Missed Child Safeguarding Referrals
Safeguarding referrals for children sometimes missed, despite mandates and training, putting children at risk.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
Nicholas Stout
The coroner noted concerns regarding the Crisis Team's achievement of the 4-hour assessment target and inconsistent completion of the mandated Triage Tool. Further issues included insufficient safeguarding referrals for children when warranted and a lack of assurance that crucial Safety Plans are completed in all cases.
Matched on
terms: child, referral, safeguarding
PFD report
85match
Christopher Vickers
The coroner noted repeated missed opportunities to coordinate the deceased's care through multi-agency meetings and to make safeguarding referrals, despite escalating risks to self and others.
Matched on
terms: missed, referral, safeguarding
PFD report
81match
Shneur Kaye
The coroner noted that closing safeguarding referrals without prior parental contact limits social workers' ability to assess child welfare. Not sharing information about closed referrals with other agencies may prevent them from taking appropriate action, potentially undermining child protection.
Matched on
terms: child, referral, safeguarding
PHSO casework decision
81match
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.
Matched on
terms: child, referral, safeguarding
Inquiry recommendation
78match
LAMI-98 - Social services must inform police immediately of child criminal offence referrals.
The guideline set out at paragraph 5.8 of Working Together must be strictly adhered to: whenever social services receive a referral which may constitute a criminal offence against a child, they must inform the police at the earliest opportunity.
Matched on
terms: child, referral
Inquiry recommendation
78match
LAMI-63 - Hospital social workers must promptly respond to suspected child harm referrals
Hospital social workers must always respond promptly to any referral of suspected deliberate harm to a child. They must see and talk to the child, to the child’s carer and to those responsible for the care of the child in hospital, while avoiding the risk of appearing to coach the child.
Matched on
terms: child, referral
CQC action
78match
Sheffield Children's Hospital
Follow up two week referrals to the Children and Young People's Independent Sexual Violence Advisors. (ChISVAs).
Matched on
terms: child, referral
CJINI report
78match
First joint inspection of Child Protection Arrangements
Matched on
terms: child, safeguarding
PFD report
77match
Michaela Hall
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.
Matched on
terms: child, safeguarding
PFD report
73match
Kesia Leatherbarrow
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.
Matched on
terms: child, referral
PFD report
73match
Harry Mellor
The coroner identifies concerns regarding the lack of a legal requirement or reliable system for tracking child GP registration and de-registration. This creates potential safeguarding risks, especially for children with chronic health needs, and specialist teams were not informed of Harry's de-registration.
Matched on
terms: child, safeguarding
PFD report
73match
Carol Leesley
A safeguarding referral made by a GP was not acted upon despite automated acknowledgment, and it was unclear if this was due to human or IT error.
Matched on
terms: referral, safeguarding
PFD report
73match
Archie Spriggs
The coroner noted concerns regarding the clarity and auditing of referral pathways to children's social care, and the understanding of professionals making urgent referrals. There were also gaps in multi-agency knowledge concerning private law proceedings and features of filicide cases.
Matched on
terms: child, referral
PFD report
73match
Harper Denton
Police had not adopted specific guidance for managing sexual and violent offenders, and proactive information sharing to protect children was lacking. Concerns also related to the absence of an offender register for those with child cruelty convictions and non-mandatory health visitor safeguarding assessments for co-parent risks.
Matched on
terms: child, safeguarding
PFD report
73match
Lucy Walles
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.
Matched on
terms: referral, safeguarding
PFD report
73match
Alexander Eastwood
The coroner identified a lack of guidance and regulation for children's contact sports, meaning there are no minimum standards for safeguarding, risk management, medical support, or incident planning, particularly for unofficial matches.
Matched on
terms: child, safeguarding
PFD report
73match
Ella Murray
The coroner noted insufficient urgent safeguarding action for a child despite disclosures of fear and self-harm intent. Concerns also include a lack of multi-agency information sharing and no clear system for urgent cross-agency meetings to assess child safety.
Matched on
terms: child, safeguarding
Inquiry recommendation
73match
WATE-(22) - Conduct inter-agency review of child abuse investigation procedures to issue guidance
In the light of the recent experience gained in both England and Wales in major investigations of alleged wide ranging abuse of children in care/looked after children, an inter-agency review of the procedures followed and personnel employed in those investigations should now be arranged with a view to issuing practical procedural guidance for the future. In any event...
Matched on
terms: child, safeguarding
Committee recommendation
73match
#12 - Third Report - COVID-19: Support for children’s education
The Department told us that there had not been the spike in referrals to children’s social care services which many people had expected when schools fully re-opened in September 2020, and that referrals were still around 10% below normal levels year-on- year.19 It explained that this raised concern about the potential for ongoing hidden harm to children whose...
Matched on
terms: child, referral
Committee recommendation
73match
#31 - Significant failings in age assessment lead to children in adult asylum accommodation
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 identify and refer age dispute cases to the relevant local authority are consistently working as they should. This...
Matched on
terms: child, safeguarding
IOPC learning recommendation
73match
Investigation into the West Yorkshire Police response to reports of injuries to a one-year-old child – West Yorkshire...
The IOPC recommend that West Yorkshire Police (WYP) ensure that following reports of injuries to vulnerable children they locate and examine the injured child themselves rather than rely on opinions from other agencies. Following an IOPC led investigation it was identified that WYP received a report of a potential assault of a vulnerable child, who was not at...
Matched on
terms: child, safeguarding
LGO / SPSO decision
72match
22-003-015 - Lancashire County Council
Summary: We will not investigate this complaint about the Council failing to respond to a safeguarding referral. There is not enough evidence of fault to warrant investigation and it is for a court to decide who may safely have contact with a child.
Matched on
terms: child, referral, safeguarding
PFD report
69match
Terry Latimer
The safeguarding notice was not acted upon, specifically a request for referral to Mental Health Services, due to a lack of clarity among staff regarding whether the notice required follow-up action.
Matched on
terms: referral, safeguarding
PFD report
69match
Edward Joyce
A high temperature in a young child following a burn did not trigger an urgent hospital referral or subsequent recording by a hospital nurse when reported, resulting in no advice for parents. The coroner suggests reviewing information for other health professionals.
Matched on
terms: child, referral
PFD report
69match
Christopher Smith
Inadequate discharge planning included no home assessment, insufficient family notification, and incomplete notes. Concerns were also raised about no district nurse referral for leg ulcers and a safeguarding alert not being acted upon after unsafe home conditions were found.
Matched on
terms: referral, safeguarding
PFD report
69match
Joan Prescott
The coroner noted a lack of recorded safeguarding discussions during a welfare visit and a missed opportunity to consider safeguarding at an earlier stage, as the initial focus was on immediate health needs.
Matched on
terms: missed, safeguarding
PFD report
69match
Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent
The coroner raises concerns that critical offender information was not clearly recorded or easily accessible in Probation Service records, impacting risk assessment. Domestic abuse and child safeguarding checks were also insufficient or lacking, posing ongoing risks.
Matched on
terms: child, safeguarding
PFD report
69match
Janet Scott
The coroner noted that the principle of 'safeguarding is everyone's responsibility' is not fully adopted, risking individual agencies not making referrals if they assume other agencies are aware, potentially hindering a multi-agency approach.
Matched on
terms: referral, safeguarding
Inquiry recommendation
69match
LAMI-93 - Require manager involvement from both agencies in joint child harm investigations.
Whenever a joint investigation by police and social services is required into possible injury or harm to a child, a manager from each agency should always be involved at the referral stage, and in any further strategy discussion.
Matched on
terms: child, referral
PFD report
69match
Isla McVeigh
Date of report: 24/07/2026 Ref: 2026-0402 Deceased name: Isla McVeigh Coroner name: Robert Cohen Coroner Area: Cumbria This report is being sent to: North Cumbria Integrated Care | Cumberland Council | Cumberland Safeguarding Children Partnership REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 1 CORONERI am Robert Cohen HM Assistant Coroner for Cumbria 2 DATE OF […]
Matched on
terms: child, safeguarding
CQC enforcement action
69match
Warning Notice: South Tyneside NHS Foundation Trust
The Care Quality Commission told South Tyneside NHS Foundation Trust that it must make further improvements to protect children and young people who may be at risk of harm. A focused inspection found limitations within the patient recording system in the emergency department and limited oversight of safeguarding at management level, which the trust must address.
Matched on
terms: child, safeguarding
Committee recommendation
69match
#11 - Third Report - COVID-19: Support for children’s education
The number of referrals to children’s social care services, during the weeks surveyed between 27 April and 16 August 2020, was around 15% lower than the average for the same period over the previous three years.17 In its written evidence, the NSPCC told us that, under normal circumstances, universal services like schools and children’s centres were vital for...
Matched on
terms: child, referral
Committee recommendation
69match
#2 - Seventh Report - Children in poverty: No recourse to public funds
We recommend that the Government undertakes research to establish if children in families subject to the NRPF condition are overrepresented in serious case reviews. We are pleased that the Department for Education is enthusiastic about improving the communication between organisations on children’s welfare, neglect, and abuse and ask that the DfE report back to us within six months...
Matched on
terms: child, safeguarding
IOPC learning recommendation
69match
Police contact with a mother and unborn child subject to child protection - Metropolitan Police Service, February 2020
The IOPC recommends that the Metropolitan Police Service (MPS) deliver mandatory safeguarding training to all Child Abuse Investigation Team (CAIT) officers and staff. This should be tailored to the work carried out by the team and include areas such as: - Wider themes and issues they may encounter in their work - Dealing with issues that are not...
Matched on
terms: child, safeguarding
PHSO casework decision
69match
P-003474 - Children and Family Court Advisory and Support Service (CAFCASS)
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.
Matched on
terms: child, safeguarding
Committee recommendation
66match
#38 - 2nd Report - Human Rights of Children in the Social Care System in England
We have seen evidence that children in need, a group that includes children in care and disabled children, are four times more likely to die due to deliberately inflicted injury, abuse or neglect than children without any social care involvement. While we acknowledge that Children and Adolescent Mental Health Services are facing unprecedented strain, this reality is profoundly...
Matched on
terms: child
CJINI report
66match
Child Exploitation – Report on the independent Inquiry
Matched on
terms: child
CJINI report
66match
Child Sexual Exploitation in Northern Ireland: An Inspection of the Criminal Justice System Response
Matched on
terms: child
CJINI report
66match
Child Sexual Exploitation Follow-Up Review: An assessment of the criminal justice system’s response
Matched on
terms: child
CJINI report
66match
An Inspection of child criminal exploitation in Northern Ireland
Matched on
terms: child
PFD report
65match
Lily-Mai George
Haringey Children’s Services facilitated the discharge of Lily-Mai into her parents' unsupervised care despite professional opposition. A subsequent decision for residential placement was not implemented before she suffered fatal injuries.
Matched on
terms: child
Inquiry recommendation
65match
LAMI-90 - Ensure child protection training for liaison staff and audit policy compliance.
Liaison between hospitals and community health services plays an important part in protecting children from deliberate harm. The Department of Health must ensure that those working in such liaison roles receive child protection training. Compliance with child protection policies and procedures must be subject to regular audit by primary care trusts.
Matched on
terms: child
Inquiry recommendation
65match
LAMI-87 - Ensure GPs receive regular training in deliberate harm recognition and child protection investigations.
The Department of Health should seek to ensure that all GPs receive training in the recognition of deliberate harm to children, and in the multi-disciplinary aspects of a child protection investigation, as part of their initial vocational training in general practice, and at regular intervals of no less than three years thereafter.
Matched on
terms: child
PFD report
65match
Natasha Hill
The coroner identified gaps in formal adult safeguarding reviews and dedicated transition teams for young people approaching adulthood. Concerns also highlight the need for national standardisation in policing child sexual exploitation and guidance for missing persons.
Matched on
terms: child, safeguarding
CQC action
65match
Kettering General Hospital
The servicemust ensure an effective system in place to ensure consistent recording and referrals following child and adolescent mental health service assessments.
Matched on
terms: child, referral
LGO / SPSO decision
64match
24-005-304 - Birmingham City Council
Summary: Ms X complains the Council’s child safeguarding investigation caused her distress. She says the Council failed to consider her concerns properly, dismissing evidence of child abuse and domestic violence from the children’s father as historical. We find fault with the Council for failing to take satisfactory notes of the children’s views for the investigation, and for a...
Matched on
terms: child, safeguarding
Committee recommendation
64match
#59 - Second Report - Educational poverty: how children in residential care have been let down and what...
We continue to be extremely concerned by media reports of children’s homes— including the recent case of Calcot Services for Children—failing to meet the needs or ensure the safety of the vulnerable children in their care. In the case of Calcot, their children’s homes had been rated good or outstanding by Ofsted. Ofsted must assess its whistleblowing and...
Matched on
terms: child, safeguarding
Committee recommendation
64match
#34 - Second Report - Educational poverty: how children in residential care have been let down and what...
41% of looked-after children are placed outside of their local area, and 8,098 children had at least two placement moves over 12 months. A system that is working well does not boast these numbers. Frequent placement moves are destabilising for the child, and all too often result in missed education, especially when the child is placed outside of...
Matched on
terms: child, missed
Committee recommendation
64match
#4 - Accredit and monitor online STI test providers, and outline child safeguarding for online risks.
Online providers of STI tests and treatment should be accredited by the relevant regulatory body, and regularly monitored on their performance against national clinical guidelines. In response to this Report, the Government should set out the steps it will take to ensure that all children who identify online as a safeguarding risk receive the support they need.
Matched on
terms: child, safeguarding
Inquiry recommendation
64match
FR-13 - Mandatory Reporting
The Inquiry recommends that the UK government and Welsh Government introduce legislation which places certain individuals - 'mandated reporters' - under a statutory duty to report child sexual abuse where they: receive a disclosure of child sexual abuse from a child or perpetrator; or witness a child being sexually abused; or observe recognised indicators of child sexual abuse....
Matched on
terms: child, safeguarding