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 10 independent accountability sources, so the source mix matters as much as the headline total.
61 inquiry recs
48 PFD reports
41 committee recs
13 CQC actions
4 ICIBI recs
27 IOPC recs
1 IMB rec
1 detention investigation rec
18 PHSO decisions
1315 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(61)— showing 50 strongest matches
MAI-60 — Record images of students with weapons
Recommendation: It is recommended 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 …
Gov response: Home Secretary Suella Braverman made a statement to Parliament on 6 March 2023 following publication of Volume 3 on 2 March 2023. She stated: 'We will carefully consider the report's findings and recommendations in full' …
Accepted
MAI-54 — School records on radicalisation vulnerability
Recommendation: It is recommended 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. …
Gov response: Home Secretary Suella Braverman made a statement to Parliament on 6 March 2023 following publication of Volume 3 on 2 March 2023. She stated: 'We will carefully consider the report's findings and recommendations 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: Home Secretary Suella Braverman made a statement to Parliament on 6 March 2023 following publication of Volume 3 on 2 March 2023. She stated: 'We will carefully consider the report's findings and recommendations in full' …
Accepted
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
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, …
Response Pending
SP62 — Guidance on LEA and police visits to absent children
Recommendation: The Department for Education and the Home Office should review whether further guidance and/or minimum guidance is required in relation to local education authority and police visits to children not attending their place of education.
Response Pending
SP59 — Audit of safeguarding information transfer between schools
Recommendation: The Department for Education should carry out an audit to ensure that safeguarding information is reliably being passed between schools and should consider what further role Ofsted may play to strengthen protection in this area.
Response Pending
SP58 — KCSIE 2026 safeguarding information transfer
Recommendation: The Department for Education, in finalising the Keeping Children Safe in Education guidance 2026, and in any necessary amendments to other policy and guidance, should ensure that: 1. In cases where a child leaves a school because of permanent exclusion, …
Response Pending
SP57 — Agencies to respect school insight on risk
Recommendation: The Home Office (for police forces nationwide) Counter Terrorism Police Headquarters (for Prevent), Department of Health and Social Care (for all healthcare providers) and Ministry of Housing, Communities and Local Government (for all local authorities regarding their social care functions) …
Response Pending
SP46 — Addressing parental consent manipulation
Recommendation: 1. Lancashire County Council should consider how to address repeated lack of consent or manipulation of consent within existing legislation. 2. Phase 2 should consider whether legal reforms are needed to permit agencies, when considering children and young people who …
Response Pending
SP5 — Taxi company and school safeguarding arrangements
Recommendation: The Department for Transport should ensure that local authorities establish effective arrangements between licensed taxi companies and schools. These should enable school safeguarding teams to access taxi booking information where relevant to a legitimate safeguarding or risk concern relating to …
Response Pending
Prevention of Future Deaths reports(48)
Andrew Cairns, Rachael Slack and Auden Slack
Concerns: Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of a recent mental health assessment; an existing information-sharing policy was also undisclosed.
Overdue
Lauren Barfoot
Concerns: Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification and an ineffective search for the deceased. Social Services also failed to maintain comprehensive contact lists and hold timely strategy meetings.
Response (Bexley Borough Council): Bexley Children's Services have implemented lessons learned into social work practice, and a triage system is in place for when looked after children go missing. A risk assessment report is …
Response (Metropolitan Police Service): Greenwich Police enclosed a report detailing their actions, addressing information sharing and risk assessment, as well as their broader response to the serious case review that followed the death. Their …
Response (Ethelbert Childrens Services1): Ethelbert Childrens Services has implemented steps to address concerns regarding the collation of information, risk assessment, and contact details. They now complete a Met Police Missing Person Reporting Form upon …
Response (Ethelbert Childrens Services): Ethelbert Childrens Services has implemented steps to address concerns regarding the collation of information, risk assessment, and contact details. They now complete a Met Police Missing Person Reporting Form upon …
Responded
Alex Kelly
Concerns: A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic approach or consult outside agencies. A social worker allocation was also significantly delayed.
Response (Tower Hamlets): Tower Hamlets Council details actions taken following a Serious Case Review, including maintaining social worker numbers and updating a protocol with the Youth Offending Service to clarify responsibilities when a …
Response (Central North West London NHS Trust): Central and North West London NHS Trust (CNWL) describes its Health and Wellbeing Team's structure and processes, including mental health assessments and improved office space and IT access. They state …
Response (Oxleas NHS Trust): Oxleas NHS Foundation Trust describes implementation of the CHAT tool for assessing new arrivals at HMPYOI Cookham Wood, with training and monitoring standards. They detail information governance training for staff …
Response (Medway Youth Offending Service): The Medway Youth Offending Service (YOT) describes actions taken in response to the coroner's concerns including ACCT training for the Resettlement Team, enhanced reviews overseen by a Governor, and submission …
Response (Ministry of Justice): The Ministry of Justice outlines reforms in the Young People's Estate, including a standardised casework model, enhanced regimes, and changes to ACCT procedures. They detail night operating procedures and confirm …
Responded
Bradley Griffiths
Concerns: Health visitor services failed to maintain contact and track a child after the mother moved without providing new GP or address details, leading to lost records.
Response (Coventry and Warwickshire NHS Trust): The Trust had already implemented a 'No Trace' process and checklist, with a 3-month follow-up review and supervision by a Pre-School Manager to ensure all avenues have been considered before …
Overdue
Kesia Leatherbarrow
Concerns: Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team case, led to a lack of support for a high-risk young person.
Response (Department of Health): The Department of Health has shared the report with NHS England, who are working to develop Liaison and Diversion services in Greater Manchester. NHS England is also reshaping mental health …
Response (Home Office): The government has already made a partial change to PACE via the Criminal Justice and Courts Act to require 17 year olds to be treated as 10-16 year olds for …
Response (Pennine Care NHS Trust): Pennine Care NHS Foundation Trust has completed an investigation, requesting written clinical summaries and risk assessments when young people transfer from other mental health services. The health diversion pathway has …
Response (Crown Prosecution Service): The CPS has modified CPS training so advocates conducting youth court cases are reminded that a youth can always be remanded for their "own welfare". The Chief Crown Prosecutor for …
Overdue
Solomon Bealey
Concerns: Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was taken after failed contact attempts.
Response: Norwich Practices Health Centre will have a standing agenda item called 'Patients of Concern' at their weekly clinical meeting, and have agreed to have a 'Patients of Significant Concern' register …
Responded
Harry Mellor
Concerns: There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with chronic health needs, as specialist teams are not informed.
Response (Department of Health): The Department of Health acknowledges concerns about GP registration/de-registration, explains the current system and other opportunities for ensuring child healthcare, and notes the hospital's failure to follow up on missed …
Response (UK Health Security Agency): PHE states it doesn't have a direct role in GP registration, notes NHS England can comment on the regulation and procedure, and has alerted the relevant NHS England team and …
Response (GMC): The GMC outlines its role in setting standards for doctors but states it doesn't have a direct role in healthcare service design; it highlights existing guidance and ongoing work by …
Response (CCG): The CCG is appointing an independent author to review GP involvement in the case as part of a serious case review and has requested assurance from specialist paediatric services that …
Overdue
Amelia Calvo
Concerns: The death was contributed to by inadequate guarding of an endotracheal tube in a ventilated baby and a critical breakdown in communication among medical staff during a theatre procedure.
Response (Central Manchester University Hospitals NHS Trust): RMCH revised the Team Brief used in theatres, implemented an Introductions Board, and confirmed that if the operating surgeon is not present, the patient will not be sent for. Paediatric …
Overdue
Karnel Haughton
Concerns: Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support for parents, risking further injuries and deaths.
Overdue
Carol Leesley
Concerns: A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.
Response (Sheffield City Council): Sheffield City Council has amended the automated response to safeguarding reports to include a notification that, if the person making the report is not contacted within 2 working days, they …
Responded
Rachal Murphy
Concerns: No specific concerns were detailed in the provided text for this report.
Response: Tameside Early Help Services has undertaken a review of caseloads and allocation of work, leading to a significant reduction in the allocation of cases. In the past six months, any …
Response (Grosvenor Medical Centre): The practice has searched for patients on sodium valproate, invited them for LFTs if not checked in the last year, and added alerts to patient notes to schedule annual LFTs. …
Overdue
Chadrack Mulo
Concerns: School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a need for wider adoption of immediate welfare checks.
Response (Department for Education): The Department for Education will update the 'Keeping Children Safe in Education' and 'School Attendance' guidance to recommend schools hold multiple contact numbers and clarify the link between attendance and …
Responded
Terry Latimer
Concerns: A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.
Overdue
Sofia Legg
Concerns: Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. Critical safeguarding advice, like not leaving the patient alone, was not properly documented or communicated.
Response (Somerset Safeguarding Children Board): The Somerset Safeguarding Children Board is proposing to commission a thematic learning review to establish whether there are any specific issues that need to be addressed by organisations in Somerset.
Response (Somerset NHS CCG): The CCG notes that there is now a single point of access (SPA) for CAMHS, outlining improved access. They are working with the Trust to ensure the sharing of documented …
Response (Somerset County Council): The multi-agency Child Death Overview Panel (CDOP) made recommendations including clearer communication of crisis plans with parents, earlier school liaison, easier CAMHS access to senior medical staff, and more sensitive …
Response (Somerset NHS Trust): The Trust has commenced training staff in national investigation tools and techniques with a cohort of trained investigators to be in place by the end of 2017. Bereaved families are …
Responded
Ellie Butler
Concerns: No specific concerns were detailed in the provided text, only a reference to appended concerns.
Overdue
Edward Joyce
Concerns: A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness of burn complications and follow-up advice.
Response (Chelsea and Westminster Hospital NHS Trust): The Trust states the evidence indicates a temperature spike was not mentioned during the phone call, and the national information leaflet contains accepted advice and correct symptoms for burns injuries. …
Overdue
Janie McFadyen
Concerns: No specific concerns were detailed in the provided text.
Response (Victory Outreach): Victory Outreach Manchester has reviewed its policies and procedures, and implemented changes to comply with current regulations, including improvements to communication and reporting channels. They have also experienced a similar …
Response (Charity Commission): The Charity Commission has provided regulatory advice to Victory Outreach Manchester and requires that implemented changes are embedded. A program of diversified training is to be agreed and delivered, charges …
Responded
Caspian Thorn
Concerns: Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to missed opportunities for monitoring a vulnerable baby and identifying early sepsis.
Overdue
Archie Spriggs
Concerns: The concerns are covered within the 8 recommendations of the SCR regarding referral pathways, understanding of private law proceedings, notification processes for Section 37 reports, and engagement with multi-agency frontline staff.
Response (SSP): The Shropshire Safeguarding Partnership (SSP) acknowledges the report and states they are responsible for owning and governing delivery against the action plan related to the Serious Case Review, which was …
Overdue
Shneur Kaye
Concerns: Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.
Response (North Manchester Care Organisation): North Manchester Care Organisation outlines changes implemented after the incident, including revised discharge processes for children presenting to A&E with overdoses, new referral pathways for children with mental health needs, …
Response (Bury Council): Bury Council conducted a service review of the Multi Agency Safeguarding Hub (MASH) in early 2022, reinforcing strength-based practices and parental involvement unless safeguarding or legal reasons prevent it. The …
Responded
Avis Addison
Concerns: Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.
Response (CQC): Following the regulation 28 notice, CQC contacted the registered person of the GP practice, and were assured about the management of safeguarding and vulnerable patients; learning from the inquest will …
Responded
Xuanze Piao
Concerns: The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal risk, revealing a lack of clear communication policy.
Response (Coventry University): Coventry University is undertaking a full review of its policy and procedures relating to students who are under the age of 18, expected to be complete by January 31, 2021. …
Responded
Roy Curtis
Concerns: Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.
Response (Milton Keynes Council): Milton Keynes Council has employed a link social worker to work with the acute mental health hospital ward to coordinate social care assessments before discharge. They have also reviewed Autism …
Responded
Chelsie Greatorex
Concerns: The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.
Response (Home Office): The Home Office is conducting a review of the criminal justice response to rape, consulting on a new Victims’ Law, and investing in rape support centers and Independent Sexual Violence …
Response (MPS Redaction): The MPS is developing a Suicide Prevention Policy Document and Toolkit, including information on suicide prevention, support services, risk indicators, contacts and best practice, with a draft expected by the …
Responded
Christopher Smith
Concerns: The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of kin notification, unaddressed complex care needs, and the patient being discharged to unsafe living conditions.
Overdue
Lily-Mai George
Concerns: Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries before a planned safe placement could occur.
Overdue
Samantha Gould and Christine Gould
Concerns: Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance for police on communicating with such vulnerable minors.
Response (National Police Chiefs' Council): The NPCC has implemented an immediate addition to the Authorised Professional Practice (APP) guidance for all UK Police Forces, focusing on police engagement with reluctant victims/witnesses and ongoing support strategies. …
Response (Cambridgeshire County Council): Cambridgeshire County Council has launched the 'Strong Families Strong Communities' strategy (March 2021) and the YOUnited partnership (July 2021) to enhance emotional health and wellbeing services for children and young …
Response (Cambridgeshire and Peterborough NHS Foundation Trust): The Trust is reviewing its AWOL policy (completion by Oct 2021), undertaking a full policy review over six months, reminding doctors of ICD 11 changes, and developing a new joint …
Responded
Marc Bennett
Concerns: There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding child protection investigations and providing appropriate mental health support to parents.
Overdue
Joan Prescott
Concerns: Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare visit. This represented a missed opportunity to formally address broader safeguarding concerns.
Overdue
Harper Denton
Concerns: Police forces failed to adopt guidance for managing violent offenders and lacked proactive information sharing to protect children. Additionally, a national register for child cruelty offenders is missing, and health visitor safeguarding assessments are not mandatory.
Response (National Police Chiefs Council): The College of Policing will update APP (Authorised Professional Practice) within three months to clarify that disclosure of information about a person who poses a risk of harm can be …
Response (Metropolitan Police Service): The MPS is reviewing its MAPPA processes, including scoping the feasibility of introducing a Potentially Dangerous Person (PDP) process as outlined by the College of Policing’s APP Guidance; the outcome …
Response (Home Office): The Home Office is considering options for better management of domestic abuse offenders, including a domestic abuse 'register', and is working to improve information and data sharing between agencies for …
Response (Department of Health and Social Care): The Department is updating resources for health visitors and school nurses, emphasizing assessments of family relationships and chronology of events for children with additional needs, due to be published shortly. …
Responded
Melsadie Parris
Concerns: Social work failed to conduct renewed home visits or liaise with mental health teams regarding a carer's admitted psychosis, relying on old assessments and missing critical information about the carer's deteriorating mental state.
Response (Buckinghamshire Council): Buckinghamshire Children's Social Care acknowledges the coroner's concerns regarding a comment made by a carer. They note the coroner's finding that the child was not at risk at the time …
Responded
Lucy Walles
Concerns: Systemic issues in safeguarding, mental health provision, and inter-agency communication led to inadequate support for a vulnerable person. Concerns include slow safeguarding referrals, insufficient staff training, and resource adequacy across council and health services.
Response (Berkshire Healthcare NHS Foundation Trust): Berkshire Healthcare NHS Foundation Trust describes the 'One Team' program to improve mental health services, including clear care plans, named workers, and connections to meaningful activities. They have implemented measures …
Response (Reading Borough Council): Reading Borough Council has made improvements to the management of safeguarding referrals, including a dedicated safeguarding worker and adherence to Berkshire Safeguarding Policy. They have implemented a Quality Assurance Framework …
Responded
Sylvia Pollitt
Concerns: The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed to monitor referral outcomes, missing crucial safety oversight for vulnerable adults.
Response (LQ): L&Q took immediate action following the inquest, including self-referring to the Regulator for Social Housing. They have implemented additional processes and checks, including aligning call recording processes, instituting weekly meetings …
Responded
Nicholas Stout
Concerns: Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and safeguarding referrals for children are frequently missed.
Response (Tees Esk & Wear Valley NHS Foundation Trust): The Trust has implemented actions including updated risk assessment tools, safety plans, and a new Caseload Management Supervision Policy to support staff and improve patient safety.
Response (Tees Esk & Wear Valley NHS Foundation Trust): Tees Esk & Wear Valley NHS Foundation Trust has implemented and embedded several actions following this incident. These include improving timely assessment and treatment for people experiencing a mental health …
Responded
Jacqueline Carrey
Concerns: The patient's medical record lacked clear indication of potential abuse risk, and this crucial information was not flagged to staff before discharge, highlighting failures in record-keeping and communication.
Response (Milton Keynes University Hospital NHS Foundation Trust): Milton Keynes University Hospital has incorporated new measures into their EHR that codify information regarding restrictions on medicines supplied at discharge, including alerts for both doctors and pharmacists.
Responded
Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent
Concerns: Probation Service offender records lacked clear, prominent recording of critical risk information, leading to unread vital details and insufficient domestic abuse and child safeguarding checks. Systemic issues contributed to ongoing risks.
Response (Derbyshire Healthcare NHS Foundation Trust): Phoenix Futures will send a Probation Feedback Form within 48 hours of attended appointments and 24 hours of failed appointments and will conduct monthly audits of compliance.
Response (HM Prison and Probation Service): HMPPS is updating guidance on Drug Rehabilitation Requirements (DRR) and Alcohol Treatment Requirements (ATR), and has launched new joint working arrangements detailing the roles and responsibilities of both the Probation …
Response (Capita): Capita reinforced safeguarding requirements, created a mandatory training module, and implemented a 'clear chain notification' (CCN) for reporting potential risk of harm. The contract with MOJ ends 30 April 2024 …
Overdue
Michaela Hall
Concerns: Children and Adult Services failed to consider the family as a whole, lacked written rationale for care needs and safeguarding decisions, and neglected health-related enquiries despite signs of mental impairment.
Response (Devon and Cornwall Police): Devon & Cornwall Police are delivering further communications to all response officers confirming that the responsibility for actively reviewing logs resides with the CIM and response Sergeants. They have also …
Response (HM Prison and Probation Service): The HM Prison and Probation Service is consulting on new guidance clarifying when Probation Officers (POs) or Probation Services Officers (PSOs) should prepare pre-sentence reports, and is giving careful consideration …
Response (Cornwall Council): Cornwall Council is working with colleagues through the Domestic Homicide Review process to identify actions stemming from the Senior Coroner’s proposed recommendations. Safer Futures is reviewing practices around family involvement …
Responded
Karen Thomason
Concerns: Hospital safeguarding procedures were flawed, treating forms as a tick-box exercise and failing to communicate with support agencies. There was also a misinterpretation of patient capacity leading to unaddressed obvious vulnerability.
Response (North Cumbria Integrated Care NHS Foundation Trust): North Cumbria Integrated Care will review safeguarding training and processes and implement a standardised, consistent approach for patients who present to the emergency department with alcohol issues. An ED safeguarding …
Responded
Christopher Vickers
Concerns: There were multiple missed opportunities to coordinate care through multi-disciplinary meetings and to make safeguarding referrals despite the deceased's known escalating risks.
Response (Cumbria Northumberland Tyne and Wear NHS Foundation Trust): The Trust has implemented changes to ensure relevant safeguarding referrals and multi-agency meetings are convened, including changes to MDT processes and safeguarding as a standard agenda item; also improved engagement …
Response (South Tyneside Council): South Tyneside Council expressed condolences and stated that changes had already been made and that they had further re-evaluated internal policies and procedures. They detailed actions taken prior to the …
Responded
Jacob Shorter
Concerns: Crucial information about previous suicidal ideation was not shared with foster carers. Calderdale Council lacks clear training and escalation routes for mental health concerns, creating a risk of future deaths.
Response (Calderdale Council): The council plans to provide Independent Visitor volunteers with Mental Health First Aid Training where necessary, and to include a specific topic relating to suicide prevention and signs in the …
Responded
Lee-Ann Ince
Concerns: Agencies supporting the victim lacked understanding of coercive control and the impact of "love bombing." Children's concerns were overlooked, and the victim's physical health vulnerability was not recognised, increasing her risk.
Response (Greater Manchester Integrated Care): NHS Greater Manchester Integrated Care (NHS GM) and partners will translate recommendations into tangible actions, and the Community Safety Partnership Board will retain local governance to ensure actions are met …
Response (Greater Manchester Integrated Care): Trafford Council and NHS GM are planning specialist training on the Care Act & Domestic Abuse, and a dedicated task & finish group to develop their approach to supporting victims …
Responded
Henry Grierson
Concerns: The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication breakdown between the college and mental health organizations.
Response (Huddersfield New College): The college has reviewed and amended relevant policies and processes for contacting external agencies, particularly where a Welfare Plan has been created or when permanent exclusion is being implemented as …
Overdue
Mazeedat Adeoye
Concerns: The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child services demonstrated unprofessional, hostile behaviour, poor management, inadequate supervision, and substandard note-keeping, risking sub-optimal care for vulnerable individuals.
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges the report and expresses condolences. They state that the Department of Education has oversight for child social care and is best placed …
Response (Social Work England): Social Work England acknowledges the coroner's concerns and is reviewing documentation and recordings from the inquest to determine if there are reasonable grounds to investigate any of the individual social …
Response (Newham Council): The London Borough of Newham has re-evaluated internal policies and procedures and made significant changes and improvements, including a review of complaints, annual audits focusing on single parents with limited …
Response (National Police Air Service): NPAS will use footage from the incident as a case study/training tool to encourage Tactical Flight Officers to think beyond initial information in similar search scenarios, starting with the next …
Responded
Janet Scott
Concerns: The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if they believe others are informed, risking a fragmented multi-agency approach.
Response (Northumberland Childrens and Adults Safeguarding Partnership): NCASP will require teams across the partnership to feedback when newly introduced policies and guidance, including those on self-neglect have been discussed and the changes to practice that will follow. …
Responded
Alexander Eastwood
Concerns: There is a lack of guidance and regulation for children's contact sports, particularly for unofficial matches, leading to an absence of minimum standards for safeguarding, medical support, and risk management.
Response (Department For Culture Media And Sport): The Department is exploring ways to improve the safety and welfare of children in martial arts, asking Sport England to work with the Martial Arts Safeguarding Group, and ensuring parents …
Responded
Ella Murray
Concerns: Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an inability to convene urgent multi-agency meetings, meant a vulnerable child was left in an unsafe home environment.
Response (NHS England): NHS England acknowledges concerns about the death of Ella Murray, focusing on areas within its national policy remit, and will consider the ICB's response. It highlights the role of Integrated …
Response (Department of Health and Social Care): The Department of Health and Social Care expresses condolences and refers the coroner to NHS England, Kent and Medway Integrated Care Board, and the Department for Education for specific responses. …
Overdue
Evelyn Rae Le Masurier-O’Sullivan
Concerns: Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and escalation.
Overdue
[REDACTED]
Concerns: Child death investigation teams may be too easily reassured by well-presented homes, leading to perfunctory scene examinations and lost forensic opportunities.
Overdue
Select committee recommendations(41)
#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 …
Gov response: As noted above, the Government is committed to ensuring an effective immigration and asylum system and has retained certain measures of the IMA 2023 where they have been assessed as beneficial to that aim. The …
Under Consideration
#24 —
Recommendation: The Government must keep under review the efficacy of the mandatory reporting duty once it is in place, with a view to expanding its scope if necessary. The Government should also reconsider the consequence of failing to comply with the …
Gov response: Our aim in delivering mandatory reporting is to create a culture of support, knowledge and openness when dealing with child sexual abuse. Applying criminal sanctions to a failure to report could instead create a defensive, …
Not Accepted
#23 —
Recommendation: We welcome the introduction of mandatory reporting of child sexual abuse, which represents an important step forward for protection of children’s human rights. However, we are concerned that the scope of the duty and particularly the consequences of breach may …
Gov response: Our aim in delivering mandatory reporting is to create a culture of support, knowledge and openness when dealing with child sexual abuse. Applying criminal sanctions to a failure to report could instead create a defensive, …
Not Accepted
#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 …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: January 2022 2.2 The department continues to work with the Association of Directors of Children’s Services (ADCS) and local authorities (LAs) to collect, interpret …
Under Consideration
#24 —
Recommendation: HMCI Amanda Spielman told us it was “very un-joined up” that children who were on a child protection plan and experiencing harm could be withdrawn into home education. We share HMCI’s concerns and call on the Department to ensure that …
Gov response: 25. The Department continues to review all key statutory guidance regularly. We will consider including EHE in Working Together to Safeguard Children at the next review point.
Under Consideration
#31 — Significant failings in age assessment lead to children in adult asylum accommodation
Recommendation: There are significant failings in the current processes for making initial decisions about age and unreliable decisions are still leading to children being incorrectly placed in adult accommodation. We do not have confidence that the arrangements for accommodation providers to …
Gov response: The Home Office has made significant progress with regards to protecting the welfare of UASC. In line with the direction of the court, the Home Office closed all remaining emergency UASC hotels by January 2024 …
Not Addressed
#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, …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: January 2022 2.2 The department continues to work with the Association of Directors of Children’s Services (ADCS) and local authorities (LAs) to collect, interpret …
Under Consideration
#20 —
Recommendation: The Department must revisit and revise key statutory guidance such as Working Together to Safeguard Children as soon as possible, so that they explicitly contain EHE within their scope, and contain clear and consistent messages for families, local authorities and …
Gov response: 25. The Department continues to review all key statutory guidance regularly. We will consider including EHE in Working Together to Safeguard Children at the next review point.
Under Consideration
#3 —
Recommendation: The Committee heard from home educators that home-educated children are not ‘invisible’, and that safeguarding has failed children who were already known to local authorities. However, the relevant authorities cannot begin to reach any children who may be at risk …
Gov response: 9. The Government remains committed to a form of local authority administered statutory registration to identify children not in school. This would likely encompass children who are electively home educated and those who are missing …
Under Consideration
#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 …
Gov response: The Department for Education (DfE) welcomes the Committee’s recommendation as an opportunity to strengthen the safeguarding and child protection system. DfE is committed to ensuring that Working Together to Safeguard Children 2018 statutory guidance is …
Partially Accepted
#13 —
Recommendation: We asked the Department for Education what is being done to review multi-agency safeguarding partnerships to ensure they work better and to stop horrific events, such as the cases of Star Hobson and Arthur Labinjo-Hughes from recurring. The Department for …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The government is committed to strengthening local multi-agency safeguarding arrangements. Stable Homes, Built on Love: implementation strategy and consultation published in February 2023 set …
Accepted
#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 …
Gov response: 144. The previous Parliamentary Under Secretary of State for Children and Families met with Her Majesty’s Chief Inspector at Ofsted on 14 June 2022 to discuss action that was being taken following the allegations of …
Under Consideration
#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 …
Gov response: 137. The care review and the CMA study into the children’s social care market have both highlighted that some private providers of children’s homes and fostering agencies have high levels of profit. 138. The CMA …
Under Consideration
#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 …
Gov response: 133. Government has invested billions into local services. Local authority spending on children’s services in 2020–21 was around £11bn, funded through local authorities’ core settlement (which is around £51bn per year,). 134. In April 2022, …
Under Consideration
#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 …
Gov response: 133. Government has invested billions into local services. Local authority spending on children’s services in 2020–21 was around £11bn, funded through local authorities’ core settlement (which is around £51bn per year,). 134. In April 2022, …
Under Consideration
#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 …
Gov response: 133. Government has invested billions into local services. Local authority spending on children’s services in 2020–21 was around £11bn, funded through local authorities’ core settlement (which is around £51bn per year,). 134. In April 2022, …
Under Consideration
#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 …
Gov response: We recognise the need for all pupils with SEND to get the support they need to thrive in education. The government is making an unprecedented level of investment into the SEND system: revenue funding in …
Under Consideration
#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 …
Gov response: The SEND and Alternative Provision Green Paper is a cornerstone in a suite of reforms. With the Schools White Paper and wider reforms to health and social care, we seek to create a coherent education, …
Under Consideration
#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, …
Gov response: The department agrees that looked-after children need access to a trusted individual who will ensure that their needs are properly met, and it is the role of VSHs to provide this advocacy in respect of …
Under Consideration
#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 …
Gov response: 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 …
Under Consideration
#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 …
Gov response: 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 …
Under Consideration
#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 …
Gov response: 107. As set out in the response to other recommendations above, looked-after children have priority in school admissions and statutory guidance for VSHs states that, when arranging a looked after child’s education placement, schools judged …
Accepted
#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 …
Gov response: Accept in principle. The department recognises the need to hold local authorities to account in terms of looked-after children not in school and failing to receive the education they deserve. This will be considered as …
Under Consideration
#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 …
Gov response: Accept in principle. The department recognises the need for more detailed data in terms of looked-after children who are missing education. This will be considered as part of our wider work to develop an implementation …
Under Consideration
#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 …
Gov response: Accept in principle. The department recognises the need for more detailed data in terms of looked-after children who are missing education. This will be considered as part of our wider work to develop an implementation …
Under Consideration
#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 …
Gov response: Accept in principle. The department recognises the need for more detailed data in terms of looked-after children who are missing education. This will be considered as part of our wider work to develop an implementation …
Under Consideration
#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 …
Gov response: The department wants all looked-after children to be cared for in placements that best suit their individual needs, and recognises the importance of those placements being as close to their home area as possible–so they …
Under Consideration
#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 …
Gov response: The department recognises that placement moves can have a significantly destabilising impact on looked-after children, and is committed to improving the placement system. This will be considered as part of our wider work to develop …
Under Consideration
#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 …
Gov response: The government recognises that a balance needs to be struck between children having the ability to live in accommodation that best suits their needs, and safeguarding concerns. The department also understands concerns regarding placement sufficiency …
Under Consideration
#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 …
Gov response: We agree with the Committee on the importance of this issue. On 6 July, we laid regulations that mean that no child under the age of 16 can be placed in unregulated accommodation. These regulations …
Accepted
#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 …
Gov response: Accept in principle. The department recognises the need for local authorities to be fully discharging their duties in terms of providing suitable full-time education for children in care, including robust guidance to support them in …
Under Consideration
#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 …
Gov response: Accept in principle. The department recognises the need for more detailed data in terms of looked-after children who are missing education. This will be considered as part of our wider work to develop an implementation …
Under Consideration
#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 …
Gov response: Accept in principle. The department recognises the need to hold Directors of Children’s Services (DCSs) to account in terms of looked-after children not in school and failing to receive the education they deserve. This will …
Under Consideration
#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 …
Gov response: The extended role of the Virtual School Head (VSH) was a key recommendation and commitment from the government’s 2019 Review of Children in Need13–a recommendation made all the more important given the disproportionate impact of …
Under Consideration
#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 …
Gov response: Data is of critical importance to having a clear picture and understanding of the experiences and outcomes of looked-after children. We will publish the recommended breakdowns in the 2023 releases. Improving data was one of …
Accepted
#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 …
Gov response: Data is of critical importance to having a clear picture and understanding of the experiences and outcomes of looked-after children. We will publish the recommended breakdowns in the 2023 releases. Improving data was one of …
Accepted
#16 —
Recommendation: The national Child Safeguarding Practice Review Panel, set up to commission reviews of serious child safeguarding cases, has consistently highlighted cases in which poor coordination between services, including insufficient joined-up leadership and a lack of appropriate and timely information-sharing around …
Gov response: 4a: PAC recommendation: • Government should set out within six months how it will ensure that learning from national reviews is built into day-to-day practise, including supporting appropriate and timely data sharing, by those working …
Accepted
#4 —
Recommendation: It is not clear how lessons and learning from changing threats, serious case reviews and child safeguarding review panels are embedded in day-to-day practice. Time and again reviews into child deaths highlight poor coordination between services, including insufficient joined-up leadership …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 ‘Stable Homes, Built on Love’, published by the Department for Education in February 2023 sets out plans to transform children’s social care, ensuring the …
Accepted
#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.
Gov response: 113. The Government agrees that the best place for unaccompanied asylum- seeking children (UASC) is within the care of a local authority. Six of seven hotels were closed on 30 November 2023, with the remaining …
Not Accepted
#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 …
Gov response: We recognise the importance of professionals having the right skills and understanding to respond effectively to HBA. We are clear that cultural sensitivities must not be a barrier to tackling these crimes. That is why …
Under Consideration
#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 …
Partially Accepted
CQC inspection actions(13)
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
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 staff …
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 that South …
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)
PHSO casework decisions(18)
P-004411 — A practice in the Barnsley area
Mr A complains a GP Practice in the Barnsley area (the Practice) did not listen to or escalate his concerns over a safeguarding and domestic violence incident involving his parents and their neighbour in January 2025. He says the Practice did not signpost him to any other support organisations.
NHS in England
Nov 2025
P-004771 — A practice in the Barnet area
Miss P complains about aspects of the care and treatment her son, R, received from the Practice. She also complains about its handling of safeguarding concerns and complaint handling.
NHS in England
Feb 2026
P-001574 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs R complains the Trust did not give her son, Mr R, a care coordinator as agreed. She says it discharged him from the Children’s and Young People’s Service (CYPS) although he had been identified as a danger to himself and potentially others. She also says the Trust failed to …
NHS in England
Oct 2022
P-003474 — Children and Family Court Advisory and Support Service …
Mr X complains about Cafcass and the conduct of the Family Court Adviser (FCA) throughout the process. He says the FCA did not adhere to policy, which compromised their judgement to make an impartial recommendation in the Section 7 report. Mr X further complains that the FCA overlooked the safeguarding …
UK Government
Mar 2025
P-001840 — Cornwall Partnership NHS Foundation Trust
Mrs H complains about the Trust's service between 2017 and 2021. She complains it did not follow clinical guidelines to assess her son within the correct timeframe and CAMHS refused to assess him despite receiving eleven referrals.
NHS in England
Jan 2023
P-003574 — Alder Hey Children's NHS Foundation Trust
Mr H complains the Trusts misdiagnosed a skull fracture in his six month old son in December 2022. He also complains about being wrongly referred to social services because there was no plausible explanation for the injuries.
NHS in England
May 2025
P-004208 — A practice in the West Suffolk area
Mr B complains about the action of his family Practice when his daughter attended an appointment with symptoms of a urine infection. He complains that the Practice made an incorrect referral to the local safeguarding team.
NHS in England
Nov 2025
P-004326 — A practice in the Shropshire area
Dr A complains a GP Practice in Shropshire (the Practice) missed several opportunities to discover that his daughter, H was being bullied at school. He feels the Practice should have assigned H one specific GP for all appointments for consistency.
NHS in England
Nov 2025
P-004358 — Midlands Partnership University NHS Foundation Trust
Miss K complains the Trust attributed her sons attachment difficulties to her mental health, and refused to assess him for autism.
NHS in England
Nov 2025
P-004359 — Midlands Partnership University NHS Foundation Trust
Miss K complains the Trust refused to acknowledge her son had severe developmental delays and autistic traits, and refused to assess him for autism.
NHS in England
Nov 2025
P-002407 — London Ambulance Service NHS Trust
Mr L complains about a safeguarding referral that the Trust made after he and his wife called 111 because of a rash their son had. They complain about how the call was handled and that a random home visit was made as a result.
NHS in England
Jan 2024
P-003360 — The Queen Elizabeth Hospital King's Lynn NHS Foundation …
Miss C complains the Trust made a safeguarding referral about her when her baby was born.
NHS in England
Feb 2025
P-004639 — A practice in the Bexley area
Mr X complains about the service provided by a GP Practice following his discharge from hospital in November 2024. He is concerned that the Practice did not prioritise his physical health, focused inappropriately on his mental health, and made an unnecessary safeguarding referral about his children that included disputed information.
NHS in England
Not Upheld
Jan 2026
P-002512 — Hampshire Hospitals NHS Foundation Trust
Ms O complains about the Trust’s decision to make a safeguarding referral and that it failed to diagnose a fractured rib.
NHS in England
Mar 2024
P-003179 — Cambridgeshire Community Services NHS Trust
Miss Y complains that Cambridgeshire Community Services NHS Trust failed to listen to her concerns about her son, or to refer him to the correct services.
NHS in England
Partly Upheld
Nov 2024
P-003357 — The Hillingdon Hospitals NHS Foundation Trust
Mrs A is complaining the Hillingdon Hospitals NHS Foundation Trust failed to identify a perineal tear following birth in July 2023 and failed to identify a sacral dimple on her newborn child.
NHS in England
Feb 2025
P-003597 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs G complains about the way she and her husband were treated in April 2022 when they attended A&E with their foster child. Mrs G says the Trust did not consider the patient history when making a diagnosis and it speculated about how the injury happened.
NHS in England
Jun 2025
P-001738 — A practice in the Gateshead area
Miss T complains the Practice failed to investigate lumps in her breasts and to put her on a two-week referral path. She says this delayed the diagnosis and treatment of her breast cancer.
NHS in England
Jan 2023
LGO / SPSO decisions(1315)
24-022-732 — London Borough of Croydon
LGO (Local Government & …
Children S Care Services
25-013-452 — Isle of Wight Council
LGO (Local Government & …
Children S Care Services
25-013-019 — Kent County Council
LGO (Local Government & …
Children S Care Services
25-016-558 — Leeds City Council
LGO (Local Government & …
Children S Care Services
25-013-289 — London Borough of Barking & Dagenham
LGO (Local Government & …
Children S Care Services
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