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 18 independent accountability sources, so the source mix matters as much as the headline total.
282 inquiry recs
78 PFD reports
79 committee recs
11 HSSIB recs
123 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
43 PHSO decisions
3072 LGO/SPSO decisions
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(282)— showing 50 strongest matches
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: On 21 January 2021, the Home Office confirmed that it would bring forward the necessary legislation to give effect to this recommendation when parliamentary time allows. The Home Office stated that it had commissioned the …
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 …
Gov response: On 20 June 2018, the UK government ratified the Lanzarote Convention.
Accepted
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: On 9 March 2021, the Ministry of Justice and Home Office stated that the government would introduce the Police, Crime, Sentencing and Courts Bill. The Bill sought to extend the definition of a 'position of …
Accepted
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 …
Gov response: On 30 June 2022, the Welsh Government stated that it will amend and strengthen the independent school regulations, and that work is ongoing to draft the legislation. The Welsh Government also stated that it will …
Accepted
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 …
Gov response: On 30 June 2022, the UK government stated that anyone undertaking teaching work can be referred to the Teaching Regulation Agency (TRA) and this could include teaching assistants and learning support staff. The TRA does …
Accepted in Part
62 — Schools notify inspectorate of DBS referrals
Recommendation: The Department for Education and the Welsh Government should: require schools to inform the relevant inspectorate when they have referred a member of staff to the Disclosure and Barring Service, the Teaching Regulation Agency or the Education Workforce Council; and …
Gov response: On 30 June 2022, the UK government stated that it was cautious about creating a reporting mechanism that only related to the Disclosure and Barring Service and Teaching Regulation Agency when its position in Keeping …
Accepted in Part
59 — National LADO standards
Recommendation: The Department for Education and the Welsh Government should: introduce a set of national standards for local authority designated officers in England and in Wales to promote consistency; and clarify in statutory guidance that the local authority designated officer can …
Gov response: On 30 June 2022, the UK government stated that it was considering the scope and timetable for a review of the statutory guidance Working Together to Safeguard Children. It stated that it will consider revised …
Accepted in Part
58 — Residential schools inspection and guardians registration
Recommendation: The Department for Education and the Welsh Government should: require all residential special schools to be inspected against the quality standards used to regulate children's homes in England and care homes in Wales; reintroduce a duty on boarding schools and …
Gov response: On 30 June 2022, the UK government stated that it was still of the view that the best way to protect children in residential special schools was to strengthen the National Minimum Standards (NMS), and …
Accepted in Part
56 — Update CSE guidance with network information
Recommendation: The Department for Education should review and publish an updated version of its guidance on child sexual exploitation. The update should specify that the core element of the definition of child sexual exploitation is that a child was controlled, coerced, …
Gov response: On 30 June 2022, the UK government provided the Inquiry with its provisional response to this recommendation. The UK government stated its final response to this recommendation would be provided within six months of the …
Accepted in Part
55 — Religious organisation child protection policies
Recommendation: All religious organisations should have a child protection policy and supporting procedures, which should include advice and guidance on responding to disclosures of abuse and the needs of victims and survivors. The policy and procedures should be updated regularly, with …
Gov response: Between January and March 2022, Methodist Church, Triratna Buddhist Order and Community and United Reformed Church stated that they had updated their safeguarding policies and practices, and The Baptist Union for Great Britain stated that …
Accepted
54 — Lambeth foster carer vetting review
Recommendation: Lambeth Council should review the application of recruitment and vetting procedures for all current foster carers directly provided by Lambeth Council, to ensure that the procedures have been followed correctly. In addition, Lambeth Council should seek assurances from external agencies …
Gov response: On 15 December 2021, Lambeth Council stated that staff working with children, councillors and foster carers had appropriate and up-to-date Disclosure and Barring Service certificates. It also stated that it would implement an online Disclosure …
Accepted
51 — Review Catholic safeguarding policies manual
Recommendation: The Catholic Safeguarding Advisory Service should review its policies and procedures manual and the documents within it to ensure that they are consistent, easier to follow and more accessible.
Gov response: In November 2021, the Catholic Safeguarding Standards Agency website was launched. It contains the National Safeguarding Standards, the National Safeguarding Policy, and practice guidance documents.
Accepted
50 — Independent validation of Catholic audit programme
Recommendation: The Catholic Safeguarding Advisory Service should have the effectiveness of its audit programme regularly validated by an independent organisation which is external to the Church. These independent reports should be published.
Gov response: On 30 September 2021, the Catholic Council for the Inquiry stated that the Catholic Safeguarding Standards Agency (CSSA) Board is committed to the independent verification of its audit processes, and would undertake a formal process …
Accepted
49 — Catholic non-compliance framework
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious should publish a clear framework for dealing with cases of non-compliance with safeguarding policies and procedures. That framework should identify who is responsible for dealing with issues …
Gov response: On 30 September 2021, the Catholic Council for the Inquiry stated that the trustee bodies of all Catholic dioceses and religious orders were invited to subscribe to the Catholic Safeguarding Standards Agency. The Catholic Safeguarding …
Accepted
47 — Catholic lead clergy for safeguarding
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious in England and in Wales should each nominate a lead member of the clergy for safeguarding to provide leadership and oversight on safeguarding matters to their respective …
Gov response: On 30 April 2021, the Catholic Council for the Inquiry stated that the role description for the Lead Bishop for the Catholic Bishops' Conference of England and Wales was approved and Bishop Paul Mason was …
Accepted
46 — Church independent external safeguarding audits
Recommendation: The Church in Wales should introduce independent external auditing of its safeguarding policies and procedures, as well as the effectiveness of safeguarding practice in dioceses, cathedrals and other Church organisations. Audits should be conducted regularly and reports should be published. …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that it remained committed to their programme of five-yearly independent audits. The joint …
Accepted
45 — Local diocesan information sharing protocols
Recommendation: The Church of England, the Church in Wales and statutory partners should ensure that information-sharing protocols are in place at a local level between dioceses and statutory partners.
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that it would develop template information-sharing agreements which may be adapted and used …
Accepted
44 — Church of England/Wales information sharing protocol
Recommendation: The Church of England and the Church in Wales should agree and implement a formal information-sharing protocol. This should include the sharing of information about clergy who move between the two Churches.
Gov response: On 24 June 2021, the Church of England announced that the updated version of the House of Bishops' handling of Clergy Personal Files policy covers data sharing between the Church of England and the Church …
Accepted
43 — Church in Wales record-keeping policies
Recommendation: The Church in Wales should introduce record-keeping policies relating to safeguarding, complaints and whistleblowing. These should be implemented consistently across dioceses. The Church should develop policies and training on the information that must be recorded in files. The Church should …
Gov response: On 7 April 2021, the Church in Wales stated that its national online safeguarding case management and record-keeping system had launched, serving as a single searchable repository of all Church in Wales safeguarding and whistleblowing …
Accepted
42 — Church in Wales provincial safeguarding officers
Recommendation: The Church in Wales should make clear that the operational advice of provincial safeguarding officers must be followed by all members of the clergy and other Church officers. It should be enshrined in policy that those who are volunteers and …
Gov response: On 7 April 2021, the Church in Wales stated that its safeguarding policy, procedural documents and training materials would make it clear that the operational advice of provincial safeguarding officers should be followed by all …
Accepted
41 — Create diocesan safeguarding officers
Recommendation: The Church of England should create the role of a diocesan safeguarding officer to replace the diocesan safeguarding adviser. Diocesan safeguarding officers should have the authority to make decisions independently of the diocesan bishop in respect of key safeguarding tasks, …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that Canon C30 and the associated Diocesan Safeguarding Advisor Regulations would be amended …
Accepted
39 — Political party safeguarding policies
Recommendation: All political parties registered with the Electoral Commission in England and in Wales must ensure that they have a comprehensive safeguarding policy. All political parties must also ensure that they have procedures to accompany their policies, in order that politicians, …
Gov response: On 3 July 2020, the Electoral Commission stated that given the statutory scope of its remit, introducing a requirement that the Commission should monitor and oversee compliance of the safeguarding policies of political parties would …
Accepted
38 — Government department safeguarding policy reviews
Recommendation: The Cabinet Office must ensure that each government department reviews its child safeguarding policy or policies in light of the expert witness report of Professor Thoburn. There must also be published procedures to accompany their policies, in order that staff …
Gov response: On 18 September 2020, the UK government confirmed that all government departments were aware of Professor Thoburn's report. It also stated that Civil Service HR had launched a model safeguarding policy and 'Health Check' process, …
Accepted
37 — Westminster whistleblowing policies for CSA
Recommendation: Government, political parties and other Westminster institutions must have whistleblowing policies and procedures which cover child sexual abuse and exploitation. Every employee must be aware that they can raise any concerns using these policies and that the policies are not …
Gov response: On 18 September 2020, the UK government confirmed that all government departments have whistleblowing policies in place. It confirmed that Civil Service HR has a model policy to support departments in ensuring their policies are …
Accepted
35 — Mandatory DBS for work with children overseas
Recommendation: The Home Office should introduce legislation making it mandatory for: 1. all UK nationals and residents of England and Wales to provide a prospective employer overseas with an enhanced Disclosure and Barring Service certificate before undertaking work with children overseas …
Gov response: On 21 January 2021, the Home Office stated that although part 1 of this recommendation envisaged placing the legal obligation of providing overseas employers with an enhanced Disclosure and Barring Service certificate on UK nationals, …
Not Accepted
34 — DBS certificates for overseas work
Recommendation: The Home Office should introduce legislation permitting the Disclosure and Barring Service to provide enhanced certificates to UK nationals and residents of England and Wales applying for: 1. work or volunteering with UK-based organisations, where the recruitment decision is taken …
Gov response: On 21 January 2021, the Home Office stated that the UK government would continue to work with ACRO to publicise the existence of the International Child Protection Certificate, and to improve employers' understanding of the …
Not Accepted
33 — Assessment of potential risks posed by foster carers and residential care staff
Recommendation: Nottingham City Council should assess the potential risks posed by current and former foster carers directly provided by the council in relation to the sexual abuse of children. They should also ensure that current and former foster carers provided by …
Gov response: Nottingham City Council: On 20 December 2021, Nottingham City Council stated that an internal fostering review was complete. External assurance of the review was also complete. The review concluded that no further referrals were required …
Accepted
32 — Send internal safeguarding reviews to national body
Recommendation: If religious organisations have undertaken internal reviews or enquiries into individual safeguarding incidents, their findings should be sent to the national review body (set up under the Children and Social Work Act 2017).
Gov response: On 27 June 2019, the Church of England stated that its National Safeguarding Team would liaise with the Child Safeguarding Practice Review Panel to ensure that 'the right cases' are reported to them in accordance …
Accepted
30 — Amend Canon C30 on safeguarding due regard
Recommendation: The Church of England should amend the current canon requiring clerics to comply with the Bishop's Guidance on Safeguarding. The use of the words 'due regard' in Canon C30 is an acceptable term of art, but lacks sufficient clarity. Very …
Gov response: On 26 April 2021, the General Synod approved the Safeguarding (Code of Practice) Measure which strengthens and clarifies the obligation to follow safeguarding guidance. The statutory code replaces the existing duty to have 'due regard' …
Accepted
29 — Church of England religious communities safeguarding
Recommendation: The Church of England should introduce appropriate guidance which deals with safeguarding within the context of a religious community affiliated to the Church. It must ensure that these organisations meet adequate requirements for safeguarding and child protection. The needs of …
Gov response: On 27 June 2019, the National Safeguarding Steering Group stated that the General Synod would be asked to give final approval to amending Canon 40. The National Safeguarding Steering Group stated that the amendment inserts …
Accepted
25 — Amendment of Safeguarding Vulnerable Groups Act 2006
Recommendation: The Chair and Panel recommend that the Home Office ensures that the Safeguarding Vulnerable Groups Act 2006 is amended so that, where a fitness to practise hearing has been conducted by the keeper of a relevant register and has resulted …
Gov response: The DBS is in the process of establishing single points of contact at a strategic level with all Keepers of Registers and Supervisory Authorities. By the end of August, the DBS will have had meetings …
Not Accepted
23 — National chaperone policy for healthcare (Wales)
Recommendation: The Chair and Panel recommend that the Welsh Government develops a national policy for the training and use of chaperones in the treatment of children in healthcare services. The Chair and Panel recommend that Healthcare Inspectorate Wales considers compliance with …
Gov response: On 6 January 2020, the Welsh Government published guidance for health boards and trusts in respect of good working practice for the use of chaperones during intimate examinations or procedures within NHS Wales.
Accepted
22 — National chaperone policy for healthcare (England)
Recommendation: The Chair and Panel recommend that the Department of Health and Social Care develops a national policy for the training and use of chaperones in the treatment of children in healthcare services. The Chair and Panel recommend that the Care …
Gov response: DHSC fully supports the use of chaperones for children, young people and adults at risk. DHSC will seek assurance from NHS England and CQC that the relevant organisations have chaperone protocols in place to safeguard …
Accepted
FR-6 — Amend Children Act 1989
Recommendation: The Inquiry recommends that the UK government amends the Children Act 1989 so that, in any case where a court is satisfied that there is reasonable cause to believe that a child who is in the care of a local …
Gov response: We accept the absolute need for children and young people to have their voices heard, raise concerns and challenge any aspect of their care, including where they may be experiencing or at risk of serious …
Accepted in Part
FR-5 — Prohibit Pain Compliance Techniques
Recommendation: The Inquiry recommends (as originally stated in its Sexual Abuse of Children in Custodial Institutions: 2009-2017 Investigation Report, dated February 2019) that the UK government prohibits the use of any technique that deliberately induces pain (previously referred to by the …
Gov response: It is essential that staff are equipped to keep children safe in custodial institutions. That is why they must be trained in the use of safe pain-inducing techniques for scenarios where they may need to …
Not Accepted
18 — Joint MoJ/DfE policy for children in custody
Recommendation: The Chair and Panel recommend that the Ministry of Justice and the Department for Education share policy responsibility for managing and safeguarding children in custodial institutions. This is to ensure that standards applied in relation to children in custody are …
Gov response: On 23 July 2019, the Ministry of Justice stated that it has joint working relationships with the Department for Education on secure children's homes, safeguarding and establishing secure schools. It stated that it aims to …
Not Accepted
17 — Prohibit pain compliance techniques
Recommendation: The Chair and Panel consider that the use of pain compliance techniques should be seen as a form of child abuse, and that it is likely to contribute to a culture of violence, which may increase the risk of child …
Gov response: On 18 June 2020, the Ministry of Justice published the Charlie Taylor review of pain-inducing techniques in the youth secure estate. The review recommended that the Minimising and Managing Physical Restraint (MMPR) programme should be …
Not Accepted
16 — Review mixed justice/welfare placement risk
Recommendation: The Chair and Panel recommend that the Department for Education and the Youth Custody Service conduct a full review of the practice of placing children for justice and welfare reasons together in secure children's homes to establish whether it increases …
Gov response: On 7 May 2021, the Department for Education published its review of placement practices in secure children's homes. It concluded that the practice of placing children in mixed justice and welfare homes does not create …
Accepted
11 — Ban CSE-risk children from semi-independent placements
Recommendation: The Department for Education should ban the placement in semi-independent and independent settings of children aged 16 and 17 who have experienced, or are at heightened risk of experiencing, sexual exploitation. This should be implemented without delay.
Gov response: On 30 June 2022, the UK government provided the Inquiry with its provisional response to this recommendation. The UK government stated its final response to this recommendation would be provided within six months of the …
Accepted in Part
10 — Publish enhanced Child Exploitation Disruption Toolkit
Recommendation: As referenced in its Tackling Child Sexual Abuse Strategy, the government should publish an enhanced version of its Child Exploitation Disruption Toolkit as soon as possible. This Toolkit must: specify that the core element of the definition of child sexual …
Gov response: On 30 June 2022, the UK government provided the Inquiry with its provisional response to this recommendation. The UK government stated its final response to this recommendation would be provided within six months of the …
Accepted in Part
8 — Expand Ofsted powers for unregistered settings
Recommendation: The government should introduce legislation to: change the definition of full-time education, and to bring any setting that is the pupil's primary place of education within the scope of the definition of a registered educational setting; and provide the Office …
Gov response: On 2 March 2022, the UK government stated that in 2020 it had consulted to legislate to amend the registration requirements for independent education settings. It confirmed that it had considered responses to the consultation …
Accepted in Part
5 — Reform Church of England clergy discipline for safeguarding
Recommendation: The Church of England should make changes and improvements to the way in which it responds to safeguarding complaints (whether related to allegations of abuse, or a failure to comply with or respond to the Church's safeguarding policies and procedures) …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council endorsed the proposals of the Clergy Discipline Measure working group to replace Clergy Discipline …
Accepted
4 — National plan for overseas CSA by UK nationals
Recommendation: The Home Office should coordinate the development of a national plan of action addressing child sexual abuse and exploitation overseas by UK nationals and residents of England and Wales, involving input from all lead governmental agencies in the field.
Gov response: On 21 January 2021, the Home Office confirmed that it would implement this recommendation as part of the UK government's Tackling Child Sexual Abuse Strategy. The strategy sets out the government's national plan of action …
Accepted
R74 — Staffing review in safeguarding investigations
Recommendation: Consideration of staffing (including skill mix as well as total numbers) should be a mandatory part of safeguarding investigations in all settings.
Response Pending
R68 — Cumulative risk assessment across protection plans
Recommendation: Protection plans should include an assessment of risks arising from the plan itself. Where multiple protection plans are in place for vulnerable adults within a single unit, cumulative risks arising from those individual protection plans across all residents must also …
Response Pending
Prevention of Future Deaths reports(78)— showing 50 strongest matches
Daniel Onley
Concerns: Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.
Response (The Camphill Village Trust): The Trust has audited medicine administration, revised policies, implemented common paperwork for risk management, and shared the coroner's concerns with operational managers. The Safeguarding Board is monitoring the issues and …
Overdue
Joan Farran
Concerns: The provided text is truncated and does not clearly state the specific concerns identified by the coroner.
Overdue
Christine Williamson
Concerns: Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between agencies hindered preventative measures.
Response (Telford Wrekin Council): Telford & Wrekin Council has compiled a plan of action building upon recommendations made in the Domestic Homicide Review report, and the implementation of the action plan will be formally …
Response (Telford Wrekin Clinical Commissioning Group): The Adult Safeguarding Policy and Thresholds has been recirculated, domestic abuse leaflets and guidance has been circulated, and an education and training event for Telford & Wrekin GPs and Practice …
Response (West Mercia Police): West Mercia Police will provide a reminder regarding the requirement to complete DASH; Crime Reports and Vulnerable Adult documentation to all operational staff. The tactical equality and diversity advisor has …
Responded
Wendy Brown
Concerns: Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and lengthy application processing times, put carers under severe strain.
Response (Swindon Borough Council): Swindon Borough Council recognises complexity and potential delays in decision making are real issues. An immediate action taken is that; were services over and above the indicative budget are requested, …
Responded
Derrick Plater
Concerns: There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.
Response: The council believes that a pre-placement visit by a social worker would not have provided any added assurance and is not and will not be part of the assessment and …
Responded
Sean Morley
Concerns: The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road users and a 70mph speed limit, creating a high risk of collisions.
Response (Warwickshire County Council): • A CCTV survey was commissioned to determine the level of pedestrian and cyclist use, with analysis still to be carried out. • A feasibility study will be conducted by …
Responded
Barbara Cooke
Concerns: Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.
Overdue
Kesia Leatherbarrow
Concerns: Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team case, led to a lack of support for a high-risk young person.
Response (Department of Health): The Department of Health has shared the report with NHS England, who are working to develop Liaison and Diversion services in Greater Manchester. NHS England is also reshaping mental health …
Response (Home Office): The government has already made a partial change to PACE via the Criminal Justice and Courts Act to require 17 year olds to be treated as 10-16 year olds for …
Response (Pennine Care NHS Trust): Pennine Care NHS Foundation Trust has completed an investigation, requesting written clinical summaries and risk assessments when young people transfer from other mental health services. The health diversion pathway has …
Response (Crown Prosecution Service): The CPS has modified CPS training so advocates conducting youth court cases are reminded that a youth can always be remanded for their "own welfare". The Chief Crown Prosecutor for …
Overdue
Sidney Barnett
Concerns: The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was flawed, relying too heavily on unverified staff statements.
Response: The care home has implemented room visit charts, enhanced personal care documentation, dignity training delivered by the manager, and window checks as part of the room visit checks.
Overdue
Phyllis Broomhead
Concerns: Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.
Response (Rotherham Borough Council): Rotherham Metropolitan Borough Council will provide a detailed action plan regarding recommendations made under Regulation 28, outlining actions taken, actions to be achieved, and timescales to conclude any uncompleted actions.
Responded
Jeffrey Warren
Concerns: Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work staff inappropriately requested police for non-urgent welfare checks due to lack of training.
Response (Crawley Borough Council): Crawley Borough Council corrected some factual inaccuracies, and stated they will review all door entry systems by 30 September 2015 and then carry out an upgrade program to solve the …
Overdue
Isabel Richardson
Concerns: The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust system to address student problems.
Overdue
Allan Beasley
Concerns: Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, and unreliable patient observation practices.
Overdue
Irene Scholey
Concerns: No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.
Overdue
Robert Mansfield
Concerns: Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning notices, and readily available flotation equipment.
Overdue
Kamrul Rubel
Concerns: The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about adherence to safety protocols for gym equipment.
Overdue
Norman Dorn
Concerns: Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.
Overdue
Colin Williams
Concerns: A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.
Overdue
Anne Scott
Concerns: Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.
Overdue
Adam Rice
Concerns: There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, and a lack of understanding of welfare check protocols.
Response (Adam Rice): West Yorkshire Police has implemented measures to ensure vulnerable persons who come into contact with the Police receive the best possible care, including a full training programme for Custody Staff …
Overdue
Derrick Rose-Fowler
Concerns: A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners unwilling to name names. Critical concerns about the deceased's mental health and self-harm history were not escalated to a MASH meeting.
Overdue
Ahmedreza Fathi
Concerns: Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not investigated as a safeguarding opportunity.
Response (HM Prison and Probation Service): HMP Gartree revised local contingency plans and re-issued instructions in May 2016 to ensure all staff understand that they must not delay calling an ambulance in all cases where there …
Response (East Midlands Ambulance Service NHS Trust): East Midlands Ambulance Service (EMAS) has formed a senior regional group to address issues relating to secure environments, such as prisons and secure mental health units. They also plan a …
Overdue
Gwendoline Clarke
Concerns: Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.
Response (Social Care): The organisation plans to re-enforce the safeguarding policy, update job descriptions, include admission process under general screening, audit care plan, re-enforce home's protocols for unwitnessed accidents, plan training and supervision …
Overdue
Olive Wilmott
Concerns: An alleged assault was not effectively investigated or safeguarded, and the care home failed to meet observation requirements due to insufficient night staff for residents' needs.
Overdue
Rebecca Gilbank
Concerns: A check was missed because staff were busy with other service users, and staff lacked knowledge about how to obtain an outside telephone line to call emergency services; the coroner suggests providing sufficient staffing resources and clear guidance on obtaining an outside line.
Response (Independence Homes): The organisation has changed its telephone system so staff no longer need to dial 9 for an outside line when calling emergency services. This change was communicated to staff verbally, …
Responded
Carol Leesley
Concerns: A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.
Response (Sheffield City Council): Sheffield City Council has amended the automated response to safeguarding reports to include a notification that, if the person making the report is not contacted within 2 working days, they …
Responded
Arthur Adley
Concerns: Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.
Response (Department of Health): The Department of Health acknowledged the concerns and forwarded the report to the Care Quality Commission (CQC), the independent regulator of health and adult social care providers in England.
Responded
Ivy Mitchell
Concerns: Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes jeopardised patient safety.
Response (Fairfield View Care Centre): The care centre audited all documentation regarding falls and mobility, cascaded information to staff about completing relevant documentation, and is auditing care plans and daily records. Senior staff are undertaking …
Overdue
Ruth Milne
Concerns: Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.
Response (Ruth Milne): Lincolnshire Community Health Services reports on actions taken following a safeguarding report, including establishing leg ulcer clinics, integrating specialist nurses, reviewing caseloads, and providing training on leg ulcer care and …
Overdue
Kevin Morgan
Concerns: There was no effective follow up by social services and the housing team, a safeguarding alert was not properly addressed, and a meeting of senior professionals was not called to consider the case; there was no Serious Incident Review after the death.
Response (Milton Keynes Safeguarding Board): The Milton Keynes Safeguarding Board will not conduct a Safeguarding Adult Review but will undertake a learning review to identify practice improvements related to concerns raised in the Regulation 28 …
Responded
Robert Mullis
Concerns: A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway tracks directly from the end of the platform.
Response (Robert Mullis): Network Rail has installed platform-end fencing and anti-trespass panels on platforms 2, 5, and 6 and the London end of platform 1 at Ashford International Station. Equivalent fencing will be …
Overdue
Doreen Miller
Concerns: A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon patient transfer.
Overdue
James Harris
Concerns: Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an absent registered manager.
Response (Care First Class UK): Care First Class UK has implemented read and sign sheets for care plans, provided a falls protocol to all staff, maintained records of nightly checks, and addressed pain management procedures; …
Response (CQC): CQC acknowledges the concerns raised regarding Cherry Lodge Care Home, details actions taken by the provider, and explains its regulatory role and monitoring of the situation, including the need for …
Responded
Russell Robb
Concerns: A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.
Response (Trafford Safeguarding Board): Greater Manchester Police (GMP) now record high volume callers more accurately, and the GMP function that prioritises and allocates cases now sits within the Partnership Office. A revised policy is …
Responded
Ellie Butler
Concerns: No specific concerns were detailed in the provided text, only a reference to appended concerns.
Overdue
Janie McFadyen
Concerns: No specific concerns were detailed in the provided text.
Response (Victory Outreach): Victory Outreach Manchester has reviewed its policies and procedures, and implemented changes to comply with current regulations, including improvements to communication and reporting channels. They have also experienced a similar …
Response (Charity Commission): The Charity Commission has provided regulatory advice to Victory Outreach Manchester and requires that implemented changes are embedded. A program of diversified training is to be agreed and delivered, charges …
Responded
Barnaby Aylward
Concerns: Agencies did not collectively address the risks to a social housing tenant with serious mental illness, including heavy smoking and accumulating clutter. His care documentation also did not identify these behaviours as risks.
Response: West Yorkshire Fire and Rescue Service has agreed to a multi-agency programme of awareness training for staff from WYFRS, Together Housing and SWYFT to be delivered in June and July …
Overdue
Alex Malcolm
Concerns: Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future deaths.
Response (HM Prison and Probation Service): HMPPS introduced a new pay structure in April 2018 for the National Probation Service, including a two-year pensionable pay award and a London Allowance and Market Forces Allowance to address …
Overdue
Katie Croft
Concerns: Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, and a lack of mechanisms for schools to receive assessment data further compromised child safeguarding.
Overdue
Archie Spriggs
Concerns: The concerns are covered within the 8 recommendations of the SCR regarding referral pathways, understanding of private law proceedings, notification processes for Section 37 reports, and engagement with multi-agency frontline staff.
Response (SSP): The Shropshire Safeguarding Partnership (SSP) acknowledges the report and states they are responsible for owning and governing delivery against the action plan related to the Serious Case Review, which was …
Overdue
Jacob Bates
Concerns: Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due to resource constraints.
Response (the Secretary of State for Education): The Department for Education launched a consultation on proposals to ensure unregulated provision is used appropriately, including introducing new national standards and enforcement mechanisms, with the consultation open until April …
Responded
June Winterbottom
Concerns: Adult Social Care's urgent referral system was ineffective, failing to contact a vulnerable person in dire need, lacking accountability, and having no safety net for emergency medical assistance.
Response (Wakefield Council): Wakefield Council acknowledges the concerns but argues that their systems have been reviewed and are robust, and that no further action is needed. They also point out that the patient …
Responded
Geoffrey Banks
Concerns: A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, compounded by a poor investigation by untrained staff.
Response (Adult Social Care Health Integration and Wellbeing): The Council shared the coroner's report with the care provider and housing group, and has changed its procedure to require a full review of medication storage arrangements for residents needing …
Response (Comfort Call): Comfort Call will no longer provide care services at the scheme in question. However, they intend to reflect on practice across their Extra Care services in other locations, review their …
Overdue
Anthony Slack
Concerns: The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.
Response (NHS England and NHS Digital): NHS England liaised with the North West Ambulance Service (NWAS) who have since extended their cleaning service to sixteen Emergency Departments across the North West, including Tameside Hospital, to improve …
Response (UK Health Security Agency): PHE acknowledges the coroner's report and outlines its national activities coordinating the response to COVID-19 in adult social care settings, including surveillance, guidance development, and stakeholder engagement. It states that …
Response (CQC): CQC reviewed systems at The Vicarage Residential Care Home and is assured that the provider has taken action to improve and further reduce risks, which will be reviewed at the …
Response (Greater Manchester Health and Social Care Partnership): Greater Manchester Health and Social Care Partnership will present learning to the Greater Manchester Quality Board. They have established an Infection Prevention and Control Care Home Cell, are running monthly …
Response (Vicarage Care Home): The Vicarage Care Home has provided documentation training to staff, updated the documentation and recording policy, reissued relevant documentation pro formas, and updated the protocol regarding waiting times for emergency …
Responded
Roy Curtis
Concerns: Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.
Response (Milton Keynes Council): Milton Keynes Council has employed a link social worker to work with the acute mental health hospital ward to coordinate social care assessments before discharge. They have also reviewed Autism …
Responded
Edward Bilbey
Concerns: England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and compromising child safety measures.
Response (England Boxing): England Boxing had already implemented remedial actions to increase safety and awareness, including revising the Rule Book to make safeguarding responsibilities clear, introducing mandatory DBS checks, and implementing safeguarding training. …
Response (DCMS): DCMS acknowledges the concerns, describes existing safeguarding measures and engagement with sports bodies, but states they do not intend to introduce further sport-specific legislation at this time. They will work …
Responded
Ann Mowbray
Concerns: The Christian Congregation of Jehovah’s Witnesses lacks a safeguarding policy for vulnerable adult members, despite previous recommendations, posing a risk to their safety.
Response (Christian Congregation of Jehovahs Witnesses): The Christian Congregation of Jehovah's Witnesses asserts that while they provide support to vulnerable adults, they do not formally bring them into their care, thus a formal policy is deemed …
Responded
Glenn Macmartin
Concerns: No specific concerns were detailed in the provided text.
Response (Wonford House Hospital): The Trust has strengthened links between community and forensic social work teams, secured funding for a Local Authority assigned social worker to join the community forensic team, and developed a …
Response (CQC): CQC describes enforcement action taken culminating in the closure of Annette's Care. It states that an internal review found no gaps or areas for improvement in CQC's processes and that …
Response (Plymouth Safeguarding Adults Partnership): The PSAP will commission a multi-agency learning review, independently facilitated, to identify multi-agency learning in terms of strengths and weaknesses related to the case. This review will involve the engagement …
Responded
Dorothy Seekings
Concerns: Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents of patient care plans.
Response (Crosscrown Ltd): Crosscrown Ltd has implemented the CareDocs digital care management system, introduced "Understanding Challenging Behaviour and Dementia Training” and “Safeguarding Training", and enhanced the agenda for staff meetings to include behavioral …
Responded
Charlotte Duffield
Concerns: Adult Social Care failed to take appropriate safeguarding action despite significant police concerns, only attempting telephone contact and sending a letter, without making any physical visit to a vulnerable individual.
Response (Cumbria County Council): The Council has reviewed self-neglect policies, revised operational practice guidance, implemented a countywide operational Safeguarding Adults service, and is delivering training sessions; a practice learning session will be undertaken with …
Responded
Select committee recommendations(79)— showing 50 strongest matches
#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 Pending
#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 …
Gov response: Our aim in delivering mandatory reporting is to create a culture of support, knowledge and openness when dealing with child sexual abuse. Applying criminal sanctions to a failure to report could instead create a defensive, …
Position Not Stated
#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 …
Gov response: Our aim in delivering mandatory reporting is to create a culture of support, knowledge and openness when dealing with child sexual abuse. Applying criminal sanctions to a failure to report could instead create a defensive, …
Response Not Attributed
#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 …
Gov response: appropriate to do so, and suitable alternative accommodation has been secured. Providers are required to give advance notice to service users and under normal operations this is at least seven days. In accordance with Public …
Position Not Stated
#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 …
Gov response: 2: PAC conclusion: Discharging patients from hospital into social care without first testing them for COVID-19 was an appalling error.
Not Addressed
#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 …
Gov response: 2: PAC conclusion: Discharging patients from hospital into social care without first testing them for COVID-19 was an appalling error.
Not Addressed
#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 …
Gov response: 2. 1 The government agrees with the Committee’s recommendation. Ta rget implementation date: Spring 2021 2.2 Although the department agrees with the Committee’s recommendation, it disagrees with the Committee’s conclusion. 2.3 The department provided an …
Partially Accepted
#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 …
Gov response: 25. The Department continues to review all key statutory guidance regularly. We will consider including EHE in Working Together to Safeguard Children at the next review point.
Under Consideration
#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 …
Gov response: 4a: PAC recommendation: • Government should set out within six months how it will ensure that learning from national reviews is built into day-to-day practise, including supporting appropriate and timely data sharing, by those working …
Accepted
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The government is committed to strengthening local multi-agency safeguarding arrangements. Stable Homes, Built on Love: implementation strategy and consultation published in February 2023 set …
Accepted
#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 …
Gov response: 3: PAC conclusion: 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. 3: PAC recommendation: Government should set out …
Accepted
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The government is committed to strengthening local multi-agency safeguarding arrangements. Stable Homes, Built on Love: implementation strategy and consultation published in February 2023 set …
Accepted
#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 …
Gov response: 3.12 The government agrees with the Committee’s recommendation. Target implementation date: October 2024 for the previous quarter, continuing quarterly. 3.13 Asylum, Accommodation Support Contracts (AASC) provide a mechanism for application of service credits if provider …
Accepted
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 All individuals are able to raise concerns with the department whilst their case is under consideration and where safeguarding concerns are raised, these are …
Accepted
#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 …
Gov response: The Mandatory Reporting Duty measure (outlined in the Crime and Policing Bill) is currently progressing through Parliament and will come into force one year after the Bill receives Royal Assent. As part of the implementation, …
Response Not Attributed
#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
Gov response: Tackling child neglect is a key part of the broader children’s social care reform programme and is embedded in the legislative measures outlined in the Children’s Wellbeing and Schools Bill. The introduction of Family Help …
Position Not Stated
#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 …
Gov response: Tackling child neglect is a key part of the broader children’s social care reform programme and is embedded in the legislative measures outlined in the Children’s Wellbeing and Schools Bill. The introduction of Family Help …
Response Not Attributed
#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 …
Gov response: Clear escalation and accountability processes are essential in multi-agency safeguarding. Working Together to Safeguard Children 2023 sets out that independent scrutineers play a key role in resolving disagreements between agencies, ensuring effective collaboration, and providing …
Position Not Stated
#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 …
Gov response: We recognise the critical importance of the children’s social care workforce and are committed to improving recruitment, retention and training across the sector. While pay and staffing remain the responsibility of local authorities and providers, …
Response Not Attributed
#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 …
Gov response: The Committee’s report rightly highlighted the rising need for children’s social care over the last decade, the spiralling costs to local authorities and poor experiences and outcomes for some, but not all, children. The Government …
Not Addressed
#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. …
Gov response: The Government’s approach to tackling FGM is focused on preventing these crimes from happening, supporting and protecting survivors and those at risk, and bringing perpetrators to justice. To do this, prevention and prosecution must be …
Accepted
#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 …
Gov response: 2. PAC conclusion: 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.
Response Pending
#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 …
Gov response: 2. PAC conclusion: 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.
Response Pending
#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 …
Gov response: The government disagrees with the Committee’s recommendation. The department agrees with the Committee’s conclusion and is clear that placing children in unregistered settings is both unacceptable and unlawful. It has, however, not made a commitment …
Not Accepted
#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 …
Gov response: The Home Office has made significant progress with regards to protecting the welfare of UASC. In line with the direction of the court, the Home Office closed all remaining emergency UASC hotels by January 2024 …
Position Not Stated
#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 …
Gov response: The Home Office has made significant progress with regards to protecting the welfare of UASC. In line with the direction of the court, the Home Office closed all remaining emergency UASC hotels by January 2024 …
Response Not Attributed
#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 …
Gov response: The Home Office recognises the critical importance of safeguarding within the asylum system and remains committed to continuous improvement in this area. While statutory safeguarding duties rest with other agencies, the Home Office plays an …
Position Not Stated
#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 …
Gov response: The Home Office recognises the critical importance of safeguarding within the asylum system and remains committed to continuous improvement in this area. While statutory safeguarding duties rest with other agencies, the Home Office plays an …
Response Not Attributed
#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 Pending
#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 Pending
#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 …
Gov response: We would start by reaffirming the intention of these new offences to enable earlier, faster disruption of organised immigration crime. This criminality puts vulnerable people, the very groups to which the report refers, at risk …
Not Accepted
#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 …
Gov response: 25. The Department continues to review all key statutory guidance regularly. We will consider including EHE in Working Together to Safeguard Children at the next review point.
Under Consideration
#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 …
Gov response: 9. The Government remains committed to a form of local authority administered statutory registration to identify children not in school. This would likely encompass children who are electively home educated and those who are missing …
Under Consideration
#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 …
Gov response: 3.2 The government is committed to strengthening local multi-agency safeguarding arrangements. Stable Homes, Built on Love: implementation strategy and consultation published in February 2023 set out commitments to ensure that all agencies play a full …
Not Addressed
#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 …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 ‘Stable Homes, Built on Love’, published by the Department for Education in February 2023 sets out plans to transform children’s social care, ensuring the …
Accepted
#31 — Encourage FGM Protection Order use by increasing awareness among children's social services.
Recommendation: The Ministry of Justice should encourage the use of FGMPOs by working with the Department for Education to increase awareness among children’s social services of FGMPOs and the criteria needed to obtain one. We welcome the MoJ’s plans to ensure …
Gov response: Response: FGM Protection Orders (FGMPOs) are a vital tool to support the prevention of FGM and the protection of victims. Data on FGM Protection Orders is published quarterly by the Ministry of Justice, as part …
Accepted
#30 — FGM Protection Order usage remains low despite their effectiveness and high risk of FGM.
Recommendation: FGM Protection Orders (FGMPOs) can be an effective way of supporting FGM survivors and preventing FGM. Although the data on FGM protection orders is incomplete, the number of FGMPOs appears low, especially when compared to estimations of the number of …
Gov response: Response: FGM Protection Orders (FGMPOs) are a vital tool to support the prevention of FGM and the protection of victims. Data on FGM Protection Orders is published quarterly by the Ministry of Justice, as part …
Accepted
#27 — Ensure professionals receive adequate training to confidently ask FGM questions and increase referrals.
Recommendation: The Government should ensure that professionals, such as teachers and healthcare professionals, are adequately trained to feel confident to ask questions around female genital mutilation in order to increase the number 45 of successful safeguarding referrals for FGM. This training …
Gov response: Response: It is vital that all professionals with statutory safeguarding responsibilities such as the police, teachers and healthcare professionals have the right training and framework to identify victims and perpetrators of FGM and manage them …
Accepted
#26 — Low FGM safeguarding referrals due to professionals' lack of confidence and training.
Recommendation: Evidence suggests that safeguarding referrals are low. Professionals often lack the confidence to ask questions and get the necessary information from the families of the women and girls affected. Some professionals may also be reluctant to ask questions due to …
Gov response: Response: It is vital that all professionals with statutory safeguarding responsibilities such as the police, teachers and healthcare professionals have the right training and framework to identify victims and perpetrators of FGM and manage them …
Accepted
#13 —
Recommendation: Peer support or ‘buddy’ schemes can be an effective way to help meet the care needs of older prisoners. We commend the good work done by some prisons in partnership with third sector organisations to develop such initiatives. Prisons must …
Gov response: • In May 2018, MOJ and HMPPS launched guidance for peer-to-peer schemes with supporting operational tools for all prisons. In areas where local authorities and prisons work together to train, manage and support “buddies”, peer-to-peer …
Position Not Stated
#25 —
Recommendation: The Department must clarify and strengthen the expectation in its 2019 guidance that local authorities make contact with parents on at least an annual basis, so that local authorities have the ability to see a child in person (at a …
Gov response: 28. The Department will review its 2019 EHE guidance for local authorities and parents in due course, taking account of relevant developments that result from the impending judicial review between Portsmouth City Council and an …
Partially Accepted
#15 —
Recommendation: The SEND Review must address the need for consistent and sufficient support for children with SEND, no matter how they are educated. Access to Education, Health and Care Plans and the support they offer should not depend on being on …
Gov response: 21. The SEND Review is looking at ways to ensure the SEND system is consistent, high quality and integrated across education, health and care to improve early support for children and young people with EHC …
Under Consideration
#13 —
Recommendation: In light of the evidence we heard on children with SEND, the Department must reconsider the potential for creating an independent, neutral role, allocated to every parent or carer with a child when a request is made for a needs …
Gov response: 20. The SEND system already provides mechanisms for ensuring that families have access to support. Local authorities are bound by statute (by section 19 of the Children and Families Act 2014) to consider the views, …
Not Accepted
#12 —
Recommendation: Many children with SEND may be happiest educated at home, but this should absolutely not be a choice that parents are forced to make for lack of the right support. We accept that what begins as a negative choice can …
Gov response: 20. The SEND system already provides mechanisms for ensuring that families have access to support. Local authorities are bound by statute (by section 19 of the Children and Families Act 2014) to consider the views, …
Not Accepted
#11 —
Recommendation: Some children in those illegal schools prosecuted so far have been nominally home educated, with families misled by providers. Without the consistent and robust data on children outside school that a register could provide, we cannot know the true impact …
Gov response: 9. The Government remains committed to a form of local authority administered statutory registration to identify children not in school. This would likely encompass children who are electively home educated and those who are missing …
Under Consideration
#10 —
Recommendation: We were told government’s approach is to meet the need of many young people through focusing on individual programmes and focusing their join up on those who have complex and overlapping needs.22 The NAO found that while departments work together …
Gov response: 2.5 There is a reasoned basis for not giving any single department leadership responsibility for the needs all adolescents at risk (or indeed any age group at risk). Single needs are best met, by and …
Not Addressed
#20 —
Recommendation: The Government must introduce a nationally funded and regulated intermediary service to ensure that all adoptees and birth relatives have access to skilled, trauma-informed professionals who can support them in navigating contact, reunion, or information-sharing processes safely and sensitively. As …
Gov response: PARTIALLY ACCEPT The Government recognises the value of intermediary services in supporting sensitive contact, tracing, and information sharing. We will: Expand access to funded intermediary services for historical adoption cases where access is currently most …
Partially Accepted
#66 — Integrate neglect reduction measures and parental support into Child Poverty Strategy with a broader approach.
Recommendation: The Department should ensure that measures to reduce neglect and support parents with poor mental health and drug and alcohol addictions are considered as part of its Child Poverty Strategy and recognise that poverty is not the only circumstance in …
Gov response: We recognise that deprivation is a contributory causal factor in child abuse and neglect, and a growing body of research is strengthening the evidence of this relationship, including poverty being closely interconnected with wider factors …
Position Not Stated
#61 — Child protection reforms welcomed, requiring careful monitoring and better data on abuse prevalence.
Recommendation: The Department for Education’s reforms to child protection through the Children’s Wellbeing and Schools Bill are welcome and go some way towards alleviating many of the concerns we have heard in this inquiry. There will be a need for careful …
Gov response: The Department is collaborating with the Office for National Statistics (ONS) to develop the Safety During Childhood survey, which will gather insights from children and young people on safety and wellbeing, including experiences of violence …
Response Not Attributed
#13 — Unsustainable EHC plan levels highlight insufficient early support and parental distrust
Recommendation: Current levels of EHC plans are unsustainable; however, the solution to this cannot be to remove the statutory entitlements from a system which lacks accountability in many other areas and in which parents already have so little trust and confidence. …
Gov response: Early. Children should receive the support they need as soon as possible. This will start to break the cycle of needs going unmet and getting worse, instead intervening upstream, earlier in children’s lives when this …
Accepted
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
CQC inspection actions(123)— showing 50 strongest matches
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
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 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
Queen Elizabeth Hospital
The services should ensure specialist staff have access to appropriate safeguarding supervision to carry out their duties.
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
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
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
Continuity Healthcare Services Private Limited
The provider did not ensure systems and processes were in place to prevent people from abuse or to investigate immediately on becoming aware of an allegation of abuse.
Must Do
Ave Maria Care (Wolverhampton)
The provider did not mitigates risks to keep people safe from abuse
Must Do
Ash Court Care Centre - Camden
The registered person had not ensured that systems and processes had been established and operated effectively to prevent abuse of service users. Regulation 13 (1) (2) (3)
Must Do
Valewood House Nursing Home
People were not safeguarded against the risk of abuse because the manager had not taken reasonable steps to identify the possibility of abuse and prevent it before it occurred, or responded appropriately to any allegation of abuse.
Must Do
Haisthorpe House
The provider must ensure people who used services are safeguarded against the risks of abuse by taking reasonable steps to identify the possibility of abuse before it occurred and by responding appropriately to allegations of abuse.
Must Do
Cranmore
The provider must protect people from abuse and improper treatment.
Must Do
Benthorn Lodge
The registered person had not made suitable arrangements to ensure service users were effectively safeguarded against the risk of abuse and harm.
Must Do
Yanah Care
The provider must ensure effective systems and processes are in place to protect people from abuse and improper treatment.
Must Do
Wrottesley House
The provider must ensure they have robust safeguarding systems in place to protect people from potential harm.
Must Do
Willow Court
The provider failed to ensure systems and processes safeguarded people from the risk of abuse.
Must Do
The Hollies Care Home
The registered person had not made suitable arrangements to ensure that people were safeguarded against abuse.
Must Do
TerraBlu Homecare
The failure to protect people from abuse and improper treatment was a breach of Regulation 13 (1)(2)
Must Do
Stickley Lane
Regulation 13 HSCA RA Regulations 2014 Safeguarding service users from abuse and improper treatment
Must Do
Stewton House Nursing Home
The provider must ensure that people are safeguarded from abuse and improper treatment.
Must Do
Orchid House
The provider was unaware of what constitutes a safeguarding concern and had failed to notify CQC or the local safeguarding team of allegations of potential abuse.
Must Do
Multicare Services - Maylands Building
The provider had not always identified and effectively investigated safeguarding concerns to people.
Must Do
Ivydene Care Home
Systems to protect people from allegations of or actual abuse were not always followed. Regulation 13 (3).
Must Do
Heritage Healthcare-Middlesbrough
The provider must ensure service users are safeguarded from abuse and improper treatment, including raising safeguarding alerts and ensuring staff understanding and training in safeguarding.
Must Do
East Cosham House
There was a failure to safeguard service users from abuse and improper treatment. Records showed that that where incidents had occurred between people these had not been reported to the local safeguarding team. It was also unclear how the records …
Must Do
East Cosham House
There was a failure to notify CQC of any abuse or allegation of abuse in relation to a service user.
Must Do
Church Road
The provider must ensure service users are protected from abuse and improper treatment.
Must Do
Charmes Care
The registered persons failed to protect people from abuse and improper treatment and to have effective systems and processes in place to prevent abuse of people
Must Do
Chandos Lodge Nursing Home
We recommend the service review their approach to ensure safeguarding concerns are identified and managed promptly, using local safeguarding procedures whenever necessary, and that investigations are thoroughly evidenced.
Should Do
Ave Maria Care (Edgbaston)
The provider's safeguarding procedures were not effective and safeguarding concerns had not been consistently reported to the relevant agencies.
Must Do
Ashington Gardens
Regulation 13 HSCA RA Regulations 2014 Safeguarding service users from abuse and improper treatment
Must Do
Woodlands
Effective systems were not fully in place to protect people from the risk of abuse.
Must Do
Winterton House
People were not always protected from abuse and improper treatment. Systems and processes were not established and operated effectively to prevent abuse of service users. People were deprived of their liberty for the purpose of receiving care or treatment without …
Must Do
Walnut Villa
People were not protected from abuse because staff did not have the skills to recognise abuse or to safeguard them from this.
Must Do
Valewood House Nursing Home
The provider must ensure people are safeguarded against the risk of abuse by taking reasonable steps to identify the possibility of abuse and prevent it before it occurred, and by responding appropriately to any allegation of abuse.
Must Do
St Paul's Lodge
The registered person must protect service users from abuse or improper treatment by establishing and operating effective systems and processes to prevent abuse of service users.
Must Do
St Gabriel's House - Apartments
The provider must have systems and processes in place to effectively prevent people being at risk of abuse and investigate evidence of abuse.
Must Do
Specialist Medical Transport - North
The service must implement effective processes to safeguard patients from the risk of improper treatment and/or abuse.
Must Do
Serenity House
The provider failed to ensure robust safeguards were in place to protect people from abuse, and the undue deprivation of people's legal and human rights.
Must Do
Reside at Southwood
People had not been protected from abuse and improper treatment and the service had not followed the requirements of the Deprivation of Liberty Safeguards.
Must Do
Redcot Lodge Residential Care Home
The provider must protect people from abuse and improper treatment.
Must Do
Precious Nursing & Residential Home
The provider must ensure that systems and processes are operated effectively to safeguard people from the risk of abuse.
Must Do
Oaklands Care Home
The provider must ensure staff have awareness and recognition of potential abuse and neglect in the home.
Must Do
Leopold Muller Home
Systems in place to safeguard people were not effectively being used so placed them at risk of potential abuse and restrictive practices. This was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations …
Must Do
Kingsley Nursing Home
The registered manager and provider failed to 1. report safeguarding concerns or have effective systems to investigate allegations. 13 (2 & 3)
Must Do
Kingsleigh Residential
The provider had failed to ensure people were protected from abuse and neglect.
Must Do
HMICFRS recommendations(4)
An inspection of the service provided to victims of crime by Greater …
Cause of concern: The force is failing to make sure it correctly records all reported crimes, particularly violent crime, including domestic abuse behavioural crimes such as harassment, stalking and coercive controlling behaviour. So these crimes are often not investigated and …
Recommendation
An inspection of the service provided to victims of crime by Greater …
Cause of concern: The force is inappropriately concluding crime investigations with cautions and community resolutions that aren’t appropriate and in which it doesn’t consult the victim. The force is also recording that victims are not supporting or are withdrawing support …
Recommendation
An inspection of the service provided to victims of crime by Greater …
Cause of concern: The force is failing to make sure investigation plans are always completed to an acceptable standard and not adequately supervising investigations. This leads to poor standards of some investigations, a lack of timely progression of investigations and …
Recommendation
An inspection of the service provided to victims of crime by Greater …
Cause of concern: The force is inappropriately concluding crime investigations with cautions and community resolutions that aren’t appropriate and in which it doesn’t consult the victim. The force is also recording that victims are not supporting or are withdrawing support …
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(3)
Themes and lessons learnt from NHS investigations into matters relating … — Rec R5
All NHS hospital trusts should undertake regular reviews of: - their safeguarding resources, structures and processes (including their training programmes); and - the behaviours and responsiveness of management and staff in relation to safeguarding issues to ensure that their arrangements are robust and operate as effectively as possible.
national
Accepted
Independent investigation into the care and treatment of Mr L — Rec 2
The Trust should ensure that consideration about referral to MAPPA takes place for patients with violent histories and convictions for serious violent offences. Such referrals should consider safeguarding issues and risks of domestic violence for wider family members.
L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Investigation into matters relating to Jimmy Savile at Wythenshawe Hospital — Rec b.
A specific, stand-alone policy for Volunteers and Visitors to the Trust should be developed to consolidate current processes, protocols and guidance.
University Hospital of South Manchester NHS Foundation Trust
north_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 …
Sep 2014
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 …
Aug 2015
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
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