Care could not access NHS LIFE team assessment records, including documented risk assessments and telecare advice from hospital discharge, hindering proper review of clients' post-discharge needs.
Response (London Borough of Croydon): • The client record system has been updated so all assessments are completed within the main body of the system, rather than as attached documents. • Careline service procedures have … (AI summary)
Responded
Select committee recommendations(57)— showing 50 strongest matches
#136 —
Justice and Home Affairs Committee
Recommendation: However, maturation continues past the age of 18. Justin Russell explained that “there is evidence that the full maturation process does not happen until you are 25”. 255 Carrie Peters, as a practitioner, confirmed that “because of brain development and …
Response attribution not verified
#135 —
Justice and Home Affairs Committee
Recommendation: We heard about the transition from Youth Offending Services to the adult Probation Service. Currently, “Youth Offending Services stop supervision at 18, and there is effectively a cliff edge where children go from quite a personalised service, with speech and …
Response attribution not verified
#105 —
Justice and Home Affairs Committee
Recommendation: Witnesses told us about the “multiple and complex needs” of ‘prolific’ offenders. 193 For instance, Rebecca Robson told us that “mental health problems are very common in what we call prolific offenders, together with poor experiences of the education system …
Response attribution not verified
#1 —
Public Services Committee
Recommendation: It is vital that services supporting young disabled people are co-produced with those young people, and with disabled people who have already experienced the transition out of education—regardless of whether they have been able to move into work.
Response attribution not verified
#57 —
Human Rights (Joint Committee)
Recommendation: Children in care and those with care experience are particularly vulnerable to financial instability and legal aid is crucial to allow them access to justice. The Government must urgently act to increase provision in legal aid deserts. Where legal aid …
Response status not verified
#50 —
Human Rights (Joint Committee)
Recommendation: As a first step to address the complexity of the complaints system, the government must work with children, care leavers, their families, local authorities, the Children’s Commissioner, the Local Government and Social Care Ombudsman, and other relevant stakeholders to raise …
Response status not verified
#49 —
Human Rights (Joint Committee)
Recommendation: People in care, their carers, care leavers, and people receiving support from the children’s social care system often find it difficult or do not know how to secure legal advice and advocacy services, and they are often afraid of retaliation …
Response status not verified
#47 —
Human Rights (Joint Committee)
Recommendation: The government must urgently explore concrete options for addressing discrimination against people with care experience, including the provision of human rights training to those involved in providing public services, with a particular focus on tackling discrimination, as well as improvements …
Response status not verified
#46 —
Human Rights (Joint Committee)
Recommendation: Many stakeholders have told us about the discrimination that people with care experience face once they leave care. We heard this testimony with deep concern. Although there would be potential merits in recognising care experience as a protected characteristic in …
Response status not verified
#45 —
Human Rights (Joint Committee)
Recommendation: We heard first-hand testimony about the difference that the Archway Hub has made in the lives of care leavers in Leeds. The government should consider working with local authorities to expand Care Leaver Services across England, so that care leavers …
Response status not verified
#44 —
Human Rights (Joint Committee)
Recommendation: In addition to such changes, the government should introduce a discretion to extend support past age-based cut off points in circumstances where the needs of an individual require it to ensure a smooth transition into adulthood. In particular, targeted support …
Response status not verified
#43 —
Human Rights (Joint Committee)
Recommendation: Upon becoming adults, children leaving care face an abrupt “care cliff”, where support ends and relationships are lost. This can have severe and lasting consequences that affect young people with care experience into adulthood. We welcome the announced changes to …
Response status not verified
#19 —
Women and Equalities Committee
Recommendation: We welcome the focus on young people in the National Plan to End Homelessness, not least given the elevated risks young people can face through abuse, family breakdown and care leaving. Ensuring young people can get the right support at …
Response status not verified
#12 —
Health and Social Care Committee
Recommendation: NHS England & Improvement must accelerate the implementation of the 0–25 offer in every local area as a national priority so that young people do not continue to face a cliff edge in accessing the care they require as they …
Response attribution not verified
#11 —
Health and Social Care Committee
Recommendation: It is clear that young adults between the ages of 18 and 25 face some of the widest gaps between the support that they need and the support that is available to them. 56 Children and young people’s mental health …
Response attribution not verified
#28 —
Welsh Affairs Committee
Recommendation: Care-leavers are a vulnerable group and there is a strong case for arguing that they should have enhanced support. While the Welsh Government supports a basic income pilot for this group, we note that the UK government opposes universal basic …
Response attribution not verified
#6 — Care leavers experience a confusing patchwork of differing local authority entitlements.
Education Committee
Recommendation: Care leavers face a confusing patchwork of entitlements when they leave care. This is made more complex by the differing offers in each local authority and the fact that they are having to navigate this at a young age, often …
Response attribution not verified
#77 — Exempt care leavers from proposed Universal Credit reductions and prioritise Youth Guarantee access.
Education Committee
Recommendation: The Department for Work and Pensions must exempt care leavers from its proposed plans to reduce Universal Credit support for those aged under 22, if these reforms go ahead, and ensure that care leavers are prioritised for access to support …
Response attribution not verified
#76 — Improve financial and housing support for care leavers, including Universal Credit and bursaries.
Education Committee
Recommendation: The Department for Education should work with other relevant departments, including the Ministry of Housing, Communities and Local Government and the Department for Work and Pensions, to review the financial and housing support available to care leavers and improve it …
Response attribution not verified
#75 — Develop a National Care Offer ensuring minimum, harmonised support for care leavers nationwide.
Education Committee
Recommendation: As a priority, the Department for Education must develop a National Care Offer to harmonise the postcode lottery in entitlements and ensure that care leavers receive a minimum level of support, wherever they live. (Recommendation, Paragraph 194)
Response attribution not verified
#74 — Proposed Universal Credit reductions for under-22s will disproportionately impact care leavers.
Education Committee
Recommendation: We welcome the new Youth Guarantee and the focus on supporting young people to access employment, education and training. However, we are deeply concerned about the proposal to reduce support through Universal Credit for those aged under 22. This is …
Response attribution not verified
#73 — Care leavers face unacceptable financial hardship compromising their education upon turning 18.
Education Committee
Recommendation: It is unacceptable that young people are left to support themselves financially on turning 18 while still in full-time education and face having to reduce time spent in education or drop out completely to support themselves. No responsible parent would …
Response attribution not verified
#72 — Care leavers face poorest outcomes due to insufficient support and limited Bill measures.
Education Committee
Recommendation: Care leavers have some of the poorest outcomes in society across a range of measures, and the support available to them falls far short of what is needed. The state has a grave responsibility to the children it takes 93 …
Response attribution not verified
#52 — Develop a National Care Offer and transition strategy for care leavers entering further education.
Education Committee
Recommendation: As set out in our Children’s Social Care report, the Department for Education must develop a National Care Offer to harmonise the postcode lottery in entitlements and ensure that care leavers receive a minimum level of support, wherever they live. …
Response attribution not verified
#51 — Care leavers face significant challenges transitioning into further education, employment or training.
Education Committee
Recommendation: Care leavers face significant challenges transitioning into further education, employment or training. Care leavers aged 19–21 are three times more likely not to be in education, employment or training than their peers. There is insufficient support for those transitioning into …
Response attribution not verified
#9 — High number of care leaver deaths highlights poor transition coordination to adult services.
Public Accounts Committee
Recommendation: We asked the Department and other witnesses about the circumstances surrounding a young person recently taking their own life after turning 18 and facing the uncertainty of moving out of the children’s social care system. A situation which the Chief …
Response status not verified
#13 —
Women and Equalities Committee
Recommendation: In bringing forward the “duty to collaborate” the government should set out a clear ambition to tackle the poorer outcomes including increased risks of homelessness that minority ethnic groups experience in leaving the care of public services. The government should …
Response status not verified
#27 —
Justice and Home Affairs Committee
Recommendation: Age-appropriate solutions should be found to smooth the transition of those moving from Youth Offending Services to the adult Probation Service. These solutions should be made available to all young adults on probation . (Paragraph 149) Facilitating local delivery (paragraphs …
Response attribution not verified
#24 —
Justice and Home Affairs Committee
Recommendation: There is a ‘cliff edge’ in the response to offending when a young person transitions from Youth Justice Services to the adult Probation Service. Moving the age at which an offender undergoes this transition is unlikely, in itself, to bear …
Response attribution not verified
#14 —
Public Services Committee
Recommendation: Education, Health and Care Plans help young disabled people receive essential educational support and are fundamental to enabling many young disabled people to access employment programmes such as supported internships or more accessible apprenticeships. However, the current system does not …
Response attribution not verified
#18 —
Justice Committee
Recommendation: It is apparent that accommodation is a significant problem for some children being release from custody. It is unacceptable that a child should not know until the day of their release where they will live the day after. We agree …
Response attribution not verified
#23 —
Public Accounts Committee
Recommendation: The poor outcomes experienced by vulnerable adolescents are often overlapping. For example, we received written evidence highlighting research which shows people who have been in care are more likely to experience homelessness, long-term physical and 53 Q 39 54 C&AG’s …
Response attribution not verified
#14 —
Public Accounts Committee
Recommendation: At 31 March 2021, there were 53,790 adolescents in care between the ages of 9 and 17, making up 67% of the total care population. Between 31 March 2014 and 31 March 2021 the number of 9- to 17-year-olds in …
Response attribution not verified
#16 —
Public Accounts Committee
Recommendation: When we asked how hard it was for parents to navigate the legislation, Contact told us that it was a regular top topic on its helpline and that parents did not really know their rights. It explained that the system …
Response attribution not verified
#53 — Effective reunification with birth families positively supports children leaving care.
Education Committee
Recommendation: When done carefully and effectively, reunification of children with their birth families can be a positive way of supporting children to leave care. (Conclusion, Paragraph 132)
Response attribution not verified
#38 — Review educational support for adopted and previously looked-after children, including statutory framework.
Education Committee
Recommendation: The Department for Education should review the educational support available to adopted children, assessing the impact of the extension of policies to previously looked-after children and whether any further extensions are needed. This review should include: the introduction of a …
Response attribution not verified
#78 — Shortage of appropriate safe housing for trafficking victims, especially vulnerable children transitioning to adulthood.
Home Affairs Committee
Recommendation: There is a shortage of appropriate safe housing for victims of human trafficking whilst they are within the Modern Slavery Victim Care Contract. Accommodation provision varies significantly for children after referral to the National Referral Mechanism, and children are particularly …
Response attribution not verified
#16 —
Justice Committee
Recommendation: It is essential that children have access to appropriate Employment, Training and Education services when they leave custody, not least to reduce the risk and the rate of reoffending. The Ministry of Justice, Youth Custody Service and Youth Justice Board …
Response attribution not verified
#54 —
Education Committee
Recommendation: The Minister for Children and Families agrees that the Staying Close pilot has produced “very, very good evidence”. Without further delay, the Department must roll out Staying Close nationally as a statutory entitlement. Care leavers must have the right to …
Response attribution not verified
#53 —
Education Committee
Recommendation: The current lack of statutory support for young people leaving residential care is deeply unjust. The Department’s own evidence rightly acknowledges the “cliff- edge” transition from residential care to independent living at age 18. Staying Close offers a chance to …
Response attribution not verified
#52 —
Education Committee
Recommendation: Where a care leaver is over 25, and an apprenticeship would be their first qualification since leaving compulsory education, the Department must raise the age limit for receipt of the £1,000 apprenticeship bursary from age 25 to age 30. This …
Response attribution not verified
#51 —
Education Committee
Recommendation: Just 2% of care leavers go on to do an apprenticeship. To address this, the Department must strategically weigh the apprenticeship levy in favour of care-experienced young apprentices under age 25. Too much of the levy is going unspent, the …
Response attribution not verified
#50 —
Education Committee
Recommendation: Just 2% of care leavers go on to do an apprenticeship. The apprenticeship wage rate— £4.81 per hour for apprentices aged 16–18 or aged 19 and over and in the first year of their apprenticeship—is prohibitive for young care leavers …
Response attribution not verified
#49 —
Education Committee
Recommendation: The Government must expand existing the existing Civil Service care leaver internship scheme and other employment schemes, increasing the number of places so that more care leavers can take advantage of, and benefit from, these opportunities.
Response attribution not verified
#48 —
Education Committee
Recommendation: Careers and employability outcomes for care-experienced young people up to age 25 should be a core part of the Virtual School Head remit. Every Virtual School should have a designated careers lead whose function is to promote and support the …
Response attribution not verified
#47 —
Education Committee
Recommendation: The Department must publish education, employment and training outcomes data disaggregated by care placement type. The absence of disaggregated data is a barrier to scrutiny and accountability and hinders the development of targeted, evidence- based interventions.
Response attribution not verified
#46 —
Education Committee
Recommendation: 41% of care leavers aged 19–21 are not in education, employment or training, up from 39% in 2020. This is a shameful reflection of an education and careers system that routinely—and without consequences—fails far too many looked-after children. Too often, …
Response attribution not verified
#11 —
Education Committee
Recommendation: When rolled out nationally, post-16 Pupil Premium Plus funding must be calculated using the same funding formula as for the pre-16 cohort. Virtual School Heads must ensure Post-16 Pupil Premium Plus funding is used on specific, evidence- based interventions to …
Response attribution not verified
#16 —
Education Committee
Recommendation: The needs of looked-after pupils do not suddenly cease to exist when they turn
Response attribution not verified
#9 —
Education Committee
Recommendation: There is a cliff-edge in Pupil Premium Plus funding when a looked-after pupil turns
Response attribution not verified
HSSIB safety recommendations(14)
Transition from child and adolescent mental health services to adult mental health services
and develop and implement training packages for clinicians across the EU.
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
create clinical, organisational, policy and ethical guidelines for improving care and outcomes for transition-age youth;
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
develop and test, in a cluster-randomised trial, the clinical and cost-effectiveness of an innovative transitional care model;
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
conduct a longitudinal cohort study of transition process and outcomes across eight EU countries;
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
develop and validate transition-specific outcomes measures;
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
map current services and transitional policies across EU;
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
That NHS England and NHS Improvement work with commissioners and providers of mental health services to ensure that the care of a young person before, during and after transition is shared in line with best practice, including joint agency working.
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
It is recommended that NHS England, within the ‘Long-Term Plan’, requires services to move from aged-based transition criteria towards more flexible criteria based on an individual’s needs.
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
It is recommended that NHS England and NHS Improvement ensure that transition guidance, pathways or performance measures require structured conversations to take place with the young person transitioning to assess their readiness, develop their understanding of their condition and empower …
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
It is recommended that NHS England, within the ‘Long-Term Plan’, works with partners to identify and meet the needs of young adults who have mental health problems that require support but do not meet the current criteria for access to …
Safety Recommendation
Mental health inpatient settings
HSSIB recommends that NHS England provides guidance regarding communication of essential safety and risk mitigation information when patients transition from inpatient children and young people’s mental health services due to reaching transition age. This is to safeguard vulnerable people and …
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
It is recommended that the Care Quality Commission (CQC) extends the remit of its inspections to ensure that the whole care pathway, from child and adolescent mental health services to adult mental health services, is examined.
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
It is recommended that NHS England requires Clinical Commissioning Groups to demonstrate that the budget identified for current children and young people’s services – those delivering care up until the age of 18 – is spent only on this group.
Safety Recommendation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
HSSIB recommends that the Department of Health and Social Care works across government to identify opportunities to support closer cooperation between local government, education and health systems for the safe and effective transition of young people into adulthood. This is …
Safety Recommendation
NCEPOD recommendations(18)
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
CQC inspection actions(3)
ICIBI immigration recommendations(2)
PPO death in custody recommendations(2)
IMB annual reports(11)
Hull (2022)
This report for HMP Hull, ending February 2022, highlights a challenging period marked by the ongoing impact of Covid-19 restrictions, which limited IMB monitoring capacity and led to significant staff absences. While safety metrics showed reductions in violence, self-harm, and use of force, serious concerns remain regarding healthcare provision, which was deemed failing by HMIP and led to contract termination. Other critical issues include insufficient cell capacity, restricted key worker support, and ineffective resettlement pathways due to poor external agency communication.
PRISON Key concerns
Hewell (2022)
HMP Hewell, a Category B local prison, has shown continued progress in improving safety, cleanliness, and overall humane treatment. Positive developments include enhanced physical healthcare and the establishment of a mental health unit. However, the report highlights persistent challenges such as overcrowding, the poor physical condition of the estate, delays in court proceedings impacting remand prisoners, and slow implementation of a rehabilitative culture, alongside inadequate provision for prisoners with complex needs and disabilities.
PRISON Key concerns
Ford (2022)
HMP Ford is largely deemed a safe environment with fair and humane treatment, effective healthcare, and strong resettlement efforts. However, significant concerns remain regarding unsuitable prisoner arrivals, chronic understaffing in Probation, and a deteriorating prison estate, including outdated accommodation and delays in new builds. The Board also highlights issues with procurement, the lack of consistency in property rules nationally, and challenges in catering and post-release accommodation.
PRISON Key concerns
Guys Marsh (2022)
HMP Guys Marsh saw a return to a more normal regime after Covid restrictions, but persistent challenges remained, notably in staffing, safety, and healthcare provision. Violence, often driven by illicit substances, and the lack of effective key working were significant concerns. While some areas like the ISMS team and chaplaincy were commended, mental health services were hampered by the absence of a psychiatrist, and a death in custody highlighted communication and ACCT deficiencies. The Board also raised concerns about low attendance at purposeful activity, the condition of the estate's infrastructure, and the slow complaints process.
PRISON Key concerns
Hollesley Bay (2022)
Hollesley Bay is an open Category D YOI prison commend for its safe and humane treatment of prisoners, effective COVID-19 management, and progress in equality and resettlement. The introduction of the 'sequencing' regime has provided a more structured approach to learning and external employment. However, the report highlights concerns regarding the prevalence of multiple-occupancy cells, significant backlog in estate maintenance, and perceived inadequacy of food provision. Healthcare delivery is generally satisfactory, though high DNA rates for appointments due to communication issues and dental waiting times require attention.
PRISON Key concerns
High Down (2022)
HMP High Down transitioned to a Category C training and resettlement prison in 2022, implementing gradual regime changes that have positively impacted prisoner life, including improved time out of cell and new community units. The Board noted reductions in self-harm and assaults, and commended improvements in induction and the visits hall. However, significant concerns remain regarding the welfare of IPP prisoners, long delays in transferring mentally unwell individuals, and a high proportion of prisoners leaving without settled accommodation. Persistent issues with lost property, inconsistent key work, and a lack of high-quality employment opportunities continue to hinder effective resettlement and overall humane treatment.
PRISON Key concerns
Holme House (2022)
HMP Holme House demonstrated significant improvements in 2022, effectively recovering from Covid-19 disruptions and enhancing safety, healthcare, and resettlement services. While the prison maintained a safe and humane environment, key challenges included slow estate maintenance, deterioration in food quality, and the disproportionate impact of a growing young adult population on violence and self-harm. The IMB also highlighted issues with contractual transparency and the provision of adequate programs for vulnerable prisoners, making several recommendations to address these concerns.
PRISON Key concerns
Kirkham (2022)
HMP Kirkham, a Category D open prison, maintained a population of 470 against a capacity of 699 during 2022. The Board reported low levels of violence and no deaths in custody, commending staff efforts to re-establish a workable regime post-Covid. Key concerns included the persistent transfer of unsuitable prisoners, the urgent need for CCTV and in-cell technology upgrades, and the curtailment of prisoner activities due to staff redeployments. Despite challenges, 100% of prisoners were accommodated on release, and 62% secured employment.
PRISON Key concerns
East Sutton Park (2022)
This report for HMP East Sutton Park covers the period from November 2021 to October 2022. The Board finds the open women's prison to be largely safe and well-run, with good staff-resident relationships and effective resettlement efforts, particularly in securing external employment. Key concerns include the low population numbers hindering full use of capacity, residents arriving with insufficient time for resettlement, and the need to review fire evacuation procedures.
PRISON Key concerns
Drake Hall (2022)
Drake Hall generally provides a safe and humane environment, with commendable staff efforts and good healthcare provision. Key concerns persist regarding the unfit condition of two accommodation units, persistent issues with lost property on transfer, and challenges in education provision post-pandemic. The Board also highlights the difficulty in preparing women transferred close to their release dates for resettlement and issues with mental health staffing and low reporting of discrimination incidents.
PRISON Key concerns
Haverigg (2022)
HMP Haverigg, an open Category D prison, maintains a safe and settled environment with very low levels of self-harm and violence. Despite significant staffing challenges, particularly in healthcare and offender management, the Board notes improvements in OMU staffing and highly regarded healthcare provision. Key concerns include the ineffective management of transfers from closed estates, inconsistencies across prisons, the need for enhanced IPP prisoner support, and persistent issues with prisoner property and communication from offender managers.
PRISON Key concerns
IMB individual recommendations(44)
Feltham (2025)
What plans are in place to support 18-year-olds with complex needs who are released from a children’s prison, in terms of housing and probation support?
Other
Belmarsh (2021)
Will the prison appoint champions in each houseblock to be responsible for care leavers (see section 4.4 Safeguarding)?
Governor / Director
Wetherby (2025)
What specific actions and resources will be committed to ensure care leavers receive comprehensive support on release, including stable accommodation, access to education or employment and continuity of care, to prevent them from falling through the gaps?
Other
Werrington (2020)
What changes can be made to improve the young people’s life skills for discharge?
Governor / Director In Progress
Wetherby (2021)
Many young people already held at Wetherby who are aged 18+ continue to experience delay while waiting to transfer to the adult estate. It is unreasonable for young people to have to endure a lengthy wait while negotiations take place between establishments. These are frequently complex young people with challenging behaviour, many of whom face long sentences. The heightened anxiety …
HMPPS
Feltham (2021)
Young prisoners returning to the community need a coordinated approach to resettlement that integrates training, employment, and accommodation, as well as social and financial support. What will you put in place to achieve this?
Ministry of Justice In Progress
Cookham Wood (2022)
Transition of 18+ boys: Is there end-to-end sentence planning and support for these boys? Do they carry their sentence plan with them when they transition to a young adult institution? Or do they have to start afresh? What steps will be taken to arrange transfers to the adult estate for young adults who are aged 18+ and have long sentences …
HMPPS
Wetherby (2025)
What steps will the Youth Custody Service take to reduce delays and ensure a smooth, timely transition for young people moving from youth custody to the adult estate?
HMPPS
Wetherby (2025)
What mechanisms will be put in place to ensure local authorities are fully accountable for meeting their statutory duties toward young people in care - both during custody and on release - and what consequences will follow if these obligations are not met?
Other
Wetherby (2025)
What specific steps will the local authority take to guarantee that accommodation is secured and assigned well before release?
Other
Werrington (2020)
Why is there a delay in the transfer of 18 year olds and how can this be improved?
Other In Progress
Cookham Wood (2020)
The YCS should provide additional care plus end-to-end sentence planning and support for long-sentence boys - with regard to whether young adult institutions (specifically, Aylesbury, Deerbolt and Swinfen Hall) have the capacity to accept an increasing number of 18-year-olds transitioning from juvenile YOIs What steps will be taken to arrange transfers to the adult estate for young adults who are …
HMPPS In Progress
Cookham Wood (2020)
There have been several occasions when boys with long sentences, who have reached the age of 18 years, have remained at Cookham Wood for a period of months, instead of being moved to a YOI facility for 18–21-year-olds. This situation has been exacerbated when the boys have been kept in segregation for safety reasons. The delay in organising transfers to …
Ministry of Justice In Progress
Pentonville (2022)
Remanded prisoners are given few services to assist them with their release: given the big increase in the number of prisoners on remand, when will you address this critical gap in resettlement services?
Ministry of Justice
Feltham (2023)
What will the Government do to achieve better information sharing between Social Services and Youth Custody Services so that Looked After Children (LAC) can easily receive their statutory entitlements? Will you follow up on measures promised last year about how this can be addressed?
Other
Feltham (2024)
What will the Government do to improve information sharing between social services and the YCS so looked-after children (LACs) receive entitlements.
Ministry of Justice
Bronzefield (2024)
How does the Minister plan to improve ‘through the gate services’ to ensure that discharged prisoners are properly supported in the community? (7.5)
Ministry of Justice In Progress
Wetherby (2025)
What decisive actions will the Minister take to strengthen coordination and accountability between YOIs and partner agencies, such as immigration services, the adult estate and local authorities, to ensure a seamless and safe handover?
Ministry of Justice
New Hall (2025)
The continued development of appropriate support for vulnerable prisoners on release.
Governor / Director
Derwentside (2024)
To continue to improve pathways with local authorities and other external agencies, including probation, to enable prompt access to housing, social support and other services, which are required to be put in place before vulnerable women leave detention.
Home Office In Progress
Foston Hall (2021)
The IMB is concerned about: the increase in the number of prisoners being released without an address
Governor / Director In Progress
Drake Hall (2022)
Resettlement services operate in an increasingly demanding environment where policy changes have impacted differently in different areas served by the provision. The IMB looks forward to seeing evidence of the development of a more joined up approach to services provided to women as they leave prison (see section 7.5).
HMPPS
Foston Hall (2023)
How will you address the problem of prisoners being homelessness on release?
Governor / Director
Woodhill (2024)
Will the Minister work with Government departments to facilitate and provide appropriate training and resettlement for prisoners?
Ministry of Justice In Progress
Brixton (2025)
The decision to send to Brixton men with as little as 28 days left to serve impeded or negated a range of resettlement actions. Will the Prison Service take measures to avoid a repetition of this damage?
HMPPS In Progress
Belmarsh (2025)
Will the Governor continue with initiatives to provide improved conditions and opportunities for young adult prisoners, and to improve the orientation for young offenders, under 21, who are sent to HMP Belmarsh?
Governor / Director In Progress
Whatton (2020)
Will the Prison Service review, with other agencies, the timely notification of approved premises for released prisoners, to give them the best chance of resettlement and rehabilitation (see section 7.5)?
HMPPS In Progress
Wetherby (2020)
YP already held at Wetherby who are aged 18+ experience lengthy delays while waiting to transfer to the adult estate. Some improvement in the speed with which these YP were being transferred was seen during the latter stages of our reporting year, as a result of COVID-19. The Board wonders if this improvement will continue. It is unreasonable for YP …
HMPPS
Swansea (2021)
We would make a plea that this scheme [housing all rough sleepers during Covid-19] be continued for prisoners leaving custody without accommodation in future.
Other In Progress
Swaleside (2021)
Despite being quite low, the number of residents released directly into the community is rising. Those directly released deserve to have the appropriate help to achieve similar employment and accommodation opportunities afforded to those residents released from resettlement prisons. This does not happen. In our report last year, we mentioned that it is essential that residents are provided with resettlement …
HMPPS Partially Accepted
Exeter (2021)
Intensify efforts to support individuals who are at risk of homelessness on their release from prison and increase the level of expectations on local authorities and the Probation Service to improve accommodation outcomes (see 7.4).
Ministry of Justice
Rye Hill (2022)
The Board remains concerned that the stated preparation for release path of staged movements from category B to category C and then to a local or category D prison, as defined by HMPPS, represents a particular problem for prisoners convicted of sexual offences and frequently does not seem to happen in practice leaving them to be released from an establishment …
HMPPS In Progress
Wetherby (2023)
The Board remains concerned about those young people who are ‘looked after’ by the local authority and consider that they are frequently financially disadvantaged due to late payments or lack of financial support. How can this situation be improved?
Other
Exeter (2023)
Address the lack of accommodation available for some prisoners on their release from prison?
Ministry of Justice In Progress
Cookham Wood (2023)
When will local authorities improve their communications regarding accommodation to the boys in Cookham Wood?
Other
Wormwood Scrubs (2024)
What support can be provided to help remand prisoners with release planning?
Other In Progress
Styal (2024)
When will the RECONNECT service (care after custody service) be available for prisoners leaving Styal?
HMPPS Implemented
Bullingdon (2024)
How will the Minister work with others to find accommodation for men at risk of being homeless on their release from Bullingdon?
Ministry of Justice In Progress
Buckley Hall (2024)
The problems faced by men serving IPPs are still not being addressed. Can the money, which is used to keep them in prison, not be used to provide support, accommodation and employment on release. We have witnessed the upturn in a man’s chances of succeeding once he is released by the extensive work which was carried out here prior to …
Other In Progress
Bronzefield (2024)
How does the Minister plan to improve the support of prisoners released from court or at short notice, who are discharged without suitable accommodation? (7.5)
Ministry of Justice Implemented
Werrington (2025)
How will the induction programme be improved to ensure all young people understand how to access basic services within the first 24 hours?
Governor / Director
Eastwood Park (2021)
Will HMPPS confirm what actions they are taking to improve the accommodation options for women leaving prisons and when this is likely to have an impact on outcomes?
HMPPS In Progress
Bedford (2023)
We hope that there will be a strong and continued focus on making the young adults wing a success.
Governor / Director
Buckley Hall (2024)
The general lack of funding of HMPPS has led to a huge failing in preparing prisoners for release and their continued progress in society, which has far too often seen men returning to custody.
Other In Progress
Health investigations(17)
Independent investigation: Simon Widger, Eastbourne, Sussex (2000) — Rec 3
Young people should not be placed by Statutory Authorities to live in independent settings before the age of 16 and even when over 16 (up to the age of 18) only with an individually tailored care package.
south_east
Independent investigation: Kenneth Auger, Merthyr Tydfil (2008) — Rec 3.1d
Encourage carers, especially young carers, to engage and make contact with services including in transition planning when young people themselves become adults and move out of contact with children’s services. This process needs to be audited and reviewed to ensure its efficiency.
wales
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R31
The trust should continue to review how they could develop a service for the 16 to 25 age group which would overlap with CAMHS and adult services rather than be separate from them.
london
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.28
Resources linked to the Department of Health’s Quality Protects initiatives and to recent Care Leavers’ legislation should be used to ensure that appropriate educational opportunities and specialist mental health and drug and alcohol services are available for accommodated young people when planning for independence is underway.
north_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.22
Access to appropriate mental health services, including access to services for adults, should be integrated into Social Services’ leaving care policies and procedures.
north_west
Independent investigation: Eduardo Mendoza, Hammersmith (2007) — Rec R1
The trust should ensure that a transition policy providing guidance on the transition from local authority children‟s services to adult mental health services is produced and sent to all staff that need to know about it.
london
A post-publication assurance review in relation to the implementation of … — Rec A5
Referral between forensic CAMHS and adult forensic services needs to be streamlined. To be taken to the Business Delivery Group, Safety, for further discussion. Quality improvement meeting planned for 17.04.19.
north_east_yorkshire
A post-publication assurance review in relation to the implementation of … — Rec A4
The revised arrangements for transition between CAMHS (Children and Adolescent Mental Health Services) and ADHD (Attention Deficit Hyperactivity Disorder) Services should be audited within three months to ensure they are timely and effective.
north_east_yorkshire
Independent investigation into the care and treatment of Mrs A … — Rec 3
Royal Borough of Greenwich should update its 2015 Carers Policy to cover mental health and children in transition.
Mrs A and Miss B, published on 03 July 2019. Mrs A and Miss B was in receipt of services from Oxleas NHS Foundation Trust london
Independent investigation into the care and treatment of Mr N — Rec Regional recommendat
The North West London Integrated Care System to seek assurance that all planning for care leavers discharged from mental health in-patient services formally involves the relevant local authority. Furthermore, to seek assurance that the application of Section 117 Mental Health Act has been considered for patients who have been detained …
london
Independent investigation into the care and treatment of Mr N — Rec 9
The Trust must provide assurance that all transitions between services for children and young people are completed in line with NICE guidance on the Transition of children and young people.
london Accepted
Independent investigation into the care and treatment of Mr N — Rec 10
The Trust CAMHS to review its approach to transferring patients and to benchmark itself against the NICE guidance on the Transition of Children and Young People, to use the findings to develop a robust patient centred approach to transfer and discharge.
london Accepted
A system-wide independent investigation into concerns and issues raised relating … — Rec 5
TEWV, CNTW and System Partners need to seek assurance that they have resolved the problems associated with the clinical transitions phase (between services and child to adult). A compound recommendation is required to address this deficit: a) TEWV must provide assurance that a full gap analysis between the 2018 Healthcare …
CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust north_east_yorkshire
Independent investigation: Jean RobinsonDerek RobinsonKevin Molloy, Highgate/Tottenham (2004) — Rec 3.24.8
That transition procedures between CAMHS and adult services are reviewed and that care planning for that individual is jointly set between the two services.
london
*Independent investigation into the care and treatment of Patient I: … — Rec 6
It is recommended that the transition from child to adult health care should be set at the statutory school leaving age. School leaving age was 16. It is due to become age 17 in 2013 but will be at age 18 from the year 2015 onwards. Transition has been a …
Northumberland, Tyne and Wear NHS Foundation Trust north_east_yorkshire Not Accepted
Independent external quality assurance review following the independent investigation into … — Rec 22
Forward Thinking Birmingham, HMP Birmingham (Healthcare) and HMP Hewell (Healthcare) should review the new service provision, to ensure that the referral and homeless pathways are effectively utilised to identify and support young offenders being released into the community.
midlands Accepted
An independent investigation into the care and treatment of Emily … — Rec 11
TEWV, CNTW, NHS England and Durham County Council must provide assurance that all transitions between services for children and young people are completed in line with NICE guidance on the Transition of Children and Young people.
An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust north_east_yorkshire
Independent reviews(24)
Harris Review: Deaths in Custody — Rec 38
NOMS should further develop its work on care leavers, in order to ensure that care leavers can be accurately and reliably identified upon arrival in Prison and that data is collected to ensure that progress through custody for care leavers is properly recorded, researched and improved.
Justice & Legal
Harris Review: Deaths in Custody — Rec 32
Local authorities must have an explicit statutory duty to provide a corporate parenting and support role to all young people who are in NOMS custody, in addition to their existing statutory duties towards care leavers in custody. This should include providing a ‘Significant Adult’ who would be able to visit …
Justice & Legal
Dilnot Commission — Rec 3
People born with a care and support need or who develop one in early life cannot be expected to have planned in the same way as older people. Those who enter adulthood already having a care and support need should immediately be eligible for free state support to meet their …
Health & Social Care
MacAlister Review — Rec 56
As part of recommendation in Chapter Eight (improving data collection), the Office for National Statistics should collect and report data on the mortality rate of care leavers and care leaver health outcomes. Government should also launch a new cohort study which tracks the health outcomes of care experienced people and …
Education
MacAlister Review — Rec 55
Integrated Care Boards should publish their plans for improving the mental and physical health of those in care and leaving care and routinely publish progress. As part of these plans and new corporate parenting responsibilities, the Department of Health and Social Care and the NHS should exempt care leavers from …
Education
MacAlister Review — Rec 54
All local authorities must improve care leaver mental and physical health support, and the National Children’s Social Care Framework should promote the most effective multidisciplinary models of doing this.
Education
MacAlister Review — Rec 52
Introduce a stronger safety net against care leaver homelessness by removing the local area connection test, ending intentionally homelessness practice, providing a rent guarantor scheme and increasing the leaving care grant to £2,438 for care experienced people.
Education
MacAlister Review — Rec 51
There should be a range of housing options open to young people transitioning out of care or who need to return, such as Staying Put, Staying Close and supported lodgings. Staying Put and Staying Close should be a legal entitlement and extended to age 23 with an ‘opt-out’ rather than …
Education
MacAlister Review — Rec 50
An annual care leaver bursary should be made available to all apprentices up to the age of 25, and employers should be allowed to use unspent apprenticeship levy funds to tailor support for those with care experience.
Education
MacAlister Review — Rec 49
The Care Leaver Covenant should be refreshed to align with the five missions set out in this report and co-produced with care experienced people. Employers should be able to apply for a new government led accreditation scheme which recognises their commitment to supporting care leavers into well paid jobs.
Education
MacAlister Review — Rec 48
Introduce a new kitemark scheme for higher education to drive improvements in admissions, access and support for those with care experience.
Education
MacAlister Review — Rec 45
A new lifelong guardianship order should be created, allowing a care experienced person and an adult who loves them to form a lifelong legal bond.
Education
MacAlister Review — Rec 43
Local authorities should redesign their existing Independent Visitors scheme for children in care and care leavers to allow for long term relationships to be built.
Education
Modern Slavery Act Review — Rec 40
The Government should provide more effective support and guidance for trafficked young people transitioning from children’s to adult services.
Justice & Legal Accepted
Modern Slavery Act Review — Rec 38
The Government should extend the ICTA service to young people who need the service over the age of 18 and up to 21 or 25, subject to their circumstances.
Justice & Legal Accepted
Lammy Review — Rec 17
The MoJ and Department of Health (DH) should work together to develop a method to assess the maturity of offenders entering the justice system up to the age of 21. The results of this assessment should inform the interventions applied to any offender in this cohort, including extending the support …
Justice & Legal Accepted
Cass Review — Rec 24
Given that the changing demographic presenting to children and young people's services is reflected in a change of presentations to adult services, NHS England should consider bringing forward any planned update of the adult service specification and review the model of care and operating procedures.
Health & Social Care Accepted
Cass Review — Rec 23
NHS England should ensure that each Regional Centre has a follow-through service for 17-25-year-olds; either by extending the range of the regional children and young people's service or through linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey. This will also allow …
Health & Social Care Accepted
Harris Review: Deaths in Custody — Rec 74
When the transfer is between the youth estate and an adult institution, the YJB will be accountable for the transfer of all relevant information from the YOT, including health, mental health and care leaver status.
Justice & Legal
Harris Review: Deaths in Custody — Rec 37
YOTs and other relevant agencies should be required to remain in contact with a young adult who transfers from the youth estate to an adult or young adult establishment for at least 6 months after they reach 18, and longer if particular vulnerabilities are identified. This may extend to 21 …
Justice & Legal
Harris Review: Deaths in Custody — Rec 36
If the YOT and other key organisations believe that due to an individual’s lack of maturity, it would be in the best interest of a vulnerable young adult to remain in the under-18 estate after they reach 18, suitable accommodation should be found for that person within the juvenile estate, …
Justice & Legal
MacAlister Review — Rec 46
As part of our recommendations about Ofsted inspection (Chapter Eight), Virtual School Heads should be held accountable for the education attainment of children in care and care leavers up to age 25 through Ofsted’s ILACS framework. Pupil Premium funding should be focused on evidence led tutoring and mentoring programmes.
Education
Coates Prison Education Review — Rec 16
Education Health and Care Plans (EHCP) that apply in secure youth custody and require local authority action should be extended to cover those in the secure adult estate aged up to the age of 25.
Justice & Legal
Timpson Review — Rec 20
DfE should publish the number and rate of exclusion of previously looked after children who have left local authority care via adoption, Special Guardianship Order or Child Arrangement Order.
Education Accepted
PHSO casework decisions(2)
LGO / SPSO decisions(207)
23-014-163 — London Borough of Merton
Summary: Mrs Q complains the Council delayed referring her daughter for an Adult Social Care assessment, in the time before her 18th birthday. And when it did make the referral it did not tell them and delayed responding to her contacts. We uphold the complaint. The Council has agreed to …
LGO (Local Government & … Adult Care Services Upheld Jul 2024
23-017-457 — Hertfordshire County Council
Summary: Mrs X complains about how the Council planned care for her son, Mr K. The Council took too long to start planning Mr K’s transition from children’s services to adult social care. Despite its best efforts, the Council failed to provide overnight respite care and has not fully supported …
LGO (Local Government & … Adult Care Services Upheld Aug 2024
24-004-827 — London Borough of Hammersmith & Fulham
Ms D complained the Council failed to carry out an occupational therapy assessment when her son, Mr J, transferred from children’s to adult’s social care services. We have found the Council significantly delayed completing an occupational therapy assessment. This delay caused Ms D avoidable frustration, uncertainty and distress. It affected …
LGO (Local Government & … Adult Care Services Upheld May 2025
24-016-539 — Norfolk County Council
Summary: Ms D complains the Council failed to provide suitable support to her and safeguard her. The Council is at fault for failing to make proper transition arrangements for Ms D, to consider safeguarding alerts and for failing to complete carers’ assessments. This has caused uncertainty about whether Ms D …
LGO (Local Government & … Adult Care Services Upheld Sep 2025
25-006-163 — Somerset Council
Summary: We will not investigate this complaint about the Council’s delay in securing social care support for Mrs X’s son. This is because
LGO (Local Government & … Adult Care Services Oct 2025
24-003-485 — Somerset Council
Summary: Ms X complained about the Council’s actions when she moved from children’s to adult’s social care. The Council failed to investigate Ms X’s complaint under the children’s statutory complaints procedure. This fault has caused avoidable frustration to Ms X. In recognition of this, the Council has agreed to apologise, …
LGO (Local Government & … Adult Care Services Upheld Nov 2024
24-021-187 — Tameside Metropolitan Borough Council
Summary: Miss X complained about the Council’s failure to secure part of the provision set out in her child’s Education, Health and Care Plan, which she said adversely impacted her child’s transition to adulthood. We found the Council at fault in not securing the provision. To put right the injustice …
LGO (Local Government & … Education Upheld Nov 2025
21-003-856 — Manchester City Council
Summary: Mr B complained that the Council stopped his education incentive payment without notice or explanation on two occasions and refused to backdate the money to cover the gaps. The Council has now offered to pay him £500, support him until the end of his course and review its policies. …
LGO (Local Government & … Adult Care Services Upheld Jan 2022
20-012-417 — Staffordshire County Council
Miss C complained about the care and support she received from the Council as a child. Miss C says because of the Council’s fault she did not receive proper support and missed out on a care leavers grant.
LGO (Local Government & … Children S Care Services Upheld Mar 2022
21-017-188 — City of York Council
Summary: The Council is at fault for delaying consideration of this complaint at stage two of the children’s statutory complaints procedure. The Council will issue its stage two response in the coming days. It has also agreed to offer to make a payment to the complainant to remedy the time …
LGO (Local Government & … Adult Care Services Upheld Mar 2022
21-007-240 — Cornwall Council
Summary: Mr D complained the Council failed to properly support his grandson when he transitioned from children’s services to adult care services. He also says the Council failed to give him information about his grandson’s wellbeing. We find the Council delayed assessing Mr D’s grandson. It also should have done …
LGO (Local Government & … Adult Care Services Upheld May 2022
21-011-122 — Manchester City Council
Summary: Miss F complains the Council delayed planning her son’s transition to adult services. There was fault as the Council should have sought alternative respite providers sooner. The Council has agreed to make a payment to Miss F to acknowledge the impact the loss of respite for three months has …
LGO (Local Government & … Adult Care Services Upheld May 2022
21-012-774 — Buckinghamshire Council
Summary: Miss X complained the Council failed to appropriately plan for her transition from children to adult care services, and to support her to stay with her foster family until she was 25 on a staying put arrangement it had previously agreed. There was fault in the way the Council …
LGO (Local Government & … Adult Care Services Upheld Jul 2022
21-015-390 — Gloucestershire County Council
Summary: Mr and Mrs X complained the Council failed to carry out the recommendations made at Stage 2 and 3 of the statutory complaints process. The Council has provided information about the action it has taken as well as now arranging a meeting as agreed. These actions, along with a …
LGO (Local Government & … Adult Care Services Upheld Aug 2022
22-001-593 — Suffolk County Council
Summary: Mrs X complained the Council refused to carry out social care assessments and did not provide advice on her son’s social care needs for the review of his Education, Health and Care plan. She also complained about poor communication and complaints handling, which caused frustration and delays, and put …
LGO (Local Government & … Adult Care Services Upheld Oct 2022
21-017-132 — Cambridgeshire County Council
Summary: Mr B complains on behalf of his adult son, Mr F, about the way the Council managed his transition to adult social care and that it failed to provide him with care and support from July to September 2021. We have found fault which has caused injustice to Mr …
LGO (Local Government & … Adult Care Services Upheld Dec 2022
22-005-749 — Nottinghamshire County Council
Summary: There is no fault by the Council in relation to its planning for the complainant’s son’s transition from children’s to adult social care. Whilst only limited services have been provided since the complainant’s son became 18, there is no fault by the Council as it offered suitable provision that …
LGO (Local Government & … Adult Care Services Not Upheld Dec 2022
23-008-097 — London Borough of Croydon
Summary: Mrs Y complained about the way the Council dealt with Mr X’s social care support and its response to her complaint. We have found fault by the Council in failing to review Mr X’s need for support managing his finances, and failing to consider part of Mrs Y’s complaint, …
LGO (Local Government & … Adult Care Services Upheld Mar 2024
23-015-297 — Torbay Council
Summary: We will not investigate this complaint about transition planning into Adult Services. The Council has investigated the complaint under the Children’s Statutory Complaint Procedure and upheld most of the complaint. Further investigation would not lead to a different outcome.
LGO (Local Government & … Children S Care Services Upheld Apr 2024
24-003-509 — Bournemouth, Christchurch and Poole Council
Summary: We will not investigate Mr X’s complaint about the Council’s handling of several matters in relation to his daughter’s care and support. This is because there is insufficient evidence of fault. In addition, the faults accepted have not caused any significant injustice and an investigation would not lead to …
LGO (Local Government & … Adult Care Services Aug 2024
23-001-435 — Devon County Council
Miss B complained on behalf of her son, Mr C, that the Council failed to ensure an effective transition of social work services when he turned 18. In particular, that he had to leave a children’s home placement and move to a supported living placement 30 miles away. This left …
LGO (Local Government & … Children S Care Services Upheld Aug 2024
24-010-194 — Southampton City Council
Summary: Mrs X complained about the Council’s handling of her child’s care and support when he turned 18. We find no fault in the Council’s overall decision making but do find fault for it failing to consider Mrs X’s request for an additional day at Placement A. This caused Mrs …
LGO (Local Government & … Adult Care Services Upheld Apr 2025
24-009-874 — Shropshire Council
Summary: The Council delayed making a decision about Mr Y’s social care provision and issuing the decision to cease to maintain his Education, Health and Care Plan. This caused avoidable uncertainty, distress and a delay in appeal rights which have not been used. The Council has already apologised and this …
LGO (Local Government & … Adult Care Services Upheld Jun 2025
23-020-425 — Milton Keynes Council
Summary: Mrs X complained about the Council’s failure to provide respite care for her disabled child. We found the Council to be at fault because it failed to properly consider the issue. There was also fault with the Council’s complaint handling. To remedy the distress and uncertainty caused by its …
LGO (Local Government & … Adult Care Services Upheld Oct 2025
24-020-730 — London Borough of Croydon
Summary: Mr X complained the Council delayed providing his son with respite care when he transitioned from children to adult services. We find the Council was at fault for the delay in securing suitable respite care for Mr X’s son. This caused distress and upset, and Mr X’s son lost …
LGO (Local Government & … Adult Care Services Upheld Oct 2025
24-007-419 — London Borough of Wandsworth
Summary: We will not investigate this complaint about how to meet adult social care needs when the current provision ends. The court of protection is better placed to settle a dispute about how best to meet a person’s needs when they do not have capacity to decide. The claimed injustice …
LGO (Local Government & … Adult Care Services Oct 2024
23-018-546 — London Borough of Haringey
Mr and Mrs X complain about delay by the Council in carrying out an assessment for the transition of Mr Y from children to adult care services.
LGO (Local Government & … Adult Care Services Upheld Nov 2024
24-003-915 — Hertfordshire County Council
Summary: Mr Z, on behalf of his grandson Mr X, complained the Council failed to provide appropriate support when he turned 18. The matters Mr Z raised were known to him in 2021 and he raised them with the Council at that time. This is a late complaint and falls …
LGO (Local Government & … Adult Care Services Nov 2024
25-009-655 — East Sussex County Council
Summary: We will not investigate this complaint about the way the Council has handled Mr X’s care. This is because the complaint is late and there is no good reason to investigate this now.
LGO (Local Government & … Adult Care Services Dec 2025
201904147 — Aberdeenshire Council
C was on a Compulsory Supervision Order (CSO) and in the care of their grandparents. When C became a care leaver, C complained to the council that they failed to provide the appropriate Throughcare and Aftercare. C said that the council wrongly advised that C was not entitled to any …
SPSO (Scottish Public Se… Local Government Upheld Nov 2020
24-016-538 — Birmingham City Council
Mr Y complains about the Council’s poor handling of his child’s transition from Children’s Services to Adult Social Care. Mr Y also complains about the Council’s handling of his complaint. The Council has now upheld all aspects of Mr Y’s complaint and there is no further fault for us to …
LGO (Local Government & … Adult Care Services Feb 2026
25-011-263 — Derbyshire County Council
Summary: We will not investigate Mr F’s complaint about direct payments during his son’s transition from children’s to adults’ services because there is nothing we could add to the Council’s response. The Council is about to respond to Mr F’s complaint about an audit. If he remains dissatisfied once he …
LGO (Local Government & … Adult Care Services Feb 2026
24-008-108 — London Borough of Haringey
Summary: Ms Y complained about the Council’s support for her late son, Z, and the standard of support by the service provider the Council commissioned to deliver Z’s support. We have found fault causing injustice by the Council in failing to: properly monitor the service provider’s support for Z and …
LGO (Local Government & … Adult Care Services Upheld Jan 2026
25-008-644 — Surrey County Council
Summary: We will not investigate this complaint about failures in communication about adult social care support. The injustice is not enough to justify our involvement. We are satisfied with the actions the Council has already taken to apologise and offer to meet, and it is unlikely we would achieve anything …
LGO (Local Government & … Adult Care Services Jan 2026
21-009-699 — Wiltshire Council
Summary: Ms M complains, on behalf of three young adults, the Council gave them misleading advice about applying for social housing. The Council was at fault as it failed to manage their expectations about the likely success of their application given restrictions imposed by local housing providers. It failed to …
LGO (Local Government & … Housing Upheld Mar 2022
22-001-253 — Leicester City Council
Summary: We will not investigate Ms X’s complaint the Council has refused to investigate her complaint about her son being taken into care, her involvement in decisions about his life, and her current relationship with her son. We cannot achieve what Ms X wants. Her son is now an adult …
LGO (Local Government & … Children S Care Services May 2022
21-011-789 — City of York Council
Summary: Mr and Mrs X complained the Council poorly managed their child, Y’s, transition from children’s services to adult services as a care leaver. They say this caused them and Y distress and affected Y’s health. They also say the Council handled their complaint poorly. The Council is at fault. …
LGO (Local Government & … Adult Care Services Upheld Aug 2022
21-018-574 — London Borough of Camden
Summary: there is no fault by the Council in relation to Ms B’s complaints about the actions of her personal advisor towards her and in its handling of her complaints about this.
LGO (Local Government & … Children S Care Services Not Upheld Sep 2022
21-014-948 — London Borough of Newham
Summary: There was fault by the Council because it did not properly plan Miss K’s transition from Children to Adult Services and how it would arrange and fund her care. There was also fault in its complaint handling as it failed to refer Miss K’s complaint to a stage three …
LGO (Local Government & … Adult Care Services Upheld Sep 2022
23-014-746 — London Borough of Haringey
Summary: Miss X complains the Council has failed to provide the support agreed during the Special Guardianship Order process and has unreasonably rejected her application to the housing register. The Ombudsman finds fault with the Council for how it managed the Special Guardianship process, for failing to provide support, and …
LGO (Local Government & … Children S Care Services Upheld May 2024
24-002-229 — Norfolk County Council
Summary: We will not investigate Mr X’s complaint about children services reply to his complaint. It is reasonable to expect Mr X to have requested a stage three review panel hearing on time. And it is unlikely we would criticise its decision to refuse a late request.
LGO (Local Government & … Children S Care Services Jul 2024
24-015-863 — London Borough of Croydon
Summary: We will not investigate this complaint about how the Council dealt with Ms Y’s transition from children’s to adult services. This is because the complaint is late and there is no good reason for us to investigate now.
LGO (Local Government & … Adult Care Services Apr 2025
24-012-631 — Devon County Council
Summary: Ms X complained on behalf of Y, a looked after child. She says the Council failed to properly consider Y’s complaint about its handling of a child in care review and how Y’s placement dealt with their belongings. The Council failed to properly consider Y’s stage one complaint and …
LGO (Local Government & … Children S Care Services Upheld Apr 2025
24-021-375 — London Borough of Southwark
Summary: We will not investigate this complaint about the Council’s decision not to regard the complainant as a kinship carer and her granddaughter as a looked-after child. There is insufficient evidence of fault on the Council’s part to warrant investigation.
LGO (Local Government & … Children S Care Services May 2025
25-000-139 — Norfolk County Council
Summary: We will not investigate Mr X’s complaint about the Council’s care planning and decision-making related to his accommodation and support after he turns 18. The Council is considering his complaint under the children’s statutory complaints procedure and in the process of arranging a stage three panel. It is reasonable …
LGO (Local Government & … Adult Care Services Jul 2025
23-013-847 — London Borough of Haringey
Summary: Mr X complained the Council stopped his son Mr Y’s direct payment and did not manage the transition from childrens to adult social care adequately. We upheld the complaint. The Council did not deal with the transition in line with the Children Act 1989 or Care Act 2014. This …
LGO (Local Government & … Adult Care Services Upheld Jul 2025
25-004-813 — Cambridgeshire County Council
Summary: We will not investigate Mrs X’s complaint the Council delayed moving her daughter, Miss Y, from her children’s residential placement to an adult one. Any outstanding injustice is not significant enough to warrant an investigation and our involvement would be unlikely to achieve anything meaningful.
LGO (Local Government & … Adult Care Services Oct 2025
25-007-024 — West Sussex County Council
Summary: We will not investigate Mr X’s complaints about the Council’s decision to cease his daughter’s college placement and Education, Health and Care Plan and its communications and complaints handling. The substantive matters are appealable, or could have been appealed, to the SEND Tribunal. The other complaints do not warrant …
LGO (Local Government & … Adult Care Services Nov 2025
24-008-866 — London Borough of Croydon
Summary: We will not investigate this complaint the Council failed to complete an adult care needs review. That is because it is late.
LGO (Local Government & … Adult Care Services Nov 2024
24-009-869 — Suffolk County Council
Summary: We will not investigate this complaint about the children’s statutory complaints procedure. The Council has upheld the complaint and offered a suitable remedy. Further investigation would not lead to a different outcome.
LGO (Local Government & … Adult Care Services Upheld Nov 2024
Domestic Homicide Reviews(32)
Kent — recommendation 9
Social Services have a responsibility to assist young adults leaving care, which will include helping them find suitable accommodation in which to live. In addition to establishing the accommodation is suitable for the care leaver, a risk assessment should also take place intended to identify safeguarding issues in relation to …
Kent Social Services | Medway Social …
Kent — recommendation 7
In exercising their responsibility in assisting young adults leaving care, Social Services should endeavour to ensure such individuals are registered with a GP, (none of the Rose Brothers were registered with a GP at the time they attacked Joyce).
Kent and Medway Social Services
Oxford — recommendation CEF 3
Detailed consideration needs to be given by CEF to creating a multi-agency, co-located Leaving Care service for 18-25 year olds.
Oxfordshire County Council Children’s Social Care …
Oxford — recommendation 3a
Children and young people who request to become LAC and who are refused should be offered an advocate so their views can be represented in decision-making
Oxfordshire County Council Children’s Social Care …
Kent — recommendation 9
Social Services have a responsibility to assist young adults leaving care, which will include helping them find suitable accommodation in which to live. In addition to establishing the accommodation is suitable for the care leaver, a risk assessment should also take place intended to identify safeguarding issues in relation to …
Kent Social Services | Medway Social …
Kent — recommendation 7
In exercising their responsibility in assisting young adults leaving care, Social Services should endeavour to ensure such individuals are registered with a GP, (none of the perpetrators were registered with a GP at the time they attacked the victim).
Kent and Medway Social Services
Wiltshire — recommendation R24
Professionals to consider what services can step up when young person reaches 18 but does not meet threshold for adult mental health services.
YOT | Early Help | CAMHS CAMHS
Wiltshire — recommendation R23
YOT to improve transition arrangements with Probation
YOT | Early Help | CAMHS CAMHS
Leicester — recommendation 14.4
When current service provision for adolescents who are subject to transition from child services to adult services is reviewed, the review process considers the wealth of learning from research and national good practice.
Safer Leicester Partnership
Croydon — recommendation 6.1.5.g
Review Croydon Housing Needs procedures for eviction of leaving care clients. In this case, Croydon procedures were followed, however it is recommended that Croydon Housing Needs carries out a further review of procedures for eviction of vulnerable clients to ensure procedures are up to date and comply with current procedures.
London Borough of Croydon Housing Services London Borough of Croydon
Lewisham — recommendation 7)
That a policy of transferring care, when necessary and following risk assessment, from CSC to ASC be implemented.
Lewisham Children’s Social Services | Lewisham …
Lewisham — recommendation 4)
That the Leaving Care Service examine its processes (including risk assessment) when young people move towards independent living, to include consideration of the method of making plans according to specific need and the maintenance of appropriate records, including paper and computer based.
Lewisham Children’s Social Services
Bristol — recommendation 21
Where a care leaver is an adult but is known to be in an abusive or vulnerable situation a risk assessment should always be undertaken and completed with that young person.
Children’s Social Care
Bristol — recommendation 20
South Gloucestershire council should consider the viability of having Path way Plan reviews Independently chaired, post 18 years of age.
South Gloucestershire Council South Gloucestershire Council
Bristol — recommendation 17
Given that young people often lack the skills to make good choices on their own, care leavers should be provided with mentoring services where this is assessed as needed.
Children’s Social Care
Chelmsford — recommendation 12
More focus and attention should be given to the view of foster carers when considering a move onto semi-independent/independent living.
Essex County Council Children’s Social Care Essex County Council
Bristol — recommendation Bristol City Council
Pre-birth assessments of the expected babies of Care Leavers should be carried out in a timely way and should be holistic.
Bristol City Council Children’s Social Care … Bristol City Council
Bristol — recommendation Bristol City Council
Consideration to be given to specific training for Leaving Care Personal Advisers around some the complexities of working with Care Leavers, including a focus on how past experiences of trauma and abuse can impact on their choices as they move into adulthood, and how best they can support them with …
Bristol City Council Children’s Social Care … Bristol City Council
Bristol — recommendation Bristol City Council
Improve standards of practice for Care Leavers.
Bristol City Council Children’s Social Care … Bristol City Council
Doncaster — recommendation 2
The partnership should explore the complex issue faced by looked after children regarding their access to services, for example, CAMHS referral and the continuity of care in primary care due to moving to placements in other areas.
Safer Doncaster Community Safety Partnership
Walsall — recommendation 8.7
The Black Country & Birmingham West CCG and The Black Country Healthcare Foundation Trust should agree a protocol to ensure that every child or adolescent prescribed ADHD medication is offered a consultant-led review of the need for continued medication into adulthood.
Black Country & Birmingham West ICB … NHS Black Country ICB
Walsall — recommendation 8.3
The Black Country Healthcare Foundation Trust should ensure that ADHD services provided for children and adolescents recognise that when a patient of school-leaving age is discharged, there should be active consideration as to whether a patient should be referred to adult ADHD services and ensure that transition is achieved in …
Black Country Healthcare Foundation Trust Black Country Healthcare NHS …
Salford — recommendation 1
The Health and Social Care Partnership in Scotland should seek to review policies and practice in relation to referring to adult services.
Health and Social Care Partnership in … Scottish Government
Oxford — recommendation 3b
Staff and managers are aware of Viva, the CEF advocacy service and how to access it.
Oxfordshire County Council Children’s Social Care …
Bristol — recommendation 19
Pathway Plans must be focussed on the future, aspirational and led by the young person and reflects their changing needs and ambitions.
Children’s Social Care
Bristol — recommendation 16
Pathway Plans should be carried out to make sure the young person’s voice is always heard. They should be completed with young person and where possible signed by the young person and the supervisor responsible for overseeing the support worker.
Children’s Social Care
Chelmsford — recommendation 10
Given the uncertainty around the immigration status of UASC and young people, they should not be provided with a stand-alone independent living accommodation. Consideration should be given to placement within supported Living, Supported Accommodation with Sharing Housing being considered the least favourable and last option.
Essex County Council Children’s Social Care Essex County Council
Stoke-on-Trent — recommendation SOTCC_R9
Disseminate message through CSE training that a child is a child until they are 18 years and should be offered an assessment as this may provide a smooth transition into accessing services for adults
Stoke-on-Trent City Council Early Intervention and …
Middlesbrough — recommendation 17.2
Paragraph 14.7.13 outlines that a report has been submitted to the Middlesbrough Executive group to consider new models of transition from children’s to adult services. The progress of their considerations should be reported to the Community Safety Partnership so that assurance can be given that the proposed model addresses the …
Middlesbrough Executive group | Community Safety …
Basildon — recommendation 11.10.1
That the Government introduces national standards for provision for 16 and 17-year-olds.
National Government
Basildon — recommendation 11.5.2
The review is aware that Leaving and Aftercare Staff have access to a full training package regarding domestic abuse, but it is recommended that further training is provided to Leaving Care practitioners on the impact of domestic abuse on teenagers, and to refresh their knowledge on the range of legal …
Essex County Council – Children’s Social …
Chelmsford — recommendation 9
The Assessment of Need and Pathway Plan is currently devised with the young person by the Personal Advisor and reviewed every six months. More consideration could be given to this being a joint meeting with all professionals involved in the young person’s life and chaired by an independent person equal …
Essex County Council Children’s Social Care Essex County Council
CJINI inspection reports(1)
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