Care safeguarding systems
Absence of effective systems to protect people from abuse and avoidable harm, including failures in reporting suspected abuse.
3,661 items
16 sources
7 inquiries
Source spread
Where this theme appears
Care safeguarding systems has been flagged across 16 independent accountability sources:
201 inquiry recs
77 PFD reports
67 committee recs
105 CQC actions
44 HMICFRS recs
6 ICIBI recs
1 PPO rec
2 IOPC recs
1 NAO rec
4 IMB reports
23 IMB recs
1 Article 2 learning point
10 detention investigation recs
43 PHSO decisions
3072 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (201) — showing 50 strongest matches
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-(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-(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-(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-(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-(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-(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-(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
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-(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-(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-(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
LAMI-99 — Amend Working Together for police to exclusively conduct child criminal investigations.
Recommendation: The Working Together arrangements must be amended to ensure the police carry out completely, and exclusively, any criminal investigation elements in a case of suspected injury or harm to a child, including the evidential interview with a child victim. This …
Unknown
LAMI-98 — Social services must inform police immediately of child criminal offence referrals.
Recommendation: The guideline set out at paragraph 5.8 of Working Together must be strictly adhered to: whenever social services receive a referral which may constitute a criminal offence against a child, they must inform the police at the earliest opportunity.
Unknown
LAMI-97 — Ensure child crime investigation is equal to other serious crime investigations.
Recommendation: Chief constables must ensure that the investigation of crime against children is as important as the investigation of any other form of serious crime. Any suggestion that child protection policing is of a lower status than other forms of policing …
Unknown
LAMI-96 — Review police protection systems for Children Act compliance and designated inspector officer.
Recommendation: Police forces must review their systems for taking children into police protection and ensure they comply with the Children Act 1989 and Home Office guidelines. In particular, they must ensure that an independent officer of at least inspector rank acts …
Unknown
LAMI-95 — ACPO must produce and implement standards-based child protection service.
Recommendation: The Association of Chief Police Officers must produce and implement the standards-based service, as recommended by Her Majesty’s Inspectorate of Constabulary in the 1999 thematic inspection report, Child Protection.
Unknown
LAMI-94 — Require supervisory officers to actively ensure proper investigation of serious child crimes.
Recommendation: In cases of serious crime against children, supervisory officers must, from the beginning, take an active role in ensuring that a proper investigation is carried out.
Unknown
LAMI-93 — Require manager involvement from both agencies in joint child harm investigations.
Recommendation: Whenever a joint investigation by police and social services is required into possible injury or harm to a child, a manager from each agency should always be involved at the referral stage, and in any further strategy discussion.
Unknown
LAMI-92 — Ensure prompt, efficient investigation of child victim crimes to adult standards.
Recommendation: Chief constables must ensure that crimes involving a child victim are dealt with promptly and efficiently, and to the same standard as equivalent crimes against adults.
Unknown
LAMI-91 — Require child assessment before police protection, except in exceptional circumstances.
Recommendation: Save in exceptional circumstances, no child is to be taken into police protection until he or she has been seen and an assessment of his or her circumstances has been undertaken.
Unknown
LAMI-90 — Ensure child protection training for liaison staff and audit policy compliance.
Recommendation: Liaison between hospitals and community health services plays an important part in protecting children from deliberate harm. The Department of Health must ensure that those working in such liaison roles receive child protection training. Compliance with child protection policies and …
Unknown
LAMI-89 — GPs must ensure staff know local child protection agency contact procedures.
Recommendation: All GPs must devise and maintain procedures to ensure that they, and all members of their practice staff, are aware of whom to contact in the local health agencies, social services and the police in the event of child protection …
Unknown
LAMI-88 — Examine feasibility of deliberate harm training for all primary healthcare staff.
Recommendation: The Department of Health should examine the feasibility of introducing training in the recognition of deliberate harm to children as part of the professional education of all general practice staff and for all those working in primary healthcare services for …
Unknown
LAMI-87 — Ensure GPs receive regular training in deliberate harm recognition and child protection investigations.
Recommendation: The Department of Health should seek to ensure that all GPs receive training in the recognition of deliberate harm to children, and in the multi-disciplinary aspects of a child protection investigation, as part of their initial vocational training in general …
Unknown
LAMI-86 — Explore extending child patient registration to include social and developmental welfare information.
Recommendation: The Department of Health should invite the Royal College of General Practitioners to explore the feasibility of extending the process of new child patient registration to include gathering information on wider social and developmental issues likely to affect the welfare …
Unknown
LAMI-85 — Develop continuing education models for deliberate harm diagnosis and multi-disciplinary child protection investigations.
Recommendation: The Department of Health should invite the Royal College of Paediatrics and Child Health to develop models of continuing education in the diagnosis and treatment of the deliberate harm of children, and in the multi-disciplinary aspects of a child protection …
Unknown
LAMI-84 — Revalidate doctors and paediatricians in deliberate harm diagnosis and multi-disciplinary child protection investigations.
Recommendation: All designated and named doctors in child protection and all consultant paediatricians must be revalidated in the diagnosis and treatment of deliberate harm and in the multi-disciplinary aspects of a child protection investigation.
Unknown
LAMI-83 — Systematically and rigorously investigate and manage cases of deliberate harm to children.
Recommendation: The investigation and management of a case of possible deliberate harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease.
Unknown
LAMI-82 — Examine feasibility of clinical governance for children at risk of deliberate harm.
Recommendation: The Department of Health should examine the feasibility of bringing the care of children about whom there are concerns about deliberate harm within the framework of clinical governance.
Unknown
LAMI-81 — Implement systems to record, complete, and check actions for deliberate harm cases.
Recommendation: Hospital chief executives must introduce systems to ensure that actions agreed in relation to the care of a child about whom there are concerns of deliberate harm are recorded, carried through and checked for completion.
Unknown
LAMI-80 — Record all discussions, decisions, and actions in hospital notes for deliberate harm.
Recommendation: When a child for whom there are concerns about deliberate harm is admitted to hospital, a record must be made in the hospital notes of all face-to-face discussions (including medical and nursing ‘handover’) and telephone conversations relating to the care …
Unknown
LAMI-79 — Ensure all available information is reviewed during ward rounds for deliberate harm.
Recommendation: During the course of a ward round, when assessing a child about whom there are concerns about deliberate harm, the doctor conducting the ward round should ensure that all available information is reviewed and taken account of before decisions on …
Unknown
LAMI-78 — Implement single set of records for each child across health professionals.
Recommendation: Within a given location, health professionals should work from a single set of records for each child.
Unknown
LAMI-77 — Doctors must provide written statement of deliberate harm concerns to social services.
Recommendation: All doctors involved in the care of a child about whom there are concerns about possible deliberate harm must provide social services with a written statement of the nature and extent of their concerns. If misunderstandings of medical diagnosis occur, …
Unknown
LAMI-76 — Clearly identify responsible consultant for child protection aspects in deliberate harm cases.
Recommendation: When a child is admitted to hospital with concerns about deliberate harm, a clear decision must be taken as to which consultant is to be responsible for the child protection aspects of the child’s care. The identity of that consultant …
Unknown
LAMI-75 — Require senior doctor to seek carer permission for deliberate harm investigation or treatment.
Recommendation: In a case of possible deliberate harm to a child in hospital, when permission is required from the child’s carer for the investigation of such possible deliberate harm, or for the treatment of a child’s injuries, the permission must be …
Unknown
LAMI-74 — Mandate full, documented physical examination within 24 hours for suspected deliberate harm.
Recommendation: Any child admitted to hospital about whom there are concerns about deliberate harm must receive a full and fully-documented physical examination within 24 hours of their admission, except when doing so would, in the opinion of the examining doctor, compromise …
Unknown
LAMI-73 — Require inquiry and review of previous hospital admissions for suspected deliberate harm.
Recommendation: When a child is admitted to hospital and deliberate harm is suspected, the doctor or nurse admitting the child must inquire about previous admissions to hospital. In the event of a positive response, information concerning the previous admissions must be …
Unknown
LAMI-72 — Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Recommendation: No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been …
Unknown
LAMI-71 — Require documented future care plan for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. …
Unknown
LAMI-70 — Require consultant or paediatrician permission for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without the permission of either the consultant in charge of the child’s care or of a paediatrician …
Unknown
LAMI-69 — Record all discussions, including phone calls, in child deliberate harm case notes.
Recommendation: When concerns about the deliberate harm of a child have been raised, a record must be kept in the case notes of all discussions about the child, including telephone conversations. When doctors and nurses are working in circumstances in which …
Unknown
LAMI-68 — Doctors must make comprehensive, contemporaneous notes for suspected child deliberate harm.
Recommendation: When concerns about the deliberate harm of a child have been raised, doctors must ensure that comprehensive and contemporaneous notes are made of these concerns. If doctors are unable to make their own notes, they must be clear about what …
Unknown
LAMI-67 — Require recorded discussion and further opinion for differing deliberate harm diagnoses.
Recommendation: When differences of medical opinion occur in relation to the diagnosis of possible deliberate harm to a child, a recorded discussion must take place between the persons holding the different views. When the deliberate harm of a child has been …
Unknown
LAMI-66 — Ensure all deliberate harm concerns are fully addressed and documented in appraisals.
Recommendation: When a child has been examined by a doctor, and concerns about deliberate harm have been raised, no subsequent appraisal of these concerns should be considered complete until each of the concerns has been fully addressed, accounted for and documented.
Unknown
LAMI-65 — Doctors must take child's history directly for suspected harm, recording consent reasons.
Recommendation: When the deliberate harm of a child is identified as a possibility, the examining doctor should consider whether taking a history directly from the child is in that child’s best interests. When that is so, the history should be taken …
Unknown
LAMI-63 — Hospital social workers must promptly respond to suspected child harm referrals
Recommendation: Hospital social workers must always respond promptly to any referral of suspected deliberate harm to a child. They must see and talk to the child, to the child’s carer and to those responsible for the care of the child in …
Unknown
LAMI-62 — Implement single agreed guidance for hospital social workers with out-of-area children
Recommendation: Where hospital-based social work staff come into contact with children from other local authority areas, the directors of social services of their employing authorities must ensure that they work to a single set of guidance agreed by all the authorities …
Unknown
LAMI-61 — Ensure hospital social workers participate in all child safeguarding hospital meetings
Recommendation: Directors of social services must ensure that hospital social workers participate in all hospital meetings concerned with the safeguarding of children.
Unknown
PFD Reports (77) — showing 50 strongest matches
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 Camphill Village Trust): The Trust has audited medicine administration, revised policies, implemented common paperwork for risk management, and shared the coroner's concerns with operational managers. The Safeguarding Board is monitoring the issues and …
Overdue
Joan Farran
Concerns: The provided text is truncated and does not clearly state the specific concerns identified by the coroner.
Overdue
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): Telford & Wrekin Council has compiled a plan of action building upon recommendations made in the Domestic Homicide Review report, and the implementation of the action plan will be formally …
Response (Telford Wrekin Clinical Commissioning Group): The Adult Safeguarding Policy and Thresholds has been recirculated, domestic abuse leaflets and guidance has been circulated, and an education and training event for Telford & Wrekin GPs and Practice …
Response (West Mercia Police): West Mercia Police will provide a reminder regarding the requirement to complete DASH; Crime Reports and Vulnerable Adult documentation to all operational staff. The tactical equality and diversity advisor has …
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.
Response (Swindon Borough Council): Swindon Borough Council recognises complexity and potential delays in decision making are real issues. An immediate action taken is that; were services over and above the indicative budget are requested, …
Responded
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.
Response: The council believes that a pre-placement visit by a social worker would not have provided any added assurance and is not and will not be part of the assessment and …
Responded
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
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
Kesia Leatherbarrow
Concerns: Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team case, led to a lack of support for a high-risk young person.
Response (Department of Health): The Department of Health has shared the report with NHS England, who are working to develop Liaison and Diversion services in Greater Manchester. NHS England is also reshaping mental health …
Response (Home Office): The government has already made a partial change to PACE via the Criminal Justice and Courts Act to require 17 year olds to be treated as 10-16 year olds for …
Response (Pennine Care NHS Trust): Pennine Care NHS Foundation Trust has completed an investigation, requesting written clinical summaries and risk assessments when young people transfer from other mental health services. The health diversion pathway has …
Response (Crown Prosecution Service): The CPS has modified CPS training so advocates conducting youth court cases are reminded that a youth can always be remanded for their "own welfare". The Chief Crown Prosecutor for …
Overdue
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.
Response: The care home has implemented room visit charts, enhanced personal care documentation, dignity training delivered by the manager, and window checks as part of the room visit checks.
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.
Response (Rotherham Borough Council): Rotherham Metropolitan Borough Council will provide a detailed action plan regarding recommendations made under Regulation 28, outlining actions taken, actions to be achieved, and timescales to conclude any uncompleted actions.
Responded
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.
Response (Crawley Borough Council): Crawley Borough Council corrected some factual inaccuracies, and stated they will review all door entry systems by 30 September 2015 and then carry out an upgrade program to solve the …
Overdue
Isabel Richardson
Concerns: The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust system to address student problems.
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.
Overdue
Irene Scholey
Concerns: No specific concerns were detailed in the provided text, which instead referred to an external narrative conclusion.
Overdue
Robert Mansfield
Concerns: Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning notices, and readily available flotation equipment.
Overdue
Kamrul Rubel
Concerns: The gym did not enforce the use of the emergency stop cord despite providing advice, raising concerns about adherence to safety protocols for gym equipment.
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
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
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
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.
Response (Adam Rice): West Yorkshire Police has implemented measures to ensure vulnerable persons who come into contact with the Police receive the best possible care, including a full training programme for Custody Staff …
Overdue
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
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.
Response (HM Prison and Probation Service): HMP Gartree revised local contingency plans and re-issued instructions in May 2016 to ensure all staff understand that they must not delay calling an ambulance in all cases where there …
Response (East Midlands Ambulance Service NHS Trust): East Midlands Ambulance Service (EMAS) has formed a senior regional group to address issues relating to secure environments, such as prisons and secure mental health units. They also plan a …
Overdue
Gwendoline Clarke
Concerns: Staff failed to report a resident's injury and delayed escalating allegations of abuse for approximately 12 hours.
Response (Social Care): The organisation plans to re-enforce the safeguarding policy, update job descriptions, include admission process under general screening, audit care plan, re-enforce home's protocols for unwitnessed accidents, plan training and supervision …
Overdue
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
Rebecca Gilbank
Concerns: A check was missed because staff were busy with other service users, and staff lacked knowledge about how to obtain an outside telephone line to call emergency services; the coroner suggests providing sufficient staffing resources and clear guidance on obtaining an outside line.
Response (Independence Homes): The organisation has changed its telephone system so staff no longer need to dial 9 for an outside line when calling emergency services. This change was communicated to staff verbally, …
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.
Response (Sheffield City Council): Sheffield City Council has amended the automated response to safeguarding reports to include a notification that, if the person making the report is not contacted within 2 working days, they …
Responded
Arthur Adley
Concerns: Safeguarding systems in care homes were inadequate to prevent a resident who posed a risk to others from causing harm.
Response (Department of Health): The Department of Health acknowledged the concerns and forwarded the report to the Care Quality Commission (CQC), the independent regulator of health and adult social care providers in England.
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.
Response (Fairfield View Care Centre): The care centre audited all documentation regarding falls and mobility, cascaded information to staff about completing relevant documentation, and is auditing care plans and daily records. Senior staff are undertaking …
Overdue
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.
Response (Ruth Milne): Lincolnshire Community Health Services reports on actions taken following a safeguarding report, including establishing leg ulcer clinics, integrating specialist nurses, reviewing caseloads, and providing training on leg ulcer care and …
Overdue
Kevin Morgan
Concerns: There was no effective follow up by social services and the housing team, a safeguarding alert was not properly addressed, and a meeting of senior professionals was not called to consider the case; there was no Serious Incident Review after the death.
Response (Milton Keynes Safeguarding Board): The Milton Keynes Safeguarding Board will not conduct a Safeguarding Adult Review but will undertake a learning review to identify practice improvements related to concerns raised in the Regulation 28 …
Responded
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.
Response (Robert Mullis): Network Rail has installed platform-end fencing and anti-trespass panels on platforms 2, 5, and 6 and the London end of platform 1 at Ashford International Station. Equivalent fencing will be …
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
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.
Response (Care First Class UK): Care First Class UK has implemented read and sign sheets for care plans, provided a falls protocol to all staff, maintained records of nightly checks, and addressed pain management procedures; …
Response (CQC): CQC acknowledges the concerns raised regarding Cherry Lodge Care Home, details actions taken by the provider, and explains its regulatory role and monitoring of the situation, including the need for …
Responded
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.
Response (Trafford Safeguarding Board): Greater Manchester Police (GMP) now record high volume callers more accurately, and the GMP function that prioritises and allocates cases now sits within the Partnership Office. A revised policy is …
Responded
Ellie Butler
Concerns: No specific concerns were detailed in the provided text, only a reference to appended concerns.
Overdue
Janie McFadyen
Concerns: No specific concerns were detailed in the provided text.
Response (Victory Outreach): Victory Outreach Manchester has reviewed its policies and procedures, and implemented changes to comply with current regulations, including improvements to communication and reporting channels. They have also experienced a similar …
Response (Charity Commission): The Charity Commission has provided regulatory advice to Victory Outreach Manchester and requires that implemented changes are embedded. A program of diversified training is to be agreed and delivered, charges …
Responded
Barnaby Aylward
Concerns: Agencies did not collectively address the risks to a social housing tenant with serious mental illness, including heavy smoking and accumulating clutter. His care documentation also did not identify these behaviours as risks.
Response: West Yorkshire Fire and Rescue Service has agreed to a multi-agency programme of awareness training for staff from WYFRS, Together Housing and SWYFT to be delivered in June and July …
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.
Response (HM Prison and Probation Service): HMPPS introduced a new pay structure in April 2018 for the National Probation Service, including a two-year pensionable pay award and a London Allowance and Market Forces Allowance to address …
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
Archie Spriggs
Concerns: The concerns are covered within the 8 recommendations of the SCR regarding referral pathways, understanding of private law proceedings, notification processes for Section 37 reports, and engagement with multi-agency frontline staff.
Response (SSP): The Shropshire Safeguarding Partnership (SSP) acknowledges the report and states they are responsible for owning and governing delivery against the action plan related to the Serious Case Review, which was …
Overdue
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.
Response (the Secretary of State for Education): The Department for Education launched a consultation on proposals to ensure unregulated provision is used appropriately, including introducing new national standards and enforcement mechanisms, with the consultation open until April …
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.
Response (Wakefield Council): Wakefield Council acknowledges the concerns but argues that their systems have been reviewed and are robust, and that no further action is needed. They also point out that the patient …
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.
Response (Adult Social Care Health Integration and Wellbeing): The Council shared the coroner's report with the care provider and housing group, and has changed its procedure to require a full review of medication storage arrangements for residents needing …
Response (Comfort Call): Comfort Call will no longer provide care services at the scheme in question. However, they intend to reflect on practice across their Extra Care services in other locations, review their …
Overdue
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.
Response (NHS England and NHS Digital): NHS England liaised with the North West Ambulance Service (NWAS) who have since extended their cleaning service to sixteen Emergency Departments across the North West, including Tameside Hospital, to improve …
Response (UK Health Security Agency): PHE acknowledges the coroner's report and outlines its national activities coordinating the response to COVID-19 in adult social care settings, including surveillance, guidance development, and stakeholder engagement. It states that …
Response (CQC): CQC reviewed systems at The Vicarage Residential Care Home and is assured that the provider has taken action to improve and further reduce risks, which will be reviewed at the …
Response (Greater Manchester Health and Social Care Partnership): Greater Manchester Health and Social Care Partnership will present learning to the Greater Manchester Quality Board. They have established an Infection Prevention and Control Care Home Cell, are running monthly …
Response (Vicarage Care Home): The Vicarage Care Home has provided documentation training to staff, updated the documentation and recording policy, reissued relevant documentation pro formas, and updated the protocol regarding waiting times for emergency …
Responded
Roy Curtis
Concerns: Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.
Response (Milton Keynes Council): Milton Keynes Council has employed a link social worker to work with the acute mental health hospital ward to coordinate social care assessments before discharge. They have also reviewed Autism …
Responded
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.
Response (England Boxing): England Boxing had already implemented remedial actions to increase safety and awareness, including revising the Rule Book to make safeguarding responsibilities clear, introducing mandatory DBS checks, and implementing safeguarding training. …
Response (DCMS): DCMS acknowledges the concerns, describes existing safeguarding measures and engagement with sports bodies, but states they do not intend to introduce further sport-specific legislation at this time. They will work …
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.
Response (Christian Congregation of Jehovahs Witnesses): The Christian Congregation of Jehovah's Witnesses asserts that while they provide support to vulnerable adults, they do not formally bring them into their care, thus a formal policy is deemed …
Responded
Glenn Macmartin
Concerns: No specific concerns were detailed in the provided text.
Response (Wonford House Hospital): The Trust has strengthened links between community and forensic social work teams, secured funding for a Local Authority assigned social worker to join the community forensic team, and developed a …
Response (CQC): CQC describes enforcement action taken culminating in the closure of Annette's Care. It states that an internal review found no gaps or areas for improvement in CQC's processes and that …
Response (Plymouth Safeguarding Adults Partnership): The PSAP will commission a multi-agency learning review, independently facilitated, to identify multi-agency learning in terms of strengths and weaknesses related to the case. This review will involve the engagement …
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.
Response (Crosscrown Ltd): Crosscrown Ltd has implemented the CareDocs digital care management system, introduced "Understanding Challenging Behaviour and Dementia Training” and “Safeguarding Training", and enhanced the agenda for staff meetings to include behavioral …
Responded
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.
Response (Cumbria County Council): The Council has reviewed self-neglect policies, revised operational practice guidance, implemented a countywide operational Safeguarding Adults service, and is delivering training sessions; a practice learning session will be undertaken with …
Responded
Committee Recommendations (67) — showing 50 strongest matches
#24 —
Recommendation: HMCI Amanda Spielman told us it was “very un-joined up” that children who were on a child protection plan and experiencing harm could be withdrawn into home education. We share HMCI’s concerns and call on the Department to ensure that …
Gov response: 25. The Department continues to review all key statutory guidance regularly. We will consider including EHE in Working Together to Safeguard Children at the next review point.
Under Consideration
#16 —
Recommendation: The national Child Safeguarding Practice Review Panel, set up to commission reviews of serious child safeguarding cases, has consistently highlighted cases in which poor coordination between services, including insufficient joined-up leadership and a lack of appropriate and timely information-sharing around …
Gov response: 4a: PAC recommendation: • Government should set out within six months how it will ensure that learning from national reviews is built into day-to-day practise, including supporting appropriate and timely data sharing, by those working …
Accepted
#13 —
Recommendation: We asked the Department for Education what is being done to review multi-agency safeguarding partnerships to ensure they work better and to stop horrific events, such as the cases of Star Hobson and Arthur Labinjo-Hughes from recurring. The Department for …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The government is committed to strengthening local multi-agency safeguarding arrangements. Stable Homes, Built on Love: implementation strategy and consultation published in February 2023 set …
Accepted
#11 —
Recommendation: Multi-agency safeguarding partnerships started in 2019, aimed at joining up local NHS, policing, and local authority services to safeguard and promote the welfare of all children in their area.25 In May 2022, three years after they started, the Child Safeguarding …
Gov response: 3: PAC conclusion: Critical local multi-agency safeguarding partnerships are still not working well enough, which risks those vulnerable adolescents that need support and help falling through the gaps. 3: PAC recommendation: Government should set out …
Accepted
#3 —
Recommendation: Critical local multi-agency safeguarding partnerships are still not working well enough, which risks those vulnerable adolescents that need support and help falling through the gaps. While in some places multi-agency safeguarding partnerships may work well, in other places, sadly, they …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The government is committed to strengthening local multi-agency safeguarding arrangements. Stable Homes, Built on Love: implementation strategy and consultation published in February 2023 set …
Accepted
#19 — Home Office contracts for migrant accommodation lack specified penalties for safeguarding failures.
Recommendation: The Home Office told us that health and welfare of migrants was “baked into” the way that it runs the sites and the contracts with suppliers. It said there were clear key performance indicators (KPIs) on accommodation being safe and …
Gov response: 3.12 The government agrees with the Committee’s recommendation. Target implementation date: October 2024 for the previous quarter, continuing quarterly. 3.13 Asylum, Accommodation Support Contracts (AASC) provide a mechanism for application of service credits if provider …
Accepted
#18 — Home Office still developing specific safety measures for residents in large accommodation sites.
Recommendation: The Home Office is responsible for the safety and wellbeing of people in its care, whether they are claiming asylum or pending relocation. But the National Audit Office reported that, in January 2024, the Home Office was still developing specific …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 All individuals are able to raise concerns with the department whilst their case is under consideration and where safeguarding concerns are raised, these are …
Accepted
#67 — Urgent need to implement IICSA recommendations as mandatory reporting is limited.
Recommendation: There is an urgent need to take forward the recommendations of the Independent Inquiry into Child Sexual Abuse. The introduction of the mandatory reporting duty is an important step forward, but it is limited in scope to instances of a …
Gov response: The Mandatory Reporting Duty measure (outlined in the Crime and Policing Bill) is currently progressing through Parliament and will come into force one year after the Bill receives Royal Assent. As part of the implementation, …
Accepted
#65 — Put in place a national strategy to reduce the incidence of child neglect.
Recommendation: The Department for Education must put in place a national neglect strategy to set out how it will reduce the incidence of neglect. (Recommendation, Paragraph 161) 92
Gov response: Tackling child neglect is a key part of the broader children’s social care reform programme and is embedded in the legislative measures outlined in the Children’s Wellbeing and Schools Bill. The introduction of Family Help …
Accepted
#64 — Rising child neglect linked to poverty lacks clear DfE strategy and social care response.
Recommendation: Neglect is sadly on the rise in England and is clearly linked to poverty and poor parental mental health. The Department for Education does not appear to have a clear strategy for addressing neglect and there are concerns that the …
Gov response: Tackling child neglect is a key part of the broader children’s social care reform programme and is embedded in the legislative measures outlined in the Children’s Wellbeing and Schools Bill. The introduction of Family Help …
Accepted
#62 — Establish clear processes for reviewing and escalating multi-agency child safeguarding disagreements.
Recommendation: Multi-agency working is crucial in child safeguarding processes. Where there is disagreement between children’s social care and other agencies such as health, police and education on a safeguarding matter, there must be clear processes in place to review and escalate …
Gov response: Clear escalation and accountability processes are essential in multi-agency safeguarding. Working Together to Safeguard Children 2023 sets out that independent scrutineers play a key role in resolving disagreements between agencies, ensuring effective collaboration, and providing …
Accepted
#46 — Serious recruitment and retention problems in children's social care workforce require wholesale review.
Recommendation: There is a serious problem with recruitment and retention in the social care workforce. High turnover and overstretched staff are exacerbating the instability experienced by children in care and increase the risk of 89 safeguarding concerns being overlooked. The Department …
Gov response: We recognise the critical importance of the children’s social care workforce and are committed to improving recruitment, retention and training across the sector. While pay and staffing remain the responsibility of local authorities and providers, …
Partially Accepted
#1 — Children’s social care problems persist and worsen without comprehensive reform following the Independent Review.
Recommendation: Evidence given to the Committee during our inquiry indicates that many of the problems highlighted by the Independent Review of Children’s Social Care in 2022 persist, and in a significant number of cases have worsened since the Review. Increases in …
Gov response: The Committee’s report rightly highlighted the rising need for children’s social care over the last decade, the spiralling costs to local authorities and poor experiences and outcomes for some, but not all, children. The Government …
Not Addressed
#24 — A balance between FGM prevention and prosecution is crucial, rejecting cultural sensitivities.
Recommendation: While some FGM survivors and campaigners believe more needs to be done to secure convictions against perpetrators of FGM, others believe a strong focus on criminalisation can hinder efforts to engage with communities to prevent FGM and support FGM survivors. …
Gov response: The Government’s approach to tackling FGM is focused on preventing these crimes from happening, supporting and protecting survivors and those at risk, and bringing perpetrators to justice. To do this, prevention and prosecution must be …
Accepted
#13 — Ofsted faces significant delays registering supported accommodation providers, impacting the use of illegal provision.
Recommendation: The Department described the delays in Ofsted registering providers, and how this impacted the use of illegal provision. Changes to the law requiring the registration of those providing supported accommodation for 16 and 17-year-olds, strengthening oversight, led to a significant …
Gov response: 2. PAC conclusion: It is unacceptable that children are placed in illegal settings that are not inspected, increasing safety risks and offering no assurance over the quality of care.
Response Pending
#11 — Lack of oversight leaves children in illegal unregistered homes at significant risk.
Recommendation: Ofsted cannot routinely inspect unregistered homes and local authorities are not obliged to inform Ofsted when they place children in unregistered care, even though it is illegal for providers to operate such homes.22 In such cases there are no formal …
Gov response: 2. PAC conclusion: It is unacceptable that children are placed in illegal settings that are not inspected, increasing safety risks and offering no assurance over the quality of care.
Response Pending
#2 — Reaffirm commitment to reducing children in unregistered homes to zero by 2027 and detail specific actions.
Recommendation: It is unacceptable that children are placed in illegal settings that are not inspected, increasing safety risks and offering no assurance over the quality of care. Over the last five years, local authorities have reported placing more and more children …
Gov response: The government disagrees with the Committee’s recommendation. The department agrees with the Committee’s conclusion and is clear that placing children in unregistered settings is both unacceptable and unlawful. It has, however, not made a commitment …
Not Accepted
#32 — Improve age dispute identification in asylum accommodation, ensuring staff training and compliance monitoring
Recommendation: The Home Office should review and make improvements to arrangements for identifying and responding to age dispute cases in adult asylum accommodation and ensure that there is clear guidance for accommodation providers. To protect the welfare of children in the …
Gov response: The Home Office has made significant progress with regards to protecting the welfare of UASC. In line with the direction of the court, the Home Office closed all remaining emergency UASC hotels by January 2024 …
Accepted
#31 — Significant failings in age assessment lead to children in adult asylum accommodation
Recommendation: There are significant failings in the current processes for making initial decisions about age and unreliable decisions are still leading to children being incorrectly placed in adult accommodation. We do not have confidence that the arrangements for accommodation providers to …
Gov response: The Home Office has made significant progress with regards to protecting the welfare of UASC. In line with the direction of the court, the Home Office closed all remaining emergency UASC hotels by January 2024 …
Not Addressed
#30 — Strengthen safeguarding framework, training, and oversight for asylum accommodation providers
Recommendation: We recommend that the Home Office strengthens its approach to safeguarding by: a. Ensuring that there is a robust framework for overseeing and auditing how safeguarding policies and processes are applied on the ground by contractors and subcontractors; b. Ensuring …
Gov response: The Home Office recognises the critical importance of safeguarding within the asylum system and remains committed to continuous improvement in this area. While statutory safeguarding duties rest with other agencies, the Home Office plays an …
Partially Accepted
#29 — Significant safeguarding failings persist in asylum accommodation with inadequate oversight
Recommendation: We are deeply concerned by the volume of evidence indicating significant safeguarding failings in asylum accommodation. While there are evidently pockets of localised good practice, the response to safeguarding concerns is inconsistent and often inadequate, leaving vulnerable people at risk …
Gov response: The Home Office recognises the critical importance of safeguarding within the asylum system and remains committed to continuous improvement in this area. While statutory safeguarding duties rest with other agencies, the Home Office plays an …
Partially Accepted
#20 —
Recommendation: The Department must revisit and revise key statutory guidance such as Working Together to Safeguard Children as soon as possible, so that they explicitly contain EHE within their scope, and contain clear and consistent messages for families, local authorities and …
Gov response: 25. The Department continues to review all key statutory guidance regularly. We will consider including EHE in Working Together to Safeguard Children at the next review point.
Under Consideration
#3 —
Recommendation: The Committee heard from home educators that home-educated children are not ‘invisible’, and that safeguarding has failed children who were already known to local authorities. However, the relevant authorities cannot begin to reach any children who may be at risk …
Gov response: 9. The Government remains committed to a form of local authority administered statutory registration to identify children not in school. This would likely encompass children who are electively home educated and those who are missing …
Under Consideration
#12 —
Recommendation: The three statutory partners (police, health, and local authorities) of multi-agency safeguarding partnerships’ have a shared and equal duty to protect children and young people. We asked who in the system has responsibility for children who fall through the gaps …
Gov response: 3.2 The government is committed to strengthening local multi-agency safeguarding arrangements. Stable Homes, Built on Love: implementation strategy and consultation published in February 2023 set out commitments to ensure that all agencies play a full …
Not Addressed
#4 —
Recommendation: It is not clear how lessons and learning from changing threats, serious case reviews and child safeguarding review panels are embedded in day-to-day practice. Time and again reviews into child deaths highlight poor coordination between services, including insufficient joined-up leadership …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 ‘Stable Homes, Built on Love’, published by the Department for Education in February 2023 sets out plans to transform children’s social care, ensuring the …
Accepted
#31 — Encourage FGM Protection Order use by increasing awareness among children's social services.
Recommendation: The Ministry of Justice should encourage the use of FGMPOs by working with the Department for Education to increase awareness among children’s social services of FGMPOs and the criteria needed to obtain one. We welcome the MoJ’s plans to ensure …
Gov response: Response: FGM Protection Orders (FGMPOs) are a vital tool to support the prevention of FGM and the protection of victims. Data on FGM Protection Orders is published quarterly by the Ministry of Justice, as part …
Accepted
#30 — FGM Protection Order usage remains low despite their effectiveness and high risk of FGM.
Recommendation: FGM Protection Orders (FGMPOs) can be an effective way of supporting FGM survivors and preventing FGM. Although the data on FGM protection orders is incomplete, the number of FGMPOs appears low, especially when compared to estimations of the number of …
Gov response: Response: FGM Protection Orders (FGMPOs) are a vital tool to support the prevention of FGM and the protection of victims. Data on FGM Protection Orders is published quarterly by the Ministry of Justice, as part …
Accepted
#27 — Ensure professionals receive adequate training to confidently ask FGM questions and increase referrals.
Recommendation: The Government should ensure that professionals, such as teachers and healthcare professionals, are adequately trained to feel confident to ask questions around female genital mutilation in order to increase the number 45 of successful safeguarding referrals for FGM. This training …
Gov response: Response: It is vital that all professionals with statutory safeguarding responsibilities such as the police, teachers and healthcare professionals have the right training and framework to identify victims and perpetrators of FGM and manage them …
Accepted
#26 — Low FGM safeguarding referrals due to professionals' lack of confidence and training.
Recommendation: Evidence suggests that safeguarding referrals are low. Professionals often lack the confidence to ask questions and get the necessary information from the families of the women and girls affected. Some professionals may also be reluctant to ask questions due to …
Gov response: Response: It is vital that all professionals with statutory safeguarding responsibilities such as the police, teachers and healthcare professionals have the right training and framework to identify victims and perpetrators of FGM and manage them …
Accepted
#25 —
Recommendation: The Department must clarify and strengthen the expectation in its 2019 guidance that local authorities make contact with parents on at least an annual basis, so that local authorities have the ability to see a child in person (at a …
Gov response: 28. The Department will review its 2019 EHE guidance for local authorities and parents in due course, taking account of relevant developments that result from the impending judicial review between Portsmouth City Council and an …
Under Consideration
#15 —
Recommendation: The SEND Review must address the need for consistent and sufficient support for children with SEND, no matter how they are educated. Access to Education, Health and Care Plans and the support they offer should not depend on being on …
Gov response: 21. The SEND Review is looking at ways to ensure the SEND system is consistent, high quality and integrated across education, health and care to improve early support for children and young people with EHC …
Under Consideration
#13 —
Recommendation: In light of the evidence we heard on children with SEND, the Department must reconsider the potential for creating an independent, neutral role, allocated to every parent or carer with a child when a request is made for a needs …
Gov response: 20. The SEND system already provides mechanisms for ensuring that families have access to support. Local authorities are bound by statute (by section 19 of the Children and Families Act 2014) to consider the views, …
Under Consideration
#12 —
Recommendation: Many children with SEND may be happiest educated at home, but this should absolutely not be a choice that parents are forced to make for lack of the right support. We accept that what begins as a negative choice can …
Gov response: 20. The SEND system already provides mechanisms for ensuring that families have access to support. Local authorities are bound by statute (by section 19 of the Children and Families Act 2014) to consider the views, …
Under Consideration
#11 —
Recommendation: Some children in those illegal schools prosecuted so far have been nominally home educated, with families misled by providers. Without the consistent and robust data on children outside school that a register could provide, we cannot know the true impact …
Gov response: 9. The Government remains committed to a form of local authority administered statutory registration to identify children not in school. This would likely encompass children who are electively home educated and those who are missing …
Under Consideration
#10 —
Recommendation: We were told government’s approach is to meet the need of many young people through focusing on individual programmes and focusing their join up on those who have complex and overlapping needs.22 The NAO found that while departments work together …
Gov response: 2.5 There is a reasoned basis for not giving any single department leadership responsibility for the needs all adolescents at risk (or indeed any age group at risk). Single needs are best met, by and …
Not Addressed
#20 —
Recommendation: The Government must introduce a nationally funded and regulated intermediary service to ensure that all adoptees and birth relatives have access to skilled, trauma-informed professionals who can support them in navigating contact, reunion, or information-sharing processes safely and sensitively. As …
Response Pending
#66 — Integrate neglect reduction measures and parental support into Child Poverty Strategy with a broader approach.
Recommendation: The Department should ensure that measures to reduce neglect and support parents with poor mental health and drug and alcohol addictions are considered as part of its Child Poverty Strategy and recognise that poverty is not the only circumstance in …
Gov response: We recognise that deprivation is a contributory causal factor in child abuse and neglect, and a growing body of research is strengthening the evidence of this relationship, including poverty being closely interconnected with wider factors …
Under Consideration
#61 — Child protection reforms welcomed, requiring careful monitoring and better data on abuse prevalence.
Recommendation: The Department for Education’s reforms to child protection through the Children’s Wellbeing and Schools Bill are welcome and go some way towards alleviating many of the concerns we have heard in this inquiry. There will be a need for careful …
Gov response: The Department is collaborating with the Office for National Statistics (ONS) to develop the Safety During Childhood survey, which will gather insights from children and young people on safety and wellbeing, including experiences of violence …
Accepted
#13 — Unsustainable EHC plan levels highlight insufficient early support and parental distrust
Recommendation: Current levels of EHC plans are unsustainable; however, the solution to this cannot be to remove the statutory entitlements from a system which lacks accountability in many other areas and in which parents already have so little trust and confidence. …
Gov response: Early. Children should receive the support they need as soon as possible. This will start to break the cycle of needs going unmet and getting worse, instead intervening upstream, earlier in children’s lives when this …
Accepted
#11 —
Recommendation: The Ministry of Justice, Youth Custody Service, HMPPS and MTC failed in their management and oversight of Rainsbrook STC, and the evidence suggests that, in varying degrees, that failure was not limited to one body. We are deeply concerned that …
No Published Response
#1 —
Recommendation: The litany of inaction and what one inspector called “utter incompetence” at Rainsbrook year after year provides a cautionary tale of how badly an arms-length relationship between the Ministry of Justice as a client and MTC as the company hired …
No Published Response
#19 —
Recommendation: Although we were pleased to see that Keeping Children Safe in Education was updated during the inquiry, we heard that key guidance documents on safeguarding did not recognise EHE. It is therefore hardly surprising that that local authorities and others …
Gov response: 25. The Department continues to review all key statutory guidance regularly. We will consider including EHE in Working Together to Safeguard Children at the next review point.
Under Consideration
#18 —
Recommendation: When the Department responds to the 2019 consultation, it must clearly set out the expectations on LAs, other parts of the public sector (including health and social care) and parents with regards to EHE. It should supply case study examples …
Gov response: 22. EHE expectations on local authorities, other parts of the sector and parents was not part of the scope of the Children Not In School consultation and as such would not be included in the …
Under Consideration
#17 —
Recommendation: Without a clearer definition of what a ‘suitable’ education is and what the threshold might be for intervention, local authorities have to rely on their safeguarding powers. We understand that, where powers are seen to be used inappropriately, there is …
Gov response: 22. EHE expectations on local authorities, other parts of the sector and parents was not part of the scope of the Children Not In School consultation and as such would not be included in the …
Under Consideration
#16 —
Recommendation: Local authorities told us that they lack sufficient powers. It seems to us that the grey area in the Departmental guidance—where there is no legal duty for parents to respond to enquiries about EHE, but the local authority is entitled …
Gov response: 22. EHE expectations on local authorities, other parts of the sector and parents was not part of the scope of the Children Not In School consultation and as such would not be included in the …
Under Consideration
#9 —
Recommendation: There is clearly a distinction between those families who make a free choice to EHE, and those for whom it is not truly ‘elective.’ We understand that many home educators do not see off-rolling, exclusion or illegal schools as a …
Gov response: 9. The Department remains committed to a form of local authority administered statutory registration to identify children not in school. This would likely encompass children who are electively home educated and those who are missing …
Under Consideration
#4 —
Recommendation: The Committee’s view remains that a statutory register, serving to more consistently identify children outside of school, is absolutely necessary. This would aim not to remove freedoms from those who are providing an effective education for their families, but to …
Gov response: 9. The Government remains committed to a form of local authority administered statutory registration to identify children not in school. This would likely encompass children who are electively home educated and those who are missing …
Under Consideration
#15 —
Recommendation: The Department for Education explained that the care system was originally set up to address issues that originate from within the home and was not designed to address ‘extra- familial’ harms that take place outside the home.37 It said that …
Gov response: 4b: PAC recommendation: • The Department for Education, in its response to the Care Review should set out how the revised care system will more effectively address the risks to adolescents posed by extra-familial threats. …
Accepted
#1 —
Recommendation: On the basis of a report by the Comptroller and Auditor General, in November 2022 we took evidence from the Department for Education, the Department for Levelling Up, Housing and Communities, the Home Office and the Ministry of Justice about …
Gov response: Based on a report by the National Audit Office, the Committee took evidence on 21 November 2022 from the Department for Education, the Department for Levelling Up, Housing and Communities, the Home Office and the …
Not Addressed
#36 — Monitor and mitigate safeguarding concerns within Ukrainian schemes and conduct a comprehensive review.
Recommendation: We heard worrying evidence of safeguarding risks to vulnerable adults and children where UK sponsors and Ukrainians in the Homes for Ukraine scheme have self- matched via the internet and social media. We welcome safeguarding guidance to local authorities published …
Gov response: In relation to the recommendation at paragraph 221, we carry out mandatory security checks on all adults prior to issuing a visa for each application, to keep people safe in the UK, and protect people …
Not Addressed
CQC Inspection Actions (105) — showing 50 strongest matches
Continuity Healthcare Services Private Limited
The provider did not ensure systems and processes were in place to prevent people from abuse or to investigate immediately on becoming aware of an allegation of abuse.
Must Do
Ave Maria Care (Wolverhampton)
The provider did not mitigates risks to keep people safe from abuse
Must Do
Ash Court Care Centre - Camden
The registered person had not ensured that systems and processes had been established and operated effectively to prevent abuse of service users. Regulation 13 (1) (2) (3)
Must Do
Valewood House Nursing Home
People were not safeguarded against the risk of abuse because the manager had not taken reasonable steps to identify the possibility of abuse and prevent it before it occurred, or responded appropriately to any allegation of abuse.
Must Do
Haisthorpe House
The provider must ensure people who used services are safeguarded against the risks of abuse by taking reasonable steps to identify the possibility of abuse before it occurred and by responding appropriately to allegations of abuse.
Must Do
Cranmore
The provider must protect people from abuse and improper treatment.
Must Do
Benthorn Lodge
The registered person had not made suitable arrangements to ensure service users were effectively safeguarded against the risk of abuse and harm.
Must Do
Yanah Care
The provider must ensure effective systems and processes are in place to protect people from abuse and improper treatment.
Must Do
Wrottesley House
The provider must ensure they have robust safeguarding systems in place to protect people from potential harm.
Must Do
Willow Court
The provider failed to ensure systems and processes safeguarded people from the risk of abuse.
Must Do
The Hollies Care Home
The registered person had not made suitable arrangements to ensure that people were safeguarded against abuse.
Must Do
TerraBlu Homecare
The failure to protect people from abuse and improper treatment was a breach of Regulation 13 (1)(2)
Must Do
Stickley Lane
Regulation 13 HSCA RA Regulations 2014 Safeguarding service users from abuse and improper treatment
Must Do
Stewton House Nursing Home
The provider must ensure that people are safeguarded from abuse and improper treatment.
Must Do
Orchid House
The provider was unaware of what constitutes a safeguarding concern and had failed to notify CQC or the local safeguarding team of allegations of potential abuse.
Must Do
Multicare Services - Maylands Building
The provider had not always identified and effectively investigated safeguarding concerns to people.
Must Do
Ivydene Care Home
Systems to protect people from allegations of or actual abuse were not always followed. Regulation 13 (3).
Must Do
Heritage Healthcare-Middlesbrough
The provider must ensure service users are safeguarded from abuse and improper treatment, including raising safeguarding alerts and ensuring staff understanding and training in safeguarding.
Must Do
East Cosham House
There was a failure to safeguard service users from abuse and improper treatment. Records showed that that where incidents had occurred between people these had not been reported to the local safeguarding team. It was also unclear how the records …
Must Do
East Cosham House
There was a failure to notify CQC of any abuse or allegation of abuse in relation to a service user.
Must Do
Church Road
The provider must ensure service users are protected from abuse and improper treatment.
Must Do
Charmes Care
The registered persons failed to protect people from abuse and improper treatment and to have effective systems and processes in place to prevent abuse of people
Must Do
Chandos Lodge Nursing Home
We recommend the service review their approach to ensure safeguarding concerns are identified and managed promptly, using local safeguarding procedures whenever necessary, and that investigations are thoroughly evidenced.
Should Do
Ave Maria Care (Edgbaston)
The provider's safeguarding procedures were not effective and safeguarding concerns had not been consistently reported to the relevant agencies.
Must Do
Ashington Gardens
Regulation 13 HSCA RA Regulations 2014 Safeguarding service users from abuse and improper treatment
Must Do
Woodlands
Effective systems were not fully in place to protect people from the risk of abuse.
Must Do
Winterton House
People were not always protected from abuse and improper treatment. Systems and processes were not established and operated effectively to prevent abuse of service users. People were deprived of their liberty for the purpose of receiving care or treatment without …
Must Do
Walnut Villa
People were not protected from abuse because staff did not have the skills to recognise abuse or to safeguard them from this.
Must Do
Valewood House Nursing Home
The provider must ensure people are safeguarded against the risk of abuse by taking reasonable steps to identify the possibility of abuse and prevent it before it occurred, and by responding appropriately to any allegation of abuse.
Must Do
St Paul's Lodge
The registered person must protect service users from abuse or improper treatment by establishing and operating effective systems and processes to prevent abuse of service users.
Must Do
St Gabriel's House - Apartments
The provider must have systems and processes in place to effectively prevent people being at risk of abuse and investigate evidence of abuse.
Must Do
Specialist Medical Transport - North
The service must implement effective processes to safeguard patients from the risk of improper treatment and/or abuse.
Must Do
Serenity House
The provider failed to ensure robust safeguards were in place to protect people from abuse, and the undue deprivation of people's legal and human rights.
Must Do
Reside at Southwood
People had not been protected from abuse and improper treatment and the service had not followed the requirements of the Deprivation of Liberty Safeguards.
Must Do
Redcot Lodge Residential Care Home
The provider must protect people from abuse and improper treatment.
Must Do
Precious Nursing & Residential Home
The provider must ensure that systems and processes are operated effectively to safeguard people from the risk of abuse.
Must Do
Oaklands Care Home
The provider must ensure staff have awareness and recognition of potential abuse and neglect in the home.
Must Do
Leopold Muller Home
Systems in place to safeguard people were not effectively being used so placed them at risk of potential abuse and restrictive practices. This was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations …
Must Do
Kingsley Nursing Home
The registered manager and provider failed to 1. report safeguarding concerns or have effective systems to investigate allegations. 13 (2 & 3)
Must Do
Kingsleigh Residential
The provider had failed to ensure people were protected from abuse and neglect.
Must Do
Haisthorpe House
People who used the service were not safeguarded against the risks of abuse because the provider had not taken reasonable steps to identify the possibility of abuse before it occurred and had not responded appropriately to allegations of abuse.
Must Do
Grosvenor Hall
The provider failed to establish and operate systems and processes effectively to prevent abuse of service users and they failed to investigate and report any allegations of abuse
Must Do
Gledhow Lodge
Systems and processes around safeguarding vulnerable adults were not robust.
Must Do
Fairglen Residential Home
The provider must operate an effective safeguarding system that reports and investigates concerns.
Must Do
Elsinor Residential Home
Comply with Regulation 13 (Safeguarding service users from abuse and improper treatment)
Must Do
Eleanor House
The provider must ensure all episodes of challenging and aggressive behaviour were reported and investigated to ensure lessons could be learnt and action taken to reduce or prevent future incidents taking place.
Must Do
Dr French Memorial Home Limited
Safeguarding service users from abuse and improper treatment
Must Do
Chatting Independently Limited - Rectory Drive
People who use the service were not protected against the risk of abuse as staff did not respond appropriately to allegations of abuse.
Must Do
Chatting Independently Limited - Orchard View
The provider must ensure people who use the service are protected against the risk of abuse.
Must Do
Bourne House
systems and processes were not established and operated effectively to prevent the risk of abuse or ensure effective investigation of allegation of abuse.
Must Do
HMICFRS Recommendations (44)
PEEL 2023-25 CoC Recommendations: West Midlands Police
Cause of concern: The force needs to make sure that its multi-agency risk assessment conferences work effectively to keep vulnerable people safe. Recommendation: Immediately, West Midlands Police should review the backlog of cases waiting to be discussed at multi-agency risk …
Recommendation
PEEL 2018-19 CoC Recommendations: Greater Manchester Police
Cause of concern: Greater Manchester Police is failing to respond appropriately to some people who are vulnerable and at risk. This means that it is missing some opportunities to safeguard victims and secure evidence at the scene and victims are …
Recommendation
PEEL 2021-22 CoC Recommendations: Greater Manchester Police
Cause of concern: Greater Manchester Police is failing to respond appropriately to some people who are vulnerable and at risk. This means that it is missing some opportunities to safeguard victims and secure evidence at the scene. This enduring service …
Recommendation
PEEL 2021-22 CoC Recommendations: Greater Manchester Police
Cause of concern: Greater Manchester Police is failing to respond appropriately to some people who are vulnerable and at risk. This means that it is missing some opportunities to safeguard victims and secure evidence at the scene. This enduring service …
Recommendation
PEEL 2021-22 CoC Recommendations: Greater Manchester Police
Cause of concern: Greater Manchester Police is failing to respond appropriately to some people who are vulnerable and at risk. This means that it is missing some opportunities to safeguard victims and secure evidence at the scene. This enduring service …
Recommendation
PEEL 2021-22 CoC Recommendations: Greater Manchester Police
Cause of concern: Greater Manchester Police is failing to respond appropriately to some people who are vulnerable and at risk. This means that it is missing some opportunities to safeguard victims and secure evidence at the scene. This enduring service …
Recommendation
PEEL 2018-19 CoC Recommendations: Cleveland Police
Cause of concern: Cleveland Police is failing to respond appropriately to vulnerable people, including children. It is missing opportunities to safeguard them and is exposing them to risk. Recommendation: The force must take immediate action to ensure that: • it …
Recommendation
PEEL 2021-22 CoC Recommendations: Wiltshire Police
Cause of concern: The force does not protect vulnerable people from harm to an acceptable standard. Recommendation: Wiltshire Police should, within three months, make sure that:- domestic abuse, stalking and harassment (DASH) risk assessments are effectively supervised, quality assured and …
Recommendation
PEEL 2023-25 CoC Recommendations: West Midlands Police
Cause of concern: The force needs to make sure that its multi-agency risk assessment conferences work effectively to keep vulnerable people safe. Recommendation: Within six months, West Midlands Police should make sure that multi-agency risk assessment conferences have the right …
Recommendation
PEEL 2023-25 CoC Recommendations: West Midlands Police
Cause of concern: The force needs to make sure that its multi-agency risk assessment conferences work effectively to keep vulnerable people safe. Recommendation: Within six months, West Midlands Police should make sure it carries out proportionate, thorough and timely investigations …
Recommendation
PEEL 2023-25 CoC Recommendations: West Midlands Police
Cause of concern: The force needs to make sure it carries out effective investigations which lead to satisfactory results for victims. Recommendation: Within six months, West Midlands Police should introduce a multi-agency risk assessment conference structure that can manage current …
Recommendation
PEEL 2023-25 CoC Recommendations: West Midlands Police
Cause of concern: The force doesn’t manage the risk posed by online child abuse offenders effectively. Recommendation: Immediately, West Midlands Police should make sure that it supports the online child sexual exploitation and digital forensic unit teams’ well-being.
Recommendation
PEEL 2023-25 CoC Recommendations: West Midlands Police
Cause of concern: The force doesn’t manage the risk posed by online child abuse offenders effectively. Recommendation: Immediately, West Midlands Police should make sure that it implements an effective management framework so it can make fully informed decisions about the …
Recommendation
PEEL 2023-25 CoC Recommendations: West Midlands Police
Cause of concern: The force doesn’t manage the risk posed by online child abuse offenders effectively. Recommendation: Immediately, West Midlands Police should make sure that it assesses the demand faced by the digital forensic unit and mitigates the effects of …
Recommendation
PEEL 2023-25 CoC Recommendations: Thames Valley Police
Cause of concern: Thames Valley Police needs to improve its performance in the multi-agency safeguarding hubs to better protect vulnerable people. Recommendation: Within six months, Thames Valley Police should have sustainable safeguarding systems and processes, with sufficient trained personnel in …
Recommendation
PEEL 2023-25 CoC Recommendations: Metropolitan Police Service
Cause of concern: The force doesn’t manage the risk posed by online child abuse offenders effectively Recommendation: The Metropolitan Police Service should immediately review its operating model for online child sexual abuse and exploitation (OCSAE) to make sure it has …
Recommendation
PEEL 2018-19 CoC Recommendations: Cleveland Police
Cause of concern: Cleveland Police is failing to respond appropriately to vulnerable people, including children. It is missing opportunities to safeguard them and is exposing them to risk. Recommendation: The force must take immediate action to ensure that: • there …
Recommendation
PEEL 2018-19 CoC Recommendations: Cleveland Police
Cause of concern: Cleveland Police is failing to respond appropriately to vulnerable people, including children. It is missing opportunities to safeguard them and is exposing them to risk. Recommendation: The force must take immediate action to ensure that: • there …
Recommendation
PEEL 2023-25 CoC Recommendations: Thames Valley Police
Cause of concern: Thames Valley Police needs to improve its performance in the multi-agency safeguarding hubs to better protect vulnerable people. Recommendation: Within six months, Thames Valley Police should:- have reviewed its training arrangements to make sure that all officers …
Recommendation
PEEL 2018-19 CoC Recommendations: Northumbria Police
Cause of concern: The force’s ability to assess vulnerability when victims first make contact, and the timeliness of the response they receive, are causes of concern. Northumbria Police needs to be certain that there are officers available to respond to …
Recommendation
PEEL 2018-19 CoC Recommendations: Greater Manchester Police
Cause of concern: Greater Manchester Police is failing to respond appropriately to some people who are vulnerable and at risk. This means that it is missing some opportunities to safeguard victims and secure evidence at the scene and victims are …
Recommendation
PEEL 2021-22 CoC Recommendations: Gloucestershire Constabulary
Cause of concern: The inconsistent application of an effective THRIVE (threat, harm, risk, investigation, vulnerability and engagement) risk assessment by call handlers, accompanied by the absence of victim needs assessments and the limited extent to which repeat victims are identified …
Recommendation
PEEL 2018-19 CoC Recommendations: Dyfed-Powys Police
Cause of concern: It is a cause of concern to HMICFRS that Dyfed-Powys Police is failing to risk assess all incidents of domestic abuse. This means that opportunities to intervene and take appropriate action at the earliest opportunity are being …
Recommendation
PEEL 2021-22 CoC Recommendations: Wiltshire Police
Cause of concern: The force is failing to understand and promptly identify vulnerability at the first point of contact. Recommendation: Wiltshire Police should, within three months:- improve the process of risk assessing callers to identify those that are vulnerable or …
Recommendation
PEEL 2018-19 CoC Recommendations: Sussex Police
Cause of concern: Sussex Police is failing to manage risk effectively. In the force control room, some vulnerable victims are left without police attendance for considerable periods of time. Some victims may not be getting through to the police at …
Recommendation
PEEL 2021-22 CoC Recommendations: Staffordshire Police
Cause of concern: The force needs to improve how it identifies and assesses vulnerability at first point of contact. Recommendation: Within three months, Staffordshire Police should make sure that vulnerable and repeat callers are routinely identified, as are other people …
Recommendation
PEEL 2021-22 CoC Recommendations: Staffordshire Police
Cause of concern: The force needs to improve how it identifies and assesses vulnerability at first point of contact. Recommendation: Within three months, Staffordshire Police should make sure that call handlers use and correctly record structured initial triage and risk …
Recommendation
PEEL 2018-19 CoC Recommendations: Northamptonshire Police
Cause of concern: The force can’t manage current demand effectively. It doesn’t have enough capacity or capability to investigate crime as effectively as it should. This is affecting the service too often. Northamptonshire Police is failing to respond appropriately to …
Recommendation
PEEL 2023-25 CoC Recommendations: Metropolitan Police Service
Cause of concern: The force isn’t safely managing risks posed by registered sex offenders in the community Recommendation: The Metropolitan Police Service should immediately review its operating model for the Jigsaw teams, who are responsible for the day-to-day management of …
Recommendation
PEEL 2023-25 CoC Recommendations: Metropolitan Police Service
Cause of concern: The force isn’t safely managing risks posed by registered sex offenders in the community Recommendation: The Metropolitan Police Service should immediately record and monitor the number of announced visits to registered sex offenders to make sure they …
Recommendation
PEEL 2023-25 CoC Recommendations: Lincolnshire Police
Cause of concern: The force needs to make sure that it has the capacity and capability to manage the risks posed to the public by registered sex offenders. Recommendation: Within six months from the date of publication of this letter, …
Recommendation
PEEL 2021-22 CoC Recommendations: Gloucestershire Constabulary
Cause of concern: Gloucestershire Constabulary is unable to manage current demand effectively. It doesn’t have enough capacity or capability to respond to calls effectively, or to investigate crime as well as it should. Too often, this is affecting the service …
Recommendation
PEEL 2021-22 CoC Recommendations: Gloucestershire Constabulary
Cause of concern: The inconsistent application of an effective THRIVE (threat, harm, risk, investigation, vulnerability and engagement) risk assessment by call handlers, accompanied by the absence of victim needs assessments and the limited extent to which repeat victims are identified …
Recommendation
PEEL 2021-22 CoC Recommendations: Gloucestershire Constabulary
Cause of concern: The inconsistent application of an effective THRIVE (threat, harm, risk, investigation, vulnerability and engagement) risk assessment by call handlers, accompanied by the absence of victim needs assessments and the limited extent to which repeat victims are identified …
Recommendation
PEEL 2018-19 CoC Recommendations: Cleveland Police
Cause of concern: Cleveland Police is failing to respond appropriately to vulnerable people, including children. It is missing opportunities to safeguard them and is exposing them to risk. Recommendation: The force must take immediate action to ensure that: • it …
Recommendation
PEEL 2021-22 CoC Recommendations: Wiltshire Police
Cause of concern: The force does not protect vulnerable people from harm to an acceptable standard. Recommendation: Wiltshire Police should, within three months, make sure that:- opportunities to engage with and get feedback from victims are maximised and drive service …
Recommendation
PEEL 2021-22 CoC Recommendations: Gwent Police
Cause of concern: The force needs to improve how it answers calls for service, identifies vulnerability at first point of contact and attends incidents within its published time frames. Recommendation: Within three months, Gwent Police should make sure that vulnerable …
Recommendation
An inspection of the service provided to victims of crime by Greater …
Cause of concern: The force is failing to make sure it correctly records all reported crimes, particularly violent crime, including domestic abuse behavioural crimes such as harassment, stalking and coercive controlling behaviour. So these crimes are often not investigated and …
Recommendation
An inspection of the service provided to victims of crime by Greater …
Cause of concern: The force is inappropriately concluding crime investigations with cautions and community resolutions that aren’t appropriate and in which it doesn’t consult the victim. The force is also recording that victims are not supporting or are withdrawing support …
Recommendation
An inspection of the service provided to victims of crime by Greater …
Cause of concern: The force is failing to make sure investigation plans are always completed to an acceptable standard and not adequately supervising investigations. This leads to poor standards of some investigations, a lack of timely progression of investigations and …
Recommendation
An inspection of the service provided to victims of crime by Greater …
Cause of concern: The force is inappropriately concluding crime investigations with cautions and community resolutions that aren’t appropriate and in which it doesn’t consult the victim. The force is also recording that victims are not supporting or are withdrawing support …
Recommendation
PEEL 2018-19 CoC Recommendations: West Mercia Police
Cause of concern: The force does not have suitable arrangements in place to make sure it can maintain the full range of public services when its alliance with Warwickshire Police ends. There are gaps in its workforce skills assessment, and …
Recommendation
PEEL 2018-19 CoC Recommendations: West Mercia Police
Cause of concern: The force does not have suitable arrangements in place to make sure it can maintain the full range of public services when its alliance with Warwickshire Police ends. There are gaps in its workforce skills assessment, and …
Recommendation
PEEL 2018-19 CoC Recommendations: Northumbria Police
Cause of concern: The force’s ability to assess vulnerability when victims first make contact, and the timeliness of the response they receive, are causes of concern. Northumbria Police needs to be certain that there are officers available to respond to …
Recommendation
ICIBI Immigration Recommendations (6)
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 6 Review the guidance to “Monitoring Officers” regarding their safeguarding responsibilities and produce workable advice on how they are to satisfy themselves that a child or young person, or …
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 5 Ensure that sufficient “Roving Officers” are deployed at Stansted to discharge fully Border Force’s responsibilities for safeguarding passengers, both adults and children, in particular when 15 or more …
An inspection of the use of hotels for housing unaccompanied asylum-seeking children …
Strengthen assurance and monitoring mechanisms to ensure it is satisfied that contractors are meeting safeguarding and other requirements, including, but not limited to:
An inspection of contingency asylum accommodation for families with children in Northern …
The Home Office should strengthen assurance and monitoring arrangements to ensure accommodation providers, and their contractors and sub-contractors, are meeting all the standards set out in the Asylum Support Contracts …
An inspection of Border Force operations at Stansted Airport
Recommendation 6 Review the guidance to “Monitoring Officers” regarding their safeguarding responsibilities and produce workable advice on how they are to satisfy themselves that a child or young person, or …
Inspection report on an interim re-inspection of family reunion, July 2017
Introduce a criteria for expediting applications based on vulnerability.
IOPC Learning Recommendations (2)
Recommendation - Metropolitan Police Service, February 2020
The IOPC recommends that the Metropolitan Police Service (MPS) take steps to make Safeguarding teams and departments aware that special schemes can apply to serial perpetrators of abuse and should be used where appropriate to do so. The MPS use …
Police actions relating to a teenage boy’s arrest, welfare and disappearance prior …
The IOPC recommends that the Metropolitan Police Service (MPS) amend their custody policy to include a responsibility on MPS staff to ensure safeguarding forms are completed by them for vulnerable members of the public who they come into contact with …
IMB Annual Reports (4)
Gatwick pre-departure accommodation (2023)
The IMB report for Gatwick Pre-Departure Accommodation for 2023 highlights concerns regarding the detention of four families, all of whose removal attempts failed. The Board questions the fairness and humanity of the process, particularly noting the trauma to children and callous treatment of a pregnant mother. Key recommendations include the closure of the PDA and prohibiting the detention of pregnant women.
PRISON
Key concerns
Kent Coast Short Term Holding Facilities (STHF) (2023)
The IMB's report for Kent Coast STHF (WJF, KIU, Manston) for 2023 highlights commendable staff empathy and improved medical provisions. However, it raises significant concerns regarding the lack of clear information for detainees about their processing and length of stay, inadequate privacy for interviews, and substandard conditions in isolation units and sleeping arrangements. The Board also noted issues with facility maintenance and the inconsistent receipt of vital monitoring reports.
PRISON
Key concerns
Gatwick IRC (2023)
The Gatwick IRC experienced a deterioration in safety during 2023, marked by increased violence, assaults on staff, and a rise in use of force incidents, partly attributed to a changing detainee population. Key safeguards for vulnerable individuals, such as Rule 34 and Rule 35 assessments, were found to be insufficient or subject to unacceptable delays. The report highlighted significant concerns regarding inadequate mental health provision, unfair regime practices including prolonged lock-in times, and a lack of effective pathways for release for detainees granted bail.
IRC
Key concerns
Gatwick IRC (2024)
Gatwick IRC experienced a volatile year ending March 2024, marked by high levels of violence, self-harm, and one death in custody. The Board expresses significant concerns over inadequate safeguards for vulnerable detainees, long detention periods, and systemic failures in healthcare, particularly around Rules 34 and 35. Detainees also face issues with interpretation services, excessive handcuffing, and an inhumane regime with long lock-up times and increased segregation.
IRC
Key concerns
IMB Recommendations (23)
Brook House (2020)
The Board repeats all of its recommendations from 2019 relating to reviews of adults at risk; and assessment, care in detention and teamwork (ACDT) and Rule 35 policies and processes.
Home Office
Yarl’s Wood (2020)
The Board recommends that the Centre should maintain its vigilance in the identification of vulnerable persons and minors.
Governor / Director
Brook House (2020)
There should be a requirement for systematic and ongoing review of vulnerable detainees, to monitor the effect of continued detention on their wellbeing.
NHS / Healthcare Provider
Brook House (2020)
There should be a requirement for systematic and ongoing review of vulnerable detainees, to monitor the effect of continued detention on their wellbeing.
Home Office
Isle of Wight (2024)
What changes can be made to ensure there is a proactive, timely and robust system to identify and assess prisoner social care needs and ensure that prisoners understand they can self-refer?
Governor / Director
South and West short term holding facilities (2025)
Ensure that the recording of children’s detention fully reflects the individual child’s treatment.
Other
South and East Short Term Holding Facilities (STHF) (2025)
The Board recommends that the Home Office considers strengthening the relationship between Border Force and Children’s Services. The Board notes there is no service level agreement between BF and Children’s Services, resulting in some unaccompanied children waiting for 16 or 17 hours for support, as noted in 7.4.
Home Office
Brook House (2020)
Review systems and processes in the detention journey, to ensure that vulnerabilities such as age, modern slavery and Rule 35 torture claims are identified and assessed at earliest stages.
Home Office
Yarl’s Wood (2021)
The Board recommends that the centre should maintain its vigilance in the identification of vulnerable persons and minors and strictly follow procedures when these persons are released from the centre.
Governor / Director
London STHF (2024)
Unaccompanied minors are not always allocated a responsible adult when they are in the CWA. We would like each minor to be accompanied by a responsible adult.
Home Office
Feltham (2024)
Can steps be taken to ensure LA funding for SEN/EHCP children follows them into custody?
HMPPS
Feltham (2025)
Improve information sharing between social services and the YCS, so looked-after children (LACs) receive entitlements.
HMPPS
Cardiff IMB (2025)
Sut bydd y carchar yn gweithio gyda chyngor Caerdydd i sefydlu proses gofal cymdeithasol ffurfiol a chadarn, o ystyried nad oes un yn bodoli, fel yr amlygwyd yn yr Asesiad o Anghenion Iechyd a Gofal Cymdeithasol?
Governor / Director
Cardiff (2025)
How will the prison work with Cardiff council to establish a formal and robust social care process, given that none exists, as highlighted in the H&SCNA?
Governor / Director
Yarl’s Wood (2020)
Vulnerable adults are still being detained despite there being a pilot underway to explore an enhanced pre-detention screening tool to help facilitate the disclosure of vulnerability. The Board recommends that a clear evaluation of this pilot is published to ensure that the measures necessary for the safeguarding of vulnerable individuals are in place.
Ministry of Justice
Wandsworth (2023)
With the current staff shortages, will it be possible to operate the new healthcare centre safely?
Governor / Director
Yarl’s Wood IRC (2024)
The Detention Gatekeeper should be more robust in its safeguarding purpose of protecting vulnerable people from being detained
Home Office
Downview (2025)
The Board hopes that the successful HMPPS audit carried out in the reporting year may be a catalyst for more ambition and creativity with family engagement at Downview. How does the prison intend to sustain the focus on families and significant others (7.4)?
Governor / Director
Ashfield (2020)
What more can be done to ensure that other prisons conduct accurate and robust assessments of contact arrangements?
HMPPS
Downview (2021)
Collate data centrally regarding the numbers of dependent children of prisoners to enable effective family engagement.
HMPPS
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
Instruct officials to undertake assurance activity, informed by expert input, on the following areas where we cannot reach conclusions based on our observations: o Ensuring that vulnerable adults are always identified properly and that their care, and that provided to children, is effective in safeguarding and improving physical and mental health and wellbeing. o Ensuring that repairs to accommodation take …
Other
Ashfield (2024)
With the large number of elderly prisoners in the custodial estate (particularly in prisons such as Ashfield), cases of dementia and terminal illness requiring 24-hour care are increasing. The specific needs of these prisoners cannot be adequately met in normal prison conditions. What plans does the Prison Service have for addressing this issue through the creation of special custodial centres?
HMPPS
Warren Hill (2025)
The IMB recognises that the age profile of the prisoner population is increasing. What is the Governor’s/HMPPS’s plan to accommodate elderly prisoners in a more purposeful way, including making physical adaptations to the prison to be age-friendly and ensuring appropriate care packages are in place for prisoners with social care needs?
HMPPS
Health Investigations (4)
Themes and lessons learnt from NHS investigations into matters relating … — Rec R5
All NHS hospital trusts should undertake regular reviews of: - their safeguarding resources, structures and processes (including their training programmes); and - the behaviours and responsiveness of management and staff in relation to safeguarding issues to ensure that their arrangements are robust and operate as effectively as possible.
national
Accepted
Independent investigation into the care and treatment of Mr L — Rec 2
The Trust should ensure that consideration about referral to MAPPA takes place for patients with violent histories and convictions for serious violent offences. Such referrals should consider safeguarding issues and risks of domestic violence for wider family members.
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr L — Rec 2
The Trust should ensure that consideration about referral to MAPPA takes place for patients with violent histories and convictions for serious violent offences. Such referrals should consider safeguarding issues and risks of domestic violence for wider family members.
Independent investigation into the care and treatment of Mr L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
Accepted
Investigation into matters relating to Jimmy Savile at Wythenshawe Hospital — Rec b.
A specific, stand-alone policy for Volunteers and Visitors to the Trust should be developed to consolidate current processes, protocols and guidance.
University Hospital of South Manchester NHS Foundation Trust
north_west
Detention Investigations (10)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R39
The SMT, in consultation with the local safeguarding boards, should review and redraft the safeguarding policy to ensure that it: • has a clear and easy-to-follow scheme and does not contain errors in drafting and meaning; • makes clear to staff their principle duties and responsibilities in relation to safeguarding, …
Immigration Detention
Investigation into the Failing of Medomsley Detention Centre — Rec 1
The first is that it is still not a requirement for every child in detention to be proactively, and regularly, asked by an independent party about their custody experience seen through a safeguarding lens. If the right environment was created and they were conducted by suitably trained, trauma-informed professionals, these …
Prisons
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R26
In consultation with the LSCB, managers should review the training of staff in relation to safeguarding and child protection to ensure that they are given regular training to help them understand and meet their responsibilities for safeguarding and promoting the wellbeing of children.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R25
In consultation with the LSCB, managers should review and redraft Yarl’s Wood’s child protection and safeguarding policies to ensure that they clearly and consistently identify the extent of staff responsibilities for safeguarding and promoting the wellbeing of children, including children in the community, and conform to the requirements of the …
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R24
Managers at Yarl’s Wood should actively engage with the local authority safeguarding team and the safeguarding adults board and ensure establish appropriate and ongoing information sharing to secure the safeguarding of residents.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R23
Managers at Yarl’s Wood, in consultation with the local safeguarding adults board, should devise appropriate adult safeguarding policy and practice, including staff training.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R27
Managers should agree with the LSCB on arrangements for reporting concerns and on the pattern and frequency of future contact between the LSCB and Yarl’s Wood.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R40
The SMT in consultation with the local safeguarding boards must ensure that all staff receive appropriate annual safeguarding refresher training. (To be completed within 3 months)
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 29
I recommend that the Home Office and the Department of Health work together to consider whether current arrangements for safeguarding are adequate.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R31
Serco managers should undertake a thorough review of the initial training course and the refresher training programme to ensure that they enable staff to fulfil their roles and responsibilities. The review and any consequent redesign of staff training should ensure that staff are adequately trained in mental health matters affecting …
Immigration Detention
PHSO Casework Decisions (43)
P-003103 — Charity Commission
Mr U complains the Charity Commission failed to respond appropriately to and investigate serious allegations he made about concealment of child sexual abuse.
UK Government
Upheld
Mar 2024
P-002833 — Charity Commission
Miss A complains she was institutionally betrayed by the Commission when it investigated her complaint about her sexual exploitation by a Trustee of a UK charity. She says the Commission also failed to recognise her sensitive personal circumstances and make sure of her welfare.
UK Government
Upheld
Mar 2024
P-003544 — University Hospitals of Derby and Burton NHS Foundation …
Mrs M complains about the treatment her son received during his admission in June 2023. She says the Trust did not follow its own safeguarding policy, it did not complete a referral to cardiology, it gave her conflicting information about her son’s possible heart murmur and the discharge papers included …
NHS in England
May 2025
P-003733 — Avon and Wiltshire Mental Health Partnership NHS Trust
Mr E complains about his brother's care and treatment from April - October 2019. He told us the Trust did not raise a safeguarding alert when concerns were raised by both his brother and his family about drug dealers taking over his flat.
NHS in England
Partly Upheld
Jul 2025
P-004301 — Guy's and St Thomas' NHS Foundation Trust
Mr E complains the Trust failed to take appropriate action in response to his safeguarding concerns.
NHS in England
Nov 2025
P-003045 — Care Quality Commission
Dr C explains that after the coroner’s inquest concluded, more information came to light and she raised concerns with the CQC about her foster son’s care. She complains it has not correctly addressed the issues she raised or taken any enforcement action.
UK Government
Upheld
Aug 2024
P-002972 — Children and Family Court Advisory and Support Service …
Mr A complains that Cafcass did not follow its own process when considering a defamatory safeguarding referral made against him. He also complains the Family Court Advisor used false third party information and lies about him in court documents.
UK Government
Sep 2024
P-003195 — Children and Family Court Advisory and Support Service …
Mr J complains about the contents of a Cafcass storyboard sent to his son by the Cafcass Family Court Advisor (FCA).
UK Government
Dec 2024
P-003474 — Children and Family Court Advisory and Support Service …
Mr X complains about Cafcass and the conduct of the Family Court Adviser (FCA) throughout the process. He says the FCA did not adhere to policy, which compromised their judgement to make an impartial recommendation in the Section 7 report. Mr X further complains that the FCA overlooked the safeguarding …
UK Government
Mar 2025
P-004233 — Charity Commission
Mr D complains that Charity Commission (the Commission) did not intervene with the concerns he raised about a charity that he alleges are taking advantage of his son who he says has mental health issues and is vulnerable.
UK Government
Nov 2025
P-001798 — Bolton NHS Foundation Trust
Miss I complains about her mother’s nutritional and nursing care, a lack of safeguarding leading to an assault by another patient and about the Trust's poor communication.
NHS in England
Feb 2023
P-002389 — An independent provider in the Redcar and Cleveland …
Miss Y complains that between December 2020 and April 2021 the care home left Mr Y on the floor unconscious.
NHS in England
Aug 2023
P-002737 — Somerset NHS Foundation Trust
Miss X complains Somerset NHS Foundation Trust did not tell her it was raising a safeguarding concern which led to the police coming to her home in August 2022.
NHS in England
Jun 2024
P-002803 — Northern Care Alliance NHS Foundation Trust
Mrs A is concerned about the way staff implemented a Deprivation of Liberty Safeguards (DoLS) for her mother. She is also concerned she was not able to visit her mother whilst she was in hospital.
NHS in England
Not Upheld
Jul 2024
P-003114 — South West London Integrated Care Board
Mrs A says the ICB inappropriately allowed her brother to sign a tenancy agreement when he did not have capacity to do so.
NHS in England
Nov 2024
P-003183 — South West Yorkshire Partnership NHS Foundation Trust
Miss A complains about a learning disability health service run by the Trust. Miss A also complains the Practice removed her son’s learning disability from his records, did not allow her to speak on her son’s behalf at appointments and referred her to safeguarding.
NHS in England
Dec 2024
P-003574 — Alder Hey Children's NHS Foundation Trust
Mr H complains the Trusts misdiagnosed a skull fracture in his six month old son in December 2022. He also complains about being wrongly referred to social services because there was no plausible explanation for the injuries.
NHS in England
May 2025
P-003805 — Berkshire Healthcare NHS Foundation Trust
Mr R complains the Trust requested his mother be put under a Deprivation of Liberty Safeguards instead of a Section 3 and did not communicate effectively with him and his sister, who both have Lasting Power of Attorney.
NHS in England
Aug 2025
P-003994 — Kent and Medway Mental Health NHS Trust
Ms N complains about the support given to her and her son when he was experiencing mental health crises in the community. This includes a failure to assess his level of risk, review his medication, and support her as his carer.
NHS in England
Upheld
Sep 2025
P-004046 — Tees, Esk and Wear Valleys NHS Foundation Trust
Mrs I complains the Tees, Esk and Wear Valleys NHS Foundation Trust's safeguarding referral on 10 January 2024 was incorrect. Mrs I also complains the Trust did not provide her with any support after this event.
NHS in England
Sep 2025
P-004376 — An independent provider in the City of Kingston …
Mrs P complains about aspects of her care and treatment from the Provider from January 2024 to January 2025. These relate to therapy, record keeping and safeguarding.
NHS in England
Nov 2025
P-004411 — A practice in the Barnsley area
Mr A complains a GP Practice in the Barnsley area (the Practice) did not listen to or escalate his concerns over a safeguarding and domestic violence incident involving his parents and their neighbour in January 2025. He says the Practice did not signpost him to any other support organisations.
NHS in England
Nov 2025
P-001975 — Bedfordshire Hospitals NHS Foundation Trust
Mrs T complains the Trust did not refer her father to the safeguarding team during his admission. She also complains that staff made comments about his mental health that affected the care he was given.
NHS in England
Not Upheld
Feb 2023
P-001966 — Chesterfield Royal Hospital NHS Foundation Trust
Ms W complains the Trust clinicians referred her to social services after her newborn child had bruising on their heels.
NHS in England
Apr 2023
P-002280 — Humber and North Yorkshire Integrated Care Board
Mr A complains the ICB failed to fund a suitable wheelchair for his son. He also complains it made a safeguarding referral against him and tried to make him drop his complaint.
NHS in England
Nov 2023
P-002512 — Hampshire Hospitals NHS Foundation Trust
Ms O complains about the Trust’s decision to make a safeguarding referral and that it failed to diagnose a fractured rib.
NHS in England
Mar 2024
P-002796 — Hull University Teaching Hospitals NHS Trust
Mr R complains that when his mother was in hospital in June 2022 the Trust ignored his status as Lasting Power of Attorney and did not communicate with him. He also complains it did not put a deprivation of liberty safeguard (DoLS) in place for his mother and discharged her …
NHS in England
Jul 2024
P-002960 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs R complains the Trust inappropriately placed her under a Deprivation of Liberty Safeguard order. She also says the Trust incorrectly raised a safeguarding concern about her and her husband’s relationship.
NHS in England
Sep 2024
P-003360 — The Queen Elizabeth Hospital King's Lynn NHS Foundation …
Miss C complains the Trust made a safeguarding referral about her when her baby was born.
NHS in England
Feb 2025
P-003456 — Hertfordshire Community NHS Trust
Mrs J complains about the care and treatment her brother, Mr P, received during admissions at East and North Hertfordshire NHS Trust and Hertfordshire Community NHS Trust between 21 December 2019 and 5 January 2020. She complains the failings the safeguarding team and coroner identified may have contributed to or …
NHS in England
Upheld
Mar 2025
P-003410 — Buckinghamshire Healthcare NHS Trust
Ms R complains about how staff looked after her mother at the end of her life. This includes issues with a safeguarding concerns, communication and prescribing.
NHS in England
Mar 2025
P-003566 — Birmingham and Solihull Integrated Care Board
Miss A complains about the organisations failure to act on safeguarding concerns she raised about her mother. She is also concerned about the organisations care and treatment of her mother.
NHS in England
May 2025
P-003711 — Barts Health NHS Trust
Miss K complains about the Trust's care of her son. She complains about continence care, medication and treatment, communication, physiotherapy, safeguarding and how her complaint was handled.
NHS in England
Jul 2025
P-003717 — South Central Ambulance Service NHS Foundation Trust
Mr B complains South Central Ambulance Service NHS Foundation Trust (SCAS) raised a false safeguarding concern about him, and this delayed his wife's discharge from hospital.
NHS in England
Jul 2025
P-004714 — University Hospitals Birmingham NHS Foundation Trust
Mr A complains while his father, Mr S, was in University Hospitals Birmingham NHS Foundation Trust (the Trust), he was sexually assaulted by another patient while the staff knew the patient posed a risk. He also complains in the Trust response, it supplied false and misleading information.
NHS in England
Jan 2026
P-001383 — North Middlesex University Hospital NHS Trust
Mrs E complains that North Middlesex University Hospital NHS Trust did not follow the correct process after her late father fell in hospital and she told us it did not put in place a Deprivation of Liberty Safeguard for him soon enough.
NHS in England
Feb 2022
P-001199 — Children and Family Court Advisory and Support Service
Mr E complains about Cafcass. He specifically complains about the safeguarding letter, the conduct of the FCA and how his complaint was handled.
UK Government
Nov 2021
P-001775 — Office of the Public Guardian
Mrs N complains the Office of the Public Guardian failed to properly investigate her allegations about how her father's partner managed his financial affairs.
UK Government
Feb 2023
P-001761 — A practice in the Cornwall area
Miss A complains on behalf of herself and her mother, Mrs A, about the care and treatment the Practice gave to her father in 2019. She also complains the Practice did not share information with the Court of Protection.
NHS in England
Jan 2023
P-002407 — London Ambulance Service NHS Trust
Mr L complains about a safeguarding referral that the Trust made after he and his wife called 111 because of a rash their son had. They complain about how the call was handled and that a random home visit was made as a result.
NHS in England
Jan 2024
P-003254 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs A is complaining the Trust did not appropriately manage her falls care or share information correctly. She also complains the Trust inappropriately supported her care.
NHS in England
Dec 2024
P-003527 — University Hospitals Coventry and Warwickshire NHS Trust
Mr U complains that on 20 June 2023 the Trust raised a safeguarding concern after he queried why they needed to know which school his daughter attended.
NHS in England
Apr 2025
P-002503 — Office of the Public Guardian
Mr O and Ms O complain that the OPG accepted as valid a Deed of Revocation which they say their mother had been forced into signing when she lacked capacity.
UK Government
Mar 2024
LGO / SPSO Decisions (3072)
PSOW-202410313 — Cardiff Council
Mr A complained that Cardiff Council had not given fair and proper consideration to his request for unsupervised contact with his children. The Ombudsman decided that the Council had failed to properly assess the children’s needs and views and that the information it provided in response to Mr A’s complaints …
PSOW (Public Services Om…
Local Government
Jul 2025
21-008-002 — Essex County Council
Summary: There was some fault in the way the Council investigated safeguarding concerns into Mrs C’s care at the care home. The Council has agreed to apologise to Mr B.
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-000-348 — Brighton & Hove City Council
Summary: Dr B complained ESC Council and the NHS Trust failed to properly safeguard her when it undertook an investigation into allegations of physical assault when she lived in a care home jointly funded by the CCG and BHC Council. She also complained about the home’s investigation and its decision …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-018-627 — Wirral Metropolitan Borough Council
Summary: We will not investigate this late complaint about inconsistent information regarding a fall to Mr X’s Mother in March 2020. This is because we cannot add to the Council’s response or make a finding of the kind Mr X wants.
LGO (Local Government & …
Adult Care Services
Apr 2022
21-009-157 — London Borough of Sutton
Summary: Ms X complained the Council failed to arrange a follow up safeguarding meeting as agreed, in relation to concerns a care home failed to call an ambulance in response to her mother’s seizures. The Council’s failure to communicate clearly with Ms X amounts to fault. This fault has caused …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
20-012-369 — London Borough of Newham
Summary: Ms Z, on behalf of her mother Ms X, complained about the Council’s action in respect of her finances. There is fault by the Council in failing to start a safeguarding investigation at the appropriate time; delay in progressing a safeguarding investigation and failure to ensure Ms X's needs …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
22-000-705 — Newcastle upon Tyne City Council
Summary: We will not investigate Mr X’s complaint about the way the Council treated Mr and Mrs Y when they took Mr Z back to their home during the Covid19 pandemic. This is because further investigation by the Ombudsman could not add to the Council’s investigation and we cannot investigate …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-006-495 — Hertfordshire County Council
Summary: We have not found fault in the way the Council made its decisions regarding safeguarding enquiries, but there was a delay in its completion of the assessments and there was fault in the way the Council communicated with Dr C about the powers of the attorney and the requirement …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-016-655 — Liverpool City Council
Summary: The Council’s refusal to consider Ms X’s complaint about how it protected her when she was a child is fault. The Council has agreed to apologise, pay Ms X £200, investigate her complaint, and take action to improve its services.
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2022
21-007-914 — Dudley Metropolitan Borough Council
Summary: I have not investigated Mr B’s complaints about how the Council facilitated contact with his children, the contents of its assessments or the conduct of the social worker. This is because these matters are subject to court proceedings, or we cannot add to the Council’s own investigation. The Council …
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2022
22-003-151 — Liverpool City Council
Summary: We will not investigate Miss X’s complaint about children service’s actions. We are unlikely to achieve a significantly different outcome than she has already achieved.
LGO (Local Government & …
Children S Care Services
Jun 2022
22-002-690 — Middlesbrough Borough Council
Summary: We cannot investigate this complaint about a child’s education and Special Educational Needs provision. This is because this matter is currently part of ongoing court proceedings.
LGO (Local Government & …
Children S Care Services
Jun 2022
21-007-224 — Suffolk County Council
Summary: Mr X complains about the care the late Mr Y received in Highfield House Care Home and the safeguarding enquiry it undertook. Mr X says Mr Y was subject to incidents of abuse from care workers and although he was told the Council was investigating with Police, he heard …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-011-766 — Northumberland County Council
Summary: The Council was at fault for ending its support of Mr X without warning and without considering referring him to an advocate. The Council has agreed to apologise to Mr X, pay him £500 and take action to improve its service.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
22-005-921 — Torbay Council
Summary: We will not investigate this complaint about how the Council completed safeguarding enquiries. That is because we could not add to the Council’s previous investigation.
LGO (Local Government & …
Adult Care Services
Aug 2022
22-004-774 — Norfolk County Council
Summary: We cannot investigate this complaint about the safety of children when visiting a parent. The matter complained of is not separable from matters that form part of court proceedings.
LGO (Local Government & …
Children S Care Services
Sep 2022
22-001-529 — London Borough of Brent
Summary: We will not investigate this complaint about the actions of the Council in child protection. Investigation would not be likely to lead to a worthwhile outcome. The substantive matter at the heart of the complaint concerns the residence and contact arrangements for children, which are for a court to …
LGO (Local Government & …
Children S Care Services
Sep 2022
22-006-372 — Leicester City Council
Summary: We will not investigate this complaint about the Council’s adult safeguarding enquiries. That is because there is insufficient evidence of fault.
LGO (Local Government & …
Adult Care Services
Sep 2022
21-017-685 — London Borough of Islington
Summary: Mrs X complains on behalf of her deceased aunt about the Council’s safeguarding investigation. She says this had a significant impact on her mental health and has caused the family trauma. We find the Council at fault, and this fault caused Mrs X injustice. The Council will apologise to …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-007-888 — Brighton & Hove City Council
Summary: We will not investigate this complaint about the care given to Ms X’s mother. This is because further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Sep 2022
21-008-532 — Reading Borough Council
Summary: We will not investigate this complaint about the Council’s decision to start a safeguarding investigation. This is because there is no evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-007-324 — Wokingham Borough Council
Summary: We will not investigate this late complaint about how the Council responded to concerns about Ms X’s parents’ finances and overcharging for care. There is not a good reason Ms X did not complain to us sooner.
LGO (Local Government & …
Adult Care Services
Oct 2022
22-007-199 — Gloucestershire County Council
Summary: We will not investigate this complaint about bias by the Council when Mr B raised concerns about his mother’s adult social care. There is not enough evidence of fault to justify investigating.
LGO (Local Government & …
Adult Care Services
Oct 2022
22-008-564 — Newcastle upon Tyne City Council
Summary: We will not investigate this complaint about safeguarding a vulnerable adult because there is not enough evidence of fault to justify our involvement. We could not achieve a remedy for the person affected because they have died, and the injustice to their representative is not sufficient to warrant our …
LGO (Local Government & …
Adult Care Services
Oct 2022
21-016-608 — Dudley Metropolitan Borough Council
Summary: The Council is not at fault in considering safeguarding referrals made by Ms Z and viewing camera footage as part of its enquiries. The Council is not at fault for considering Mrs Y’s care options including residential care. The Council is at fault for not considering Mr X’s complaint …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-015-962 — Dorset Council
Summary: Mr X complains the Council did not properly undertake a safeguarding investigation in relation to his father. The Council should have contacted Mr X when it decided the initial safeguarding concern did not meet the threshold for further investigation. This did not cause Mr X any injustice.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
23-013-776 — City of Wolverhampton Council
Summary: We will not investigate this complaint about the Council’s involvement when Mrs X raised safeguarding concerns about her father. There is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Apr 2024
23-018-281 — Trafford Council
Summary: We will not investigate this complaint about adult safeguarding. There is not enough evidence of fault causing significant injustice. We cannot achieve the outcome the complainant wants for the Council to confirm there was no finding of abuse or neglect, because the safeguarding investigation is continuing.
LGO (Local Government & …
Adult Care Services
Apr 2024
23-008-465 — London Borough of Waltham Forest
Summary: Mr X complained the Council delayed carrying out a social care needs assessment, wrongly decided he does not have any social care needs and has failed to respond to safeguarding concerns. The Council was at fault for the delay in assessing Mr X’s needs. It has already apologised for …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
23-016-556 — Rochdale Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s decision to manage Miss Y’s daughter Miss X’s finances. This is because the complaint relates to events that took place more than 12 months ago; it would have been reasonable for Miss Y to bring the complaint to us at …
LGO (Local Government & …
Adult Care Services
May 2024
23-002-919 — Newcastle upon Tyne City Council
Summary: We will not investigate this complaint about the Council’s involvement in Miss X’s children’s case. The substantive part of the complaint is late and there is not a good reason for the delay. There is insufficient evidence of fault in more recent events, nor could we provide a meaningful …
LGO (Local Government & …
Children S Care Services
Jul 2024
23-011-874 — Cambridgeshire County Council
Summary: Miss A complained about a council and care agency regarding her placement at supported accommodation. We found fault with the agency for the care it provided which led to risks to Miss A’s mental and physical health. The agency has carried out work to improve its care and will …
LGO (Local Government & …
Adult Care Services
Not Upheld
Aug 2024
24-005-947 — City of Bradford Metropolitan District Council
Summary: We will not investigate Mr X’s complaint about adult safeguarding provision, as it is unlikely, we would find evidence of Council fault. Part of the complaint is late and there are no good reasons the late complaint rule should not apply. Other issues have been in a previous complaint …
LGO (Local Government & …
Adult Care Services
Sep 2024
24-014-257 — London Borough of Hammersmith & Fulham
Summary: We will not investigate this complaint about how the Council dealt with a safeguarding referral. There is not enough evidence of fault to justify our involvement.
LGO (Local Government & …
Adult Care Services
May 2025
24-016-641 — Sandwell Metropolitan Borough Council
Summary: Mr X complained the NHS Trust and the Council moved his father from hospital into a care home that could not meet his needs. Mr X says the failings led to his father suffering an injury which hastened his death. Mr X also complained the Council missed carer’s assessments, …
LGO (Local Government & …
Adult Care Services
May 2025
24-019-870 — Surrey County Council
Summary: We will not investigate this complaint about the Council’s actions relating to Mrs X’s mental capacity. This is because we do not have consent from Mrs X to investigate, and nor do we believe Mrs Y can make a complaint about these actions, on Mrs X’s behalf as her …
LGO (Local Government & …
Adult Care Services
May 2025
24-017-091 — West Sussex County Council
Summary: We will not investigate this complaint about the Council’s response to safeguarding and other actions relating to Mrs X’s mental capacity assessment. This is because we do not have consent from Mrs X to investigate, and nor do we believe Mrs Y can make a complaint about these actions, …
LGO (Local Government & …
Adult Care Services
May 2025
25-000-015 — Westminster City Council
Summary: We will not investigate Ms X’s complaint about the removal of her sibling’s child from their care. The law prevents us from investigating anything that is or has been the subject of court proceedings.
LGO (Local Government & …
Children S Care Services
May 2025
24-023-226 — Kent County Council
Summary: We cannot investigate Mr X’s complaint about the Council’s children’s services involvement with his family because the law prevents us from considering complaints about matters that have been considered in court proceedings.
LGO (Local Government & …
Children S Care Services
May 2025
24-022-857 — Cornwall Council
Summary: We will not investigate Mr X’s complaint about the Council’s children’s services involvement with his family because it lies outside our jurisdiction. The law prevents us from considering complaints about matters that have been considered in court proceedings. Investigation into other issues raised would not lead to a different …
LGO (Local Government & …
Children S Care Services
May 2025
24-021-852 — Isle of Wight Council
Summary: We will not investigate Mr and Mrs X’s complaint about the Council’s involvement with their child. The law prevents us from investigating anything that is or has been the subject of court proceedings.
LGO (Local Government & …
Children S Care Services
May 2025
24-023-163 — Blackpool Borough Council
Summary: We cannot investigate this complaint about how a Council has exercised its safeguarding duties. The law says we cannot investigate a complaint about the start of court action or what happened in court.
LGO (Local Government & …
Children S Care Services
Jun 2025
25-000-290 — Redcar & Cleveland Council
Summary: We will not investigate Ms X’s complaint about the actions of a social worker and the response of Children’s Social Care. This is because
LGO (Local Government & …
Children S Care Services
Jun 2025
24-021-065 — London Borough of Barnet
Summary: We will not investigate this complaint about Miss X’s time in Council care between 2016 and 2021. While it is understandable that she has not complained sooner, we would be unlikely to be able to conduct a robust investigation or achieve a worthwhile outcome.
LGO (Local Government & …
Children S Care Services
Jun 2025
24-020-325 — Surrey County Council
Summary: We will not investigate this complaint about the Council’s investigation of a bruise Mr Y sustained. There is insufficient evidence of fault, and we could not achieve the outcome Mrs X seeks.
LGO (Local Government & …
Adult Care Services
Jun 2025
24-013-950 — Worcestershire County Council
Summary: Mr X complained about how the Council made a best interest decision for his brother, Mr Y, when it decided he did not have capacity to make decisions about his finances. The Council was at fault because it did not keep proper oversight when it referred Mr Y to …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2025
24-011-204 — Lancashire County Council
Summary: Miss X complained on behalf of her father (Mr Y) about the Council’s handling of safeguarding concerns that he was vulnerable and at risk of harm and neglect due to alleged poor care he received while in residential care. Based on current information, there is no evidence the Council …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2025
24-019-772 — London Borough of Barking & Dagenham
Summary: Mr X complained that the Council failed to safeguard him, did not assess his social care needs properly, and did not implement the reasonable adjustments he needed under the Equality Act. There was no fault in how the Council considered its safeguarding duties and how it assessed Mr X’s …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2025
25-005-066 — Coventry City Council
Summary: We will not investigate this complaint about reports that the Council provided to the courts. The law prevents us from investigating anything that has been subject to court proceedings.
LGO (Local Government & …
Children S Care Services
Jul 2025
25-003-284 — Hampshire County Council
Summary: We will not investigate Mr X’s complaint about how the Council and other bodies dealt with matters concerning the care of his child. Mr X’s complaint about the actions of the Council is made late and is about what happened in court. We have no powers to investigate the …
LGO (Local Government & …
Children S Care Services
Jul 2025