Care safeguarding systems
266 items
2 sources
Absence of effective systems to protect people from abuse and avoidable harm, including failures in reporting suspected abuse.
Cross-Source Insight
Care safeguarding systems has been flagged across 2 independent accountability sources:
198 inquiry recs
68 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (198)
BRIS-130 — Establish single, coherent set of generic standards for safe, quality care.
Recommendation: There must be a single, coherent, co-ordinated set of generic standards: that is, standards relating to the patient’s experience and the systems for ensuring that care is safe and of good quality (for example corporate management, clinical governance, risk management, …
Unknown
DUNB-27 — Establish national accreditation for children's clubs with leader suitability checks
Recommendation: There should be a system for the accreditation to a national body of clubs and groups voluntarily attended by children and young persons under 16 years of age for their recreation, education or development, the main purpose of which would …
Unknown
11 — Ban CSE-risk children from semi-independent placements
Recommendation: The Department for Education should ban the placement in semi-independent and independent settings of children aged 16 and 17 who have experienced, or are at heightened risk of experiencing, sexual exploitation. This should be implemented without delay.
Gov response: On 30 June 2022, the UK government provided the Inquiry with its provisional response to this recommendation. The UK government stated its final response to this recommendation would be provided within six months of the …
Accepted in Part
In progress
16 — Review mixed justice/welfare placement risk
Recommendation: The Chair and Panel recommend that the Department for Education and the Youth Custody Service conduct a full review of the practice of placing children for justice and welfare reasons together in secure children's homes to establish whether it increases …
Gov response: On 7 May 2021, the Department for Education published its review of placement practices in secure children's homes. It concluded that the practice of placing children in mixed justice and welfare homes does not create …
Accepted
Delivered
18 — Joint MoJ/DfE policy for children in custody
Recommendation: The Chair and Panel recommend that the Ministry of Justice and the Department for Education share policy responsibility for managing and safeguarding children in custodial institutions. This is to ensure that standards applied in relation to children in custody are …
Gov response: On 23 July 2019, the Ministry of Justice stated that it has joint working relationships with the Department for Education on secure children's homes, safeguarding and establishing secure schools. It stated that it aims to …
Not Accepted
29 — Church of England religious communities safeguarding
Recommendation: The Church of England should introduce appropriate guidance which deals with safeguarding within the context of a religious community affiliated to the Church. It must ensure that these organisations meet adequate requirements for safeguarding and child protection. The needs of …
Gov response: On 27 June 2019, the National Safeguarding Steering Group stated that the General Synod would be asked to give final approval to amending Canon 40. The National Safeguarding Steering Group stated that the amendment inserts …
Accepted
Delivered
30 — Amend Canon C30 on safeguarding due regard
Recommendation: The Church of England should amend the current canon requiring clerics to comply with the Bishop's Guidance on Safeguarding. The use of the words 'due regard' in Canon C30 is an acceptable term of art, but lacks sufficient clarity. Very …
Gov response: On 26 April 2021, the General Synod approved the Safeguarding (Code of Practice) Measure which strengthens and clarifies the obligation to follow safeguarding guidance. The statutory code replaces the existing duty to have 'due regard' …
Accepted
Delivered
31 — DBS and training compliance for Church officers
Recommendation: Individuals engaged in regulated activity who have failed to undergo a Disclosure and Barring Service check or complete compulsory training should not be permitted to hold voluntary offices within the Church. Failure by ordained clergy to comply with either requirement …
Gov response: On 27 June 2019, the Church of England agreed that those in regulated roles who have failed to undergo a Disclosure and Barring Service check or complete mandatory safeguarding training should not be allowed to …
Accepted
Delivered
32 — Send internal safeguarding reviews to national body
Recommendation: If religious organisations have undertaken internal reviews or enquiries into individual safeguarding incidents, their findings should be sent to the national review body (set up under the Children and Social Work Act 2017).
Gov response: On 27 June 2019, the Church of England stated that its National Safeguarding Team would liaise with the Child Safeguarding Practice Review Panel to ensure that 'the right cases' are reported to them in accordance …
Accepted
No update 2+ yrs
37 — Westminster whistleblowing policies for CSA
Recommendation: Government, political parties and other Westminster institutions must have whistleblowing policies and procedures which cover child sexual abuse and exploitation. Every employee must be aware that they can raise any concerns using these policies and that the policies are not …
Gov response: On 18 September 2020, the UK government confirmed that all government departments have whistleblowing policies in place. It confirmed that Civil Service HR has a model policy to support departments in ensuring their policies are …
Accepted
Delivered
38 — Government department safeguarding policy reviews
Recommendation: The Cabinet Office must ensure that each government department reviews its child safeguarding policy or policies in light of the expert witness report of Professor Thoburn. There must also be published procedures to accompany their policies, in order that staff …
Gov response: On 18 September 2020, the UK government confirmed that all government departments were aware of Professor Thoburn's report. It also stated that Civil Service HR had launched a model safeguarding policy and 'Health Check' process, …
Accepted
Delivered
39 — Political party safeguarding policies
Recommendation: All political parties registered with the Electoral Commission in England and in Wales must ensure that they have a comprehensive safeguarding policy. All political parties must also ensure that they have procedures to accompany their policies, in order that politicians, …
Gov response: On 3 July 2020, the Electoral Commission stated that given the statutory scope of its remit, introducing a requirement that the Commission should monitor and oversee compliance of the safeguarding policies of political parties would …
Accepted
No update 2+ yrs
41 — Create diocesan safeguarding officers
Recommendation: The Church of England should create the role of a diocesan safeguarding officer to replace the diocesan safeguarding adviser. Diocesan safeguarding officers should have the authority to make decisions independently of the diocesan bishop in respect of key safeguarding tasks, …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that Canon C30 and the associated Diocesan Safeguarding Advisor Regulations would be amended …
Accepted
No update 2+ yrs
42 — Church in Wales provincial safeguarding officers
Recommendation: The Church in Wales should make clear that the operational advice of provincial safeguarding officers must be followed by all members of the clergy and other Church officers. It should be enshrined in policy that those who are volunteers and …
Gov response: On 7 April 2021, the Church in Wales stated that its safeguarding policy, procedural documents and training materials would make it clear that the operational advice of provincial safeguarding officers should be followed by all …
Accepted
No update 2+ yrs
43 — Church in Wales record-keeping policies
Recommendation: The Church in Wales should introduce record-keeping policies relating to safeguarding, complaints and whistleblowing. These should be implemented consistently across dioceses. The Church should develop policies and training on the information that must be recorded in files. The Church should …
Gov response: On 7 April 2021, the Church in Wales stated that its national online safeguarding case management and record-keeping system had launched, serving as a single searchable repository of all Church in Wales safeguarding and whistleblowing …
Accepted
Delivered
44 — Church of England/Wales information sharing protocol
Recommendation: The Church of England and the Church in Wales should agree and implement a formal information-sharing protocol. This should include the sharing of information about clergy who move between the two Churches.
Gov response: On 24 June 2021, the Church of England announced that the updated version of the House of Bishops' handling of Clergy Personal Files policy covers data sharing between the Church of England and the Church …
Accepted
Delivered
45 — Local diocesan information sharing protocols
Recommendation: The Church of England, the Church in Wales and statutory partners should ensure that information-sharing protocols are in place at a local level between dioceses and statutory partners.
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that it would develop template information-sharing agreements which may be adapted and used …
Accepted
No update 2+ yrs
46 — Church independent external safeguarding audits
Recommendation: The Church in Wales should introduce independent external auditing of its safeguarding policies and procedures, as well as the effectiveness of safeguarding practice in dioceses, cathedrals and other Church organisations. Audits should be conducted regularly and reports should be published. …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that it remained committed to their programme of five-yearly independent audits. The joint …
Accepted
No update 2+ yrs
5 — Reform Church of England clergy discipline for safeguarding
Recommendation: The Church of England should make changes and improvements to the way in which it responds to safeguarding complaints (whether related to allegations of abuse, or a failure to comply with or respond to the Church's safeguarding policies and procedures) …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council endorsed the proposals of the Clergy Discipline Measure working group to replace Clergy Discipline …
Accepted
No update 2+ yrs
57 — Distinguish CSE risk from actual exploitation
Recommendation: The Department for Education and the Welsh Government must ensure that their updated national guidance makes clear that signs that a child is being sexually exploited must never be treated as indications that a child is only 'at risk' of …
Gov response: On 30 June 2022, the UK government provided the Inquiry with its provisional response to this recommendation. The UK government stated its final response to this recommendation would be provided within six months of the …
Accepted in Part
In progress
6 — Redraft canonical crimes as crimes against the child
Recommendation: The Catholic Bishops' Conference of England and Wales should request that the Holy See redraft the canonical crimes relating to child sexual abuse as crimes against the child.
Gov response: On 30 September 2021, the Catholic Council for the Inquiry confirmed that Book VI of the Code of Canon Law determines the penal norms in order to give precise and sure guidance to those who …
Accepted
Delivered
7 — Catholic complaints policy with escalation process
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious should publish a national policy for complaints about the way in which a safeguarding case is handled. The policy should deal with communication with complainants during the …
Gov response: On 30 April 2021, the Catholic Council for the Inquiry stated that a framework and template for complaints was ratified by the Bishops. The framework and template include the need for clear communication between the …
Accepted
Delivered
70 — Include clergy in position of trust definition
Recommendation: The government should amend Section 21 of the Sexual Offences Act 2003 so as to include clergy within the definition of a position of trust. This would criminalise under s16-s20 sexual activity between clergy and a person aged 16-18, over …
Gov response: On 9 March 2021, the Ministry of Justice and Home Office stated that the government would introduce the Police, Crime, Sentencing and Courts Bill. The Bill sought to extend the definition of a 'position of …
Accepted
Delivered
89 — Church funding policy for victim support
Recommendation: The Church of England and the Church in Wales should each introduce a Church-wide policy on the funding and provision of support to victims and survivors of child sexual abuse concerning clergy, Church officers or those with some connection to …
Gov response: On 7 April 2021, the Church in Wales stated that it had introduced Independent Sexual Violence Adviser (ISVA) support for survivors. The Church in Wales committed to offer funding towards counselling recommended by an ISVA …
Accepted
No update 2+ yrs
FR-6 — Amend Children Act 1989
Recommendation: The Inquiry recommends that the UK government amends the Children Act 1989 so that, in any case where a court is satisfied that there is reasonable cause to believe that a child who is in the care of a local …
Gov response: We accept the absolute need for children and young people to have their voices heard, raise concerns and challenge any aspect of their care, including where they may be experiencing or at risk of serious …
Accepted in Part
In progress
P1-1 — Non-mortuary staff accompanied in mortuary
Recommendation: Maidstone and Tunbridge Wells NHS Trust must ensure that non-mortuary staff and contractors, including maintenance staff employed by the Trust's external facilities management provider, are always accompanied by another staff member when they visit the mortuary. For example, maintenance staff …
Gov response: Implemented. The Trust has implemented this requirement. All non-mortuary staff and contractors must be accompanied when visiting the mortuary. This was confirmed in NHS England's oversight meetings with the Trust. (Source: Trust assurance statement, February …
Accepted
Delivered
P1-10 — Regular CCTV review with swipe card data
Recommendation: Maidstone and Tunbridge Wells NHS Trust must ensure that footage from the CCTV is reviewed on a regular basis by appropriately trained staff and examined in conjunction with swipe card data to identify trends that might be of concern.
Gov response: Implemented. CCTV footage is reviewed regularly in conjunction with swipe card access data. Staff have been trained in monitoring procedures. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement HCWS132, 15 October 2024)
Accepted
Delivered
P1-12 — Local authorities examine contractual arrangements
Recommendation: Kent County Council and East Sussex County Council should examine their contractual arrangements with Maidstone and Tunbridge Wells NHS Trust to ensure that they are effective in protecting the safety and dignity of the deceased.
Gov response: Implemented. Both Kent County Council and East Sussex County Council have reviewed their contractual arrangements with the Trust to strengthen protections for the deceased. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial Statement …
Accepted
Delivered
P1-17 — Deceased treated with same dignity as patients
Recommendation: Maidstone and Tunbridge Wells NHS Trust must treat the deceased with the same due regard to dignity and safeguarding as it does its other patients.
Gov response: Implemented. The Trust has embedded this principle in policy and practice. The deceased are now afforded the same safeguarding and dignity considerations as living patients. (Source: Trust assurance statement, February 2024; confirmed in Written Ministerial …
Accepted
Delivered
P2-19 — Deceased included in safeguarding training and policy
Recommendation: NHS trust boards should ensure that the security and dignity of deceased people are included in safeguarding training, policies and assurance.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-20 — Chief Nurse responsibility for deceased safeguarding
Recommendation: The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased people in NHS mortuaries and body stores.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-21 — NHS England incorporate deceased in safeguarding framework
Recommendation: NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-22 — Independent sector SOPs for deceased patients
Recommendation: Independent sector healthcare providers should ensure that there are Standard Operating Procedures and policies in place to protect the security and dignity of any patients that die under their care. Wherever possible, deceased patients' rooms should be kept locked. Providers …
Gov response: The Department of Health and Social Care has met with the Independent Healthcare Provider Network (IHPN), who engaged with its members in September 2025. IHPN members have confirmed they have taken action on the report, …
Accepted
In progress
P2-23 — Independent sector accompanied access to deceased
Recommendation: Independent sector healthcare providers should ensure that only people who have a legitimate reason to access a room that contains a deceased patient do so, even if they are staff members, and that they are always accompanied.
Gov response: The Department of Health and Social Care has met with the Independent Healthcare Provider Network (IHPN), who engaged with its members in September 2025. IHPN members have confirmed they have taken action on the report, …
Accepted
In progress
P2-24 — Anatomical education security and dignity policies
Recommendation: All organisations providing anatomical education and training using donors should make sure that policies and procedures are in place to ensure the security and dignity of donors. These should include: security and access policies and the auditing of security and …
Gov response: This recommendation is under consideration.
Response Unclear
In progress
P2-25 — Postgraduate training governance clarity
Recommendation: Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include formal agreements, where relevant, including management, governance and Human Tissue …
Gov response: This recommendation is under consideration.
Response Unclear
P2-27 — Hospice security and access controls
Recommendation: Hospices that care for deceased people on their premises should: introduce auditable access control of the area where deceased people are kept; have Standard Operating Procedures regarding the care of deceased people, including security of and access to the areas …
Gov response: The Department of Health and Social Care has worked with Hospice UK to ask its clinical leaders group network to urgently review their clinical practices against the recommendations. Hospice UK has already updated its Care …
Accepted
In progress
P2-3 — Audit access data for deceased storage
Recommendation: All NHS trusts should routinely audit the access data of all facilities used to store deceased people.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-31 — Ambulance policy on crew position with deceased
Recommendation: Every NHS ambulance service should have a policy setting out where ambulance crew members should sit when conveying deceased patients. This should include reference to the risk of abuse of deceased patients, as well as training requirements.
Gov response: The Association of Ambulance Chief Executives (AACE) has written to the Department of Health and Social Care setting out the work they are doing to implement recommendations 31-33. This includes discussing with ambulance service leads …
Accepted
In progress
P2-32 — Ambulance policies on deceased security and dignity
Recommendation: NHS ambulance services should also have policies regarding the security and dignity of the deceased, including when the deceased should be covered and/or secured. NHS England should monitor that such policies are in place.
Gov response: The Association of Ambulance Chief Executives (AACE) has written to the Department of Health and Social Care setting out the work they are doing to implement recommendations 31-33. This includes discussing with ambulance service leads …
Accepted
In progress
P2-33 — Ambulance photography policies
Recommendation: Every NHS ambulance service must put policies in place regarding taking photographs of deceased patients, including any circumstances in which this may be required, and ensure that ambulance staff are aware of these and comply with them.
Gov response: The Association of Ambulance Chief Executives (AACE) has written to the Department of Health and Social Care setting out the work they are doing to implement recommendations 31-33. This includes discussing with ambulance service leads …
Accepted
In progress
P2-34 — Recommendations apply to independent ambulances
Recommendation: The Inquiry has focused its investigations into ambulance services on NHS ambulance services. However, the Inquiry considers that these recommendations could also be applied to independent ambulance services, including private ambulances.
Gov response: The Association of Ambulance Chief Executives (AACE) has made the Independent Ambulance Association (IAA) aware of the Inquiry recommendations. Where ambulance services have contractual agreements with independent ambulance services, those commissioned services must comply with …
Accepted
In progress
P2-35 — Local authority mortuary access review
Recommendation: There should be a process to routinely review who is permitted to access the mortuary unsupervised.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-36 — Local authority individualised access controls
Recommendation: Where unsupervised access is permitted for a legitimate and unavoidable purpose, there should be individualised electronic access controls to enter the mortuary and restrict access to specific areas of the mortuary, such as the post-mortem room. There should be a …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-37 — Local authority visitor supervision
Recommendation: Where people other than mortuary staff are visiting the mortuary during working hours, for example contractors, cleaners and other visitors: Access must be limited to specific areas required for the purposes of their work or visit. They must be supervised …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-38 — Local authority lone working review
Recommendation: Where mortuary staff are permitted to work alone in the mortuary, there should be a review of lone working policies, including consideration of activities involving direct handling of the deceased, alongside mitigations that can be put in place to safeguard …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-39 — Local authority security audits
Recommendation: Routine and regular audits of security must be conducted, encompassing both access to and exit from the mortuary and movement within it, including the post-mortem room. Access data must be reconciled against CCTV footage. Audits must be reported to the …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-4 — End shared swipe cards
Recommendation: The practice of using shared electronic swipe cards for specific staff groups should cease immediately.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-40 — Local authority strategic security review
Recommendation: Immediate steps must be taken to commission a specialist strategic review of the systems in place to protect the deceased, which should include a detailed risk assessment of the potential breaches of security that could occur. The review should include …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-41 — No reliance on keys/keypads alone
Recommendation: There must be no reliance on keys and keypad codes alone to secure access to the mortuary.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-42 — Lock fridges and freezers at all times
Recommendation: Fridges and freezers containing deceased people must be locked at all times, with appropriate key security in place.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-43 — Local authority CCTV installation
Recommendation: CCTV must be installed inside the mortuary facing all doors and access points, the reception area and the doors of all fridges containing deceased people, including where these are accessible from within the post-mortem room. Local authorities must put appropriate …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-44 — Local authority incident response SOPs
Recommendation: Arrangements for responding to incidents of unauthorised access must be reviewed and incorporated into Standard Operating Procedures.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-45 — Local authority single security SOP
Recommendation: All policies and procedures in relation to the security of the mortuary must be accurately and comprehensively reflected in a single security Standard Operating Procedure.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-46 — Local authority funding for security expedited
Recommendation: There must be a process to ensure that, where there is a requirement for funding to strengthen mortuary security, it is expedited and considered at the highest levels within the local authority.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-47 — Local authority security breach investigation
Recommendation: There must be an investigation into the root cause of each security breach. Each incident, the investigation and action plan must be reported to director level within the local authority as a minimum. Serious security breaches must also be reported …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-48 — Local authority annual SOP and HTA audits
Recommendation: There must be audits of the mortuary Standard Operating Procedures and compliance with Human Tissue Authority requirements, undertaken annually as a minimum, with a clear record of authorisation by the Designated Individual, head of service or equivalent. Audits of staff …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-49 — Local authority DI management and oversight review
Recommendation: There must be a review of the management and oversight arrangements for the mortuary service, taking into consideration who is appointed as the Designated Individual, their direct contact with the mortuary, level of influence within the local authority, and attendance …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-5 — Operational barriers including device restrictions
Recommendation: All NHS trusts should consider putting in place systemic operational barriers that prevent the security and dignity of deceased people being compromised. An example of this would be implementation of a rule that prevents electronic devices such as phones or …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-50 — Local authority mortuary as regulated service
Recommendation: The mortuary service must be treated in the same way as other regulatory services within local authority reporting structures: The mortuary must be visible to scrutiny at the relevant statutory committee, with regular reporting. Key performance indicators must be identified …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-51 — Local authority biennial audits and peer review
Recommendation: The mortuary service must be reviewed by professional auditors at least biennially, with the results of the audit reported to a formal committee regardless of the level of assurance. Local authorities must arrange a peer review of the mortuary service …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-52 — Share mortuary reports with coroner service
Recommendation: All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service (and the Senior Coroner if they wish to see these reports). Local authorities that are not the lead …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-53 — Local authority report implementation to committee
Recommendation: The implementation of these recommendations must be reported to the relevant statutory committee.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-55 — Unlicensed body stores prepared for HTA compliance
Recommendation: Local authorities providing an unlicensed body store must be prepared to comply with the Human Tissue Authority's standards and guidance where applicable, in the event that a Human Tissue Authority licence is required to enable activities outside Human Tissue Authority …
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
P2-56 — Unlicensed body stores follow same standards
Recommendation: Where local authorities provide an unlicensed body store, they should do so in line with this Report's recommendations to local authority providers of licensed mortuaries.
Gov response: The Government has agreed to accept in principle this recommendation subject to further work to determine its full impact.
Accepted in Part
In progress
IBI-2c — Community Support Events
Recommendation: There should be at least three events, approximately six months apart, drawing together those infected and affected, the nature and timing of which should be determined by a working party as described above, facilitated by some central funding.
Gov response: The Inquiry’s report emphasised the need for public recognition and a formal apology for all of those impacted. The previous and current UK governments have issued unequivocal apologies for what happened on behalf of the …
Accepted
In progress
WATE-(20) — Expedite disciplinary proceedings for child abuse, independent of police investigations
Recommendation: Any disciplinary proceedings that are necessary following a complaint of abuse to a child should be conducted with the greatest possible expedition and should not automatically await the outcome of parallel investigations by the police or the report on any …
Unknown
WATE-(21) — Remind personnel of suspension guidelines: child's best interests, neutral, avoid long periods
Recommendation: Personnel departments and other persons responsible for disciplinary proceedings within local authorities should be reminded that: (a) in deciding whether or not a member of staff should be suspended following an allegation of abuse to a looked after child, first …
Unknown
WATE-(22) — Conduct inter-agency review of child abuse investigation procedures to issue guidance
Recommendation: In the light of the recent experience gained in both England and Wales in major investigations of alleged wide ranging abuse of children in care/looked after children, an inter-agency review of the procedures followed and personnel employed in those investigations …
Unknown
WATE-(23) — Periodically audit Social Services staff recruitment and management vigilance
Recommendation: Social Services Departments should be reminded periodically that they must exercise vigilance in the recruitment and management of their staff in strict accordance with the detailed recommendations of the Warner committee917; and compliance with them by individual local authorities should …
Unknown
WATE-(24) — Mandate stringent, independent vetting for all foster parent applications, especially staff
Recommendation: Similar vigilance should be mandatory in relation to all applications for approval as foster parents. In particular, any application to foster by a member of a local authority's child care staff should be stringently vetted by a social worker who …
Unknown
WATE-(25) — Provide appropriate and timely induction training for new residential child care staff
Recommendation: Social Services Departments should ensure that appropriate and timely induction training is provided for all newly recruited residential child care staff.
Unknown
WATE-(26) — Implement Utting's recommendations for children's home staff training expeditiously
Recommendation: The Tribunal endorses all five of the most recent recommendations of Sir William Utting in "People Like Us"918 in relation to the content and provision of training for staff in children's homes and the care units of residential special schools …
Unknown
WATE-(27) — Require senior children's home staff to be qualified social workers or train
Recommendation: It should be a requirement that senior staff of children's homes (including private and voluntary homes) must be qualified social workers or, if that is not practicable before appointment, that it should be a condition of their appointment that they …
Unknown
WATE-(28) — Promote and validate training in safe restraint methods for child care staff
Recommendation: Central government should take the initiative to promote and validate training in safe methods of restraint with a view to making such training readily available for residential child care staff and foster parents.
Unknown
WATE-(29) — Make specialist post-qualifying child care training widely available for senior staff
Recommendation: Suitable specialist training in child care at post-qualifying level should be made widely available and, in particular, to the senior residential care staff of children's homes and to field social workers.
Unknown
WATE-(3) — Require appointment of independent Children's Complaints Officer in every social services authority
Recommendation: Every social services authority should be required to appoint an appropriately qualified or experienced Children's Complaints Officer, who should not be the line manager of residential or other staff who may be the subject of children's complaints or complaints relating …
Unknown
WATE-(30) — Conduct national review of pay and career for residential child care staff
Recommendation: There should be a national review of the pay, status and career development of residential child care staff and field social workers to ensure as far as possible that there is a sufficient supply of candidates for such posts of …
Unknown
WATE-(31) — Require comprehensive child needs assessment before admission to care
Recommendation: Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Unknown
WATE-(32) — Follow emergency child admissions with comprehensive assessment within prescribed period
Recommendation: All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Unknown
WATE-(33) — Base care plans on comprehensive assessment, prepared with child consultation
Recommendation: The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Unknown
WATE-(34) — Designate social worker responsible for care plan implementation and child supervision
Recommendation: An appropriate social worker should be designated as the person responsible for the implementation of the care plan and supervision of the looked after child.
Unknown
WATE-(35) — Ensure foster carers receive continuing support and access to specialist services
Recommendation: Foster carers should receive continuing support and have access as necessary to specialist services. In this context we endorse the recommendations of Sir William Utting in relation to training in "People Like Us"919.
Unknown
WATE-(36) — Provide facilities and encourage acquisition of independent living skills in care settings
Recommendation: The daily regime in residential establishments and foster homes should encourage and provide facilities for the acquisition of skills necessary for independent living.
Unknown
WATE-(37) — Prepare and periodically review leaving care plans for all looked after children
Recommendation: A leaving care plan should be prepared for each looked after child, in consultation with that child, a year in advance of the event and should be reviewed periodically thereafter until the child ceases to require or be eligible for …
Unknown
WATE-(38) — Extend local authority duty to provide parental-level support for care leavers
Recommendation: The duty upon local authorities under section 24(1) of the Children Act 1989 to advise, assist and befriend a child with a view to promoting his welfare when he ceases to be looked after by them should be extended so …
Unknown
WATE-(39) — Require fostering services to monitor, analyse, and report placement breakdowns periodically
Recommendation: Every local authority's fostering service, whether provided directly or by another agency, should monitor breakdowns in placements with a view to analysing the causes and remedying any faults in the service and should report upon them periodically to the Director …
Unknown
WATE-(4) — Define specific duties for Children's Complaints Officers, prioritising child's best interests
Recommendation: Amongst the duties of the Children's Complaints Officer should be: (a) to act in the best interests of the child; (b) on receiving a complaint, to see the affected child and the complainant, if it is not the affected child; …
Unknown
WATE-(40) — Develop key indicators to monitor compliance with safeguards for looked after children
Recommendation: Appropriate key indicators of compliance with safeguards for looked after children should be developed, covering particularly:34, 62(i) (a) the allocation of a designated social worker to each looked after child; (b) compliance with fostering and placement regulations; (c) statutory review …
Unknown
WATE-(41) — Require all private children's homes to register with the independent regulatory agency
Recommendation: All private children's homes should be required to register with the independent agency referred to in recommendation (47).
Unknown
WATE-(42) — Mandate governing bodies for larger private children's homes and residential schools
Recommendation: The owner of a private children's home and the owner of a private residential school approved generally for SEN children or receiving SEN children with the consent of the Secretary of State should be required, if the establishment is above …
Unknown
WATE-(43) — Disclose financial information of private children's homes and residential schools to regulators
Recommendation: The accounts and other relevant financial information relating to private children's homes and private residential schools approved generally for SEN children or receiving SEN children with the consent of the Secretary of State should be disclosed to the relevant regulatory …
Unknown
WATE-(44) — Urgently review legislation to establish stricter regulation for private residential schools
Recommendation: There should be an urgent review of the legislation governing the regulation of private residential schools to include particularly:71 (a) approvals and consents under section 347 of the Education Act 1996921 and for provisional registration of schools, (b) the Notice …
Unknown
WATE-(45) — Require social worker assessment and inter-departmental consultation before residential school placement
Recommendation: Any placement of a child by a local education department or by a social services department in a residential school should be preceded by: (a) consultation between the departments as to whether an assessment by an appropriate social worker of …
Unknown
WATE-(46) — Prohibit emergency admissions to all private residential schools
Recommendation: Emergency admissions should not be made to private residential schools.
Unknown
WATE-(47) — Establish an independent regulatory agency for all children's services in Wales
Recommendation: Without prejudice to the continuing role generally of the Social Services Inspectorate for Wales, an independent regulatory agency for children's services in Wales should be established, with a local base or local bases in North Wales, and charged with the …
Unknown
WATE-(48) — Ensure inspectors of children's services have substantial child care experience
Recommendation: When inspections are made by the agency of homes, schools or services mentioned in recommendation (47) at least one of the inspectors should have substantial experience of child care.
Unknown
WATE-(49) — Mandate joint inspection programmes for educational and welfare oversight of residential schools
Recommendation: The agencies responsible for educational and welfare inspections of private residential schools accommodating children with SEN pursuant to section 347 of the Education Act 1996 should be required to agree joint programmes of inspection and reporting.
Unknown
WATE-(5) — Ensure all decisions regarding abused children are made in their best interests
Recommendation: Any decision about the future of a child who is alleged to have been abused should be made in that child's best interests. In particular, the child should not be transferred to another placement unless it is in the child's …
Unknown
WATE-(50) — Apply common standards across all sectors for looked after children's services
Recommendation: A common set of standards should be applied to the local authority, voluntary and private sectors in relation to residential provision and other services for looked after children.
Unknown
WATE-(51) — Send local authority children's homes inspection reports to Chief Executives
Recommendation: Copies of the reports of inspections of local authorities' children's homes and services should be sent to the Chief Executives as well as the Directors of Social Services.
Unknown
WATE-(52) — Send private and voluntary care inspection reports to relevant placing authorities
Recommendation: Copies of reports of inspections of private and voluntary children's homes and of private residential schools should be sent to the Director of Social Services of any placing authority with a child at the school and of the authority in …
Unknown
WATE-(54) — Mandate child care expert on local authority social services management team
Recommendation: There should be at least one full member of a local authority's social services department management team with child care expertise and experience.
Unknown
WATE-(55) — Assign children's services policy and oversight to Assistant Director level manager
Recommendation: The responsibility for policy and service development and for oversight of the delivery of a local authority's children's services should be assigned to one member of the social services department management team of at least Assistant Director status.
Unknown
WATE-(56) — Ensure sufficient intermediate management staff for children's services supervision and support
Recommendation: Staffing resources at intermediate management level for a local authority's children's services should be sufficient in number and quality to enable positive and close supervision and support to be given to residential establishments and the fostering service.
Unknown
WATE-(57) — Local authorities in Wales review senior management training and development
Recommendation: Local authorities in Wales should review their current arrangements for management training and development for senior managers, including social services managers, giving particular attention to the development of skills in strategic planning, policy implementation and performance appraisal.
Unknown
WATE-(58) — Advise elected members on responsibilities for looked after children policy and oversight
Recommendation: Elected members should from time to time be advised about and reminded of their responsibilities to develop policy and to oversee and monitor the discharge by the local authority of its parental obligations towards looked after children.
Unknown
WATE-(59) — Mandate Director of Social Services to support elected members on children's services
Recommendation: It should be the explicit duty of the Director of Social Services to assist and support elected members in discharging those responsibilities and, in particular:40 to 42, 62(vi) to (viii), 63 (a) to inform elected members of all matters of …
Unknown
WATE-(6) — Local authorities promote awareness of complaints procedures for looked after children
Recommendation: Every local authority should promote vigorously awareness by children and staff of its complaints procedures for looked after children and the importance of applying them conscientiously without any threat or fear of reprisals in any form.
Unknown
WATE-(60) — Clearly define purpose and scope of visits to children's homes
Recommendation: The purpose and scope of visits to children's homes, whether by councillors or by senior and intermediate managers, should be clearly defined and made known to all such visitors.
Unknown
WATE-(61) — Make willingness to visit children's homes pre-condition for committee appointment
Recommendation: The willingness of councillors to visit children's homes should be a pre-condition of appointment to the committee responsible for the homes and the importance of fulfilling the duty to visit and to report on visits conscientiously should be emphasised to …
Unknown
WATE-(62) — Establish Advisory Council for Children's Services in Wales to strengthen provision
Recommendation: An Advisory Council for Children's Services in Wales comprised of members covering a wide range of expertise in children's services, including practice, research, management and training, should be established in order to strengthen the provision of children's services in Wales …
Unknown
WATE-(63) — Define Advisory Council functions: advise, research, disseminate information, and recommend
Recommendation: The functions of the Advisory Council should include: (a) advising on government policy and legislation with regard to their likely impact on children and young people; (b) commissioning research; (c) disseminating information and making recommendations.
Unknown
WATE-(64) — Conduct nationwide review of children's services needs and costs for strategy
Recommendation: There should be a nationwide review of the needs and costs of children's services based on local authorities' development plans and leading to a comprehensive and costed strategy for those services, including any necessary education and health elements.
Unknown
WATE-(65) — Local authorities prepare costed development plans for children's services provision
Recommendation: Local authorities, in collaboration with voluntary and other relevant organisations and acting together with other local authorities where appropriate, should prepare costed development plans for children's services as a prelude to the proposed nationwide review, such plans to ensure (amongst …
Unknown
WATE-(66) — Central government examine residential schools use as social services substitute
Recommendation: Central government should examine the extent to which residential schools are being used as a substitute for social services care and support, and identify the implications for children's long term welfare.
Unknown
WATE-(67) — Monitor nationwide availability and quality of residential placements and fostering services
Recommendation: Provision should be made for repeated monitoring at appropriate intervals of the availability and quality of residential placements and fostering services on a nationwide basis.
Unknown
WATE-(68) — Consider national training and management development for senior local authority managers
Recommendation: Consideration should be given at national level to the need for, and provision of, training and management development for senior managers in local authorities in Wales, including the availability of such facilities for social services managers922.
Unknown
WATE-(69) — Provide adequate resources for national children's services departments in Wales
Recommendation: Adequate resources should be provided to ensure that the departments in Wales responsible at national level for children's services are sufficiently and appropriately staffed to support and monitor the provision of these services in Wales.
Unknown
WATE-(7) — Ensure comprehensive and impartial complaints procedures for looked after children
Recommendation: Such complaints procedures should: (a) be neither too prescriptive nor too restrictive in categorising what constitutes a complaint; (b) encompass a wide variety of channels through which complaints by or relating to looked after children may be made or referred …
Unknown
WATE-(70) — Strengthen national statistics services in Wales for management information system
Recommendation: The national statistics services in Wales should be strengthened to provide a comprehensive management information system.
Unknown
WATE-(8) — Establish clear whistleblowing procedures for staff reporting child welfare concerns.
Recommendation: Every local authority should establish and implement conscientiously clear whistleblowing procedures enabling members of staff to make complaints and raise matters of concern affecting the treatment or welfare of looked after children without threats or fear of reprisals in any …
Unknown
WATE-(9) — Make failure to report child abuse by staff an explicit disciplinary offence.
Recommendation: Consideration should be given to requiring failure by a member of staff to report actual or suspected physical or sexual abuse of a child by another member of staff or other person having contact with the child to be made …
Unknown
LAMI-28 — Require local authorities to assess and plan improvements for children's duty systems
Recommendation: The Department of Health should require chief executives of local authorities with social services responsibilities to prepare a position statement on the true picture of the current strengths and weaknesses of their ‘front door’ duty systems for children and families. …
Unknown
LAMI-29 — Implement system for directors to monitor children's social services duty team data
Recommendation: Directors of social services must devise and implement a system which provides them with the following information about the work of the duty teams for which they are responsible: • number of children referred to the teams; • number of …
Unknown
LAMI-30 — Directors must ensure senior managers regularly inspect children's social services case files
Recommendation: Directors of social services must ensure that senior managers inspect, at least once every three months, a random selection of case files and supervision notes.
Unknown
LAMI-31 — Ensure all staff working with children receive comprehensive vocational and ongoing training
Recommendation: Directors of social services must ensure that all staff who work with children have received appropriate vocational training, receive a thorough induction in local procedures and are obliged to participate in regular continuing training so as to ensure that their …
Unknown
LAMI-32 — Ensure single, compatible electronic database for all children and families services
Recommendation: Local authority chief executives must ensure that only one electronic database system is used by all those working in children and families’ services for the recording of information. This should be the same system in use across the council, or …
Unknown
LAMI-33 — Establish 24-hour public referral line for child concerns, pilot electronic recording
Recommendation: Local authorities with responsibility for safeguarding children should establish and advertise a 24-hour free telephone referral number for use by members of the public who wish to report concerns about a child. A pilot study should be undertaken to evaluate …
Unknown
LAMI-34 — Standardise social worker home visits: clarify purpose, check records, document findings
Recommendation: Social workers must not undertake home visits without being clear about the purpose of the visit, the information to be gathered during the course of it, and the steps to be taken if no one is at home. No visits …
Unknown
LAMI-35 — Ensure children subject to harm allegations are seen within 24 hours
Recommendation: Directors of social services must ensure that children who are the subject of allegations of deliberate harm are seen and spoken to within 24 hours of the allegation being communicated to social services. If this timescale is not met, the …
Unknown
LAMI-36 — Require legal advice before emergency child harm action, ensure 24-hour availability
Recommendation: No emergency action on a case concerning an allegation of deliberate harm to a child should be taken without first obtaining legal advice. Local authorities must ensure that such legal advice is available 24 hours a day.
Unknown
LAMI-37 — Train social workers to confidently challenge other professionals' opinions on child needs
Recommendation: The training of social workers must equip them with the confidence to question the opinion of professionals in other agencies when conducting their own assessment of the needs of the child.
Unknown
LAMI-38 — Ensure inter-departmental case transfers are recorded and confirmed in writing
Recommendation: Directors of social services must ensure that the transfer of responsibility of a case between local authority social services departments is always recorded on the case file of each authority, and is confirmed in writing by the authority to which …
Unknown
LAMI-39 — Train front-line staff to promptly record and transfer child safety calls
Recommendation: All front-line staff within local authorities must be trained to pass all calls about the safety of children through to the appropriate duty team without delay, having first recorded the name of the child, his or her address, and the …
Unknown
LAMI-40 — Establish mandatory steps for closing child harm cases, including welfare plan
Recommendation: Directors of social services must ensure that no case that has been opened in response to allegations of deliberate harm to a child is closed until the following steps have been taken: • The child has been spoken to alone. …
Unknown
LAMI-41 — Require senior managers and councillors to regularly visit children's intake teams
Recommendation: Chief executives of local authorities with social services responsibilities must make arrangements for senior managers and councillors to regularly visit intake teams in their children’s services department, and to report their findings to the chief executive and social services committee.
Unknown
LAMI-42 — Implement systems to detect failures in internal social services case transfers
Recommendation: Directors of social services must ensure that where the procedures of a social services department stipulate requirements for the transfer of a case between teams within the department, systems are in place to detect when such a transfer does not …
Unknown
LAMI-43 — Mandate training for Section 47 inquiries and audit staff for compliance
Recommendation: No social worker shall undertake section 47 inquiries unless he or she has been trained to do so. Directors of social services must undertake an audit of staff currently carrying out section 47 inquiries to identify gaps in training and …
Unknown
LAMI-44 — Conduct six-monthly reviews of temporary staff promotions and record outcomes
Recommendation: When staff are temporarily promoted to fill vacancies, directors of social services must subject such arrangements to six-monthly reviews and record the outcome.
Unknown
LAMI-45 — Ensure regular supervision of staff working with children, including case file review
Recommendation: Directors of social services must ensure that the work of staff working directly with children is regularly supervised. This must include the supervisor reading, reviewing and signing the case file at regular intervals.
Unknown
LAMI-46 — Ensure clear understanding of child protection adviser roles across children's services
Recommendation: Directors of social services must ensure that the roles and responsibilities of child protection advisers (and those employed in similar posts) are clearly understood by all those working within children’s services.
Unknown
LAMI-47 — Provide 24/7 specialist services for children and families, separate from general teams
Recommendation: The chief executive of each local authority with social services responsibilities must ensure that specialist services are available to respond to the needs of children and families 24 hours a day, seven days a week. The safeguarding of children should …
Unknown
LAMI-48 — Require social worker agreement and record purpose for all agency referrals
Recommendation: Directors of social services must ensure that when children and families are referred to other agencies for additional services, that referral is only made with the agreement of the allocated social worker and/or their manager. The purpose of the referral …
Unknown
LAMI-49 — Review cases and meet professionals when other agencies raise concerns
Recommendation: When a professional from another agency expresses concern to social services about their handling of a particular case, the file must be read and reviewed, the professional concerned must be met and spoken to, and the outcome of this discussion …
Unknown
LAMI-50 — Implement systems to action communications during social services staff absence
Recommendation: Directors of social services must ensure that when staff are absent from work, systems are in place to ensure that post, emails and telephone contacts are checked and actioned as necessary.
Unknown
LAMI-51 — Ensure strategy meetings include action points, records, and review mechanisms
Recommendation: Directors of social services must ensure that all strategy meetings and discussions involve the following three basic steps: • A list of action points must be drawn up, each with an agreed timescale and the identity of the person responsible …
Unknown
LAMI-52 — Allocate cases only when social workers have adequate training, experience, and time
Recommendation: Directors of social services must ensure that no case is allocated to a social worker unless and until his or her manager ensures that he or she has the necessary training, experience and time to deal with it properly.
Unknown
LAMI-53 — Managers must ensure social workers understand allocated cases, actions, and supervision
Recommendation: When allocating a case to a social worker, the manager must ensure that the social worker is clear as to what has been allocated, what action is required and how that action will be reviewed and supervised.
Unknown
LAMI-54 — Allocate social workers to all children's cases or report unallocated cases monthly
Recommendation: Directors of social services must ensure that all cases of children assessed as needing a service have an allocated social worker. In cases where this proves to be impossible, arrangements must be made to maintain contact with the child. The …
Unknown
LAMI-55 — Define 'allocated' cases as those with active social worker engagement
Recommendation: Directors of social services must ensure that only those cases in which a social worker is actively engaged in work with a child and the child’s family are deemed to be ‘allocated’.
Unknown
LAMI-56 — Prevent discharge of hospitalised children with concerns until home is safe
Recommendation: Directors of social services must ensure that no child known to social services who is an inpatient in a hospital and about whom there are child protection concerns is allowed to be taken home until it has been established by …
Unknown
LAMI-57 — Ensure social workers can access international information on vulnerable children
Recommendation: Directors of social services must ensure that social work staff are made aware of how to access effectively information concerning vulnerable children which may be held in other countries.
Unknown
LAMI-58 — Require a properly maintained chronology in every child's case file
Recommendation: Directors of social services must ensure that every child’s case file includes, on the inside of the front cover, a properly maintained chronology.
Unknown
LAMI-59 — Provide single-source, up-to-date guidance and monitor adherence for staff
Recommendation: Directors of social services must ensure that staff working with vulnerable children and families are provided with up-to-date procedures, protocols and guidance. Such practice guidance must be located in a single-source document. The work should be monitored so as to …
Unknown
LAMI-60 — Line manage hospital social workers within children and families' services section
Recommendation: Directors of social services must ensure that hospital social workers working with children and families are line managed by the children and families’ section of their social services department.
Unknown
LAMI-61 — Ensure hospital social workers participate in all child safeguarding hospital meetings
Recommendation: Directors of social services must ensure that hospital social workers participate in all hospital meetings concerned with the safeguarding of children.
Unknown
LAMI-62 — Implement single agreed guidance for hospital social workers with out-of-area children
Recommendation: Where hospital-based social work staff come into contact with children from other local authority areas, the directors of social services of their employing authorities must ensure that they work to a single set of guidance agreed by all the authorities …
Unknown
LAMI-63 — Hospital social workers must promptly respond to suspected child harm referrals
Recommendation: Hospital social workers must always respond promptly to any referral of suspected deliberate harm to a child. They must see and talk to the child, to the child’s carer and to those responsible for the care of the child in …
Unknown
LAMI-64 — Ensure nursing care plans account for suspected deliberate harm in hospitalised children.
Recommendation: When a child is admitted to hospital and deliberate harm is suspected, the nursing care plan must take full account of this diagnosis.
Unknown
LAMI-65 — Doctors must take child's history directly for suspected harm, recording consent reasons.
Recommendation: When the deliberate harm of a child is identified as a possibility, the examining doctor should consider whether taking a history directly from the child is in that child’s best interests. When that is so, the history should be taken …
Unknown
LAMI-66 — Ensure all deliberate harm concerns are fully addressed and documented in appraisals.
Recommendation: When a child has been examined by a doctor, and concerns about deliberate harm have been raised, no subsequent appraisal of these concerns should be considered complete until each of the concerns has been fully addressed, accounted for and documented.
Unknown
LAMI-67 — Require recorded discussion and further opinion for differing deliberate harm diagnoses.
Recommendation: When differences of medical opinion occur in relation to the diagnosis of possible deliberate harm to a child, a recorded discussion must take place between the persons holding the different views. When the deliberate harm of a child has been …
Unknown
LAMI-68 — Doctors must make comprehensive, contemporaneous notes for suspected child deliberate harm.
Recommendation: When concerns about the deliberate harm of a child have been raised, doctors must ensure that comprehensive and contemporaneous notes are made of these concerns. If doctors are unable to make their own notes, they must be clear about what …
Unknown
LAMI-69 — Record all discussions, including phone calls, in child deliberate harm case notes.
Recommendation: When concerns about the deliberate harm of a child have been raised, a record must be kept in the case notes of all discussions about the child, including telephone conversations. When doctors and nurses are working in circumstances in which …
Unknown
LAMI-7 — Establish local authority Management Board for Children and Families, ensuring staff training.
Recommendation: The local authority chief executive should chair a Management Board for Services to Children and Families which will report to the Member Committee referred to above. The Management Board for Services to Children and Families must include senior officers from …
Unknown
LAMI-70 — Require consultant or paediatrician permission for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without the permission of either the consultant in charge of the child’s care or of a paediatrician …
Unknown
LAMI-71 — Require documented future care plan for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. …
Unknown
LAMI-72 — Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Recommendation: No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been …
Unknown
LAMI-73 — Require inquiry and review of previous hospital admissions for suspected deliberate harm.
Recommendation: When a child is admitted to hospital and deliberate harm is suspected, the doctor or nurse admitting the child must inquire about previous admissions to hospital. In the event of a positive response, information concerning the previous admissions must be …
Unknown
LAMI-74 — Mandate full, documented physical examination within 24 hours for suspected deliberate harm.
Recommendation: Any child admitted to hospital about whom there are concerns about deliberate harm must receive a full and fully-documented physical examination within 24 hours of their admission, except when doing so would, in the opinion of the examining doctor, compromise …
Unknown
LAMI-75 — Require senior doctor to seek carer permission for deliberate harm investigation or treatment.
Recommendation: In a case of possible deliberate harm to a child in hospital, when permission is required from the child’s carer for the investigation of such possible deliberate harm, or for the treatment of a child’s injuries, the permission must be …
Unknown
LAMI-76 — Clearly identify responsible consultant for child protection aspects in deliberate harm cases.
Recommendation: When a child is admitted to hospital with concerns about deliberate harm, a clear decision must be taken as to which consultant is to be responsible for the child protection aspects of the child’s care. The identity of that consultant …
Unknown
LAMI-77 — Doctors must provide written statement of deliberate harm concerns to social services.
Recommendation: All doctors involved in the care of a child about whom there are concerns about possible deliberate harm must provide social services with a written statement of the nature and extent of their concerns. If misunderstandings of medical diagnosis occur, …
Unknown
LAMI-78 — Implement single set of records for each child across health professionals.
Recommendation: Within a given location, health professionals should work from a single set of records for each child.
Unknown
LAMI-79 — Ensure all available information is reviewed during ward rounds for deliberate harm.
Recommendation: During the course of a ward round, when assessing a child about whom there are concerns about deliberate harm, the doctor conducting the ward round should ensure that all available information is reviewed and taken account of before decisions on …
Unknown
LAMI-8 — Appoint director to ensure effective inter-agency arrangements and assess child needs.
Recommendation: The Management Board for Services to Children and Families must appoint a director responsible for ensuring that inter-agency arrangements are appropriate and effective, and for advising the Management Board for Services to Children and Families on the development of services …
Unknown
LAMI-80 — Record all discussions, decisions, and actions in hospital notes for deliberate harm.
Recommendation: When a child for whom there are concerns about deliberate harm is admitted to hospital, a record must be made in the hospital notes of all face-to-face discussions (including medical and nursing ‘handover’) and telephone conversations relating to the care …
Unknown
LAMI-81 — Implement systems to record, complete, and check actions for deliberate harm cases.
Recommendation: Hospital chief executives must introduce systems to ensure that actions agreed in relation to the care of a child about whom there are concerns of deliberate harm are recorded, carried through and checked for completion.
Unknown
LAMI-82 — Examine feasibility of clinical governance for children at risk of deliberate harm.
Recommendation: The Department of Health should examine the feasibility of bringing the care of children about whom there are concerns about deliberate harm within the framework of clinical governance.
Unknown
LAMI-83 — Systematically and rigorously investigate and manage cases of deliberate harm to children.
Recommendation: The investigation and management of a case of possible deliberate harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease.
Unknown
LAMI-84 — Revalidate doctors and paediatricians in deliberate harm diagnosis and multi-disciplinary child protection investigations.
Recommendation: All designated and named doctors in child protection and all consultant paediatricians must be revalidated in the diagnosis and treatment of deliberate harm and in the multi-disciplinary aspects of a child protection investigation.
Unknown
LAMI-85 — Develop continuing education models for deliberate harm diagnosis and multi-disciplinary child protection investigations.
Recommendation: The Department of Health should invite the Royal College of Paediatrics and Child Health to develop models of continuing education in the diagnosis and treatment of the deliberate harm of children, and in the multi-disciplinary aspects of a child protection …
Unknown
LAMI-86 — Explore extending child patient registration to include social and developmental welfare information.
Recommendation: The Department of Health should invite the Royal College of General Practitioners to explore the feasibility of extending the process of new child patient registration to include gathering information on wider social and developmental issues likely to affect the welfare …
Unknown
LAMI-87 — Ensure GPs receive regular training in deliberate harm recognition and child protection investigations.
Recommendation: The Department of Health should seek to ensure that all GPs receive training in the recognition of deliberate harm to children, and in the multi-disciplinary aspects of a child protection investigation, as part of their initial vocational training in general …
Unknown
LAMI-88 — Examine feasibility of deliberate harm training for all primary healthcare staff.
Recommendation: The Department of Health should examine the feasibility of introducing training in the recognition of deliberate harm to children as part of the professional education of all general practice staff and for all those working in primary healthcare services for …
Unknown
LAMI-89 — GPs must ensure staff know local child protection agency contact procedures.
Recommendation: All GPs must devise and maintain procedures to ensure that they, and all members of their practice staff, are aware of whom to contact in the local health agencies, social services and the police in the event of child protection …
Unknown
LAMI-9 — Identify agency budgets for vulnerable children to enable flexible resource use.
Recommendation: The budget contributed by each of the local agencies in support of vulnerable children and families should be identified by the Management Board for Services to Children and Families so that staff and resources can be used in the most …
Unknown
LAMI-90 — Ensure child protection training for liaison staff and audit policy compliance.
Recommendation: Liaison between hospitals and community health services plays an important part in protecting children from deliberate harm. The Department of Health must ensure that those working in such liaison roles receive child protection training. Compliance with child protection policies and …
Unknown
LAMI-91 — Require child assessment before police protection, except in exceptional circumstances.
Recommendation: Save in exceptional circumstances, no child is to be taken into police protection until he or she has been seen and an assessment of his or her circumstances has been undertaken.
Unknown
LAMI-92 — Ensure prompt, efficient investigation of child victim crimes to adult standards.
Recommendation: Chief constables must ensure that crimes involving a child victim are dealt with promptly and efficiently, and to the same standard as equivalent crimes against adults.
Unknown
LAMI-93 — Require manager involvement from both agencies in joint child harm investigations.
Recommendation: Whenever a joint investigation by police and social services is required into possible injury or harm to a child, a manager from each agency should always be involved at the referral stage, and in any further strategy discussion.
Unknown
LAMI-94 — Require supervisory officers to actively ensure proper investigation of serious child crimes.
Recommendation: In cases of serious crime against children, supervisory officers must, from the beginning, take an active role in ensuring that a proper investigation is carried out.
Unknown
LAMI-95 — ACPO must produce and implement standards-based child protection service.
Recommendation: The Association of Chief Police Officers must produce and implement the standards-based service, as recommended by Her Majesty’s Inspectorate of Constabulary in the 1999 thematic inspection report, Child Protection.
Unknown
LAMI-96 — Review police protection systems for Children Act compliance and designated inspector officer.
Recommendation: Police forces must review their systems for taking children into police protection and ensure they comply with the Children Act 1989 and Home Office guidelines. In particular, they must ensure that an independent officer of at least inspector rank acts …
Unknown
LAMI-97 — Ensure child crime investigation is equal to other serious crime investigations.
Recommendation: Chief constables must ensure that the investigation of crime against children is as important as the investigation of any other form of serious crime. Any suggestion that child protection policing is of a lower status than other forms of policing …
Unknown
LAMI-98 — Social services must inform police immediately of child criminal offence referrals.
Recommendation: The guideline set out at paragraph 5.8 of Working Together must be strictly adhered to: whenever social services receive a referral which may constitute a criminal offence against a child, they must inform the police at the earliest opportunity.
Unknown
LAMI-99 — Amend Working Together for police to exclusively conduct child criminal investigations.
Recommendation: The Working Together arrangements must be amended to ensure the police carry out completely, and exclusively, any criminal investigation elements in a case of suspected injury or harm to a child, including the evidential interview with a child victim. This …
Unknown
PFD Reports (68)
Georgia Scarff
Concerns: School staff unfamiliarity with the safeguarding system led to missed recordings. The lack of a single national safeguarding information management tool for schools creates inconsistent practices and risks.
Pending
Lucy-Anne Dyson
Concerns: A lack of national interface for safeguarding system communication between schools and agencies, coupled with inconsistent referral guidance, risks missed or inadequate child protection actions.
Response: The Department for Education is committed to developing a new children’s social care data platform to enable more effective information sharing and working with other departments to digitise domestic abuse …
Responded
Linda Sitch
Concerns: Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of priority cases. ASC lacks robust oversight and auditing to prevent such systemic failures, risking future harm.
Responded
Janet Scott
Concerns: The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if they believe others are informed, risking a fragmented multi-agency approach.
Responded
Diane Poole
Concerns: A faulty emergency exit door, combined with staff's lack of awareness, inadequate alarm checks, and poor shift handover procedures, created significant safety risks for residents.
Responded
Peter Good
Concerns: Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home owner failed to investigate this to identify learning or assess ongoing risks to other residents.
Responded
Adrian Green
Concerns: The local authority failed to review independent care providers' contractual duties for vulnerable individuals, and a Disclosure and Barring Service referral regarding actions of a former manager received no response.
Overdue
Thomas Godderidge
Concerns: Inadequate liaison between Adult Social Care and care providers regarding service-users' fluctuating capacity risks missed care opportunities for vulnerable individuals.
Responded
Jake Baker
Concerns: Surrey County Council has failed to address inadequate pathway plans, opaque diagnostic processes, and poor access to adult social care for care leavers. Deficiencies in risk assessment standards and non-mandatory Mental Capacity Act training persist.
Responded
Gerard Goodwin
Concerns: A vulnerable adult's safeguarding concerns were disregarded at triage, and a recommended care assessment was overridden. Systemic failures in referral processing and case management risk vulnerable individuals being overlooked.
Responded
Igor Szalapski
Concerns: Hostel staff failed to re-contact the crisis team despite a resident's deterioration, lacked meaningful engagement, and did not perform consistent welfare checks. Inadequate self-harm training and a chaotic culture contributed to missed opportunities for intervention.
Responded
Eileen Walsh
Concerns: The care home failed to complete critical policies and implement a monitoring system for years. Issues include unaddressed faulty alarms, conflicting record-editing policies, and an internal investigation that missed key facts, mirroring CQC concerns.
Responded
Sylvia Pollitt
Concerns: The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed to monitor referral outcomes, missing crucial safety oversight for vulnerable adults.
Responded
Colin Gumm
Concerns: Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A Section 42 assessment was prematurely closed, missing critical signs of neglect and conflicting staff evidence, preventing identification of risks.
Responded
Diane Austin-Martin
Concerns: There was a critical systemic failure in inter-agency communication, leaving a vulnerable person's relocation unknown to social services and without oversight of the quality of her private care arrangements.
Responded
Kate Hedges
Concerns: Disparate record-keeping systems prevent comprehensive risk assessments, safeguarding policies were not followed, and mental health service design lacks sufficient trauma-informed care.
Responded
Gemma Ingham
Concerns: Inadequate clinical record keeping, incomplete risk assessments, and a flawed discharge decision for a vulnerable patient lacking appropriate community support and clinical rationale.
Overdue
Melanie Elms
Concerns: The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, and there was no proper missing person plan in place.
Overdue
Charlotte Duffield
Concerns: Adult Social Care failed to take appropriate safeguarding action despite significant police concerns, only attempting telephone contact and sending a letter, without making any physical visit to a vulnerable individual.
Responded
Dorothy Seekings
Concerns: Care plans failed to document aggressive patient incidents, and a safeguarding alert was not raised after staff assault. Staff also appeared unaware of the contents of patient care plans.
Responded
Glenn Macmartin
Concerns: No specific concerns were detailed in the provided text.
Responded
Ann Mowbray
Concerns: The Christian Congregation of Jehovah’s Witnesses lacks a safeguarding policy for vulnerable adult members, despite previous recommendations, posing a risk to their safety.
Responded
Edward Bilbey
Concerns: England Boxing lacked adequate child protection policies, enforcement, and up-to-date records for welfare officers, leaving clubs vulnerable and compromising child safety measures.
Responded
Roy Curtis
Concerns: Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.
Responded
Anthony Slack
Concerns: The care home suffered from poor documentation and observation quality, unclear Covid-19 infection control (no admission risk assessment), and staff confusion over PPE. Ambulance delays also impacted patient transfer.
Responded
Geoffrey Banks
Concerns: A vulnerable patient's medication was unsafely stored due to a faulty lock, despite being identified as needing supervision, compounded by a poor investigation by untrained staff.
Responded
June Winterbottom
Concerns: Adult Social Care's urgent referral system was ineffective, failing to contact a vulnerable person in dire need, lacking accountability, and having no safety net for emergency medical assistance.
Responded
Jacob Bates
Concerns: Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due to resource constraints.
Responded
Archie Spriggs
Concerns: Systemic failures in child safeguarding include unclear referral pathways, delayed responses to urgent concerns, insufficient multi-agency understanding of complex family dynamics, and inadequate information sharing regarding children's welfare in private law proceedings.
Overdue
Katie Croft
Concerns: Inexperienced police officers handled serious allegations, failing to seize evidence promptly or collaborate effectively with social services. Reliance on agency social workers, poor information sharing, and a lack of mechanisms for schools to receive assessment data further compromised child safeguarding.
Overdue
Alex Malcolm
Concerns: Insufficient Approved Premises, delays in making MARACs statutory, and difficulties recruiting probation officers due to low pay are systemic issues hindering efforts to prevent future deaths.
Overdue
Janie McFadyen
Concerns: No specific concerns were detailed in the provided text.
Responded
Barnaby Aylward
Concerns: Systemic failure in multi-agency review and responsibility for known home safety risks linked to mental illness was compounded by poor communication and inadequate mental health documentation. Family support was also insufficient.
Overdue
Ellie Butler
Concerns: No specific concerns were detailed in the provided text, only a reference to appended concerns.
Overdue
Russell Robb
Concerns: A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.
Responded
James Harris
Concerns: Care home staff failed to read care plans, adhere to falls protocols, and provide medical attention after a fall, compounded by poor record-keeping and an absent registered manager.
Responded
Ivy Mitchell
Concerns: Inaccurate falls risk documentation, poor staff understanding of risk assessments and post-fall procedures, and non-compliance with escalation processes jeopardised patient safety.
Overdue
Doreen Miller
Concerns: A safeguarding referral was improperly signed off by Wiltshire Council without investigation, and crucial cognitive assessment information was missing from the hospital discharge summary upon patient transfer.
Overdue
Robert Mullis
Concerns: A vulnerable, partially sighted patient with dementia was able to disembark a high-speed train unaccompanied and access railway tracks directly from the end of the platform.
Overdue
Kevin Morgan
Concerns: Systemic failures in social services included inadequate follow-up on known problems, insufficient response to a safeguarding alert, lack of police welfare checks, and no serious incident review to learn lessons.
Responded
Ruth Milne
Concerns: Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.
Responded
Cedric Skyers
Concerns: The care home's smoking risk assessment for immobile residents fails to adequately address immobility risks, lacks clear guidance on safety equipment provision, and does not document refusal of professional advice.
Responded
Carol Leesley
Concerns: A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.
Responded
Arthur Adley
Concerns: Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.
Responded
Rebecca Gilbank
Responded
Olive Wilmott
Concerns: An alleged assault was not effectively investigated or safeguarded, and the care home failed to meet observation requirements due to insufficient night staff for residents' needs.
Overdue
Gwendoline Clarke
Concerns: Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.
Overdue
Ahmedreza Fathi
Concerns: Healthcare complex case planning was inadequate and not updated, multi-disciplinary meetings lacked formalisation and information access, and a prior overdose was not investigated as a safeguarding opportunity.
Responded
Derrick Rose-Fowler
Concerns: A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners unwilling to name names. Critical concerns about the deceased's mental health and self-harm history were not escalated to a MASH meeting.
Overdue
Adam Rice
Concerns: There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, and a lack of understanding of welfare check protocols.
Overdue
Anne Scott
Concerns: Community care providers lacked training to correctly interpret and act upon data from health monitoring devices, and county-wide safeguarding recommendations for such training remain unconfirmed.
Overdue
Colin Williams
Concerns: A client with complex health and social needs, exacerbated by alcoholism, experienced "agency blindness" and lacked consistent support due to fragmented services, funding changes, and administrative difficulties.
Overdue
Norman Dorn
Concerns: Cornwall care homes may lack adequate or updated policies for recognising and confirming death and for resuscitation, with staff often lacking awareness and proper training.
Overdue
Irene Scholey
Concerns: No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.
Overdue
Allan Beasley
Concerns: Care home staff were unaware of the falls prevention policy, leading to inaccurate recording, delayed escalation of falls, and unreliable patient observation practices.
Pending
Jeffrey Warren
Concerns: Neither council formally reviewed the case, delaying lessons. A hazardous electric fire was left unaddressed, and social work staff inappropriately requested police for non-urgent welfare checks due to lack of training.
Overdue
Phyllis Broomhead
Concerns: Care home staff lacked training in head injury protocols and record-keeping, while safeguarding screening was insufficient. There's a systemic gap in monitoring high-risk residents when nursing care isn't deemed necessary, leaving them vulnerable.
Responded
Sidney Barnett
Concerns: The care home provided inadequate observation and general welfare for the client, and the subsequent safeguarding investigation was flawed, relying too heavily on unverified staff statements.
Overdue
Kesia Leatherbarrow
Concerns: Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team case, led to a lack of support for a high-risk young person.
Overdue
Barbara Cooke
Concerns: Severe understaffing at a care home caused patient neglect, poor infection control, and lacking external nurse communication protocols. The hospital also had no system to record safeguarding alerts or notify authorities of deaths for vulnerable patients.
Overdue
Sean Morley
Concerns: The A444 stretch lacks pedestrian/cyclist warning signs, street lighting, and protective barriers, despite regular use by vulnerable road users and a 70mph speed limit, creating a high risk of collisions.
Overdue
Derrick Plater
Concerns: There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.
Responded
Wendy Brown
Concerns: Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and lengthy application processing times, put carers under severe strain.
Responded
Christine Williamson
Concerns: Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between agencies hindered preventative measures.
Response: Telford & Wrekin Council has compiled and endorsed an action plan, with many actions already underway, building on recommendations from a Domestic Homicide Review. The implementation of this plan will …
Response: Telford & Wrekin Clinical Commissioning Group has recirculated Adult Safeguarding Policy and domestic abuse guidance to GP practices. They have also established a link with Admiral Nurses, have a dementia …
Response: West Mercia Police has circulated new guidance to all staff regarding Domestic Abuse Single Point of Contact (SPOC) processes and delivered domestic abuse training to 119 officers. They have also …
Responded
Joan Farran
Concerns: The provided text is truncated and does not clearly state the specific concerns identified by the coroner.
Overdue
Daniel Onley
Concerns: Insufficient arrangements were in place to support the patient in taking anti-convulsant medication, and there was a failure to manage associated risks.
Response: The Trust conducted internal audits, updated policies and procedures for medicine handling (including controlled drugs and drug errors), and delivered mandatory medicines management training to all staff. They have also …
Overdue
Rose Hollingworth
Concerns: The care agency failed to provide suitably trained and supervised carers, leading to errors in the care plan and inadequate monitoring of service performance for a vulnerable person.
Responded
Shona Campbell
Concerns: Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had access to ligatures, and risk assessments were not properly updated.
Pending