Missed Child Safeguarding Referrals
Safeguarding referrals for children sometimes missed, despite mandates and training, putting children at risk.
Source spread
Where this theme appears
This theme appears across 16 independent accountability sources, so the source mix matters as much as the headline total.
67 inquiry recs
51 PFD reports
43 committee recs
20 CQC actions
4 ICIBI recs
27 IOPC recs
1 IMB rec
1 detention investigation rec
157 DHR recs
18 PHSO decisions
1315 LGO/SPSO decisions
7 CJINI reports
1 CQC enforcement action
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(67)— showing 50 strongest matches
164 — Police duty to inform Reporter
Recommendation: In all cases where a police constable has reasonable cause to believe that a child may be in need of compulsory measures of care he should be under a statutory duty to pass that information to the Reporter (18.52).
Unknown
57 — Distinguish CSE risk from actual exploitation
Recommendation: The Department for Education and the Welsh Government must ensure that their updated national guidance makes clear that signs that a child is being sexually exploited must never be treated as indications that a child is only 'at risk' of …
Gov response: 19. We recognise that local and national understanding of child sexual exploitation, including where perpetrated by organised networks, has progressed since the guide for practitioners was published in 2017. We therefore propose accepting these recommendations …
Accepted in part
MAI-60 — Record images of students with weapons
Recommendation: I recommend to all educational establishments and the Department for Education that images of school pupils or college students handling firearms, explosives or other weapons that come to the attention of staff be recorded as a potential indicator of violent …
Gov response: Accepted in full
Accepted
MAI-54 — School records on radicalisation vulnerability
Recommendation: I recommend that the Department for Education consider whether schools should include notes of any significant behavioural problems on the Common Transfer File, or some other suitable new form of record which follows a student if they move school. The …
Gov response: Accepted in full
Accepted
MAI-1 — School-to-college records on radicalisation vulnerability
Recommendation: A clean start should be possible when a student moves from school to college or higher education, such that it would not be appropriate for a general file on significant behavioural problems to follow them at that point. However, there …
Gov response: Accepted in full
Accepted
16 — Awareness for school administrative bodies
Recommendation: The administrative bodies of all schools should be helped to develop an awareness of the problems involved in child sexual abuse and the roles of the various agencies engaged in dealing with it (15.36).
Unknown
15 — Schools to link with Social Work Departments
Recommendation: The discovery of sexual abuse is not the monopoly of any agency. In particular, schools should establish close links with their local Social Work Departments. Teachers should be designated to be trained in the recognition of child sexual abuse and …
Unknown
WATE-(22) — Conduct inter-agency review of child abuse investigation procedures to issue guidance
Recommendation: 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 …
Unknown
WATE-(20) — Expedite disciplinary proceedings for child abuse, independent of police investigations
Recommendation: Any disciplinary proceedings that are necessary following a complaint of abuse to a child should be conducted with the greatest possible expedition and should not automatically await the outcome of parallel investigations by the police or the report on any …
Unknown
WATE-(17) — Require reporting of absconsions to social worker and independent follow-up
Recommendation: It should be a rule of practice that any absconsion should be reported as soon as possible to the absconder's field social worker and that the absconder should be seen on his return by that social worker or by another …
Unknown
WATE-(16) — Advise police on absconders from care homes and social worker consultation
Recommendation: Police officers should be reminded periodically that an absconder from a residential care or foster home may have been motivated to abscond by abuse in the home. They should be advised that, when apprehended, an absconder should be encouraged to …
Unknown
LAMI-99 — Amend Working Together for police to exclusively conduct child criminal investigations.
Recommendation: The Working Together arrangements must be amended to ensure the police carry out completely, and exclusively, any criminal investigation elements in a case of suspected injury or harm to a child, including the evidential interview with a child victim. This …
Unknown
LAMI-98 — Social services must inform police immediately of child criminal offence referrals.
Recommendation: 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.
Unknown
LAMI-97 — Ensure child crime investigation is equal to other serious crime investigations.
Recommendation: 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 …
Unknown
LAMI-96 — Review police protection systems for Children Act compliance and designated inspector officer.
Recommendation: 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 …
Unknown
LAMI-95 — ACPO must produce and implement standards-based child protection service.
Recommendation: The Association of Chief Police Officers must produce and implement the standards-based service, as recommended by Her Majesty’s Inspectorate of Constabulary in the 1999 thematic inspection report, Child Protection.
Unknown
LAMI-94 — Require supervisory officers to actively ensure proper investigation of serious child crimes.
Recommendation: 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.
Unknown
LAMI-93 — Require manager involvement from both agencies in joint child harm investigations.
Recommendation: 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.
Unknown
LAMI-92 — Ensure prompt, efficient investigation of child victim crimes to adult standards.
Recommendation: Chief constables must ensure that crimes involving a child victim are dealt with promptly and efficiently, and to the same standard as equivalent crimes against adults.
Unknown
LAMI-91 — Require child assessment before police protection, except in exceptional circumstances.
Recommendation: Save in exceptional circumstances, no child is to be taken into police protection until he or she has been seen and an assessment of his or her circumstances has been undertaken.
Unknown
LAMI-90 — Ensure child protection training for liaison staff and audit policy compliance.
Recommendation: 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 …
Unknown
LAMI-89 — GPs must ensure staff know local child protection agency contact procedures.
Recommendation: All GPs must devise and maintain procedures to ensure that they, and all members of their practice staff, are aware of whom to contact in the local health agencies, social services and the police in the event of child protection …
Unknown
LAMI-88 — Examine feasibility of deliberate harm training for all primary healthcare staff.
Recommendation: The Department of Health should examine the feasibility of introducing training in the recognition of deliberate harm to children as part of the professional education of all general practice staff and for all those working in primary healthcare services for …
Unknown
LAMI-87 — Ensure GPs receive regular training in deliberate harm recognition and child protection investigations.
Recommendation: 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 …
Unknown
LAMI-86 — Explore extending child patient registration to include social and developmental welfare information.
Recommendation: The Department of Health should invite the Royal College of General Practitioners to explore the feasibility of extending the process of new child patient registration to include gathering information on wider social and developmental issues likely to affect the welfare …
Unknown
LAMI-85 — Develop continuing education models for deliberate harm diagnosis and multi-disciplinary child protection investigations.
Recommendation: 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 …
Unknown
LAMI-84 — Revalidate doctors and paediatricians in deliberate harm diagnosis and multi-disciplinary child protection investigations.
Recommendation: All designated and named doctors in child protection and all consultant paediatricians must be revalidated in the diagnosis and treatment of deliberate harm and in the multi-disciplinary aspects of a child protection investigation.
Unknown
LAMI-83 — Systematically and rigorously investigate and manage cases of deliberate harm to children.
Recommendation: 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.
Unknown
LAMI-82 — Examine feasibility of clinical governance for children at risk of deliberate harm.
Recommendation: 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.
Unknown
LAMI-81 — Implement systems to record, complete, and check actions for deliberate harm cases.
Recommendation: Hospital chief executives must introduce systems to ensure that actions agreed in relation to the care of a child about whom there are concerns of deliberate harm are recorded, carried through and checked for completion.
Unknown
LAMI-80 — Record all discussions, decisions, and actions in hospital notes for deliberate harm.
Recommendation: When a child for whom there are concerns about deliberate harm is admitted to hospital, a record must be made in the hospital notes of all face-to-face discussions (including medical and nursing ‘handover’) and telephone conversations relating to the care …
Unknown
LAMI-79 — Ensure all available information is reviewed during ward rounds for deliberate harm.
Recommendation: During the course of a ward round, when assessing a child about whom there are concerns about deliberate harm, the doctor conducting the ward round should ensure that all available information is reviewed and taken account of before decisions on …
Unknown
LAMI-78 — Implement single set of records for each child across health professionals.
Recommendation: Within a given location, health professionals should work from a single set of records for each child.
Unknown
LAMI-77 — Doctors must provide written statement of deliberate harm concerns to social services.
Recommendation: All doctors involved in the care of a child about whom there are concerns about possible deliberate harm must provide social services with a written statement of the nature and extent of their concerns. If misunderstandings of medical diagnosis occur, …
Unknown
LAMI-76 — Clearly identify responsible consultant for child protection aspects in deliberate harm cases.
Recommendation: When a child is admitted to hospital with concerns about deliberate harm, a clear decision must be taken as to which consultant is to be responsible for the child protection aspects of the child’s care. The identity of that consultant …
Unknown
LAMI-75 — Require senior doctor to seek carer permission for deliberate harm investigation or treatment.
Recommendation: In a case of possible deliberate harm to a child in hospital, when permission is required from the child’s carer for the investigation of such possible deliberate harm, or for the treatment of a child’s injuries, the permission must be …
Unknown
LAMI-74 — Mandate full, documented physical examination within 24 hours for suspected deliberate harm.
Recommendation: Any child admitted to hospital about whom there are concerns about deliberate harm must receive a full and fully-documented physical examination within 24 hours of their admission, except when doing so would, in the opinion of the examining doctor, compromise …
Unknown
LAMI-73 — Require inquiry and review of previous hospital admissions for suspected deliberate harm.
Recommendation: When a child is admitted to hospital and deliberate harm is suspected, the doctor or nurse admitting the child must inquire about previous admissions to hospital. In the event of a positive response, information concerning the previous admissions must be …
Unknown
LAMI-72 — Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Recommendation: No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been …
Unknown
LAMI-71 — Require documented future care plan for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. …
Unknown
LAMI-70 — Require consultant or paediatrician permission for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without the permission of either the consultant in charge of the child’s care or of a paediatrician …
Unknown
LAMI-69 — Record all discussions, including phone calls, in child deliberate harm case notes.
Recommendation: When concerns about the deliberate harm of a child have been raised, a record must be kept in the case notes of all discussions about the child, including telephone conversations. When doctors and nurses are working in circumstances in which …
Unknown
LAMI-68 — Doctors must make comprehensive, contemporaneous notes for suspected child deliberate harm.
Recommendation: When concerns about the deliberate harm of a child have been raised, doctors must ensure that comprehensive and contemporaneous notes are made of these concerns. If doctors are unable to make their own notes, they must be clear about what …
Unknown
LAMI-67 — Require recorded discussion and further opinion for differing deliberate harm diagnoses.
Recommendation: When differences of medical opinion occur in relation to the diagnosis of possible deliberate harm to a child, a recorded discussion must take place between the persons holding the different views. When the deliberate harm of a child has been …
Unknown
LAMI-66 — Ensure all deliberate harm concerns are fully addressed and documented in appraisals.
Recommendation: When a child has been examined by a doctor, and concerns about deliberate harm have been raised, no subsequent appraisal of these concerns should be considered complete until each of the concerns has been fully addressed, accounted for and documented.
Unknown
LAMI-65 — Doctors must take child's history directly for suspected harm, recording consent reasons.
Recommendation: When the deliberate harm of a child is identified as a possibility, the examining doctor should consider whether taking a history directly from the child is in that child’s best interests. When that is so, the history should be taken …
Unknown
LAMI-63 — Hospital social workers must promptly respond to suspected child harm referrals
Recommendation: 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 …
Unknown
FR-13 — Mandatory Reporting
Recommendation: 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 …
Gov response: We accept the need for mandatory reporting; the Government has agreed to implement a mandatory reporting regime for child sexual abuse which will be informed by a full public consultation, beginning with the publication of …
Accepted in part
FR-1 — Single Core Data Set
Recommendation: The Inquiry recommends that the UK government and the Welsh Government improve data collected by children's social care and criminal justice agencies concerning child sexual abuse and child sexual exploitation by the introduction of one single core data set covering …
Gov response: We accept that robust data collection on the scale and nature of child sexual abuse is critical to underpin and drive a more effective response to child sexual abuse. We have made a number of …
Accepted in part
SP66 — Guidance for parents of children found with weapons
Recommendation: The Youth Justice Board should ensure that a form of clear practical written guidance is drafted which relevant professionals (social care, healthcare, police, education) can provide to parents of children who have been found with a knife or offensive weapon, …
Gov response: The Ministry of Justice agrees with the Chair that is important that youth justice services can hold young offenders to sufficient standards and boundaries in referral orders, and that interventions are focussed and appropriate. The …
Accepted
Prevention of Future Deaths reports(51)— showing 50 strongest matches
Andrew Cairns, Rachael Slack and Auden Slack
Concerns: The coroner noted a lack of reciprocal information sharing between the Police and Mental Health Team regarding an individual's arrest and prior mental health assessment. An existing policy for mutual information sharing was not disclosed during the inquest, preventing witness questioning on it.
Overdue
Lauren Barfoot
Concerns: The coroner identified gaps in recording Lauren's contact information and sharing high-risk details (solvent abuse, sexual exploitation vulnerability) with the Missing Person's Unit, which hindered an effective search and delayed a multi-agency strategy meeting.
Response (Bexley Borough Council): • Bexley Children's Social Care implemented a process to send a proforma document to residential providers to ensure comprehensive contact lists for young people are maintained and returned centrally. • … (AI summary)
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) enclosed a report detailing actions taken to address information sharing and risk assessment. • The MPS stated that its broader response to the serious … (AI summary)
Response (Ethelbert Childrens Services): • The organisation implemented steps to address concerns regarding the collation and sharing of information for child risk assessment and contact details. • A missing persons reporting form is completed … (AI summary)
Response (Ethelbert Childrens Services1): • The organisation stated it had implemented steps to address concerns regarding the collation and sharing of information, child risk assessment, and contact details. • It confirmed the use of … (AI summary)
Responded
Alex Kelly
Concerns: The coroner identified concerns regarding the absence of forensic psychiatric assessments for vulnerable children entering custody, deficiencies in the ACCT process regarding external agency input and interpretation of distress, and issues with social worker allocation and documentation practices.
Response (Tower Hamlets): • The council confirmed that systems are in place to ensure all looked after children have an allocated social worker, including monthly reporting and an escalation policy for Independent Reviewing … (AI summary)
Response (Central North West London NHS Trust): • The Trust's new service has improved partnership working and information exchange among professionals. • Healthcare staff are required to share knowledge of medication non-compliance and have completed information governance … (AI summary)
Response (Oxleas NHS Trust): • The Trust confirmed that every child arriving at Cookham Wood is assessed using a Comprehensive Health Assessment Tool (CHAT), with staff trained in its use and monitoring standards implemented. … (AI summary)
Response (Ministry of Justice): • The Comprehensive Health Assessment Tool (CHAT) has been rolled out across the Young People's Estate for new admissions, with staff trained and standards in place for its use. • … (AI summary)
Responded
Bradley Griffiths
Concerns: Concerns were raised regarding the process for tracking and transferring a child's health records when a parent moves without providing new contact or GP details, leading to records being placed in 'No Trace storage'.
Response (Coventry and Warwickshire NHS Trust): • The Trust confirmed it had implemented robust arrangements for managing 'Transferred Out of Area' records. • These arrangements included a 'No Trace' process/checklist with a three-month follow-up review and … (AI summary)
Overdue
Kesia Leatherbarrow
Concerns: Incomplete information transfer between children's services meant a high-risk referral was not fully assessed or led to a CAMHS appointment. A Youth Offending Team case was also not transferred after a change of address, preventing a timely referral order assessment.
Response (Department of Health): • The Department of Health shared the coroner's report with NHS England. • The Children and Young People's Mental Health Taskforce published 'Future in Mind', which sets out a national … (AI summary)
Response (Home Office): • The Government partially amended the Police and Criminal Evidence Act (PACE) to treat 17-year-olds as children for detention after charge, requiring transfer to local authority accommodation. • The Government … (AI summary)
Response (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)
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)
Overdue
Solomon Bealey
Concerns: Concerns were raised regarding the lack of follow-up action after a nurse identified signs of stress in a child and arranged for a doctor to see him. The matter was not pursued further when letters sent to the child's mother received no reply.
Response: • The practice has read-coded existing Mental Health Care Plans to trigger patient status alerts and is developing a template for new plans. • For patients identified as a significant … (AI summary)
Responded
Harry Mellor
Concerns: 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.
Response (Department of Health): • The Minister stated an intention to ask the Department of Health and NHS England to review current NHS processes to reduce the possibility of similar incidents. (AI summary)
Response (UK Health Security Agency): • The UK Health Security Agency alerted the relevant NHS England team and the Director of Public Health for Nottinghamshire. • The agency noted that the Nottinghamshire Safeguarding Board had … (AI summary)
Response (GMC): • The GMC discussed the safeguarding concerns with the Royal College of General Practitioners (RCGP). • The GMC reported that work is ongoing to improve clinical guidance for doctors regarding … (AI summary)
Response (CCG): • The CCG has requested assurance from specialist paediatric services regarding the effective implementation of 'Did Not Attend' (DNA) procedures. • The CCG will appoint an independent author to undertake … (AI summary)
Overdue
Amelia Calvo
Concerns: The coroner identified a lack of a nationally accepted guideline for airway assessment grading in neonatal practice and noted that neonatologists lacked clear criteria for identifying and communicating a potentially difficult airway to anaesthetists.
Response (Central Manchester University Hospitals NHS Trust): • The Trust implemented a revised Team Brief process across all RMCH Theatres, including an Introductions Board and a policy requiring the Operating Surgeon's presence before patient transfer. • The … (AI summary)
Overdue
Karnel Haughton
Concerns: Concerns were raised about the open accessibility of uncensored online videos depicting dangerous 'choking game' activities without warnings. The coroner also identified a lack of national guidance for schools and youth groups, and no dedicated support for parents regarding these online challenges.
Overdue
Carol Leesley
Concerns: A safeguarding referral made by a GP was not acted upon despite automated acknowledgment, and it was unclear if this was due to human or IT error.
Response (Sheffield City Council): • The automated email response was amended to include a notification for referrers to contact the team if they do not receive a response within two working days. • All … (AI summary)
Responded
Rachal Murphy
Concerns: No specific concerns were detailed in the provided text for this report.
Response: • Tameside Early Help Services implemented measures that reduced case allocation delays and established ongoing monitoring. • Pennine Care NHS Foundation Trust and NHS Tameside and Glossop Integrated Care NHS … (AI summary)
Response (Grosvenor Medical Centre): • The Practice searched its patient list for individuals prescribed sodium valproate and invited those without recent LFTs for a blood test. • An alert system was implemented in patient … (AI summary)
Overdue
Chadrack Mulo
Concerns: The coroner identified that the school had insufficient emergency contact information, delayed acting on unexplained non-attendance for several days, and lacked a protocol for immediate police contact when welfare checks at home were unsuccessful.
Response (Department for Education): • The Department committed to updating 'Keeping Children Safe in Education' and 'School Attendance' guidance to recommend schools hold more than one contact number. • The Department stated it would … (AI summary)
Responded
Terry Latimer
Concerns: 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.
Overdue
Sofia Legg
Concerns: Concerns were raised regarding Sofia's initial rejection for CAMHS referral and a significant delay in accessing CBT. The care co-ordinator did not obtain urgent psychiatric input as per guidance, and Sofia's care plan lacked sufficient detail to safeguard her.
Response (Somerset Safeguarding Children Board): • The Somerset Safeguarding Children Board stated it would commission a thematic learning review. • The review aims to establish whether specific issues need to be addressed by organisations in … (AI summary)
Response (Somerset NHS CCG): • The Somerset CCG has implemented a single point of access for CAMHS and established an enhanced outreach service. • Additional funding was invested to improve CBT access, and new … (AI summary)
Response (Somerset County Council): • The multi-agency Child Death Overview Panel (CDOP) considered the circumstances of the death and made recommendations. • Recommendations include clearer communication of crisis plans to parents, earlier liaison with … (AI summary)
Response (Somerset NHS Trust): • The Trust introduced a Single Point of Access for CAMHS referrals and reduced waiting times for specialist therapies. • New services, including an Enhanced Outreach Team and psychiatric liaison … (AI summary)
Responded
Ellie Butler
Concerns: The provided text indicates that specific concerns were appended to the report but does not detail them.
Overdue
Edward Joyce
Concerns: 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.
Response (Chelsea and Westminster Hospital NHS Trust): • The Trust has alerted the Paediatric Burns Network to the coroner's advice. (AI summary)
Overdue
Janie McFadyen
Concerns: The coroner identified a lack of clear protocols for managing missing persons, particularly high-risk individuals, and insufficient arrangements for seeking help from NHS services. Concerns were also raised about placing reporting responsibility on family and the need for updated staff training.
Response (Victory Outreach): • Victory Outreach Manchester reviewed and updated its protocols, policies, and procedures, including new policies for safeguarding, missing persons, and incident reporting. • Resident files were updated to include comprehensive … (AI summary)
Response (Charity Commission): • The Charity confirmed that communication gaps have been closed and the system for informing trustees is functioning properly. • The Charity provided copies of revised policies, including review dates. … (AI summary)
Responded
Caspian Thorn
Concerns: The coroner noted gaps in communication between midwifery and social worker teams, exacerbated by staff shortages, impacting fetal monitoring. Concerns also included undocumented triage calls, unrecorded decision-making, and delayed identification of sepsis.
Overdue
Archie Spriggs
Concerns: The coroner noted concerns regarding the clarity and auditing of referral pathways to children's social care, and the understanding of professionals making urgent referrals. There were also gaps in multi-agency knowledge concerning private law proceedings and features of filicide cases.
Response (SSP): • The Shropshire Safeguarding Partnership (SSP) stated it is responsible for owning and governing delivery against the action plan derived from the Serious Case Review. • The SSP confirmed it … (AI summary)
Overdue
Shneur Kaye
Concerns: 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.
Response (North Manchester Care Organisation): • The Trust ratified a new safeguarding training strategy and policy in November 2019. • Safeguarding children and adults training is now a mandatory course for all new staff on … (AI summary)
Response (Bury Council): • Bury’s Multi Agency Safeguarding Hub (MASH) underwent a systematic service review in early 2022, which examined practice, operating principles, and standards. • It is now standard practice within the … (AI summary)
Responded
Avis Addison
Concerns: The coroner raised concerns regarding CQC inspections of GP practices, suggesting checks for domestic violence and safeguarding policies, staff training, and 'early warning systems' for uncollected prescriptions or cancelled appointments.
Response (CQC): • The CQC conducted an inspection of the GP practice in March 2019, finding no concerns regarding policies, training, or systems for vulnerable patients. • Following the Regulation 28 notice, … (AI summary)
Responded
Xuanze Piao
Concerns: The university did not hold a face-to-face meeting with a student under 18 or contact their guardian/parents before emailing about potential course removal, and lacked a clear policy for these actions.
Response (Coventry University): • The university has implemented an additional process for international students under 18 who are at risk of course withdrawal, which includes a face-to-face welfare meeting to assess concerns and … (AI summary)
Responded
Roy Curtis
Concerns: The coroner noted that the procedure for urgent adult social care assessments is overly bureaucratic and these referrals are not given sufficient priority within social services.
Response (Milton Keynes Council): • The Adult Social Care Practice Guidance was updated to include procedures for managing situations where contact with a person referred for assessment has not been possible. • A link … (AI summary)
Responded
Chelsie Greatorex
Concerns: The coroner noted that the investigation into a sexual assault allegation was not conducted by a specialist officer despite the complainant being a child, leading to significant delays. Concerns were also raised about the Metropolitan Police Service's support, which involved a four-day delay in initial contact and minimal assistance.
Response (Home Office): • The Home Office stated it is conducting a review of the criminal justice response to rape, which considers victim support, specialist officers, and investigation delays. • The government indicated … (AI summary)
Response (MPS Redaction): • The MPS has made improvements to the supervision and team structures of response teams, including establishing a Response Support Team on the North East Basic Command Unit. • A … (AI summary)
Responded
Christopher Smith
Concerns: 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.
Overdue
Lily-Mai George
Concerns: 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.
Overdue
Samantha Gould and Christine Gould
Concerns: The coroner noted a lack of follow-up between police and clinicians or parents regarding young victims with mental ill health to keep open the option of providing an evidential account. There was also no guidance for police on communicating with such victims who are initially unwilling to provide a statement.
Response (National Police Chiefs' Council): • The National Police Chiefs' Council (NPCC) agreed an immediate addition to the Authorised Professional Practice (APP) to provide guidance for investigating officers on communicating with reluctant victims/witnesses. • The … (AI summary)
Response (Cambridgeshire and Peterborough NHS Foundation Trust): • The CCG has commissioned an expanded First Response Service, including a dedicated CAMHS crisis team and a CAMHS home treatment team, with recruitment ongoing. • The Trust is reviewing … (AI summary)
Response (Cambridgeshire County Council): • The Council launched the 'Strong Families Strong Communities' strategy and the 'YOUnited' Partnership to integrate mental and emotional health services for children and young people. • New policies and … (AI summary)
Responded
Marc Bennett
Concerns: The coroner highlighted the need for improved communication between Devon Partnership Trust staff and Children's Services to ensure appropriate support for parents with mental health problems during child protection investigations or care proceedings planning.
Overdue
Joan Prescott
Concerns: 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.
Overdue
Harper Denton
Concerns: 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.
Response (National Police Chiefs Council): • The College of Policing will update its Authorised Professional Practice (APP) within three months to clarify that information disclosure can be made to parents and carers of children who … (AI summary)
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) stated it uses existing mechanisms, including Category 3 Multi-Agency Public Protection Arrangements (MAPPA) and Violent Offender Orders, for managing violent offenders. • The MPS … (AI summary)
Response (Home Office): • HM Government is continuing to consider options for better management of domestic abuse offenders, including the implementation of a domestic abuse register. • The Home Office stated it would … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care is updating resources for health visitor and school nurse-led services, which are due to be published shortly. • A cross-Government programme of … (AI summary)
Responded
Melsadie Parris
Concerns: The social work team did not conduct renewed home visits, seek updated information from the family, or liaise with mental health services after receiving new information about a carer's mental health. This led to undue reliance on old investigations and assessments, potentially missing critical details of the carer's illness.
Response (Buckinghamshire Council): • Buckinghamshire Council accepted the Assistant Coroner’s view that best practice in employing policies was not followed when the file was closed. • The council stated that staff will be … (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
Sylvia Pollitt
Concerns: The Housing Association lacked a system to ensure escalation of non-contact cases from their subcontractor Liberty, and no audit system to monitor referral outcomes or identify frequent non-escalation issues.
Response (LQ): • The organisation reviewed all gas repair requests previously closed by its subcontractor without escalation and identified no similar issues. • It implemented new processes to ensure all repair calls … (AI summary)
Responded
Nicholas Stout
Concerns: 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.
Response (Tees Esk & Wear Valley NHS Foundation Trust): • The Trust implemented an escalation procedure to ensure crisis assessments are not delayed and introduced weekly reporting to monitor urgent referrals. • Development work was undertaken to embed the … (AI summary)
Response (Tees Esk & Wear Valley NHS Foundation Trust): • The Trust introduced an escalation procedure for potential assessment delays and implemented a new Caseload Management Supervision Policy in January 2023. • Development work was undertaken to embed the … (AI summary)
Responded
Jacqueline Carrey
Concerns: The coroner identified a lack of clear indication on the patient's medical record regarding potential medication abuse risk, which was not flagged to staff before discharge. This raises concerns about the hospital's procedures for managing medication and patient records.
Response (Milton Keynes University Hospital NHS Foundation Trust): • The Trust used Mrs Carrey's case for awareness raising and education within the pharmacy team. • The Electronic Health Record (EHR) was reviewed, and new measures were incorporated to … (AI summary)
Responded
Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent
Concerns: 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.
Response (Derbyshire Healthcare NHS Foundation Trust): • Phoenix Futures will use a Probation Feedback Form to report attendance by individuals open to probation within 48 hours of attended appointments and 24 hours of failed appointments. • … (AI summary)
Response (HM Prison and Probation Service): • New guidance for recording closed cases and handling sensitive information will be issued by April 2024, and a new assessment service is being developed for rollout by 2026. • … (AI summary)
Response (Capita): • Capita reinforced safeguarding requirements for field operatives through briefings and a new e-learning module. • Additional safeguarding training was provided to Duty Shift Managers responsible for incident reporting. • … (AI summary)
Overdue
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
Karen Thomason
Concerns: Concerns include errors in completing safeguarding forms, a failure to notify housing staff of a vulnerable patient's discharge despite requests, and an incorrect conflation of patient capacity with a lack of vulnerability.
Response (North Cumbria Integrated Care NHS Foundation Trust): • The Trust will modify the electronic Emergency Department system's safeguarding question to differentiate between new and existing concerns. • The Trust will update the electronic Emergency Department system to … (AI summary)
Responded
Christopher Vickers
Concerns: 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.
Response (Cumbria Northumberland Tyne and Wear NHS Foundation Trust): • The Trust implemented changes to Multi-Disciplinary Team (MDT) processes, making safeguarding and multi-agency meetings standing agenda items in relevant teams. • A new weekly telephone triage review process was … (AI summary)
Response (South Tyneside Council): • South Tyneside Council established several new multi-agency meetings and groups to enhance coordination and oversight for individuals with complex needs and high risks. • The council launched new Safeguarding … (AI summary)
Responded
Jacob Shorter
Concerns: Information about previous suicidal ideation was not shared from the Independent Visitor to the foster carer, and Calderdale Council could not provide details on training or escalation procedures for mental health disclosures.
Response (Calderdale Council): • The Independent Visitor volunteer reported Jacob's disclosure regarding past suicidal ideation to the Independent Visitor team, who then relayed this information to the Pathways Team. • The Council provides … (AI summary)
Responded
Lee-Ann Ince
Concerns: Agencies had a limited understanding of how coercive and controlling behaviours impact mental health, did not effectively listen to children's concerns, and failed to recognise the victim's additional vulnerability due to physical health and dependency on the perpetrator.
Response (Greater Manchester Integrated Care): • Partners in Trafford agreed to file a joint response to the Regulation 28 report. • A working group was convened, including colleagues from Health, Adult Social Care, Children’s Services, … (AI summary)
Response (Greater Manchester Integrated Care): • The organisation stated it would develop and commission specialist training for practitioners to enhance understanding of coercive control dynamics, with training to commence in September 2024. • It committed … (AI summary)
Responded
Henry Grierson
Concerns: The coroner noted a lack of maintained communication between Huddersfield New College and mental health support organisations (CAMHS, Recovery Steps) regarding Mr Grierson's mental health status and decisions to cease external support.
Response (Huddersfield New College): • The College met with representatives of the Department for Education to discuss challenges regarding multi-agency communication. • The College reviewed and amended relevant policies and processes for contacting external … (AI summary)
Overdue
Mazeedat Adeoye
Concerns: The London Borough of Newham's social work and NRPF teams exhibited unprofessional behaviour, poor management, inadequate supervision, and insufficient record-keeping, risking sub-optimal care. The National Police Air Service also discounted a relevant heat signature during a search.
Response (Department of Health and Social Care): • The Department of Health and Social Care stated that the Department of Education has oversight for child social care. • The Department of Health and Social Care suggested the … (AI summary)
Response (Social Work England): • Social Work England contacted London Borough of Newham to obtain details of involved social workers and information on any ongoing employer investigations. • Fitness to practise cases were opened … (AI summary)
Response (National Police Air Service): • The National Police Air Service stated it would review its training and operational practices. • The footage from the incident would be utilised as a case study and training … (AI summary)
Response (Newham Council): • The council introduced a Quality Assurance process with monthly audits and specific investigations into NRPF staff practices. • Mandatory training on family shared decision-making, trauma-informed practice, and 'Language That … (AI summary)
Responded
Janet Scott
Concerns: 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.
Response (Northumberland Childrens and Adults Safeguarding Partnership): • The partnership launched an updated Self-neglect Policy and adopted nine Principles of Engagement in 2024, supported by multi-agency training. • A Multi-agency Risk Management Framework will be introduced within … (AI summary)
Responded
Alexander Eastwood
Concerns: 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.
Response (Department For Culture Media And Sport): • The Department for Culture, Media and Sport has tasked its Department with exploring ways to urgently improve the safety and welfare of children in martial arts. • Sport England … (AI summary)
Responded
Ella Murray
Concerns: 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.
Response (NHS England): • NHS England noted the 2024-25 Children’s Wellbeing and School’s Bill will strengthen multi-agency safeguarding arrangements and information sharing. • The NHS England South East regional safeguarding team will oversee … (AI summary)
Response (Department of Health and Social Care): • The Government's Families First Partnership programme is delivering the national rollout of reforms, including multi-agency child protection teams. • The Department for Education's Children's Wellbeing and Schools Bill, currently … (AI summary)
Response (Kent and Medway Integrated Care Board): • North East London Foundation Trust (NELFT) agreed to formulate a child-focused safety plan to be shared with the child’s school and social worker, if identified. • NELFT agreed to … (AI summary)
Responded
Evelyn Rae Le Masurier-O’Sullivan
Concerns: The coroner identifies a training gap where temporary agency staff do not receive in-house training on eliciting parental concerns about a baby's wellbeing during postnatal contacts. This impacts opportunities for neonatal assessment and escalation.
Response (NHS England): • NHS England reported that Croydon Health Services NHS Trust plans to issue a key message to all staff regarding NICE sepsis management guidelines. • NHS England reported that Croydon … (AI summary)
Overdue
Isla McVeigh
Response (North Cumbria Integrated Care NHS Foundation Trust): The Trust accepts the concerns and has developed an action plan. This includes mandatory briefings and simulation-based training on opioid dependency and safeguarding, review of clinical guidance, enhanced safeguarding supervision, … (AI summary)
Response (Cumberland Council): Cumberland Council and the Safeguarding Children Partnership will review multi-agency threshold guidance and associated arrangements, including referral and escalation processes, between October 2026 and January 2027. They will also undertake … (AI summary)
Responded
Natasha Hill
Concerns: 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.
Response (Home Office): • The Home Office is working to create a consistent, victim-centred response to child sexual exploitation, including establishing Operation Beaconport and providing funding to the CSE Taskforce and TOEX Programme. … (AI summary)
Response (Department for Education): • The Department for Health and Social Care published a briefing in 2021 on transitional safeguarding within adult social work. • An 11-month project was launched in March 2026 to … (AI summary)
Response (National Police Chiefs Council): • The National Police Chiefs Council (NPCC) stated that national partners continue to advance policy and practice in transitional safeguarding to support greater continuity of protection and risk management through … (AI summary)
Response (National Police Chiefs' Council): • The National Police Chiefs' Council (NPCC) undertook an urgent review of the Child Abuse Authorised Professional Practice (APP) currently out for consultation. • The NPCC identified a gap in … (AI summary)
Responded
Ollie Lee
Concerns: The coroner identified poor communication and engagement between agencies involved with Ollie, specifically noting a lack of record-keeping for discussions and that Ollie's pronoun preference was not acted upon.
Response (Barnsley Metropolitan Borough Council): • Barnsley Metropolitan Borough Council strengthened multi-agency working, including introducing named link workers for schools and developing a more integrated approach to communication with CAMHS, supported by updated practice standards … (AI summary)
Response (Barnsley Metroplitan Borough Council): • Barnsley Metropolitan Borough Council has strengthened multi-agency working, introducing named link workers for schools and clarifying pathways between Early Help and CAMHS. • Staff have undertaken training in multi-agency … (AI summary)
Response (Barnsley Community Academy): • The academy completed professional development training for safeguarding colleagues on multi-agency information sharing and formalised its Safeguarding Quality Assurance and Supervision process guidance to include routine audits of multi-agency … (AI summary)
Response (South West Yorkshire Partnership NHS Trust): • The Trust completed a case note review and a Patient Safety Improvement Plan, addressing identified learning areas. • Crisis guidance for schools was developed, and training on multi-agency information … (AI summary)
Responded
Select committee recommendations(43)
#38 —
Recommendation: 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. …
Response status not verified
#106 —
Recommendation: Sarah Dineley, Deputy Chief Crown Prosecutor at the CPS, stated: “[i]t is vital that, wherever possible, victims of trafficking are identified before any decisions are made on charge and prosecution; this is particularly important where the suspect is a child …
Response attribution not verified
#24 —
Recommendation: The Government must keep under review the efficacy of the mandatory reporting duty once it is in place, with a view to expanding its scope if necessary. The Government should also reconsider the consequence of failing to comply with the …
Response attribution not verified
#23 —
Recommendation: We welcome the introduction of mandatory reporting of child sexual abuse, which represents an important step forward for protection of children’s human rights. However, we are concerned that the scope of the duty and particularly the consequences of breach may …
Response attribution not verified
#12 —
Recommendation: 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 …
Response attribution not verified
#24 —
Recommendation: HMCI Amanda Spielman told us it was “very un-joined up” that children who were on a child protection plan and experiencing harm could be withdrawn into home education. We share HMCI’s concerns and call on the Department to ensure that …
Response attribution not verified
#31 — Significant failings in age assessment lead to children in adult asylum accommodation
Recommendation: There are significant failings in the current processes for making initial decisions about age and unreliable decisions are still leading to children being incorrectly placed in adult accommodation. We do not have confidence that the arrangements for accommodation providers to …
Response attribution not verified
#14 —
Recommendation: The Home Office and the police should be added to the list of public bodies subject to the statutory ‘duty to refer’ and included in the forthcoming proposals for a ‘duty to collaborate’. (Recommendation, Paragraph 75)
Response status not verified
#11 —
Recommendation: 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, …
Response attribution not verified
#20 —
Recommendation: The Department must revisit and revise key statutory guidance such as Working Together to Safeguard Children as soon as possible, so that they explicitly contain EHE within their scope, and contain clear and consistent messages for families, local authorities and …
Response attribution not verified
#3 —
Recommendation: The Committee heard from home educators that home-educated children are not ‘invisible’, and that safeguarding has failed children who were already known to local authorities. However, the relevant authorities cannot begin to reach any children who may be at risk …
Response attribution not verified
#2 —
Recommendation: 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 …
Response attribution not verified
#13 —
Recommendation: We asked the Department for Education what is being done to review multi-agency safeguarding partnerships to ensure they work better and to stop horrific events, such as the cases of Star Hobson and Arthur Labinjo-Hughes from recurring. The Department for …
Response attribution not verified
#59 —
Recommendation: 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 …
Response attribution not verified
#58 —
Recommendation: For far too long, some private providers have extracted significant profits from the public purse, operating under a monopoly market. At the same time, they have not demonstrated equivalent value for taxpayer money in terms of improved outcomes for the …
Response attribution not verified
#57 —
Recommendation: The Department must set out their response to the £2 billion expenditure proposed by The independent review of children’s social care, indicating how much additional funding they believe is necessary to ensure the care system is fit for purpose, how …
Response attribution not verified
#56 —
Recommendation: Local authorities must tackle the imbalance between the 48% reduction in early intervention spending, and the 34% rise in spending on costlier downstream interventions over the last decade. Local authorities cannot simply achieve this by reshuffling spending priorities and reducing …
Response attribution not verified
#55 —
Recommendation: A record 80,850 children are in care. Early intervention is key to tackling the needs of vulnerable families and children before they escalate. The record rise of children in care cannot be disconnected from the 48% reduction in early intervention …
Response attribution not verified
#45 —
Recommendation: The Government must also increase its investment in SEND provision to ensure that children in care, alongside all pupils with SEND, get the support they need to thrive in education. Children in care are more likely to have experienced educational …
Response attribution not verified
#44 —
Recommendation: The Government’s 2022 SEND Green Paper sets out proposals for a more inclusive education system with enhanced mainstream provision for learners with special educational needs. As these reforms are taken forward, the Government must set out its plan to ensure …
Response attribution not verified
#43 —
Recommendation: All looked-after children must have an independent advocate whose function is to champion their best interests, ensuring they are admitted to the best, most appropriate schools, and that they are fully supported to appeal to SEND tribunals where their Education, …
Response attribution not verified
#42 —
Recommendation: Over 90% of SEND tribunal decisions are made in favour of the parent and child. But where a child with SEND lives in residential care, and does not have a school place or Education, Health and Care plan that meets …
Response attribution not verified
#40 —
Recommendation: The Department must ensure looked-after children are quickly able to access vital mental health support services in a timely way despite being placed out-of-area or moved around. The child must not be disadvantaged in terms of waiting times if they …
Response attribution not verified
#39 —
Recommendation: The Department must take overall responsibility for monitoring the register of children not in school, and must set out clear and robust accountability for local authorities who fail to secure full-time places at good or outstanding DfE registered schools for …
Response attribution not verified
#38 —
Recommendation: The Department has set out a new legal requirement for local authorities to maintain registers of children not in school. The Department must issue clear guidance to local authorities on the definition of a child missing education, to ensure that …
Response attribution not verified
#37 —
Recommendation: The Department must make it a priority to collect and publish national data on how often school places are not being provided within the statutory 20 school days timeframe for looked-after children under an emergency care order. The lack of …
Response attribution not verified
#36 —
Recommendation: Current national-level data is not available to illustrate the scale of gaps in education for looked-after children. It should be a priority for the Department to ensure this data is collected and published, so that responsible parties can be held …
Response attribution not verified
#35 —
Recommendation: Where this is in the child’s best interest, every looked-after child should be cared for in a local care placement, receiving their education at a good or outstanding local school. The Department must take greater responsibility for overseeing the placements …
Response attribution not verified
#34 —
Recommendation: 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 …
Response attribution not verified
#33 —
Recommendation: The Department must aim towards banning unregulated provision for looked-after children once it has addressed placement sufficiency issues using the mechanisms outlined by The independent review of children’s social care. In the meantime, while these reforms are being undertaken, the …
Response attribution not verified
#32 —
Recommendation: The Department has banned unregulated accommodation for children under 16. We hold deep concerns that children aged 16 and 17 can still be placed in unsafe, unsuitable accommodation without care or oversight. No looked-after child should be living in a …
Response attribution not verified
#31 —
Recommendation: Before the start of the next academic year—at the very latest—the Department should issue robust guidance on how the section 19 duty on local authorities to provide children with a suitable full-time education should be fulfilled by local authorities. Where …
Response attribution not verified
#30 —
Recommendation: Section 19 of the Education Act 1996 places a duty on local authorities to provide children with suitable full-time education. However, there is no Departmental guidance outlining how this responsibility should be implemented, and no clear consequences for non-compliance. Given …
Response attribution not verified
#29 —
Recommendation: As part of the proposed register of children not in school, the Department must set out how it will collect and publish data on how many looked-after children are falling through the gaps by missing education or being ‘educated’ in …
Response attribution not verified
#28 —
Recommendation: The 2022 Schools Bill sets out a new duty for local authorities to maintain a register of children not in school. Alongside this, the Department must issue guidance to clearly outline how it will hold Directors of Children’s Services to …
Response attribution not verified
#5 —
Recommendation: It is welcome that the Department has announced a further year of funding for the extension of Virtual School Head duties to include all children with a social worker. Children with a social worker face significant barriers to education, but …
Response attribution not verified
#4 —
Recommendation: The Department must urgently tackle the black hole of data on the educational outcomes of children in children’s homes. It must commit to annual data publication through a data dashboard on outcomes for looked-after children which is disaggregated by care …
Response attribution not verified
#3 —
Recommendation: The Department’s data on the educational outcomes of children in care does not distinguish between placement type. Existing data is not good enough, it does not provide the visibility into the education of children in care that we would expect …
Response attribution not verified
#16 —
Recommendation: The national Child Safeguarding Practice Review Panel, set up to commission reviews of serious child safeguarding cases, has consistently highlighted cases in which poor coordination between services, including insufficient joined-up leadership and a lack of appropriate and timely information-sharing around …
Response attribution not verified
#4 —
Recommendation: It is not clear how lessons and learning from changing threats, serious case reviews and child safeguarding review panels are embedded in day-to-day practice. Time and again reviews into child deaths highlight poor coordination between services, including insufficient joined-up leadership …
Response attribution not verified
#102 — Consider every child missing from home or care as a potential victim of trafficking.
Recommendation: Every child who goes missing from home or care should be considered as a potential victim of trafficking, even if they are subsequently found safe.
Response attribution not verified
#3 — Add honour-based abuse options to children's social care assessment census categories
Recommendation: The Department of Health and Social Care and the Department of Education should add options for honour-based abuse to both the ‘primary need at first social work assessment’ and ‘factors identified at the end of the assessment’ categories in the …
Response attribution not verified
#4 — Accredit and monitor online STI test providers, and outline child safeguarding for online risks.
Recommendation: 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 …
Gov response: Partially accept The government partially accepts this recommendation. We are committed to ensuring high quality, safe–to–use STI testing and as such, self–test online diagnostic STI tests that meet the definition of a medical device or …
Accepted in Part
CQC inspection actions(20)
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.
Must Do
Sheffield Children's Hospital
Follow up two week referrals to the Children and Young People's Independent Sexual Violence Advisors. (ChISVAs).
Should Do
Baldock - The Rowans
Safeguarding were either not identified or notified to the appropriate organisations. This placed people at risk of harm. This was a breach of regulation 13 (safeguarding) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Archers Point Residential Home
Safeguarding notifications were not always sent to the local authority or CQC as required.
Must Do
Psychiatry-UK LLP
The service must ensure known safeguarding risks are followed up and/or acted upon when patients disengage and cannot be contacted.
Must Do
Hey Baby 4D Halifax
The service should record all safeguarding referrals in the safeguarding log, in accordance with local policy.
Should Do
Hey Baby 4D Halifax
The service must implement effective systems and processes to mitigate the risk of women under the age of 18 receiving regulated activities.
Must Do
Pilgrim Hospital
The service must ensure systems and processes to check nationally approved child protection information sharing systems are fully embedded and compliance is monitored.
Must Do
Pilgrim Hospital
The trust must ensure systems and processes to check nationally approved child protection information sharing systems are fully embedded and compliance is monitored.
Must Do
Medway Maritime Hospital
The service should ensure, in line with trust policy, all indicated staff are trained to adult safeguarding level 3 and that staff are aware of how they can assess young women and birthing people at risk of child sexual exploitation.
Should Do
Kettering General Hospital
The servicemust ensure staff consistently complete safeguarding documentation in the emergency department and make external safeguarding referrals in a timely manner in line with trust policy.
Must Do
School Health
The service should ensure that there are robust arrangements in place to mitigate any risks associated with staff non-attendance at any child protection case conferences and reviews.
Should Do
Linden Road Surgery
Identify and support young carers (those under 18 years of age).
Should Do
Hey Baby 4D Halifax
The service should consider further ways of signposting service users to safeguarding help and advocacy.
Should Do
Block Lane Surgery
Add alerts to all family members of children on the safeguarding register.
Should Do
Billet Lane Medical Practice
Improveandformalisethemonitoringofthechildren'ssafeguardingregister.
Should Do
APT Care Central Bedfordshire & Bedford
The provider must notify CQC or the local safeguarding team of allegations of potential abuse.
Must Do
Kingsley Nursing Home
The registered manager and provider failed to 1. report safeguarding concerns or have effective systems to investigate allegations. 13 (2 & 3)
Must Do
Ave Maria Care (Edgbaston)
The provider's safeguarding procedures were not effective and safeguarding concerns had not been consistently reported to the relevant agencies.
Must Do
Ability Associates Limited - 77 The Street
The registered manager had not ensured they notified the Care Quality Commission of allegations of abuse and incidents reported to the police.
Must Do
ICIBI immigration recommendations(4)
A re-inspection of the use of hotels for housing unaccompanied asylum-seeking children …
Strengthen assurance and monitoring mechanisms to ensure it is satisfied that contractors are meeting safeguarding and other requirements, including, but not limited to:
An inspection of contingency asylum accommodation for families with children in Northern …
The Home Office should clarify the respective safeguarding responsibilities of all agencies, including contractors and sub-contractors, involved in supporting asylum-seeking families with children in contingency accommodation and communicate this to …
An inspection of contingency asylum accommodation (November 2023 – June 2024)
Improve the safeguarding of vulnerable asylum accommodation service users by: a) seeking input regarding its current policies and practices from agencies and organisations with knowledge and experience of dealing with …
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to safeguarding, establish a dedicated, full-time safeguarding team within the IECA with the capacity and expertise to: a) Respond to all cases where a safeguarding risk (Levels One, …
IOPC learning recommendations(27)
Recommendation - Avon and Somerset Police and Wiltshire Police, April 2026
The IOPC recommends that Wiltshire Police and Avon & Somerset Police create and maintain an up-to-date list of STORM Codes and Transfer Codes on their STORM systems to allow the effective use and transfer of incidents between the two forces. …
Investigation into the West Yorkshire Police response to reports of injuries to …
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 …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends South Yorkshire Police ensures knowledge and skills of those involved in child sexual exploitation work are kept up to date as part of their continuous improvement cycle. This should include: • regular training to take into account …
Police contact with a mother and unborn child subject to child protection …
The IOPC recommends that the Metropolitan Police Service (MPS) deliver mandatory bespoke training to Police Conference Liaison Officers (PCLOs) and their respective Detective Sergeants on the Child Abuse Investigation Team (CAIT) to highlight the policies and procedures within which they …
Police contact with a mother and unborn child subject to child protection …
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: …
Recommendations - Cleveland Police, May 2022
The IOPC recommends that Cleveland police should identify all officers and staff who must undergo it's mandatory child sexual exploitation (CSE) training packages. The force should maintain accurate and auditable records of all officers and staff who have attended such …
Investigation into the West Yorkshire Police response to reports of injuries to …
The IOPC recommend that West Yorkshire Police (WYP) ensure that they review their mechanisms already in place, by the use of dip sampling or regular audits between WYP, Children’s Social Care (CSC) and their partner agencies to ensure that WYP …
Suicide after police contact - Metropolitan Police Service, September 2017
The Metropolitan Police Service to put necessary measures in place to ensure they are able to comply with the NPCC Suicide Prevention Risk Management guidance in relation to perpetrators of child sexual exploitation and indecent images of children. The MPS …
Recommendation - Metropolitan Police Service, February 2020
The IOPC recommends that the Metropolitan Police Service (MPS) take steps to make Safeguarding teams and departments aware that special schemes can apply to serial perpetrators of abuse and should be used where appropriate to do so. The MPS use …
Recommendations - Greater Manchester Police, December 2020
The IOPC recommends that GMP ensure that officers and staff working with children in any capacity are aware of the appropriate communications channels and that contact with a child via social media is never appropriate. This follows an IOPC investigation …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends South Yorkshire Police considers how it can assess and demonstrate the impact of action taken to address issues in handling child sexual exploitation. This should include how they understand whether actions have achieved the intended effect and …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends that the Chair and CEO of the Police Digital Service consider whether existing ICT solutions could be used differently or any changes to ICT (and any other supporting systems and protocols) are required to enable frontline officers …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends that South Yorkshire Police continues to improve processes that enable SYP and partner agencies to better collaborate so that information that should be available and considered by everyone is effectively shared, understood and acted upon in a …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends that during its mapping exercise South Yorkshire Police continues to engage with communities to strengthen and build trust and confidence in the police service to encourage a willingness to provide information/intelligence to help tackle local issues. When …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends South Yorkshire Police continues to work with the local ISVA service to improve its working arrangements. This should include: • a named point of contact at South Yorkshire Police for use by the ISVA service • ensuring …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends South Yorkshire Police take steps to ensure that victims are regularly updated, and at least once every 28 days, in line with expectations. South Yorkshire Police told us that IT system changes mean that once a crime …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends that South Yorkshire Police ensure it has a way of effectively monitoring compliance with the Victims’ Code. This should include the quality of interactions between itself and others and not just a ‘tick box exercise’ of the …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
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 …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends the College of Policing looks for opportunities to use any elements of Operation Linden in future training (for example case studies). While the issues we examined happened between 1992 and 2013, and there has been a great …
Operation Linden recommendations - South Yorkshire Police and College of Policing, November …
The IOPC recommends the College of Policing looks for further opportunities to incorporate the ‘voice of survivors’ in national training about child sexual exploitation and provide guidance on how the ‘voice of survivors’ can be incorporated into local training by …
Man tasered during arrest in the presence of a child – Greater …
The IOPC recommends that the College of Policing include a learning point in national training for officers equipped with Taser, in relation to considerations when a child is present during an incident where Taser is used. This is to enable …
Man tasered during arrest in the presence of a child – Greater …
The IOPC recommends that Greater Manchester Police include a learning point in local training for officers equipped with Taser, in relation to considerations when a child is present during an incident where Taser is used. This is to enable officers …
Police actions relating to a teenage boy’s arrest, welfare and disappearance prior …
The IOPC recommends that the Metropolitan Police Service (MPS) amend their custody policy to include a responsibility on MPS staff to ensure safeguarding forms are completed by them for vulnerable members of the public who they come into contact with …
Recommendations - Sussex Police
The IOPC recommends that Sussex Police amend its missing persons policy to clearly reflect the College of Policing Authorised Professional Practice for notifying the British Transport Police of when a missing person may potentially use the rail network. This follows …
Recommendations - Sussex Police
The IOPC recommends that Sussex Police reviews its missing persons policy and relevant training and guidance, to ensure vulnerabilities in individual missing persons cases are acknowledged, assessed, and graded appropriately. This follows an IOPC investigation in which a 15-year-old child …
Recommendations - Sussex Police
The IOPC recommends that Sussex Police takes steps to ensure the responsibility of sergeants to actively supervise medium risk missing persons cases is complied with. This follows an IOPC investigation in which a 15-year-old child was found deceased, having taken …
Recommendations - Cambridgeshire Constabulary, September 2021
The IOPC recommends that Cambridgeshire Constabulary takes steps to ensure it provides clear direction to officers on handling and recording allegations of crime which come to light during a missing person investigation. In particular, that appropriate guidance is provided regarding …
IMB individual recommendations(1)
Health investigations(54)
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 29
The same training issues apply for the CMHTas are set out in Recommendation (10) above, and should include when to notify child protection professionals that there are children in the same household as a patient who is violent, and in the case of adults at risk of violence from a …
london
Independent investigation: Faith Lovemore (6 wks), Cambridge (2009) — Rec 8
Where a service user does not comply with clinical advice about their mental ill health and their child is subject to a Child Protection Plan formal steps must be taken to ensure the child’s/or childrens’ safety needs are met. The following must be ensured: • the mental health care needs …
east_of_england
Independent investigation: Faith Lovemore (6 wks), Cambridge (2009) — Rec 2
Where a service user has fundamental and unusual religious beliefs to which they totally adhere, the clinicians might debate what the delusions and ideation of the parents were, but from a clinical perspective should determine whether the Mental Health Act criteria are met. The Social Care Services should concentrate on …
east_of_england
Independent investigation: Asiya Khatun, Newham (2000) — Rec 12
The London Borough of Newham and the Metropolitan Police should ensure that child protection teams and agencies assess the possible co-existence of domestic violence against adult family members when investigating cases of suspected child abuse.
london
Independent investigation: Asiya Khatun, Newham (2000) — Rec 11
East London and The City Mental Health NHS Trust and the London Borough of Newham should introduce protocols into CMHT management which direct that where domestic violence is suspected in a family with which a CMHT is working, a routine check shall be made with child protection agencies.
london
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 7
The DSCB will receive an annual report from MARAC with specific reference to the identification of risk to children and the appropriate referral of children to the MASH in incidents where the risk meet the threshold for social care intervention.
south_west
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 3
GP practices need to find ways to receive and respond to indicators of risk to children, including incidents of domestic violence. A nominated Senior person within every GP practice is to ensure that there is a recognised and effective system within their practice to flag up incidents (including domestic violence) …
south_west
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 1
All services engaged primarily with adults to develop practice tools that will assist staff to identify the risks that adults may pose to their children. All agencies working with adults must make their own assessment of risk to children and should not rely on whether or not the child is …
south_west
Independent investigation: Sarah Smart, Oxford (2005) — Rec 15.9
The Crisis Resolution and Home Treatment Team needs to develop its Risk Assessment / Risk Management practice and processes to routinely check with Child Protection systems to ensure the safety of children. In Risk Management this may then involve joint working with Child Protection Teams to provide family based approaches …
south_east
Independent investigation: Rodney Wells, Nottingham (2006) — Rec R3
The trust should reassure itself that the implementation of its current policy and procedures for safeguarding children are robust, particularly in relation to cases where risk requires clinical staff to consult the trust’s lead person on safeguarding children or in cases where referral to the local safeguarding (child protection) team …
midlands
Independent investigation: Nihaal Kapede, Staincliffe (2000) — Rec 5
Once a referral to Social Services for a child protection risk assessment has been made, involving an in-patient, systems should be set up within wards to ensure that the referral and its progress should always be taken into account in any subsequent decisions related to home leave or discharge.
north_east_yorkshire
Independent investigation: Nihaal Kapede, Staincliffe (2000) — Rec 3
Social Services must deliver a more robust system, whereby the Child and Family Team must carry out an assessment of risk where threats to children have been raised. Such a system should not allow for individuals to make decisions on such issues until an initial assessment under Section 47 has …
north_east_yorkshire
Independent investigation: Nihaal Kapede, Staincliffe (2000) — Rec 2
Where a mental health client raises issues of domestic violence, especially where there are children involved, professionals must assess the situation effectively following agreed policy.
north_east_yorkshire
Independent investigation: Margaret McIntyre, Corby, Northants (2007) — Rec 7.5
Safeguarding children should be at the forefront of staff working in service users homes where there are children. The Trust should ensure that all service users families are offered a carers assessment and where children are involved this should be mandatory factoring in any of the safeguarding concerns or needs …
midlands
Independent investigation: Lisa Sullivan, Walton on the Naze (2005) — Rec 5
When a service user is being seen by only one member of the mental health services there should be a review, at least annually, to include: diagnosis, care plan and treatment plan, current risk assessment, social and family circumstances, risk to any children in the household and consideration of their …
east_of_england
Independent investigation: Lisa Sullivan, Walton on the Naze (2005) — Rec 2
The National Service Framework for Children includes a recommendation that CPA meetings (and their equivalent) should take account of children’s needs and any risk of harm to them. Therefore, when a service user is the parent of a child for whom a child protection/safeguarding conference is called, and the mental …
east_of_england
Independent investigation: Keziah Flux Edmonds, East Cowes, IoW (2016) — Rec 4
A review should be undertaken to ascertain why the Named Nurse for Safeguarding Children does not always receive all CA/12 Child and Young Person at Risk forms (now referred to as Public Protection Notices). Any issues identified should be promptly addressed.
south_east
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.15
The agencies should decide whether referral to the Area Child Protection Committee (ACPC) is appropriate to consider whether any follow-up action is necessary.
north_west
Independent investigation: Hamidi HamidullahKhizer Hayat, Tulse Hill (2006) — Rec Recommendation Numbe
All active Lambeth cases should be reviewed regarding the current Trust Safeguarding Children Policy to ensure that children are identified appropriately and that plans are in place to promote both their wellbeing and safety.
london
Independent investigation: Chloe Fahey, Manchester (2003) — Rec A.5
It is recommended that a review of the telephone lines into the CDAT team be carried out with particular reference to a provision of a dedicated line with a queuing system which other employees of Trafford Metropolitan Borough Council can use.
north_west
Independent investigation: Chloe Fahey, Manchester (2003) — Rec A.4
It is recommended that the functionality of the CDAT/dedicated child protection lines is tested each day.
north_west
Independent investigation: Chloe Fahey, Manchester (2003) — Rec A.3
It is recommended that a process for auditing the accessibility of the Community Advice Team/Children’s Duty & Assessment Team (CAT/CDAT) and of a dedicated child protection line be devised and carried out three monthly with reports going to the senior manager and the Local Safeguarding Children’s Board (LSCB).
north_west
Independent investigation: Abida Bi, Bradford (2010) — Rec 2
Safeguarding children Because the assessment of risk to children is central to the contemporary assessment of risk, and because it is a complex issue, BDCT and the provider of its electronic records system should consider including a dedicated section in its risk assessment form for safeguarding children. This would enable …
north_east_yorkshire
An independent investigation into the care and treatment of Darren … — Rec 4
A review should be undertaken to ascertain why the Named Nurse for Safeguarding Children does not always receive all CA/12 Child and Young Person at Risk forms (now referred to as Public Protection Notices). Any issues identified should be promptly addressed.
Isle of Wight NHS Trust
south_east
An assessment of a mental health trust’s internal investigation of … — Rec R9
The Trust should ensure that children are never considered as protective factors for parents with mental ill health, and that safeguarding indications are routinely examined and acted upon, especially when service users live with children or other vulnerable family members. Staff should be trained on evidence-based risk theories and child …
north_east_yorkshire
An independent investigation into the care and treatment of service … — Rec Recommendation 2
There was a lack of clarity regarding the assessment of domestic abuse and children at risk. Assessment questions about domestic abuse should include the possibility that the service user is a potential perpetrator. The wording in the child safeguarding tool should be clear on how and when the tool should …
midlands
Independent investigation: Alan Riddock, Bristol (2008) — Rec 6
The Avon and Wiltshire Mental Health Partnership NHS Trust, possibly in conjunction with its partner agencies, should ensure that the local Children’s Safeguarding Policies and Procedures are being implemented in a consistent manner. It should ensure that: • assessments and risk assessments routinely identify contact with and concerns regarding children; …
south_west
Independent investigation: Terrance Hall, Weston Super Mare (2008) — Rec 5
The Trust, in conjunction with its partner agencies and commissioners, should ensure that the local Children’s Safeguarding policies and procedures are being implemented in a consistent manner. It should ensure that: • assessments and risk assessments routinely identify contact with and concerns regarding children; • this information is communicated to …
south_west
Independent investigation: Tracey Baker, Chard (2015) — Rec 5
Somerset Partnership NHS Foundation Trust ‘s Serious Incidents Requiring Investigation (SIRI) Policy and Procedure should be amended to include: • a specific section on child protection which clearly outlines the investigator’s safeguarding responsibility throughout the course of their investigation; • guidance as to how an investigator should respond with regard …
south_west
Independent investigation: Simran Sidhu (5)Aman Raj (23 mths), Southall Station … — Rec 15
Ealing Primary Care Trust should require both GPs and Health Visiting staff to consider whether inappropriate anxiety in a parent as exhibited by one who takes the children too frequently to the doctor, hospital or health visitor clinic may be pathological and share that information with the CMHT ifitis involved.
london
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 6
An appropriate representative from all agencies who are signed up to the MARAC operating protocol should ensure regular and effective attendance at all MARAC meetings. Alongside the assessment of risk to the adult victim, the risk to children should be specifically considered in every case. The chair of the MARAC …
south_west
Independent investigation: Sandra Bowring (Vincent), Rhyl, Denbighshire (2006) — Rec 10
Clear protocols for the sharing of information between voluntary agencies and statutory services should be developed; these should be clear about who should take any action required in respect of risk, POVA and child protection procedures.
wales
Independent investigation: Ms B, Cheltenham (2008) — Rec 1
The Trust should ensure that the welfare of any children living with, or regularly visiting, a service user is considered as part of the risk assessment process and audit compliance with this on an annual basis.
south_west
Independent investigation: Michael Galloway, Illingworth (1999) — Rec 6.16
The panel recommends that there should be a review of the Child Protection Procedures to emphasize potential risk to children in households where a carer is mentally ill.
north_east_yorkshire
Independent investigation: Keziah Flux Edmonds, East Cowes, IoW (2016) — 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), within its primary and secondary mental health services, including the IAPT service.
south_east
Independent investigation: Jim Ward, Ayr (2007) — Rec 12
NHS Board A and SWD1 must ensure that all workers involved in the Mr F case receive refresher training in child protection issues. They should also consider whether this may equally applicable to the rest of their workforce.
scotland
Independent investigation: Freya Emson(3 mnths), NE London (2000) — Rec 3
Mental Health Trusts should not wait for their local Area Child Protection Committees but should make proposals for ‘child protection proofing’ their services with Social Services Departments immediately.
london
Independent investigation: Freya Emson(3 mnths), NE London (2000) — Rec 1
The Department of Health through the National Institute For Mental Health England and Strategic Health Authorities and the National Care Standards Agency through the agency of Local Authority Social Services Area Child Protection Committees, should ensure that mental health services to patients with children are child sensitive and ‘child protection …
london
Independent investigation: Chloe Fahey, Manchester (2003) — Rec O.5
It is recommended that a template fax be devised for use after domestic violence incidents adapted from the Domestic Abuse Information Sharing Form (or similar) to ensure that key information is not omitted from any onward transfer such as the time of the incident, whether children were present in the …
north_west
An independent investigation into the care and treatment of a … — Rec 4
The Trust must ensure that all clinical teams follow trust safeguarding policies when they are made aware of safeguarding concerns about children or adults, and that appropriate referrals are made to the relevant social care department.
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
Independent investigation into the care and treatment of Mr B … — Rec Trust action 4 (Resi
We recommend that, 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 …
Mr B and Ms A, published on 13 November 2019. Mr B and Ms A were in receipt of services from Central and North West London NHS Foundation Trust
london
An independent external quality assurance review of the independent investigation … — Rec 4
The Trust must ensure that all clinical teams follow Trust Safeguarding policies when they are made aware of safeguarding concerns about children or adults, and that appropriate referrals are made to the relevant social care department.
north_west
Independent investigation: Philip Ellison, Preston (2008) — Rec 1
The Trust should ensure that initial assessment of people with mental health problems takes full account of social care factors: this is particularly relevant when the service user has responsibilities as a carer and there are known child care difficulties. Initial assessments should include thorough analysis of social care factors …
north_west
Independent investigation: Faith Lovemore (6 wks), Cambridge (2009) — Rec 1
Where a person has the care of, or regular contact with, a baby or young child and s/he has a mental illness or it is reasonable to assume that their mental illness is likely to recur: • a clear crisis and contingency plan will be required and must be shared …
east_of_england
Independent investigation: Nico Meli, Nottingham (2003) — Rec R2
Safeguarding children. This report has highlighted a number of concerns about the risk presented to children. There are also examples of when these risks were handled well. We recommend that this report is tabled at the local safeguarding children’s board to consider these risks and whether similar situations are occurring …
midlands
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R29
The trust should amend its existing child protection policies and procedures so that they explicitly cover circumstances in which someone with a mental illness is living in the same house as a child.
london
Independent investigation: Bertha Martin, Cleadon (2008) — Rec 14.
The panel recommends that whenever a social or health care service has any concerns in relation to a service user, insofar as the potential risks that that individual may pose to a vulnerable adult or child, this information should be passed onto all the services involved, including the GP’s involved …
north_east_yorkshire
Independent investigation: Benjamin Durao, Brixton (2004) — Rec 1
To have robust escalation processes in place when social services have concluded that an initial referral does not meet their criteria, but concerns remain with health staff, that there are mechanisms that can address this concerns at the appropriate level within both organisations.
london
Independent investigation: Annie Garbutt, Mirfield (2007) — Rec R7
The trust should ensure all staff are aware of the expectation that they seek advice on safeguarding children whenever there is the potential for concern or a difference of opinion, even if they have felt no actual concern.
north_east_yorkshire
Independent investigation: Annette Sturt, Dover (2012) — Rec 8
where social services departments receive information that drug dealing is taking place at an address they have involvement with, particularly one where children are living, they should refer this to the police.
south_east
Independent reviews(11)
Laming Review (Baby P) — Rec 20
All police, probation, adult mental health and adult drug and alcohol services should have well understood referral processes which prioritise the protection and well-being of children. These should include automatic referral where domestic violence or drug or alcohol abuse may put a child at risk of abuse or neglect.
Other
Laming Review (Baby P) — Rec 19
The Department for Children, Schools and Families must strengthen Working Together to Safeguard Children, and Children's Trusts must take appropriate action to ensure: all referrals to children's services from other professionals lead to an initial assessment, including direct involvement with the child or young person and their family, and the …
Other
Laming Review (Baby P) — Rec 11
The Department for Children, Schools and Families should revise Working Together to Safeguard Children to set out clear expectations at all points where concerns about a child's safety are received, ensuring intake/duty teams have sufficient training and expertise to take referrals and that staff have immediate, on-site support available from …
Other
Wood Review of LSCBs — Rec 7
The Department for Education should review what approaches to early cross agency intervention and intelligence gathering to identify children and young people at risk are most effective, including considering whether the Multi-Agency Safeguarding Hubs model offers an effective approach.
Other
Timpson Review — Rec 29
Real-time data on exclusion and other moves out of education should be routinely shared with Local Safeguarding Children Boards and their successors, Safeguarding Partners, so they can assess and address any safeguarding concerns such as involvement in crime. This should include information on exclusion by characteristic.
Education
Accepted
Timpson Review — Rec 28
Relevant regulations and guidance should be changed so that social workers must be notified, alongside parents, when a Child in Need is moved out of their school, whether through a managed move, direction off-site into AP or to home education, as well as involved in any processes for challenging, reconsidering …
Education
Accepted
Timpson Review — Rec 27
In making changes that strengthen accountability around the use of exclusion, DfE should consider any possible unintended consequences and mitigate the risk that schools seek to remove children from their roll in other ways. This should include: reviewing a 'right to return' period where children could return from home education …
Education
Accepted
Timpson Review — Rec 26
Ofsted must continue its approach set out in the draft framework and handbook of routinely considering whether there are concerning patterns to exclusions, off-rolling, absence from school or direction to alternative provision and reflecting this in their inspection judgements. Where it finds off-rolling, this should always be reflected in inspections …
Education
Accepted
Casey Review — Rec 7
The Met should create an overarching children's strategy for London to address long-standing concerns about its child protection and safeguarding practices. This should: i) address its approach to children and young people who are suspected of crimes, and its approach to protecting children and young people who are both victims …
Policing & Security
Accepted
Field Review on Poverty and Life Chances — Rec 13
Local Authorities should pool data and track the children most in need in their areas. A Local Authority should understand where the children who are most deprived are, and how their services impact upon them. Central Government should review legislation that prevents Local Authorities using existing data to identify and …
Other
Corston Report — Rec 22
Defendants who are primary carers of young children should be remanded in custody only after consideration of a probation report on the probable impact on the children.
Justice & Legal
PHSO casework decisions(18)
P-004411 — A practice in the Barnsley area
Mr A complained the Practice did not listen to or escalate his concerns about a safeguarding and domestic violence incident involving his parents and their neighbour, leaving him frustrated and unheard.
NHS in England
Nov 2025
P-004771 — A practice in the Barnet area
Miss P complained the Practice refused tests for her son, wrongly reported her to social services, asked about past referrals, and was dishonest in its complaint response.
NHS in England
Feb 2026
P-001574 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs R complained Mr R was not allocated a care coordinator, discharged despite being at risk, and the Trust failed to diagnose Foetal Alcohol Syndrome.
NHS in England
Oct 2022
P-003474 — Children and Family Court Advisory and Support Service …
Mr X complained CAFCASS and the FCA showed bias, did not adhere to policy, overlooked safeguarding concerns, and failed to investigate his complaints about the FCA's conduct.
UK Government
Mar 2025
P-001840 — Cornwall Partnership NHS Foundation Trust
Mrs H complained about delays in her son's autism assessment and Child and Adolescent Mental Health Services' (CAMHS) refusal to assess him, leading to a lack of support.
NHS in England
Jan 2023
P-003574 — Alder Hey Children's NHS Foundation Trust
Mr H complained two Trusts misdiagnosed his son's skull fracture and made an inappropriate safeguarding referral, causing separation from his son, financial loss, and reputational damage.
NHS in England
May 2025
P-004208 — A practice in the West Suffolk area
Mr B complained a nurse incorrectly referred his daughter to MASH, alleging trauma, and asked inappropriate questions, causing his family significant distress.
NHS in England
Nov 2025
P-004326 — A practice in the Shropshire area
Dr A complained a GP Practice failed to identify his daughter was being bullied despite emotional and physical symptoms, and lacked consistent clinician care, severely impacting her wellbeing.
NHS in England
Nov 2025
P-004358 — Midlands Partnership University NHS Foundation Trust
The Trust wrongly blamed Miss K's mental health for A's difficulties and refused autism assessment (2014-2018), causing distress and delayed support.
NHS in England
Nov 2025
P-004359 — Midlands Partnership University NHS Foundation Trust
The Trust refused to acknowledge B's severe developmental delays or assess for autism (2018-2019), leading to distress and a delayed diagnosis.
NHS in England
Nov 2025
P-002407 — London Ambulance Service NHS Trust
Mr L complained NHS 111 wrongly made a safeguarding referral for neglect, leading to social services involvement, harassment, and an unrequested paramedic visit.
NHS in England
Jan 2024
P-003360 — The Queen Elizabeth Hospital King's Lynn NHS Foundation …
The Trust made a social services referral without communicating the reason, causing Miss C significant stress and fear of accessing future care.
NHS in England
Feb 2025
P-004639 — A practice in the Bexley area
Mr X complained the Practice didn't prioritize his physical health, focused on mental health, and made an unnecessary safeguarding referral with disputed information, causing emotional distress.
NHS in England
Not Upheld
Jan 2026
P-002512 — Hampshire Hospitals NHS Foundation Trust
Ms O complained doctors made false safeguarding allegations without permission and failed to diagnose a broken rib in ED, causing distress, loss of trust, and prolonged pain.
NHS in England
Mar 2024
P-003179 — Cambridgeshire Community Services NHS Trust
Miss Y complained the Trust failed to listen to her concerns about her son's behaviour, delaying assessment and referral for potential autism symptoms since October 2021.
NHS in England
Partly Upheld
Nov 2024
P-003357 — The Hillingdon Hospitals NHS Foundation Trust
Mrs A complained the Trust failed to diagnose a perineal tear after childbirth and missed her daughter's sacral dimple, causing distress and requiring further medical procedures.
NHS in England
Feb 2025
P-003597 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs G complained the Trust didn't consider patient history for her foster child's injury, and a paediatrician's speculation in a report led to their arrest.
NHS in England
Jun 2025
P-001738 — A practice in the Gateshead area
Miss T complained a practice failed to refer her for breast lump investigations due to her age and delayed a two-week referral, causing more severe treatment and distress.
NHS in England
Jan 2023
LGO / SPSO decisions(1315)
24-022-732 — London Borough of Croydon
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Children S Care Services
Feb 2026
25-013-452 — Isle of Wight Council
We will not investigate this complaint about the Council’s failure to provide early support to Mrs X’s child. This is because most of the events complained about are late. The remaining complaint points relate to matters that took place inside a school or Mrs X had right of appeal for.
LGO (Local Government & …
Children S Care Services
Feb 2026
25-013-019 — Kent County Council
We cannot investigate Miss X’s complaint about whether the Council should take action to safeguard her children as the Court is considering their care. There are other bodies better suited to considering officers’ professionalism and whether the Council has provided her with all the information she is entitled to.
LGO (Local Government & …
Children S Care Services
Feb 2026
25-016-558 — Leeds City Council
Summary: We will not investigate this complaint about the Council’s alleged lack of support to Mr X and the failure to safeguard his children. The law says we cannot investigate complaints about court action or what happened in court. It is reasonable for Mr X to raise all concerns as …
LGO (Local Government & …
Children S Care Services
Feb 2026
25-013-289 — London Borough of Barking & Dagenham
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Children S Care Services
Feb 2026
21-013-222 — Kirklees Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s refusal to provide the complainant with information about what it has said to his ex-wife. This is because there is no evidence of fault on the Council’s part.
LGO (Local Government & …
Children S Care Services
Jan 2022
21-006-743 — West Sussex County Council
Summary: Mr X complains that the Council’s investigation into a disclosure by his daughter was inadequate and that a social worker made a false statement about him to his daughter’s mother. The Council is not at fault.
LGO (Local Government & …
Children S Care Services
Not Upheld
Jan 2022
20-006-042 — London Borough of Havering
Summary: Mr X complains about the Council’s actions after something that happened at his son’s school. I have discontinued my investigation. This is because we cannot investigate what happens in schools and there is no evidence that the Council’s investigation and assessment or complaint handling caused significant injustice to Mr …
LGO (Local Government & …
Children S Care Services
Jan 2022
21-005-916 — Leicester City Council
Summary: Mr Y and Mr and Mrs X complain about the actions of Council staff members, which they feel were racially motivated, and about the Council’s complaints handling. The Council had accepted fault and offered a financial remedy before the Ombudsman’s involvement. It has agreed a further financial remedy and …
LGO (Local Government & …
Children S Care Services
Upheld
Jan 2022
21-015-545 — Southend-on-Sea City 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 has agreed to start a stage two investigation by allocating the complaint to an Independent Investigator within a month.
LGO (Local Government & …
Children S Care Services
Upheld
Mar 2022
21-009-888 — Lancashire County Council
Summary: The Council is at fault for delaying consideration of this complaint under the children’s statutory complaints procedure. The Council has agreed to arrange a stage three panel and increase the payment offered to the complainant for the time and trouble its delay has caused her.
LGO (Local Government & …
Children S Care Services
Upheld
Mar 2022
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.
LGO (Local Government & …
Children S Care Services
Jun 2022
22-001-215 — Birmingham City Council
Summary: The Ombudsman will not investigate a complaint about how a Council considered a complaint about child protection under the statutory children’s complaints procedure. This is because there is insufficient evidence of fault and investigation by the Ombudsman is unlikely to achieve more.
LGO (Local Government & …
Children S Care Services
Jun 2022
21-015-816 — London Borough of Lewisham
Summary: Ms X complains the Council has failed to investigate her complaint about historic sexual abuse, causing her distress. The Ombudsman did not find fault in the way the Council proposes to investigate Ms X’s complaint about historic abuse. The Ombudsman has found fault in the time the Council has …
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2022
22-002-437 — Newcastle upon Tyne City Council
Summary: We will not investigate Miss X’s complaint about children services actions as the Court is now considering the child’s care.
LGO (Local Government & …
Children S Care Services
Jun 2022
21-015-276 — Brighton & Hove City Council
Summary: There was no fault in how the Council dealt with Miss B’s allegation that she was sexually assaulted by a social worker. The Council has no record of Miss B reporting this before 2019, by which point the social worker – who had left to work for a different …
LGO (Local Government & …
Children S Care Services
Not Upheld
Jun 2022
22-003-326 — Hampshire County Council
Summary: We will not investigate this complaint that the Council has declined to implement a recommendation made by the Review Panel considering a complaint against children’s services. This is because the Council’s actions have not caused the complainant an injustice.
LGO (Local Government & …
Children S Care Services
Jun 2022
21-013-115 — London Borough of Sutton
Summary: Ms X complained about the actions of the Council when it placed her children on child protection plans. The Council has already accepted it was at fault for poor communication with Ms X at times. It has apologised and told her what it will do to help prevent a …
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2022
22-007-427 — London Borough of Bromley
Summary: We will not investigate this complaint about the Council’s decision to continue the complainant’s daughter’s child protection plan. This is because we cannot achieve the outcome the complainant is seeking.
LGO (Local Government & …
Children S Care Services
Sep 2022
22-006-677 — Norfolk County Council
Summary: We cannot investigate this complaint about the Council’s actions concerning Mr X’s child. This is because the matter complained of are not separable from matters that were or could have been raised in court.
LGO (Local Government & …
Children S Care Services
Sep 2022
21-012-067 — Wigan Metropolitan Borough Council
Summary: Miss Y complained her complaint the Council failed to support and protect her daughter was not properly considered by the Council under the statutory complaints procedure. We have found fault by the Council regarding the remedy proposed in response to her complaint, and the delay in completing the Stage …
LGO (Local Government & …
Children S Care Services
Upheld
Sep 2022
22-006-649 — Gloucestershire County Council
Summary: We uphold Mr X’s complaint that the Council failed to consider his complaint within its children statutory complaints’ procedure. The Council has agreed to do so without further delay.
LGO (Local Government & …
Children S Care Services
Upheld
Sep 2022
21-018-664 — Surrey County Council
Summary: Mr N complains about the Council’s decision to make his children subject to child protection plans and its administration of the plans. He also complains the Council gave his ex-partner wrong information about what contact he could have with his daughter. The Ombudsman upholds the complaint, as we have …
LGO (Local Government & …
Children S Care Services
Upheld
Dec 2022
23-018-514 — Barnsley Metropolitan Borough Council
Summary: We cannot investigate Mr X’s complaint about the contents of a court ordered report which has been considered in court proceedings because it lies outside our jurisdiction. The law prevents us from considering complaints about matters that have been considered in court, we have no discretion to do so.
LGO (Local Government & …
Children S Care Services
Apr 2024
23-014-642 — Newcastle upon Tyne City Council
Summary: Ms X says the Council’s Local Authority Designated Officer failed to conduct the multi-agency meetings according to the Statutory Disclosure Guidelines. Ms X says this led to an incorrect disclosure to the Disclosure Barring Service. Ms X also says the Council failed to deal with her complaint. We have …
LGO (Local Government & …
Children S Care Services
Upheld
Apr 2024
22-016-423 — City of Bradford Metropolitan District Council
LGO (Local Government & …
Children S Care Services
Upheld
23-014-508 — Derbyshire County Council
Summary: Mr X complained about the way the council dealt with child protection proceedings. We find the Council at fault for failing to provide copies of plans, failing to follow its policy around identification and not advising Mr X of how long he would need to leave the family home. …
LGO (Local Government & …
Children S Care Services
Upheld
May 2024
24-005-324 — Lancashire County Council
Summary: We will not investigate Mr X’s complaint. This is because there is no sign of fault in the Council’s decision not to consider his complaint whilst there are ongoing court proceedings.
LGO (Local Government & …
Children S Care Services
Jul 2024
24-004-715 — Surrey County Council
Summary: We will not investigate this complaint about the Council’s involvement in Ms X’s child’s case. The law prevents us investigating complaints about what happened in court, and we have no power to overturn a court decision and return Ms X’s child to her care.
LGO (Local Government & …
Children S Care Services
Jul 2024
24-004-580 — London Borough of Havering
Summary: We will not investigate this complaint about the Council’s involvement in Mr X’s child’s case. The matter is being considered by the courts, and we are therefore prevented in law from investigating it.
LGO (Local Government & …
Children S Care Services
Jul 2024
24-003-323 — Nottinghamshire County Council
Summary: We will not investigate this complaint about how the Council dealt with matters concerning a safeguarding matter. This is because there is insufficient evidence of fault.
LGO (Local Government & …
Children S Care Services
Jul 2024
24-005-818 — Middlesbrough Borough Council
Summary: We will not investigate Miss X’s complaint. This is because there is no sign of fault in the Council’s decision not to consider her complaint whilst there are ongoing court proceedings.
LGO (Local Government & …
Children S Care Services
Aug 2024
23-018-063 — Devon County Council
Summary: Miss X complained about the Council’s actions in respect of its care of her daughter, Miss Y, and the way in which it dealt with her complaint about the matter. We have not found fault with the Council.
LGO (Local Government & …
Children S Care Services
Upheld
Aug 2024
23-012-673 — Cambridgeshire County Council
Summary: Mr and Mrs X complain the Council was at fault in how it managed its child protection enquiry relating to their children following an incident in June 2023. We found the Council was at fault for delay in completing the Child and Family Assessment as well as the poor …
LGO (Local Government & …
Children S Care Services
Upheld
Sep 2024
25-000-774 — Central Bedfordshire Council
Summary: We cannot investigate Mr X’s complaint about his children being removed from his care following family court proceedings because it lies outside our jurisdiction. The law prevents us from investigating complaints about matters that have been subject to court proceedings. We have no discretion to do so.
LGO (Local Government & …
Children S Care Services
Jun 2025
25-000-593 — Hertfordshire County Council
Summary: We will not investigate Mrs X’s complaint that a safeguarding referral was unlawfully made and then considered by the Local Authority Designated Officer. This is because there is insufficient evidence of fault.
LGO (Local Government & …
Children S Care Services
Jun 2025
25-000-495 — Suffolk County Council
Summary: We will not investigate this complaint about the removal of a child from their mother’s care and related events. We cannot investigate matters that have been considered in court. We have no power to investigate the actions of police officers and a judge.
LGO (Local Government & …
Children S Care Services
Jun 2025
25-000-995 — Isle of Wight Council
Summary: We will not investigate Mr X’s complaint about the Council’s handling of concerns he has raised in relation to his daughter over the past year. This is because there is no sign of fault in the Council’s decision not to consider his complaint until the ongoing court proceedings have …
LGO (Local Government & …
Children S Care Services
Jun 2025
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 …
LGO (Local Government & …
Education
Upheld
Jun 2025
25-001-730 — Lancashire County Council
Summary: We will not investigate this complaint about the alleged failure of the Council to protect Miss X’s grandchildren from harm. There is not enough evidence of fault by the Council to warrant our further involvement.
LGO (Local Government & …
Children S Care Services
Jul 2025
25-006-768 — Wigan Metropolitan Borough Council
Summary: We cannot investigate this complaint about a court report. The law prevents us from investigating anything that has or is the subject of court proceedings.
LGO (Local Government & …
Children S Care Services
Aug 2025
25-004-518 — Liverpool City Council
Summary: We will not investigate Mr X’s complaint about the Council’s decision that his children should be made subject to child protection plans. This is because it is unlikely we would find fault and we are unable to achieve the outcome he seeks.
LGO (Local Government & …
Children S Care Services
Aug 2025
25-011-639 — North Tyneside Metropolitan Borough Council
Summary: We will not investigate this complaint about how the Council dealt with Mr X’s concerns about the safety and wellbeing of one of his children. It is unlikely an investigation would find fault with the Council.
LGO (Local Government & …
Children S Care Services
Aug 2025
25-009-198 — Reading Borough Council
Summary: We will not investigate this complaint from Mr X about the Council making false claims and interfering with his email account. The complaint was made late, and there is no good reason to consider it now.
LGO (Local Government & …
Children S Care Services
Nov 2025
25-007-229 — West Northamptonshire Council
Summary: We will not investigate Mr Z’s complaint about how the Council responded to his safeguarding concerns and carried out a Child and Family Assessment. There is not enough evidence of fault and an investigation is unlikely to lead to a different outcome.
LGO (Local Government & …
Children S Care Services
Nov 2025
25-009-318 — Southampton City Council
Summary: We will not investigate Mr X’s complaint about how the Council handled safeguarding concerns. The Council has already looked into the matter and responded appropriately. It has addressed the outcomes Mr X asked for, and further investigation is unlikely to find fault
LGO (Local Government & …
Children S Care Services
Nov 2025
25-008-745 — West Northamptonshire Council
Summary: We cannot investigate Miss X’s complaint about historic failure to provide suitable equipment to her during her time in education or for failing to make safeguarding referrals. The issues Miss X complained about related to Miss X’s school, not the Council, and the law says we cannot investigate.
LGO (Local Government & …
Education
Nov 2025
25-009-561 — Sefton Metropolitan Borough Council
Summary: We will not investigate Mr X’s complaint about his children being placed with other relatives. This is because it concerns matters decided in court and we have no power to intervene.
LGO (Local Government & …
Children S Care Services
Nov 2025
25-009-459 — Hertfordshire County Council
Summary: We cannot investigate Miss X’s complaint about the Council’s child protection actions and decisions after her baby suffered an unexplained injury, because it lies outside our jurisdiction. The law prevents us from investigating complaints about matters that are being considered in court proceedings. We have no discretion to do …
LGO (Local Government & …
Children S Care Services
Nov 2025
25-013-481 — Gateshead Metropolitan Borough Council
Summary: We upheld Miss X’s complaint about delays in the children’s statutory complaints process. The Council agreed to resolve the complaint early by apologising, paying Miss X a symbolic financial remedy, and completing stage two of the children’s statutory complaints process.
LGO (Local Government & …
Children S Care Services
Upheld
Nov 2025
Domestic Homicide Reviews(157)— showing 50 strongest matches
Tewkesbury — recommendation 17.5.2
Agencies need to consider the safeguarding needs of all children in a domestic abuse household following a domestic abuse incident and take the appropriate action according to the agreed Gloucestershire Safeguarding Children’s Board Levels of Need document and complete a DASH form as appropriate.
Gloucestershire County Council | Gloucestershire Safeguarding …
Gloucestershire County Council
Bromley — recommendation 4.4.8
Children’s Services & the BSCB should review ‘The Child’s Journey In Bromley ’ to ensure referral routes to early intervention services & children’s social care services are clear for all partners and that ‘escalation’ is also clear when referrals are not sufficiently addressed.
Bromley Children’s Services | Bromley Safeguarding …
Sheffield — recommendation 2
STHFT should ensure there are effective monitoring and audit arrangements in place to provide reassurance that where a child safeguarding (or vulnerable adult) referral is raised that safeguarding concerns are noted during initial assessment.
STHFT
Oxford — recommendation 1
Thames Valley Police to revise their Domestic Abuse Standard Operating Procedure to ensure that referrals as opposed to notifications are made to Children’s Social care following domestic abuse incidents were either party is a child. The referral should then prompt a strategy discussion between police and CSC to consider the …
Thames Valley Police
Thames Valley Police
Oxford — recommendation 4
Reducing the Risk should work proactively in partnership with child social care and ensure immediate liaison following a referral.
Reducing the Risk of Domestic Violence
Bath and North East Somerset — recommendation R10
Referrals to Children's Social Care to ensure clarity on what constitutes a referral to CSC
Bath & NES Council Children’s Social …
Bath and North East Somerset — recommendation R2
All operational staff to be reminded of the importance of recognising the risk to children living within a parent declining mental health. To be measured by an increase in referrals from the Safeguarding Coordination Units to Children’s social care.
Avon and Somerset Constabulary
Avon and Somerset Police
Hackney — recommendation 2c
When children are named as potential victims, witnesses or are living in the household, a pre-assessment checklist has been generated and shared with Children’s Services
Metropolitan Police Service
Metropolitan Police Service
Hackney — recommendation IMR2
It is recommended that officers are reminded of the necessity to complete MERLIN/PAC reports in relation to all cases of Domestic Abuse where there are children within the family
Metropolitan Police Service
Metropolitan Police Service
Chiltern — recommendation Panel Recommendation
BCC Children’s Services undertakes a review of the processes for recording and indexing information received and of referrals made, to ensure that key information is recorded and acted on appropriately.
BCC Childrens’ Services
Wigan — recommendation 5
Children who notify school staff or comment upon family difficulties should be monitored and referred to School Safeguarding Officer / Head teacher and an Early help referral completed.
Primary School ‘A’
Wigan — recommendation 3
Possibility of Safeguarding Officer /Headteacher being informed when parents/carers are undergoing support/ treatment for serious mental health issues.
Primary School ‘A’
Kingston upon Thames — recommendation 43
A referral of a parent to MARAC should also trigger a referral to CSC and to Safeguarding Adults where relevant.
Domestic Violence Strategic Board
Kingston upon Thames — recommendation 36
Where a subsequent referral is made to children’s services within 30 days of the previous referral, Helpline practitioners should seek an update on action taken and record the response on the case file.
NSPCC
Newham — recommendation 4
The Panel originally wanted to recommend the following for Cafcass: Where there are allegations of current domestic violence and disputes over child contact, the local Children’s Services should be routinely notified. However, Cafcass rejected this recommendation stating: We did, in fact, do that as a matter of policy for a …
Government
UK Government
Newham — recommendation 3
All agencies to review their referral processes for children at risk of significant harm
LB Newham Domestic & Sexual Violence …
Newham — recommendation 2
Ensure commissioning of school nursing services includes providers that have a policy in place which follows up those children not known to health services at school entry. This needs to include pro-active work with families where they do not respond to school entry health questionnaires as these will be the …
NHS North East London & the …
Kent — recommendation 13
When training officers and staff in dealing with domestic abuse incidents, Kent Police should emphasise the importance of speaking to children who are old enough to speak for themselves.
Kent Police
Kent Police
Kent — recommendation 12
Kent Police, in consultation with KSCS, should review the domestic abuse child referral matrix to ensure that there are no anomalies and that it provides the right criteria for safeguarding children who are living in households where domestic abuse is taking place.
Kent Police | KSCS
Kent Police
Bolton — recommendation 3
Practices should recognise the links between DVA and safeguarding children and young people
NHS Bolton ICB
Leeds — recommendation LYPFT5
Where a child is involved in a case such as this a referral should be made to the child safeguarding team in their own right.
Leeds & York Partnership Foundation Trust
Leeds and York Partnership …
Nuneaton and Bedworth — recommendation 36
Children’s Services ensure and reinforce that Children’s Teams follow the existing guidance in respect of referrals where children may be at risk of significant harm and the protocol for Domestic Abuse referrals in a timely manner.
Warwickshire County Council - Children’s Services
Harlow — recommendation 15.8.2
Where possible information recorded on the DV/1 form should indicate any children or an unborn child who may be at risk together with the victim.
Essex Police
Essex Police
Harlow — recommendation 15.3.6
Children and/or an unborn child identified within an abusive relationship should be flagged as routine, and this process should initiate a referral to CSC.
North Essex Partnership NHS Foundation Trust
North Essex Partnership University …
Rochdale — recommendation iv
That Rochdale Safer Communities Partnership reinforce to all agencies the importance of early identification of families as ‘troubled’ and the mechanisms for referring concerns and sharing information.
Rochdale Safer Communities Partnership
North Worcestershire — recommendation DHR 1
Warwickshire Safeguarding Children Board (WSCB) is to seek assurance that: a) Children in Warwickshire seeking a school place are identified and an appropriate offer of a school place is made in a timely manner b) When children in Warwickshire are not in education relevant assessments are undertaken in relation to …
Warwickshire Safeguarding Children Board (WSCB)
Bridgend — recommendation Safeguarding 3
Children must be spoken to alone for the purposes of Assessment and protection.
Bridgend County Borough Council Social Care …
Wiltshire — recommendation R59
DAIT/MASH to identify potential victims of child sexual exploitation in domestic abuse cases and make a referral to the CSE team.
Wiltshire Police
Wiltshire Police
Nuneaton and Bedworth — recommendation 36
Children’s Services ensure and reinforce that Children’s Teams follow the existing guidance in respect of referrals where children may be at risk of significant harm and the protocol for Domestic Abuse referrals in a timely manner.
Children’s Services
Children’s Services
Gloucestershire — recommendation 7.3.11
All schools to agree a system with Children’s Social Care whereby receipt of key safeguarding information is recorded so that there is no doubt on whether that information has been received and acted upon.
Gloucester Education Services
Somerset — recommendation 20.7
Where there are children living in a domestic abuse environment, consideration should be given for referrals to be made to domestic abuse services for Young People.
Children Social Care
Somerset — recommendation 20.6
Staff should be reminded when an assessment is being completed and the potential risk is around a child’s contact with one particular parent, that parent should be included in the assessment to widen the safety net for the child.
Children Social Care
Somerset — recommendation 20.5
It is recommended that when a disclosure needs to be made to keep a child safe, personnel must clearly evidence who needs to be party to the information in order to act in the best interest of the child.
Children Social Care
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 …
Torbay — recommendation 11
The importance of notifying partners of the risk to children seen in homes where domestic abuse is occurring should be included in any Domestic Abuse policies that are developed and should be promoted to staff.
Torbay Council | Devon and Cornwall …
Torbay Council
Sandwell — recommendation 2
Propose that the Tier 2 provider routinely checks ECAF upon receipt of particular referrals to ensure Early Help contacts and risks are collated
Black Country Partnership NHS Foundation Trust
Black Country Partnership NHS …
Brent — recommendation Brent Social Care
Brent Social Care considers developing and implementing a system to introduce more scrutiny to the management of repeat referrals.
Brent Children's Social Care
London Borough of Brent
Brent — recommendation Metropolitan Police
Brent BOCU must ensure that when children come to notice in the process of a domestic violence investigation, a Merlin entry is completed (vide Every Child Matters (ECM).
Metropolitan Police
Metropolitan Police Service
Aylesbury Vale — recommendation Recommendation 2 - B
Reports are analysed in a timely manner to identify any young people for whom we do not have a registered school base or an Elective Home Education base. Reports to include children on the data base for whose education base was closed before they become statutory school age.
Buckinghamshire Education Service
Aylesbury Vale — recommendation Recommendation for B
Processes in MASH and First Response will be reviewed by the Head of Service to ensure staff have due regard to the potential risks that home schooling and lack of engagement with universal services may have on the safety and welfare of children.
Buckinghamshire Children’s Social Care
Kent — recommendation 1.
Kent and Medway NHS and Social Care Partnership Trust must ensure that if patients disclose child abuse to professionals, the nature of this should be explored. Any further detail should be recorded and consideration given to sharing this information if serious criminal offences are disclosed because the patient may not …
Kent and Medway NHS and Social …
Kent and Medway NHS …
New Forest — recommendation 4
The Local Safeguarding Children’s Board to set out and implement actions to ensure that all agencies in contact with victims/survivors of abuse offer them support regardless of whether they are exhibiting obvious signs of distress; this includes multi-agency action plans made when a case does not meet the Children’s Social …
Local Safeguarding Children’s Board
Kirklees — recommendation 17
To develop strategies for the management of referrals where the situation is complex or there is a risk of poor outcomes for children and parents.
Kirklees Council Single Point of Access
Kirklees Council
Kirklees — recommendation 15
To ensure that specific family related questions are asked at SPA and point of referral, such as: Who lives with you? Does anyone support you? What is important in your life? Do you care for anyone? Do you have child(ren) / extended family? Do you need support if you are …
Kirklees Council Single Point of Access
Kirklees Council
Bristol — recommendation Bristol City Council
Early Help should ensure that agencies are aware that should concerns re-emerge that a new referral can and should be made.
Bristol City Council Children’s Early Help …
Bristol — recommendation Bristol City Council
Early Help should challenge case closure by commissioned services or external Lead Professionals when a full assessment of all the risk factors included in the referral have not been explored. There are systems in place whereby this could be actioned from immediate effect.
Bristol City Council Children’s Early Help …
Somerset — recommendation 9.8.2
Re-emphasize need for professional curiosity particularly when patient flagged as domestic abuse victim and presents with assault injuries to ED.
Taunton and Somerset NHS Foundation Trust
Taunton and Somerset NHS …
Harrow — recommendation 8
As a safeguard, the MARAC Coordinator will check with the referrer that a safeguarding referral has also been made where children are present.
Hestia
Harrow — recommendation 16
Improve Safeguarding practice (for children) so that alerts are made more proactively.
Compass
Tendring — recommendation 4.28
To support health visitors to identify when parental non-engagement could indicate increased risk of harm to a child.
Anglian Community Enterprises
Anglian Community Enterprise
CJINI inspection reports(7)
Child Exploitation – Report on the independent Inquiry
Abuse and Exploitation, Children and Young People
Nov 2014
Child Sexual Exploitation in Northern Ireland: An Inspection of the Criminal Justice System Response
Abuse and Exploitation, Children and Young People
Jun 2020
First joint inspection of Child Protection Arrangements
Abuse and Exploitation, Probation and Public Safety, Safegu…
Jun 2023
Child Sexual Exploitation Follow-Up Review: An assessment of the criminal justice system’s response
Abuse and Exploitation, Children and Young People
Dec 2025
An Inspection of child criminal exploitation in Northern Ireland
Abuse and Exploitation, Children and Young People
Feb 2026
Sexual Violence and Abuse: The handling of sexual violence and abuse by the criminal justice system in Northern Ireland
Domestic and Sexual Abuse, Crime
Jul 2010
An inspection of the handling of sexual offence cases by the justice system in Northern Ireland: Donagh sexual abuse cases inspection
Risk Management and public protection arrangements, Domesti…
Nov 2010