Vulnerable child care
Lack of consistent prescribed care for highly vulnerable children due to insufficient care package reviews and staff training.
Source spread
Where this theme appears
This theme appears across 20 independent accountability sources, so the source mix matters as much as the headline total.
97 inquiry recs
29 PFD reports
205 committee recs
3 HSSIB recs
22 CQC actions
3 ICIBI recs
6 IOPC recs
4 NAO recs
27 IMB recs
1 IMB report
1 Scottish FAI
389 DHR recs
1 PHSO decision
330 LGO/SPSO decisions
26 CJINI reports
1 Law Commission project
3 CQC enforcement actions
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(97)— showing 50 strongest matches
193 — Assistance for the nine children
Recommendation: Every opportunity should be taken to secure such advice and assistance for the nine children whose removal was the subject of this Inquiry to ensure that they are untroubled for the future so far as any effects of the Inquiry …
Unknown
162 — Consult before abandoning a case
Recommendation: Where a Reporter requires to consider the abandonment of a case which has been passed to the Sheriff for proof he should consult the Social Work Department before finally deciding to do so (18.50).
Unknown
161 — Local guidelines on information to Reporter
Recommendation: It should be clearly stated in all local guidelines in what form if any information requires to be given to the Reporter (18.48-49).
Unknown
159 — Reporter to check continued detention
Recommendation: The Reporter on being informed of the execution of a Child Protection Order should check the propriety of the continued detention of a child (18.45) but should also proceed with his statutory functions under Sections 38 and 39 in light …
Unknown
155 — Press to promote public understanding
Recommendation: The press should be encouraged to enable a greater understanding by the public of the problems of child sexual abuse and of child protection work (18.38).
Unknown
153 — Press reporting restraints
Recommendation: Consideration should be given to the desirability or otherwise of introducing further restraints on press reporting of proceedings before Children’s Hearings and in the Sheriff Court in children’s cases (18.35-36).
Unknown
152 — Procedure and evidence in children's cases
Recommendation: Consideration should be given to certain matters of procedure and evidence in relation to cases involving children (18.34).
Unknown
151 — Representation before Hearings
Recommendation: In considering the whole question of the representation of children and of their parents before Children’s Hearings attention should be paid to the necessity to avoid the introduction of any formal or adversarial character into the proceedings (18.33).
Unknown
150 — Parents' presence and child's interests
Recommendation: The right of parents to be present throughout a Children’s Hearing should give way to the interests of the child when the child’s interests so require (18.32).
Unknown
149 — Inform parties of business meetings
Recommendation: The child and the child’s parent or guardian should be informed of any ‘business meeting’ of the Children’s Hearing and their position presented orally or in writing at that meeting (18.31).
Unknown
148 — No extension of time for proof
Recommendation: No special provision should be made for extending the time for a proof on the grounds for referral (18.29-30).
Unknown
145 — Single overall limit on detention
Recommendation: A single overall time limit on the detention of a child whether under Section 37 or Section 40 or both Sections of the 1968 Act should be introduced (18.25-26).
Unknown
144 — Order falls if grounds not served
Recommendation: If grounds for referral have not been served within seven days of the removal of a child under a Child Protection Order, the Order should fall (18.23).
Unknown
142 — Transfer processing of Orders to Sheriff
Recommendation: The processing of Child Protection Orders should be transferred from the Children’s Hearing to the Sheriff with certain consequential changes in the procedure of referral (18.21).
Unknown
141 — Application for recall within seven days
Recommendation: A parent, guardian or safeguarder of the child should be entitled to apply to the Sheriff for recall of the Order at any time within seven days after the removal of the child (18.20).
Unknown
140 — Immediate recourse to Sheriff
Recommendation: A procedure should be introduced by an amendment to the Social Work (Scotland) Act 1968 enabling immediate recourse to be made to the Sheriff for a decision on the question whether a child reasonably requires to be in a place …
Unknown
139 — Clarify first lawful day hearing
Recommendation: Clarification of the statutory provisions relating to the first lawful day hearing under Section 37(4) of the 1968 Act is required (18.8-18).
Unknown
138 — Review Children's Hearings in child protection
Recommendation: Consideration should be given to the review and revisal of the work of the Children’s Hearings in the area of child protection (18.1-6), including as is suggested later the transference to the Sheriff of all matters relating to a child …
Unknown
136 — SWSG to prepare interviewing guidelines
Recommendation: As part of the national guidance already recommended SWSG should undertake the preparation of guidelines for the investigative interviewing of children in consultation with representatives of all the agencies and professions who may be involved in that work (17.78).
Unknown
135 — Matters to consider before interviewing
Recommendation: Before embarking on an investigative interview interviewers should consider the matters of denial and retraction by a child, the interviewer’s knowledge of information relating to allegations, the interviewer’s own agenda, the use of leading questions and the introduction of personal …
Unknown
134 — Review before departing from interview plan
Recommendation: Any departure from the purpose or number of interviews should only be made after a full review of the situation and the agreement of all agencies (17.76).
Unknown
133 — Initial interview series not above four
Recommendation: An initial series of investigative interviews should usually not exceed four (17.75).
Unknown
132 — Timescale set at planning meetings
Recommendation: The timescale for investigative interviews should be determined at planning meetings (17.74).
Unknown
131 — Maximum two interviews per child per week
Recommendation: In general a maximum of two investigative interviews per child per week should be appropriate and the frequency of interviews is a matter for regular review (17.73).
Unknown
130 — Decide number of interviewers in advance
Recommendation: A decision should be made on the number of interviewers required prior to any interviews starting (17.72).
Unknown
128 — Planned supervision of joint interviews
Recommendation: Where interviews are being undertaken jointly, supervision should be planned on an occasional but regular joint basis (17.70).
Unknown
127 — Supervision in complex interviews
Recommendation: Where interviews involve complex or multiple sexual abuse allegations there must be provided individual personal supervision, management supervision and detailed interview supervision (17.69).
Unknown
122 — Facilities for interviewing children
Recommendation: Attention should be given to the development of more facilities suitable for interviewing children in relation to child abuse (17.62). Area Child Protection Committees should undertake an audit of premises and facilities that may be available locally (17.63).
Unknown
120 — Interviewers involved in care decisions
Recommendation: Interviewers should be involved in decisions relating to the care of the children while they are in places of safety and the extent of their involvement should be defined (17.60).
Unknown
115 — Consistent background information for interviewers
Recommendation: Each interviewer should wherever possible have consistent and relevant background information about the child and in particular about his or her emotional, physical and mental development (17.54), and an assessment of the child’s wider family (17.55).
Unknown
112 — Seek consents before interviewing
Recommendation: The consents of parents and of children where of a maturity to give consent should be sought prior to investigative interviewing being undertaken (17.51).
Unknown
105 — Tell parent the examination results
Recommendation: In general, a parent should be told the results of a medical examination of their child (17.43).
Unknown
104 — Sheriff may authorise medical examination
Recommendation: The Sheriff should be empowered to authorise a child to be taken for a medical examination (17.41), although the carrying out of the examination should not proceed if the child refuses to be examined (17.42).
Unknown
103 — General health examination alongside abuse examination
Recommendation: Where a child is being examined for evidence of sexual abuse a general examination of the child’s health should be carried out at the same time (17.40).
Unknown
102 — Lists of persons for medical examinations
Recommendation: Local authorities should prepare lists of appropriate persons to carry out medical examinations of children suspected of sexual abuse in so far as they have not already done so (17.39).
Unknown
101 — Medical examinations before placement
Recommendation: Medical examinations of children removed under Child Protection Orders should be carried out before they enter their placements (17.38).
Unknown
100 — No Parent's Advocate at present
Recommendation: It is not recommended at present that a Parent’s Advocate should be appointed to represent parents in contacts with the Social Work Department (17.37).
Unknown
99 — Agreement terms available to foster carers
Recommendation: Where children are placed with foster carers belonging to another local authority, a copy of the terms of the agreement between the two authorities regarding the placement should be available to the foster carer so that lines of support and …
Unknown
98 — Keep foster carers informed
Recommendation: Foster carers should be kept informed of any developments regarding any child in their care and of any course of action being taken with the child (17.35).
Unknown
97 — Written report for foster carers
Recommendation: Foster carers should be given a written report at the time when the child is placed, or as soon as practicable thereafter, with as much personal information about the child as possible (17.34).
Unknown
93 — Continued education of children
Recommendation: Where local authorities exercise any powers involving the removal of a child from home, their Social Work and Education Departments must, at the earliest practicable stage secure that provision is made for the continued education of that child (17.31).
Unknown
91 — Same principles for communication
Recommendation: The same principles and procedures as apply to access should also be made applicable to all forms of communication between parent and child (17.29).
Unknown
89 — Keep access under review
Recommendation: Access should be kept under constant review while a child is in a place of safety (17.25).
Unknown
88 — Reasonable access for parents and relatives
Recommendation: In general, reasonable access to a child in a place of safety should be permitted to parents, relatives and friends (17.23) and restrictions on access should only be imposed if there are compelling reasons justifying such restrictions in the interests …
Unknown
87 — Children keep personal possessions
Recommendation: In general, children should be allowed to retain such personal possessions as they reasonably wish or require (17.22).
Unknown
86 — Review and access for separated siblings
Recommendation: Where siblings are placed separately that matter should be kept under regular review (17.20) and they should be permitted reasonable access to each other subject to an appropriate degree of supervision (17.21).
Unknown
85 — Keep siblings together
Recommendation: Where siblings who have been living together are taken into care following allegations of abuse they should not be placed separately unless there is some compelling reason in their own interests for so doing (17.18-19).
Unknown
79 — Allocate a social worker of home authority
Recommendation: Where a child is placed outside the area of its own home authority a social worker preferably of the home authority should be identified and allocated to that child (17.9).
Unknown
77 — Consider the views of the child
Recommendation: Due consideration should be given to the views of the child in all matters affecting him or her (17.7).
Unknown
67 — Information for the child's carer
Recommendation: The fullest possible information about the background of the child should be made available to the child’s carer together with such administrative detail as the carer will require for the well-being of the child (16.41).
Unknown
Prevention of Future Deaths reports(29)
Timothy Cowen
Concerns: Concerns were raised that new procedures and protocols training is not mandatory for all relevant staff. Additionally, there are insufficient Acute Liaison Nurses, and no cover is in place for their absences.
Overdue
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
Finnulla Martin
Concerns: The coroner identified unclear protocols for mental health patients brought voluntarily by police, resulting in inadequate information sharing between agencies and incomplete risk assessments. Concerns were also noted regarding poor record-keeping and insufficient urgency in escalating patient information.
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): • 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 (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 (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
Natalie Gray
Concerns: The coroner raised concerns regarding unfinalised discharge planning for patients with personality disorders and deficiencies in risk assessment processes. These included issues with form clarity, doctor sign-off, and terminology in the Missing Person Procedure, alongside unrecorded third-party information.
Response (Kent and Medway NHS Trust): • The Trust launched a newly reviewed risk policy and risk summary form in January 2017, which is being implemented Trust-wide with updated mandatory training. • Links between Community Mental … (AI summary)
Responded
Steffan Bonnot
Concerns: The coroner identified a lack of full disclosure of a child's background information to prospective foster carers and insufficient formal documentation of what was shared. This created uncertainty and increased anxiety for the child regarding their placement.
Overdue
Jeremiah Obaka
Concerns: There was no agreed or consistent policy for managing service users who are unresponsive or cannot be found, and separate guidelines from the local authority and care agency had not been communicated to each other.
Overdue
Enric Elliott
Concerns: The coroner identified that vulnerable young mothers who book maternity care late (after 28 weeks) are often excluded from the Family Nurse Partnership, thereby missing crucial support despite late booking being a risk factor for their child.
Response (Whittington Health NHS Trust): • The Trust changed its referral criteria to accept mothers up to 25 years old into the local programme. • The Trust will consider, on a case-by-case basis, accepting referrals … (AI summary)
Responded
Joseph Grantham
Concerns: Delays in discharge and specialist letters led to unclear care responsibility and delayed assessments. The coroner also noted missing patient notes, a lack of clear guidance for community staff, and no protocols for complex paediatric care transfers.
Overdue
Ezra Boulton
Concerns: The coroner identified a lack of continuity in antenatal care, which could lead to missed abnormalities or risk factors, and insufficient direct provision of safe-sleeping information to new parents.
Response (Portsmouth Hospitals NHS Trust): • Portsmouth Hospitals NHS Trust (PHT) is establishing two continuity of carer pathway teams, with the first team expected by the end of August and the second by the end … (AI summary)
Overdue
Shannon Quinn
Concerns: The coroner identified inconsistent medical note sharing and a lack of a joint care plan between the Mental Health Trust and care home. Insufficient staff training and inadequate self-harm risk management, including observation adherence, were also noted.
Response (Camino Healthcare): • The service is in the process of closing and is anticipated to be fully closed within 6 to 8 weeks. • Camino Healthcare undertook a review of the service … (AI summary)
Response (CQC): • The CQC conducted comprehensive inspections of Oak House in May and June 2019, identifying serious concerns regarding risk management, incident reporting, and managerial oversight. • The CQC took urgent … (AI summary)
Overdue
Xuanze Piao
Concerns: The university did not hold a face-to-face meeting with a student under 18 or contact their guardian/parents before emailing about potential course removal, and lacked a clear policy for these actions.
Response (Coventry University): • The university has implemented an additional process for international students under 18 who are at risk of course withdrawal, which includes a face-to-face welfare meeting to assess concerns and … (AI summary)
Responded
Ewan Brown
Concerns: The coroner noted the absence of a joint policy and multi-agency structure for police and health professionals to share information regarding vulnerable missing persons with mental health difficulties, and a lack of mandatory refresher training for officers on mental health issues.
Overdue
Samuel Alban-Stanley
Concerns: The coroner noted inadequate support for families of children with rare diseases, with social services refusing assessment and providing limited assistance. Concerns also included a mental health trust's lack of commissioned psychosocial interventions and poor inter-agency communication.
Response (Department of Health and Social Care): • The Department's officials made enquiries with NHS England and NHS Improvement and the Care Quality Commission. • The Department reported that the North East London Foundation Trust, Kent and … (AI summary)
Response (Kent and Medway Clinical Commissioning Group): • Training on Prader-Willi syndrome and Autistic Spectrum Disorders has been provided to staff, and joint assessments for complex neurodevelopmental cases have been introduced. • Working protocols between the local … (AI summary)
Response (Department for Education): • The Department for Education is working with the Children’s Commissioner’s Office and the Information Commissioner’s Office to identify ways to improve data sharing in child safeguarding cases. • The … (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
Rebecca Hayward
Concerns: Assessments for individuals with severe and multiple disadvantage are undertaken by staff without specialist training, leading to inaccurate plans. Care Act assessments are not consistently extended to consider changed care needs when a person moves to different accommodation.
Response (Nottingham Council): • Nottingham City Council's Adult Social Care Senior Leadership Team and Principal Social Workers reviewed and addressed the concerns. • An overarching action plan has been developed in response to … (AI summary)
Responded
Melsadie Parris
Concerns: The social work team did not conduct renewed home visits, seek updated information from the family, or liaise with mental health services after receiving new information about a carer's mental health. This led to undue reliance on old investigations and assessments, potentially missing critical details of the carer's illness.
Response (Buckinghamshire Council): • Buckinghamshire Council accepted the Assistant Coroner’s view that best practice in employing policies was not followed when the file was closed. • The council stated that staff will be … (AI summary)
Responded
Stefan Kluibenschadl
Concerns: The coroner raised concerns that Stefan, a young person with autism, did not have a case manager or key worker as recommended by NICE guidance. Current service provision for these roles is restricted to a small cohort, leaving many young people with autism without this support to navigate services.
Overdue
Terence Davenport
Concerns: A lack of suitable care beds resulted in a patient with dementia's unnecessary acute hospital stay. Insufficient information sharing between authorities and care homes meant safeguarding risks from an unsuitable resident placement were not recognised.
Response (Greater Manchester Integrated Care Board): • A communication will be sent to providers highlighting the importance of robust pre-admission risk assessments and personalised care planning. • Learning from the report will be presented to Tameside … (AI summary)
Responded
Christopher Vickers
Concerns: The coroner noted repeated missed opportunities to coordinate the deceased's care through multi-agency meetings and to make safeguarding referrals, despite escalating risks to self and others.
Response (Cumbria Northumberland Tyne and Wear NHS Foundation Trust): • The Trust implemented changes to Multi-Disciplinary Team (MDT) processes, making safeguarding and multi-agency meetings standing agenda items in relevant teams. • A new weekly telephone triage review process was … (AI summary)
Response (South Tyneside Council): • South Tyneside Council established several new multi-agency meetings and groups to enhance coordination and oversight for individuals with complex needs and high risks. • The council launched new Safeguarding … (AI summary)
Responded
Locket Williams
Concerns: Insufficient psychiatric inpatient beds for children in Surrey, noting a new unit's limited capacity and scope. The new risk assessment system also lacks a clear suicide risk alert on medical records, potentially leading clinicians to miss vital information.
Response (Surrey and Borders Partnership NHS): • The Trust opened Emerald Place in March 2024, stating it has sufficient bed capacity for General Adolescent Unit inpatient beds, and is accessing beds through independent providers while admissions … (AI summary)
Responded
Sebastian ‘Benji’ Oliver
Concerns: The coroner noted shortcomings in West Midlands Police training and communication protocols, specifically regarding reliance on outdated capacity assessments and not seeking clarification from paramedics when individuals with fluctuating capacity abscond.
Response (West Midlands Police): • West Midlands Police implemented the Right Care, Right Person (RCRP) operational model, including mandatory training for call handlers and front-line officers. • A Vulnerability Desk was established within Force … (AI summary)
Responded
Callum Hargreaves
Concerns: Sanctuary Housing did not adequately determine if a vulnerable tenant was being cuckooed or who caused significant property damage. This led to an inappropriate possession notice and highlighted a lack of clear process for responding to cuckooing concerns.
Response (Sanctuary Housing): • Sanctuary Housing committed to an internal review to identify improvements to its multi-agency approach to anti-social behaviour and cuckooing. • Sanctuary Housing will externally benchmark its policies and procedures … (AI summary)
Responded
Callum Hargreaves
Concerns: The coroner noted a prolonged disagreement between a housing provider and the Council over responsibility for housing a cuckooed tenant, and conflicting internal Council views on homelessness applications for tenants with social tenancies.
Response (Conrwall Council Housing): • A Housing Options all-staff briefing was held in June 2025 to highlight the importance of applying the correct homelessness test and s.188 duty. • Housing Options staff have completed … (AI summary)
Responded
Marcia Grant
Concerns: The coroner identified that a shortage of foster placements led to unsuitable child placements. Additionally, there were inadequate documentation, communication of risks, and formal risk assessments regarding foster carers and other children in their care.
Response (Department for Education): • The Department has supported over 60% of local authorities through 10 regional recruitment support hubs, most of which launched in 2024. • The Department has invested in and is … (AI summary)
Response (Rotherham Metropolitan Borough Council): • Rotherham Metropolitan Borough Council approved a Children in Care Sufficiency Strategy (2023-2028) and established a Sufficiency Board to increase placement availability, including residential beds and foster carers. • A … (AI summary)
Responded
Isla McVeigh
Response (North Cumbria Integrated Care NHS Foundation Trust): The Trust accepts the concerns and has developed an action plan. This includes mandatory briefings and simulation-based training on opioid dependency and safeguarding, review of clinical guidance, enhanced safeguarding supervision, … (AI summary)
Response (Cumberland Council): Cumberland Council and the Safeguarding Children Partnership will review multi-agency threshold guidance and associated arrangements, including referral and escalation processes, between October 2026 and January 2027. They will also undertake … (AI summary)
Responded
Georgia Scarff
Response (Department for Education): The Department for Education plans to introduce an information sharing duty and a Single Unique Identifier via the Children’s Wellbeing and Schools Bill to improve safeguarding information sharing, though it … (AI summary)
Response (Royal Hospital School): The Royal Hospital School introduced a new assessment template, strengthened its safeguarding leadership, and implemented regular safeguarding updates and meetings. Following the inquest, all staff attended in-person CPOMS training, were … (AI summary)
Responded
Natasha Hill
Concerns: The coroner identified gaps in formal adult safeguarding reviews and dedicated transition teams for young people approaching adulthood. Concerns also highlight the need for national standardisation in policing child sexual exploitation and guidance for missing persons.
Response (Home Office): • The Home Office is working to create a consistent, victim-centred response to child sexual exploitation, including establishing Operation Beaconport and providing funding to the CSE Taskforce and TOEX Programme. … (AI summary)
Response (Department for Education): • The Department for Health and Social Care published a briefing in 2021 on transitional safeguarding within adult social work. • An 11-month project was launched in March 2026 to … (AI summary)
Response (National Police Chiefs Council): • The National Police Chiefs Council (NPCC) stated that national partners continue to advance policy and practice in transitional safeguarding to support greater continuity of protection and risk management through … (AI summary)
Response (National Police Chiefs' Council): • The National Police Chiefs' Council (NPCC) undertook an urgent review of the Child Abuse Authorised Professional Practice (APP) currently out for consultation. • The NPCC identified a gap in … (AI summary)
Responded
Matilda Davis
Concerns: Suicide prevention training is not mandatory for frontline staff in Warwickshire Children’s Services, leading to variability in practice. This meant staff did not directly explore suicidal ideation or signpost to crisis support for Matilda.
Response (Warwickshire County Council): • Warwickshire County Council will implement a three-tiered suicide prevention training programme for staff. • Mandatory Tier 2 training for Children & Families staff will commence in Autumn 2026, with … (AI summary)
Responded
Select committee recommendations(205)— showing 50 strongest matches
#95 —
Recommendation: Nikki Scordi added that âwomen in particular worry about their children, whether they are with them or notâ. She explained that âoften, they are separated because of prison and cannot have them back, and that is a real concern for …
Response attribution not verified
#57 —
Recommendation: Children in care and those with care experience are particularly vulnerable to financial instability and legal aid is crucial to allow them access to justice. The Government must urgently act to increase provision in legal aid deserts. Where legal aid …
Response status not verified
#56 —
Recommendation: Children’s right to independent advocacy must be strengthened. Although there is a statutory entitlement to advocacy services, many individuals are unaware of this or unable to secure advocacy in an appropriate timeframe. We support the recommendation of the Independent Review …
Response status not verified
#53 —
Recommendation: Independent Reviewing Officers (IROs) should be part of a system that ensures that children have their human rights respected whilst in care. However, we have heard that IROs sometimes struggle to challenge local authorities with independence. We note with concern …
Response status not verified
#41 —
Recommendation: We have heard evidence about the inadequate provision of mental health support and care in social care settings, which can be one of the contributing causes for self-inflicted injuries and deaths. The government must tackle this as a matter of …
Response status not verified
#40 —
Recommendation: This change in the law would be of particular relevance to children in care, because there would be increased protections for children before they enter the care system, potentially allowing for concerns in home environments to be identified and flagged …
Response status not verified
#39 —
Recommendation: In line with recommendations made by the Children’s Commissioner for England and the UN Committee on the Rights of the Child, there should be a change in the law to give children equal protection from physical assault to adults. The …
Response status not verified
#38 —
Recommendation: We have seen evidence that children in need, a group that includes children in care and disabled children, are four times more likely to die due to deliberately inflicted injury, abuse or neglect than children without any social care involvement. …
Response status not verified
#37 —
Recommendation: The review of the National Protocol on Reducing Unnecessary Criminalisation of Looked-After Children and Care Leavers is a welcome step, although its publication is already late. The government should consider placing it on a statutory footing, to ensure that local …
Response status not verified
#36 —
Recommendation: The government must work with local authorities, law enforcement professionals and other relevant stakeholders, to address the root causes and drivers of the overrepresentation of children and young people with care experience in the criminal system. These include poor practices, …
Response status not verified
#35 —
Recommendation: Whilst criminal sanctions may be appropriate in some cases, children and young people with care experience are disproportionately at risk of criminalisation. Data we have seen shows that care-experienced young people constitute nearly half of the population in youth custody, …
Response status not verified
#33 —
Recommendation: The government should also make clear what specific action is being taken to locate these children, to investigate the causes for them going missing, and to avoid unaccompanied asylum-seeking children going missing in the future. The Home Office should update …
Response status not verified
#31 —
Recommendation: We welcome the fact that the majority of missing children have now been found. However, we continue to be extremely concerned about the fact that some children who went missing from asylum hotels in previous years remain missing. (Conclusion, Paragraph …
Response status not verified
#30 —
Recommendation: The consequences for children in care of the Supreme Court’s recent changes to the law on deprivation of liberty should be kept carefully under review. It is crucial that children who are held in conditions akin to confinement are not …
Response status not verified
#29 —
Recommendation: We appreciate that in certain circumstances, for welfare reasons, children in care may be deprived of their liberty. But every effort should be employed to offer support to children before depriving them of their liberty. Deprivation of liberty must be …
Response status not verified
#27 —
Recommendation: We have heard evidence that many children do not feel safe or do not have their needs met whilst in so-called supported accommodation. Many of these children are legally looked after but not receiving day-to-day care. While the new regulatory …
Response status not verified
#25 —
Recommendation: We welcome the Government’s renewed focus on expanding fostering. Long- term solutions will involve systematic changes to ensure loving homes for all children in care. However, the accommodation of children in illegal homes is a problem that cannot wait. (Conclusion, …
Response status not verified
#24 —
Recommendation: Unregulated accommodation, including caravans, holiday rentals or AirBnBs, do not allow for formal inspections or scrutiny. Such settings are unlawful, unsafe, and represent a serious failure to protect children. They are also not good value for public money. We are …
Response status not verified
#23 —
Recommendation: While we understand that it can be very difficult for local authorities to arrange suitable accommodation for all children in their care, it is never acceptable to place a child in an illegal home. (Conclusion, Paragraph 130)
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
#21 —
Recommendation: There must be greater emphasis on the need to maintain and prioritise stable, lifelong relationships. The availability and promotion of contact with family members and friends, where safe and in the best interests of the child, must be the default …
Response status not verified
#20 —
Recommendation: Children are too often placed in accommodation far from family and friends. Failure to promote contact with siblings and other family members could amount to a breach of children’s rights to private and family life under Article 8 ECHR. (Conclusion, …
Response status not verified
#15 —
Recommendation: We also welcome the Law Commission’s project on legal reform of kinship care. We particularly welcome the Law Commission’s plans to investigate the benefits and drawbacks of introducing a bespoke order to recognise, support, and regulate kinship care. Such an …
Response status not verified
#14 —
Recommendation: We welcome the government’s recent and planned reforms and focused work in the area of kinship care. However, efforts must not end there. Children should be able to stay within family networks wherever possible, having due regard to the child’s …
Response status not verified
#13 —
Recommendation: We have heard evidence about the considerable benefits of keeping children within family networks. We believe that the government must emphasise the importance of loving kinship arrangements and support them whenever possible. (Conclusion, Paragraph 82)
Response status not verified
#9 —
Recommendation: Ensuring that disabled children are safe from harm is, of course, extremely important. In some circumstances, such as where there is evidence of risk of harm or abuse to the child, a child protection approach may be appropriate and, indeed, …
Response status not verified
#8 —
Recommendation: Assessments of children’s needs must also effectively identify neurodivergence, and must lead to the provision of adequate support to meet the needs of neurodivergent children. (Recommendation, Paragraph 59)
Response status not verified
#7 —
Recommendation: To ensure that disabled children and their families are aware that they are entitled to an assessment of their needs, the duty on local authorities to provide one should be clear and explicit. We agree with the Law Commission’s recommendation …
Response status not verified
#6 —
Recommendation: We agree with the Law Commission: the definition of disability in the Children Act 1989 is outdated. It contains stigmatising language and it does not match modern definitions of disability used in other areas of law. The definition should be …
Response status not verified
#5 —
Recommendation: The disabled children’s social care framework is complex and difficult to navigate. In line with the Law Commission’s recommendations, we agree that there should be a single, comprehensive piece of statutory guidance on disabled children’s social care law, clearly setting …
Response status not verified
#41 —
Recommendation: It is striking that libraries are statutory requirements in prisons, but not schools. Once funding for primary and secondary schools is in place, the Department must recognise school libraries as essential public services and place them on a statutory footing. …
Response status not verified
#40 —
Recommendation: The evidence the Committee has seen points to a sharp drop off in reading for pleasure amongst teenagers, but the Department is focusing its efforts on school libraries in primary schools. The Department should extend its pledge to fund a …
Response status not verified
#39 —
Recommendation: Access to books is not a luxury but a fundamental driver of educational success. For many children, schools are the first and only place they encounter a wide range of books and stories. School libraries are not optional enhancements but …
Response status not verified
#31 —
Recommendation: The Department must include a stronger focus for English Hubs on reading for pleasure, alongside reading proficiency. This should include work on how to support reading for pleasure among children with SEND, especially those with dyslexia and other reading difficulties. …
Response status not verified
#30 —
Recommendation: The new school breakfast clubs provide a key opportunity to introduce disadvantaged pupils to reading and books in a fun environment away from the pressures and stresses of learning. The Department must ensure that schools delivering the new breakfast clubs …
Response status not verified
#26 —
Recommendation: Schools play a key role in developing a love of reading among children, especially those from disadvantaged backgrounds who otherwise lack opportunities to access books. The Department acknowledges this, but its policies do not reflect this, with work on reading …
Response status not verified
#14 —
Recommendation: The Department must act decisively and evaluate the benefits of the different programmes being undertaken, with a particular focus on supporting children from those groups least likely to read for pleasure. This should include looking at the benefits of book …
Response status not verified
#11 —
Recommendation: One key priority group missing from the National Year of Reading is children with SEND, particularly those with dyslexia and other reading difficulties. The Department must set out what steps it is taking to support these children to develop an …
Response status not verified
#16 —
Recommendation: The Government must adopt a proactive approach and seek to identify and locate minors and where feasible repatriate them as soon as practically possible. (Recommendation, Paragraph 97)
Response attribution not verified
#18 —
Recommendation: We support the call from the Joint Committee on the Draft Mental Health Bill for the Government to consult on the introduction of a statutory test for competency, or “child capacity”, for children aged under 16. (Recommendation, Paragraph 106) Race …
Response attribution not verified
#17 —
Recommendation: We agree with witnesses that children under 16 may be denied the opportunity to benefit from the rights provided by the Bill if their ability to make decisions for themselves is not properly assessed. Clarity in such assessments is therefore …
Response attribution not verified
#16 —
Recommendation: We welcome the introduction of an “opt–out” system in respect of independent advocacy but call on the Government to ensure that this system extends to children who are informal patients as well as those who are compulsory patients. (Recommendation, Paragraph …
Response attribution not verified
#15 —
Recommendation: We recognise the special importance of advocacy services for children, who may face particular difficulties in understanding and enforcing their legal rights when separated from their families. Independent advocates represent an important method of ensuring the child’s right to be …
Response attribution not verified
#14 —
Recommendation: We agree with submissions made to us that the Mental Health Bill could and should do more to protect against children being placed on adult wards. The Bill should be amended to include a requirement that a child should not …
Response attribution not verified
#13 —
Recommendation: While the recent Government amendment to the Bill, introducing a review of notification requirements in respect of children on adult wards represents a welcome acknowledgement that the status quo may not be satisfactory, it does not guarantee the prompt protection …
Response attribution not verified
#87 —
Recommendation: With regard to children, Open Rights Group notes that collecting biometric data from children over 16 without consent could violate child protection standards: “According to the guidance of the Information Commissioner’s Office (ICO) on processing sensitive personal data under the …
Response attribution not verified
#34 —
Recommendation: The bill should be amended so that cases involving child defendants cannot be allocated to the Crown Court Bench Division. (Recommendation, Paragraph 125)
Response status not verified
#27 —
Recommendation: The sole reliance on using the likely length of sentence to determine allocation to the Crown Court Bench Division (CCBD) will cause problems. A defendant with several previous convictions is more likely to receive a jury trial than a defendant …
Response status not verified
#23 —
Recommendation: The government must set out what specific consideration has been given to the impact of the proposed reforms on children and young people tried in the youth court. In particular, the government must set out how it intends to mitigate …
Response status not verified
#22 —
Recommendation: The youth court occupies a distinct position within the magistrates’ court system, dealing with serious cases involving some of the most vulnerable defendants in the criminal justice system. As 90% of children and young people are tried in the youth …
Response status not verified
HSSIB safety recommendations(3)
Keeping children and young people with mental health needs safe: the design of the paediatric …
It may be beneficial if NHS organisations ensure that systemic risks associated with caring for children and young people with high-risk behaviours on the paediatric ward, including the safety and wellbeing risks to patients and staff, are escalated to integrated …
Safety Observation
Non-accidental injuries in infants attending the emergency department
Psychosocial multidisciplinary team (MDT) meetings: These meetings were held to discuss children (under 18 years) who had attended the ED and about whom there were safeguarding concerns. It was attended by various safeguarding stakeholders, including the police, violence reduction team …
Learning Prompt
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
Providers of inpatient children and young people’s mental health services can improve patient safety by ensuring there is not a blanket approach to safeguarding mitigation measures based on a person’s age, and that mitigation measures are individualised and based on …
Safety Observation
CQC inspection actions(22)
Royal Shrewsbury Hospital
The service should consider how it segregates children and adults in the main waiting area.
Should Do
North Manchester General Hospital
The trust should consider provisions for children for example access to a child friendly area and play specialist to provide distraction and coping skills for children waiting for surgery.
Should Do
Kettering General Hospital
The service should ensure children and young people receive the right care in a timely manner.
Should Do
Clatterbridge Hospital
The services should ensure initial health assessments for looked after children are undertaken within the designated timeframes.
Should Do
Clatterbridge Hospital
The services should consider tailoring the entrance to the women’s and children’s department to the needs of children accessing its service.
Should Do
Fairfield General Hospital
The trust should consider provisions for children for example access to a child friendly area and play specialist to provide distraction and coping skills for children waiting for surgery.
Should Do
Rochdale Infirmary
The trust should consider provisions for children for example access to a child friendly area and play specialist to provide distraction and coping skills for children waiting for surgery.
Should Do
Rochdale Infirmary
The trust should ensure staff caring for children are familiar with Gillick competence and understand the importance of it.
Should Do
Clifton Hospital
The trust should work with partners to ensure that mental health needs of children and young people with a moderate-severe learning disability are met.
Should Do
The York Hospital
The trust should consider recruiting looked after children specialist nurses to support capacity for initial health reviews.
Should Do
The Princess Royal Hospital
The trust should ensure that they complete audits to monitor effectiveness and care for children on neonates.
Should Do
Scarborough Hospital
The trust should consider recruiting looked after children specialist nurses to support capacity for initial health reviews.
Should Do
North Manchester General Hospital
The trust should ensure staff caring for children are familiar with Gillick competence and understand the importance of it.
Should Do
Cumberland Infirmary
The trust must implement an effective system to identify and assess any potential safeguarding issues and the management of vulnerable children and young persons. Regulation 13(1)(2).
Must Do
Fairfield General Hospital
The trust should ensure staff caring for children are familiar with Gillick competence and understand the importance of it.
Should Do
Queens Hospital
Ensure staff are up to date with yearly appraisals and maternity mandatory training including, cardiotocograph interpretation, safeguarding adults’ level 3 and safeguarding children level 3.
Must Do
Andover War Memorial Hospital
The trust should ensure all medical staff complete safeguarding children training
Should Do
The York Hospital
The service should ensure ED medical staff complete their required level of safeguarding training, especially for safeguarding children.
Should Do
The Princess Royal Hospital
The trust should ensure that sepsis trolley within neonates is checked daily.
Should Do
The Princess Royal Hospital
The trust should ensure that all staff in neonates have completed sepsis training.
Should Do
Family Nurse Partnership & Health Visiting
The service should ensure that they continue work to improve performance in completing checks for the mandated milestones outlined in the Healthy Child Programme.
Should Do
Family Nurse Partnership & Health Visiting
The provider must ensure that it has robust systems in place to oversee and monitor the quality and safety of care provided to vulnerable children and families and which can be used to underpin improvement work.
Must Do
ICIBI immigration recommendations(3)
An inspection of the use of hotels for housing unaccompanied asylum-seeking children …
Work with partners to provide written information for children, as necessary in their own first language, including: a) what will happen to them next, in terms of their transfer and …
A re-inspection of the use of hotels for housing unaccompanied asylum-seeking children …
Work with partners to provide written information for children, as necessary in their own first language, including: a) what will happen to them next, in terms of their transfer and …
An inspection of asylum casework (August 2020 – May 2021)
Prioritise claims for unaccompanied asylum-seeking children (UASC), as per the Immigration Rules
IOPC learning recommendations(6)
Recommendations - Northamptonshire Police, March 2021
The IOPC recommends that Northamptonshire Police takes steps to ensure that custody officers are best supported to decide whether to authorise the detention of a juvenile. This shoud include consideration of whether appropriate sources of advice are available to custody …
Police contact with man preceding murder – Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Constabulary should explore ways to highlight previous incidents, in respect of a person or address; when a new incident log is created or when the information is sought. Police responded to five separate calls over …
Police contact with man preceding murder – Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police should write and implement a comprehensive Vulnerable Adult Policy that incorporates ACPO guidance and complements existing local authority safeguarding policies. As a result of this incident, Derbyshire Police have introduced guidance and learning for …
Reported concerns of welfare and subsequent police actions to conduct a missing …
The IOPC recommends the Metropolitan Police Service North Wembley borough command unit (BCU) reviews its current missing person investigation and supervision process to; - provide clear guidance on the roles and responsibility for those based within the Operations room, Local …
Investigation into police contact with a woman and response to concerns for …
The IOPC Recommends that West Yorkshire Police (WYP) should review current policy and guidance in relation to safeguarding of victims of crime to ensure that, where more than one force is involved, safeguarding responsibilities are appropriately agreed between the forces, …
Investigation into police contact with a woman and response to concerns for …
The IOPC Recommends that North Yorkshire Police (NYP) should review current policy and guidance in relation to safeguarding of victims of crime to ensure that, where more than one force is involved, safeguarding responsibilities are appropriately agreed between the forces, …
NAO audit recommendations(4)
Support for vulnerable adolescents
We recommend that those central government departments involved should, through formal governance, work together to: d) set out how they will support local bodies to improve local safeguarding arrangements and respond to the two recent reviews which found they were …
Accepted
Support for vulnerable adolescents
We recommend that those central government departments involved should, through formal governance, work together to: a) build on recent data-sharing exercises to understand better the relationship between risk factors and adverse outcomes for vulnerable adolescents;
Accepted
Support for children’s education during the early stages of the Covid-19 pandemic
d) act quickly on its early assessments of the catch-up programme during 2020/21, to ensure that the funding is achieving value for money and the National Tutoring Programme schemes are reaching disadvantaged children as intended; and
Accepted
Support for children’s education during the early stages of the Covid-19 pandemic
b) put in place effective monitoring to track the longer-term impact of COVID-19 disruption on all pupils’ development and attainment, with a particular focus on vulnerable and disadvantaged children, and take action in light of the results;
Accepted
IMB individual recommendations(27)
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport] The Detention Contractor should arrange for a DCO or other responsible adult to sit in the family holding room with a young or otherwise vulnerable unaccompanied child (para. 6.6).
Other
Werrington (2023)
Is it safe to keep together a third of the establishment’s population who are over 18 years old with two-thirds who are under 18?
Other
Pentonville (2023)
What additional measures will you take to ensure the safety and access to activities of vulnerable prisoners who, due to a lack of space on the vulnerable prisoners’ unit, are housed separately?
Governor / Director
Pentonville (2023)
Will HMPPS commit to the expediting of the transfer of sentenced vulnerable prisoners from Pentonville to other more suitable establishments, where they can be kept safe and have access to offence-based courses?
HMPPS
London STHF (2023)
The Board has observed that some children had extended waits in the CWA. The facilities in the CWA do not compare with the environment in the family holding room and the Board would like to see these children accommodated in the holding room instead.
Other
Werrington (2024)
With the closure of YOI Cookham Wood, the Board believes it is inhumane that about a quarter of young people, who are legally recognised as children, are accommodated at Werrington from the other end of the country, far away from family? How does the Minister intend to address this serious issue?
Ministry of Justice
In Progress
Swinfen Hall (2024)
Can the Minister instruct the Ministry of Justice to implement a system to record the details of all children affected by parental imprisonment at the time of sentencing to assist prisons in providing prisoner family support?
Ministry of Justice
In Progress
London short term holding facilities (STHF) (2025)
The Board has observed that some children had extended waits in the CWA. The facilities in the CWA do not compare with the environment of a family holding room and the Board would like to see these children accommodated in the holding room instead.
Home Office
Yarl’s Wood (2020)
The Board recommends that the Centre should maintain its vigilance in the identification of vulnerable persons and minors.
Governor / Director
Yarl’s Wood (2020)
Vulnerable adults are still being detained despite there being a pilot underway to explore an enhanced pre-detention screening tool to help facilitate the disclosure of vulnerability. The Board recommends that a clear evaluation of this pilot is published to ensure that the measures necessary for the safeguarding of vulnerable individuals are in place.
Ministry of Justice
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport] The Detention Contractor should ensure that DCOs are proactive in their care for older children (para. 6.7).
Other
Dover (2020)
Supervision of detainees in the holding rooms should be improved during times when the holding rooms are close to full capacity in particular to safeguard the needs of children detainees who are vulnerable.
Other
Gatwick IRC/RSTHF (2022)
Undertake a complete review of Adults at Risk, ACDT and Rule 35 policy and procedure (repeated from 2019, 2020 and 2021) (section 4.4.1).
Home Office
Wetherby (2023)
Although every young person has been released to an address, not all addresses are deemed to be suitable by the social care team. Local authorities have been challenged on this on more than 29 occasions. What can be done to assure young people and the Board that this unsatisfactory situation will be improved?
Other
Werrington (2025)
Why are children with complex needs sent to Werrington when there are no specialist facilities available? And why is it so time-consuming to get them transferred? How will this be improved?
HMPPS
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport] The Detention Contractor should ensure that the toys are kept in good repair and in a clean condition and that the DVD boxes are stored so that children can easily see what is available (para.6.12).
Other
Belmarsh (2021)
Will the prison appoint champions in each houseblock to be responsible for care leavers (see section 4.4 Safeguarding)?
Governor / Director
Gatwick, Stansted, Luton and Lunar House (2022)
The short-term holding facilities at Gatwick airport’s North Terminal, for families, children and vulnerable detained individuals should be improved, by the provision of additional accommodation.
Home Office
Gatwick IRC/RSTHF (2022)
Improve the proactivity with which caseowners and local Home Office staff address the immigration cases of all detained men, and particularly those who are vulnerable, long-staying or disengaging (sections 4.4.1, 6.3, 7.2, 7.2.4).
Home Office
Lewes (2023)
Will the Governor ensure that the induction processes at HMP Lewes are improved and that the vulnerable prisoners wing is not used for new receptions in the future?
Governor / Director
Feltham (2023)
What will the Government do to achieve better information sharing between Social Services and Youth Custody Services so that Looked After Children (LAC) can easily receive their statutory entitlements? Will you follow up on measures promised last year about how this can be addressed?
Other
London STHF (2024)
The Board has observed that some children had extended waits in the CWA. There are no facilities for children in the CWA, nor is the environment comparable to that in the family room. The Board would like to see these children accommodated in the holding room instead.
Home Office
Nottingham (2020)
We have concerns regarding the wider circumstance of a falling population of those convicted of a sexual offence, resulting in wings for these prisoners also being used to house prisoners who are vulnerable because of other issues. Given that this is a service-wide circumstance, it may be an area that merits strategic reconsideration by the Director-General of Prisons.
HMPPS
In Progress
Wetherby (2023)
The Board remains concerned about the suitability of placing girls at Wetherby, in their present accommodation. When will a decision be reached regarding their future placement?
Ministry of Justice
Heathrow immigration removal centre (2023)
There are many people detained at HIRC who have been identified as Adults at Risk (AAR) Level 3 and who have been in the detention centre for more than 80 days. These individuals should be released from Heathrow IRC as soon possible.
Home Office
Pentonville (2024)
Growing numbers of prisoners accused or convicted of sex offences are held in Pentonville. Delivering a meaningful and rehabilitative regime to this vulnerable group safely is very challenging. Will HMPPS commit to delivering greater local support and a national strategy?
HMPPS
In Progress
Altcourse (2025)
Are there any permanent solutions to the problems caused by housing an overspill of vulnerable prisoners on the induction unit (Bechers)?
Governor / Director
Health investigations(79)
Independent investigation: Janet Frost, Meadowfielsd – County Hospital Durham (1999) — Rec 8.6
Social services should review its approach to looked after children where their parents have mental health or substance abuse problems.
north_east_yorkshire
Independent investigation: Tyler Warmington, Faringdon, Oxon (2017) — Rec 7.2
In addition to monitoring carefully the implementation and impact of their revised `Think Family’ policy, our team recommends that staff should be prompted to ensure that families (as appropriate) and partners in primary health, social care and education are engaged, informed and heard whenever there is a potentially vulnerable child …
south_east
Independent investigation: Tracey Baker, Chard (2015) — Rec 6
Somerset Partnership NHS Foundation Trust should consider introducing an assessment tool, such as PAMIC and/or the Crossing Bridges Family Model, in order to increase its practitioners’ awareness and understanding of the Think Family Agenda and the potential impact of parents’ mental health on their children.
south_west
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 12
A joint protocol should be developed between Children‟s Services and Mental Health Services to enable better communication and shared practice for children whose parents have mental health problems. (AA)
london
Independent investigation: Paul BrownDorothy Brown, Liverpool (2014) — Rec 4
Where there is a question of responsibility for the welfare of a child, specific focussed risk assessments must be conducted with respect to risk towards the child, in conjunction with other statutory agencies
north_west
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 11
Risk assessments concerning child protection issues must be detailed and fully recorded in patient records, in addition to any pro-forma that is completed.
midlands
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 10
Staff working with families where safeguarding children may be an issue need time to undertake qualitative assessments, appropriate child-centred training and child-focused supervision.
midlands
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 7
IT systems should alert primary care practitioners when a child is within the household of an adult with mental health issues and should highlight key patient issues.
midlands
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 6
Assessing risk to safeguard children’s welfare should be standard and training provided for all practitioners who come into contact with families where there are children in the household.
midlands
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 5
It is important that children’s views and feelings should form part of any risk assessment.
midlands
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 3
The Framework for the Assessment of Children in Need [DH 2000] is a key tool for use by all professionals attempting to safeguard children’s welfare. This or any subsequent common assessment tool should be utilised by everyone working with children and their families.
midlands
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 2
There needs to be clarity on what training staff should attend irrespective of discipline or geographical boundaries. Safeguarding children training needs to be formalised and structured across the organisation(s).
midlands
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 1
Standardised referral letters (in part) should give an assessment of risk for child(ren) more explicitly and provide key issues/risks to a secondary provider. They should also give enough information to identify where other family members have issues pertinent to child safety.
midlands
Independent investigation: Nihaal Kapede, Staincliffe (2000) — Rec 6
The significance of the extended family and family dynamics must be addressed more effectively by all professionals involved in a client‟s care. Where child protection issues are involved this must be addressed by Social Services.
north_east_yorkshire
Independent investigation: Nico Meli, Nottingham (2003) — Rec R2
Safeguarding children. This report has highlighted a number of concerns about the risk presented to children. There are also examples of when these risks were handled well. We recommend that this report is tabled at the local safeguarding children’s board to consider these risks and whether similar situations are occurring …
midlands
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 35
DHSSPS in collaboration with corresponding Departments in England, Wales and Scotland should commission UK wide research into all aspects of child killing to ensure that attention is given to increasing the understanding of cases involving parents who are mentally disordered but where there are no pre-existing child care concerns. This …
northern_ireland
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 20
South and East Belfast Trust should review the assessment models used by CRT and FCC IAT in cases where a parent with dependent children has attempted suicide or made a serious threat of self-harm.
northern_ireland
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 19
DHSSPS should ensure that consideration of parental mental health is integrated into all stages of the new Northern Ireland Assessment Framework for Children. (Understanding the Needs of Children in Northern Ireland).
northern_ireland
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R29
The trust should amend its existing child protection policies and procedures so that they explicitly cover circumstances in which someone with a mental illness is living in the same house as a child.
london
Independent investigation: Hamidi HamidullahKhizer Hayat, Tulse Hill (2006) — Rec Recommendation Numbe
All active Lambeth cases should be reviewed regarding the current Trust Safeguarding Children Policy to ensure that children are identified appropriately and that plans are in place to promote both their wellbeing and safety.
london
Independent investigation: Edward Miles, Tower Hamlets (2003) — Rec 7
The Trust must ensure that the needs of children of service users are systematically identified and addressed within the care planning process. This must include routine enquiry about children, assessment of their needs and risks, and appropriate referral to children's services where concerns are identified. The Trust must establish clear …
london
Independent investigation: Casey Kearney, Doncaster (2012) — Rec 7
Doncaster Safeguarding Childrens Board will ensure through a quality assurance process, that the welfare and care needs of looked after children are given the highest priority, and that improvements in the outcomes for looked after children are met and sustained.
north_east_yorkshire
Independent investigation: Casey Kearney, Doncaster (2012) — Rec 6
Doncaster Safeguarding Children‘s Board will ensure that the safeguarding and education of children and young people being home educated is effectively monitored.
north_east_yorkshire
Independent investigation: Benjamin Durao, Brixton (2004) — Rec 2
That the Common Assessment Framework for Children to be implemented and used across the Trust, to improve the identification of support required for children and families affected by mental health.
london
Independent investigation: Anthony Harrison, Andover (1998) — Rec 6
The Health Authority, PCGs and NHS Trusts should support local programmes for vulnerable children and families, for example through Sure Start schemes.
south_east
Investigation into matters relating to Jimmy Savile at Leeds General … — Rec 11
The Trust should conduct an audit of placements of children and young people on adult in-patient areas to ensure that this no longer happens (source: chapters six, seven and eight).
Leeds Teaching Hospitals NHS Trust
north_east_yorkshire
An independent investigation into the care and treatment of Mr … — Rec 15
The Trust must properly consider and document risks where children and young people are having contact with a vulnerable adult.
south_east
An independent investigation into the care and treatment of a … — Rec 8
Services for young people, including schools and SaBP CAMHS services should raise awareness of inter relationship abuse amongst young people, and ensure that opportunities for education, support and disclosure are available.
south_east
An independent inquiry into the care and treatment of Ms … — Rec 11
We recommend that in light of the information provided to us, a further internal review into the care and protection of Adult B and Adult D be undertaken by Children’s social care in conjunction with local mental health services, given that the account of their childhood raises a number of …
south_east
Independent investigation into the care and treatment of Mr N — Rec Regional recommendat
The North West London Integrated Care System should seek assurance that an understanding of the risks to vulnerable young people of ‘county lines’, and gang related threats is embedded in all services and systems dealing with the mental health of young people. This will help to ensure there are no …
london
Independent investigation into the care and treatment of Mr N — Rec 17
The Trust and Local Authority should complete a review of the current processes in place for identifying children and young people who may be vulnerable to child exploitation, county lines drug gangs or general involvement with gangs to ensure that these are in line with current national best practice and …
london
Accepted
Independent investigation into the care and treatment of Mr B — Rec 4
The Trust must review the impact of the changes to policy and processes for child safeguarding, including obtaining feedback from staff about how effective the new processes are.
Mr B who committed a homicide in 2012. Mr B was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of Nadia … — Rec 9
TEWV/NHS England and Middlesbrough Council must provide assurance that all looked after children with a diagnosis of autism have care provided that is in line with the NICE guidance on Autism spectrum disorder in under 19s: support and management, recognising the challenges in the system.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Nadia … — Rec 12
South Tees Safeguarding Children’s Partnership must seek assurance that the needs of young people in inpatient mental health care in the locality are appropriately safeguarded.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Mr … — Rec 2
Early work with families when children are diagnosed with a learning disability to be re-visited and a protocol developed (in general).
north_west
An independent investigation into the care and treatment of Mr … — Rec 1
Stakeholders to examine current processes and systems using Mr X’s case as a worked example in order to understand how processes can be improved for the future. This to be focused upon safeguarding of children and vulnerable adults.
north_west
An independent investigation into the care and treatment of Mr … — Rec 1
A family protocol to be developed to establish boundaries and statutory agency response when differences of opinion develop between families and health and social care agencies when providing care and treatment to both children and vulnerable adults.
north_west
Independent investigation: Lenny Leak, Gateshead (2001) — Rec 1
Strategies should be developed within inter agency working to improve the understanding of domestic violence, often a hidden problem in society, in the management of risk within the community. These strategies should also deal with the well established links between domestic violence and child protection issues.
north_east_yorkshire
Independent investigation: Simon Widger, Eastbourne, Sussex (2000) — Rec 3
Young people should not be placed by Statutory Authorities to live in independent settings before the age of 16 and even when over 16 (up to the age of 18) only with an individually tailored care package.
south_east
Independent investigation: Sarah Smart, Oxford (2005) — Rec 15.9
The Crisis Resolution and Home Treatment Team needs to develop its Risk Assessment / Risk Management practice and processes to routinely check with Child Protection systems to ensure the safety of children. In Risk Management this may then involve joint working with Child Protection Teams to provide family based approaches …
south_east
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 12
Professionals working with families with children in primary care mental health services, should access GP records prior to the commencement of work with the client/family, so that as much information as possible is known to a practitioner from the outset.
midlands
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 4
A risk assessment should review both parents’ or carers’ backgrounds so that any pertinent information is included.
midlands
Independent investigation: Nihaal Kapede, Staincliffe (2000) — Rec 3
Social Services must deliver a more robust system, whereby the Child and Family Team must carry out an assessment of risk where threats to children have been raised. Such a system should not allow for individuals to make decisions on such issues until an initial assessment under Section 47 has …
north_east_yorkshire
Independent investigation: Nihaal Kapede, Staincliffe (2000) — Rec 2
Where a mental health client raises issues of domestic violence, especially where there are children involved, professionals must assess the situation effectively following agreed policy.
north_east_yorkshire
Independent investigation: Lisa Sullivan, Walton on the Naze (2005) — Rec 2
The National Service Framework for Children includes a recommendation that CPA meetings (and their equivalent) should take account of children’s needs and any risk of harm to them. Therefore, when a service user is the parent of a child for whom a child protection/safeguarding conference is called, and the mental …
east_of_england
Independent investigation: Leanne Unsworth, Burnley (2019) — Rec 4
The Trust should ensure that risk assessment, formulation and management are dynamic, comprehensive and regularly updated in the light of any changes in presentation. This should include multi-agency risk assessments where appropriate, and specific consideration of child safeguarding issues.
north_west
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 34
We fully endorse and support the recommendation of the Inquiry Panel (McCleery) and the guidance in ’Co-operating to Safeguard Children’. In light of events in this case, the DHSSPS should issue further formal guidance / instructions to all Trusts in relation to the need to secure all relevant documentation and …
northern_ireland
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 30
In light of the circumstances leading up to the deaths of Madeleine and Lauren, the DHSSPS should request CREST or its successor organisation to urgently review its August 2006 Protocol relating to inter-hospital transfer of mental health patients, with a view to including: - A section dealing with Child Protection …
northern_ireland
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 4
The DHSSPS and the Boards should instruct Trusts to draw up and implement policies regarding consultation by staff with patients’ families during an in-patient stay, in particular at admission, discharge and where the patient has a dependent child or children.
northern_ireland
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.11
Each agency (CAMHS, Social Services, Community Health, Primary Care, Education, Judiciary) must ensure that the other agencies involved in a high-risk case (not subject to the Child Protection Review system) are informed of risky incidents. The development of the use of chronologies to assist in identifying high risk behaviours is …
north_west
Independent reviews(50)
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 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
Narey-Owers Foster Care Review — Rec 33
As part of the assessment process when siblings enter care, individually or simultaneously, local authorities should not presume that keeping groups together is in the interests of all children in that group. Instead they should consider the individual needs of each child and whether they are likely to thrive when …
Other
Narey-Owers Foster Care Review — Rec 32
Local authorities should review the environments in which family contact takes place and the way it is supervised to ensure that it can be as positive an experience for the child as possible.
Other
Narey-Owers Foster Care Review — Rec 31
When children move placement they should routinely be consulted about the adults and children who are important to them and, unless it is not in their interests, contact with those adults and children should be encouraged and facilitated.
Other
Narey-Owers Foster Care Review — Rec 30
We urge the Department for Education to remind local authorities of the change in the law and the need for professionals to ensure that birth family contact takes place only when in the interests of the child. Professionals should not shirk offering evidence to the courts about the potentially damaging …
Other
Narey-Owers Foster Care Review — Rec 28
Children must routinely be better prepared for a placement (as already required in Regulation 11) by being told much more about the carers, their family and the carers' home, day-to-day care and routines before the first meeting (including seeing video messages and scenes of their bedroom and learning about some …
Other
Narey-Owers Foster Care Review — Rec 27
Carers should, wherever possible, be able to play a proactive role in matching. Adapting adopter-led family finding techniques, such as activity days, to help find suitable long-term fostering placements should be piloted in a number of local authorities.
Other
Narey-Owers Foster Care Review — Rec 26
Local authorities need to monitor the quality of referral information and ensure that, inadvertently; they do not demonise a child by over emphasising the negative aspects of a child's background.
Other
Narey-Owers Foster Care Review — Rec 25
We therefore believe that it is time to reinforce the statutory guidance that children should know their rights to advocacy and how to access an advocate and urge the Department for Education to work with the Children's Commissioner and voluntary sector providers of advocacy, including Coram Voice, to ensure this …
Other
Narey-Owers Foster Care Review — Rec 14
A number of organisations called for a national register of carers. They suggest that such a database could hold details of their fostering agency; the date of their approval as carers; where they live; the number of beds and bedrooms in their home; the number of vacancies for children; personal …
Other
Narey-Owers Foster Care Review — Rec 13
It may be for the courts to determine the employment status of carers. But we believe that were it to be obtained, employment would radically and negatively affect the heart of fostering and would not be in the interests of children in care. We encourage the Government and local authorities …
Other
Narey-Owers Foster Care Review — Rec 11
We warmly endorse tiered approaches to paying fees, linked to the skills and experience of the carers. Implemented widely, such models could drive greater consistency in fostering, aid better matching between child and carer and would provide improved knowledge about the skills of the foster carer population.
Other
Narey-Owers Foster Care Review — Rec 9
We do not believe that Department for Education guidance on allegations needs to be changed. But local authorities need to be sure that it is followed in all cases. And carers need to be reassured that, however unlikely the prospect of an allegation being made, they can be confident that …
Other
Narey-Owers Foster Care Review — Rec 8
We believe there needs to be a thorough assessment and consultation with the sector and with carers about the effectiveness, cost, and value for money of fostering panels and we urge the Department for Education to commission such an assessment.
Other
Narey-Owers Foster Care Review — Rec 7
Our conclusion is that, despite the commendable commitment of some individuals, there is little to recommend the IRO role and believe local authorities should be allowed to dispense with the role; re-investing savings in front line staffing.
Other
Narey-Owers Foster Care Review — Rec 6
We suggest that local authorities should decide which individual social worker is best placed to offer the support to the foster family in long-term placements. As well as resulting in a welcome reduction in family intrusion, and sometimes confusion, this change would deliver cost savings to hard-pressed local authorities. But …
Other
Narey-Owers Foster Care Review — Rec 5
Department for Education guidance and regulations are silent on physical affection and such silence - which is disappointing - must encourage the view that physical affection is considered inappropriate. Carers should be in no doubt that, unless it is unwelcome to the child, they should not curb the natural instinct …
Other
Narey-Owers Foster Care Review — Rec 4
We do not believe it is reasonably practicable for carers to be asked to parent a child, while simultaneously preventing them from making minor decisions. We would urge the Department for Education and local authorities to recognise that automatic delegated authority to carers must apply for voluntarily accommodated children too, …
Other
Narey-Owers Foster Care Review — Rec 3
We think that the categorisation of types of decision which might be delegated to carers is sensibly defined in the statutory guidance. But unless carers are explicitly clear about being able, independently, to take decisions, they will continue to feel exasperated. More importantly, children will, unnecessarily, be frustrated, unhappy, and …
Other
Narey-Owers Foster Care Review — Rec 2
Statutory guidance includes lots of commendable references to involving carers. But the key document that deals with reviews of children who are in foster care is inconsistent in promoting the importance of the role of carers and fails to list them as people who must be involved in reviews. Instead, …
Other
Narey-Owers Foster Care Review — Rec 1
We are clear that it is unrealistic to believe that foster carers, however competent they are, indeed, even if they happen to hold professional qualifications, can play an equal part alongside necessarily dispassionate social work professionals, in determining what is best for a child in care. Frankly, often the last …
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
Laming Review (Baby P) — Rec 43
The Department for Children, Schools and Families should revise Working Together to Safeguard Children to underline the importance of a high quality, publicly available executive summary which accurately represents the full report, contains the action plan in full, and includes the names of the Serious Case Review panel members.
Other
Laming Review (Baby P) — Rec 42
Ofsted should focus its evaluation of Serious Case Reviews on the depth of the learning a review has provided and the quality of recommendations it has made to protect children.
Other
Laming Review (Baby P) — Rec 41
The Department for Children, Schools and Families should revise Working Together to Safeguard Children to ensure Serious Case Reviews focus on the effective learning of lessons and implementation of recommendations and the timely introduction of changes to protect children.
Other
Laming Review (Baby P) — Rec 40
The Department for Children, Schools and Families should revise the framework for Serious Case Reviews to ensure that the Serious Case Review panel chair has access to all of the relevant documents and staff they need to conduct a thorough and effective learning exercise.
Other
Laming Review (Baby P) — Rec 39
The Department for Children, Schools and Families should revise Working Together to Safeguard Children so that it is explicit that the formal purpose of Serious Case Reviews is to learn lessons for improving individual agencies, as well as for improving multi-agency working.
Other
Laming Review (Baby P) — Rec 37
The Care Quality Commission, HMI Constabulary and HMI Probation should review the inspection frameworks of their frontline services to drive improvements in safeguarding and child protection in a similar way to the new Ofsted framework
Other
Laming Review (Baby P) — Rec 36
The Home Office should take national action to ensure that police child protection teams are well resourced and have specialist training to support them in their important responsibilities.
Other
Laming Review (Baby P) — Rec 35
The Department of Health should work with partners to develop a national training programme to improve the understanding and skills of the children's health workforce (including paediatricians, midwives, health visitors, GPs and school nurses) to further support them in dealing with safeguarding and child protection issues.
Other
Laming Review (Baby P) — Rec 34
The Department of Health should promote the statutory duty of all GP providers to comply with child protection legislation and to ensure that all individual GPs have the necessary skills and training to carry out their duties. They should also take further steps to raise the profile and level of …
Other
Laming Review (Baby P) — Rec 33
The Department of Health should review the Healthy Child Programme for 0–5-year-olds to ensure that the role of health visitors in safeguarding and child protection is prioritised and has sufficient clarity, and ensure that similar clarity is provided in the Healthy Child Programme for 5–19-year-olds.
Other
Laming Review (Baby P) — Rec 31
The General Social Care Council should review the Code of Practice for Social Workers and the employers' code ensuring the needs of children are paramount in both and that the employers' code provides for clear lines of accountability, quality supervision and support, and time for reflective practice. The employers' code …
Other
Laming Review (Baby P) — Rec 30
All Children's Trusts should have sufficient multi-agency training in place to create a shared language and understanding of local referral procedures, assessment, information sharing and decision making across early years, schools, youth services, health, police and other services who work to protect children. A named child protection lead in each …
Other
Laming Review (Baby P) — Rec 29
Children's Trusts should ensure that all staff who work with children receive initial training and continuing professional development which enables them to understand normal child development and recognise potential signs of abuse or neglect.
Other
Laming Review (Baby P) — Rec 25
Children's Trusts should ensure a named, and preferably co-located, representative from the police service, community paediatric specialist and health visitor are active partners within each children's social work department.
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
Laming Review (Baby P) — Rec 23
Every Children's Trust should assure themselves that partners consistently apply the Information Sharing Guidance published by the Department for Children, Schools and Families and Department for Communities and Local Government to protect children.
Other
Laming Review (Baby P) — Rec 22
The Department for Children, Schools and Families should establish statutory representation on Local Safeguarding Children Boards from schools, adult mental health and adult drug and alcohol services.
Other
Laming Review (Baby P) — Rec 21
The National Safeguarding Delivery Unit should urgently develop guidance on referral and assessment systems for children affected by domestic violence, adult mental health problems, and drugs and alcohol misuse using current best practice. This should be shared with local authorities, health and police with an expectation that the assessment of …
Other
Laming Review (Baby P) — Rec 20
All police, probation, adult mental health and adult drug and alcohol services should have well understood referral processes which prioritise the protection and well-being of children. These should include automatic referral where domestic violence or drug or alcohol abuse may put a child at risk of abuse or neglect.
Other
Laming Review (Baby P) — Rec 19
The Department for Children, Schools and Families must strengthen Working Together to Safeguard Children, and Children's Trusts must take appropriate action to ensure: all referrals to children's services from other professionals lead to an initial assessment, including direct involvement with the child or young person and their family, and the …
Other
Laming Review (Baby P) — Rec 14
Local authorities must ensure that 'Children in Need', as defined by Section 17 of the Children Act 1989, have early access to effective specialist services and support to meet their needs.
Other
Laming Review (Baby P) — Rec 13
Children's Trusts must ensure that all assessments of need for children and their families include evidence from all the professionals involved in their lives, take account of case histories and significant events (including previous assessments) and above all must include direct contact with the child.
Other
Laming Review (Baby P) — Rec 12
The Department of Health and the Department for Children, Schools and Families must strengthen current guidance and put in place the systems and training so that staff in Accident and Emergency departments are able to tell if a child has recently presented at any Accident and Emergency department and if …
Other
Laming Review (Baby P) — Rec 11
The Department for Children, Schools and Families should revise Working Together to Safeguard Children to set out clear expectations at all points where concerns about a child's safety are received, ensuring intake/duty teams have sufficient training and expertise to take referrals and that staff have immediate, on-site support available from …
Other
Laming Review (Baby P) — Rec 10
Ofsted should revise the inspection and improvement regime for schools giving greater prominence to how well schools are fulfilling their responsibilities for child protection.
Other
Laming Review (Baby P) — Rec 4
The Government should introduce new statutory targets for safeguarding and child protection alongside the existing statutory attainment and early years targets as quickly as possible. The National Indicator Set should be revised with new national indicators for safeguarding and child protection developed for inclusion in Local Area Agreements for the …
Other
Laming Review (Baby P) — Rec 3
The Cabinet Sub-Committee on Families, Children and Young People should ensure that all government departments that impact on the safety of children take action to create a comprehensive approach to children through national strategies, the organisation of their central services, and the models they promote for the delivery of local …
Other
LGO / SPSO decisions(330)
24-009-954 — Bristol City Council
Summary: We will not investigate Miss X’s complaint about the Council’s response to her complaint and safeguarding concern relating to her ex-partners child and girlfriend. This is because there is insufficient evidence of fault by the Council to warrant an investigation.
LGO (Local Government & …
Children S Care Services
Nov 2024
24-012-072 — Sefton Metropolitan Borough Council
Summary: Miss D complained that the Council delayed progressing grant-funded adaptations to her home. As a result, her family has been overcrowded for over four years. The Council has accepted there was delay. It has agreed to make a payment to Miss D to remedy the distress caused.
LGO (Local Government & …
Children S Care Services
Upheld
May 2025
24-022-424 — London Borough of Harrow
Summary: We cannot investigate this complaint about the Council’s actions in removing Miss X’s infant child. She has commenced court action to seek the return of her child and a legal bar thus permanently prevents us considering the Council’s actions.
LGO (Local Government & …
Children S Care Services
May 2025
25-004-797 — Surrey County Council
Summary: We will not investigate Mr X’s complaint about how the Council dealt with his concerns about an investigation into bullying at his son’s school. This is because the complaint is made late to us.
LGO (Local Government & …
Children S Care Services
Sep 2025
25-006-946 — Reading Borough Council
Summary: We will not investigate Mr X’s complaint about the Council’s decision not to consider his complaint until ongoing family court proceedings have concluded. This is because there is insufficient evidence of fault by the Council to warrant an investigation.
LGO (Local Government & …
Children S Care Services
Sep 2025
25-007-928 — North Yorkshire Council
Summary: We cannot investigate this complaint that the police interviewed children without parental consent, and the Council misadvised the school. This is because we do not have the power to investigate the actions of the police. For those complaints within our jurisdiction, further investigation would not lead to a different …
LGO (Local Government & …
Children S Care Services
Oct 2025
25-010-400 — Sheffield City Council
Summary: We will not investigate Ms X’s complaint about the Council’s actions in relation to ongoing family court proceedings which have led to her children being removed from her care. This is because there is no sign of fault in the Council’s decision not to consider her complaint until the …
LGO (Local Government & …
Children S Care Services
Nov 2025
25-009-059 — Leeds City Council
Summary: We will not investigate Mr X’s complaint about information the Council has recorded about him. It is too late for us to consider some of his complaint. There is not enough evidence of fault by the Council to justify us investigating other more recent issues. The law prevents us …
LGO (Local Government & …
Children S Care Services
Nov 2025
25-008-741 — West Sussex County Council
Summary: We will not investigate this complaint about the Council’s handling of Ms X’s complaint. The substantive matters are better considered by the Information Commissioner’s Office. Any injustice relating to the Council’s complaint handling is not significant enough to warrant our involvement.
LGO (Local Government & …
Children S Care Services
Nov 2025
24-000-836 — Somerset Council
Summary: Mrs X complained of the Council’s handling of her Disabled Facilities Grant (DFG) application after it delayed commissioning a contractor to carry out adaptations to her house for her disabled son (Y). The Council is at fault because it took 16 months after receiving Mrs X’s DFG application to …
LGO (Local Government & …
Children S Care Services
Upheld
Dec 2024
25-019-278 — London Borough of Croydon
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Children S Care Services
Feb 2026
25-013-710 — Nottingham City 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
25-012-138 — London Borough of Lambeth
We have upheld Ms X’s complaint that the Council failed to consider offering financial compensation or acknowledge the distress it caused. The Council has agreed to apologise to Ms X, offer her compensation and make service improvements.
LGO (Local Government & …
Children S Care Services
Feb 2026
25-013-075 — London Borough of Bexley
We will not investigate Miss X’s complaint about the Council’s children services teams handling of safeguarding allegations between 2017 and 2019. There are not enough reasons to disapply the late complaint rule. We cannot investigate recent safeguarding referrals as the Court could have made orders about this.
LGO (Local Government & …
Children S Care Services
Feb 2026
25-012-261 — Kent County Council
We have upheld Mrs X’s complaint about the Council’s delay in applying for a passport for a child she fosters. The Council have agreed to resolve the complaint by offering a suitable remedy.
LGO (Local Government & …
Children S Care Services
Feb 2026
25-013-044 — London Borough of Barnet
We cannot investigate Mr X’s complaint about information the Council gave a court or his contact with a child, as the Court is deciding this. The Information Commissioner’s Office is better placed to consider an information sharing complaint.
LGO (Local Government & …
Children S Care Services
Feb 2026
25-002-240 — London Borough of Lewisham
We will not investigate this complaint about delay at stage two of the children’s statutory complaints procedure. It is unlikely an investigation would lead to a different outcome.
LGO (Local Government & …
Children S Care Services
Feb 2026
24-021-332 — Birmingham City Council
Mr B complained about the Council’s handling of child protection matters regarding his children. He also complained about delays in the Council’s complaint-handling through the children’s statutory complaint procedure. There was fault by the Council. It did not follow statutory timescales when considering Mr B’s complaint. Because of this, Mr …
LGO (Local Government & …
Children S Care Services
Upheld
Feb 2026
25-012-142 — Brighton & Hove City Council
Summary: We cannot investigate Ms X’s complaint that the Council failed to disclose information during court proceedings. The law prevents us from investigating what happened in court.
LGO (Local Government & …
Children S Care Services
Jan 2026
25-010-688 — Surrey County Council
Summary: We will not investigate Mr X’s complaint about the Council’s handling of a Blue Badge application for his child. The Council has now issued a Blue Badge. An investigation would not lead to a different outcome.
LGO (Local Government & …
Children S Care Services
Jan 2026
21-013-222 — Kirklees Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s refusal to provide the complainant with information about what it has said to his ex-wife. This is because there is no evidence of fault on the Council’s part.
LGO (Local Government & …
Children S Care Services
Jan 2022
21-006-743 — West Sussex County Council
Summary: Mr X complains that the Council’s investigation into a disclosure by his daughter was inadequate and that a social worker made a false statement about him to his daughter’s mother. The Council is not at fault.
LGO (Local Government & …
Children S Care Services
Not Upheld
Jan 2022
21-004-445 — Devon County Council
Summary: Miss X complained the Council failed to respond to her concerns about the care of her two children, who were in foster care. We found the Council at fault for failing to tell Miss X she could return to the complaints process after concurrent investigations were complete. We recommended …
LGO (Local Government & …
Children S Care Services
Upheld
Jan 2022
20-006-042 — London Borough of Havering
Summary: Mr X complains about the Council’s actions after something that happened at his son’s school. I have discontinued my investigation. This is because we cannot investigate what happens in schools and there is no evidence that the Council’s investigation and assessment or complaint handling caused significant injustice to Mr …
LGO (Local Government & …
Children S Care Services
Jan 2022
21-013-118 — London Borough of Bexley
Summary: We will not investigate Mr X’s complaint about children services’ actions. It is unlikely our investigation could achieve significantly more than the Council has already offered.
LGO (Local Government & …
Children S Care Services
Upheld
Jan 2022
22-001-381 — Bournemouth, Christchurch and Poole Council
Summary: We will not investigate Mr X’s complaint the Council failed to financially support a placement in late 2016/early 2017 when he cared for a grandchild. Mr X complains late and could have complained sooner.
LGO (Local Government & …
Children S Care Services
Jun 2022
21-006-448 — Torbay Council
Summary: Ms X complains about the Council handling since it placed two grandchildren (Child Y and Child Z) in her care. The Council was at fault for delays in providing support to Child Y, responding to Ms X’s complaints and completing recommendations made during the children’s statutory complaints process. The …
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2022
22-003-225 — Cumbria County Council
Summary: We will not investigate this complaint that the Council has delayed to a complaint under the children’s statutory complaints procedure. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Children S Care Services
Jul 2022
21-016-233 — Nottingham City Council
Summary: Mr B complained that the Council failed to provide support to him as a care leaver and failed to consider his complaint properly. We found Mr B was not a care leaver in terms of the law and so the Council does not have a duty towards him. But …
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2022
21-006-071 — Kingston Upon Hull City Council
Summary: There was fault in how the Council dealt with Ms B when it placed her siblings in her care. The Council has completed the statutory children’s complaints process, which means the issues have been independently investigated, and a Panel has reviewed the investigation. The Council has acknowledged there was …
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2022
22-003-528 — Royal Borough of Greenwich
Summary: We will not investigate Ms X’s complaint about the Council changing a looked after child’s bank account. It is unlikely we would recommend any further remedy.
LGO (Local Government & …
Children S Care Services
Aug 2022
22-003-832 — London Borough of Croydon
Summary: Ms Y complains the Council failed to consider whether her family’s housing conditions meant any of her children were ‘in need’ (under Section 17 of the Children Act 1989). We found fault by the Council, which meant Ms Y missed out on the Council carrying out Child in Need …
LGO (Local Government & …
Children S Care Services
Upheld
Oct 2022
23-019-715 — Hertfordshire County Council
Summary: We cannot investigate Mrs X’s complaint about the Council removing her children from her care under false pretences because the Ombudsman cannot investigate matters which are being dealt with in a court of law.
LGO (Local Government & …
Children S Care Services
Apr 2024
23-019-488 — Medway Council
Summary: We will not investigate Ms X’s complaint. This is because there is no sign of fault in the Council’s decision not to consider her complaint because she does not have parental responsibility for her grandchildren.
LGO (Local Government & …
Children S Care Services
Apr 2024
23-020-148 — Cumberland Council
Summary: We will not investigate this complaint about delay on the Council’s part in completing the statutory procedure for complaints about children’s services matters. This is because there is insufficient outstanding injustice to warrant investigation.
LGO (Local Government & …
Children S Care Services
Apr 2024
24-005-818 — Middlesbrough Borough Council
Summary: We will not investigate Miss X’s complaint. This is because there is no sign of fault in the Council’s decision not to consider her complaint whilst there are ongoing court proceedings.
LGO (Local Government & …
Children S Care Services
Aug 2024
23-018-063 — Devon County Council
Summary: Miss X complained about the Council’s actions in respect of its care of her daughter, Miss Y, and the way in which it dealt with her complaint about the matter. We have not found fault with the Council.
LGO (Local Government & …
Children S Care Services
Upheld
Aug 2024
23-018-379 — Southend-on-Sea City Council
Summary: Mrs Y complains about the Council’s decision to approve her as a connected foster carer. As a result of that decision, Mrs Y says she has experienced financial loss because the Council has not paid the relevant fostering fees. We have not investigated the whole complaint because the Council’s …
LGO (Local Government & …
Children S Care Services
Upheld
Sep 2024
24-008-441 — London Borough of Havering
Summary: Miss X complained about how the Council manged her savings as a looked after child.
LGO (Local Government & …
Children S Care Services
Upheld
Apr 2025
24-009-233 — Devon County Council
Summary: Mr X complained about the way the Council dealt with foster carer payments. The Council was at fault for having unclear policies in place and failing to respond fully to Mr X’s complaint. This caused Mr X distress and uncertainty. The Council will apologise, make payments and provide evidence …
LGO (Local Government & …
Children S Care Services
Upheld
May 2025
24-013-866 — Staffordshire County Council
Summary: Miss X complains the Council did not deal properly with a safeguarding investigation regarding a foster family. The Council acted disproportionately, and unprofessionally. Miss X suffered avoidable distress. The Council should pay Miss X £1500.
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2025
24-020-172 — London Borough of Redbridge
Summary: We will not investigate Miss X’s complaint about children services’ actions. We have upheld Miss X’s complaint as the Council has now agreed to follow the Children Act statutory complaints’ procedure and has agreed a proportionate way to resolve the complaint.
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2025
24-016-713 — Surrey County Council
Summary: Mrs X complained about how the Council has delivered social care for Y. The Council was at fault for not commencing a stage two statutory investigation under the Children Act 1989, causing distress, uncertainty and frustration to Mrs X. The Council has agreed to apologise, make a payment to …
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2025
24-004-212 — London Borough of Hillingdon
Summary: The Council has agreed to commission an independent investigation of Mrs M’s complaint at the second stage of the statutory children’s services complaints process. We consider this an appropriate response to her concerns.
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2025
24-012-792 — London Borough of Harrow
Summary: Miss Y complains the Council did not properly investigate the injuries her child obtained whilst in Council arranged foster care. We find procedural fault which creates uncertainty about the Council’s consideration of the injuries. The Council will pay £500 in recognition of that distress and remind staff of the …
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2025
25-005-504 — London Borough of Croydon
Summary: We will not investigate this complaint about the Council’s decision to refuse Mrs X’s application for a Blue Badge for her daughter. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Children S Care Services
Sep 2025
25-003-931 — Kingston Upon Hull City Council
Summary: We will not investigate this complaint about the content of a Child and Family Assessment completed by the Council’s social worker. Investigation would not lead to a different outcome and is not therefore warranted.
LGO (Local Government & …
Children S Care Services
Sep 2025
25-000-049 — London Borough of Haringey
Summary: Ms X complained the Council failed to carry out the recommendations set out by the statutory complaints process. We find the Council at fault for failing to complete the recommendations in the panel review, causing uncertainty and frustration for Ms X. The Council should apologise, reconsider the remedy findings …
LGO (Local Government & …
Children S Care Services
Upheld
Sep 2025
25-011-399 — London Borough of Lambeth
Summary: We have upheld Miss X’s complaint because the Council delayed considering her complaint at stage three of the children’s statutory complaints procedure. The Council has agreed to resolve the complaint early by providing a proportionate remedy for the injustice caused to Miss X.
LGO (Local Government & …
Children S Care Services
Upheld
Sep 2025
25-003-216 — Staffordshire County Council
Summary: We cannot investigate Miss X’s complaint about matters related to the care arrangements of her child. This is because it concerns matters that have formed part of court proceedings.
LGO (Local Government & …
Children S Care Services
Oct 2025
Domestic Homicide Reviews(389)— showing 50 strongest matches
Tewkesbury — recommendation 17.5.1
Gloucestershire County Council, where they are the lead professional, will speak to all children in a domestic abuse household following a domestic abuse incident.
Gloucestershire County Council
Gloucestershire County Council
Bromley — recommendation 4.4.10
Children’s Services to lead on a multi-agency SCIE review, using this case as an example, to improve practice in relation to vulnerable young people who may come into contact with oppressive and abusive individuals.
Bromley Children’s Services
Bromley — recommendation 4.4.9
Children’s Services & the BSCB should consider how to improve the success of necessary interventions when families are resistant to those interventions.
Bromley Children’s Services | Bromley Safeguarding …
Lincoln — recommendation Recommendation 3 ii)
The Safer Lincolnshire Partnership and the Lincolnshire Domestic Abuse Partnership should seek assurance from all agencies that their staff are aware of the impact that Domestic Abuse has on Safeguarding Children. That the agencies also ensure that any perpetrator risk assessments feed into the safety planning around any children in …
Safer Lincolnshire Partnership | Lincolnshire Domestic …
Lincoln — recommendation Recommendation 3 i)
The Lincolnshire Safeguarding Children Partnership must seek assurance from Children Social Care that they have made changes to the local Child in Need processes which makes them more inclusive and that all relevant agencies, including those providing services to adults, are included more consistently in the process and meetings. This …
Lincolnshire Safeguarding Children Partnership | Children …
Lincoln — recommendation Recommendation 2
The Lincolnshire Domestic Abuse Partnership and the Local Safeguarding Children Partnership should seek assurance from partners that when they work with victims of domestic abuse, who are unable to or reluctant to engage, that they consider the best individual, or agency, who could facilitate this engagement, in order to ensure …
Lincolnshire Domestic Abuse Partnership | Lincolnshire …
Lincoln — recommendation (ii)
Safeguarding leaders have already improved procedures for sustaining routine contact with all parents whose children with special educational needs and disabilities travel independently to the school.
Special School
Lincoln — recommendation 1
Whilst learning has been identified in terms of how practitioner practice could be improved in terms of multiagency working; it remains unclear as to why Probation services were not involved in the Child in Need process or whether the concerns of the supported housing provider were shared and acted on. …
Probation Service
Probation Service
Lincoln — recommendation iii)
Internal Children Services review of MOSAIC recording and reporting of CIN meetings and attendance of partner agencies.
Lincolnshire County Council Children Services
Lincoln — recommendation ii)
Children’s services staff to be supported to ensure attendance and contributions from all relevant agencies at multi-agency meetings and in children’s plans.
Lincolnshire County Council Children Services
Lincoln — recommendation i)
PNC checks submitted by children’s services practitioners will routinely seek disclosure to include all information relating to a person’s offending history and make clear this is not limited to just information from the preceding two years.
Lincolnshire County Council Children Services
Derby — recommendation 8
All partners must evidence their organisational focus and practice in relation to the impact of domestic abuse and its cumulative harm on children and demonstrate their continued commitment to identify children living in abusive households as victims in their own right, to listen to their voices and to enable them …
All partners
Derby — recommendation 3
The Derbyshire and Derby Safeguarding Children Partnership, after the re-promotion of the Pre-Birth Protocol through the briefing issued May 2020, should provide assurance and data that pre-birth assessments are being completed when risks are identified to improve outcomes for pregnant women, unborn children and their wider families.
Derbyshire and Derby Safeguarding Children Partnership
Oxford — recommendation 2
To ensure that the critical information schools hold about the most vulnerable children and young people, particular where they are living with domestic violence, substance misuse and mental health issues, is used for planning.
Schools and Special Educational Needs
Somerset — recommendation 2
The domestic abuse policy and procedure ‘Children Affected by Domestic Abuse – last updated in October 2014’ needs to develop guidance on safety planning, emergency planning including procedures for closing a case file, and good practice guidance.
Somerset Safeguarding Children Board
Somerset — recommendation 4
Ensure that Core Groups are held in a timely manner in accordance with Government guidelines for the prompt identification and actions to address risks to children on Child Protection Plans.
Somerset County Council Children's Social Care
Somerset — recommendation 3
For Child In Need cases - expectations of visiting frequency, and regularity of review are set out in the practice framework and highlighted to all teams as the agreed standard.
Somerset County Council Children's Social Care
Wigan — recommendation 5
Children who notify school staff or comment upon family difficulties should be monitored and referred to School Safeguarding Officer / Head teacher and an Early help referral completed.
Primary School ‘A’
Elmbridge — recommendation 10
Integrate the Spiralling toolkit into PSHE (personal, social, health and economic) education.
Independent Secondary School
Elmbridge — recommendation 3
Ensure that the agreed intention of providing Police information about vulnerable people to relevant agencies, including schools is promulgated with urgency.
Elmbridge Community Safety Partnership
Kingston upon Thames — recommendation 45
Explore the local response to threats to abduct a child/remove from the jurisdiction. Ensure appropriate guidance on child abduction is circulated to LSCB member agencies. All agencies to ensure that their risk assessment tools in relation to domestic violence and safeguarding children, include reference to the threat of child abduction. …
Kingston LSCB
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
St Helens — recommendation 15
The voice of the child should be clearly heard and reflected in all social work children and families assessments encompassing both direct input but also any consistent deficiencies in parenting.
People’s Services
Leeds — recommendation YAS1
A bulletin will be placed in OU to remind staff that Police should be requested to attend 999 calls where children of substance misusing parents & carers are at significant risk from the event (e.g. needle stick injuries, cross-infection, ingestion / Overdose.
Yorkshire Ambulance Service
Yorkshire Ambulance Service NHS …
Leeds — recommendation LYPFT5
Leeds Addiction Unit should work with Children’s Social Work Service to review the thresholds for when a pregnancy should be referred for substance misusing parents.
Leeds and York Partnership NHS Trust
Leeds and York Partnership …
Kirklees — recommendation 3
That Kirklees Safer Stronger Communities Partnership seek assurance from education and children’s social care as to the following. That when a child displays challenging behaviour at school, and the parents are living apart, there is a process for informing or engaging both parents in trying to solve the problem (unless …
Kirklees Safer Stronger Communities Partnership
Kirklees — recommendation 2
That Kirklees Safer Stronger Communities Partnership incorporates the impact of domestic abuse on children when offering advice and materials to victims and perpetrators
Kirklees Safer Stronger Communities Partnership
Harlow — recommendation 11.1.1
In line with policy, procedure and good practice, practitioners need to ensure that children’s voices are heard. They need to be seen and interviewed in order for practitioners to gain a better understanding of what’s going on within the whole family and within that child’s world.
Essex County Council, Children’s Social Care
Leeds — recommendation YAS1
Within 3 months YAS will put a bulletin in Operational Update to remind staff of the impact on children and young people witnessing or affected by Deliberate Self-Harm/Para-suicide or suicide. The age & relationship of the child or young person must be documented and a referral to Children’s Social Care …
Yorkshire Ambulance Service
Yorkshire Ambulance Service NHS …
Bradford — recommendation 17
The CSP will therefore seek assurance that the voice of older young people in households where there is domestic abuse, is not ignored. Further, that service providers consider developing specific pathways for additional age-appropriate support.
COMMUNITY SAFETY PARTNERSHIP (DSV Team, LSCB …
Bradford — recommendation 9
Child and Family assessments will consider past and present domestic abuse of all adults in past and present relationships as well as the current conflict and how this may impact on the child. This will include consideration of the environment that the child lives in and visits regardless of whether …
CSC
Civil Service Commission
Bradford — recommendation 5
The recognition of the key learning from this DHR for BDCFT staff includes: 1) Risks to adolescents & boys to be given the same consideration & responses as those risks to younger children & girls 2) That staff professional curiosity is extended to adolescents including boys ensuring that they’re given …
BDCFT
Bradford District Care NHS …
Bradford — recommendation 4
When there is an indication of risk for a child, BDCFT staff must engage with multi-agency services to gain clarity around this risk where possible. This will be implemented through safeguarding supervision, training and duty.
BDCFT
Bradford District Care NHS …
North Worcestershire — recommendation DHR 1
Warwickshire Safeguarding Children Board (WSCB) is to seek assurance that: a) Children in Warwickshire seeking a school place are identified and an appropriate offer of a school place is made in a timely manner b) When children in Warwickshire are not in education relevant assessments are undertaken in relation to …
Warwickshire Safeguarding Children Board (WSCB)
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 …
Chorley and South Ribble — recommendation 4
Lancashire Children’s Services and the Blackburn with Darwen, Blackpool and Lancashire Children's Safeguarding Assurance Partnership (CSAP) should use learning from this review to develop practice in relation to supporting vulnerable parents when children are removed from their care.
Lancashire Children’s Services | Blackburn with …
Kent — recommendation 2
The Department of Education should seek to progress the implementation of their proposed legislation intended to address the issues raised regarding registration of school age children and the monitoring and assessment of those engaged in EHE.
Department of Education
Department for Education
Wiltshire — recommendation R53
Young people who are in domestically abusive relationships and are subject to physical harm should be considered under our child protection procedures.
Children’s Social Care
Wiltshire — recommendation R28
There should be a ‘flag’ of some sort on a child’s electronic file so that staff are aware not to contact home.
Kingdown School
Wiltshire — recommendation R25
All staff to receive training on healthy relationships including co dependence, violent and manipulative relationships. An understanding of the complexities of working with young people within their relationships
Early Help | YOT
Wiltshire — recommendation R20
YP homelessness protocol to be reviewed and rewritten to ensure that there are clear pathways for homeless young people.
Early Help | YOT | Housing …
Wiltshire — recommendation R6
EWO’s are to be encouraged to undertake home visits in instances of poor or non engagement of family or young person
EWS
Wiltshire — recommendation R4
The NNSC in CAMHS will explore training for all CAMHS clinicians about domestic abuse in young people can be delivered.
Oxford Health NHS Foundation Trust
Oxford Health NHS Foundation …
Wiltshire — recommendation R3
The use of the assessment triangle will be actively promoted as part of Safeguarding Children case discussion, training and supervision by CAMHS staff.
Oxford Health NHS Foundation Trust
Oxford Health NHS Foundation …
Wiltshire — recommendation R1
Domestic Abuse will always be discussed with the Named Nurse Safeguarding Children within CAMHS
Oxford Health NHS Foundation Trust
Oxford Health NHS Foundation …
Kent — recommendation 3
Raise awareness of the supportive services available to young people from different cultural and religious backgrounds through a system of information sharing.
Kent Community Safety Partnership
Kent — recommendation 1
Schools should be supported where appropriate, with understanding and recognising cultures and customs which may lead to family conflict, honour based violence and domestic abuse for students from minority communities. This should include support regarding how to appropriately respond.
Kent Education
Nuneaton and Bedworth — recommendation 37
Children’s Services to develop guidance/ process for frontline staff to support them in risk assessing victims when domestic abuse is disclosed by clients/ children. This should also extend to when historic abuse is disclosed by a partner who still has contact with the perpetrator due to child access arrangements.
Children’s Services
Children’s Services
Nuneaton and Bedworth — recommendation 36
Children’s Services ensure and reinforce that Children’s Teams follow the existing guidance in respect of referrals where children may be at risk of significant harm and the protocol for Domestic Abuse referrals in a timely manner.
Children’s Services
Children’s Services
Solihull — recommendation 5c
Safer Solihull Partnership shares this report with Solihull Safeguarding Children Partnership in order that (a) promotion of DVPOs and DVPNs are undertaken with the children’s workforce to protect children and their non-abusing parent in plans ranging from early help to child protection and (b) that preparations are made for updating …
Safer Solihull Partnership | Solihull Safeguarding …
CJINI inspection reports(26)
Inspection of the Juvenile Justice Centre (Northern Ireland)
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
Apr 2005
Hydebank Wood Young Offender’s Centre (Secure College) (14-17 March 2005)
Prisons, Hydebank Wood Secure College
Oct 2005
Youth Conference Service: A Follow-Up Review of inspection recommendations
Youth Justice and Intervention, Children and Young People
Apr 2010
The use of Youth Diversion in the criminal justice system
Youth Justice and Intervention, Children and Young People
Jul 2011
An announced inspection of Woodlands Juvenile Justice Centre November 2011
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
Nov 2011
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
Child Sexual Exploitation in Northern Ireland: An Inspection of the Criminal Justice System Response
Abuse and Exploitation, Children and Young People
Jun 2020
Modern Slavery and Human Trafficking: An inspection of how the Criminal Justice System deals with Modern Slavery and Human Trafficking in Northern Ireland
Modern Slavery and Human Trafficking, Crime
Oct 2020
An announced inspection of Woodlands Juvenile Justice Centre
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
Sep 2022
First joint inspection of Child Protection Arrangements
Abuse and Exploitation, Probation and Public Safety, Safegu…
Jun 2023
Youth Interventions: An Inspection of the Youth Justice Agency’s Community Interventions
Youth Justice and Intervention, Children and Young People
Sep 2024
Report on an unannounced Inspection of Hydebank Wood Secure College (21 May – 6 June 2024)
Prisons, Hydebank Wood Secure College
Nov 2024
Child Sexual Exploitation Follow-Up Review: An assessment of the criminal justice system’s response
Abuse and Exploitation, Children and Young People
Dec 2025
An Inspection of child criminal exploitation in Northern Ireland
Abuse and Exploitation, Children and Young People
Feb 2026
Early Youth Interventions
Youth Justice and Intervention, Children and Young People
Jul 2012
Hydebank Wood Young Offenders Centre (18–22 February 2013)
Prisons, Hydebank Wood Secure College
Oct 2013
Report on an unannounced short Follow-Up Inspection of Hydebank Wood Young Offenders Centre (21-25 March 2011)
Prisons, Hydebank Wood Secure College
Oct 2011
The use of special measures by the criminal justice system in Northern Ireland
Prosecution and the Courts, Court Operations, Victims and W…
Apr 2012
Progress of Youth Justice review recommendations
Youth Justice and Intervention, Children and Young People
Dec 2013
The approach of the criminal justice system to investigating and prosecuting crimes against vulnerable adults
Probation and Public Safety, Safeguarding
Sep 2015
Law Commission projects(1)
CQC enforcement actions(3)
Warning Notice: Kettering General Hospital NHS Foundation Trust
The Care Quality Commission (CQC) found improvement is needed in the children and young people’s (CYP) services run by Kettering General Hospital NHS Foundation Trust, after an inspection in December. Due to concerns found at this inspection, CQC has taken …
Kettering General Hospital
Apr 2023
Urgent Enforcement Action: Shrewsbury and Telford Hospital NHS Trust
The Care Quality Commission (CQC) took urgent action following a focused inspection of children and young people ext{
The Princess Royal Hospital in Telford
Apr 2021
Fixed Penalty Notice: Shrewsbury and Telford Hospitals NHS Trust
The Care Quality Commission (CQC) issued a fixed penalty notice to Shrewsbury and Telford Hospitals NHS Trust, fining it £4,000. This was for not triaging patients within 15 minutes of attending the emergency department and not ensuring follow-ups for children …
Oct 2020