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
85match
Nicholas Stout
Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and safeguarding referrals for children are frequently missed.
Matched on
terms: child, missed, referral, safeguarding
PFD report
85match
Christopher Vickers
There were multiple missed opportunities to coordinate care through multi-disciplinary meetings and to make safeguarding referrals despite the deceased's known escalating risks.
Matched on
terms: missed, referral, safeguarding
PFD report
81match
Shneur Kaye
Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.
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
PFD report
77match
Michaela Hall
Children and Adult Services failed to consider the family as a whole, lacked written rationale for care needs and safeguarding decisions, and neglected health-related enquiries despite signs of mental impairment.
Matched on
terms: child, safeguarding
PFD report
73match
Harry Mellor
There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with chronic health needs, as specialist teams are not informed.
Matched on
terms: child, safeguarding
PFD report
73match
Avis Addison
Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.
Matched on
terms: missed, safeguarding
PFD report
73match
Harper Denton
Police forces failed to adopt guidance for managing violent offenders and lacked proactive information sharing to protect children. Additionally, a national register for child cruelty offenders is missing, and health visitor safeguarding assessments are not mandatory.
Matched on
terms: child, safeguarding
PFD report
73match
Lucy Walles
Systemic issues in safeguarding, mental health provision, and inter-agency communication led to inadequate support for a vulnerable person. Concerns include slow safeguarding referrals, insufficient staff training, and resource adequacy across council and health services.
Matched on
terms: referral, safeguarding
PFD report
73match
Alexander Eastwood
There is a lack of guidance and regulation for children's contact sports, particularly for unofficial matches, leading to an absence of minimum standards for safeguarding, medical support, and risk management.
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
IOPC learning recommendation
71match
Operation Linden recommendations - South Yorkshire Police and College of Policing, November 2021
The IOPC recommends South Yorkshire Police takes steps to ensure that crime recording practice in its public protection departments is compliant with the Home Office Counting Rules for Recorded Crime. We found many instances where crimes were not recorded when they should have been, including reports of sexual assault or sexual activity with a child. South Yorkshire Police...
Matched on
terms: child, referral, safeguarding
PFD report
69match
Terry Latimer
A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.
Matched on
terms: referral, safeguarding
PFD report
69match
Sofia Legg
Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. Critical safeguarding advice, like not leaving the patient alone, was not properly documented or communicated.
Matched on
terms: referral, safeguarding
PFD report
69match
Edward Joyce
A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness of burn complications and follow-up advice.
Matched on
terms: child, missed
PFD report
69match
Joan Prescott
Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare visit. This represented a missed opportunity to formally address broader safeguarding concerns.
Matched on
terms: missed, safeguarding
PFD report
69match
Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent
Probation Service offender records lacked clear, prominent recording of critical risk information, leading to unread vital details and insufficient domestic abuse and child safeguarding checks. Systemic issues contributed to ongoing risks.
Matched on
terms: child, safeguarding
PFD report
69match
Janet Scott
The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if they believe others are informed, risking a fragmented multi-agency approach.
Matched on
terms: referral, safeguarding
PFD report
69match
Ella Murray
Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an inability to convene urgent multi-agency meetings, meant a vulnerable child was left in an unsafe home environment.
Matched on
terms: child, 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
Inquiry recommendation
69match
SP58 - KCSIE 2026 safeguarding information transfer
The Department for Education, in finalising the Keeping Children Safe in Education guidance 2026, and in any necessary amendments to other policy and guidance, should ensure that: 1. In cases where a child leaves a school because of permanent exclusion, there is absolute clarity concerning the relative responsibilities of the excluding school and the local authority over the...
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: Refresher training should be provided on an annual basis (in addition to the requirements of the Specialist Child...
Matched on
terms: child, safeguarding
PHSO casework decision
69match
P-003474 - Children and Family Court Advisory and Support Service (CAFCASS)
Mr X complains about Cafcass and the conduct of the Family Court Adviser (FCA) throughout the process. He says the FCA did not adhere to policy, which compromised their judgement to make an impartial recommendation in the Section 7 report. Mr X further complains that the FCA overlooked the safeguarding concern he had raised.
Matched on
terms: child, safeguarding
PFD report
65match
Lily-Mai George
Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries before a planned safe placement could occur.
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
Inquiry recommendation
65match
SP5 - Taxi company and school safeguarding arrangements
The Department for Transport should ensure that local authorities establish effective arrangements between licensed taxi companies and schools. These should enable school safeguarding teams to access taxi booking information where relevant to a legitimate safeguarding or risk concern relating to a child who should be at school.
Matched on
terms: child, safeguarding
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
Committee recommendation
64match
#13 - Thirty-Seventh Report - Support for vulnerable adolescents
We asked the Department for Education what is being done to review multi-agency safeguarding partnerships to ensure they work better and to stop horrific events, such as the cases of Star Hobson and Arthur Labinjo-Hughes from recurring. The Department for Education said there are 135 safeguarding partnerships across the country covering 151 local authority areas. It is looking...
Matched on
terms: child, safeguarding
PHSO casework decision
63match
P-004639 - A practice in the Bexley area
Mr X complains about the service provided by a GP Practice following his discharge from hospital in November 2024. He is concerned that the Practice did not prioritise his physical health, focused inappropriately on his mental health, and made an unnecessary safeguarding referral about his children that included disputed information.
Matched on
terms: child, referral, safeguarding
PFD report
61match
Kesia Leatherbarrow
Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team case, led to a lack of support for a high-risk young person.
Matched on
terms: child
PFD report
61match
Carol Leesley
A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.
Matched on
terms: safeguarding
PFD report
61match
Marc Bennett
There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding child protection investigations and providing appropriate mental health support to parents.
Matched on
terms: child
PFD report
61match
Lee-Ann Ince
Agencies supporting the victim lacked understanding of coercive control and the impact of "love bombing." Children's concerns were overlooked, and the victim's physical health vulnerability was not recognised, increasing her risk.
Matched on
terms: child
Inquiry recommendation
61match
LAMI-97 - Ensure child crime investigation is equal to other serious crime investigations.
Chief constables must ensure that the investigation of crime against children is as important as the investigation of any other form of serious crime. Any suggestion that child protection policing is of a lower status than other forms of policing must be eradicated.
Matched on
terms: child
Inquiry recommendation
61match
LAMI-96 - Review police protection systems for Children Act compliance and designated inspector officer.
Police forces must review their systems for taking children into police protection and ensure they comply with the Children Act 1989 and Home Office guidelines. In particular, they must ensure that an independent officer of at least inspector rank acts as the designated officer in all cases.
Matched on
terms: child
Inquiry recommendation
61match
LAMI-94 - Require supervisory officers to actively ensure proper investigation of serious child crimes.
In cases of serious crime against children, supervisory officers must, from the beginning, take an active role in ensuring that a proper investigation is carried out.
Matched on
terms: child
Inquiry recommendation
61match
LAMI-85 - Develop continuing education models for deliberate harm diagnosis and multi-disciplinary child protection investigations.
The Department of Health should invite the Royal College of Paediatrics and Child Health to develop models of continuing education in the diagnosis and treatment of the deliberate harm of children, and in the multi-disciplinary aspects of a child protection investigation, to support the revalidation of doctors described in the preceding recommendation.
Matched on
terms: child
Inquiry recommendation
61match
LAMI-83 - Systematically and rigorously investigate and manage cases of deliberate harm to children.
The investigation and management of a case of possible deliberate harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease.
Matched on
terms: child
Inquiry recommendation
61match
LAMI-82 - Examine feasibility of clinical governance for children at risk of deliberate harm.
The Department of Health should examine the feasibility of bringing the care of children about whom there are concerns about deliberate harm within the framework of clinical governance.
Matched on
terms: child