Underinvestment in Children's Social Care
Historical underinvestment in children's social care, impacting family support and increasing reliance on family court interventions.
Source spread
Where this theme appears
This theme appears across 17 independent accountability sources, so the source mix matters as much as the headline total.
139 inquiry recs
35 PFD reports
466 committee recs
2 HSSIB recs
1 CQC action
3 ICIBI recs
2 IOPC recs
13 NAO recs
17 IMB recs
14 DHR recs
7 PHSO decisions
4232 LGO/SPSO decisions
8 CJINI reports
1 Law Commission project
1 CQC enforcement action
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(139)— showing 50 strongest matches
33 — Central resource for expertise and support
Recommendation: While practical assistance by way of extra staff may be obtained from geographically adjacent regions or failing that from other parts of Scotland (15.81) a central resource should be established to provide a high level of expertise for guidance, advice …
Unknown
86 — Review CSA support services expenditure (England)
Recommendation: The Chair and Panel recommend that the Department of Health and Social Care, the Department for Education, the Ministry of Justice and the Home Office work together to establish current levels of public expenditure, and the effectiveness of that expenditure …
Gov response: 63. The Government agrees that more clarity is needed on the effectiveness of public expenditure on services for victims of child sexual abuse. The recently published Victims Strategy includes commitments to undertake deep dives into …
Accepted
15 — Research high child remand population
Recommendation: The Inquiry was told that children should only be placed in custody as a last resort. However, it was concerned to hear evidence that some children are remanded in custody because of a lack of appropriate community provision. Given that …
No response yet
175 — Resources for training needs
Recommendation: Local and central government should consider as a matter of priority the problems of resource and facilities involved in meeting that need (19.10).
Unknown
FR-16 — Specialist Therapeutic Support
Recommendation: The Inquiry recommends that the UK government and the Welsh Government introduce a national guarantee that child victims of sexual abuse will be offered specialist and accredited therapeutic support. There should be sufficient supply of these services so that children …
Gov response: We accept that victims and survivors must be able to access effective systems for provision of therapeutic support. We will elicit views on the future of therapeutic support, including possible systemic changes to provision, through …
Accepted in part
WATE-(11) — Require field social workers to visit looked after children every eight weeks
Recommendation: Field social workers should be required by regulation to visit any looked after child for whom they are responsible not less than once every eight weeks916. In the case of older children, they should be required also to see the …
Unknown
LAMI-62 — Implement single agreed guidance for hospital social workers with out-of-area children
Recommendation: Where hospital-based social work staff come into contact with children from other local authority areas, the directors of social services of their employing authorities must ensure that they work to a single set of guidance agreed by all the authorities …
Unknown
LAMI-61 — Ensure hospital social workers participate in all child safeguarding hospital meetings
Recommendation: Directors of social services must ensure that hospital social workers participate in all hospital meetings concerned with the safeguarding of children.
Unknown
LAMI-60 — Line manage hospital social workers within children and families' services section
Recommendation: Directors of social services must ensure that hospital social workers working with children and families are line managed by the children and families’ section of their social services department.
Unknown
LAMI-59 — Provide single-source, up-to-date guidance and monitor adherence for staff
Recommendation: Directors of social services must ensure that staff working with vulnerable children and families are provided with up-to-date procedures, protocols and guidance. Such practice guidance must be located in a single-source document. The work should be monitored so as to …
Unknown
LAMI-58 — Require a properly maintained chronology in every child's case file
Recommendation: Directors of social services must ensure that every child’s case file includes, on the inside of the front cover, a properly maintained chronology.
Unknown
LAMI-57 — Ensure social workers can access international information on vulnerable children
Recommendation: Directors of social services must ensure that social work staff are made aware of how to access effectively information concerning vulnerable children which may be held in other countries.
Unknown
LAMI-56 — Prevent discharge of hospitalised children with concerns until home is safe
Recommendation: Directors of social services must ensure that no child known to social services who is an inpatient in a hospital and about whom there are child protection concerns is allowed to be taken home until it has been established by …
Unknown
LAMI-55 — Define 'allocated' cases as those with active social worker engagement
Recommendation: Directors of social services must ensure that only those cases in which a social worker is actively engaged in work with a child and the child’s family are deemed to be ‘allocated’.
Unknown
LAMI-54 — Allocate social workers to all children's cases or report unallocated cases monthly
Recommendation: Directors of social services must ensure that all cases of children assessed as needing a service have an allocated social worker. In cases where this proves to be impossible, arrangements must be made to maintain contact with the child. The …
Unknown
LAMI-53 — Managers must ensure social workers understand allocated cases, actions, and supervision
Recommendation: When allocating a case to a social worker, the manager must ensure that the social worker is clear as to what has been allocated, what action is required and how that action will be reviewed and supervised.
Unknown
LAMI-52 — Allocate cases only when social workers have adequate training, experience, and time
Recommendation: Directors of social services must ensure that no case is allocated to a social worker unless and until his or her manager ensures that he or she has the necessary training, experience and time to deal with it properly.
Unknown
LAMI-51 — Ensure strategy meetings include action points, records, and review mechanisms
Recommendation: Directors of social services must ensure that all strategy meetings and discussions involve the following three basic steps: • A list of action points must be drawn up, each with an agreed timescale and the identity of the person responsible …
Unknown
LAMI-50 — Implement systems to action communications during social services staff absence
Recommendation: Directors of social services must ensure that when staff are absent from work, systems are in place to ensure that post, emails and telephone contacts are checked and actioned as necessary.
Unknown
LAMI-49 — Review cases and meet professionals when other agencies raise concerns
Recommendation: When a professional from another agency expresses concern to social services about their handling of a particular case, the file must be read and reviewed, the professional concerned must be met and spoken to, and the outcome of this discussion …
Unknown
LAMI-48 — Require social worker agreement and record purpose for all agency referrals
Recommendation: Directors of social services must ensure that when children and families are referred to other agencies for additional services, that referral is only made with the agreement of the allocated social worker and/or their manager. The purpose of the referral …
Unknown
LAMI-47 — Provide 24/7 specialist services for children and families, separate from general teams
Recommendation: The chief executive of each local authority with social services responsibilities must ensure that specialist services are available to respond to the needs of children and families 24 hours a day, seven days a week. The safeguarding of children should …
Unknown
LAMI-46 — Ensure clear understanding of child protection adviser roles across children's services
Recommendation: Directors of social services must ensure that the roles and responsibilities of child protection advisers (and those employed in similar posts) are clearly understood by all those working within children’s services.
Unknown
LAMI-45 — Ensure regular supervision of staff working with children, including case file review
Recommendation: Directors of social services must ensure that the work of staff working directly with children is regularly supervised. This must include the supervisor reading, reviewing and signing the case file at regular intervals.
Unknown
LAMI-44 — Conduct six-monthly reviews of temporary staff promotions and record outcomes
Recommendation: When staff are temporarily promoted to fill vacancies, directors of social services must subject such arrangements to six-monthly reviews and record the outcome.
Unknown
LAMI-43 — Mandate training for Section 47 inquiries and audit staff for compliance
Recommendation: No social worker shall undertake section 47 inquiries unless he or she has been trained to do so. Directors of social services must undertake an audit of staff currently carrying out section 47 inquiries to identify gaps in training and …
Unknown
LAMI-42 — Implement systems to detect failures in internal social services case transfers
Recommendation: Directors of social services must ensure that where the procedures of a social services department stipulate requirements for the transfer of a case between teams within the department, systems are in place to detect when such a transfer does not …
Unknown
LAMI-41 — Require senior managers and councillors to regularly visit children's intake teams
Recommendation: Chief executives of local authorities with social services responsibilities must make arrangements for senior managers and councillors to regularly visit intake teams in their children’s services department, and to report their findings to the chief executive and social services committee.
Unknown
LAMI-40 — Establish mandatory steps for closing child harm cases, including welfare plan
Recommendation: Directors of social services must ensure that no case that has been opened in response to allegations of deliberate harm to a child is closed until the following steps have been taken: • The child has been spoken to alone. …
Unknown
LAMI-39 — Train front-line staff to promptly record and transfer child safety calls
Recommendation: All front-line staff within local authorities must be trained to pass all calls about the safety of children through to the appropriate duty team without delay, having first recorded the name of the child, his or her address, and the …
Unknown
LAMI-38 — Ensure inter-departmental case transfers are recorded and confirmed in writing
Recommendation: Directors of social services must ensure that the transfer of responsibility of a case between local authority social services departments is always recorded on the case file of each authority, and is confirmed in writing by the authority to which …
Unknown
LAMI-37 — Train social workers to confidently challenge other professionals' opinions on child needs
Recommendation: The training of social workers must equip them with the confidence to question the opinion of professionals in other agencies when conducting their own assessment of the needs of the child.
Unknown
LAMI-36 — Require legal advice before emergency child harm action, ensure 24-hour availability
Recommendation: No emergency action on a case concerning an allegation of deliberate harm to a child should be taken without first obtaining legal advice. Local authorities must ensure that such legal advice is available 24 hours a day.
Unknown
LAMI-35 — Ensure children subject to harm allegations are seen within 24 hours
Recommendation: Directors of social services must ensure that children who are the subject of allegations of deliberate harm are seen and spoken to within 24 hours of the allegation being communicated to social services. If this timescale is not met, the …
Unknown
LAMI-34 — Standardise social worker home visits: clarify purpose, check records, document findings
Recommendation: Social workers must not undertake home visits without being clear about the purpose of the visit, the information to be gathered during the course of it, and the steps to be taken if no one is at home. No visits …
Unknown
LAMI-33 — Establish 24-hour public referral line for child concerns, pilot electronic recording
Recommendation: Local authorities with responsibility for safeguarding children should establish and advertise a 24-hour free telephone referral number for use by members of the public who wish to report concerns about a child. A pilot study should be undertaken to evaluate …
Unknown
LAMI-32 — Ensure single, compatible electronic database for all children and families services
Recommendation: Local authority chief executives must ensure that only one electronic database system is used by all those working in children and families’ services for the recording of information. This should be the same system in use across the council, or …
Unknown
LAMI-31 — Ensure all staff working with children receive comprehensive vocational and ongoing training
Recommendation: Directors of social services must ensure that all staff who work with children have received appropriate vocational training, receive a thorough induction in local procedures and are obliged to participate in regular continuing training so as to ensure that their …
Unknown
LAMI-30 — Directors must ensure senior managers regularly inspect children's social services case files
Recommendation: Directors of social services must ensure that senior managers inspect, at least once every three months, a random selection of case files and supervision notes.
Unknown
LAMI-29 — Implement system for directors to monitor children's social services duty team data
Recommendation: Directors of social services must devise and implement a system which provides them with the following information about the work of the duty teams for which they are responsible: • number of children referred to the teams; • number of …
Unknown
LAMI-28 — Require local authorities to assess and plan improvements for children's duty systems
Recommendation: The Department of Health should require chief executives of local authorities with social services responsibilities to prepare a position statement on the true picture of the current strengths and weaknesses of their ‘front door’ duty systems for children and families. …
Unknown
LAMI-27 — Include children's services explicitly in local authority priorities and operational plans
Recommendation: Chief executives and lead members of local authorities with social services responsibilities must ensure that children’s services are explicitly included in their authority’s list of priorities and operational plans.
Unknown
LAMI-6 — Establish a Committee for Children and Families to coordinate inter-agency services
Recommendation: Each local authority with social services responsibilities must establish a Committee of Members for Children and Families with lay members drawn from the management committees of each of the key services. This Committee must ensure the services to children and …
Unknown
LAMI-5 — National Agency to conduct or oversee and publish serious child case reviews
Recommendation: The National Agency for Children and Families should, at their discretion, conduct serious case reviews (Part 8 reviews) or oversee the process if they decide to delegate this task to other agencies following the death or serious deliberate injury to …
Unknown
LAMI-4 — National Agency to use regional structure for local policy implementation and monitoring
Recommendation: The National Agency for Children and Families will operate through a regional structure which will ensure that legislation and policy are being implemented at a local level, as well as providing central government with up-to-date and reliable information about the …
Unknown
LAMI-3 — Establish National Agency to assess, advise, and monitor children and families policy
Recommendation: The newly established National Agency for Children and Families should have the following responsibilities: • to assess, and advise the ministerial Children and Families Board about, the impact on children and families of proposed changes in policy; • to scrutinise …
Unknown
184 — SWSG to promote training
Recommendation: SWSG should be given every encouragement to initiate and promote further and fuller facilities for training including joint training between agencies, to recognise the resource implications and to secure a level of training which will produce standards of practice to …
Unknown
95 — SWSG to increase foster carers
Recommendation: SWSG should take urgent steps to assist all local Social Work Departments in a positive initiative to increase their stock of foster carers (17.33).
Unknown
94 — Recruit foster carers in Orkney
Recommendation: Orkney Islands Council should take immediate steps to recruit more foster carers within the islands (17.32).
Unknown
34 — ADSW and SWSG resource group
Recommendation: ADSW with the support of SWSG should set about the creation of a resource group whose members would be available when required to advise any social work agency in cases of particular complexity (15.80).
Unknown
Prevention of Future Deaths reports(35)
Mary Stroman
Concerns: The coroner identifies delays in the decision-making and funding processes for long-term therapeutic placements, noting concerns that such delays could negatively impact an individual's mental health and contribute to self-harm or death.
Response (Haringey Council): • Management and oversight over decision-making processes, including assessment timeliness, have been strengthened and are reviewed weekly. • The Complex Care Panel's functioning has been refreshed, enabling more effective information … (AI summary)
Responded
George Werb
Concerns: The coroner noted a lack of an effective bed bureau system and insufficient local child psychiatric beds, leading to placements far from home. This resulted in inadequate facilities, disrupted family therapy, and communication issues, which impacted patient care.
Response (NHS England): • NHS England implemented a national situation report process and a weekly teleconference for CAMHS case managers to identify available inpatient bed capacity. • NHS England commissioned additional inpatient CAMHS … (AI summary)
Overdue
Alex Kelly
Concerns: The coroner identified concerns regarding the absence of forensic psychiatric assessments for vulnerable children entering custody, deficiencies in the ACCT process regarding external agency input and interpretation of distress, and issues with social worker allocation and documentation practices.
Response (Tower Hamlets): • The council confirmed that systems are in place to ensure all looked after children have an allocated social worker, including monthly reporting and an escalation policy for Independent Reviewing … (AI summary)
Response (Central North West London NHS Trust): • The Trust's new service has improved partnership working and information exchange among professionals. • Healthcare staff are required to share knowledge of medication non-compliance and have completed information governance … (AI summary)
Response (Oxleas NHS Trust): • The Trust confirmed that every child arriving at Cookham Wood is assessed using a Comprehensive Health Assessment Tool (CHAT), with staff trained in its use and monitoring standards implemented. … (AI summary)
Response (Ministry of Justice): • The Comprehensive Health Assessment Tool (CHAT) has been rolled out across the Young People's Estate for new admissions, with staff trained and standards in place for its use. • … (AI summary)
Responded
Isaac Nash
Concerns: The coroner noted that the river estuary part of Aberffraw beach can be subject to very strong currents, of which the public are unaware without local knowledge. The report suggests erecting signs to warn the public of this potential danger.
Response (Response Isle of Anglesey County Council): • The Council held six meetings with the local community, including the Aberffraw Community Council. • A risk assessment was undertaken by the Council's Maritime Team, and arrangements are in … (AI summary)
Responded
Efan James
Concerns: The coroner identified that guidance from the Welsh Assembly Government on reducing cot death was confusing, as it advised against bed-sharing if parents 'feel very tired,' a test deemed unrealistic.
Response (Welsh Government): • The Welsh Government asked the Wales Child Death Review team to review the guidance leaflet in light of the coroner's comments. • The review team concluded that the leaflet … (AI summary)
Responded
Tamara Mills
Concerns: The coroner noted a lack of coordinated, long-term management for the child's chronic asthma, with care focused solely on acute events and no single individual taking overall responsibility. This was compounded by poor communication between services and issues with specialist paediatric referrals.
Overdue
Peter Embra
Concerns: The local authority delayed in acting on an urgent GP referral for an assessment of Mr. Embra, resulting in approximately a one-week wait before a social worker visit.
Overdue
Amy El-Keria
Concerns: Hounslow Social Services had a misapprehension regarding their ongoing welfare role for a child placed at a facility. They also did not assess the need for support regarding family contact, despite the mother raising difficulties.
Response (Department of Health and Social Care): • NHS England commissioned guidance on staffing for mental health care, with completion expected by December 2017. • An additional 56 CAMHS inpatient beds have been commissioned, and £400 million … (AI summary)
Response (Department of Health): • NHS England and Health Education England are working to improve the capacity and capability of the workforce delivering mental health care for children and young people. • This work … (AI summary)
Response (London Borough of Hounslow): • The London Borough of Hounslow re-drafted and updated its Thresholds Guidance & Assessment Protocols. • The updated protocols include specific references to local authority duties for children placed away … (AI summary)
Response (Priory Group): • An enhanced Risk Assessment Tool was launched on 28 November 2016, and staff briefings on its use are underway. • Observation recording forms have been enhanced, and the policy … (AI summary)
Response (Priory Group): • An enhanced Risk Assessment Tool was launched on 28 November 2016, and staff briefings on its use are underway. • Observation recording forms have been enhanced, and the policy … (AI summary)
Responded
Brandon Singh Rayat
Concerns: The coroner noted a lack of long-term mental health care provision for children in Leicestershire who cannot attend hospital due to anxiety, as the existing CRISIS team is not equipped for this function.
Response (Leicestershire and Rutland NHS CCG): • A systematic review and update of the Children and Adolescent Mental Health Services (CAMHs) outpatient and community service specification has commenced. • Lessons learned from a Serious Incident investigation … (AI summary)
Response (Department of Health): • The Leicester, Leicestershire and Rutland Clinical Commissioning Groups (CCGs) commission outpatient and community Child and Adolescent Mental Health Services (CAMHS). • A new Crisis and Home Treatment service, operational … (AI summary)
Responded
Jac Davies
Concerns: The coroner identified that landlords in Wales are not under a legal duty to install working smoke alarms in rented properties, contrasting with the legal requirements in England.
Response: • The Welsh Government is consulting on draft regulations under the Renting Homes (Wales) Act 2016. • These draft regulations propose to place a legal duty on landlords to install … (AI summary)
Responded
Ellie Butler
Concerns: The provided text indicates that specific concerns were appended to the report but does not detail them.
Overdue
Karen Edgar
Concerns: The coroner noted underfunding and long delays in mental health services for children and young people in Cumbria. This raises concerns about young people entering adulthood with unresolved mental health issues, leading to significant human and financial costs.
Response (Department of Health Social Care): • The Government has made an additional £1.4 billion available to improve children and young people's mental health services. • NHS England has developed a service transformation programme and invested … (AI summary)
Overdue
Aryan Akhgar
Concerns: A gap in urgent mental health services meant 16 and 17-year-olds experienced delayed access to CAMHS input. The report notes uncertainty regarding guaranteed funding for additional resources to address this service gap.
Response (Sheffield Childrens NHS Trust): • An addendum to the Transitions Policy was approved and implemented in January 2019 to ensure emergency home treatment for 16/17 year olds by adult services. • A process for … (AI summary)
Response (Sheffield Childrens NHS CCG): • The business case for a CAMHS Home Intensive Treatment Team (HITT) was completed and approved by the Clinical Commissioning Group. • The Trust has begun recruiting nursing staff for … (AI summary)
Responded
Michael Cox
Concerns: The coroner identified a potential shortage of suitable placements for individuals with mental health history, leading to persistent difficulties for social workers and occupational therapists in finding appropriate facilities.
Response (Cornwall Council): • Cornwall Council has developed a draft multiagency Cornwall Complex Needs Strategy and a draft Adult Mental Health Strategy. • A multiagency operational dual diagnosis steering group was formed in … (AI summary)
Responded
Daniel Shorrocks
Concerns: The coroner asks the Department to review resource availability for Local Authorities with many young people in care and limited qualified staff, and to review the integration of services between Local Authority Care Services, Adolescent Mental Health Services, and educational pastoral care.
Response (Department of Health and Social Care): • The Department stated it would review the care system and allocated a 4.4% real-terms increase in Core Spending Power for local authorities for 2020-21, including an additional £1 billion … (AI summary)
Responded
Sam Grant
Concerns: Concerns were raised regarding a lack of accessible lower-level mental health support for young people who do not meet CAMHS thresholds. There were also gaps in information sharing between the GP, CAMHS, and school, hindering a comprehensive understanding of the individual's needs.
Overdue
Jacob Bates
Concerns: The coroner raised concerns that vulnerable 16-18 year olds are placed in unregulated settings, which lack statutory inspection and regulatory compliance. This means staff competency and adequate policies are not consistently verified, placing an impractical burden on local authorities for oversight.
Response (the Secretary of State for Education): • The Secretary of State for Education launched a consultation on proposals for unregulated provision on 12 February 2020. • The proposals include introducing new national standards for providers of … (AI summary)
Responded
Lily-Mai George
Concerns: Haringey Children’s Services facilitated the discharge of Lily-Mai into her parents' unsupervised care despite professional opposition. A subsequent decision for residential placement was not implemented before she suffered fatal injuries.
Overdue
Helena Opuku
Concerns: The London Borough of Redbridge adult social care team was unable to properly investigate most safeguarding referrals, appoint social workers in a timely manner, or carry out home suitability assessments for vulnerable residents during January-March 2021.
Overdue
Katrina Makunova
Concerns: Police and social services did not consistently recognise or record knife possession and gang affiliation as risk factors in assessments. Concerns were also raised about the Metropolitan Police Service's Child Safety Unit workload and capacity to effectively fulfil safeguarding roles.
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) will engage with academics to provide expert advice on considering knife carrying and gang membership in domestic abuse risk assessments. • Katrina Makunova's death … (AI summary)
Responded
Asher Sinclair
Concerns: The coroner identified that a highly vulnerable ventilator-dependent child did not consistently receive prescribed 2:1 care, and the complex care package lacked appropriate review, quality checks, and escalation of parents' concerns.
Response (NHS NorthWest London): • NHS North West London has established a single children’s continuing care team and implemented a standard operating procedure for consistent service delivery. • Reviews of care packages are now … (AI summary)
Response (Response form NHS England): • NHS England noted the existence of the National Tracheostomy Safety Project (NTSP), which provides resources for paediatric tracheostomy care. • NHS England delivered the 2020 Safer Tracheostomy Care program … (AI summary)
Responded
Lance Walker
Concerns: The coroner raised concerns about the lack of regulation for supported accommodation for 18-21 year olds, which means some providers lack adequate training and resources for complex needs. Additionally, there is no standard referral form for 16-25 year olds entering supported housing, which can lead to vital information being missed.
Overdue
Samuel Howes
Concerns: The provided document extract contains boilerplate text regarding report distribution and recipients, but does not detail specific coroner's concerns for future death prevention.
Response (NHS England): • NHS England has established Clinical Networks and regional delivery groups for mental health across NHS regions to support commissioning of effective services. • A Task and Finish Group is … (AI summary)
Response (Department of Health and Social Care): • The Department noted that spending on mental health services has increased by £4.7 billion between 2018/19 and 2023/24, with an aim for an additional 345,000 children and young people … (AI summary)
Responded
Leah Barber
Concerns: Bradford Council lacked a single point of overview or a system for coordinating its various departments' involvement with the deceased child, both before and after her death. This absence made it difficult for the Council to identify and learn lessons from the case.
Response (City of Bradford Metropolitan District Council): • The council confirmed it has strengthened processes to ensure organisational oversight when multiple teams are involved with a child who dies. • It implemented a risk register for serious … (AI summary)
Responded
Allison Aules
Concerns: The coroner raises concerns about significant under-resourcing of CAMHS, leading to delays in assessment, a lack of consultant psychiatrist leadership, and insufficient funding, amidst increasing demand.
Response (NHS England): • NHS England stated that significant additional funding, rising to over £900m in 2023/24, was allocated to increase access to children and young people's mental health support. • The children … (AI summary)
Response (North East London NHS Foundation Trust): • The Trust stated it continues to audit its work and provides monthly supervision to staff to ensure the young person's voice is captured and considered in care planning. • … (AI summary)
Response (North East London Integrated Care Board): • The Integrated Care Board is developing a business case to secure additional funding for CAMHS services, which will include proposals for seven-day and evening working and face-to-face initial assessments. … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care stated that spending on mental health services, including for children and young people, increased between 2018/19 and 2023/24. • The department reported … (AI summary)
Responded
David Hall
Concerns: The coroner raised concerns regarding the lack of suitable emergency social care placements in Stockport. This led to Mr Hall's hospital admission and subsequent rapid deterioration, as his needs could have been met more appropriately in a social care setting.
Response (Stockport Metropolitan Borough Council): • Stockport Metropolitan Borough Council stated it utilises block-booked residential and nursing beds within the community. • The council confirmed it has dedicated step-down capacity available to accommodate individuals. • … (AI summary)
Responded
Benjamin Hazelden
Concerns: The coroner noted a severe lack of suitable specialist placements and beds for young adults with autism who are at risk of self-harm or harm to others, leading to an unsuitable hospital stay and limited options for urgent care.
Overdue
Katie Madden
Concerns: The coroner noted a lack of formal systems to assess the mental health impact on vulnerable parents during child services interventions or to provide independent support. Concerns were also raised about the difficulty in securing funding for specialist therapy.
Response (NSFT): • NSFT has instructed clinicians receiving referrals to identify cases where treatments have been recommended by non-NSFT clinicians. • Clinicians will offer an assessment to determine if alternative treatments are … (AI summary)
Response (SCC): • Suffolk County Council will update MASH Standard Operating Procedures and practice notes to ensure practitioners identify adult vulnerabilities in safeguarding referrals. • A process of prompts in Multi-Agency Referral … (AI summary)
Response (Norfolk Waveney ICB): • The ICB reviewed its Mental Health Individual Funding Request records. • The ICB did not identify any Individual Funding Request for Schema-based Cognitive Behavioural Therapy made on behalf of … (AI summary)
Response (Suffolk Constabulary): • The Constabulary noted its existing practice of conducting risk assessments, including the wellbeing of the recipient, when delivering Claire's Law disclosures. • A domestic homicide review referral was completed … (AI summary)
Response (Department of Health and Social Care): • Norfolk and Suffolk NHS Foundation Trust has instructed its clinicians to identify referrals where external clinicians have recommended treatments, to facilitate assessment. • Norfolk & Waveney Integrated Care Board … (AI summary)
Responded
Amina Ismail
Concerns: The coroner noted underfunding for local mental health beds and a national scarcity of specialist Personality Disorder rehabilitation units, which contributed to delayed patient transfers and prolonged stays in unsuitable out-of-area placements.
Response (NHS England): • NHS England launched the Mental Health, Learning Disability and Autism Inpatient Quality Transformation programme, which included publishing a commissioning framework and requiring Integrated Care Boards to develop 3-year plans … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care stated it would continue to work with NHS England to maximise mental health capacity. • The Department of Health and Social Care … (AI summary)
Responded
Nathan Scantlebury
Concerns: The coroner noted the ongoing local and national lack of suitable placements for high-risk children with complex mental health needs.
Response (NHS England): • NHS England has introduced NHS-Led Provider Collaboratives and invested funding to enhance local inpatient and alternative provision for children and young people. • A CYPMH Transformation Programme is developing … (AI summary)
Response (Department of Health and Social Care): • The Department stated it would work with NHS England to ensure appropriate steps are taken. • The model of inpatient mental health care is being re-designed to enable a … (AI summary)
Overdue
Sunnah Khan and Joseph Abbess
Concerns: The coroner notes that many children do not receive vital water safety education in school, resulting in insufficient awareness of water dangers. This situation is compounded by reduced access to swimming pools and the voluntary nature of supplementary water safety initiatives.
Response (Department for Education): • The Department will consider how to ensure all pupils are taught water safety through changes to statutory Health Education. • The Department committed to supporting the RLSS UK’s 2025 … (AI summary)
Responded
Jennifer Chalkley
Concerns: The coroner notes a widespread misunderstanding among schools and colleges that £6,000 must be spent on a child’s Special Educational Needs before applying for a statutory assessment. This delay in assessment and early support may increase the risk of mental health difficulties and suicidality developing.
Response (Surrey County Council): • Surrey County Council prepared a communication for all Surrey education providers. • The communication clarifies that no financial threshold is a prerequisite for an Education, Health, and Care Needs … (AI summary)
Response (Department for Education): • The Department for Education wrote to local authorities to clarify the statutory threshold for EHC plan consideration and stated it would keep related guidance under review. • The Department … (AI summary)
Responded
Ellame Ford-Dunn Prevention of future deaths report
Concerns: The coroner noted insufficient Tier 4 Paediatric Mental Health beds and an average 8-day wait. Children needing mental health care are accommodated on acute paediatric wards not designed or staffed for their needs, lacking community care or specialist beds.
Response (NHS England): • NHS England published a framework in 2022 to support acute paediatric settings in providing care for children with mental health needs and launched a digital platform for staff training. … (AI summary)
Responded
Emma Turner
Concerns: The coroner identified inadequate information sharing and system connectivity between agencies. The GP safeguarding referral form for vulnerable adults with learning difficulties was found not tailored to GP input, risking incomplete information and delayed responses.
Response (Derby City Council): • Derby City Council and Derbyshire County Council are co-producing a revised Safeguarding Adults Referral Form with partners. • The revised form will aim to clarify critical information, ensure questions … (AI summary)
Overdue
Elizabeth Lang and Katie Lang
Concerns: The coroner identified a low coefficient of friction on the road surface at the bend where the collision occurred. Additionally, there was an absence of advance warning signage to alert drivers to the severity of the notorious bend.
Response (Northumberland County Council): • The Council identified the location on the A1068 Sheepwash Road as a high-risk site and included it in the 2026–2027 Local Transport Plan programme for traffic safety improvements. • … (AI summary)
Responded
Select committee recommendations(466)— showing 50 strongest matches
#26 —
Recommendation: We agree with the Children’s Commissioner: the government and Ofsted must sort this out and must move children to suitable regulated accommodation as a matter of urgency. We also agree that measures that should be explored include increasing efforts to …
Response status not verified
#22 —
Recommendation: We welcome the changes introduced by the Children’s Wellbeing and Schools Act 2026 to require local authorities to allow reasonable contact between children in care and their siblings but note that such a flexible 101 standard could be interpreted narrowly …
Response status not verified
#19 —
Recommendation: We welcome the expansion of Regional Care Cooperatives (RCCs), alongside the suite of changes to combat care market profiteering. While it is too early to tell whether these measures will be effective, these are steps in the right direction. Alongside …
Response status not verified
#18 —
Recommendation: We agree with the government that the children’s social care market is fundamentally broken. There is a serious sufficiency crisis across the country, leading to children not being placed in accommodation that supports their needs. (Conclusion, Paragraph 106)
Response status not verified
#17 —
Recommendation: We welcome the Kinship Allowance Pilot, and we welcome the initiative by some local authorities to provide financial support to kinship carers prior to, and outside of, the Pilot. But efforts must not end there. The majority of children in …
Response status not verified
#16 —
Recommendation: Kinship carers and the children they care for in England are often in need of financial support, and inconsistent provision of that support can place them in significant difficulties. This is especially the case when informal arrangements are in place. …
Response status not verified
#11 —
Recommendation: The lack of national eligibility criteria for the provision of support to disabled children means that some children are able to receive the support they need while others with similar needs are unable to receive support simply because of where …
Response status not verified
#12 —
Recommendation: Many children with SEND may be happiest educated at home, but this should absolutely not be a choice that parents are forced to make for lack of the right support. We accept that what begins as a negative choice can …
Response attribution not verified
#16 —
Recommendation: The Department told us it wants the care system to be more flexible, and accepts the system is currently not very good at adapting to innovative or usual requests. The result is that the child will often end up in …
Response attribution not verified
#14 —
Recommendation: At 31 March 2021, there were 53,790 adolescents in care between the ages of 9 and 17, making up 67% of the total care population. Between 31 March 2014 and 31 March 2021 the number of 9- to 17-year-olds in …
Response attribution not verified
#6 — Mandate DfE to provide support for local authorities to manage long-term sustainable SEN spending.
Recommendation: In the longer term, the SEN system remains unviable with piecemeal interventions, such as Safety Valve, doing nothing to provide a financially sustainable system. Based on the Department’s current forecasts on the need for SEN support, the annual gap between …
Response attribution not verified
#5 — Require central government to involve local authorities in solving critical SEN financial challenges.
Recommendation: Departmental witnesses could not provide any potential solution to the critical and immediate financial challenges facing many local authorities due to persistent and significant SEN-related overspends. The impact of these are being deferred under the temporary “statutory override” scheme, which …
Response attribution not verified
#8 — Increased spending on SEND and temporary accommodation fails to meet people's needs.
Recommendation: Despite increased spending , there are indications that services are not meeting peoples’ needs, such as only 50% of Education, Health and Care (EHC) plans for children and young people being issued within the 20-week statutory limit in 2023.15 MHCLG …
Response attribution not verified
#72 — Care leavers face poorest outcomes due to insufficient support and limited Bill measures.
Recommendation: Care leavers have some of the poorest outcomes in society across a range of measures, and the support available to them falls far short of what is needed. The state has a grave responsibility to the children it takes 93 …
Response attribution not verified
#63 — Make funding available for a national survey on different types of child abuse and neglect.
Recommendation: The Department for Education should make funding available for a national survey on the prevalence of the different types of abuse and neglect, to improve its understanding of these issues and inform the development of future policy interventions. (Recommendation, Paragraph …
Response attribution not verified
#59 — Conduct review of disabled children’s short breaks availability and fund local authority provision.
Recommendation: The Department should conduct a review of the availability of short breaks, respite care and holiday provision for disabled children to understand where the shortages are most acute. It should work with the Ministry of Housing, 91 Communities and Local …
Response attribution not verified
#48 — Mental health support for children in care is currently falling far short of needs.
Recommendation: Children in care have experienced trauma, abuse and neglect, and they are over four times more likely to suffer from emotional or mental health problems than their peers. It is therefore essential that there is a strong system in place …
Response attribution not verified
#40 — Make Adoption and Special Guardianship Support Fund permanent; consult on a support plan.
Recommendation: The Department must end the annual cliff-edge of uncertainty faced by adoptive families and make funding for the Adoption and Special Guardianship Support Fund permanent. It should monitor the impact of the reduced funding limits after 12 months of the …
Response attribution not verified
#39 — Uncertainty surrounds Adoption and Special Guardianship Support Fund continuation and reduced funding limits.
Recommendation: It is unacceptable that the continuation of the Adoption and Special Guardianship Support Fund was not announced until 1 April 2025, leaving families and children uncertain about the future of their support. We also note many concerns about the new …
Response attribution not verified
#21 — Children's social care market is failing due to excessive profits and provider financial risk.
Recommendation: The children’s social care market is not delivering for children or for local authorities. We are particularly concerned at the reports of excessive profits being made by some providers and the risk of financial failure among large providers. We hope …
Response attribution not verified
#16 — Produce DfE analysis of funding needed for children's social care reforms and implementation plan.
Recommendation: The Department for Education should produce an analysis of the level of funding that is still needed to achieve the necessary reforms to children’s social care and set out how it will work towards achieving the level of funding recommended …
Response attribution not verified
#15 — Additional funding for children's social care welcomed, but full implementation funding gap remains.
Recommendation: We warmly welcome the additional funding for children’s social care and capital investment in children’s homes announced at the recent Spending Review, which will be an important step forward in working towards the amount recommended by the Independent Review of …
Response attribution not verified
#10 — Rising care numbers demand cross-departmental action to address external contributing factors.
Recommendation: The pressure caused by rising numbers of children coming into care is putting serious strain on the system. The only way to effectively reduce these numbers is to address the factors outside the care system which are contributing to this …
Response attribution not verified
#6 — Commit to making Families First permanent and restore early intervention funding to 2010 levels.
Recommendation: The Department for Education must commit to making the Families First Partnership programme permanent if it demonstrates a positive impact. The Government must ensure that a significant majority of the new funding announced in the Spending Review is allocated to …
Response attribution not verified
#5 — Early intervention funding remains insufficient despite welcome grants, requiring urgent additional resources.
Recommendation: The Government’s focus on early intervention is the right one and long overdue. The additional £270 million provided through the Children’s Social Care Prevention Grant is welcome but falls far short of the £1.2 billion that has been removed from …
Response attribution not verified
#2 — Require Department for Education to issue comprehensive response to Children’s Social Care Review by year-end.
Recommendation: By the end of this year, the Department for Education must issue a comprehensive response to the Independent Review of Children’s Social Care which was published over three years ago. This should set out which recommendations have already been taken …
Response attribution not verified
#1 — Children’s social care problems persist and worsen without comprehensive reform following the Independent Review.
Recommendation: Evidence given to the Committee during our inquiry indicates that many of the problems highlighted by the Independent Review of Children’s Social Care in 2022 persist, and in a significant number of cases have worsened since the Review. Increases in …
Response attribution not verified
#27 — Accelerate adult social care commission timescale and fully fund sector by Parliament's end
Recommendation: The timescale for the commission into adult social care should be brought forward, and it must present actionable reforms to the sector as part of its interim findings in 2026. The Government must not wait for the commission to publish …
Response attribution not verified
#26 — Proposed timescale for adult social care commission risks insufficient and delayed reform
Recommendation: While we support the new independent commission into adult social care led by Baroness Casey, we are concerned that the proposed timescale means that urgent reforms to social care services will not be implemented soon enough to overcome the severity …
Response attribution not verified
#25 — Inaction on adult social care reform creates unsustainable human and financial costs
Recommendation: We support and echo the conclusions of the recent report Adult Social Care Reform by the Health and Social Care committee. As they have said in the summary of their report, successive Governments have not fully considered the human and …
Response attribution not verified
#17 — FGM persists within UK and through travel abroad, undermined by inconsistent government funding.
Recommendation: It is a matter of serious concern that evidence given to us and available data indicate both that FGM is taking place in the UK and that UK citizens or residents are being taken abroad to undergo FGM. The Government …
Response attribution not verified
#19 — New investment in children's social care aims to reduce family court cases.
Recommendation: DfE told us its major contribution to the overall system is to reduce the flow of cases to family courts. It told us that successive governments have under-invested in children’s social care but the Spending Review in June this year …
Response status not verified
#81 — Require health sector financial investment and robust partnership arrangements by autumn 2026.
Recommendation: Crucially, this must be backed by appropriate financial investment from the health sector to meet statutory duties, provide timely access to therapies and assessments, and contribute equitably to joint commissioning arrangements. All areas should have a robust and fully operational …
Response attribution not verified
#69 — Uprate £6,000 SEND funding threshold annually and establish sustainable, equitable funding model
Recommendation: The current £6,000 notional threshold is outdated and inadequate. It must be automatically uprated each year in line with inflation to prevent further erosion of support for pupils with SEND. This is a necessary correction to address years of chronic …
Response attribution not verified
#68 — Current funding for SEND inclusion and £6,000 threshold remain significantly inadequate
Recommendation: It is clear that the current levels of funding provided to schools and multi- academy trusts are inadequate to support the effective inclusion of pupils with SEND. The notional £6,000 threshold is insufficient to deliver good SEN support, placing unsustainable …
Response attribution not verified
#26 — Competition among local authorities for children's home places drives up costs significantly.
Recommendation: When finding children’s homes places, local authorities must often look outside of their own area, putting them in competition with each other. Local authorities also often rely on finding places just at the time children need to be housed, rather …
Response attribution not verified
#24 — Some private providers of children's social care achieve unacceptably high profit margins.
Recommendation: We raised concerns about the high levels of profits of some private providers.64 The Competition and Markets Authority found in 2022 that the fifteen largest providers of children’s social care had average profit rates of 22.6% for children’s homes, and …
Response attribution not verified
#20 — Insufficient fees, home adaptation needs, and societal shifts create barriers to increasing foster care.
Recommendation: The Association for Directors of Children’s Services explained that there are barriers to increasing foster care numbers. This includes insufficient fees and allowances for foster carers, the need for foster carers to adapt their 47 Qq 26, 59 48 C&AG’s …
Response attribution not verified
#19 — Departmental fostering recruitment hubs show limited immediate impact on increasing foster carer numbers.
Recommendation: The Department has initiatives to increase foster carer numbers. It described, for example, launching 10 fostering recruitment hubs by 2024, covering around two thirds of local authorities.50 It explained that these hubs are boosting co-ordinated recruitment of foster carers between …
Response attribution not verified
#18 — Foster care households and placements have significantly decreased despite the Department's reduction goals.
Recommendation: The Department told us that it sees reducing the need for residential care as key to addressing some of the drivers behind the increased cost. It plans to reduce the need by preventing children becoming looked after by a local …
Response attribution not verified
#17 — Inconsistent capital funding and local authority competition impede creating children's homes where needed.
Recommendation: The Association of Directors of Children’s Services described inconsistencies in capital funding, and competition between local authorities for funding, as barriers to creating homes where they are needed. Where one local authority might be delighted to win several million pounds …
Response attribution not verified
#15 — Barriers and lack of incentives hinder the creation of children's homes matching children's needs.
Recommendation: Local authorities and private providers face barriers and lack incentives to open homes and create places matching children’s needs at the scale required.35 The Association of Directors of Children’s Services told us that the distribution of residential provision is based …
Response attribution not verified
#14 — Significant geographical disparities in children's home availability lead to unsuitable placements and poor outcomes.
Recommendation: There are disparities in the number and types of children’s home available in different areas across the country, particularly for children with more complex needs.29 For example, there are no secure homes across all of London, while South West England …
Response attribution not verified
#12 — Local authorities resort to unregistered homes as last resort due to placement scarcity.
Recommendation: We asked the Association of Directors of Children’s Services how it could possibly be right for any local authority to place children in homes that are not inspected. It described this as a consequence of local authorities having an absolute …
Response attribution not verified
#8 — Department lacks up-to-date information on children's care provision, demand, and available places.
Recommendation: The Children’s Commissioner told us that there needs to be a much tighter grip on the amount and type of provision needed and where.13 The Department lacks up-to-date information on the support children need, the demand for places and places …
Response attribution not verified
#1 — Committee took evidence on sustainability of children's residential care.
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department for Education (the Department) on the sustainability of children’s residential care.2 We also took evidence from the Children’s Commissioner, the Association of …
Response attribution not verified
#4 — Set out how to address barriers to increasing foster carer numbers with clear timeframe and milestones.
Recommendation: To reduce the demand for children’s residential care, the Department is relying on there being more foster carers, but it has yet to address the significant challenges to increase numbers. The Department sees reducing demand for residential care as key …
Response attribution not verified
#3 — Detail plans to address barriers creating children's home places, including funding and staffing.
Recommendation: Providers of children’s homes, including local authorities, are not offering the places needed locally, leading to children being placed in homes that do not meet their needs. There are disparities in the places available across the country, particularly for children …
Response attribution not verified
#12 — Commit to increasing mandatory health visitor contacts from five to six for children in England.
Recommendation: We recommend that the Government commit to increasing the number of mandatory health visitor contacts for children in England from five to six. To help it deliver this it should look at the approach that the devolved administrations have taken, …
Response attribution not verified
#11 — Government's health visit ambitions are inadequate compared to other UK nations' provision.
Recommendation: The Government’s ambitions for the number of health visits are woefully inadequate. Children in England receive fewer mandated health visits than children in any other part of the UK. While the Government’s immediate priority must be supporting and growing the …
Response attribution not verified
HSSIB safety recommendations(2)
Transition from child and adolescent mental health services to adult mental health services
It is recommended that NHS England requires Clinical Commissioning Groups to demonstrate that the budget identified for current children and young people’s services – those delivering care up until the age of 18 – is spent only on this group.
Safety Recommendation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
HSSIB recommends that NHS England reviews and updates its inpatient children and young people’s mental health services specifications and commissioning guidance to ensure they support developmentally appropriate, needs-based transitions. Any changes to service delivery will require a review of funding …
Safety Recommendation
CQC inspection actions(1)
ICIBI immigration recommendations(3)
An inspection of asylum casework (June – October 2023)
Prioritise claims for unaccompanied asylum-seeking children (UASC), as per the Immigration Rules
A re-inspection of the use of hotels for housing unaccompanied asylum-seeking children …
Work with partners to provide advocacy support for children, to act on their behalf, for example in terms of challenging their length of stay in the hotel, or ensuring the …
An inspection of the Home Office’s use of age assessments (July 2024 …
In relation to the end-to-end age dispute process: Confirm the funding for the Unaccompanied Asylum-Seeking Children (UASC) Service Management Team and set out its initial programme of work with delivery …
IOPC learning recommendations(2)
Investigation into the West Yorkshire Police response to reports of injuries to …
The IOPC recommends that West Yorkshire Police ensures that it is able to adequately resource the supervisory responsibilities in the safeguarding unit, taking into account both the number of people required and their levels of training and experience. This follows …
Recommendation - Devon and Cornwall Police, March 2023
The IOPC recommends that the NHS England review the resourcing of Sexual Assault Referral Centres (SARCs) within the Devon and Cornwall area. This follows an IOPC review of a Death or Serious Injury case in relation to the death of …
NAO audit recommendations(13)
Support for children and young people with special educational needs
DfE should: i) improve the data, incentives and processes to ensure children's needs are identified and supported as early as possible, particularly within early years
Accepted
Support for children and young people with special educational needs
DfE should: h) undertake a specific exercise, drawing on local authority insights, to identify and share opportunities for efficiencies. This should consider routine reviews of individual EHC plans to assess if they are working, and benchmarks for local authorities to …
Accepted
Support for children and young people with special educational needs
DfE should: g) ensure that it consistently translates its ambitions into an implementation approach with actions and sufficient detail on how improvements will be achieved, how much they will cost, how they inter-relate, how long they will take and the …
Accepted
Support for children and young people with special educational needs
DfE should: f) develop a vision and long-term plan for inclusivity across mainstream education. This should consider opportunities to adapt funding and accountability arrangements to encourage inclusivity, building an evidence base for where mainstream settings can best support children with …
Accepted
Support for children and young people with special educational needs
DfE should: e) develop its use of evidence to better understand how and why pupil numbers change across different settings to asses the need for spaces across local areas and types of setting, and how this will impact, for example, …
Accepted
Support for children and young people with special educational needs
DfE should d) as a matter of urgency, work with MHCLG and HM Treasury, to share with local authorities its plans for ensuring each local authority can achieve a sustainable financial position once the statutory override ends in 2025-26, including …
Accepted
Support for children and young people with special educational needs
DfE and the wider government should: c) build a more integrated system by, for example, developing a shared understanding of how identifying and supporting SEN should be prioritised, including within the health system; ensure those with accountability can act, including …
Accepted
Support for children and young people with special educational needs
DfE and the wider government should: b) undertake work to understand the root causes behind increases in SEN and demand for EHC plans and special school places to ensure the whole system addresses them
Accepted
Support for children and young people with special educational needs
DfE and the wider government should: a) explicitly consider whole-system reform, to improve outcomes for children with SEN and put SEN provision on a financially sustainable footing
Accepted
Local government financial sustainability
We recommend that MHCLG: as a matter of urgency, work with DfE to support local authorities to sustainably manage their dedicated schools grant and address the cumulative deficits before the statutory override ends on 31 March 2026.
Accepted
School funding in England
d) Take action to help mainstream schools deal with high-needs cost pressures. The Department needs to complete its review of support for pupils with special educational needs and disabilities and set out how it will improve this aspect of the …
Accepted
Support for pupils with special educational needs and disabilities in England
The Department should prepare for the next full Spending Review by making an evidence-based assessment of how much it would cost to provide the system for supporting pupils with SEND created by the 2014 reforms. It should use this assessment …
Accepted
Support for pupils with special educational needs and disabilities in England
The Department should identify and share good practice on how mainstream schools can effectively meet the needs of those pupils with SEND who do not have EHC plans.
Accepted
IMB individual recommendations(17)
Werrington (2023)
Why was there no adequate social work cover for the maternity leave of a social worker and the sick leave of the senior social worker?
Other
Werrington (2023)
With the increase in the cost of living, why hasn’t the “Looked After Children” (a young person who was in the care of their local authority before custody) allowance been increased?
Other
Bedford (2023)
It is disappointing that funding to support staffing in the young adults’ unit has been removed.
HMPPS
Feltham (2025)
Investigate if local authority funding for SEN/EHCP children can follow them into custody.
HMPPS
Cookham Wood (2021)
What can the YCS do to monitor and support YOIs when dealing with youth offending teams? Is the staffing level for youth offending teams adequate?
HMPPS
In Progress
Feltham (2022)
What steps will the HMPPS and YCS take to address this moving forward?
HMPPS
Feltham (2022)
Will you discuss with the Youth Justice Board and colleague Ministers how this can be addressed?
Ministry of Justice
Feltham (2023)
Can steps be taken to ensure the Local Education Authority funding for these children follows them?
HMPPS
Cookham Wood (2024)
How has the closure of Cookham Wood improved the outcomes for those boys moved to other YOIs and, crucially, how has the decision to reduce the youth estate by one impacted the outcomes for all boys in the youth estate?
HMPPS
Noted
Wetherby (2025)
What specific actions and resources will be committed to ensure care leavers receive comprehensive support on release, including stable accommodation, access to education or employment and continuity of care, to prevent them from falling through the gaps?
Other
Wetherby (2025)
What mechanisms will be put in place to ensure local authorities are fully accountable for meeting their statutory duties toward young people in care - both during custody and on release - and what consequences will follow if these obligations are not met?
Other
Isis (2024)
What is the MoJ strategy for the management of young adults in the prison estate?
Ministry of Justice
Noted
Wetherby (2023)
The Board remains concerned about those young people who are ‘looked after’ by the local authority and consider that they are frequently financially disadvantaged due to late payments or lack of financial support. How can this situation be improved?
Other
New Hall (2024)
In the Board’s view, it is obvious that higher levels of funding are essential to meet the complex and severe mental health needs of the women.
HMPPS
In Progress
Isis (2024)
How will the Minister allocate the necessary resources for this age group in HMP/YOI Isis?
Ministry of Justice
Implemented
Bronzefield (2023)
What are the Minister’s plans to address this issue?
Ministry of Justice
Durham (2024)
Could the Minister let the Board know how many additional Tier 2 (CAS2) and Tier 3 (CAS3) bed spaces are planned for the northeast and Cumbria in 2025?
Other
In Progress
Health investigations(5)
Independent investigation: Simon Widger, Eastbourne, Sussex (2000) — Rec 2
The local authority should be more proactive in developing specific services under the umbrella of the Lansdowne Unit (or any equivalent centre,) working with its partners in the health and education services to disperse the costs associated with such provision. Such a development might also link with more specialist fostering …
south_east
An independent investigation into the care and treatment of Emily … — Rec 9
NHS England Specialised Commissioning and the North East region Integrated Care Systems (ICSs), as system leaders, should work with the Directors of Children’s Services in the North East region to commission services that will meet the needs of the small but growing number of young people with complex needs and …
An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Christie … — Rec 14
NHS North East and North Cumbria (NENC) Integrated Care Board, as system leaders, should work with the Directors of Children’s Services North East region to commission services that will meet the needs of the small but growing number of young people with complex needs and challenging behaviours that have both …
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation: Liaquat Ali, Bury (1999) — Rec 3.ii
A review of funding for the Mental Health Service in Bury is, in our view, necessary so that there can be proper consideration of the years of under-funding that the service has had to endure. We accept that the service in Bury will not be able to catch up in …
north_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.29
There should be further development of jointly commissioned services helping to ensure good quality services for “looked after children” as they have high mental health needs.
north_west
Independent reviews(50)
Neurodivergence Task and Finish Group: report — Rec 8
Recommendation Eight: Increase funding levels to schools to reflect the level of need within their population so they can support more neurodivergent children and young people within their core offer We welcome the additional funding secured in the 2025 Spending Review, and the commitment that this funding will be used …
Health & Social Care
Kerslake Birmingham Review — Rec 7
Birmingham City Council should establish a new model for devolution: a. the council needs to focus on getting basic services right, including getting on with improving children and education services. To do so, services should be organised in the way that is most efficient for that service, where appropriate these …
Other
Acheson Report — Rec 23.1
we recommend the further development of the role and capacity of health visitors to provide social and emotional support to expectant parents, and parents with young children.
Health & Social Care
Acheson Report — Rec 23
We RECOMMEND policies that promote the social and emotional support for parents and children. Specifically:
Health & Social Care
Acheson Report — Rec 21.1
we recommend an integrated policy for the provision of affordable, high quality day care and pre-school education with extra resources for disadvantaged communities (see also: recommendation 5).
Health & Social Care
Cantle Report — Rec 6.32
We believe that some aspects of youth provision should be considered for a clear statutory role, to a given national standard. This must take account of resource requirements and but may gain efficiency and clarity from the rationalisation of existing services.
Other
Cantle Report — Rec 6.31
However, a major review of youth services is now urgently required, with new provision developed on a more joined up basis. A stronger linkage between school based programmes (and outreach work), the voluntary sector and the various statutory services is essential.
Other
Laming Review (Baby P) — Rec 56
A national annual report should be published reviewing safeguarding and child protection spend against assessed needs of children across the partners in each Children's Trust.
Other
Laming Review (Baby P) — Rec 55
The Department for Children, Schools and Families must sufficiently resource children's services to ensure that early intervention and preventative services have capacity to respond to all children and families identified as vulnerable or 'in need'.
Other
Laming Review (Baby P) — Rec 54
The Department for Children, Schools and Families, the Department of Health, and the Home Office, together with HM Treasury, must ensure children's services, police and health services have protected budgets for the staffing and training for child protection services.
Other
Laming Review (Baby P) — Rec 24
The Social Work Task Force should: develop the basis for a national children's social worker supply strategy that will address recruitment and retention difficulties, to be implemented by the Department for Children, Schools and Families. This should have a particular emphasis on child protection social workers; work with the Children's …
Other
Field Review on Poverty and Life Chances — Rec 7
The Review has focussed on the early years, but recognises that important changes can and do take place later in children's lives and that investment in the early years will not be fully effective unless it is followed up with high quality services for those who need them most later …
Other
Selous Review — Rec 92
The Ministry of Defence and the Armed Forces to: • encourage the replication of good practice across the Armed Forces to support military children and young people • strengthen the delivery of the Defence Youth Offer through appropriate resourcing and investment in community spaces for military children and young people …
Other
Carol Black Drugs Review (Part 2) — Rec 13
We recommend that DHSC make increased funding available to specialist substance misuse services for young people to improve the capacity and quality of these services, and also through the national Commissioning Quality Standard ensure that these services are linked with other local services for vulnerable young people and that family …
Health & Social Care
MacAlister Review — Rec 76
Government should introduce an updated funding formula for children’s services, and take greater care to ensure that changes in government policy that impact the cost of delivering children’s social care are accompanied by additional resources for local government.
Education
MacAlister Review — Rec 74
Government should incentivise greater partner contributions through requiring partners to publish their financial contribution and making receiving the full funding for reform contingent on partner contributions.
Education
MacAlister Review — Rec 33
A windfall tax on profits made by the largest private children’s home providers and independent fostering agencies should be levied to contribute to the costs of transforming the care system.
Education
MacAlister Review — Rec 32
Regional Care Cooperatives should be established to plan, run and commission residential care, fostering, and secure care.
Education
MacAlister Review — Rec 25
All local authorities should make a financial allowance paid at the same rate as their fostering allowance available for special guardians and kinship carers with a Child Arrangement Order looking after children who would otherwise be in care.
Education
MacAlister Review — Rec 12
Investment in Family Help will provide resources for multidisciplinary responses to extra familial harms.
Education
MacAlister Review — Rec 5
Government should make an investment of roughly £2 billion in supporting local authorities, alongside their partners, to implement the proposed transformation in Family Help. National government pots of funding should be mainstreamed into this funding stream and local partners should be incentivised to contribute. Once transformation is complete, the government …
Education
Wessely Review — Rec 117
Section 17 of the Children Act 1989 should be amended to clarify that any child or young person admitted to a mental health facility is regarded as a 'child in need' so that parents can ask for services from their local authority.
Health & Social Care
Accepted
Angiolini Review — Rec 13
Local Authorities should ensure that they have reasonable systems in place to ensure that all police requests for accommodation, whether secure or non-secure, are accepted. Adequate funding must be made available for local authority overnight secure accommodation of children in police custody.
Policing & Security
Accepted
Narey-Owers Foster Care Review — Rec 34
We believe that children on the edge of care and their families should routinely gain earlier access to foster care. The Department for Education, together with select local authorities and independent fostering agencies, should further explore the potential for support foster care as a means of: avoiding unnecessary entry into …
Other
Acheson Report — Rec 23.2
We recommend local authorities identify and address the physical and psychological health needs of looked-after children.
Health & Social Care
Narey Review of Children's Residential Care — Rec 6
We must ensure we are recruiting and retaining the best possible foster carers, and with a sufficient number able to care for the most challenging children. And we need to pay foster carers well: their contribution is often heroic. But we have to ensure that the charges that local authorities …
Other
Field Review on Poverty and Life Chances — Rec 10
Local Authorities should aim to make Children's Centres a hub of the local community. They should maintain some universal services so that Centres are welcoming, inclusive, socially mixed and non-stigmatising, but aim to target services towards those who can benefit from them most. They should look at how they could …
Other
Field Review on Poverty and Life Chances — Rec 9
Local Authorities should open up the commissioning of Children's Centres, or services within them, to service providers from all sectors to allow any sector, or combination of sectors, to bid for contracts. They should ensure services within Children's Centres do not replicate existing provision from private, voluntary and independent groups …
Other
Field Review on Poverty and Life Chances — Rec 8
Sure Start Children's Centres should re-focus on their original purpose and identify, reach and provide targeted help to the most disadvantaged families. New Sure Start contracts should include conditions that reward Centres for reaching out effectively and improving the outcomes of the most disadvantaged children.
Other
Field Review on Poverty and Life Chances — Rec 6
The strategy should include a commitment that all disadvantaged children should have access to affordable full-time, graduate-led childcare from age two. This is essential to support parents returning to work as well as child development.
Other
Field Review on Poverty and Life Chances — Rec 4
The increased funding should be targeted at those factors we know matter most in the early years: high quality and consistent support for parents during pregnancy, and in the early years, support for better parenting; support for a good home learning environment; and, high quality childcare.
Other
Field Review on Poverty and Life Chances — Rec 2
The Review recommends that the Government gradually moves funding to the early years, and that this funding is weighted toward the most disadvantaged children as we build the evidence base of effective programmes. The Fairness Premium, introduced in the 2010 Spending Review, should begin in pregnancy.
Other
Allen Early Intervention Review (Part 2) — Rec 3
I recommend that government, when planning the next Comprehensive Spending Review, should consider making Early Intervention its theme, and that work undertaken by a Treasury-led team should signal a decisive rebalancing of central government spending from late intervention to investing in Early Intervention. I believe that steady and incremental migration …
Other
Munro Child Protection Review — Rec 10
The Government should place a duty on local authorities and statutory partners to secure the sufficient provision of local early help services for children, young people and families. The arrangements setting out how they will do this should: ●● specify the range of professional help available to local children, young …
Other
Farmer Review (Women) — Rec 26
A Case Review of children removed from primary carers when they entered prison to be carried out by the Chief Social Worker for England (Children and Families), to ensure that decisions taken are always in the best interests of children. The review should examine social work practice, including the role …
Justice & Legal
MacAlister Review — Rec 6
As part of the National Children’s Social Care Framework, the government should define outcomes, objectives, indicators of success and the most effective models for delivering help. Funding should be conditional on meeting the goals of the Framework.
Education
Angiolini Review — Rec 15
The use of police custody for children detained under section 136 should be brought to an end with all NHS Trusts required to make sufficient provision of health-based places of safety to meet this requirement.
Policing & Security
Accepted
National workload action group: reports on social worker workload — Rec 10
DfE should, with the children’s social care sector, develop and implement a national workforce strategy for social workers and the wider social care workforce to inform national workforce planning, focusing on retention of the existing workforce and career pathways in non-social worker roles, including career pathways into social work from …
Health & Social Care
Narey-Owers Foster Care Review — Rec 35
The priority therefore must be to convert more fostering placements to arrangements which are more likely to last forever, either encouraging foster carers to adopt or to become special guardians, not least through longer term guarantees of financial support. In either case, the child will leave the care system.
Other
Narey-Owers Foster Care Review — Rec 23
We recommend that larger local authorities or the consortia should consider making a determined attempt to become self-sufficient in carer recruitment or, alternatively, consider partnering with one or more IFAs to provide their complete fostering service. Either of these options is likely to be cheaper and provide greater assurance of …
Other
Cantle Report — Rec 6.33
However, new methods of service delivery seem to offer a greater prospect of success and there must be a clear aim of reaching out to disaffected youth in more engaging ways, perhaps by using peers, positive role models and individual capacity building programmes.
Other
Cantle Report — Rec 6.29
A well resourced programme of engaging young people in the decision making process affecting their communities should be established, possibly by developing the Youth Parliament scheme. The form of engagement should respect the needs and style of young people, not replicate existing institutions. The aim should be to develop a …
Other
Cantle Report — Rec 6.24
Local partnerships should also be asked to develop a wide range of thematic bids as a more flexible and more equitable approach to regeneration, which whilst still allowing for area treatment, can focus on specific needs in all local communities. We would suggest that these are targeted at the needs …
Other
Mental Health Taskforce 2016 — Rec 55
The CQC should work with Ofsted, Her Majesty’s Inspectorate of Constabulary and Her Majesty’s Inspectorate of Probation to undertake a Joint Targeted Area Inspection to assess how the health, education and social care systems are working together to improve children and young people’s mental health outcomes.
Health & Social Care
Mental Health Taskforce 2016 — Rec 40
The Department of Health should develop national metrics to support improvements in children and young people’s mental health outcomes, drawing on data sources from across the whole system, including NHS, public health, local authority children’s services and education, to report with proposals by 2017.
Health & Social Care
Narey Review of Children's Residential Care — Rec 14
The extent of the use of single placements for children (including an assessment of the cost and effectiveness of such arrangements) as an alternative to using secure beds needs to be investigated by DfE.
Other
Henley Review of Cultural Education — Rec 1
Recommendation 1: Broad Cultural Education for all children — There should be a minimum level of Cultural Education that a child should expect to receive during his or her schooling as a whole. For children to leave full-time education without having engaged in the spectrum of Cultural Education outlined below …
Other
Field Review on Poverty and Life Chances — Rec 5
Government should start now to develop a long term strategy, to increase the life chances of poorer children by narrowing the gaps in outcomes between poorer and richer children in the Foundation Years. This will prove the most cost effective way of addressing inequalities in adult life outcomes. We hope …
Other
Sewell Commission — Rec 18
Improve safety and support for children at risk The Commission recommends that the Youth Justice Board (YJB), working with partners across government with expertise in child criminal exploitation, develops a digital solution that can be accessed and used by children and young people before or at the point of crisis. …
Other
Farmer Review (Women) — Rec 10
Given the particular spending implications across government for women's offending, such as those relating to the greater likelihood that their children will end up in local authority care, the Reducing Reoffending Board (which takes a cross-Government approach to reducing reoffending) to have a ministerial lead for and pay regular attention …
Justice & Legal
PHSO casework decisions(7)
P-003179 — Cambridgeshire Community Services NHS Trust
Miss Y complained the Trust failed to listen to her concerns about her son's behaviour, delaying assessment and referral for potential autism symptoms since October 2021.
NHS in England
Partly Upheld
Nov 2024
P-004357 — Hampshire and Isle of Wight Integrated Care Board
The ICB wrongly found her son ineligible for care and withdrew provision, failing to take a holistic view of his complex needs.
NHS in England
Partly Upheld
Nov 2025
P-002380 — Coventry and Warwickshire Integrated Care Board
Dr U complained the ICB failed to provide his daughter with respite care as outlined in her care plan, causing frustration and carer strain for him and his partner.
NHS in England
Dec 2023
P-002682 — Humber and North Yorkshire Integrated Care Board
Ms D complained the CCG failed to properly assess and fund her mother's care needs, delayed setting up a personal health budget, and provided inaccurate information, causing financial loss and distress.
NHS in England
Upheld
Dec 2023
P-004505 — Children and Family Court Advisory and Support Service …
Miss A complained her son's family court guardian refused to consider evidence about the father, made false accusations in reports, refused contact, and had secret conversations, making her fear losing her son.
UK Government
Dec 2025
P-002280 — Humber and North Yorkshire Integrated Care Board
The ICB's contractor refused a suitable wheelchair, and the ICB allegedly made an unnecessary safeguarding referral and pressured Mr A to drop his complaint.
NHS in England
Nov 2023
P-002537 — North West London Integrated Care Board
Mrs I complained the ICB wrongly denied her son Children's Continuing Care funding, alleging inadequate assessment of his needs and proceeding with a DST meeting despite her difficulties. She sought reconsideration and apology.
NHS in England
Apr 2024
LGO / SPSO decisions(4232)
22-011-910 — North Northamptonshire Council
Summary: Miss X complained the Council has failed to provide alternative provision for her daughter, F since May 2021 when she stopped attending school. The Council was at fault. It failed to have sufficient oversight or consider whether to put alternative provision in place for F during the 2021/2022 academic …
LGO (Local Government & …
Education
Upheld
Jun 2024
23-002-919 — Newcastle upon Tyne City Council
Summary: We will not investigate this complaint about the Council’s involvement in Miss X’s children’s case. The substantive part of the complaint is late and there is not a good reason for the delay. There is insufficient evidence of fault in more recent events, nor could we provide a meaningful …
LGO (Local Government & …
Children S Care Services
Jul 2024
202000338 — The Moray Council
C is an independent advocate who complained on behalf of their client (A). Following social work involvement, A’s child (B) was placed with kinship carers. This was a voluntary arrangement, in terms of section 25 of the Children (Scotland) Act 1995. After the relationship with kinship carers broke down, C …
SPSO (Scottish Public Se…
Local Government
Upheld
Feb 2021
201806620 — East Lothian Council
Mr C complained that for over three years, the council failed to reasonably respond to his and his wife's (Mrs C) concerns about their child's (Child A) additional support for learning needs. Child A has a developmental learning disability. Mr C also said that the council unreasonably removed Child A’s …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Feb 2021
25-014-161 — London Borough of Lewisham
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Children S Care Services
Feb 2026
25-013-374 — Dudley Metropolitan Borough Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Children S Care Services
Feb 2026
24-016-104 — Gloucestershire County Council
Summary: We have upheld this complaint about the Council’s failure to complete an Education Health and Care Needs Assessment and issue an Education Health and Care plan for the complainant’s child within the statutory timescale. The Council has agreed to provide a proportionate remedy and this removes the need for …
LGO (Local Government & …
Education
Upheld
Jan 2026
24-007-408 — Royal Borough of Greenwich
Summary: Miss X complained the Council failed to ensure Y received all the provision set out in his Education, Health and Care Plan and failed to provide holiday free school meals support. The Council was at fault, meaning Y missed out on provision he was entitled to and causing confusion …
LGO (Local Government & …
Education
Upheld
Jan 2026
25-015-691 — London Borough of Tower Hamlets
Summary: We will not investigate this complaint about a child’s education because the complainant has initiated legal proceedings against the Council.
LGO (Local Government & …
Education
Feb 2026
25-013-565 — Buckinghamshire Council
Summary: We will not investigate this complaint about the Education, Health and Care plan process. This is because the Council has agreed to an appropriate remedy for the injustice caused by the delay.
LGO (Local Government & …
Education
Upheld
Feb 2026
25-013-010 — Wirral Metropolitan Borough Council
Summary: We will not investigate Miss X’s complaint about the Council’s response to her child being unable to attend school and its delay in issuing an Education Health and Care Plan. The Council has already accepted fault and offered a suitable remedy. Investigation by us would be unlikely to add …
LGO (Local Government & …
Education
Upheld
Feb 2026
25-012-848 — Stockton-on-Tees Borough Council
Summary: We will not investigate Mr X’s complaint about a failure to review his statement of Special Educational Needs between 2008 and 2014. It is unlikely an investigation would reach a worthwhile outcome. The Information Commissioner’s Office is better placed to consider a complaint about the Council’s response to his …
LGO (Local Government & …
Education
Feb 2026
25-002-888 — North Northamptonshire Council
Summary: Miss X complained the Council did not provide suitable education for her child. She says this impacted their education and emotional wellbeing and caused her financial strain. We find no fault with the Council.
LGO (Local Government & …
Education
Not Upheld
Feb 2026
25-001-414 — Hampshire County Council
Summary: Mrs X complained the Council did not review her child’s Education Health and Care Plan in line with statutory timescales. She also complained the Council did not provide her child with alternative provision. She says this impacted her child’s education and impacted her emotional wellbeing. We find no fault …
LGO (Local Government & …
Education
Upheld
Feb 2026
24-020-246 — Bolton Metropolitan Borough Council
Summary: Miss X complained about delays by the Council in reviewing her child’s Education, Health and Care Plan and its failure to provide a suitable education for them when they could not attend a school. We found the Council was at fault for not completing the review on time and …
LGO (Local Government & …
Education
Upheld
Feb 2026
25-015-391 — Essex County Council
Summary: We will not investigate this complaint about the Education, Health and Care plan process. This is because the Council has agreed to an appropriate remedy for the injustice caused by the delay.
LGO (Local Government & …
Education
Upheld
Feb 2026
25-014-704 — Essex County Council
Summary: We will not investigate this complaint about the Education, Health and Care plan process. This is because the Council has agreed to an appropriate remedy for the injustice caused by the delay.
LGO (Local Government & …
Education
Upheld
Jan 2026
PSOW-202202192 — Swansea Council
Ms X complained about delays with the Council’s investigation in response to her Social Services complaint about the care of her son. The Ombudsman decided that the Council should provide Ms X with its Stage 2 response by 31 August 2022. It should also write to her to advise of …
PSOW (Public Services Om…
Local Government
Aug 2022
PSOW-202302987 — Rhondda Cynon Taf County Borough Council
Mr G complained that Rhondda Cynon Taff Borough Council failed to comply with its complaint’s procedure in relation to his concerns about children’s social services. The Ombudsman found that there had been a delay in the Council issuing a Stage 1 complaint response. Furthermore, the Council failed to respond to …
PSOW (Public Services Om…
Local Government
Aug 2023
PSOW-202306531 — Vale of Glamorgan Council
Ms A complained about the way the Vale of Glamorgan Council removed her children and the subsequent care arrangements it put in place. The Ombudsman decided that whilst the Council had carried out a Stage 2 investigation, the findings of which it had accepted in full, it had not completed …
PSOW (Public Services Om…
Local Government
Jan 2024
PSOW-202106412 — Merthyr Tydfil County Borough Council
We investigated a complaint from Mrs A that the Council did not implement the recommendation made by a Stage 2 Independent Investigator in relation to the payment of a special guardianship allowance (“SGO allowance”), and that its decision to do so was unreasonable. The recommendation was that the Council should …
PSOW (Public Services Om…
Local Government
Upheld
Nov 2023
PSOW-202306410 — Wrexham County Borough Council
Miss F complained that Wrexham County Borough Council had failed to respond to the complaint that had been referred to it by the Ombudsman in July. The Ombudsman found that there had been a breakdown in communication between the teams dealing with the complaint and it had subsequently been overlooked. …
PSOW (Public Services Om…
Local Government
Nov 2023
PSOW-202405325 — Cardiff Council
Miss A complained that in over 5 months, Cardiff Council failed to respond to her request for her complaint about Children’s Services to be escalated to Stage 2 of the Council’s complaints policy. She said the lack of appropriate communication and handling of her complaint, compounded her feeling that she …
PSOW (Public Services Om…
Local Government
Jan 2025
PSOW-202406900 — Caerphilly County Borough Council
Ms A was dissatisfied with the Council’s response to her complaint and requested an independent investigation. The Ombudsman found that the Council had provided a response to the concerns raised by Ms A at Stage 1 of its complaint policy. Ms A was dissatisfied with the response. However, the Council …
PSOW (Public Services Om…
Local Government
Jan 2025
21-003-354 — North Yorkshire County Council
Summary: Mr X and Ms Y complained the Council failed to make ‘reasonable endeavours’ to provide for their son, Z’s, special educational needs during the COVID-19 pandemic. The Council failed to properly consider and make ‘reasonable endeavours’ to arrange Z’s special education when there was an alternative provider available. It …
LGO (Local Government & …
Education
Upheld
Jan 2022
20-001-927 — London Borough of Redbridge
Summary: Miss X complains that the Council failed to provide special educational provision for her daughter in line with her Education, Health and Care plan. She also complains that the Council ignored her request for a personal budget and failed to respond to her complaint. Miss X says her daughter …
LGO (Local Government & …
Education
Upheld
Jan 2022
21-001-405 — London Borough of Southwark
Summary: There was delay by the Council in putting in place alternative education when a child was unable to attend school due to ill-health or ‘otherwise’. The Council has agreed to apologise, make a financial payment and make service improvements.
LGO (Local Government & …
Education
Upheld
Feb 2022
21-005-861 — Dorset Council
Summary: Miss X complained about delays in the Council assessing and meeting her child, Y’s, special educational needs between 2019 and 2021. The Council accepted there were significant delays in assessing and planning for Y’s needs and that it failed to provide a suitable education for over two years. The …
LGO (Local Government & …
Education
Upheld
Mar 2022
21-004-622 — Buckinghamshire Council
Summary: Mr X complained the Council failed to provide his son, F, with alternative provision or any education between February 2020 and July 2021. The Council failed to provide alternative provision for F between September and December 2020. The Council agreed to pay Mr X a total of £1650 to …
LGO (Local Government & …
Education
Upheld
Mar 2022
21-000-614 — Hampshire County Council
Summary: The complainant alleged that the Council delayed in preparing her son’s Education, Health and Care Plan and, as a result, he missed out on receiving a suitable education and support. The Council has accepted there was an avoidable delay. We have recommended an improved remedy for the injustice caused …
LGO (Local Government & …
Education
Upheld
Mar 2022
20-011-281 — London Borough of Hounslow
Summary: Miss B complained that the Council failed to provide alternative education to her child, C when they were unable to attend school for medical reasons and delayed in considering her complaint. We found the Council did not provide alternative education for C for approximately eight months. We recognise the …
LGO (Local Government & …
Education
Upheld
Mar 2022
21-010-646 — Lincolnshire County Council
Summary: Mrs X complained the Council failed to provide her son with appropriate social care support from March 2021, and failed to complete appropriate assessments of his needs. The Council was at fault as it failed to investigate Mrs X’s complaint under the statutory children’s complaints procedure. The Council will …
LGO (Local Government & …
Children S Care Services
Upheld
Mar 2022
21-007-404 — Trafford Council
Summary: Mr X complained about the Council's response to his children’s statutory complaint. The Council was at fault in how it responded to Mr X’s concerns about the actions of its education department and health services and for a delay in arranging an educational placement for Mr X’s son, W. …
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2022
21-017-441 — Plymouth City Council
Summary: The complainant (Ms X) said the Council failed to provide suitable education for her daughter (B) following her permanent exclusion from the school. She said the lack of full-time education for 18 months affected B’s academic and personal development and had detrimental impact on the whole family. We found …
LGO (Local Government & …
Education
Upheld
Jun 2022
21-006-452 — Kingston Upon Hull City Council
Summary: The Council was at fault for a delay in deciding whether to reassess Y’s special educational needs, a delay in carrying out that reassessment and a failure to either provide full-time alternative education whilst Y was out of school or record the reasons part-time provision was a suitable education …
LGO (Local Government & …
Education
Upheld
Jul 2022
21-014-757 — Peterborough City Council
Summary: Mrs B complains the Council has not provided support to her disabled children and about the way it dealt with her complaint. We have found fault that has caused injustice. The Council has agreed to make payments to Mrs B and her family and review its complaints handling.
LGO (Local Government & …
Children S Care Services
Upheld
Aug 2022
22-000-077 — Derbyshire County Council
Summary: Mr and Mrs B complained the Council failed to ensure an adequate investigation into a complaint they made in December 2017. We upheld the complaint finding the Council at fault for a series of delays which prevented the complaint progressing through the statutory complaint procedure for complaints about children’s …
LGO (Local Government & …
Children S Care Services
Upheld
Oct 2022
21-012-425 — London Borough of Newham
Summary: The complainant (Ms X) complained about the lack of children’s services support for her son (Y) despite his diagnosis of epilepsy and Occupational Therapist’s (OT) recommendations. She also said the Council failed in the way it considered her complaint. We found fault with the Council’s handling of Ms X’s …
LGO (Local Government & …
Children S Care Services
Upheld
Nov 2022
23-018-488 — London Borough of Waltham Forest
Summary: We will not investigate this complaint that the Council has declined to consult the schools of the complainant’s choice when considering which placement to name in her child’s Education Health and Care Plan. This is because it would be reasonable for the complainant to use her right to appeal …
LGO (Local Government & …
Education
Mar 2024
23-010-123 — Stockport Metropolitan Borough Council
Summary: The Council has recognised that there were faults in its child protection procedures when deciding whether to place the complainant’s son on a child protection plan. We have recommended a way to remedy the injustice caused which the Council has accepted. We are therefore closing the complaint.
LGO (Local Government & …
Children S Care Services
Upheld
Mar 2024
23-005-051 — Birmingham City Council
Summary: Miss X complains the Council has not properly dealt with Y’s special educational needs. The Council has not completed annual reviews properly, has not communicated with Miss X and did not respond to her complaint. Y has lost special educational provision, missed educational opportunities and suffered avoidable distress. The …
LGO (Local Government & …
Education
Upheld
Mar 2024
22-018-130 — Kent County Council
Summary: Miss B complained about matters connected to the Council’s management of a personal budget she receives to meet some of her child’s special educational needs. We upheld the complaint, mainly because the Council delayed too long in responding to Miss B’s complaints. We consider this caused her an injustice, …
LGO (Local Government & …
Education
Upheld
Mar 2024
23-007-194 — North Yorkshire Council
Summary: The Council failed to ensure that Y received the special educational provision set out in their EHC Plan. The Council has agreed to apologise and make payments to Y and to Ms X and to take action to prevent similar failings in future.
LGO (Local Government & …
Education
Upheld
Mar 2024
23-005-967 — East Sussex County Council
Summary: The complainant said that the Council failed to provide suitable education to her son, who has special educational needs. We find that there has been some fault causing injustice. We have recommended ways to remedy the injustice, which the Council has accepted. We are therefore closing the complaint.
LGO (Local Government & …
Education
Upheld
Mar 2024
23-005-064 — Norfolk County Council
Summary: Ms X complained the Council implemented an unlawful policy to temporarily provide 50% of the speech and language therapy needed in Education Health and Care Plans. We found fault by the Council because it implemented an unlawful policy and did not meet its statutory duty to provide the required …
LGO (Local Government & …
Education
Upheld
Mar 2024
23-009-810 — Hertfordshire County Council
Summary: Miss C complained about delays by the Council in taking action to support her child, who has special educational needs. We uphold the complaint. We find the Council delayed in consulting a specialist school, in obtaining advice about the child’s speech and language needs and in completing a review …
LGO (Local Government & …
Education
Upheld
Mar 2024
23-009-405 — London Borough of Hillingdon
Summary: X complained the Council failed to provide the OT provision specified in their child’s EHC plan or reimburse the transport costs for their child attending school between September 2022 and July 2023. X also complained the Council has failed to properly assess their child’s care needs or their own …
LGO (Local Government & …
Education
Upheld
Mar 2024
23-009-049 — Dorset Council
Summary: Miss X complained about the Council’s failure to issue her son’s Education, Health and Care Plan within statutory timescales. The Council was at fault because it took too long to issue the plan following an annual review. We have also found the Council at fault for not communicating with …
LGO (Local Government & …
Education
Upheld
Mar 2024
23-007-209 — Derbyshire County Council
Summary: Mrs X complained the Council failed to secure the special educational needs provision in her child D’s Education, Health, and Care plan. The Council was at fault because it failed to ensure the plan was in place, which caused D to miss special educational needs provision. The Council’s fault …
LGO (Local Government & …
Education
Upheld
Mar 2024
23-005-741 — West Sussex County Council
Summary: Mrs X complained the Council failed to provide her child with alternative education when she was unable to attend school due to ill health. The Council was at fault for failing to consider its duty under Section 19 of the Education Act 1996 from April 2022 to February 2023. …
LGO (Local Government & …
Education
Upheld
Mar 2024
Domestic Homicide Reviews(14)
Leeds — recommendation CSWS2
Children’s Social Work Service should develop a service which supports parents who have their children removed through care proceedings.
Leeds Children’s Social Work Service
Lincoln — source paragraph 199
Lincolnshire Safeguarding Partnership to evaluate the capacity and performance of services to address the needs of adolescents with difficult or risky behaviours, but without diagnosed mental health illness.
Lincolnshire Safeguarding Partnership
Oxford — recommendation 2
The OSCB to seek assurance from the relevant health and children’s services commissioning agencies that suitable services are available for young people with complex emotional and behavioural problems who do not meet current CAMHS thresholds.
Oxfordshire Safeguarding Children Board
Kingston upon Thames — recommendation 28
Analysis to be completed to ascertain whether we have the right amount available
Victim Support
St Helens — recommendation 32
Public Health will explore the Borough offer in relation to providing appropriate support for the children of parents with drug and alcohol problems. Support should be available even if parents are unwilling or unable to change their use of drugs or alcohol.
Public Health
St Helens — recommendation 31
All services should ensure that the voices of the children of problem drug users are heard and listened to. Work is required to develop means of enabling the children of problem drug users safely to express their thoughts and feelings about their circumstances.
Public Health
Cheltenham — recommendation 12
There should be an assessment of the needs of children and young people where Domestic Abuse has occurred and this should be part of any risk assessment. It is considered that there is a need for specialist group and individual programmes which would support children witnessing or affected by domestic …
Local agencies | GDASS | Infobuzz …
Bristol — recommendation 5
The Bristol Safeguarding Children Board consider identifying working with adolescent boys as a thematic priority in its strategic plan.
Bristol Safeguarding Children Board
Sutton Local Safeguarding Children’s …
Middlesbrough — recommendation 17.6
Children’s Social Care learning and recommendations [paragraph 14.12.1] are remitted to the Children’s Social Care Improvement Board.
Children’s Social Care Improvement Board
Middlesbrough — recommendation 17.4
The learning from this review should be shared with the Children’s Social Care Improvement Board.
Children’s Social Care Improvement Board
Welwyn Hatfield — recommendation c
Hertfordshire Children Services contacts the carers of the three children in this case and establishes whether they have access to the therapeutic resources needed to support the three children. If this is not the case that they establish a fund to enable the children to access the support, they need.
Hertfordshire Children’s Services
Welwyn Hatfield — recommendation 1
An allocated lead at the Home Office is responsible for establishing a national fund to enable a package of therapeutic and advocacy support to be put in place for child survivors of Domestic Homicide and suicide linked to domestic abuse. The Home Office to report back to Hertfordshire County Council …
Home Office
Home Office
Birmingham — recommendation 7
The Community Safety Partnership should seek further information from the statutory director for children’s services regarding the capacity of the service to participate in statutory reviews.
Community Safety Partnership
Bristol — recommendation 1
A review of the running of meetings by Children’s Services
Bristol City Council Children’s Services
CJINI inspection reports(8)
Child Exploitation – Report on the independent Inquiry
Abuse and Exploitation, Children and Young People
Nov 2014
The effectiveness of youth conferencing
Youth Justice and Intervention, Children and Young People
Mar 2015
An announced inspection of Woodlands Juvenile Justice Centre
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
May 2015
Progress on implementation of review of the Youth Justice Review recommendations
Youth Justice and Intervention, Children and Young People
Dec 2015
Woodlands Juvenile Justice Centre
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
Jun 2018
The effectiveness of Youth Conferencing – A Follow-Up Review
Youth Justice and Intervention, Children and Young People
Apr 2019
Report on an Unannounced Inspection of Hydebank Wood Secure College (23-24 October and 4-7 November 2019)
Prisons, Hydebank Wood Secure College
Jun 2020
An announced inspection of Woodlands Juvenile Justice Centre
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
Sep 2022