Care safeguarding systems
Absence of effective systems to protect people from abuse and avoidable harm, including failures in reporting suspected abuse.
Source spread
Where this theme appears
This theme appears across 25 independent accountability sources, so the source mix matters as much as the headline total.
342 inquiry recs
81 PFD reports
98 committee recs
11 HSSIB recs
203 CQC actions
4 HMICFRS recs
6 ICIBI recs
1 PPO rec
4 IOPC recs
1 NAO rec
23 IMB recs
4 IMB reports
2 Scottish FAIs
1 Article 2 learning point
10 detention investigation recs
2210 DHR recs
43 PHSO decisions
3072 LGO/SPSO decisions
7 CJINI reports
12 CQC enforcement actions
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.
Inquiry recommendations(342)— showing 50 strongest matches
96 — Refuge provision and definition of places of safety
Recommendation: Consideration should be given to a possible provision for refuge for children and to a possible amendment of the definition of ‘places of safety’ (17.33).
Unknown
92 — Sheriff to resolve disputes on visits
Recommendation: Any dispute regarding visits by professionals to a child should be resolved by application to the Sheriff (17.30).
Unknown
90 — Sheriff to regulate access
Recommendation: The Sheriff should be empowered to regulate access to a child in a place of safety and should be obliged to consider that matter when the case first comes before him or her after the granting of the Order (17.26-27) …
Unknown
84 — Pilot scheme for enhanced safeguarder role
Recommendation: A pilot scheme should be run in order to try out an enhanced role of a safeguarder in cases of child protection before further consideration is given to the possible development of a Child’s Advocate (17.17).
Unknown
83 — Powers of curators ad litem
Recommendation: Where curators ad litem are appointed their specific powers should be stated in the interlocutor of their appointment (17.16).
Unknown
82 — Consider appointing a safeguarder
Recommendation: In every case when a child is removed under a Child Protection Order the appointment of a safeguarder must be considered at the time of the granting of the Order or if the appointment is not then made at any …
Unknown
81 — Sufficient supply of safeguarders
Recommendation: All local authorities should explore the sufficiency of their supply of persons able and willing to serve in the capacity of safeguarders and if that supply is deficient should take steps to recruit a greater number and arrange training for …
Unknown
80 — Independent person to protect child's interests
Recommendation: In all cases of Child Protection Orders there should be an opportunity for the appointment of an independent person with a role wider than that of the present safeguarder to protect the child’s interests (17.10-12).
Unknown
76 — Constable to intimate removal likewise
Recommendation: Correspondingly any constable or other person removing a child should give a like intimation to the Social Work Department (17.6).
Unknown
75 — Intimate removal to Social Work Department
Recommendation: Any Order authorising the removal of a child should require the person so authorised to intimate the removal and the whereabouts of the child to the appropriate Social Work Department (17.5).
Unknown
74 — Procedures to resolve welfare disputes
Recommendation: Procedures should be provided for the resolution of any disputes regarding the welfare of the child either by the Sheriff or by the Children’s Hearing, depending on which of them has last given directions regarding the child (17.4).
Unknown
73 — Sheriff powers where consents not given
Recommendation: Where consents are required for matters of the care of the child, for interviewing or for examination and parental consents are not forthcoming, specific powers should be obtained from the Sheriff (17.3).
Unknown
72 — Local authority obligations under section 20
Recommendation: When a child is removed under a Child Protection Order the local authority should be under the same obligations as are set out in Section 20(1) and (2) of the Act of 1968 (17.1-2).
Unknown
71 — Guidance on Interim Protection Orders
Recommendation: Guidance should be given on the matters to be considered before resort is had to an Interim Protection Order (16.46).
Unknown
70 — Intimation of Interim Protection Order application
Recommendation: The application for an Interim Protection Order should be intimated to the child and to the parent and they should be given an opportunity to object to it (16.45).
Unknown
69 — Interim Protection Orders
Recommendation: A procedure should be introduced for application to the Sheriff to obtain any of a wide range of Orders as may be appropriate in the circumstances either for purposes of investigation or for the immediate protection of a child pending …
Unknown
68 — No special forms on removal
Recommendation: No special forms need be required when a child is removed to a place of safety but where occasion permits the Reception into Care Forms should be completed as far as possible to reflect the information available (16.42).
Unknown
60 — Three day enforcement period
Recommendation: Child Protection Orders should be enforceable only within a period of three days only from the date of the grant (16.33).
Unknown
59 — Concealing child's address from parent
Recommendation: Where the address of the child or children should be concealed from the parent a specific Order should be made to that effect at the time of the grant of the Order with or without a limit on the period …
Unknown
58 — Supplementary Orders when Order granted
Recommendation: On the occasion of the grant of a Child Protection Order such authorisations or supplementary Orders as may be appropriate to the circumstances should also be granted (16.31).
Unknown
56 — Reporter's power to return the child
Recommendation: The Reporter’s existing power to have the child returned should continue but should be qualified in its exercise by the proviso that the return of the child would not expose the child to the risk of significant harm (16.29).
Unknown
55 — Immediate opportunity to vary or cancel
Recommendation: The child and his or her parent or guardian should have an immediate opportunity to have the Order varied or cancelled by the Sheriff (16.28).
Unknown
54 — Order to state its grounds
Recommendation: The Order should contain a brief statement of the grounds on which it was granted in addition to the other necessary details (16.27).
Unknown
53 — Written statement of grounds
Recommendation: At the time of making the application or within forty-eight hours thereafter a written statement of facts setting out the grounds for the perceived risk to the child should be prepared and presented to the Sheriff or JP (16.25) The …
Unknown
52 — Standard form of application
Recommendation: A simple standard form should be designed for applications for Child Protection Orders in Scotland (16.24).
Unknown
51 — Amend Criminal Procedure Act terminology
Recommendation: Consideration should be given to the possible amendment of Sections 14 and 323 of the Criminal Procedure (Scotland) Act 1975 so as to bring their terminology into accord with the revised provisions of Section 37(2) of the Act of 1968 …
Unknown
50 — No change to who may remove a child
Recommendation: No change should be made so far as concerns the definition of the persons who may remove a child to a place of safety (16.22).
Unknown
48 — Orders from Sheriff or JP
Recommendation: Child Protection Orders should be obtained either from a Sheriff or a JP but where the case is one of suspected sexual abuse the Order should if practicable be obtained from a Sheriff (16.20).
Unknown
47 — Two sources of evidence not necessary
Recommendation: Guidance should state for the avoidance of doubt that evidence from two or more separate sources is not a formal necessity for the obtaining of a Child Protection Order (16.19).
Unknown
46 — Standard of satisfaction for Sheriff or JP
Recommendation: The Sheriff or JP granting the Order must be satisfied on the whole material which is placed before him or her that there is reasonable cause to believe that the child is likely to suffer significant harm if the child …
Unknown
45 — Evidence sufficient to secure retention
Recommendation: Where there is a likelihood of harm continuing to the child if he or she is not retained in care the evidence for a Child Protection Order should be sufficient to give a reasonable expectation of securing such retention after …
Unknown
41 — New name for Place of Safety Order
Recommendation: To avoid confusion a name other than ‘Place of Safety Order’ or the corresponding English Order should be adopted and the title ‘Child Protection Order’ is used for convenience (16.13)
Unknown
40 — Removal as last resort
Recommendation: Removal of a child should be recognised as a course to be considered where no alternative exists and the urgency of the risk requires it (16.9). Caution must be exercised (16.10). The gravity of the threat has to be considered …
Unknown
37 — Rewrite section 37(2) removal power
Recommendation: Section 37(2) of the Social Work (Scotland) Act 1968 should be re-written so as expressly to empower removal of a child where the child is likely to suffer imminent and significant harm of any kind and the removal is necessary …
Unknown
28 — Local authority child abuse guidelines
Recommendation: All local authorities should have guidelines for the management of cases of child abuse consistent with and in the context of national guidelines (15.57).
Unknown
24 — Sheriff power to exclude suspected abuser
Recommendation: Consideration should be given to empowering a Sheriff to order a suspected abuser to be excluded from contact with a child where abuse is suspected (15.51).
Unknown
8 — Treat allegations seriously but test them
Recommendation: Where allegations are made by a child regarding sexual abuse those allegations should be treated seriously, should not necessarily be accepted as true but should be examined and tested by whatever means are available before they are used as the …
Unknown
7 — Keep an open mind when investigating
Recommendation: Those involved in investigating allegations of child sexual abuse must keep an open mind and not fall into the trap of confusing the taking of what a child says seriously with believing what the child has said (15.22).
Unknown
9 — Suspicion of Deliberate Harm Protocol and guidance
Recommendation: Protocol i. By 31 March 2027, NHS England must produce and distribute a one-page protocol setting out the steps to be taken by managers when concerns or suspicions are raised that a healthcare professional may have deliberately harmed a patient. …
Gov response: On the crucial issue of safeguarding, just as Lady Justice Thirlwall recommends, compulsory training, a new protocol, employment requirements. Madam Deputy Speaker, a revised NHS safeguarding framework was published in April 2026, but I have …
Response Unclear
4 — Safeguarding and contracts of employment
Recommendation: i. All Trusts must provide safeguarding training to all staff (appropriate to their role and expertise) and Board members, including Non-Executive Directors. This training should include how to deal with concerns and suspicions about deliberate harm caused by staff. ii. …
Gov response: On the crucial issue of safeguarding, just as Lady Justice Thirlwall recommends, compulsory training, a new protocol, employment requirements. Madam Deputy Speaker, a revised NHS safeguarding framework was published in April 2026, but I have …
Response Unclear
FR-20 — Age Verification Online
Recommendation: The Inquiry recommends (as originally stated in its The Internet Investigation Report, dated March 2020) that the UK government introduces legislation requiring providers of online services and social media platforms to implement more stringent age verification measures.
Gov response: We accept the need to protect children from harmful and age-inappropriate content. The Online Safety Bill requires all in-scope companies to assess whether their service is likely to be accessed by children and, if so, …
Accepted in part
104 — High risk countries list for travel orders
Recommendation: The Home Office should bring forward legislation providing for the establishment and maintenance by the National Crime Agency of a list of countries where children are considered to be at high risk of sexual abuse and exploitation from overseas offenders. …
Gov response: 8. The Home Office fully accepts the Inquiry’s recommendation and will bring forward the necessary legislation to give effect to this recommendation when parliamentary time allows. To deliver on this recommendation, the Home Office has …
Accepted
103 — Ratify Lanzarote Convention
Recommendation: The Chair and Panel recommend that the UK government ratifies the Council of Europe Convention on the Protection of Children against Sexual Exploitation and Sexual Abuse (the 'Lanzarote Convention') without further delay. They also recommend that ratification is followed, again …
No response yet
FR-12 — Pre-screening by Internet Providers
Recommendation: The Inquiry recommends that the UK government makes it mandatory for all regulated providers of search services and user-to-user services to pre-screen for known child sexual abuse material.
Gov response: We accept the need to hold companies to account for removing, reporting and limiting the spread of child sexual abuse material on their services. The UK’s world- leading Online Safety Bill will address this by …
Accepted in part
70 — Include clergy in position of trust definition
Recommendation: The government should amend Section 21 of the Sexual Offences Act 2003 so as to include clergy within the definition of a position of trust. This would criminalise under s16-s20 sexual activity between clergy and a person aged 16-18, over …
Gov response: I should first like to assure the Inquiry that the criminal law already provides a number of protections to deal with non-consensual and unwanted sexual activity and abuse. These offences rightly carry robust sentences to …
Noted
FR-11 — Extend Disclosure Regime Overseas
Recommendation: The Inquiry recommends (as originally stated in its Children Outside the United Kingdom Phase 2 Investigation Report, dated January 2020) that the UK government introduces legislation permitting the Disclosure and Barring Service to provide enhanced certificates with barred list checks …
Gov response: We accept the need to review whether disclosure arrangements can be further strengthened for those working with children overseas, and we will consider the scope of further strengthening the regime, taking into account the findings …
Accepted in part
FR-10 — Improve DBS Referral Compliance
Recommendation: The Inquiry recommends that the UK government takes steps to improve compliance by regulated activity providers with their statutory duty to refer concerns about the suitability of individuals to work with children to the Disclosure and Barring Service, including: all …
Gov response: We accept the need to improve compliance with statutory duties to inform the Disclosure and Barring Service about individuals who may pose a risk of harm to children. We will work with the relevant bodies …
Accepted in part
FR-9 — Greater Use of DBS
Recommendation: The Inquiry recommends that the UK government enables any person engaging an individual to work or volunteer with children on a frequent basis to check whether or not they have been barred by the Disclosure and Barring Service from working …
Gov response: We accept subject to further assessment of feasibility and impact, taking into account the findings of the Bailey Review of Disclosure and Barring Regime published in April 2023.
Accepted in part
64 — Welsh independent school standards update
Recommendation: The Welsh Government should: update the Independent School Standards as a matter of urgency; update the national minimum standards for boarding schools as a matter of urgency; legislate so that all residential special schools are judged against the quality standards …
No response yet
63 — Extend TRA jurisdiction to teaching assistants
Recommendation: The Department for Education should amend the Teachers' Disciplinary (England) Regulations 2012 to bring all teaching assistants, learning support staff and cover supervisors within the misconduct jurisdiction of the Teaching Regulation Agency. The Department for Education and the Welsh Government …
No response yet
Prevention of Future Deaths reports(81)— showing 50 strongest matches
Daniel Onley
Concerns: The coroner noted insufficient arrangements and risk management for Daniel's anti-convulsant medication, and that the supervision provided for his safety and wellbeing was inadequate.
Response (The Camphill Village Trust): • The Trust completed internal audits of medicine administration and implemented a revised Medicines Policy. • The Trust incorporated regular training on risk management into its staff training plan and … (AI summary)
Overdue
Joan Farran
Concerns: The coroner noted that initial home visits by Social Services and healthcare professionals were limited to one room, overlooking significant clutter in other areas. Concerns were also raised about insufficient communication between services and delays in follow-up on medication and welfare.
Overdue
Christine Williamson
Concerns: The coroner identified that the deceased was not assessed as a Vulnerable Adult at risk, which led to insufficient information sharing among professionals and hindered the implementation of preventative measures.
Response (Telford Wrekin Council): • The Council compiled and submitted an action plan in response to the Regulation 28 report. • Most actions within the plan were already under way to implementation. • The … (AI summary)
Response (Telford Wrekin Clinical Commissioning Group): • The Adult Safeguarding Policy and Thresholds, along with domestic abuse guidance, have been recirculated to all GP Practices. • An education and training event for GPs and Practice Nurses, … (AI summary)
Response (West Mercia Police): • West Mercia Police stated it would provide a reminder to all operational staff regarding the requirement to complete DASH risk assessments, crime reports, and vulnerable adult documentation by 31 … (AI summary)
Responded
Wendy Brown
Concerns: The coroner noted concerns about the adequacy of public service signposting and funding routes for adult care, leading to a carer lacking respite support. There were also concerns about delays in processing applications for care packages, creating gaps in essential support for carers.
Response (Swindon Borough Council): • The Council confirmed that robust contractual arrangements and management, alongside internal audits, were in place for the separation of Adult Social Care functions. • An immediate action was taken … (AI summary)
Responded
Derrick Plater
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
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
Barbara Cooke
Concerns: Inadequate staffing at Waxham House impacted timely personal care and dignity, alongside insufficient protocols for chasing district nurses. St Mary's Hospital lacked systems for recording and reporting safeguarding alerts for inpatients.
Overdue
Kesia Leatherbarrow
Concerns: Incomplete information transfer between children's services meant a high-risk referral was not fully assessed or led to a CAMHS appointment. A Youth Offending Team case was also not transferred after a change of address, preventing a timely referral order assessment.
Response (Department of Health): • The Department of Health shared the coroner's report with NHS England. • The Children and Young People's Mental Health Taskforce published 'Future in Mind', which sets out a national … (AI summary)
Response (Home Office): • The Government partially amended the Police and Criminal Evidence Act (PACE) to treat 17-year-olds as children for detention after charge, requiring transfer to local authority accommodation. • The Government … (AI summary)
Response (Pennine Care NHS Trust): • A single point of access has been developed for CAMHS and RAID services, and a tracking system implemented to monitor administration timescales. • Standard practice now requires CAMHS mental … (AI summary)
Response (Crown Prosecution Service): • The Crown Prosecution Service (CPS) obtained a report from the Acting Chief Crown Prosecutor for CPS North West. • The Chief Crown Prosecutor for Greater Manchester is in dialogue … (AI summary)
Overdue
Sidney Barnett
Concerns: The coroner identified inadequate observation, general welfare care, and a lack of clear window opening policies at Berrycroft. Concerns were also raised regarding the Council's safeguarding investigation process, described as vague, unstructured, and over-reliant on care home staff statements.
Response: • The care home implemented a new room visit chart for all residents, requiring hourly checks and 15-minute checks if meals are taken in rooms. • All personal care forms … (AI summary)
Overdue
Phyllis Broomhead
Concerns: The coroner noted staff training needs at Lord Hardy Court EMI Residential Home concerning head injury protocols and seeking social worker input. Concerns were also raised regarding the sufficiency and objectivity of initial safeguarding referral screenings and the monitoring of high-risk residents.
Response (Rotherham Borough Council): • Rotherham Borough Council provided a detailed action plan in response to the Regulation 28 report. • The action plan outlined actions already taken by the Council. • The action … (AI summary)
Responded
Jeffrey Warren
Concerns: The coroner identified a lack of formal case review by local authorities, a hazardous electric fire left in a home, and social work staff's insufficient training and awareness regarding criteria for requesting police welfare checks.
Response (Crawley Borough Council): • The Council has implemented a procedure to consider alternative heating options for tenants who decline gas central heating. • The Council has implemented a procedure to increase efforts to … (AI summary)
Overdue
Isabel Richardson
Concerns: The coroner identified a lack of clarity regarding the purpose, operation, and training of the school's pastoral team, noting the system was insufficiently robust to address the student's needs.
Overdue
Allan Beasley
Concerns: The coroner noted staff were unaware of the falls prevention policy, leading to inadequate recording, escalation, and review of falls incidents. Additionally, patient observation forms were found to be inaccurate and documentation was not completed contemporaneously.
Overdue
Irene Scholey
Concerns: The coroner noted that Mrs Scholey's wellbeing could have been safeguarded had relevant agencies been able to access and share information about her home environment. The report describes that the Multi-Agency Safeguarding Hub (MASH) in Wakefield, currently serving children, could be extended to include elderly and vulnerable adults.
Overdue
Robert Mansfield
Concerns: Concerns were raised regarding the safety of the Millpond following three deaths, specifically the potential need for fencing, improved lighting, better warning notices, and accessible flotation equipment.
Overdue
Kamrul Rubel
Concerns: The gym did not enforce the use of the emergency stop cord, despite advising users to attach it, which raised concerns about the adequacy of advice and warnings provided to users.
Overdue
Norman Dorn
Concerns: The coroner raised concerns that some care homes in Cornwall may lack adequate policies for recognising and confirming death, and for resuscitation. There are also concerns that existing policies might not be regularly updated, or that staff may not be aware of them or adequately trained.
Overdue
Colin Williams
Concerns: The coroner expressed concern that individuals with complex needs and variable mental capacity faced significant difficulty navigating multiple agencies and understanding service funding. This "agency blindness" prevented access to support, compounded by changes in funding models and complex paperwork requirements.
Overdue
Anne Scott
Concerns: Care providers in the community lack adequate training to interpret special health monitoring devices (Telehealth) and act on the information provided. This leads to missed conditions, and the coroner highlights the need for county-wide implementation of relevant training recommendations.
Overdue
Adam Rice
Concerns: The coroner noted that clinicians should inform police about self-discharged patients requiring further investigation, and raised issues regarding West Yorkshire Police custody staff's knowledge of relevant acts and codes, as well as staffing levels during high demand.
Response (Adam Rice): • West Yorkshire Police confirmed that all custody staff receive initial and annual refresher training on relevant legislation and professional practice. • West Yorkshire Police is recruiting additional Detention Officers … (AI summary)
Overdue
Derrick Rose-Fowler
Concerns: The coroner noted insufficient first aid training for all prison officers, questioned the effectiveness of the prison's anti-bullying policy, and identified a lack of referral of the deceased's mental health and self-harm history to a Multi-Agency Safeguarding Hub (MASH) meeting.
Overdue
Ahmedreza Fathi
Concerns: Healthcare complex case planning lacked robustness and updates, with multi-disciplinary team meetings being informal and not providing ready access to all relevant risk assessment information. Services also failed to adequately investigate an earlier overdose event, which missed a safeguarding and learning opportunity.
Response (HM Prison and Probation Service): • HMP Gartree revised local contingency plans and re-issued instructions in May 2016 to ensure staff understanding of ambulance call procedures. • Local protocols now provide clear guidance for timely … (AI summary)
Response (East Midlands Ambulance Service NHS Trust): • The Trust stated that its management of Coronial processes is under review. • An initial meeting with HMP Gartree has been scheduled to address access issues, ambulance activation protocols, … (AI summary)
Responded
Gwendoline Clarke
Concerns: The coroner noted no staff reported a resident's injury and there was a 12-hour delay in escalating her allegations of being harmed by a staff member.
Response (Social Care): • The safeguarding policy will be reinforced, shared with staff, and updated to include out-of-hours reporting processes. • Protocols for unwitnessed accidents will be reinforced, and staff will receive refresher … (AI summary)
Overdue
Olive Wilmott
Concerns: The coroner noted a lack of effective investigation or safeguarding referral regarding possible pushing, despite medical records, and insufficient evidence of mandated 15-minute observations. There were also insufficient night staff to meet residents' needs on the dementia unit.
Overdue
Rebecca Gilbank
Concerns: The coroner noted insufficient staff resources led to missed checks for service users, and staff lacked knowledge on how to obtain an outside telephone line for emergency calls, causing a delay.
Response (Independence Homes): • The organisation changed its telephone contract to remove the requirement to dial 9 for an outside line. • The change was communicated to staff verbally, by email, and in … (AI summary)
Responded
Carol Leesley
Concerns: A safeguarding referral made by a GP was not acted upon despite automated acknowledgment, and it was unclear if this was due to human or IT error.
Response (Sheffield City Council): • The automated email response was amended to include a notification for referrers to contact the team if they do not receive a response within two working days. • All … (AI summary)
Responded
Arthur Adley
Concerns: Safeguarding systems for residents who present a risk to other residents in care homes did not prevent that risk to other residents.
Response (Department of Health): • The Department of Health forwarded the report to the Care Quality Commission. (AI summary)
Responded
Ivy Mitchell
Concerns: The coroner noted inaccurate falls risk documentation, a lack of staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes following a fall. There was also a lack of understanding regarding triggers for community nutrition team referrals.
Response (Fairfield View Care Centre): • The care centre audited documentation related to falls and mobility for all service users. • Senior staff attended a meeting on documentation and falls procedures, and this information was … (AI summary)
Overdue
Ruth Milne
Concerns: The coroner identified concerns regarding the continuity and appropriateness of medical staff dispatched by Hawthorn Medical Practice GPs, and questioned the implementation status of recommendations from a November 2015 safeguarding report.
Response (Ruth Milne): • The organisation has established additional leg ulcer clinics and implemented a caseload review tool across Lincolnshire Community Health Services (LCHS), with case managers allocated to GP practices. • A … (AI summary)
Overdue
Kevin Morgan
Concerns: The coroner raised concerns about the lack of effective follow-up by social services and housing, an inadequate response to a safeguarding alert, and the absence of a serious incident review following the death.
Response (Milton Keynes Safeguarding Board): • A referral was made to the Milton Keynes Safeguarding Board for a Safeguarding Adults Review (SAR). • A multi-agency learning review was commissioned to identify learning and improve practice. … (AI summary)
Responded
Robert Mullis
Concerns: A vulnerable, partially sighted passenger with dementia was able to disembark a train unsupervised at an intermediate station, subsequently accessing railway tracks and being struck by trains.
Response (Robert Mullis): • Platform-end fencing and anti-trespass panels have been installed at both ends of platforms 2, 5, and 6, and the London end of platform 1 at Ashford International Station. • … (AI summary)
Overdue
Doreen Miller
Concerns: The coroner noted insufficient investigation by Wiltshire Council into a safeguarding referral regarding possible financial abuse. Additionally, Great Western Hospital's discharge summary did not include critical information about a patient's failed cognitive assessment.
Overdue
James Harris
Concerns: The coroner identified that care home staff did not follow a resident's falls risk care plan or post-fall protocols for seeking medical attention and offering pain relief. Insufficient staff awareness of policies and inadequate record-keeping were also noted.
Response (Care First Class UK): • The organisation has implemented read and sign sheets for staff to acknowledge care plans within 72 hours of a resident's arrival. • The falls protocol has been distributed to … (AI summary)
Response (CQC): • The Care Quality Commission (CQC) conducted a comprehensive inspection of Cherry Lodge Care Home in August 2017, bringing forward its scheduled date. • Cherry Lodge Care Home implemented new … (AI summary)
Responded
Russell Robb
Concerns: The coroner identified a lack of regular medication reviews and no guidelines to limit medication availability. Additionally, limited information sharing within the Trafford Adult Safeguarding Board hindered awareness of police interactions with Mr Robb and restricted strategic oversight.
Response (Trafford Safeguarding Board): • Greater Manchester Police (GMP) now records high volume callers more accurately and has co-located its prioritisation and allocation function within the Partnership Office. • The adult social care Screening … (AI summary)
Responded
Ellie Butler
Concerns: The provided text indicates that specific concerns were appended to the report but does not detail them.
Overdue
Janie McFadyen
Concerns: The coroner identified a lack of clear protocols for managing missing persons, particularly high-risk individuals, and insufficient arrangements for seeking help from NHS services. Concerns were also raised about placing reporting responsibility on family and the need for updated staff training.
Response (Victory Outreach): • Victory Outreach Manchester reviewed and updated its protocols, policies, and procedures, including new policies for safeguarding, missing persons, and incident reporting. • Resident files were updated to include comprehensive … (AI summary)
Response (Charity Commission): • The Charity confirmed that communication gaps have been closed and the system for informing trustees is functioning properly. • The Charity provided copies of revised policies, including review dates. … (AI summary)
Responded
Barnaby Aylward
Concerns: The coroner raised concerns regarding the absence of a multi-agency preventative approach to assess and manage risks from a social housing tenant's behaviours linked to his serious mental illness, including insufficient documentation of these risks in mental health care plans and clinical notes.
Response: • West Yorkshire Fire and Rescue Service (WYFRS) led a Serious Incident Review in October 2017, which included actions to review partnership arrangements and provide refresher training to partner staff. … (AI summary)
Overdue
Alex Malcolm
Concerns: Concerns were raised about the sufficiency of Approved Premises places and difficulties in recruiting and retaining probation officers. The coroner also noted the need to strengthen domestic violence arrangements, including statutory MARACs, with details on actions taken often absent.
Response (HM Prison and Probation Service): • HM Prison and Probation Service introduced a new pay structure for the National Probation Service in April 2018, which included a two-year pensionable pay award. • It implemented a … (AI summary)
Overdue
Katie Croft
Concerns: The coroner identified an inexperienced police officer handling the investigation, which led to delayed evidence seizure and insufficient focus on the child's voice. There were also gaps in information sharing between agencies and reliance on agency social workers by the Local Authority.
Overdue
Archie Spriggs
Concerns: The coroner noted concerns regarding the clarity and auditing of referral pathways to children's social care, and the understanding of professionals making urgent referrals. There were also gaps in multi-agency knowledge concerning private law proceedings and features of filicide cases.
Response (SSP): • The Shropshire Safeguarding Partnership (SSP) stated it is responsible for owning and governing delivery against the action plan derived from the Serious Case Review. • The SSP confirmed it … (AI summary)
Overdue
Jacob Bates
Concerns: The coroner raised concerns that vulnerable 16-18 year olds are placed in unregulated settings, which lack statutory inspection and regulatory compliance. This means staff competency and adequate policies are not consistently verified, placing an impractical burden on local authorities for oversight.
Response (the Secretary of State for Education): • The Secretary of State for Education launched a consultation on proposals for unregulated provision on 12 February 2020. • The proposals include introducing new national standards for providers of … (AI summary)
Responded
June Winterbottom
Concerns: The urgent referral system within Adult Social Care was ineffective, leading to no contact with a vulnerable individual. Additionally, there was no safety net for ambulance referral if the Adult Social Care team could not respond promptly.
Response (Wakefield Council): • The council implemented immediate arrangements for Social Care Direct staff to access extended hours rotas and directly confirm urgent referral receipt. • The referral transfer process was made robust … (AI summary)
Responded
Geoffrey Banks
Concerns: The coroner identified a lack of a safe medication storage system for residents requiring supervision, noting the deceased could easily access a locked cupboard and subsequently overdosed. Additionally, the investigation into the incident was perfunctory and conducted by untrained staff.
Response (Adult Social Care Health Integration and Wellbeing): • The council shared the coroner's report and concerns with the care provider and housing group. • The council committed to reviewing lockable cupboard specifications in contracts and inspecting existing … (AI summary)
Response (Comfort Call): • The organisation will review its standard Extra Care Scheme protocols template to consider secure medicines storage in each flat and require managers to review their schemes. • Management training … (AI summary)
Overdue
Anthony Slack
Concerns: The coroner noted limited documentation and observations at the care home, an unclear COVID-19 origin due to no admission risk assessment, and staff confusion over PPE guidance. Ambulance delays also impacted the transport of vulnerable patients to acute settings.
Response (NHS England and NHS Digital): • North West Ambulance Service (NWAS) established cleaning teams to assist ambulance crews with additional cleaning following patient handovers. • The cleaning service was initially rolled out to eight Emergency … (AI summary)
Response (UK Health Security Agency): • The UK Health Security Agency (formerly Public Health England) established a national team to lead the organisational response to COVID-19 in adult social care settings, coordinating with partners and … (AI summary)
Response (CQC): • The care home implemented improved post-falls management systems, including new observation protocols, monitoring equipment, and staff training on daily record keeping. • The care home confirmed adherence to government … (AI summary)
Response (Greater Manchester Health and Social Care Partnership): • The care home accepted documentation awareness training and updated its Covid-19 admission procedures to require a negative test. • NWAS established cleaning teams at Emergency Departments, including Tameside Hospital, … (AI summary)
Response (Vicarage Care Home): • The care home completed documentation training for all staff and updated its recording policy and proformas. • It implemented regular COVID-19 and infection control training, reviewed its admission policy, … (AI summary)
Responded
Roy Curtis
Concerns: The coroner noted that the procedure for urgent adult social care assessments is overly bureaucratic and these referrals are not given sufficient priority within social services.
Response (Milton Keynes Council): • The Adult Social Care Practice Guidance was updated to include procedures for managing situations where contact with a person referred for assessment has not been possible. • A link … (AI summary)
Responded
Edward Bilbey
Concerns: England Boxing lacked adequate and enforceable child protection and safeguarding measures, along with a policy for checking compliance. This resulted in outdated welfare officer information and registered inactive coaches at a club.
Response (England Boxing): • England Boxing has updated its rule book, overhauled its website, and drafted new emergency action policies. • It has restructured coaching courses, introduced mandatory safeguarding training, and updated certification … (AI summary)
Response (DCMS): • The department works with Sport England and the Child Protection in Sport Unit (CPSU) to review and strengthen safeguarding provision. • Publicly funded sports organisations are required to meet … (AI summary)
Responded
Ann Mowbray
Concerns: The coroner noted that the Christian Congregation of Jehovah's Witnesses (CCJW) does not have a safeguarding policy for vulnerable adult members, and their response to adopting one was unclear.
Response (Christian Congregation of Jehovahs Witnesses): • The Christian Congregation of Jehovah’s Witnesses outlined its long-standing religious practice and guidance, detailed in publications, for supporting vulnerable adult members. • The Congregation stated that its members are … (AI summary)
Responded
Glenn Macmartin
Concerns: The organisation responsible for providing accommodation selected the deceased's care home, which later closed due to poor service, without first physically inspecting its suitability.
Response (Wonford House Hospital): • The Trust implemented a policy requiring physical inspections of new care providers before contracting. • A redesign of social care delivery within the Trust has been completed, establishing dedicated … (AI summary)
Response (CQC): • The CQC took enforcement action against Annette’s Care Limited, which resulted in the cancellation of its registration and the closure of the care home. • The CQC conducted an … (AI summary)
Response (Plymouth Safeguarding Adults Partnership): • The Plymouth Safeguarding Adults Partnership (PSAP) SAR sub-group reviewed a referral for a Safeguarding Adult Review (SAR) for Mr MacMartin and determined it did not meet the statutory criteria. … (AI summary)
Responded
Dorothy Seekings
Concerns: Care plans for the resident did not record incidents of aggression towards staff, nor was a safeguarding alert raised for such an incident. Additionally, staff appeared unaware of the contents of the resident's care plan.
Response (Crosscrown Ltd): • Crosscrown Ltd implemented a digital care management software system, CareDocs, across all homes, enabling staff to record daily notes, conduct care assessments, and access resident care plans. • An … (AI summary)
Responded
Charlotte Duffield
Concerns: The coroner noted that despite a referral to Adult Social Care due to significant safety concerns, no safeguarding action was taken, particularly after the individual did not respond to telephone contact and no in-person visit was made.
Response (Cumbria County Council): • Cumbria County Council completed a systematic review of its self-neglect policy and procedure documentation. • Operational practice guidance for self-neglect concerns was reviewed and revised to reinforce the requirement … (AI summary)
Responded
Select committee recommendations(98)— showing 50 strongest matches
#163 —
Recommendation: The Probation Service is aware of these challenges. Chris Jennings told us that âthere are still definitely areas where sharing information across the system is complicatedâ. For instance, he told us that âgetting information on child safeguarding is not straightforwardâ …
Response attribution not verified
#13 —
Recommendation: For those consumers who are aware that support is available through the PSR, there is confusion about what that support is. CCW research indicates that, during supply interruptions in Tunbridge Wells around Christmas 2025, half of the people on the …
#42 —
Recommendation: We have heard some concerns about the varying quality of reviews of deaths of children in care. The government should investigate these concerns to ensure that safeguarding partners understand their role in notifying relevant authorities of children’s deaths, and that …
Response status not verified
#40 —
Recommendation: This change in the law would be of particular relevance to children in care, because there would be increased protections for children before they enter the care system, potentially allowing for concerns in home environments to be identified and flagged …
Response status not verified
#39 —
Recommendation: In line with recommendations made by the Children’s Commissioner for England and the UN Committee on the Rights of the Child, there should be a change in the law to give children equal protection from physical assault to adults. The …
Response status not verified
#30 —
Recommendation: The consequences for children in care of the Supreme Court’s recent changes to the law on deprivation of liberty should be kept carefully under review. It is crucial that children who are held in conditions akin to confinement are not …
Response status not verified
#29 —
Recommendation: We appreciate that in certain circumstances, for welfare reasons, children in care may be deprived of their liberty. But every effort should be employed to offer support to children before depriving them of their liberty. Deprivation of liberty must be …
Response status not verified
#28 —
Recommendation: We agree with the Children’s Commissioner for England and with the recommendation made in the 2022 Independent Review of Children’s Social Care that a universal set of standards of care should be introduced and applied to all settings of the …
Response status not verified
#24 —
Recommendation: Unregulated accommodation, including caravans, holiday rentals or AirBnBs, do not allow for formal inspections or scrutiny. Such settings are unlawful, unsafe, and represent a serious failure to protect children. They are also not good value for public money. We are …
Response status not verified
#15 —
Recommendation: We also welcome the Law Commission’s project on legal reform of kinship care. We particularly welcome the Law Commission’s plans to investigate the benefits and drawbacks of introducing a bespoke order to recognise, support, and regulate kinship care. Such an …
Response status not verified
#9 —
Recommendation: Ensuring that disabled children are safe from harm is, of course, extremely important. In some circumstances, such as where there is evidence of risk of harm or abuse to the child, a child protection approach may be appropriate and, indeed, …
Response status not verified
#4 —
Recommendation: The government should take steps to fully incorporate the UNCRC into domestic law in England. Until full incorporation takes place, the government should consider short-term measures, such as developing mandatory child-rights impact assessment procedures for legislation and policies relevant to …
Response status not verified
#3 —
Recommendation: Incorporation of the UNCRC could be very beneficial for children in care and children receiving support from the children’s social care system. Benefits could include the promotion of care standards and the creation of further avenues for dealing with breaches …
Response status not verified
#2 —
Recommendation: As mentioned by many stakeholders, including the Children’s Commissioner for England, the UN Committee on the Rights of the Child, and UNICEF, incorporation would give the UNCRC teeth, increasing protections for children in England, and enhancing accountability of public authorities. …
Response status not verified
#1 —
Recommendation: Although the UK has signed and ratified the UNCRC, England has not incorporated the Convention, while Wales has indirectly incorporated it, and Scotland has directly incorporated it into Scots Law. This creates inconsistency in the application of UNCRC protections for …
Response status not verified
#17 —
Recommendation: Where government manages disclosure after a period of operational secrecy in a case involving credible risk to life, it should treat disclosure and notification as a safeguarding intervention. Break- glass arrangements should be tested in advance and designed around the …
Response status not verified
#24 —
Recommendation: The Government must keep under review the efficacy of the mandatory reporting duty once it is in place, with a view to expanding its scope if necessary. The Government should also reconsider the consequence of failing to comply with the …
Response attribution not verified
#23 —
Recommendation: We welcome the introduction of mandatory reporting of child sexual abuse, which represents an important step forward for protection of children’s human rights. However, we are concerned that the scope of the duty and particularly the consequences of breach may …
Response attribution not verified
#28 —
Recommendation: The Department should ensure that lessons learned from the handling of asylum moves during the lockdown are referred to the safeguarding board and incorporated into the safeguarding and assurance frameworks. The Department should consider how local authorities and third sector …
Response attribution not verified
#11 —
Recommendation: We remained concerned that the Department had continued its policy of discharging people untested into care homes even once it was clear there was an emerging problem.26 The number of first-time outbreaks in individual care homes peaked at 1,009 in …
Response attribution not verified
#10 —
Recommendation: Some organisations such as Care England highlighted to us the flawed nature of this policy and reported that, given the absence of testing and inadequate PPE, social care felt abandoned.21 When we challenged the Department and the NHS on such …
Response attribution not verified
#2 —
Recommendation: Discharging patients from hospital into social care without first testing them for COVID-19 was an appalling error. Shockingly, Government policy up to and including 15 April was to not test all patients discharged from hospital for COVID-19. In the period …
Response attribution not verified
#24 —
Recommendation: HMCI Amanda Spielman told us it was “very un-joined up” that children who were on a child protection plan and experiencing harm could be withdrawn into home education. We share HMCI’s concerns and call on the Department to ensure that …
Response attribution not verified
#16 —
Recommendation: The national Child Safeguarding Practice Review Panel, set up to commission reviews of serious child safeguarding cases, has consistently highlighted cases in which poor coordination between services, including insufficient joined-up leadership and a lack of appropriate and timely information-sharing around …
Response attribution not verified
#13 —
Recommendation: We asked the Department for Education what is being done to review multi-agency safeguarding partnerships to ensure they work better and to stop horrific events, such as the cases of Star Hobson and Arthur Labinjo-Hughes from recurring. The Department for …
Response attribution not verified
#11 —
Recommendation: Multi-agency safeguarding partnerships started in 2019, aimed at joining up local NHS, policing, and local authority services to safeguard and promote the welfare of all children in their area.25 In May 2022, three years after they started, the Child Safeguarding …
Response attribution not verified
#3 —
Recommendation: Critical local multi-agency safeguarding partnerships are still not working well enough, which risks those vulnerable adolescents that need support and help falling through the gaps. While in some places multi-agency safeguarding partnerships may work well, in other places, sadly, they …
Response attribution not verified
#19 — Home Office contracts for migrant accommodation lack specified penalties for safeguarding failures.
Recommendation: The Home Office told us that health and welfare of migrants was “baked into” the way that it runs the sites and the contracts with suppliers. It said there were clear key performance indicators (KPIs) on accommodation being safe and …
Response attribution not verified
#18 — Home Office still developing specific safety measures for residents in large accommodation sites.
Recommendation: The Home Office is responsible for the safety and wellbeing of people in its care, whether they are claiming asylum or pending relocation. But the National Audit Office reported that, in January 2024, the Home Office was still developing specific …
Response attribution not verified
#67 — Urgent need to implement IICSA recommendations as mandatory reporting is limited.
Recommendation: There is an urgent need to take forward the recommendations of the Independent Inquiry into Child Sexual Abuse. The introduction of the mandatory reporting duty is an important step forward, but it is limited in scope to instances of a …
Response attribution not verified
#65 — Put in place a national strategy to reduce the incidence of child neglect.
Recommendation: The Department for Education must put in place a national neglect strategy to set out how it will reduce the incidence of neglect. (Recommendation, Paragraph 161) 92
Response attribution not verified
#64 — Rising child neglect linked to poverty lacks clear DfE strategy and social care response.
Recommendation: Neglect is sadly on the rise in England and is clearly linked to poverty and poor parental mental health. The Department for Education does not appear to have a clear strategy for addressing neglect and there are concerns that the …
Response attribution not verified
#62 — Establish clear processes for reviewing and escalating multi-agency child safeguarding disagreements.
Recommendation: Multi-agency working is crucial in child safeguarding processes. Where there is disagreement between children’s social care and other agencies such as health, police and education on a safeguarding matter, there must be clear processes in place to review and escalate …
Response attribution not verified
#46 — Serious recruitment and retention problems in children's social care workforce require wholesale review.
Recommendation: There is a serious problem with recruitment and retention in the social care workforce. High turnover and overstretched staff are exacerbating the instability experienced by children in care and increase the risk of 89 safeguarding concerns being overlooked. The Department …
Response attribution not verified
#1 — Children’s social care problems persist and worsen without comprehensive reform following the Independent Review.
Recommendation: Evidence given to the Committee during our inquiry indicates that many of the problems highlighted by the Independent Review of Children’s Social Care in 2022 persist, and in a significant number of cases have worsened since the Review. Increases in …
Response attribution not verified
#24 — A balance between FGM prevention and prosecution is crucial, rejecting cultural sensitivities.
Recommendation: While some FGM survivors and campaigners believe more needs to be done to secure convictions against perpetrators of FGM, others believe a strong focus on criminalisation can hinder efforts to engage with communities to prevent FGM and support FGM survivors. …
Response attribution not verified
#13 — Ofsted faces significant delays registering supported accommodation providers, impacting the use of illegal provision.
Recommendation: The Department described the delays in Ofsted registering providers, and how this impacted the use of illegal provision. Changes to the law requiring the registration of those providing supported accommodation for 16 and 17-year-olds, strengthening oversight, led to a significant …
Response attribution not verified
#11 — Lack of oversight leaves children in illegal unregistered homes at significant risk.
Recommendation: Ofsted cannot routinely inspect unregistered homes and local authorities are not obliged to inform Ofsted when they place children in unregistered care, even though it is illegal for providers to operate such homes.22 In such cases there are no formal …
Response attribution not verified
#2 — Reaffirm commitment to reducing children in unregistered homes to zero by 2027 and detail specific actions.
Recommendation: It is unacceptable that children are placed in illegal settings that are not inspected, increasing safety risks and offering no assurance over the quality of care. Over the last five years, local authorities have reported placing more and more children …
Response attribution not verified
#32 — Improve age dispute identification in asylum accommodation, ensuring staff training and compliance monitoring
Recommendation: The Home Office should review and make improvements to arrangements for identifying and responding to age dispute cases in adult asylum accommodation and ensure that there is clear guidance for accommodation providers. To protect the welfare of children in the …
Response attribution not verified
#31 — Significant failings in age assessment lead to children in adult asylum accommodation
Recommendation: There are significant failings in the current processes for making initial decisions about age and unreliable decisions are still leading to children being incorrectly placed in adult accommodation. We do not have confidence that the arrangements for accommodation providers to …
Response attribution not verified
#30 — Strengthen safeguarding framework, training, and oversight for asylum accommodation providers
Recommendation: We recommend that the Home Office strengthens its approach to safeguarding by: a. Ensuring that there is a robust framework for overseeing and auditing how safeguarding policies and processes are applied on the ground by contractors and subcontractors; b. Ensuring …
Response attribution not verified
#29 — Significant safeguarding failings persist in asylum accommodation with inadequate oversight
Recommendation: We are deeply concerned by the volume of evidence indicating significant safeguarding failings in asylum accommodation. While there are evidently pockets of localised good practice, the response to safeguarding concerns is inconsistent and often inadequate, leaving vulnerable people at risk …
Response attribution not verified
#16 —
Recommendation: The government approached notification of affected Afghans primarily as a communications exercise rather than as a safeguarding intervention. Although the notification reached most affected individuals, it did not provide sufficiently specific, actionable or individualised information to enable people to understand …
Response status not verified
#14 —
Recommendation: The Home Office and the police should be added to the list of public bodies subject to the statutory ‘duty to refer’ and included in the forthcoming proposals for a ‘duty to collaborate’. (Recommendation, Paragraph 75)
Response status not verified
#1 —
Recommendation: We are concerned that the breadth of these precursor offences poses a risk of unintended harms to those who are most vulnerable. To mitigate this risk, we consider that the precursor offences would benefit from greater circumscription and more robust …
Response attribution not verified
#20 —
Recommendation: The Department must revisit and revise key statutory guidance such as Working Together to Safeguard Children as soon as possible, so that they explicitly contain EHE within their scope, and contain clear and consistent messages for families, local authorities and …
Response attribution not verified
#3 —
Recommendation: The Committee heard from home educators that home-educated children are not ‘invisible’, and that safeguarding has failed children who were already known to local authorities. However, the relevant authorities cannot begin to reach any children who may be at risk …
Response attribution not verified
#12 —
Recommendation: The three statutory partners (police, health, and local authorities) of multi-agency safeguarding partnerships’ have a shared and equal duty to protect children and young people. We asked who in the system has responsibility for children who fall through the gaps …
Response attribution not verified
#4 —
Recommendation: It is not clear how lessons and learning from changing threats, serious case reviews and child safeguarding review panels are embedded in day-to-day practice. Time and again reviews into child deaths highlight poor coordination between services, including insufficient joined-up leadership …
Response attribution not verified
HSSIB safety recommendations(11)
Safety issues for people experiencing a mental health crisis who come into contact with urgent …
HSSIB recommends that the Department of Health and Social Care urgently reviews the current legal framework and addresses the current legislative gaps in emergency care for people in mental health crisis and clarify the extension of legal powers for health …
Safety Recommendation
Non-accidental injuries in infants attending the emergency department
Psychosocial multidisciplinary team (MDT) meetings: These meetings were held to discuss children (under 18 years) who had attended the ED and about whom there were safeguarding concerns. It was attended by various safeguarding stakeholders, including the police, violence reduction team …
Learning Prompt
Non-accidental injuries in infants attending the emergency department
Induction training: Benefits were seen where relevant staff had undergone a training session during which adult and child safeguarding was discussed, with a focus on how and when sharing of information between organisations is appropriate for safeguarding.
Learning Prompt
Non-accidental injuries in infants attending the emergency department
It may be beneficial if safeguarding teams are either physically located near to, or make efforts to promote their visibility in, emergency departments.
Safety Observation
Non-accidental injuries in infants attending the emergency department
It would be beneficial if the safeguarding operating model, to be tested through pathfinders, included a response time for advice when sought by professionals such as emergency department clinicians.
Safety Observation
Non-accidental injuries in infants attending the emergency department
It may be beneficial if there was an electronic system available for clinicians to view any safeguarding information to assist in decision making.
Safety Observation
Non-accidental injuries in infants attending the emergency department
HSIB recommends that NHS England, working with relevant stakeholders, reviews the utility of the safeguarding data in the Emergency Care Data Set and agrees a process for assuring the quality of any data to be captured.
Safety Recommendation
Non-accidental injuries in infants attending the emergency department
HSIB recommends that the Royal College of Emergency Medicine, working with relevant stakeholders, develops guidance to support clinicians in the diagnosis and management of non-accidental injuries.
Safety Recommendation
Sexual safety: the implications for patient safety
Health and care organisations can improve patient safety by capturing the impacts, events and circumstances where sexual safety incidents have affected the provision of safe care. This would help organisations to understand and assess the risks posed to patient safety.
Safety Observation
Non-accidental injuries in infants attending the emergency department
Simulation training: The regular inclusion of a safeguarding element within simulation training has been seen to increase the confidence of staff to deal with safeguarding issues.
Learning Prompt
Surgical care of NHS patients in independent hospitals
HSIB recommends that the Care Quality Commission reviews and appropriately develops its methodology for regulatory assurance of arrangements between NHS and independent providers for the provision of care across care pathways. This is to include any screening and risk management …
Safety Recommendation
NCEPOD recommendations(1)
CQC inspection actions(203)— showing 50 strongest matches
The York Hospital
The trust should consider increasing the frequency of safeguarding reporting to board to improve oversight.
Should Do
The York Hospital
The service must implement an effective system to assess and monitor compliance to ensure the baby tagging process is adhered to in line with trust policy.
Must Do
The York Hospital
The service must ensure ED nursing and medical staff training compliance in the mental capacity act (MCA) and deprivation of liberty safeguard (DoLS) meets trust target.
Must Do
The York Hospital
The service must ensure all patients in ED are wearing wristbands at all times for improved safeguarding, security and easier identification when prescribing and administering medications.
Must Do
The Princess Royal Hospital
The service should consider applying for a Deprivation of Liberty Safeguard for patient’s whose liberty is deprived for extended periods of time in the emergency department.
Should Do
The Princess Royal Hospital
The trust must ensure systems and processes to safeguard patients from abuse and improper treatment are fully implemented. This includes safeguarding checks and assessments are completed and actions taken to safeguard patients are documented.
Must Do
South Tyneside District Hospital
The trust must ensure service user records are audited appropriately to evidence ongoing compliance with the requirements of the Mental Capacity Act 2005 and to identify missed opportunities to safeguard service users.
Must Do
South Tyneside District Hospital
The trust must ensure service user records are audited appropriately to evidence ongoing compliance with the requirements of the Mental Capacity Act 2005 and to identify missed opportunities to safeguard service users.
Must Do
Scarborough Hospital
The service must ensure ED nursing and medical staff training compliance in the mental capacity act (MCA) and deprivation of liberty safeguard (DoLS) meets trust target.
Must Do
Scarborough Hospital
The service must ensure all patients in ED are wearing wristbands at all times for improved safeguarding, security and easier identification when prescribing and administering medications.
Must Do
Royal Sussex County Hospital
The trust should review safeguarding arrangements in line with the intercollegiate guidance for safeguarding to ensure staff training is suitable for frontline staff.
Should Do
Royal Stoke University Hospital
The service should review current safeguarding processes in place to ensure staff complete safeguarding risk assessments at every appointment.
Should Do
Royal Shrewsbury Hospital
The service should consider applying for a Deprivation of Liberty Safeguard for patient’s whose liberty is deprived for extended periods of time in the emergency department.
Should Do
Royal Shrewsbury Hospital
The service should consider how it segregates children and adults in the main waiting area.
Should Do
Royal Shrewsbury Hospital
The trust must ensure systems and processes to safeguard patients from abuse and improper treatment are fully implemented. This includes safeguarding checks and assessments are completed and actions taken to safeguard patients are documented.
Must Do
Rotherham General Hospital
The trust should ensure that all continuing improvements to safeguarding processes are fully embedded.
Should Do
Rotherham General Hospital
The trust must ensure that staff escalate all safeguarding concerns appropriately.
Must Do
Queen's Medical Centre
The trust must ensure staff carry out risk assessments to keep women, their babies and staff safe from potential abuse.
Must Do
Queen Elizabeth Hospital
The services should ensure specialist staff have access to appropriate safeguarding supervision to carry out their duties.
Should Do
Pilgrim Hospital
The service must ensure systems and processes to check nationally approved child protection information sharing systems are fully embedded and compliance is monitored.
Must Do
Pilgrim Hospital
The trust must ensure systems and processes to check nationally approved child protection information sharing systems are fully embedded and compliance is monitored.
Must Do
Orpington Hospital
The provider must ensure that service users are safeguarded from abuse and improper treatment.
Must Do
Mount Vernon Cancer Centre
The trust should ensure that all practicable steps have been taken to meet national guidance in regard to the environment to ensure the safety of children and young people accessing the service.
Should Do
Kettering General Hospital
The servicemust ensure staff consistently complete safeguarding documentation in the emergency department and make external safeguarding referrals in a timely manner in line with trust policy.
Must Do
Kent & Canterbury Hospital
The trust must ensure staff maintain comprehensive records of deprivation of liberty safeguards.
Must Do
Fleetwood Hospital
The trust should ensure staff complete an incident form when safeguarding referrals are made, in line with trust policy.
Should Do
Ellesmere Port Hospital
The trust must ensure service user records are audited appropriately to evidence ongoing compliance with the requirements of the Mental Capacity Act 2005 and to identify missed opportunities to safeguard service users.
Must Do
Cumberland Infirmary
The trust must implement an effective system to identify and assess any potential safeguarding issues and the management of vulnerable children and young persons. Regulation 13(1)(2).
Must Do
Colchester General Hospital
The trust should ensure all areas are secure and only authorised personnel have access.
Should Do
Clatterbridge Hospital
The services should continue to monitor adherence with Deprivation of Liberty Safeguards documentation requirements.
Should Do
Clatterbridge Hospital
The services should consider how best to have an effective track and monitoring of deprivation of liberty safeguarding applications.
Should Do
Ambulance Headquarters, Bernicia House
Ensure patients are protected from abuse and improper treatment.
Must Do
Airedale General Hospital
The service must ensure that safeguarding systems and processes are established and operated effectively to prevent abuse of service users.(Regulation13(2))
Must Do
The Walton Centre
The service should consider reviewing staff’s understanding of Mental Capacity Act 2005 and Deprivation of Liberty Safeguards to ensure all staff understand the rationale for actions taken.
Should Do
The Walton Centre
The trust should continue to improve the systems for the management of Deprivation of Liberty applications.
Should Do
St Benedict's Hospice
The service should ensure that children’s services take formal responsibility for the children managed at the eye infirmary.
Should Do
St Benedict's Hospice
The service must ensure the environment where children and young people are cared for is secure and access limited to those who need it.
Must Do
St Benedict's Hospice
The service MUST ensure staff always follow national guidance when patients lack capacity to give consent. Staff must always use measures that limited patients' liberty appropriately.
Must Do
Fairfield General Hospital
The trust should ensure the system to track and monitor compliance with Deprivation of Liberty Safeguards and the Mental Health Act is understood by staff.
Should Do
Fairfield General Hospital
The trust should ensure all staff follow Deprivation of Liberty Safeguards legislation so that no patients are deprived of their liberty without lawful authority.
Should Do
Oakwood
The provider must ensure the principles of the Mental Capacity Act 2005 are followed.
Must Do
West Cornwall Hospital
The service should improve compliance with safeguarding checklist before patients are discharged from the urgent treatment centre.
Should Do
St Lawrence Road Surgery
Add alerts to the electronic record of children with a safeguarding concern.
Should Do
School Health
The service should ensure that there are robust arrangements in place to mitigate any risks associated with staff non-attendance at any child protection case conferences and reviews.
Should Do
School Health
The service must ensure that the safeguarding children policy and any associated procedures are thoroughly reviewed to check they accurately reflect current national guidance and are relevant to the current provider.
Must Do
Royal United Hospital Bath
The service should make sure all women and birthing people are asked the relevant safeguarding questions at each contact.
Should Do
Royal Primary Care Chesterfield West
Add alerts to all the records of family members living in the same household as children with a known safeguarding concern.
Should Do
Rochdale Infirmary
The trust should ensure the system to track and monitor compliance with Deprivation of Liberty Safeguards and the Mental Health Act is understood by staff.
Should Do
Rochdale Infirmary
The trust should ensure all staff follow Deprivation of Liberty Safeguards legislation so that no patients are deprived of their liberty without lawful authority.
Should Do
Poole Hospital
Embed the revised process for safeguarding particularly when women are transferred from another healthcare provider.
Should Do
HMICFRS recommendations(4)
An inspection of the service provided to victims of crime by Greater …
Within three months the force should start crime-recording training for all supervisors, officers and staff in a crime recording role, to include the crime-recording requirements for harassment, stalking and coercive and controlling behaviour offences.
Recommendation
An inspection of the service provided to victims of crime by Greater …
Within three months the force should make arrangements to improve the use and supervision of cautions and community resolutions so that they are only applied in appropriate circumstances, taking into account the nature of the offence and the background of …
Recommendation
An inspection of the service provided to victims of crime by Greater …
Within three months the force should complete an assessment of the standard and supervision of investigation plans and put in place any identified remedial actions to ensure the plans support a high standard of investigation and a good service to …
Recommendation
An inspection of the service provided to victims of crime by Greater …
Within three months the force should complete a review to understand why it uses such a high proportion of outcome 16 (where a victim is recorded as not supporting or withdrawing support for police action) in respect of domestic abuse. …
Recommendation
ICIBI immigration recommendations(6)
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 6 Review the guidance to “Monitoring Officers” regarding their safeguarding responsibilities and produce workable advice on how they are to satisfy themselves that a child or young person, or …
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 5 Ensure that sufficient “Roving Officers” are deployed at Stansted to discharge fully Border Force’s responsibilities for safeguarding passengers, both adults and children, in particular when 15 or more …
An inspection of the use of hotels for housing unaccompanied asylum-seeking children …
Strengthen assurance and monitoring mechanisms to ensure it is satisfied that contractors are meeting safeguarding and other requirements, including, but not limited to:
An inspection of contingency asylum accommodation for families with children in Northern …
The Home Office should strengthen assurance and monitoring arrangements to ensure accommodation providers, and their contractors and sub-contractors, are meeting all the standards set out in the Asylum Support Contracts …
An inspection of Border Force operations at Stansted Airport
Recommendation 6 Review the guidance to “Monitoring Officers” regarding their safeguarding responsibilities and produce workable advice on how they are to satisfy themselves that a child or young person, or …
Inspection report on an interim re-inspection of family reunion, July 2017
Introduce a criteria for expediting applications based on vulnerability.
PPO death in custody recommendations(1)
IOPC learning recommendations(4)
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police remind OIC’s of their responsibility to consider Clare’s Law when dealing with domestic violence cases at all stages and whenever a domestic violence case is reviewed in order to safeguard potential victims. They should …
Recommendation - Derbyshire Constabulary, April 2026
The IOPC recommends that Derbyshire Constabulary should implement improvements in longer term safeguarding practices within high-risk investigations. This recommendation was raised by the investigating officer as the result of a death or serious injury investigation. Suspects who qualify for a …
Recommendation - Metropolitan Police Service, February 2020
The IOPC recommends that the Metropolitan Police Service (MPS) take steps to make Safeguarding teams and departments aware that special schemes can apply to serial perpetrators of abuse and should be used where appropriate to do so. The MPS use …
Police actions relating to a teenage boy’s arrest, welfare and disappearance prior …
The IOPC recommends that the Metropolitan Police Service (MPS) amend their custody policy to include a responsibility on MPS staff to ensure safeguarding forms are completed by them for vulnerable members of the public who they come into contact with …
IMB annual reports(4)
Gatwick pre-departure accommodation (2023)
The IMB report for Gatwick Pre-Departure Accommodation for 2023 highlights concerns regarding the detention of four families, all of whose removal attempts failed. The Board questions the fairness and humanity of the process, particularly noting the trauma to children and callous treatment of a pregnant mother. Key recommendations include the closure of the PDA and prohibiting the detention of pregnant women.
PRISON
Key concerns
Kent Coast Short Term Holding Facilities (STHF) (2023)
The IMB's report for Kent Coast STHF (WJF, KIU, Manston) for 2023 highlights commendable staff empathy and improved medical provisions. However, it raises significant concerns regarding the lack of clear information for detainees about their processing and length of stay, inadequate privacy for interviews, and substandard conditions in isolation units and sleeping arrangements. The Board also noted issues with facility maintenance and the inconsistent receipt of vital monitoring reports.
PRISON
Key concerns
Gatwick IRC (2023)
The Gatwick IRC experienced a deterioration in safety during 2023, marked by increased violence, assaults on staff, and a rise in use of force incidents, partly attributed to a changing detainee population. Key safeguards for vulnerable individuals, such as Rule 34 and Rule 35 assessments, were found to be insufficient or subject to unacceptable delays. The report highlighted significant concerns regarding inadequate mental health provision, unfair regime practices including prolonged lock-in times, and a lack of effective pathways for release for detainees granted bail.
IRC
Key concerns
Gatwick IRC (2024)
Gatwick IRC experienced a volatile year ending March 2024, marked by high levels of violence, self-harm, and one death in custody. The Board expresses significant concerns over inadequate safeguards for vulnerable detainees, long detention periods, and systemic failures in healthcare, particularly around Rules 34 and 35. Detainees also face issues with interpretation services, excessive handcuffing, and an inhumane regime with long lock-up times and increased segregation.
IRC
Key concerns
IMB individual recommendations(23)
Brook House (2020)
The Board repeats all of its recommendations from 2019 relating to reviews of adults at risk; and assessment, care in detention and teamwork (ACDT) and Rule 35 policies and processes.
Home Office
Yarl’s Wood (2020)
The Board recommends that the Centre should maintain its vigilance in the identification of vulnerable persons and minors.
Governor / Director
Brook House (2020)
There should be a requirement for systematic and ongoing review of vulnerable detainees, to monitor the effect of continued detention on their wellbeing.
NHS / Healthcare Provider
Brook House (2020)
There should be a requirement for systematic and ongoing review of vulnerable detainees, to monitor the effect of continued detention on their wellbeing.
Home Office
Isle of Wight (2024)
What changes can be made to ensure there is a proactive, timely and robust system to identify and assess prisoner social care needs and ensure that prisoners understand they can self-refer?
Governor / Director
South and West short term holding facilities (2025)
Ensure that the recording of children’s detention fully reflects the individual child’s treatment.
Other
In Progress
South and East Short Term Holding Facilities (STHF) (2025)
The Board recommends that the Home Office considers strengthening the relationship between Border Force and Children’s Services. The Board notes there is no service level agreement between BF and Children’s Services, resulting in some unaccompanied children waiting for 16 or 17 hours for support, as noted in 7.4.
Home Office
Brook House (2020)
Review systems and processes in the detention journey, to ensure that vulnerabilities such as age, modern slavery and Rule 35 torture claims are identified and assessed at earliest stages.
Home Office
Yarl’s Wood (2021)
The Board recommends that the centre should maintain its vigilance in the identification of vulnerable persons and minors and strictly follow procedures when these persons are released from the centre.
Governor / Director
London STHF (2024)
Unaccompanied minors are not always allocated a responsible adult when they are in the CWA. We would like each minor to be accompanied by a responsible adult.
Home Office
Feltham (2024)
Can steps be taken to ensure LA funding for SEN/EHCP children follows them into custody?
HMPPS
Feltham (2025)
Improve information sharing between social services and the YCS, so looked-after children (LACs) receive entitlements.
HMPPS
Cardiff IMB (2025)
Sut bydd y carchar yn gweithio gyda chyngor Caerdydd i sefydlu proses gofal cymdeithasol ffurfiol a chadarn, o ystyried nad oes un yn bodoli, fel yr amlygwyd yn yr Asesiad o Anghenion Iechyd a Gofal Cymdeithasol?
Governor / Director
Cardiff (2025)
How will the prison work with Cardiff council to establish a formal and robust social care process, given that none exists, as highlighted in the H&SCNA?
Governor / Director
Yarl’s Wood (2020)
Vulnerable adults are still being detained despite there being a pilot underway to explore an enhanced pre-detention screening tool to help facilitate the disclosure of vulnerability. The Board recommends that a clear evaluation of this pilot is published to ensure that the measures necessary for the safeguarding of vulnerable individuals are in place.
Ministry of Justice
Wandsworth (2023)
With the current staff shortages, will it be possible to operate the new healthcare centre safely?
Governor / Director
Yarl’s Wood IRC (2024)
The Detention Gatekeeper should be more robust in its safeguarding purpose of protecting vulnerable people from being detained
Home Office
Rejected
Downview (2025)
The Board hopes that the successful HMPPS audit carried out in the reporting year may be a catalyst for more ambition and creativity with family engagement at Downview. How does the prison intend to sustain the focus on families and significant others (7.4)?
Governor / Director
Ashfield (2020)
What more can be done to ensure that other prisons conduct accurate and robust assessments of contact arrangements?
HMPPS
Implemented
Downview (2021)
Collate data centrally regarding the numbers of dependent children of prisoners to enable effective family engagement.
HMPPS
In Progress
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
Instruct officials to undertake assurance activity, informed by expert input, on the following areas where we cannot reach conclusions based on our observations: o Ensuring that vulnerable adults are always identified properly and that their care, and that provided to children, is effective in safeguarding and improving physical and mental health and wellbeing. o Ensuring that repairs to accommodation take …
Other
Ashfield (2024)
With the large number of elderly prisoners in the custodial estate (particularly in prisons such as Ashfield), cases of dementia and terminal illness requiring 24-hour care are increasing. The specific needs of these prisoners cannot be adequately met in normal prison conditions. What plans does the Prison Service have for addressing this issue through the creation of special custodial centres?
HMPPS
Warren Hill (2025)
The IMB recognises that the age profile of the prisoner population is increasing. What is the Governor’s/HMPPS’s plan to accommodate elderly prisoners in a more purposeful way, including making physical adaptations to the prison to be age-friendly and ensuring appropriate care packages are in place for prisoners with social care needs?
HMPPS
In Progress
Health investigations(488)
Independent investigation: Alan Riddock, Bristol (2008) — Rec 6
The Avon and Wiltshire Mental Health Partnership NHS Trust, possibly in conjunction with its partner agencies, should ensure that the local Children’s Safeguarding Policies and Procedures are being implemented in a consistent manner. It should ensure that: • assessments and risk assessments routinely identify contact with and concerns regarding children; …
south_west
Independent investigation: Alan Clarke, Salisbury (2008) — Rec 7
• The Trust should ensure that its policy on Safeguarding Adults is reviewed: • with reference to the South West Safeguarding Adult Threshold Guidance; • to enshrine emerging locally agreed best practice and ensure that it employs language that is consonant with local multi-agency guidance, policies and protocols. • The …
south_west
Independent investigation: Katie Kazmi, Reading (1999) — Rec 13
In its review of Guidance the Home Office should include the recommendation that all conditionally discharged patients are considered by Potentially Dangerous Persons Panels.
south_east
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 8
The Trust should assure itself and its Local Authority partners that the Safeguarding policies and procedures which it has put in place and supported with training are being implemented. It should include audits of compliance with its Safeguarding policies in its regular audit cycle.
north_east_yorkshire
Independent investigation: Terrance Hall, Weston Super Mare (2008) — Rec 5
The Trust, in conjunction with its partner agencies and commissioners, should ensure that the local Children’s Safeguarding policies and procedures are being implemented in a consistent manner. It should ensure that: • assessments and risk assessments routinely identify contact with and concerns regarding children; • this information is communicated to …
south_west
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The 'Appropriate Adult' system in criminal justice should be re-examined with a view to extending its role.
east_of_england
Independent investigation: Philip Ellison, Preston (2008) — Rec 10
The Trust should take action to raise the profile of issues associated with vulnerable adults and safeguarding. In particular the Trust should ensure that staff are aware of the inter-agency Safeguarding Policy and their obligations under it.
north_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 18
South Devon Healthcare Trust will monitor the uptake of training identified as being required in safeguarding children.
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 17
DPT will incorporate a review of the number of hours allocated to the Named Nurse post within its current review of the safeguarding governance arrangements, engaging with commissioners as required, to ensure that safeguarding maintains a high profile.
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 16
DPT will continue to monitor the uptake of training identified as being required in relation to safeguarding children and strengthen its performance management in respect of uptake.
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 14
DPT will, in conjunction with its commissioners, seek to establish a presence within MASH on an ongoing basis and will continue to advocate for the multiagency hub arrangements extending to encompass Torbay.
south_west
Independent investigation: John Stevens, Woking (2001) — Rec 16
We recommend that the Surrey Area Child Protection Committee agree how to ensure attendance by relevant mental health staff at child protection case conferences and core groups, and the need for a co-ordinated whole family plan.
south_east
Independent investigation: Jankee Jaimungal, Batley (2007) — Rec 3
The Trust should assure itself and its Local Authority partners that the Safeguarding policies and procedures which it has put in place and supported with training are being implemented. It should include audits of compliance with its Safeguarding policies in its regular audit cycle.
north_east_yorkshire
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 29
The same training issues apply for the CMHTas are set out in Recommendation (10) above, and should include when to notify child protection professionals that there are children in the same household as a patient who is violent, and in the case of adults at risk of violence from a …
london
Independent investigation into the care and treatment of Mr X — Rec 11
The Trust has fit for purpose policies and processes in relation to protecting vulnerable adults from abuse. However it is recommended that more explicit guidance is developed in relation to: service user on service user abuse; risk assessment and risk management of vulnerable adults which support detailed protection plans; explicit …
X This is the independent investigation report into the care and treatment of Mr X who committed a homicide in 2013. Mr X was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr X — Rec 8
The Trust should ensure that clinical risk policies make explicit the assessment and management arrangements required for vulnerable adults.
X This is the independent investigation report into the care and treatment of Mr X who committed a homicide in 2013. Mr X was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation: Angela Titley, Private Psych hospital, Redhill, Surrey (2004) — Rec R23
We recommend to Trusts that all units providing residential care to the mentally ill should have a formal policy relating to sexual relationships involving in-patients; and that whenever a placement is being considered “out-of-area”, or in the independent sector, steps are taken to ascertain the policy adopted in this regard …
south_east
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 43
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients who are perpetrators of domestic violence receive appropriate intervention and support to address their behaviour.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 42
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients who are victims of domestic violence receive appropriate support and intervention.
midlands
Independent investigation: William Moss, Newquay (2007) — Rec 7
The Cornwall and Isles of Scilly Multi-agency Safeguarding Adults Policy is reviewed and audited to consider the interface for: young People who are leaving the care system and on a care order; young people with a diagnosed serious mental illness; people who present with self harm.
south_west
Independent investigation: Wendy Pashley, Rotherham (2006) — Rec 2
Exploring safeguarding issues, both in relation to children and adults, can be challenging. The Trust needs to introduce a section on safeguarding children and adults, to include domestic violence (emotional, verbal and physical) as part of the standardised screening and full risk assessment paperwork.
north_east_yorkshire
Independent investigation: Vera Croghan, Norwich (2020) — Rec 3
The Trust will strengthen arrangements for assessments of safeguarding and teams (in team meetings and in supervision) should strengthen the way that they engage with families to maintain their professional curiosity about the wider impact in families. The clinical team should reinforce their policy for `Think Family14.
east_of_england
Independent investigation: Valerie Donnelly, Preston (2011) — Rec R3
The trust and the GP practice must ensure that all clinical staff carry out their responsibilities in line with local adult safeguarding policy and good practice guidance.
north_west
Independent investigation: Tracy Anstice, Flitwick (2011) — Rec 6
HPFT and SEPT should provide assurance that all staff adhere to children’s and adults’ safeguarding policies and procedures and monitor that these are in routine use.
east_of_england
Independent investigation: Tracey Baker, Chard (2015) — Rec 10
Somerset Partnership NHS Foundation Trust must take immediate action to highlight the potential risks of jealousy and domestic violence by : • providing specific training for practitioners • revising the Domestic Abuse, Safeguarding and Risk Management policies.
south_west
Independent investigation: Tracey Baker, Chard (2015) — Rec 5
Somerset Partnership NHS Foundation Trust ‘s Serious Incidents Requiring Investigation (SIRI) Policy and Procedure should be amended to include: • a specific section on child protection which clearly outlines the investigator’s safeguarding responsibility throughout the course of their investigation; • guidance as to how an investigator should respond with regard …
south_west
Independent investigation: Thomas Abraham, Gloucester (2019) — Rec 3
Working with external agencies: Trusts should develop joint working practices with the police, Crime Prosecution Service, local authorities and commissioning bodies to ensure regular communication, information sharing, clarity of roles and agreed approaches towards high risk service user management.
south_west
Independent investigation: Thelma Allum, Maidenhead, Berks (1997) — Rec 4
that simple arrangements are developed which ensure that the suspected victim(s) of the assault, and any adults with whom the patient proposes to reside, are consulted about, and notified of, hospital leave and discharge decisions.
south_east
Independent investigation: Thelma Allum, Maidenhead, Berks (1997) — Rec 2
that, to this end, a protocol should be developed which addresses the issue of confidentiality and the sharing of information between agencies. This should emphasise the importance of considering— • who is most at risk of violence; • whether these individuals are aware of the risk, the history of violence, …
south_east
Independent investigation: Steven Janczuk, Arlesey, Beds (2006) — Rec 9
The Trust should seek to determine whether the current arrangements to internally investigate serious untoward incidents would identify whether a child or other vulnerable witnesses were present, in order to determine whether psychological support should be provided by the Trust.
east_of_england
Independent investigation: Steven Hoskin, St. Austell (2006) — Rec R6
Health, social care, police and probation services in Cornwall and Northamptonshire should use local Multi-Agency Risk Assessment Conference (MARAC) procedures to communicate the investigation and outcome of incidents of reported domestic abuse to relevant agencies on a confidential basis as part of child protection, Safeguarding Adults, CPA and MAPPA reviews. …
south_west
Independent investigation: Stephen O’Brien, Crewe (2016) — Rec 6
The Trust should develop guidance on when contact with relatives/partners becomes essential as part of the care of patients. This is particularly needed when patients fail to engage yet are clearly ill and, when safeguarding criteria for doing so without the patient’s permission are reached.
north_west
Independent investigation: Sindi Smith (SS), Stratford. London — Rec 11
The Trust Director with responsibility for safeguarding children and the named Child Protection Nurse should ensure that policy imperatives and guidance on pre-birth and post-natal care of women with a history of mental illness are disseminated in a relevant and timely manner
london
Independent investigation: Sindi Smith (SS), Stratford. London — Rec 10
We recommend that the Trust should ensure the adoption of a pre-birth protocol based on the London Child Protection Guidelines, familiarity with which should be part of the core competencies of community mental health services staff.
london
Independent investigation: Simran Sidhu (5)Aman Raj (23 mths), Southall Station … — Rec 16
Whereit is known that a parent is in receipt of mental health services the assessment of the children must incorporate the views of the care coordinator or theclinician working withthe serviceuser.
london
Independent investigation: Simran Sidhu (5)Aman Raj (23 mths), Southall Station … — Rec 3
All service users must be offered the opportunity to be interviewed on their own. When there are specific cultural or gender issues where this is not appropriate a chaperone should be considered. When there are known instances of abuse or coercion the service user must not be seen with the …
london
Independent investigation: Simon Widger, Eastbourne, Sussex (2000) — Rec 1
The East Sussex Area Child Protection Committee (ACPC), and the Social Services Children and Families Division are recommended to review their working practice, training, support and supervision for staff in respect of the following areas of concern: a) Inclusion of parents/carers in child protection and statutory care planning meetings. The …
south_east
Independent investigation: Simon Sutton, Birkenhead (2007) — Rec R10
The trust and probation services should ensure that service-users with a history of violence who provide care or supervision for children receive an assessment of risk under child safeguarding procedures to assess whether they are able to provide safe and consistent care.
north_west
Independent investigation: Simon Sutton, Birkenhead (2007) — Rec R9
The trust should ensure there is a robust policy in place for safeguarding children and ensure through regular audit that all staff adhere to it.
north_west
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 7
The DSCB will receive an annual report from MARAC with specific reference to the identification of risk to children and the appropriate referral of children to the MASH in incidents where the risk meet the threshold for social care intervention.
south_west
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 6
An appropriate representative from all agencies who are signed up to the MARAC operating protocol should ensure regular and effective attendance at all MARAC meetings. Alongside the assessment of risk to the adult victim, the risk to children should be specifically considered in every case. The chair of the MARAC …
south_west
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 5
The findings from this Serious Case Review relating to the MASH should be referred to the current MASH review/MASH Board.
south_west
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 3
GP practices need to find ways to receive and respond to indicators of risk to children, including incidents of domestic violence. A nominated Senior person within every GP practice is to ensure that there is a recognised and effective system within their practice to flag up incidents (including domestic violence) …
south_west
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 2
Where there is a risk of further illness in the parent that is likely to have an effect on the child/children, a multi-agency meeting should be called. The purpose of this meeting is to jointly assess the potential impact on the child/children and agree a contingency plan should protective factors …
south_west
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 1
All services engaged primarily with adults to develop practice tools that will assist staff to identify the risks that adults may pose to their children. All agencies working with adults must make their own assessment of risk to children and should not rely on whether or not the child is …
south_west
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 22
Policies concerning the identification, care and treatment of ‘vulnerable adults’ should be in place in all NHS trusts.
south_east
Independent investigation: Sandra Bowring (Vincent), Rhyl, Denbighshire (2006) — Rec 10
Clear protocols for the sharing of information between voluntary agencies and statutory services should be developed; these should be clear about who should take any action required in respect of risk, POVA and child protection procedures.
wales
Independent investigation: Sandra Bowring (Vincent), Rhyl, Denbighshire (2006) — Rec 5
The new Trust should put in place arrangements for informing the police of serious incidents involving patients, particularly in respect of those patients who may need help to take forward their wish to inform police of offences which they allege to have been committed against them. Those arrangements should include: …
wales
Independent investigation: Sandra Bowring (Vincent), Rhyl, Denbighshire (2006) — Rec 2
Training in the protection of vulnerable adults should be reviewed and provided as a priority for all mental health staff in Local Authority, Trust and Primary Care services to ensure that, in addition to awareness, it can be certain that POVA procedures are implemented and that current practice is consistent …
wales
Independent investigation: Sally Poynton, Crowlas (2021) — Rec 12
The Integrated Care Board (ICB), the Council and the Trust must ensure there are clear pathways for managing a safeguarding adult referral where there is a mental health and social care component; these should be supported by robust and detailed assurance processes.
south_west
Scottish Fatal Accident Inquiries(2)
Declan Hugh Hainey
I am unclear as to whether a ‘lead individual’ is identified at the same time as ‘the lead agency’. If this is not the case, then it is recommended that it should be, and that all councils adopt this system. Management must ensure that there is regular and ongoing assessment of the staffing levels necessary to achieve at all times …
Dawn Fiona Byrne McKenzie
1. Staff and carer training needs should be reviewed to ensure that all first time foster carers approved to take children in middle childhood or adolescence should receive Crisis Prevention and Intervention training prior to taking up their first placement. 2. Prospective foster carers when being asked to consider a placement should be given as much information as possible in …
Detention investigations(10)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R39
The SMT, in consultation with the local safeguarding boards, should review and redraft the safeguarding policy to ensure that it: • has a clear and easy-to-follow scheme and does not contain errors in drafting and meaning; • makes clear to staff their principle duties and responsibilities in relation to safeguarding, …
Immigration Detention
Investigation into the Failing of Medomsley Detention Centre — Rec 1
The first is that it is still not a requirement for every child in detention to be proactively, and regularly, asked by an independent party about their custody experience seen through a safeguarding lens. If the right environment was created and they were conducted by suitably trained, trauma-informed professionals, these …
Prisons
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R26
In consultation with the LSCB, managers should review the training of staff in relation to safeguarding and child protection to ensure that they are given regular training to help them understand and meet their responsibilities for safeguarding and promoting the wellbeing of children.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R25
In consultation with the LSCB, managers should review and redraft Yarl’s Wood’s child protection and safeguarding policies to ensure that they clearly and consistently identify the extent of staff responsibilities for safeguarding and promoting the wellbeing of children, including children in the community, and conform to the requirements of the …
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R24
Managers at Yarl’s Wood should actively engage with the local authority safeguarding team and the safeguarding adults board and ensure establish appropriate and ongoing information sharing to secure the safeguarding of residents.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R23
Managers at Yarl’s Wood, in consultation with the local safeguarding adults board, should devise appropriate adult safeguarding policy and practice, including staff training.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R27
Managers should agree with the LSCB on arrangements for reporting concerns and on the pattern and frequency of future contact between the LSCB and Yarl’s Wood.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R40
The SMT in consultation with the local safeguarding boards must ensure that all staff receive appropriate annual safeguarding refresher training. (To be completed within 3 months)
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 29
I recommend that the Home Office and the Department of Health work together to consider whether current arrangements for safeguarding are adequate.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R31
Serco managers should undertake a thorough review of the initial training course and the refresher training programme to ensure that they enable staff to fulfil their roles and responsibilities. The review and any consequent redesign of staff training should ensure that staff are adequately trained in mental health matters affecting …
Immigration Detention
Independent reviews(50)
Laming Review (Baby P) — Rec 53
Local Safeguarding Children Boards should report to the Children's Trust Board and publish an annual report on the effectiveness of safeguarding in the local area. Local Safeguarding Children Boards should provide robust challenge to the work of the Children's Trust and its partners in order to ensure that the right …
Other
Laming Review (Baby P) — Rec 52
Local Safeguarding Children Boards should include membership from the senior decision makers from all safeguarding partners, who should attend regularly and be fully involved as equal partners in Local Safeguarding Children Board decision making.
Other
Laming Review (Baby P) — Rec 37
The Care Quality Commission, HMI Constabulary and HMI Probation should review the inspection frameworks of their frontline services to drive improvements in safeguarding and child protection in a similar way to the new Ofsted framework
Other
Laming Review (Baby P) — Rec 33
The Department of Health should review the Healthy Child Programme for 0–5-year-olds to ensure that the role of health visitors in safeguarding and child protection is prioritised and has sufficient clarity, and ensure that similar clarity is provided in the Healthy Child Programme for 5–19-year-olds.
Other
Laming Review (Baby P) — Rec 22
The Department for Children, Schools and Families should establish statutory representation on Local Safeguarding Children Boards from schools, adult mental health and adult drug and alcohol services.
Other
Laming Review (Baby P) — Rec 20
All police, probation, adult mental health and adult drug and alcohol services should have well understood referral processes which prioritise the protection and well-being of children. These should include automatic referral where domestic violence or drug or alcohol abuse may put a child at risk of abuse or neglect.
Other
Laming Review (Baby P) — Rec 12
The Department of Health and the Department for Children, Schools and Families must strengthen current guidance and put in place the systems and training so that staff in Accident and Emergency departments are able to tell if a child has recently presented at any Accident and Emergency department and if …
Other
Laming Review (Baby P) — Rec 11
The Department for Children, Schools and Families should revise Working Together to Safeguard Children to set out clear expectations at all points where concerns about a child's safety are received, ensuring intake/duty teams have sufficient training and expertise to take referrals and that staff have immediate, on-site support available from …
Other
Laming Review (Baby P) — Rec 9
Every Children's Trust should ensure that the needs assessment that informs their Children and Young People's Plan regularly reviews the needs of all children and young people in their area, paying particular attention to the general need of children and those in need of protection. The National Safeguarding Delivery Unit …
Other
Laming Review (Baby P) — Rec 6
Directors of Children's Services, Chief Executives of Primary Care Trusts, Police Area Commanders and other senior service managers must regularly review all points of referral where concerns about a child's safety are received to ensure they are sound in terms of the quality of risk assessments, decision making, onward referrals …
Other
Laming Review (Baby P) — Rec 5
The Department of Health must clarify and strengthen the responsibilities of Strategic Health Authorities for the performance management of Primary Care Trusts on safeguarding and child protection. Formalised and explicit performance indicators should be introduced for Primary Care Trusts.
Other
Narey Review of Children's Residential Care — Rec 16
The Department for Education, in consultation with Ofsted, needs to reconsider their guidance – taking account of recent Court judgements – to ensure that staff are able to keep children safe by preventing them leaving homes at time of danger, either by locking doors or using restraint, and that they …
Other
Wood Review of LSCBs — Rec 28
To ensure the new body has the capacity to commission and or carry out NSCIs.
Other
Wood Review of LSCBs — Rec 26
To require the new body to be responsible for overseeing a new model for learning from serious events affecting children.
Other
Wood Review of LSCBs — Rec 22
For the Department for Education to set out the key tasks for the new body to determine. These should include: the creation of a new national learning framework; the process by which the notification of an event takes place; the process for establishing a National Serious Case Inquiry (NSCI); best …
Other
Wood Review of LSCBs — Rec 21
To discontinue Serious Case Reviews, and to establish an independent body at national level to oversee a new national learning framework for inquiries into child deaths and cases where children have experienced serious harm.
Other
Wood Review of LSCBs — Rec 20
To emphasise in all national guidance that the main purpose of inquiring into an event is to improve the systems we provide to protect children.
Other
Wood Review of LSCBs — Rec 18
To incentivise all applicants for devolution deals to include in their proposals arrangements for establishing multi-agency arrangements for protecting children.
Other
Wood Review of LSCBs — Rec 17
For the Home Office and Departments of Communities and Local Government, Health, and Education to issue joint advice and guidance on the critical importance of effective and speedy sharing of information and data in relation to protecting and safeguarding children. This should focus on the expectation that unless there is …
Other
Wood Review of LSCBs — Rec 15
The Joint Targeted Area Inspection (JTAI) should not replicate the inspection of the child protection front door. That should be a discrete inspection. The JTAI should concentrate of key themes in the life and experience of children and young people e.g. domestic violence, child sexual abuse, children with a disability, …
Other
Wood Review of LSCBs — Rec 14
There are too many separate inspections of local authority children's services: this is over burdensome, costly and needs urgent attention. In replacing the Single Inspection Framework (SIF), Ofsted should be encouraged to develop a model that is not burdensome, is unannounced, short in duration (five days), and focuses on the …
Other
Wood Review of LSCBs — Rec 13
The Care Quality Commission, Her Majesty's Inspectorate of Constabulary and Her Majesty's Inspectorate of Probation should review their inspection frameworks to ensure they focus on child protection practice without being burdensome on service providers. Their inspections should be proportionate and always assess the contribution the agency they inspect makes to …
Other
Wood Review of LSCBs — Rec 12
To consider issuing new guidance on the responsibilities of a chief officer nominated by each of health, the police and local government to agree the multi-agency arrangements and processes in an area.
Other
Wood Review of LSCBs — Rec 9
Keeping Children Safe in Education should be reviewed to ensure it covers child protection and safeguarding issues in respect of unregistered school settings, independent schools and home education. There should also be clearer guidance on the role played by the police and the NHS in that process. Keeping Children Safe …
Other
Wood Review of LSCBs — Rec 8
NHS (England) should consider how their Accountability and Assurance Framework for safeguarding vulnerable people could be amended to place greater emphasis on how local health agencies fully participate in multi-agency practice.
Other
Wood Review of LSCBs — Rec 3
To require the three key agencies, namely health, police and local authorities, in an area they determine, to design multi-agency arrangements for protecting children, underpinned by a requirement to work together on the key strategic issues set out in this report and referenced in recommendation 2.
Other
Wood Review of LSCBs — Rec 2
To require all areas to move towards new multi-agency arrangements for protecting children within a prescribed period. Local areas/regions would need to establish a plan which would describe how services would: meet the new statutory framework; be coordinated; be led by senior officials; be evaluated for their effectiveness; involve a …
Other
Wood Review of LSCBs — Rec 1
To replace the existing statutory arrangements for LSCBs and introduce a new statutory framework for multi-agency arrangements for child protection.
Other
Tickell Review of the EYFS — Rec 29
I recommend that the safeguarding and welfare requirements are made more explicit about warning signs in the behaviour of adults working in a setting. I also recommend that the EYFS sets out clearly the high level content of the child protection training that lead safeguarding practitioners are required to attend. …
Education
Tickell Review of the EYFS — Rec 28
I recommend that the welfare section of the EYFS is renamed the 'safeguarding and welfare requirements' and that the welfare requirements are redrafted to improve their clarity.
Education
Munro Child Protection Review — Rec 1
The Government should revise both the statutory guidance, Working Together to Safeguard Children and The Framework for the Assessment of Children in Need and their Families and their associated policies to: ●● distinguish the rules that are essential for effective working together, from guidance that informs professional judgment; ●● set …
Other
Shaw Detention Review — Rec 45
Recommendation 45: I recommend that the Home Office seek the views of the Ministry of Justice and the Department of Health on extending section 75 of the Sexual Offences Act 2003 to IRCs, prisons and mental hospitals.
Immigration
Shaw Detention Review — Rec 29
Recommendation 29: I recommend that the Home Office and the Department of Health work together to consider whether current arrangements for safeguarding are adequate.
Immigration
Bailey DBS Review — Rec 1
The definition of regulated activity relating to children be amended to remove the exemption for supervised activity.
Other
MacAlister Review — Rec 73
Schools should be made a statutory safeguarding partner and contribute to the strategic and operational delivery of multi-agency working.
Education
MacAlister Review — Rec 72
Each agency inspectorate should review their framework to ensure there is sufficient focus on individual agency contributions to joint working. Where there are concerns about the functioning of partnerships, joint inspections, with a judgement attached, should be triggered.
Education
MacAlister Review — Rec 71
The Child Safeguarding Practice Review Panel and relevant What Works Centres should take a more hands on role in promoting evidence and supporting partnerships to improve.
Education
MacAlister Review — Rec 70
Partnerships should become more transparent, including publishing minutes of partnership meetings and the financial contributions of each partner. The Safeguarding Children Reform Implementation Board should be reviewed and strengthened to take a greater leadership role in safeguarding arrangements, including requesting and publishing critical information about partnerships.
Education
MacAlister Review — Rec 69
The role of the Director of Children’s Service should be reviewed to give clarity to the role following this review, the SEND and AP Green Paper, and the Schools White Paper, to reflect their role as a champion for children and families within their area. The individual contributions of partners …
Education
MacAlister Review — Rec 68
Working Together should be amended to set out clear joint and equal operational responsibilities for partners. The Director of Children’s Services should be the primary interface between strategic and operational leaders to facilitate effective multi-agency working.
Education
MacAlister Review — Rec 67
The responsibilities of multi-agency safeguarding arrangements should be amended to emphasise their role as a strategic forum focused on safeguarding and promoting the welfare of children, with attendance reflecting this.
Education
MacAlister Review — Rec 24
A Family Network Plan should be introduced and enabled in law to support and give oversight to family-led alternatives to care.
Education
MacAlister Review — Rec 23
Government should introduce legislation which makes the use of family group decision making mandatory before a family reaches Public Law Outline. The features and delivery practice of effective family group decision making should also be included in the National Children’s Social Care Framework.
Education
MacAlister Review — Rec 20
The National Children’s Social Care Framework practice guides should promote effective practice for engaging families. Parental representation should be offered to all families in child protection.
Education
MacAlister Review — Rec 18
Guidance and legislation on information sharing should be strengthened and local safeguarding partners should confirm they have information sharing agreements in place and have audited practice in this area.
Education
MacAlister Review — Rec 13
Government should amend Working Together to introduce a Child Community Safety Plan to clarify where primary harm is not attributable to families, supported by practice guides and the Early Career Framework.
Education
MacAlister Review — Rec 11
Working Together should set expectations on multi-agency capabilities for child protection and the National Children’s Social Care Framework should set out effective practice models for joint working.
Education
MacAlister Review — Rec 10
All cases of significant harm should be co-worked by an Expert Child Protection Practitioner who is responsible for making key decisions (in the future this would be someone who has completed our proposed Early Career Framework).
Education
Wessely Review — Rec 31
Local Safeguarding Adult Boards should ensure that safeguarding arrangements support organisations to discharge their safeguarding duties and ensure that there are effective processes in place to identify, investigate and take action on safeguarding issues
Health & Social Care
Accepted
Narey-Owers Foster Care Review — Rec 32
Local authorities should review the environments in which family contact takes place and the way it is supervised to ensure that it can be as positive an experience for the child as possible.
Other
PHSO casework decisions(43)
P-003103 — Charity Commission
Mr U complained DfE and the Charity Commission failed to respond appropriately to his serious allegations of child sexual abuse concealment by a religious congregation and a college.
UK Government
Upheld
Mar 2024
P-002833 — Charity Commission
Miss A complained the Charity Commission institutionally betrayed her by failing to properly investigate her sexual exploitation complaint and manage communication sensitively given her vulnerabilities.
UK Government
Upheld
Mar 2024
P-003544 — University Hospitals of Derby and Burton NHS Foundation …
Mrs O complained the Trust failed to follow safeguarding policy, delayed a cardiology referral, provided conflicting information, and gave incorrect discharge papers for her son.
NHS in England
May 2025
P-003733 — Avon and Wiltshire Mental Health Partnership NHS Trust
Mr E complained the Trust failed to act on concerns about his son Mr A's flat being 'cuckooed,' a call for help, update risk assessments, or communicate with other agencies, leading to his death.
NHS in England
Partly Upheld
Jul 2025
P-004301 — Guy's and St Thomas' NHS Foundation Trust
Mr E complained the Trust failed to act on safeguarding concerns he raised about his mother's care home, lacked appropriate procedures, and did not investigate his concerns.
NHS in England
Nov 2025
P-003045 — Care Quality Commission
A doctor complained the CQC failed to adequately address new evidence about her foster son's care or reconsider enforcement action after a coroner's inquest.
UK Government
Upheld
Aug 2024
P-002972 — Children and Family Court Advisory and Support Service …
Mr A complained Cafcass made a spurious, defamatory safeguarding referral against him and used false information in court documents. This caused him mental distress and swayed court opinion.
UK Government
Sep 2024
P-003195 — Children and Family Court Advisory and Support Service …
Mr J complained Cafcass created an inappropriate storyboard for his son without his involvement, and it failed to clearly state how his children could contact him.
UK Government
Dec 2024
P-003474 — Children and Family Court Advisory and Support Service …
Mr X complained CAFCASS and the FCA showed bias, did not adhere to policy, overlooked safeguarding concerns, and failed to investigate his complaints about the FCA's conduct.
UK Government
Mar 2025
P-004233 — Charity Commission
Mr D complained the Charity Commission failed to investigate concerns about a charity exploiting his son, obstructing recovery, lacking transparency, and negatively influencing his mental health.
UK Government
Nov 2025
P-001798 — Bolton NHS Foundation Trust
Miss I complained her late mother received inadequate care, including poor nutrition support, lost hearing aids, denied visits, and an uninvestigated assault by another patient.
NHS in England
Feb 2023
P-002389 — An independent provider in the Redcar and Cleveland …
Miss Y complained a care home left Mr Y unconscious on the floor, provided incorrect nutrition, failed to test urine, lost glasses, and did not provide footwear. This allegedly worsened his health.
NHS in England
Aug 2023
P-002737 — Somerset NHS Foundation Trust
Somerset NHS Foundation Trust failed to inform her it was raising a safeguarding concern, resulting in police attending her home and causing distress.
NHS in England
Jun 2024
P-002803 — Northern Care Alliance NHS Foundation Trust
Miss A complained staff inappropriately implemented a Deprivation of Liberty Safeguards authorisation without informing her and prevented family visits, which she believes contributed to her mother's death.
NHS in England
Not Upheld
Jul 2024
P-003114 — South West London Integrated Care Board
Mrs A complained the ICB inappropriately allowed her brother to sign a tenancy agreement without capacity, resulting in rental arrears for which she is now being pursued.
NHS in England
Nov 2024
P-003183 — South West Yorkshire Partnership NHS Foundation Trust
Miss A complained the Trust wrongly discharged her son, P, from learning disability services, misjudged his abilities, and discriminated against him. She also complained the GP removed his diagnosis.
NHS in England
Dec 2024
P-003574 — Alder Hey Children's NHS Foundation Trust
Mr H complained two Trusts misdiagnosed his son's skull fracture and made an inappropriate safeguarding referral, causing separation from his son, financial loss, and reputational damage.
NHS in England
May 2025
P-003805 — Berkshire Healthcare NHS Foundation Trust
Mr R complained the Trust inappropriately requested a Deprivation of Liberty Safeguards (DoLS) instead of a Section 3 for his mother and failed to communicate effectively with family.
NHS in England
Aug 2025
P-003994 — Kent and Medway Mental Health NHS Trust
Ms N complained the Trust failed to review her son's medication, provide support, assess risk, or properly discharge him, leading to his arrest and conviction, and her distress.
NHS in England
Upheld
Sep 2025
P-004046 — Tees, Esk and Wear Valleys NHS Foundation Trust
Mrs I complained a Trust safeguarding referral was inaccurate and she received no support afterward, causing her significant mental distress and paranoia.
NHS in England
Sep 2025
P-004376 — An independent provider in the City of Kingston …
Mrs P complained she received incorrect therapy, serious disclosures were not recorded, and safeguarding concerns were unaddressed. This worsened her trauma and affected a police investigation.
NHS in England
Nov 2025
P-004411 — A practice in the Barnsley area
Mr A complained the Practice did not listen to or escalate his concerns about a safeguarding and domestic violence incident involving his parents and their neighbour, leaving him frustrated and unheard.
NHS in England
Nov 2025
P-001975 — Bedfordshire Hospitals NHS Foundation Trust
Mrs S complained staff failed to refer her father to the safeguarding team despite his distress and mental health decline, potentially affecting his care.
NHS in England
Not Upheld
Feb 2023
P-001966 — Chesterfield Royal Hospital NHS Foundation Trust
The Trust allegedly reported Ms W to social services for 'unexplained bruising' on her son's feet, which were routine heel prick marks, and nursing staff made unprofessional remarks.
NHS in England
Apr 2023
P-002280 — Humber and North Yorkshire Integrated Care Board
The ICB's contractor refused a suitable wheelchair, and the ICB allegedly made an unnecessary safeguarding referral and pressured Mr A to drop his complaint.
NHS in England
Nov 2023
P-002512 — Hampshire Hospitals NHS Foundation Trust
Ms O complained doctors made false safeguarding allegations without permission and failed to diagnose a broken rib in ED, causing distress, loss of trust, and prolonged pain.
NHS in England
Mar 2024
P-002796 — Hull University Teaching Hospitals NHS Trust
Mr R complained the Trust ignored his LPA status, failed to communicate with him, did not implement a DoLS for his mother, and discharged her without informing the family.
NHS in England
Jul 2024
P-002960 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs R complained the Trust inappropriately placed her under a Deprivation of Liberty Safeguard (DoLS) order and incorrectly raised a safeguarding concern about her relationship.
NHS in England
Sep 2024
P-003360 — The Queen Elizabeth Hospital King's Lynn NHS Foundation …
The Trust made a social services referral without communicating the reason, causing Miss C significant stress and fear of accessing future care.
NHS in England
Feb 2025
P-003456 — Hertfordshire Community NHS Trust
Mrs J complained that identified care failings may have contributed to her brother's death and that staff did not inform the family he was receiving end-of-life care, denying them precious time.
NHS in England
Upheld
Mar 2025
P-003410 — Buckinghamshire Healthcare NHS Trust
Ms Y complained the Trust wrongly denied home care, raised an unfair safeguarding concern, didn't answer care concerns, and used inappropriate end-of-life medication, causing her mother's death.
NHS in England
Mar 2025
P-003566 — Birmingham and Solihull Integrated Care Board
Miss A complained the organisations failed to act on safeguarding concerns for her mother, Ms H, and provided inappropriate care including discharge without investigations and poor care plans.
NHS in England
May 2025
P-003711 — Barts Health NHS Trust
Miss K complained about multiple failings in her son's continence care, an A&E visit, an inpatient admission, and physiotherapy over several years.
NHS in England
Jul 2025
P-003717 — South Central Ambulance Service NHS Foundation Trust
Mr B complained SCAS raised a false safeguarding concern, impacting his wife's hospital care and discharge. He also alleged Hampshire Hospitals failed to meet her needs, delayed discharge, and mishandled the safeguarding referral.
NHS in England
Jul 2025
P-004714 — University Hospitals Birmingham NHS Foundation Trust
Mr A complained his father was sexually assaulted by another patient, alleging the Trust knew of the risk but failed to safeguard and later provided false information in its response.
NHS in England
Jan 2026
P-001383 — North Middlesex University Hospital NHS Trust
Daughter complained the Trust failed to investigate her father's discomfort after a fall, discharged him too soon, and questioned a Deprivation of Liberty Safeguard.
NHS in England
Feb 2022
P-001199 — Children and Family Court Advisory and Support Service
Mr E complained Cafcass failed to send him a safeguarding letter, that the letter contained misleading information, an FCA made prejudicial statements, and Cafcass's complaint responses were inadequate or delayed.
UK Government
Nov 2021
P-001775 — Office of the Public Guardian
Mrs N complained the Office of the Public Guardian (OPG) failed to properly investigate allegations concerning her father's partner's management of his financial affairs.
UK Government
Feb 2023
P-001761 — A practice in the Cornwall area
Miss A and Mrs A complained about Mr A's care and treatment by a Trust, Practice, and Home, and information not shared with the Court of Protection.
NHS in England
Jan 2023
P-002407 — London Ambulance Service NHS Trust
Mr L complained NHS 111 wrongly made a safeguarding referral for neglect, leading to social services involvement, harassment, and an unrequested paramedic visit.
NHS in England
Jan 2024
P-003254 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs A complained about inadequate falls risk assessment, poor post-fall care, improper information sharing, and inappropriate transfer by two NHS Trusts, leading to a broken hip.
NHS in England
Dec 2024
P-003527 — University Hospitals Coventry and Warwickshire NHS Trust
Mr U complained the Trust raised a safeguarding concern after he questioned his daughter's school details, linking it to historic incidents. This caused distress and social services involvement.
NHS in England
Apr 2025
P-002503 — Office of the Public Guardian
Mr O and Ms O complained the OPG accepted a Deed of Revocation (DOR) which they believe their mother was forced to sign when she lacked capacity, causing them distress.
UK Government
Mar 2024
LGO / SPSO decisions(3072)
PSOW-202410313 — Cardiff Council
Mr A complained that Cardiff Council had not given fair and proper consideration to his request for unsupervised contact with his children. The Ombudsman decided that the Council had failed to properly assess the children’s needs and views and that the information it provided in response to Mr A’s complaints …
PSOW (Public Services Om…
Local Government
Jul 2025
21-008-002 — Essex County Council
Summary: There was some fault in the way the Council investigated safeguarding concerns into Mrs C’s care at the care home. The Council has agreed to apologise to Mr B.
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-000-348 — Brighton & Hove City Council
Summary: Dr B complained ESC Council and the NHS Trust failed to properly safeguard her when it undertook an investigation into allegations of physical assault when she lived in a care home jointly funded by the CCG and BHC Council. She also complained about the home’s investigation and its decision …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-018-627 — Wirral Metropolitan Borough Council
Summary: We will not investigate this late complaint about inconsistent information regarding a fall to Mr X’s Mother in March 2020. This is because we cannot add to the Council’s response or make a finding of the kind Mr X wants.
LGO (Local Government & …
Adult Care Services
Apr 2022
21-009-157 — London Borough of Sutton
Summary: Ms X complained the Council failed to arrange a follow up safeguarding meeting as agreed, in relation to concerns a care home failed to call an ambulance in response to her mother’s seizures. The Council’s failure to communicate clearly with Ms X amounts to fault. This fault has caused …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
20-012-369 — London Borough of Newham
Summary: Ms Z, on behalf of her mother Ms X, complained about the Council’s action in respect of her finances. There is fault by the Council in failing to start a safeguarding investigation at the appropriate time; delay in progressing a safeguarding investigation and failure to ensure Ms X's needs …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
22-000-705 — Newcastle upon Tyne City Council
Summary: We will not investigate Mr X’s complaint about the way the Council treated Mr and Mrs Y when they took Mr Z back to their home during the Covid19 pandemic. This is because further investigation by the Ombudsman could not add to the Council’s investigation and we cannot investigate …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-006-495 — Hertfordshire County Council
Summary: We have not found fault in the way the Council made its decisions regarding safeguarding enquiries, but there was a delay in its completion of the assessments and there was fault in the way the Council communicated with Dr C about the powers of the attorney and the requirement …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-016-655 — Liverpool City Council
Summary: The Council’s refusal to consider Ms X’s complaint about how it protected her when she was a child is fault. The Council has agreed to apologise, pay Ms X £200, investigate her complaint, and take action to improve its services.
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2022
21-007-914 — Dudley Metropolitan Borough Council
Summary: I have not investigated Mr B’s complaints about how the Council facilitated contact with his children, the contents of its assessments or the conduct of the social worker. This is because these matters are subject to court proceedings, or we cannot add to the Council’s own investigation. The Council …
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2022
22-003-151 — Liverpool City Council
Summary: We will not investigate Miss X’s complaint about children service’s actions. We are unlikely to achieve a significantly different outcome than she has already achieved.
LGO (Local Government & …
Children S Care Services
Jun 2022
22-002-690 — Middlesbrough Borough Council
Summary: We cannot investigate this complaint about a child’s education and Special Educational Needs provision. This is because this matter is currently part of ongoing court proceedings.
LGO (Local Government & …
Children S Care Services
Jun 2022
21-007-224 — Suffolk County Council
Summary: Mr X complains about the care the late Mr Y received in Highfield House Care Home and the safeguarding enquiry it undertook. Mr X says Mr Y was subject to incidents of abuse from care workers and although he was told the Council was investigating with Police, he heard …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-011-766 — Northumberland County Council
Summary: The Council was at fault for ending its support of Mr X without warning and without considering referring him to an advocate. The Council has agreed to apologise to Mr X, pay him £500 and take action to improve its service.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
22-005-921 — Torbay Council
Summary: We will not investigate this complaint about how the Council completed safeguarding enquiries. That is because we could not add to the Council’s previous investigation.
LGO (Local Government & …
Adult Care Services
Aug 2022
22-004-774 — Norfolk County Council
Summary: We cannot investigate this complaint about the safety of children when visiting a parent. The matter complained of is not separable from matters that form part of court proceedings.
LGO (Local Government & …
Children S Care Services
Sep 2022
22-001-529 — London Borough of Brent
Summary: We will not investigate this complaint about the actions of the Council in child protection. Investigation would not be likely to lead to a worthwhile outcome. The substantive matter at the heart of the complaint concerns the residence and contact arrangements for children, which are for a court to …
LGO (Local Government & …
Children S Care Services
Sep 2022
22-006-372 — Leicester City Council
Summary: We will not investigate this complaint about the Council’s adult safeguarding enquiries. That is because there is insufficient evidence of fault.
LGO (Local Government & …
Adult Care Services
Sep 2022
21-017-685 — London Borough of Islington
Summary: Mrs X complains on behalf of her deceased aunt about the Council’s safeguarding investigation. She says this had a significant impact on her mental health and has caused the family trauma. We find the Council at fault, and this fault caused Mrs X injustice. The Council will apologise to …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-007-888 — Brighton & Hove City Council
Summary: We will not investigate this complaint about the care given to Ms X’s mother. This is because further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Sep 2022
21-008-532 — Reading Borough Council
Summary: We will not investigate this complaint about the Council’s decision to start a safeguarding investigation. This is because there is no evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-007-324 — Wokingham Borough Council
Summary: We will not investigate this late complaint about how the Council responded to concerns about Ms X’s parents’ finances and overcharging for care. There is not a good reason Ms X did not complain to us sooner.
LGO (Local Government & …
Adult Care Services
Oct 2022
22-007-199 — Gloucestershire County Council
Summary: We will not investigate this complaint about bias by the Council when Mr B raised concerns about his mother’s adult social care. There is not enough evidence of fault to justify investigating.
LGO (Local Government & …
Adult Care Services
Oct 2022
22-008-564 — Newcastle upon Tyne City Council
Summary: We will not investigate this complaint about safeguarding a vulnerable adult because there is not enough evidence of fault to justify our involvement. We could not achieve a remedy for the person affected because they have died, and the injustice to their representative is not sufficient to warrant our …
LGO (Local Government & …
Adult Care Services
Oct 2022
21-016-608 — Dudley Metropolitan Borough Council
Summary: The Council is not at fault in considering safeguarding referrals made by Ms Z and viewing camera footage as part of its enquiries. The Council is not at fault for considering Mrs Y’s care options including residential care. The Council is at fault for not considering Mr X’s complaint …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-015-962 — Dorset Council
Summary: Mr X complains the Council did not properly undertake a safeguarding investigation in relation to his father. The Council should have contacted Mr X when it decided the initial safeguarding concern did not meet the threshold for further investigation. This did not cause Mr X any injustice.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
23-013-776 — City of Wolverhampton Council
Summary: We will not investigate this complaint about the Council’s involvement when Mrs X raised safeguarding concerns about her father. There is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Apr 2024
23-018-281 — Trafford Council
Summary: We will not investigate this complaint about adult safeguarding. There is not enough evidence of fault causing significant injustice. We cannot achieve the outcome the complainant wants for the Council to confirm there was no finding of abuse or neglect, because the safeguarding investigation is continuing.
LGO (Local Government & …
Adult Care Services
Apr 2024
23-008-465 — London Borough of Waltham Forest
Summary: Mr X complained the Council delayed carrying out a social care needs assessment, wrongly decided he does not have any social care needs and has failed to respond to safeguarding concerns. The Council was at fault for the delay in assessing Mr X’s needs. It has already apologised for …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
23-016-556 — Rochdale Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s decision to manage Miss Y’s daughter Miss X’s finances. This is because the complaint relates to events that took place more than 12 months ago; it would have been reasonable for Miss Y to bring the complaint to us at …
LGO (Local Government & …
Adult Care Services
May 2024
23-002-919 — Newcastle upon Tyne City Council
Summary: We will not investigate this complaint about the Council’s involvement in Miss X’s children’s case. The substantive part of the complaint is late and there is not a good reason for the delay. There is insufficient evidence of fault in more recent events, nor could we provide a meaningful …
LGO (Local Government & …
Children S Care Services
Jul 2024
23-011-874 — Cambridgeshire County Council
Summary: Miss A complained about a council and care agency regarding her placement at supported accommodation. We found fault with the agency for the care it provided which led to risks to Miss A’s mental and physical health. The agency has carried out work to improve its care and will …
LGO (Local Government & …
Adult Care Services
Not Upheld
Aug 2024
24-005-947 — City of Bradford Metropolitan District Council
Summary: We will not investigate Mr X’s complaint about adult safeguarding provision, as it is unlikely, we would find evidence of Council fault. Part of the complaint is late and there are no good reasons the late complaint rule should not apply. Other issues have been in a previous complaint …
LGO (Local Government & …
Adult Care Services
Sep 2024
24-014-257 — London Borough of Hammersmith & Fulham
Summary: We will not investigate this complaint about how the Council dealt with a safeguarding referral. There is not enough evidence of fault to justify our involvement.
LGO (Local Government & …
Adult Care Services
May 2025
24-016-641 — Sandwell Metropolitan Borough Council
Summary: Mr X complained the NHS Trust and the Council moved his father from hospital into a care home that could not meet his needs. Mr X says the failings led to his father suffering an injury which hastened his death. Mr X also complained the Council missed carer’s assessments, …
LGO (Local Government & …
Adult Care Services
May 2025
24-019-870 — Surrey County Council
Summary: We will not investigate this complaint about the Council’s actions relating to Mrs X’s mental capacity. This is because we do not have consent from Mrs X to investigate, and nor do we believe Mrs Y can make a complaint about these actions, on Mrs X’s behalf as her …
LGO (Local Government & …
Adult Care Services
May 2025
24-017-091 — West Sussex County Council
Summary: We will not investigate this complaint about the Council’s response to safeguarding and other actions relating to Mrs X’s mental capacity assessment. This is because we do not have consent from Mrs X to investigate, and nor do we believe Mrs Y can make a complaint about these actions, …
LGO (Local Government & …
Adult Care Services
May 2025
25-000-015 — Westminster City Council
Summary: We will not investigate Ms X’s complaint about the removal of her sibling’s child from their care. The law prevents us from investigating anything that is or has been the subject of court proceedings.
LGO (Local Government & …
Children S Care Services
May 2025
24-023-226 — Kent County Council
Summary: We cannot investigate Mr X’s complaint about the Council’s children’s services involvement with his family because the law prevents us from considering complaints about matters that have been considered in court proceedings.
LGO (Local Government & …
Children S Care Services
May 2025
24-022-857 — Cornwall Council
Summary: We will not investigate Mr X’s complaint about the Council’s children’s services involvement with his family because it lies outside our jurisdiction. The law prevents us from considering complaints about matters that have been considered in court proceedings. Investigation into other issues raised would not lead to a different …
LGO (Local Government & …
Children S Care Services
May 2025
24-021-852 — Isle of Wight Council
Summary: We will not investigate Mr and Mrs X’s complaint about the Council’s involvement with their child. The law prevents us from investigating anything that is or has been the subject of court proceedings.
LGO (Local Government & …
Children S Care Services
May 2025
24-023-163 — Blackpool Borough Council
Summary: We cannot investigate this complaint about how a Council has exercised its safeguarding duties. The law says we cannot investigate a complaint about the start of court action or what happened in court.
LGO (Local Government & …
Children S Care Services
Jun 2025
25-000-290 — Redcar & Cleveland Council
Summary: We will not investigate Ms X’s complaint about the actions of a social worker and the response of Children’s Social Care. This is because
LGO (Local Government & …
Children S Care Services
Jun 2025
24-021-065 — London Borough of Barnet
Summary: We will not investigate this complaint about Miss X’s time in Council care between 2016 and 2021. While it is understandable that she has not complained sooner, we would be unlikely to be able to conduct a robust investigation or achieve a worthwhile outcome.
LGO (Local Government & …
Children S Care Services
Jun 2025
24-020-325 — Surrey County Council
Summary: We will not investigate this complaint about the Council’s investigation of a bruise Mr Y sustained. There is insufficient evidence of fault, and we could not achieve the outcome Mrs X seeks.
LGO (Local Government & …
Adult Care Services
Jun 2025
24-013-950 — Worcestershire County Council
Summary: Mr X complained about how the Council made a best interest decision for his brother, Mr Y, when it decided he did not have capacity to make decisions about his finances. The Council was at fault because it did not keep proper oversight when it referred Mr Y to …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2025
24-011-204 — Lancashire County Council
Summary: Miss X complained on behalf of her father (Mr Y) about the Council’s handling of safeguarding concerns that he was vulnerable and at risk of harm and neglect due to alleged poor care he received while in residential care. Based on current information, there is no evidence the Council …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2025
24-019-772 — London Borough of Barking & Dagenham
Summary: Mr X complained that the Council failed to safeguard him, did not assess his social care needs properly, and did not implement the reasonable adjustments he needed under the Equality Act. There was no fault in how the Council considered its safeguarding duties and how it assessed Mr X’s …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2025
25-005-066 — Coventry City Council
Summary: We will not investigate this complaint about reports that the Council provided to the courts. The law prevents us from investigating anything that has been subject to court proceedings.
LGO (Local Government & …
Children S Care Services
Jul 2025
25-003-284 — Hampshire County Council
Summary: We will not investigate Mr X’s complaint about how the Council and other bodies dealt with matters concerning the care of his child. Mr X’s complaint about the actions of the Council is made late and is about what happened in court. We have no powers to investigate the …
LGO (Local Government & …
Children S Care Services
Jul 2025
Domestic Homicide Reviews(2210)— showing 50 strongest matches
Bromley — recommendation 4.4.10
Children’s Services to lead on a multi-agency SCIE review, using this case as an example, to improve practice in relation to vulnerable young people who may come into contact with oppressive and abusive individuals.
Bromley Children’s Services
Bromley — recommendation 4.3.3a
Victim Support management in the Southeast Division audit against internal policies shown below, a sample of domestic abuse referrals randomly from the Case Management System (CMS) for the borough of Bromley for the period January – March 2014: • Victim Support’s DV Service Delivery Operating Instructions (DVSDOI) • Victim Support’s …
Victim Support
Lambeth — recommendation 4.9.5
All DV cases should be discussed with the DV specialist or have a consultation with Child Protection Chairs.
Lambeth Council Children & Young People’s …
London Borough of Lambeth
Lambeth — recommendation 4.9.3
The NRTPF‘s team to ensure all assessments are holistic, take account of all information known or recorded ,and do not have a narrow focus ,but ensure they review safeguarding concerns over and above the financial issues.
Lambeth Council Children & Young People’s …
London Borough of Lambeth
Lambeth — recommendation 4.8.5
Re-emphasis on Health Visiting standards to include: Use of assessment framework. Risk assessment Escalation process to managers and safeguarding team when cases are not progressing Evaluate the scope and effectiveness of the lead Health Visitor role in relation to domestic abuse. Review scope of CNN …
Guy’s & St Thomas’ Hospital
Guy's and St Thomas' …
Lambeth — recommendation 4.3
Refer this review to the Lambeth Local Safeguarding Children’s Board to consider the concerns about child welfare and protection arising from this review and the C&YPS and G&St T services in particular.
Lambeth Local Safeguarding Children’s Board
Kent — recommendation 3
The police CRU should review their current procedures for facilitating Safeguarding Referrals to Health Care Professionals where these have not been assessed as ‘High Risk’ in a DARA Risk Assessment.
Kent Police
Kent Police
Lincoln — recommendation Recommendation 6
The Safer Lincolnshire Partnership and Lincolnshire Safeguarding Children Partnership should seek assurance from partners that their information sharing systems, ensure that in cases of domestic abuse, information is being shared in a timely and appropriate manner and that the voluntary sector are included as an integral part of information sharing …
Safer Lincolnshire Partnership | Lincolnshire Safeguarding …
Lincoln — recommendation Recommendation 3 ii)
The Safer Lincolnshire Partnership and the Lincolnshire Domestic Abuse Partnership should seek assurance from all agencies that their staff are aware of the impact that Domestic Abuse has on Safeguarding Children. That the agencies also ensure that any perpetrator risk assessments feed into the safety planning around any children in …
Safer Lincolnshire Partnership | Lincolnshire Domestic …
Lincoln — recommendation Recommendation 2
The Lincolnshire Domestic Abuse Partnership and the Local Safeguarding Children Partnership should seek assurance from partners that when they work with victims of domestic abuse, who are unable to or reluctant to engage, that they consider the best individual, or agency, who could facilitate this engagement, in order to ensure …
Lincolnshire Domestic Abuse Partnership | Lincolnshire …
Lincoln — recommendation (ii)
Safeguarding leaders have already improved procedures for sustaining routine contact with all parents whose children with special educational needs and disabilities travel independently to the school.
Special School
Lincoln — recommendation (i)
Additional training has since been given to school staff on Domestic Abuse and the indicators for pupils and families.
Special School
Lincoln — recommendation ii)
Further training is being delivered to staff at the Hostel in reporting concerns and will be monitored through regular service reviews.
Salvation Army
Lincoln — recommendation i)
Staff within the Hostel need to be confident in their responsibility to report disclosures of concern robustly and consistently. The service has evidence of regularly reporting safeguarding concerns appropriately, however, in this case staff felt reassured by (1) how the perpetrator presented within the service and (2) the response from …
Salvation Army
Lincoln — recommendation 1
Whilst learning has been identified in terms of how practitioner practice could be improved in terms of multiagency working; it remains unclear as to why Probation services were not involved in the Child in Need process or whether the concerns of the supported housing provider were shared and acted on. …
Probation Service
Probation Service
Lincoln — recommendation iii)
The Trust’s Head of Safeguarding to meet with the Trust Named Doctors for Safeguarding and the Trust Medical Director to review the process of how a safeguarding concern disclosed within an outpatient’s appointment is cross referenced with the record and the care coordinator to ensure it has already been identified …
Lincolnshire Partnership NHS Foundation Trust
Lincolnshire Partnership NHS Foundation …
Lincoln — recommendation ii)
For Steps2Change Service Manager, in consultation with the Trust Safeguarding team, to review their Referral Screening Protocol and consider if changes are required to improve consistency amongst the screening staff in identifying and recording safeguarding and risk history when it is recorded on the separate clinical system RIO.
Lincolnshire Partnership NHS Foundation Trust
Lincolnshire Partnership NHS Foundation …
Lincoln — recommendation ii)
Professional curiosity has been included in further LCHS safeguarding mandatory training, and safeguarding supervision for all staff within LCHS. The LCHS safeguarding team also provides an advice hub for contacts from any LCHS staff members who have experienced concerns from a contact with a patient where their aggressive behaviour may …
Lincolnshire Community Health Services
Lincolnshire Community Health Service …
Lincoln — recommendation i)
A monthly audit is undertaken of all safeguarding referrals completed by LCHS Urgent Treatment Centre staff to ensure all safeguarding procedures have been followed.
Lincolnshire Community Health Services
Lincolnshire Community Health Service …
Lincoln — recommendation i)
PNC checks submitted by children’s services practitioners will routinely seek disclosure to include all information relating to a person’s offending history and make clear this is not limited to just information from the preceding two years.
Lincolnshire County Council Children Services
Cheltenham — recommendation GHCNHST.3
GHCNHST level 2 manadatory safeguarding training has been based around a family where domestic abuse impacts on each family member from a baby to an older adult with care and suport needs. Includes reference to alcohol misuse and MAPPA.
Gloucestershire Health and Care NHS Trust
Gloucestershire Health and Care …
Cheltenham — recommendation SWASNHSFT.1
Recognising the care and support needs of those addicted to alcohol and the likely self-neglect as a consequence of this. There were a number of missed opportunities for SWASFT crews to raise safeguarding alerts for self-neglect to Adult Social Care.
South Western Ambulance Service NHS Foundation …
South Western Ambulance Service …
Cheltenham — recommendation GASC.9
For ASC practitioners to clearly document that they have considered the impact of domestic abuse on the person’s ability to make decisions with capacity free of coercion or controlling behaviours.
Gloucestershire Adult Social Care
Cheltenham — recommendation GASC.8
ASC practitioners remain aware of the principles of Making Safeguarding Personal in conjunction with the statutory requirements of s11 Care Act 2014 “Refusal of Assessment” and document where this has been considered
Gloucestershire Adult Social Care
Cheltenham — recommendation GASC.6
When working with individuals who may be at risk of abuse or neglect, practitioners remain professionally curious ensuring all appropriate methods of communication are utilized.
Gloucestershire Adult Social Care
Cheltenham — recommendation GASC.5
ASC workers to clearly record the purpose and anticipated content of ongoing welfare telephone calls and/or visits and where for any reason the welfare check is not undertaken, this is immediately escalated to the line manager for discussion and agreement on next steps. ASC workers may wish to agree in …
Gloucestershire Adult Social Care
Cheltenham — recommendation GASC.2
Customer Service Officers ensure that all suitable referrals are passed to the Locality team for assessment.
Gloucestershire Adult Social Care
Cheltenham — recommendation 6 (NATIONAL)
HM Prison Service to review its policies and practice around communications from prison in cases of domestic abuse to ensure the ongoing safeguarding of victims.
HM Prison Service
HM Prison and Probation …
Cheltenham — recommendation 5b
When engaging with people who have complex needs and where domestic abuse may be known or suspected, all professionals should exercise professional curiosity when exploring with the person their ability to self-care and/or the appropriateness of their support network in relation to any arising needs for care and support.
Safer Gloucestershire | Gloucestershire Constabulary | …
Gloucestershire Constabulary
Cheltenham — recommendation 4
When agencies contact the police regarding safe and well checks, where possible, the information should be relayed directly (phone/face to face) in order to convey the risk associated with the individuals it concerns. This will support police in ensuring Safe and well checks are conducted appropriately and victims are safeguarded.
All agencies on the Domestic Abuse …
Gloucestershire Constabulary
Cheltenham — recommendation 3b
For the Safeguarding adults board to ensure the findings from this review are considered alongside the 5 women SAR to ensure a joined up approach to the learning around ‘ensuring agencies can respond effectively at the point when someone is ready to accept support’ and the need to act fast …
Gloucestershire Safeguarding Adults Board
Cheltenham — recommendation 3a
Ensure agencies are aware of the immediate safety measures that should be considered when responding to victims of domestic abuse to ensure safety planning is not delayed or linked to ongoing victim engagement
Gloucestershire Constabulary | Gloucestershire County Council …
Gloucestershire Constabulary
Doncaster — recommendation 2
ASPIRE Drug and Alcohol Services to provide awareness sessions to the Safeguarding Adult Board
Rotherham Doncaster and South Humber NHS …
Rotherham Doncaster and South …
Doncaster — recommendation 3
MARAC Steering Group has been reinstated.
Doncaster Council IDVA Service
West Lancashire — recommendation 25
WLCSP to seek assurances that the process to ensure timely escalation of safeguarding concerns from other agencies, via letters are shared with GP leads via Practice administration staff regarding safeguarding risks/ vulnerability and DA
NHS Lancashire and South Cumbria Integrated …
NHS Lancashire and South …
West Lancashire — recommendation 22
WLCSP to seek assurances that MARAC actions are being completed within the timescales agreed or are being followed up in a timely manner of not
Lancashire Constabulary
Lancashire Constabulary
West Lancashire — recommendation 20
WLCSP to seek assurances that prompt contact is made between with Wrightington Wigan and Leigh Hospital and the Safeguarding Team
Wrightington, Wigan and Leigh NHS Trust …
Wrightington, Wigan and Leigh …
West Lancashire — recommendation 19
WLCSP to seek assurance from MARAC that the Lancashire Safeguarding team are aware of all MARAC meetings and are provided with the details of all those to be discussed at each meeting
Lancashire County Council Safeguarding Adults | …
Lancashire Constabulary
West Lancashire — recommendation 17
Lancashire County Council Safeguarding Team to have a system in place, to support safeguarding staff, who have concerns there is an increased risk to an individual, linked to their reluctance to engage with professionals.
Lancashire County Council Safeguarding Adults
West Lancashire — recommendation 16
WLBC Housing Services to encourage its maintenance contractors to make Housing staff aware of situations where they know or believe there is DA or a vulnerable adult.
West Lancashire Borough Council Housing Team
West Lancashire — recommendation 14
WLCSP to seek assurance from General Practice and the MARAC, that the template currently used to share MARAC information with General Practice, is effective and efficient; If areas of improvement are identified, to construct a means to deliver these changes.
NHS Lancashire and South Cumbria Integrated …
NHS Lancashire and South …
West Lancashire — recommendation 13
WLCSP to request the NHS Lancashire Integrated Care Board West Lancashire locality re-emphasise and promote awareness of the safeguarding duty of independent clinical practitioners.
NHS Lancashire and South Cumbria Integrated …
NHS Lancashire and South …
Manchester — recommendation GMMH 5
GMMH ‘Safeguarding Adults at Risk’ policy to be updated to include clear guidance on clinical expectations when ‘screening’ safeguarding referrals made by other agencies, including documentation required and professional communication with the referrer.
GMMH
Greater Manchester Mental Health …
Manchester — recommendation 1
The Manchester Community Safety Partnership works with the Manchester Safeguarding Partnership, the Manchester Integrated Care Board, IRIS Manchester and the Betsi Cadwaladr University Health Board to seek assurance that all independent practitioners (General Practitioners and other independent contractors) are aware of their safeguarding duties and receive training and support to …
Manchester Community Safety Partnership | Manchester …
Betsi Cadwaladr University Health …
Sheffield — recommendation STHFT 4
The STHFT ED should remind all staff of the Standard Operating Procedure for the reporting of gun and knife crime and ensure all staff working within the Emergency Department and Minor Injuries are made aware of their responsibilities for reporting such incidents to police. The SOP could include responsibilities for …
Sheffield Teaching Hospitals Foundation Trust (STHFT)
Sheffield — recommendation STHFT 1
To build upon the ongoing training as part of the safeguarding champions network awareness around the impact of ACEs and adopting trauma informed practice.
Sheffield Teaching Hospitals Foundation Trust (STHFT)
Sheffield — recommendation 13
Health Visitors (working for Sheffield Children’s NHS Foundation Trust (SCFT) or Sheffield Health and Social Care Trust) should routinely submit a DASH (Domestic Abuse, Stalking, Harassment, and ‘Honour’ Based Abuse) risk assessment where domestic violence or abuse is identified or suspected, including inter-family violence.
Sheffield Children’s NHS Foundation Trust (SCFT) …
Sheffield Health and Social …
Sheffield — recommendation 9
SCCG should build upon the training to date, and support professionals, in identifying and responding to inter-adult violence / domestic abuse between siblings.
SICB
Sheffield — recommendation 7
The STHFT ED should remind all staff of the Standard Operating Procedure for the reporting of gun and knife crime and ensure all staff working within the Emergency Department and Minor Injuries are made aware of their responsibilities for reporting such incidents to police. The SOP could include responsibilities for …
STHFT
Sheffield — recommendation 6
STHFT to raise awareness and understanding of professionals to ensure where domestic abuse is disclosed, within the Sheffield Teaching Hospital, a DASH should be submitted. Within the Emergency Department(s) a Domestic Abuse Communication Form should be used by health professionals.
STHFT
CJINI inspection reports(7)
RQIA and CJI Publishes Review of Protocol for the Joint Investigation of Alleged or Suspected Cases
Probation and Public Safety, Safeguarding
Feb 2012
Protocol for the Joint Investigation of Alleged or Suspected Cases of Abuse of Vulnerable Adults
Probation and Public Safety, Safeguarding
Feb 2012
The approach of the criminal justice system to investigating and prosecuting crimes against vulnerable adults
Probation and Public Safety, Safeguarding
Sep 2015
First joint inspection of Child Protection Arrangements
Abuse and Exploitation, Probation and Public Safety, Safegu…
Jun 2023
An Inspection of the Criminal Justice System’s Approach to Vulnerable Older People in Northern Ireland
Equality, Probation and Public Safety, Safeguarding
Sep 2023
The Management of Sex Offenders in Northern Ireland – March 2005
Risk Management and public protection arrangements, Probati…
Mar 2005
The Management of Sex Offenders
Risk Management and public protection arrangements, Probati…
Dec 2006
CQC enforcement actions(12)
Conditions Imposed: University Hospitals Birmingham NHS Foundation Trust
The Care Quality Commission placed conditions on University Hospitals Birmingham NHS Foundation Trust's registration. This action followed inspections where the trust had not met the requirements of a previous warning notice and further issues were identified. Conditions were also imposed …
Feb 2024
Warning Notice: Kettering General Hospital NHS Foundation Trust
The Care Quality Commission (CQC) found improvement is needed in the children and young people’s (CYP) services run by Kettering General Hospital NHS Foundation Trust, after an inspection in December. Due to concerns found at this inspection, CQC has taken …
Kettering General Hospital
Apr 2023
Warning Notice: Cambridgeshire and Peterborough NHS Foundation Trust
Warning notice served following an inspection of wards for older people with mental health problems on 28–29 January 2026. CQC found leaders had missed some concerning gaps in people’s safety. Two patients sustained unreported broken bones from unwitnessed injuries; safeguarding …
Fulbourn Hospital and the Cavell Centre
Mar 2026
Warning Notice: Essex Partnership University NHS Foundation Trust
Warning notice served following an unannounced inspection on 21 November 2025. CQC found leaders at 439 Ipswich Road weren’t always acting quickly on safety concerns raised by their staff or the people in their care. Safeguarding incidents affecting physical or …
439 Ipswich Road
Feb 2026
Warning Notice: South Central Ambulance NHS Foundation Trust
The Care Quality Commission (CQC) told South Central Ambulance NHS Foundation Trust to make improvements to its safeguarding processes following an unannounced focused inspection in November. Inspectors found that the trust's safeguarding policies were ambiguous, training was limited, and systems …
Feb 2022
Conditions Imposed: East of England Ambulance Service NHS Trust
The Care Quality Commission (CQC) used its enforcement powers at the East of England Ambulance Service NHS Trust, requiring it to overhaul its safeguarding processes and report back to CQC on issues it must address. This action followed an inspection …
Sep 2020
Warning Notice: Northern Care Alliance NHS Foundation Trust
Following the September inspection, CQC issued a warning notice to the trust to highlight the areas where rapid and significant improvements were needed. The service didn’t have effective systems and processes in place to ensure the wards had enough suitably …
Salford Royal Hospital
Oct 2025
Warning Notice: Sandwell and West Birmingham Hospitals NHS Trust
Section 29A warning notice covering maternity services at City Hospital, Birmingham, following an inspection in June 2024 after which the safe rating declined from good to inadequate. The notice focused the trust's attention on making significant improvements around the environment, …
City Hospital, Birmingham
Nov 2024
Criminal Prosecution: The Rotherham NHS Foundation Trust
The trust pleaded guilty to one charge of failing to provide safe care and treatment, exposing four young children and other patients to a significant risk of avoidable harm at Rotherham General Hospital. Ordered to pay £233,238 in total.
Oct 2022
£200000
Warning Notice: South Tyneside NHS Foundation Trust
The Care Quality Commission told South Tyneside NHS Foundation Trust that it must make further improvements to protect children and young people who may be at risk of harm. A focused inspection found limitations within the patient recording system in …
Oct 2016
Conditions Imposed: Portsmouth Hospitals NHS Trust
The Care Quality Commission issued a Warning Notice to Portsmouth Hospitals NHS Trust, requiring improvements in safety, patient consent, dignity and respect, safeguarding, and overall leadership. Concurrently, CQC placed six conditions on the trust's registration, mandating specific actions to ensure …
Queen Alexandra Hospital
Aug 2017
Warning Notice: Wye Valley NHS Trust
The Care Quality Commission issued Wye Valley NHS Trust with a warning notice following an inspection in September and October 2015. The warning required the trust to make significant improvements to its systems for assessing, monitoring, and mitigating risks to …
Jan 2016