Child to adult safeguarding transition
Wide variation and inadequacy in transition pathways from child to adult safeguarding services for victims turning eighteen.
Source spread
Where this theme appears
This theme appears across 15 independent accountability sources, so the source mix matters as much as the headline total.
3 inquiry recs
13 PFD reports
42 committee recs
21 HSSIB recs
2 CQC actions
1 PPO rec
3 IMB recs
58 DHR recs
1 PHSO decision
53 LGO/SPSO decisions
4 CJINI reports
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(3)
17 — Clarify legality of mixed young offender wings
Recommendation: If the practice of holding young offenders on the same wing as adult prisoners is to continue, the law should be clarified to put its legality beyond doubt.
Unknown
SP29 — Risks posed by children and young people
Recommendation: Lancashire Constabulary should ensure its procedures and training sufficiently addresses the risks children and young people may pose to others and the options for addressing that risk. The College of Policing, with national partners, should review legislation and guidance on …
Gov response: The first duty of the government is to keep citizens safe and the country secure, and the Police play a fundamental role in doing so. The Chair makes several recommendations to policing bodies, in Chapter …
Accepted
SP39 — Working Together guidance on risks to others
Recommendation: The Department for Education should update Working Together to Safeguard Children and the Children’s Social Care National Framework. These documents should highlight that safeguarding and child protection assessments, when considering what support to put in place and planned multi-agency working, …
Gov response: The Department for Education (DfE) is the lead department and expects to complete the implementation of this recommendation by spring 2027. Progress and next steps: - DfE is currently consulting on the 2027 update to …
Accepted
Prevention of Future Deaths reports(13)
Kesia Leatherbarrow
Concerns: Incomplete information transfer between children's services meant a high-risk referral was not fully assessed or led to a CAMHS appointment. A Youth Offending Team case was also not transferred after a change of address, preventing a timely referral order assessment.
Response (Department of Health): • The Department of Health shared the coroner's report with NHS England. • The Children and Young People's Mental Health Taskforce published 'Future in Mind', which sets out a national … (AI summary)
Response (Home Office): • The Government partially amended the Police and Criminal Evidence Act (PACE) to treat 17-year-olds as children for detention after charge, requiring transfer to local authority accommodation. • The Government … (AI summary)
Response (Pennine Care NHS Trust): • A single point of access has been developed for CAMHS and RAID services, and a tracking system implemented to monitor administration timescales. • Standard practice now requires CAMHS mental … (AI summary)
Response (Crown Prosecution Service): • The Crown Prosecution Service (CPS) obtained a report from the Acting Chief Crown Prosecutor for CPS North West. • The Chief Crown Prosecutor for Greater Manchester is in dialogue … (AI summary)
Overdue
Anielka Jennings
Concerns: The coroner noted a lack of an identified lead professional for individuals, particularly children transitioning to adult services, being cared for by numerous agencies, which can lead to communication breakdowns.
Overdue
Daisy French
Concerns: The coroner identifies gaps in communication and transition between CAMHS and adult mental health services for 16-18 year olds. This includes issues with out-of-hours provision, placement in adult crisis houses, and returning them to unsupervised supported living.
Response (Sheffield Health and Social Care): • The Trusts are strengthening and revising the Transitions Protocol for 16 and 17 year olds, with formal adoption planned by 31 March 2018. • A Section 136 bed for … (AI summary)
Response (Department of Health): • The NHS in Sheffield has provided staff training on transitions, opened a Section 136 suite, and employed a Mental Health Liaison Consultant. • An information sharing agreement is to … (AI summary)
Responded
Karanbir Cheema
Concerns: The coroner noted inadequate checks of school allergy plans and medication, including expired EpiPens, and a lack of standardised action plans between hospitals and schools. Insufficient national guidance and training on immediate adrenaline administration was also identified.
Response (Response Ambulance Service NHS Trust): • The Trust raised the Prevention of Future Deaths report with the UK Clinical Focus Group for IAED-MPDS and the Executive Director of MPDS. • The Chief Medical Officer shared … (AI summary)
Response (London North West University Healthcare NHS Trust): • The Trust implemented standardized BSACI Allergy Action Plans, provided two copies to parents, shared them with GPs, and provided education on medication use. • The Trust established a process … (AI summary)
Responded
Oliver Sharp
Concerns: The coroner noted varying post-16 mental health services and long waiting lists for autism diagnoses impede timely support for adolescents. Concerns also identified insufficient school understanding of mental health impacts from academic acceleration on autistic children.
Overdue
Charlotte Duffield
Concerns: The coroner noted that despite a referral to Adult Social Care due to significant safety concerns, no safeguarding action was taken, particularly after the individual did not respond to telephone contact and no in-person visit was made.
Response (Cumbria County Council): • Cumbria County Council completed a systematic review of its self-neglect policy and procedure documentation. • Operational practice guidance for self-neglect concerns was reviewed and revised to reinforce the requirement … (AI summary)
Responded
Lucy Walles
Concerns: Concerns identified gaps in safeguarding referral processes, including review timescales, staff training on thresholds, and inter-agency communication. The report also notes questions about the adequacy of mental health support post-discharge and service resourcing.
Response (Berkshire Healthcare NHS Foundation Trust): • The Trust is implementing a "One Team" programme to transform community mental health services, which includes establishing multi-agency teams and new support pathways such as the Mental Health Integrated … (AI summary)
Response (Reading Borough Council): • A priority flag has been implemented on the client recording system for high-risk safeguarding referrals, supported by daily consultations between the Safeguarding Team and the Customer Contact Centre. • … (AI summary)
Responded
Craig Burfield
Concerns: The coroner raised concerns regarding the absence of continued care for hydrocephalus patients in adulthood and the lack of a clear transfer protocol or pathway for their transition from childhood to adulthood. There was also no effective review process for adult patients with shunts.
Response (Sheffield Teaching Hospitals NHS Foundation Trust): • The Trust confirmed that a joint Transition Policy and Cross Trust Transition pathway have been agreed and implemented with Sheffield Children’s Foundation Trust, supported by specialist transition teams and … (AI summary)
Responded
Michaela Hall
Concerns: Concerns included insufficient information sharing across Children and Adult Services, a lack of documented rationale for decisions on care needs and safeguarding, and inadequate health-related enquiries despite indicators of mental impairment.
Response (Devon and Cornwall Police): • Devon & Cornwall Police has implemented a revised operational procedure for Domestic Violence Protection Notices/Orders and introduced a new 'priority vulnerable' grading for domestic incidents. • The force is … (AI summary)
Response (HM Prison and Probation Service): • Probation Instruction PI 04/2016 requires managers to ensure pre-sentence reports are undertaken by suitably qualified staff, and new guidance clarifying allocation is currently out for consultation. • Risk and … (AI summary)
Response (Cornwall Council): • The Council reinforced to practitioners the need to share concerns and information between children's and adult services, and reminded staff of existing domestic abuse support arrangements. • Practice guidance … (AI summary)
Responded
Axel Price
Concerns: The coroner notes a lack of clear understanding and accountability between agencies when young people transition from CAMHS to adult services, compounded by a lack of national guidance and recognised pathways for support.
Response (Department of Health and Social Care): • The NHS is extending current service models to create a comprehensive mental health offer for 0-25 year olds. • Nearly 500 mental health support teams have been established across … (AI summary)
Responded
Erik Marshall
Concerns: The coroner identified a gap in commissioning and support for individuals aged 17 with sensory needs, as an occupational therapy referral was rejected due to age and adult services would not accept until 18.
Response (Cheshire and Merseyside Integrated Care Board): • The Cheshire and Merseyside Commissioning Board intends to commission an Occupational Therapy service for children and young people up to the age of 18 years and 364 days. • … (AI summary)
Responded
Chloe Barber
Concerns: Concerns were raised regarding the absence of a clearly defined pathway for young people transitioning from CAMHS to adult mental health services, and a lack of clear guidelines for depot antipsychotic administration. Staff also showed uncertainty about s117 Mental Health Act aftercare.
Response (NHS England): • NHS England released funding in 2022/23 to improve young adult mental health pathways and is finalising a new Personalised Care Framework for secondary mental health services. • New guidance … (AI summary)
Response (Department for Health and Social Care): • NHS England released funding in 2022/23 for young adult mental health pathways and is developing a personalised care framework to support transitions. • Prescribing guidelines for depot antipsychotic medication … (AI summary)
Overdue
Lucy-Anne Dyson
Concerns: The coroner identified a lack of a national interface for communication between schools and safeguarding agencies, alongside an absence of national guidance for referrals, leading to inconsistent reporting practices.
Response (Department for Education): • The Department for Education stated that the Children’s Wellbeing and Schools Bill will introduce a consistent child identifier and a new legal duty for information sharing. • The Department … (AI summary)
Overdue
Select committee recommendations(42)
#149 —
Recommendation: Age-appropriate solutions should be found to smooth the transition of those moving from Youth Offending Services to the adult Probation Service. These solutions should be made available to all young adults on probation. Facilitating local delivery A case for local …
Response attribution not verified
#148 —
Recommendation: The Probation Service should learn best practices from Youth Offending Services, especially about how to communicate with offenders to ensure they understand the sentences that are imposed on them. It should also encourage the local delivery of rehabilitative services and …
Response attribution not verified
#147 —
Recommendation: However, lessons can be learnt from Youth Offending Services about the management of the probation population in general, and of young adults in particular. YOSs do not only work with smaller caseloads and with more experienced staff, but are also …
Response attribution not verified
#146 —
Recommendation: There is a âcliff edgeâ in the response to offending when a young person transitions from Youth Justice Services to the adult Probation Service. Moving the age at which an offender undergoes this transition is unlikely, in itself, to bear …
Response attribution not verified
#145 —
Recommendation: Looking forward, the Transition to Adulthood Alliance (T2A) told us about a range of potential innovative practices, including: Specialised courts. They argued that âyoung adult specific courtsâ could deliver âspecific arrangementsâ for young people âwithout legislative changeâ. They told us …
Response attribution not verified
#144 —
Recommendation: Currently, another approach is being piloted. The Ministry of Justice told us about the introduction of Young Adult Hubs in Cardiff, Manchester and Newham. They described these hubs as âpsychologically informed spaces that aid engagement and reinforce young adultsâ strengths …
Response attribution not verified
#143 —
Recommendation: Looking at historical precedents, the Probation Institute wrote that âspecialist teams used to manage the transitionâ for young adults âwith reduced caseloads and focussed trainingâ, and they told us that they âshould be reinstatedâ. 272 T2A also told us about …
Response attribution not verified
#142 —
Recommendation: We heard about a range of innovative practices that have been, are being, or could be piloted initially for the benefit of young adults on probation. Academics argued that if lessons were learnt from the Scottish presumption against short sentences …
Response attribution not verified
#141 —
Recommendation: Whether or not the threshold is moved, Chris Jennings told us that âthe cliff edge at 18, when you have one level of intensive support and then suddenly you do not, is the thing we have to worry aboutâ. He …
Response attribution not verified
#140 —
Recommendation: We heard reservations about this proposal. Phil Bowen told us that, while he was âattracted to the proposalâ, he was also âconcerned that youth justice services would need to differentiate how they supervise and treat 14 year-olds compared to 21 …
Response attribution not verified
#139 —
Recommendation: Because the maturation process continues past the age of 18, Justin Russell told us that âone of the obvious things you could do would be to shift the younger age range in probation into the Youth Offending Services themselvesâ. 264 …
Response attribution not verified
#138 —
Recommendation: Damian Hinds MP acknowledged that âthere is a watershed moment that happens on your 18th birthdayâ, when someone transitions from Youth Offending Services to the adult Probation Service. 262 He questioned: âThat is not how human beings are, is it? …
Response attribution not verified
#136 —
Recommendation: However, maturation continues past the age of 18. Justin Russell explained that âthere is evidence that the full maturation process does not happen until you are 25â. 255 Carrie Peters, as a practitioner, confirmed that âbecause of brain development and …
Response attribution not verified
#135 —
Recommendation: We heard about the transition from Youth Offending Services to the adult Probation Service. Currently, âYouth Offending Services stop supervision at 18, and there is effectively a cliff edge where children go from quite a personalised service, with speech and …
Response attribution not verified
#23 —
Recommendation: The government must set out what specific consideration has been given to the impact of the proposed reforms on children and young people tried in the youth court. In particular, the government must set out how it intends to mitigate …
Response status not verified
#75 — Develop a National Care Offer ensuring minimum, harmonised support for care leavers nationwide.
Recommendation: As a priority, the Department for Education must develop a National Care Offer to harmonise the postcode lottery in entitlements and ensure that care leavers receive a minimum level of support, wherever they live. (Recommendation, Paragraph 194)
Response attribution not verified
#95 — Inconsistent safeguarding transition pathways for child victims turning eighteen with complex needs.
Recommendation: There is wide variation among local authorities in the transition pathways from child to adult safeguarding services. Guidance exists for child victims and for adult 82 Human trafficking victims, but it does not adequately take account of child victims who …
Response attribution not verified
#17 — Create clear, actionable plan to deliver comprehensive mental health offer for 0-25 year olds.
Recommendation: Despite nearly a decade of commitments, the transition from Children and Young People’s Mental Health Services (CYPMHS) to Adult Mental Health Services (AMHS)—including Community Mental Health Services (CMHS)— remains a cliff edge and continues to fall short of what young …
Response attribution not verified
#19 —
Recommendation: We welcome the focus on young people in the National Plan to End Homelessness, not least given the elevated risks young people can face through abuse, family breakdown and care leaving. Ensuring young people can get the right support at …
Response status not verified
#11 — Publish a unified national framework for ordinarily available provision and SEN support
Recommendation: The Department for Education should publish a unified national framework for ordinarily available provision and SEN support. This should offer clear, evidence-led guidance and include practical, real-world examples tailored to educators and educational settings, ensuring that all practitioners have access …
Response attribution not verified
#52 — Develop a National Care Offer and transition strategy for care leavers entering further education.
Recommendation: As set out in our Children’s Social Care report, the Department for Education must develop a National Care Offer to harmonise the postcode lottery in entitlements and ensure that care leavers receive a minimum level of support, wherever they live. …
Response attribution not verified
#96 — Amend Modern Slavery guidance to include 'turning 18' support for transitioning child victims.
Recommendation: The Home Office should amend its Modern Slavery statutory guidance to include guidance on ‘turning 18’ to ensure that ageing out of the care system does not reduce holistic support for recovery and prevention of re-trafficking.
Response attribution not verified
#88 — Commission independent review of Recovery Needs Assessment process for children and young adults.
Recommendation: We recommend that the Home Office immediately commissions an independent review of the Recovery Needs Assessment process to determine whether it works effectively for children and young adults transitioning into adult support services. (Paragraph 251) Trafficking of children
Response attribution not verified
#80 — Develop strategy for transitioning child victims to adult services with continuity of support.
Recommendation: Local authorities and safeguarding partners should develop a defined strategy for child victims to be transitioned to appropriate adult services with continuity of support to ensure that there is no gap in services such as mental health care.
Response attribution not verified
#27 —
Recommendation: Age-appropriate solutions should be found to smooth the transition of those moving from Youth Offending Services to the adult Probation Service. These solutions should be made available to all young adults on probation . (Paragraph 149) Facilitating local delivery (paragraphs …
Response attribution not verified
#24 —
Recommendation: There is a âcliff edgeâ in the response to offending when a young person transitions from Youth Justice Services to the adult Probation Service. Moving the age at which an offender undergoes this transition is unlikely, in itself, to bear …
Response attribution not verified
#14 —
Recommendation: We agree with submissions made to us that the Mental Health Bill could and should do more to protect against children being placed on adult wards. The Bill should be amended to include a requirement that a child should not …
Response attribution not verified
#13 —
Recommendation: While the recent Government amendment to the Bill, introducing a review of notification requirements in respect of children on adult wards represents a welcome acknowledgement that the status quo may not be satisfactory, it does not guarantee the prompt protection …
Response attribution not verified
#20 —
Recommendation: While some transition planning may take place before a young person leaves the youth estate, we are not convinced that the adult estate is sufficiently equipped to support all those who make that move. We recommend that the Ministry of …
Response attribution not verified
#19 —
Recommendation: We welcome the work being done to improve transition planning, and we note that work is under way in the Ministry of Justice on how best to manage transition into adult custodial settings for those who turn 18. While cut-off …
Response attribution not verified
#12 —
Recommendation: NHS England & Improvement must accelerate the implementation of the 0–25 offer in every local area as a national priority so that young people do not continue to face a cliff edge in accessing the care they require as they …
Response attribution not verified
#11 —
Recommendation: It is clear that young adults between the ages of 18 and 25 face some of the widest gaps between the support that they need and the support that is available to them. 56 Children and young people’s mental health …
Response attribution not verified
#38 — Review educational support for adopted and previously looked-after children, including statutory framework.
Recommendation: The Department for Education should review the educational support available to adopted children, assessing the impact of the extension of policies to previously looked-after children and whether any further extensions are needed. This review should include: the introduction of a …
Response attribution not verified
#89 — National Referral Mechanism deemed inappropriate for children due to inconsistent support and fragmented approach.
Recommendation: The National Referral Mechanism is not appropriate for children. The support is not defined as it is for adults, universally available or applied consistently. There is an overall lack of a joined-up approach across the National Referral Mechanism, child welfare …
Response attribution not verified
#84 — Long-term support for human trafficking survivors post-NRM exit remains absent and inadequate.
Recommendation: Survivors of human trafficking should continue to receive long-term support once they leave the National Referral Mechanism (NRM); however, there is clearly an absence of support for victims of human trafficking once they exit the statutory support provided under the …
Response attribution not verified
#7 — Inconsistent delivery of prison resettlement services undermines effective support for prison leavers.
Recommendation: HMPPS told us one of its biggest concerns is whether it can consistently deliver its vision for probation services across all corners of England and Wales.13 In 2022–23, an HMPPS review found 14 out of 27 key events in the …
Response attribution not verified
#23 —
Recommendation: We heard that PIP assessments can be particularly challenging for young people. We recommend that young people in receipt of Disability Living Allowance should not be required to claim PIP until they are 18, as is the case in Scotland. …
Response attribution not verified
#5 —
Recommendation: We are concerned that the Minister was unable to commit to providing clear and specific standards and guidance for babies, children and young people’s palliative and end of life care in the Modern Service Framework (MSF). We strongly recommend that …
Response attribution not verified
#36 — Incorporate full domestic abuse victim definition and define CHIDVAs and CHISVAs within the Bill
Recommendation: We recommend that the Bill includes the entire definition of a domestic abuse victim as it appears in the Domestic Abuse Act 2021. We further recommend that the Bill also defines Independent Sexual Violence Advisors and Independent Domestic Violence Advisors …
Gov response: 59. As set out in paragraph 44, the Government agrees with the Committee that the Bill should align with the full Part 1 definition of domestic abuse as it appears in the Domestic Abuse Act …
Accepted
#28 — Include reference to child domestic abuse victims and mandate needs assessments in guidance.
Recommendation: We recommend that clause 8(3) also includes reference to section 3 of the Domestic Abuse Act 2021, namely that children can be victims of domestic abuse in their own right. Doing so will provide assurance that commissioners of support services …
Response attribution not verified
#27 — Expand duty to collaborate to include children's services and victims outside the CJS.
Recommendation: We welcome the duty to collaborate. This duty, however, should also include providers of children’s services to ensure the needs of child victims are met and to help facilitate the flow of necessary information between agencies. It is unclear whether …
Gov response: 41. To improve strategic commissioning, the Bill rightly requires collaboration between groups responsible for that commissioning. The Government recognises the important role that providers, including providers of children’s services, play in the commissioning process, and …
Position Not Stated
#86 — Formalise and clarify local authority duties to support slavery and trafficking victims post-NRM exit.
Recommendation: We support Recommendation 24 of the Independent Review of the Modern Slavery Act 2015 and urge the Government to formalise and clarify the duties of local authority agencies to support victims of slavery and trafficking once they have left the …
Response attribution not verified
HSSIB safety recommendations(21)
Mental health inpatient settings
HSSIB recommends that NHS England provides guidance regarding communication of essential safety and risk mitigation information when patients transition from inpatient children and young people’s mental health services due to reaching transition age. This is to safeguard vulnerable people and …
Safety Recommendation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
Inpatient children and young people’s mental health services can improve patient safety by ensuring that young people, families, and carers are involved, informed and prepared as possible for the young person’s next place of care. This may require increased levels …
Safety Observation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
Mental health providers can improve patient safety by adopting a consistent approach to involving and informing young people, and their families and carers, about how care decisions and the sharing of care information change when young people reach 18. This …
Safety Observation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
Children and young people’s mental health services and adult mental health services can improve patient safety by having more aligned thresholds and criteria to access care, and improved data sources to inform decision making. This is to support closer alignment …
Safety Observation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
HSSIB recommends that NHS England provides guidance regarding communication of essential safety and risk mitigation information when patients transition from inpatient children and young people’s mental health services due to reaching transition age. This is to safeguard vulnerable people and …
Safety Recommendation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
HSSIB recommends that the Department of Health and Social Care works across government to identify opportunities to support closer cooperation between local government, education and health systems for the safe and effective transition of young people into adulthood. This is …
Safety Recommendation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
HSSIB recommends that the Care Quality Commission work with the Department of Health and Social Care to understand prioritisation for assessing transitions in mental health care within Integrated Care System assessments. Any subsequent work should include the development of a …
Safety Recommendation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
HSSIB recommends that NHS England reviews and revises its guidance and policies to ensure consistency regarding the language used for age ranges (for example children, young people, young adults and adults). This is to support a consistent approach to healthcare …
Safety Recommendation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
HSSIB recommends that NHS England reviews and updates its inpatient children and young people’s mental health services specifications and commissioning guidance to ensure they support developmentally appropriate, needs-based transitions. Any changes to service delivery will require a review of funding …
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
and develop and implement training packages for clinicians across the EU.
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
create clinical, organisational, policy and ethical guidelines for improving care and outcomes for transition-age youth;
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
develop and test, in a cluster-randomised trial, the clinical and cost-effectiveness of an innovative transitional care model;
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
conduct a longitudinal cohort study of transition process and outcomes across eight EU countries;
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
develop and validate transition-specific outcomes measures;
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
map current services and transitional policies across EU;
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
That NHS England and NHS Improvement work with commissioners and providers of mental health services to ensure that the care of a young person before, during and after transition is shared in line with best practice, including joint agency working.
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
It is recommended that NHS England, within the ‘Long-Term Plan’, requires services to move from aged-based transition criteria towards more flexible criteria based on an individual’s needs.
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
It is recommended that NHS England and NHS Improvement ensure that transition guidance, pathways or performance measures require structured conversations to take place with the young person transitioning to assess their readiness, develop their understanding of their condition and empower …
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
It is recommended that NHS England, within the ‘Long-Term Plan’, works with partners to identify and meet the needs of young adults who have mental health problems that require support but do not meet the current criteria for access to …
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
It is recommended that the Care Quality Commission (CQC) extends the remit of its inspections to ensure that the whole care pathway, from child and adolescent mental health services to adult mental health services, is examined.
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
It is recommended that NHS England requires Clinical Commissioning Groups to demonstrate that the budget identified for current children and young people’s services – those delivering care up until the age of 18 – is spent only on this group.
Safety Recommendation
NCEPOD recommendations(3)
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
CQC inspection actions(2)
Stamford & Rutland Hospital
The service must ensure that there are systems and processes in place to support children and their families with planning, preparing and moving a child from children’s healthcare to adult healthcare.
Must Do
Cotton Exchange
Theprovidershouldconsideradaptingtheconsentprocessfor16and17yearoldsinlinewithbestpractice.
Should Do
PPO death in custody recommendations(1)
IMB individual recommendations(3)
Werrington (2024)
As an increasing proportion of young people in custody are over 18 years. If there is a safeguarding concern, how does the local authority continue to address their needs?
Other
In Progress
Cookham Wood (2022)
Transition of 18+ boys: Is there end-to-end sentence planning and support for these boys? Do they carry their sentence plan with them when they transition to a young adult institution? Or do they have to start afresh? What steps will be taken to arrange transfers to the adult estate for young adults who are aged 18+ and have long sentences …
HMPPS
Werrington (2025)
What assurance can the Minister give the Board that young people serving long sentences will be transferred without delay to the adult estate on turning 18, and what systems are in place to guarantee compliance with this requirement?
Ministry of Justice
Health investigations(42)
Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009) — Rec 3.2
Aneurin Bevan Health Board and Caerphilly County Borough Council must work together to strengthen processes for transition from children’s to adults’ services, to include mechanisms for forward planning and multi-agency consideration of needs, identifying clear roles and responsibilities with a period of overlap where possible94.
wales
Independent investigation: William Moss, Newquay (2007) — Rec 7
The Cornwall and Isles of Scilly Multi-agency Safeguarding Adults Policy is reviewed and audited to consider the interface for: young People who are leaving the care system and on a care order; young people with a diagnosed serious mental illness; people who present with self harm.
south_west
Independent investigation: Mark Blackston, Northfleet, Kent — Rec 2.6.56
The CAMHS providers in Kent and Medway and KCC Social Services Department should ensure that appropriate clinical advice is sought whenever key decisions are taken about whether or not to seek placements for young people in specialist mental health in patient units.
south_east
Independent investigation: Mark Blackston, Northfleet, Kent — Rec 2.6.7
The responsible clinician in CAMHS in-patient units should liase with Social Services at the earliest opportunity during or after admission whenever it is considered that it is in the young person’s best interests for Social Services to be involved. The aim should be for in-patient units to involve Social Services …
south_east
Independent investigation: Mark Blackston, Northfleet, Kent — Rec 2.5.19
The CAMHS providers and Mental Health and Social Care Trusts in Kent and Medway should ensure that a system is in place, with appropriate guidelines for the efficient and effective handover of each case from CAMHS to adult services whenever such a handover is decided to be necessary. The system …
south_east
Independent investigation: Mark Blackston, Northfleet, Kent — Rec 2.5.8
Lead Primary Care Trusts (PCTs) for CAMHS and Kent County Council Social Services should produce and agree a protocol to guide the management of young people with mental health problems, including emerging personality disorders who are placed away from the local area. This should include consideration of whether the management …
south_east
Independent investigation: Mark Blackston, Northfleet, Kent — Rec 2.4.5
The Strategic Health Authority and Kent County Council Social Services should jointly bring to the attention of the Department of Health the need for national guidance on the development of services for young people with emerging personality disorder. Such guidance should include the transition from children’s services to services for …
south_east
Independent investigation: Lucy Ayris, Hayes (2015) — Rec 4
The CMHT should develop robust systems of communication with children and families social services wherever children are potentially at risk, in consultation with children and families social services.
london
Independent investigation: Lucy Ayris, Hayes (2015) — Rec 1.44
as a matter of urgency, the Trust assess the risk and develop Trust wide options to address the specific action for the Hillingdon mental health services to keep a register of all service users subject to child protection procedures and to appoint a children’s and family services mental health champion …
london
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.27
Mental health services for 16 and 17 year olds should be specifically commissioned. Sufficient in-patient adolescent psychiatric beds need to be available so that the dilemma of either risky care in the community or inappropriate care in adult units can be avoided.
north_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.24
Where, as in this case, adult and child mental health services are not managed by the same organisation, CAMHS should ensure there is good liaison with adult mental health services between both professionals and managers to promote knowledge of good practice and appropriate patient care.
north_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.23
Young people “looked after”, in the transition phase, and receiving mental health care should have their needs reviewed jointly between agencies. This should include primary health care and education. The outcome should be a care plan available to all including the young person.
north_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.21
Appropriate mental health services need to be in place for 16 and 17 year olds. Transition or contingency arrangements should be made for the use of adult mental health services well before the need arises and in consultation with all relevant parties. CAMHS should develop a policy on transfer arrangements …
north_west
Independent investigation: Jean RobinsonDerek RobinsonKevin Molloy, Highgate/Tottenham (2004) — Rec 3.24.8
That transition procedures between CAMHS and adult services are reviewed and that care planning for that individual is jointly set between the two services.
london
Independent investigation: Eduardo Mendoza, Hammersmith (2007) — Rec R1
The trust should ensure that a transition policy providing guidance on the transition from local authority children‟s services to adult mental health services is produced and sent to all staff that need to know about it.
london
Independent investigation: Benjamin Durao, Brixton (2004) — Rec 4
To develop effective joint working across CAMHS and adult mental health, which can be evidenced through regular audit and evaluation.
london
*Independent investigation into the care and treatment of Patient I: … — Rec 6
It is recommended that the transition from child to adult health care should be set at the statutory school leaving age. School leaving age was 16. It is due to become age 17 in 2013 but will be at age 18 from the year 2015 onwards. Transition has been a …
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Not Accepted
Independent investigation into the care and treatment of Mrs A … — Rec 3
Royal Borough of Greenwich should update its 2015 Carers Policy to cover mental health and children in transition.
Mrs A and Miss B, published on 03 July 2019. Mrs A and Miss B was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr N — Rec 8
The Trust to review the approach that it takes to young people with established substance misuse issues and to develop a dual diagnosis approach to these patients.
london
Accepted
Independent investigation into the care and treatment of Mr N — Rec 21
The Trust must ensure that there are effective processes in place for working with the local authority to meet the accommodation needs of young people with mental health problems.
london
Accepted
Independent investigation into the care and treatment of Mr N — Rec 20
The Trust must provide assurance that appropriate accommodation is addressed in all patients’ care planning at the point of discharge from out of area CAMHS forensic admissions.
london
Accepted
Independent investigation into the care and treatment of Mr N — Rec 12
The Trust must ensure that the expectations of Section 117 MHA are applied when patients are discharged from out of area CAMHS forensic admissions.
london
Accepted
Independent investigation into the care and treatment of Mr N — Rec 10
The Trust CAMHS to review its approach to transferring patients and to benchmark itself against the NICE guidance on the Transition of Children and Young People, to use the findings to develop a robust patient centred approach to transfer and discharge.
london
Accepted
Independent investigation into the care and treatment of Mr DB: … — Rec 17
Stockport CCG : formal processes must be in place so that multiagency risk assessments are carried out for all vulnerable children and their carers on transition from children to adult services
Mr DB . At the time of homicide December 2014 Mr DB was receiving care and treatment from Pennine Care NHS Foundation Trust
north_west
An independent investigation into the care and treatment of Emily … — Rec 11
TEWV, CNTW, NHS England and Durham County Council must provide assurance that all transitions between services for children and young people are completed in line with NICE guidance on the Transition of Children and Young people.
An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
A system-wide independent investigation into concerns and issues raised relating … — Rec 5
TEWV, CNTW and System Partners need to seek assurance that they have resolved the problems associated with the clinical transitions phase (between services and child to adult). A compound recommendation is required to address this deficit: a) TEWV must provide assurance that a full gap analysis between the 2018 Healthcare …
CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation: Rina Panchal, Thurmaston, Leicester (2007) — Rec 4
For Leicester City Council’s Children and Young People’s Services (CYPS) need to consider producing a guidance note on core information it requires from other agencies in preparation for reports where professionals cannot attend for multi-agency meetings. The IIT understands that CYPS is of the view that, when professionals and agencies …
midlands
Independent investigation: Mark Blackston, Northfleet, Kent — Rec 2.3.8
Closer links should be developed between children’s and adult mental health services, Social Services and Housing Authorities to try to provide more stable living environments for vulnerable young people living chaotic lives.
south_east
Independent investigation: Kenneth Auger, Merthyr Tydfil (2008) — Rec 3.1d
Encourage carers, especially young carers, to engage and make contact with services including in transition planning when young people themselves become adults and move out of contact with children’s services. This process needs to be audited and reviewed to ensure its efficiency.
wales
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R31
The trust should continue to review how they could develop a service for the 16 to 25 age group which would overlap with CAMHS and adult services rather than be separate from them.
london
Joint Safeguarding Adult Review and Independent Mental Health Homicide Investigation, … — Rec 15
The RBG Safeguarding Adult Board should recommend that partner agencies expand the local children’s safeguarding MASH to include adult referrals. Mental health specialism should be part of this MASH. Partner agencies should report back to the Safeguarding Adult Board within three months of receipt of this report.
london
Accepted
Independent investigation into the care and treatment of Mr N — Rec 9
The Trust must provide assurance that all transitions between services for children and young people are completed in line with NICE guidance on the Transition of children and young people.
london
Accepted
An independent investigation into the care and treatment of Christie … — Rec 12
TEWV and CNTW must ensure the organisational approach to safeguarding young people proactively involves and informs the relevant local Safeguarding Children’s Partnership of all instances where a young person is placed at risk, including the use of unregulated and unsupported accommodation in the community.
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation: Vincent Francis, Wells (2009) — Rec 5
An up to date audit of the quality of joint plans with community mental health and primary care services for children and adolescents should be undertaken by the Trust and commissioners and the results disseminated to carer and interested parties.
south_west
Independent investigation: Rina Panchal, Thurmaston, Leicester (2007) — Rec 2
LPT should improve its early discharge planning This investigation identified that it is not the expected practice for LPT’s crisis resolution and home treatment (CRHT) services to receive a copy of the discharge plan for a MHSU taken on for early discharge from inpatient services. Neither is it customary for …
midlands
*Independent investigation into the care and treatment of Patient I: … — Rec 5
It is clear that school attempts were made to involve all relevant agencies in discussions on a regular basis about the various presenting problems which patient I exhibited. A system which involves health, YOT, education, police, social care is clearly of benefit. A more rigorous and regularised protocol for carrying …
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Accepted
An independent investigation into the care and treatment of Darren … — Rec 7
Isle of Wight NHS Trust should consider adopting an assessment tool, such as Potentiality for the Adult’s Mental Ill Health to Impact on the Child (PAMIC)208, within its primary and secondary mental health services, including the IAPT service.
Isle of Wight NHS Trust
south_east
An independent inquiry into the care and treatment of Ms … — Rec 11
We recommend that in light of the information provided to us, a further internal review into the care and protection of Adult B and Adult D be undertaken by Children’s social care in conjunction with local mental health services, given that the account of their childhood raises a number of …
south_east
Independent investigation into the care and treatment of Mr N — Rec 7
Trust medicine management policies for long acting antipsychotic injections should provide guidance for their use in young people.
london
Accepted
Independent external quality assurance review following the independent investigation into … — Rec 1
The Child and Family Service Operational Policy must provide clear guidance on how CAMHS clinicians are to work with other partner agencies and the young person’s family in the assessment and support planning processes.
midlands
Accepted
An independent investigation into the care and treatment of Christie … — Rec 10
Local Authorities and Health providers must ensure that there is clarity about the roles and responsibilities of each agency in the planning and delivery of care to young people in Tier 4 CAMHS provision where they are in the care of the Local Authority to ensure that support is holistic …
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
A system-wide independent investigation into concerns and issues raised relating … — Rec 9
Safeguarding between mental health providers and system partnerships was insufficient to protect young people in West Lane Hospital. Despite the availability of Working Together Guidance, responsibilities and obligations internally and externally between agencies (providers and system colleagues) were confused, interpreted differently by individuals and consequently gaps developed. A compound recommendation …
CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent reviews(7)
Harris Review: Deaths in Custody — Rec 37
YOTs and other relevant agencies should be required to remain in contact with a young adult who transfers from the youth estate to an adult or young adult establishment for at least 6 months after they reach 18, and longer if particular vulnerabilities are identified. This may extend to 21 …
Justice & Legal
Harris Review: Deaths in Custody — Rec 36
If the YOT and other key organisations believe that due to an individual’s lack of maturity, it would be in the best interest of a vulnerable young adult to remain in the under-18 estate after they reach 18, suitable accommodation should be found for that person within the juvenile estate, …
Justice & Legal
Modern Slavery Act Review — Rec 40
The Government should provide more effective support and guidance for trafficked young people transitioning from children’s to adult services.
Justice & Legal
Accepted
Modern Slavery Act Review — Rec 38
The Government should extend the ICTA service to young people who need the service over the age of 18 and up to 21 or 25, subject to their circumstances.
Justice & Legal
Accepted
Lammy Review — Rec 17
The MoJ and Department of Health (DH) should work together to develop a method to assess the maturity of offenders entering the justice system up to the age of 21. The results of this assessment should inform the interventions applied to any offender in this cohort, including extending the support …
Justice & Legal
Accepted
Wessely Review — Rec 110
Young people aged 16 or 17 should not be admitted or treated on the basis of parental consent. The MCA (LPS) or MHA should be used as appropriate if they are unable to consent to their treatment.
Health & Social Care
Accepted
Wessely Review — Rec 108
Legislation and guidance should make clear that the only test that applies in relation to those aged 16/17 to determine their ability to make decisions in relation to admission and treatment is that contained in the Mental Capacity Act.
Health & Social Care
Accepted
LGO / SPSO decisions(53)
23-014-163 — London Borough of Merton
Summary: Mrs Q complains the Council delayed referring her daughter for an Adult Social Care assessment, in the time before her 18th birthday. And when it did make the referral it did not tell them and delayed responding to her contacts. We uphold the complaint. The Council has agreed to …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2024
23-017-457 — Hertfordshire County Council
Summary: Mrs X complains about how the Council planned care for her son, Mr K. The Council took too long to start planning Mr K’s transition from children’s services to adult social care. Despite its best efforts, the Council failed to provide overnight respite care and has not fully supported …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2024
21-003-856 — Manchester City Council
Summary: Mr B complained that the Council stopped his education incentive payment without notice or explanation on two occasions and refused to backdate the money to cover the gaps. The Council has now offered to pay him £500, support him until the end of his course and review its policies. …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-017-188 — City of York Council
Summary: The Council is at fault for delaying consideration of this complaint at stage two of the children’s statutory complaints procedure. The Council will issue its stage two response in the coming days. It has also agreed to offer to make a payment to the complainant to remedy the time …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-012-774 — Buckinghamshire Council
Summary: Miss X complained the Council failed to appropriately plan for her transition from children to adult care services, and to support her to stay with her foster family until she was 25 on a staying put arrangement it had previously agreed. There was fault in the way the Council …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
22-001-593 — Suffolk County Council
Summary: Mrs X complained the Council refused to carry out social care assessments and did not provide advice on her son’s social care needs for the review of his Education, Health and Care plan. She also complained about poor communication and complaints handling, which caused frustration and delays, and put …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-017-132 — Cambridgeshire County Council
Summary: Mr B complains on behalf of his adult son, Mr F, about the way the Council managed his transition to adult social care and that it failed to provide him with care and support from July to September 2021. We have found fault which has caused injustice to Mr …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
22-005-749 — Nottinghamshire County Council
Summary: There is no fault by the Council in relation to its planning for the complainant’s son’s transition from children’s to adult social care. Whilst only limited services have been provided since the complainant’s son became 18, there is no fault by the Council as it offered suitable provision that …
LGO (Local Government & …
Adult Care Services
Not Upheld
Dec 2022
23-008-097 — London Borough of Croydon
Summary: Mrs Y complained about the way the Council dealt with Mr X’s social care support and its response to her complaint. We have found fault by the Council in failing to review Mr X’s need for support managing his finances, and failing to consider part of Mrs Y’s complaint, …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2024
23-015-297 — Torbay Council
Summary: We will not investigate this complaint about transition planning into Adult Services. The Council has investigated the complaint under the Children’s Statutory Complaint Procedure and upheld most of the complaint. Further investigation would not lead to a different outcome.
LGO (Local Government & …
Children S Care Services
Upheld
Apr 2024
24-003-509 — Bournemouth, Christchurch and Poole Council
Summary: We will not investigate Mr X’s complaint about the Council’s handling of several matters in relation to his daughter’s care and support. This is because there is insufficient evidence of fault. In addition, the faults accepted have not caused any significant injustice and an investigation would not lead to …
LGO (Local Government & …
Adult Care Services
Aug 2024
24-010-194 — Southampton City Council
Summary: Mrs X complained about the Council’s handling of her child’s care and support when he turned 18. We find no fault in the Council’s overall decision making but do find fault for it failing to consider Mrs X’s request for an additional day at Placement A. This caused Mrs …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
24-009-874 — Shropshire Council
Summary: The Council delayed making a decision about Mr Y’s social care provision and issuing the decision to cease to maintain his Education, Health and Care Plan. This caused avoidable uncertainty, distress and a delay in appeal rights which have not been used. The Council has already apologised and this …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
25-000-139 — Norfolk County Council
Summary: We will not investigate Mr X’s complaint about the Council’s care planning and decision-making related to his accommodation and support after he turns 18. The Council is considering his complaint under the children’s statutory complaints procedure and in the process of arranging a stage three panel. It is reasonable …
LGO (Local Government & …
Adult Care Services
Jul 2025
24-017-448 — Sandwell Metropolitan Borough Council
Summary: Mrs X complained about the Council’s handling of her son, Y’s, annual review. Mrs X also complained the Education, Health and Care (EHC) Plan did not focus on preparation for adulthood. Mrs X said this impacted school consultations, transition, Y’s mental health, and her mental and physical health. There …
LGO (Local Government & …
Education
Upheld
Sep 2025
23-020-425 — Milton Keynes Council
Summary: Mrs X complained about the Council’s failure to provide respite care for her disabled child. We found the Council to be at fault because it failed to properly consider the issue. There was also fault with the Council’s complaint handling. To remedy the distress and uncertainty caused by its …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2025
24-020-730 — London Borough of Croydon
Summary: Mr X complained the Council delayed providing his son with respite care when he transitioned from children to adult services. We find the Council was at fault for the delay in securing suitable respite care for Mr X’s son. This caused distress and upset, and Mr X’s son lost …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2025
23-018-546 — London Borough of Haringey
Mr and Mrs X complain about delay by the Council in carrying out an assessment for the transition of Mr Y from children to adult care services.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2024
24-003-915 — Hertfordshire County Council
Summary: Mr Z, on behalf of his grandson Mr X, complained the Council failed to provide appropriate support when he turned 18. The matters Mr Z raised were known to him in 2021 and he raised them with the Council at that time. This is a late complaint and falls …
LGO (Local Government & …
Adult Care Services
Nov 2024
25-009-655 — East Sussex County Council
Summary: We will not investigate this complaint about the way the Council has handled Mr X’s care. This is because the complaint is late and there is no good reason to investigate this now.
LGO (Local Government & …
Adult Care Services
Dec 2025
24-016-538 — Birmingham City Council
Mr Y complains about the Council’s poor handling of his child’s transition from Children’s Services to Adult Social Care. Mr Y also complains about the Council’s handling of his complaint. The Council has now upheld all aspects of Mr Y’s complaint and there is no further fault for us to …
LGO (Local Government & …
Adult Care Services
Feb 2026
25-011-263 — Derbyshire County Council
Summary: We will not investigate Mr F’s complaint about direct payments during his son’s transition from children’s to adults’ services because there is nothing we could add to the Council’s response. The Council is about to respond to Mr F’s complaint about an audit. If he remains dissatisfied once he …
LGO (Local Government & …
Adult Care Services
Feb 2026
24-008-108 — London Borough of Haringey
Summary: Ms Y complained about the Council’s support for her late son, Z, and the standard of support by the service provider the Council commissioned to deliver Z’s support. We have found fault causing injustice by the Council in failing to: properly monitor the service provider’s support for Z and …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
25-008-644 — Surrey County Council
Summary: We will not investigate this complaint about failures in communication about adult social care support. The injustice is not enough to justify our involvement. We are satisfied with the actions the Council has already taken to apologise and offer to meet, and it is unlikely we would achieve anything …
LGO (Local Government & …
Adult Care Services
Jan 2026
21-007-240 — Cornwall Council
Summary: Mr D complained the Council failed to properly support his grandson when he transitioned from children’s services to adult care services. He also says the Council failed to give him information about his grandson’s wellbeing. We find the Council delayed assessing Mr D’s grandson. It also should have done …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-011-122 — Manchester City Council
Summary: Miss F complains the Council delayed planning her son’s transition to adult services. There was fault as the Council should have sought alternative respite providers sooner. The Council has agreed to make a payment to Miss F to acknowledge the impact the loss of respite for three months has …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-015-390 — Gloucestershire County Council
Summary: Mr and Mrs X complained the Council failed to carry out the recommendations made at Stage 2 and 3 of the statutory complaints process. The Council has provided information about the action it has taken as well as now arranging a meeting as agreed. These actions, along with a …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
24-015-863 — London Borough of Croydon
Summary: We will not investigate this complaint about how the Council dealt with Ms Y’s transition from children’s to adult services. This is because the complaint is late and there is no good reason for us to investigate now.
LGO (Local Government & …
Adult Care Services
Apr 2025
24-015-301 — Essex County Council
Summary: Ms X complains the Council failed to recognise that a malicious safeguarding concern had been raised about her, resulting in it investigating the concern and subjecting her to supervised contact with her son. The Council accepts it should have started making safeguarding enquiries when it first received the concern …
LGO (Local Government & …
Adult Care Services
Upheld
May 2025
24-016-539 — Norfolk County Council
Summary: Ms D complains the Council failed to provide suitable support to her and safeguard her. The Council is at fault for failing to make proper transition arrangements for Ms D, to consider safeguarding alerts and for failing to complete carers’ assessments. This has caused uncertainty about whether Ms D …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2025
25-007-024 — West Sussex County Council
Summary: We will not investigate Mr X’s complaints about the Council’s decision to cease his daughter’s college placement and Education, Health and Care Plan and its communications and complaints handling. The substantive matters are appealable, or could have been appealed, to the SEND Tribunal. The other complaints do not warrant …
LGO (Local Government & …
Adult Care Services
Nov 2025
24-007-419 — London Borough of Wandsworth
Summary: We will not investigate this complaint about how to meet adult social care needs when the current provision ends. The court of protection is better placed to settle a dispute about how best to meet a person’s needs when they do not have capacity to decide. The claimed injustice …
LGO (Local Government & …
Adult Care Services
Oct 2024
24-008-866 — London Borough of Croydon
Summary: We will not investigate this complaint the Council failed to complete an adult care needs review. That is because it is late.
LGO (Local Government & …
Adult Care Services
Nov 2024
24-009-869 — Suffolk County Council
Summary: We will not investigate this complaint about the children’s statutory complaints procedure. The Council has upheld the complaint and offered a suitable remedy. Further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2024
PSOW-202400197 — Pembrokeshire County Council
Ms A complained about inadequacies in the support that Social Services had provided to her children. She was also dissatisfied with the initial complaint response she had received from the Council. The Ombudsman considered that the Council’s response was not sufficiently robust. The Council agreed to appoint an external independent …
PSOW (Public Services Om…
Local Government
Jul 2024
22-002-791 — Lancashire County Council
Summary: We cannot investigate Miss X’s complaint that the Council has failed to provide court ordered therapy for her daughter because it lies outside our jurisdiction. The law prevents us from investigating matters that are being, or have been, considered in court proceedings. We have no discretion to do so.
LGO (Local Government & …
Children S Care Services
Jun 2022
22-002-767 — North Yorkshire County Council
Summary: We cannot investigate this complaint about what the Council disclosed and evidence it withheld negatively affecting a court case. The matters complained of are not separable from the court process and either were or could have been raised in court.
LGO (Local Government & …
Children S Care Services
Jun 2022
21-011-789 — City of York Council
Summary: Mr and Mrs X complained the Council poorly managed their child, Y’s, transition from children’s services to adult services as a care leaver. They say this caused them and Y distress and affected Y’s health. They also say the Council handled their complaint poorly. The Council is at fault. …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-014-948 — London Borough of Newham
Summary: There was fault by the Council because it did not properly plan Miss K’s transition from Children to Adult Services and how it would arrange and fund her care. There was also fault in its complaint handling as it failed to refer Miss K’s complaint to a stage three …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-005-582 — Walsall Metropolitan Borough Council
Summary: We have discontinued our investigation into Mrs C’s complaint about the Council’s adult safeguarding enquiry. Mrs C can approach the Information Commissioner’s Office about her data protection complaints, and there is not enough evidence of fault in the remainder of her complaint to justify further investigation.
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2022
22-008-982 — West Sussex County Council
Summary: We will not investigate Ms B’s complaint about the way the Council considered safeguarding matters about her. This is because the Council’s actions have not caused Ms B a significant enough injustice to warrant an ombudsman investigation. Further investigation by us could not add to the Council’s response of …
LGO (Local Government & …
Adult Care Services
Oct 2022
24-004-827 — London Borough of Hammersmith & Fulham
Ms D complained the Council failed to carry out an occupational therapy assessment when her son, Mr J, transferred from children’s to adult’s social care services. We have found the Council significantly delayed completing an occupational therapy assessment. This delay caused Ms D avoidable frustration, uncertainty and distress. It affected …
LGO (Local Government & …
Adult Care Services
Upheld
May 2025
25-004-813 — Cambridgeshire County Council
Summary: We will not investigate Mrs X’s complaint the Council delayed moving her daughter, Miss Y, from her children’s residential placement to an adult one. Any outstanding injustice is not significant enough to warrant an investigation and our involvement would be unlikely to achieve anything meaningful.
LGO (Local Government & …
Adult Care Services
Oct 2025
PSOW-202206153 — Vale of Glamorgan Council
Mrs L complained that Vale of Glamorgan Council had failed to carry out a wellbeing assessment to allow her to apply to the courts for contact . The Ombudsman found that a formal complaint had been raised with the Council in November 2022 which had not yet concluded. This had …
PSOW (Public Services Om…
Local Government
Mar 2023
PSOW-202307520 — Flintshire County Council
Mr X complained about the actions taken by Flintshire County Council from November 2021 when his daughter, Y, went to live with her grandmother and then to a regulated care home. Mr X was unhappy with the independent Stage 2 investigation of his complaint. Mr X was also unhappy as …
PSOW (Public Services Om…
Local Government
Mar 2024
PSOW-202407666 — Caerphilly County Borough Council
Miss A complained that the records held by the Council’s Social Services Department’s relating to her daughter were inaccurate, incomplete and that false information was recorded. She also complained that the Council did not appropriately declare potential conflicts of interest with persons involved in her daughter’s case. The Ombudsman decided …
PSOW (Public Services Om…
Local Government
Apr 2025
PSOW-202505155 — Cardiff Council
Mr A complained that Cardiff Council “The Council” had taken an unreasonable amount of time to issue him a Stage 2 report to a complaint he had escalated. The Ombudsman found that the Stage 2 report was completed 8 months before it was issued to Mr A and that no …
PSOW (Public Services Om…
Local Government
Jan 2026
22-003-647 — Kent County Council
Summary: We will not investigate Mr X’s complaint about a safeguarding concern raised in relation to his friend, Mr Y. This is because an investigation by this office would not be able to add to the explanation and response already provided by the Council on this matter.
LGO (Local Government & …
Adult Care Services
Jul 2022
21-005-229 — East Riding of Yorkshire Council
Summary: We will not investigate Ms B’s complaint about the care her late mother received or the Council’s safeguarding investigation into her concerns. This is because further investigation by the Ombudsman could not add to the Council’s investigation or make a finding of the kind Ms B wants.
LGO (Local Government & …
Adult Care Services
Jul 2022
PSOW-202405925 — Carmarthenshire County Council
Miss A complained about how Carmarthenshire County Council (“the Council”) dealt with safeguarding concerns she reported regarding her daughter. Miss A said that the Council failed to share a report with her from May 2024. The Independent Investigation taken into her concerns upheld this aspect of her complaint. The Ombudsman …
PSOW (Public Services Om…
Local Government
Mar 2025
Domestic Homicide Reviews(58)— showing 50 strongest matches
Lincoln — recommendation 7
LSAB should seek assurance from partner agencies that: • The needs of those adults who would have made the transition from children to adults' services before the implementation of the MCA 2005 have appropriate MCA assessments which inform effective future planning.
LSAB | partner agencies
Oxford — recommendation 6
The Oxfordshire Safer Communities Partnership & Community Safety Partnerships and OSCB to review current multi-agency approaches for young people who present serious risks in the community, but do not meet the criteria for MAPPA and are not subject to court orders. Consideration to be given to: i) Clarifying and promoting …
Oxfordshire Safer Communities Partnership | Community …
Oxford — recommendation 1
The OSCB to request that the importance of young people’s relationships with professionals is built into the multi-agency work currently being undertaken on vulnerable adolescents. The learning should be used to identify how best practice can be developed more widely across the multi-agency partnership.
Oxfordshire Safeguarding Children Board
Kent — recommendation 11
When adult offenders have been previously subject to youth offending supervision, liaison must take place with the previous allocated YOT worker/s in order to gather information to inform risk assessment and risk management.
NPS | YOS
National Probation Service
Wiltshire — recommendation R54
Children’s Social Care should refer vulnerable young people moving into adulthood to adult safeguarding/social care as routine practice
Children’s Social Care
Flintshire — recommendation 16.57
We recommend that WCVA and NCVO provide guidance for all Voluntary Organisations, which ensures a robust standard for Child and Adult protection procedures within Voluntary Organisations and provides for procedures for dealing with and reporting Domestic Abuse. The guidance should include a nil tolerance stance to Domestic Abuse. Such guidance …
Wales Council for Voluntary Action | …
Stockport — recommendation 17
Stockport CCG : formal processes must be in place so that multiagency risk assessments are carried out for all vulnerable children and their carers on transition from children to adult services
Stockport ICB
Southend-on-Sea — recommendation 14
Improve referral pathways for IYSS into adult services for substance misuse should be developed.
Integrated Youth Support Services
Poole — recommendation 2
That this report is shared with Bournemouth and Poole Local Safeguarding Children Board so that that Board and the Bournemouth and Poole Safeguarding Adults Board can make use of the learning from this review to seek assurance about the effectiveness of arrangements by which looked after children and other children …
Bournemouth and Poole Local Safeguarding Children …
Poole — recommendation 1
That this report is shared with Dorset’s Local Safeguarding Children Board and their Safeguarding Adults Board so that the Boards can make use of the learning from this review to seek assurance about the effectiveness of arrangements by which looked after children and other children with care and support needs …
Dorset’s Local Safeguarding Children Board | …
Tower Hamlets — recommendation 3
The Home Office and Ministry of Justice review the Asset Plus structured assessment tool used by YOS in England to ensure that the system considers children and young people as perpetrators of domestic abuse and has clear pathways to DASH risk assessment and MARAC.
Home Office | Ministry of Justice
Home Office
Tower Hamlets — recommendation 2
That the Home Office amend their definition of ‘Domestic Abuse’ to incorporate incidents involving perpetrators of domestic abuse under the age of sixteen years.
Home Office
Home Office
Kirklees — recommendation 11
That Lifeline’s child safeguarding policies should make specific reference to MARAC procedures, where the procedures can be located and information about the role of the in-house nominated lead manager.
Lifeline
Harrow — recommendation 3
Update and improve safeguarding procedures and practice –and a lead safeguarding professional (manager) to be identified to hold expertise to advise internally on complex cases, including where adult and child safeguarding issues coexist.
Advance
Stoke-on-Trent — recommendation SOTCC_R9
Disseminate message through CSE training that a child is a child until they are 18 years and should be offered an assessment as this may provide a smooth transition into accessing services for adults
Stoke-on-Trent City Council Early Intervention and …
Stoke-on-Trent — recommendation 5b
reinforce the message that young people do not become any less vulnerable to exploitation as they approach adulthood and that at any age they should not be viewed as consenting to their own exploitation.
Stoke-on-Trent Safeguarding Children Board | (Staffordshire …
Middlesbrough — recommendation 17.2
Paragraph 14.7.13 outlines that a report has been submitted to the Middlesbrough Executive group to consider new models of transition from children’s to adult services. The progress of their considerations should be reported to the Community Safety Partnership so that assurance can be given that the proposed model addresses the …
Middlesbrough Executive group | Community Safety …
Northumberland — recommendation 5
To review the purpose of the Transitional Database held within the Disabled Children’s Team.
Northumberland County Council (Children’s Social Care …
Salford — recommendation 1
The Health and Social Care Partnership in Scotland should seek to review policies and practice in relation to referring to adult services.
Health and Social Care Partnership in …
Scottish Government
Bromley — recommendation 4.5.10
That this review, when finalised, be forwarded to the CSP at Bexley for them to consider the learning opportunities possible from the evidence of the perpetrator’s possible needs when a child within that borough.
Bexley Community Safety Partnership
Oxford — recommendation 2a
CSC should develop practice guidance for social workers and personal advisors on managing their responsibility to provide services to dangerous/offensive young people.
Oxfordshire County Council Children’s Social Care …
Oxford — recommendation 3
The Oxfordshire Safer Communities Partnership & Community Safety Partnerships and OSCB to work with the strategic lead on domestic abuse to ensure an effective unified approach to working with young people who are victims and/or perpetrators of domestic abuse.
Oxfordshire Safer Communities Partnership | Community …
Harlow — recommendation 11.10.1
Should raise the value and importance of adult safeguarding training and awareness to that of children’s safeguarding, and to ensure that domestic abuse features appropriately within that training.
All Agencies
Wiltshire — recommendation R24
Professionals to consider what services can step up when young person reaches 18 but does not meet threshold for adult mental health services.
YOT | Early Help | CAMHS
CAMHS
Oldham — recommendation 8 (Part 2)
The CSCP should work jointly with the local Safeguarding Children Partnership and Safeguarding Adults Board to ensure that guidance relating to the roles of Adults and Children’s Services in supporting domestic abuse victims with children is in place and that ASC and CSC are implementing this guidance.
Safeguarding Children Partnership | Safeguarding Adults …
Safeguarding Adults Board
Lincoln — recommendation 10.3.6
Further develop improved partnership working with LSCB and LSAB for both adults and children.
Addaction
Lambeth — recommendation 2
After publication of this DHR, the Safer Lambeth Partnership should liaise with Buckinghamshire and Lewisham Children’s Social Care respectively and ensure that this report is attached to Child A and Child B’s social care records. This is so that, if they wish to read the DHR when they are older, …
Safer Lambeth Partnership
North Worcestershire — recommendation O4
On behalf of the North and South Worcestershire Community Safety Partnerships to develop scope and commission domestic abuse training which seeks to bring together both Children and Adult social care and wider partners, making the links to safeguarding.
Worcestershire Public Health
Bradford — recommendation Bradford District NH
The Safeguarding Children’s team to raise awareness and disseminate information regarding the addendum (appendix 9) of the Safeguarding Adults Policy (BDCT, 2012) Guide: Working with Domestic Abuse. This will increase awareness of the opportunities of how to encourage disclosure or implement routine enquiry when School Nursing teams are working with …
Bradford District NHS Care Trust
Bradford District Care NHS …
Birmingham — recommendation 1.1
A working group should be jointly established by the BCSP and the BSCB consisting of representatives from the core agencies of both. The working group should also include some domestic violence service users, and/or surviving family members, with the aim: - To establish mechanisms to break down the boundaries and …
Birmingham Community Safety Partnership | Birmingham …
Wolverhampton — recommendation 22
Safer Wolverhampton Partnership to seek assurances from the Safeguarding Children and Adults Boards that work carried out with children and adults at risk: Is outcome focused and of a high quality; and generates specific referrals for service provision; And that: there is timely and effective information exchange; and there is …
Safer Wolverhampton Partnership
Wolverhampton — recommendation 5
The Safer Wolverhampton Partnership to ask the Domestic Violence Forum to develop an inventory of all relevant risk assessment tools and procedures currently used in Wolverhampton by Safeguarding Children and Safeguarding Adults services to promote: Consistency of language across them; The development of a pathway between them; Clarity and understanding …
Safer Wolverhampton Partnership
Oxford — recommendation 11
We recommend that in light of the information provided to us, a further internal review into the care and protection of Adult B and Adult D be undertaken by Children’s social care in conjunction with local mental health services, given that the account of their childhood raises a number of …
Children’s social care | local mental …
Harrow — recommendation 5
Embed Hidden Harm Co-ordinator within Adults Team
Compass
Nottingham — recommendation c.
Young persons who harm aged 16 and 17 should be responded to with the criminal justice system with the same degree of specialist knowledge in respect of domestic abuse as those aged 18 and over.
Nottingham Crime and Drugs Partnership | …
Cornwall — recommendation 7
That the learning from these domestic homicide reviews is routinely shared with professionals working within adult and children’s services to facilitate proactive support that could minimise the potential for escalating risk or reoccurrence within the next generation.
NHS England
NHS England
Stockport — recommendation 1c
As part of the LSCB learning review the processes and systems for information sharing with voluntary sector agencies should receive focus. This should ensure that voluntary and third sector agencies have equal access to relevant information to safeguard vulnerable adults and children.
Local Safeguarding Children Board
Sutton Local Safeguarding Children’s …
Croydon — recommendation 6
Consideration must be given (alongside the LSCB and SAB) to include adults within the Croydon MASH process.
Croydon Community Safety Partnership
Croydon — recommendation 2
In conjunction with other strategic boards, produce a domestic violence protocol, policy and care pathway. This should include domestic violence enquiry and provision for safeguarding children, adults at risk and vulnerable young people.
Croydon Community Safety Partnership
Northumberland — recommendation 2
Children’s social care and adult safeguarding to implement a clear procedure and pathway to ensure that all referrals regarding adolescent to parent violence and abuse are responded to appropriately and consistently, identifying the risks around domestic violence, to ensure that the adult victim is safeguarded and protected and that the …
Northumberland County Council (Children’s Social Care) …
Kent — recommendation 11
When adult offenders have been previously subject to youth offending supervision, liaison must take place with the previous allocated YOT worker/s in order to gather information to inform risk assessment and risk management.
NPS | YOS
National Probation Service
Cheltenham — recommendation 1
Further national guidance on risk management is given to professionals when the victim is under 16 and advice on expectations as to professional response in the context of statutory safeguarding systems.
Home Office
Home Office
Cheltenham — recommendation 5A
Children’s Social Care and the Youth Support Service will implement the BASE practice model* (developed through DfE Innovations Programme) and evaluate its effectiveness in managing adolescent risk.
Children’s Social Care | Youth Support …
Cheltenham — recommendation 4A
GSCB to ensure that risks in adolescents are appropriately identified and managed by considering training for professionals in respect of management of risk in adolescence and monitoring the effectiveness of work being undertaken by CSC/YST to review the safeguarding system for adolescents
GSCB | CSC | YST
Civil Service Commission
Chorley and South Ribble — recommendation 4
Lancashire Children’s Services and the Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership (CSAP) should use learning from this review to develop practice in relation to supporting vulnerable parents when children are removed from their care.
Lancashire Children’s Services | Blackburn with …
Hammersmith and Fulham — recommendation 11
The current children’s ‘Multi-agency Safeguarding Hub’ (MASH) and vulnerable adult ‘Safeguarding Hub’ arrangements within the Borough should be reviewed by September 2019 to ensure that a multi-agency information protocol is established to share information, which identifies risk to inform actions by the appropriate agency. This should be compliant with current …
Hammersmith & Fulham Community Safety Partnership
Cardiff — recommendation UHB Rec 1
Cardiff and Vale UHB conduct a review of referral guidelines to Children’s Services for A&E Dept. at UHW regarding young people up to 18 years of age who present with overdose and or disclosures of sexual abuse and ensure the safeguarding consideration record is completed in every case.
Cardiff and Vale University Health Board
Cardiff and Vale University …
Brent — recommendation 7.1.13
Review of Safeguarding Standard Operating Procedure (SOP) – The local Safeguarding SOP has recently been developed and expanded. It now directs staff to ensure they scan all referrals made to safeguarding (children and adults) onto the case management system. They also need to follow up the outcome once the referral …
Westminster Drug Project
Torbay — recommendation 12
Torbay is developing a Multi-Agency Safeguarding Hub (MASH) process, this should be developed as the basis for multi-agency safeguarding for both children and adults.
Torbay Council | Safer Communities Torbay
Torbay Council
Bradford — recommendation City of Bradford Met
Head Teachers and school Child Protection leads are given clear guidelines about who to contact in domestic homicide situations so that they do not inadvertently put children at risk of the suspected perpetrator.
City of Bradford Metropolitan District Council: …
CJINI inspection reports(4)
First joint inspection of Child Protection Arrangements
Abuse and Exploitation, Probation and Public Safety, Safegu…
Jun 2023
The use of Youth Diversion in the criminal justice system
Youth Justice and Intervention, Children and Young People
Jul 2011
An announced inspection of Woodlands Juvenile Justice Centre November 2011
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
Nov 2011
Youth Interventions: An Inspection of the Youth Justice Agency’s Community Interventions
Youth Justice and Intervention, Children and Young People
Sep 2024