Missed Child Safeguarding Referrals
102 items
2 sources
Safeguarding referrals for children sometimes missed, despite mandates and training, putting children at risk.
Cross-Source Insight
Missed Child Safeguarding Referrals has been flagged across 2 independent accountability sources:
57 inquiry recs
45 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (57)
R12 — Police notification of child offences
Recommendation: The Government should reaffirm the guidance in Working Together to Safeguard Children so that the police are notified as soon as possible when a criminal offence has been committed, or is suspected of having been committed, against a child – …
Gov response: The Home Secretary made a statement to Parliament on 22 June 2004, the day the Bichard Inquiry Report was published, accepting all 31 recommendations in full. The government stated it was "in principle, accepting Sir …
Accepted
Delivered
R13 — Criteria for police notification
Recommendation: National guidance should be produced to inform the decision as to whether or not to notify the police. This guidance could usefully draw upon the criteria included in a local protocol being developed by Sheffield Social Services and brought to …
Gov response: The Home Secretary made a statement to Parliament on 22 June 2004, the day the Bichard Inquiry Report was published, accepting all 31 recommendations in full. The government stated it was "in principle, accepting Sir …
Accepted
Delivered
R14 — Recording non-referral decisions
Recommendation: The Integrated Children's System should record those cases where a decision is taken not to refer to the police.
Gov response: The Home Secretary made a statement to Parliament on 22 June 2004, the day the Bichard Inquiry Report was published, accepting all 31 recommendations in full. The government stated it was "in principle, accepting Sir …
Accepted
Delivered
R15 — Inspection of non-referral decisions
Recommendation: The Commission for Social Care Inspection should, as part of any social services inspection, review whether decisions not to inform the police have been properly taken.
Gov response: The Home Secretary made a statement to Parliament on 22 June 2004, the day the Bichard Inquiry Report was published, accepting all 31 recommendations in full. The government stated it was "in principle, accepting Sir …
Accepted
Delivered
R18 — Inspection of school recruitment
Recommendation: The relevant inspection bodies should, as part of their inspection, review the existence and effectiveness of a school's selection and recruitment arrangements.
Gov response: The Home Secretary made a statement to Parliament on 22 June 2004, the day the Bichard Inquiry Report was published, accepting all 31 recommendations in full. The government stated it was "in principle, accepting Sir …
Accepted
Delivered
41 — Create diocesan safeguarding officers
Recommendation: The Church of England should create the role of a diocesan safeguarding officer to replace the diocesan safeguarding adviser. Diocesan safeguarding officers should have the authority to make decisions independently of the diocesan bishop in respect of key safeguarding tasks, …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that Canon C30 and the associated Diocesan Safeguarding Advisor Regulations would be amended …
Accepted
No update 2+ yrs
42 — Church in Wales provincial safeguarding officers
Recommendation: The Church in Wales should make clear that the operational advice of provincial safeguarding officers must be followed by all members of the clergy and other Church officers. It should be enshrined in policy that those who are volunteers and …
Gov response: On 7 April 2021, the Church in Wales stated that its safeguarding policy, procedural documents and training materials would make it clear that the operational advice of provincial safeguarding officers should be followed by all …
Accepted
No update 2+ yrs
43 — Church in Wales record-keeping policies
Recommendation: The Church in Wales should introduce record-keeping policies relating to safeguarding, complaints and whistleblowing. These should be implemented consistently across dioceses. The Church should develop policies and training on the information that must be recorded in files. The Church should …
Gov response: On 7 April 2021, the Church in Wales stated that its national online safeguarding case management and record-keeping system had launched, serving as a single searchable repository of all Church in Wales safeguarding and whistleblowing …
Accepted
Delivered
44 — Church of England/Wales information sharing protocol
Recommendation: The Church of England and the Church in Wales should agree and implement a formal information-sharing protocol. This should include the sharing of information about clergy who move between the two Churches.
Gov response: On 24 June 2021, the Church of England announced that the updated version of the House of Bishops' handling of Clergy Personal Files policy covers data sharing between the Church of England and the Church …
Accepted
Delivered
45 — Local diocesan information sharing protocols
Recommendation: The Church of England, the Church in Wales and statutory partners should ensure that information-sharing protocols are in place at a local level between dioceses and statutory partners.
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that it would develop template information-sharing agreements which may be adapted and used …
Accepted
No update 2+ yrs
MAI-1 — School-to-college records on radicalisation vulnerability
Recommendation: A clean start should be possible when a student moves from school to college or higher education, such that it would not be appropriate for a general file on significant behavioural problems to follow them at that point. However, there …
Gov response: Home Secretary Suella Braverman made a statement to Parliament on 6 March 2023 following publication of Volume 3 on 2 March 2023. She stated: 'We will carefully consider the report's findings and recommendations in full' …
Accepted
In progress
MAI-54 — School records on radicalisation vulnerability
Recommendation: It is recommended that the Department for Education consider whether schools should include notes of any significant behavioural problems on the Common Transfer File, or some other suitable new form of record which follows a student if they move school. …
Gov response: Home Secretary Suella Braverman made a statement to Parliament on 6 March 2023 following publication of Volume 3 on 2 March 2023. She stated: 'We will carefully consider the report's findings and recommendations in full' …
Accepted
In progress
MAI-60 — Record images of students with weapons
Recommendation: It is recommended to all educational establishments and the Department for Education that images of school pupils or college students handling firearms, explosives or other weapons that come to the attention of staff be recorded as a potential indicator of …
Gov response: Home Secretary Suella Braverman made a statement to Parliament on 6 March 2023 following publication of Volume 3 on 2 March 2023. She stated: 'We will carefully consider the report's findings and recommendations in full' …
Accepted
Delivered
WATE-(14) — Remind professionals of their role in identifying and reporting child abuse
Recommendation: Steps should be taken through training and professional and other channels periodically to remind persons outside social services departments who are or may be in regular contact with looked after children, such as teachers, medical practitioners, nurses and police officers, …
Unknown
WATE-(16) — Advise police on absconders from care homes and social worker consultation
Recommendation: Police officers should be reminded periodically that an absconder from a residential care or foster home may have been motivated to abscond by abuse in the home. They should be advised that, when apprehended, an absconder should be encouraged to …
Unknown
WATE-(17) — Require reporting of absconsions to social worker and independent follow-up
Recommendation: It should be a rule of practice that any absconsion should be reported as soon as possible to the absconder's field social worker and that the absconder should be seen on his return by that social worker or by another …
Unknown
WATE-(20) — Expedite disciplinary proceedings for child abuse, independent of police investigations
Recommendation: Any disciplinary proceedings that are necessary following a complaint of abuse to a child should be conducted with the greatest possible expedition and should not automatically await the outcome of parallel investigations by the police or the report on any …
Unknown
WATE-(21) — Remind personnel of suspension guidelines: child's best interests, neutral, avoid long periods
Recommendation: Personnel departments and other persons responsible for disciplinary proceedings within local authorities should be reminded that: (a) in deciding whether or not a member of staff should be suspended following an allegation of abuse to a looked after child, first …
Unknown
WATE-(22) — Conduct inter-agency review of child abuse investigation procedures to issue guidance
Recommendation: In the light of the recent experience gained in both England and Wales in major investigations of alleged wide ranging abuse of children in care/looked after children, an inter-agency review of the procedures followed and personnel employed in those investigations …
Unknown
WATE-(23) — Periodically audit Social Services staff recruitment and management vigilance
Recommendation: Social Services Departments should be reminded periodically that they must exercise vigilance in the recruitment and management of their staff in strict accordance with the detailed recommendations of the Warner committee917; and compliance with them by individual local authorities should …
Unknown
WATE-(24) — Mandate stringent, independent vetting for all foster parent applications, especially staff
Recommendation: Similar vigilance should be mandatory in relation to all applications for approval as foster parents. In particular, any application to foster by a member of a local authority's child care staff should be stringently vetted by a social worker who …
Unknown
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-65 — Doctors must take child's history directly for suspected harm, recording consent reasons.
Recommendation: When the deliberate harm of a child is identified as a possibility, the examining doctor should consider whether taking a history directly from the child is in that child’s best interests. When that is so, the history should be taken …
Unknown
LAMI-66 — Ensure all deliberate harm concerns are fully addressed and documented in appraisals.
Recommendation: When a child has been examined by a doctor, and concerns about deliberate harm have been raised, no subsequent appraisal of these concerns should be considered complete until each of the concerns has been fully addressed, accounted for and documented.
Unknown
LAMI-67 — Require recorded discussion and further opinion for differing deliberate harm diagnoses.
Recommendation: When differences of medical opinion occur in relation to the diagnosis of possible deliberate harm to a child, a recorded discussion must take place between the persons holding the different views. When the deliberate harm of a child has been …
Unknown
LAMI-68 — Doctors must make comprehensive, contemporaneous notes for suspected child deliberate harm.
Recommendation: When concerns about the deliberate harm of a child have been raised, doctors must ensure that comprehensive and contemporaneous notes are made of these concerns. If doctors are unable to make their own notes, they must be clear about what …
Unknown
LAMI-69 — Record all discussions, including phone calls, in child deliberate harm case notes.
Recommendation: When concerns about the deliberate harm of a child have been raised, a record must be kept in the case notes of all discussions about the child, including telephone conversations. When doctors and nurses are working in circumstances in which …
Unknown
LAMI-70 — Require consultant or paediatrician permission for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without the permission of either the consultant in charge of the child’s care or of a paediatrician …
Unknown
LAMI-71 — Require documented future care plan for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. …
Unknown
LAMI-72 — Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Recommendation: No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been …
Unknown
LAMI-73 — Require inquiry and review of previous hospital admissions for suspected deliberate harm.
Recommendation: When a child is admitted to hospital and deliberate harm is suspected, the doctor or nurse admitting the child must inquire about previous admissions to hospital. In the event of a positive response, information concerning the previous admissions must be …
Unknown
LAMI-74 — Mandate full, documented physical examination within 24 hours for suspected deliberate harm.
Recommendation: Any child admitted to hospital about whom there are concerns about deliberate harm must receive a full and fully-documented physical examination within 24 hours of their admission, except when doing so would, in the opinion of the examining doctor, compromise …
Unknown
LAMI-75 — Require senior doctor to seek carer permission for deliberate harm investigation or treatment.
Recommendation: In a case of possible deliberate harm to a child in hospital, when permission is required from the child’s carer for the investigation of such possible deliberate harm, or for the treatment of a child’s injuries, the permission must be …
Unknown
LAMI-76 — Clearly identify responsible consultant for child protection aspects in deliberate harm cases.
Recommendation: When a child is admitted to hospital with concerns about deliberate harm, a clear decision must be taken as to which consultant is to be responsible for the child protection aspects of the child’s care. The identity of that consultant …
Unknown
LAMI-77 — Doctors must provide written statement of deliberate harm concerns to social services.
Recommendation: All doctors involved in the care of a child about whom there are concerns about possible deliberate harm must provide social services with a written statement of the nature and extent of their concerns. If misunderstandings of medical diagnosis occur, …
Unknown
LAMI-78 — Implement single set of records for each child across health professionals.
Recommendation: Within a given location, health professionals should work from a single set of records for each child.
Unknown
LAMI-79 — Ensure all available information is reviewed during ward rounds for deliberate harm.
Recommendation: During the course of a ward round, when assessing a child about whom there are concerns about deliberate harm, the doctor conducting the ward round should ensure that all available information is reviewed and taken account of before decisions on …
Unknown
LAMI-80 — Record all discussions, decisions, and actions in hospital notes for deliberate harm.
Recommendation: When a child for whom there are concerns about deliberate harm is admitted to hospital, a record must be made in the hospital notes of all face-to-face discussions (including medical and nursing ‘handover’) and telephone conversations relating to the care …
Unknown
LAMI-81 — Implement systems to record, complete, and check actions for deliberate harm cases.
Recommendation: Hospital chief executives must introduce systems to ensure that actions agreed in relation to the care of a child about whom there are concerns of deliberate harm are recorded, carried through and checked for completion.
Unknown
LAMI-82 — Examine feasibility of clinical governance for children at risk of deliberate harm.
Recommendation: The Department of Health should examine the feasibility of bringing the care of children about whom there are concerns about deliberate harm within the framework of clinical governance.
Unknown
LAMI-83 — Systematically and rigorously investigate and manage cases of deliberate harm to children.
Recommendation: The investigation and management of a case of possible deliberate harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease.
Unknown
LAMI-84 — Revalidate doctors and paediatricians in deliberate harm diagnosis and multi-disciplinary child protection investigations.
Recommendation: All designated and named doctors in child protection and all consultant paediatricians must be revalidated in the diagnosis and treatment of deliberate harm and in the multi-disciplinary aspects of a child protection investigation.
Unknown
LAMI-85 — Develop continuing education models for deliberate harm diagnosis and multi-disciplinary child protection investigations.
Recommendation: The Department of Health should invite the Royal College of Paediatrics and Child Health to develop models of continuing education in the diagnosis and treatment of the deliberate harm of children, and in the multi-disciplinary aspects of a child protection …
Unknown
LAMI-86 — Explore extending child patient registration to include social and developmental welfare information.
Recommendation: The Department of Health should invite the Royal College of General Practitioners to explore the feasibility of extending the process of new child patient registration to include gathering information on wider social and developmental issues likely to affect the welfare …
Unknown
LAMI-87 — Ensure GPs receive regular training in deliberate harm recognition and child protection investigations.
Recommendation: The Department of Health should seek to ensure that all GPs receive training in the recognition of deliberate harm to children, and in the multi-disciplinary aspects of a child protection investigation, as part of their initial vocational training in general …
Unknown
LAMI-88 — Examine feasibility of deliberate harm training for all primary healthcare staff.
Recommendation: The Department of Health should examine the feasibility of introducing training in the recognition of deliberate harm to children as part of the professional education of all general practice staff and for all those working in primary healthcare services for …
Unknown
LAMI-89 — GPs must ensure staff know local child protection agency contact procedures.
Recommendation: All GPs must devise and maintain procedures to ensure that they, and all members of their practice staff, are aware of whom to contact in the local health agencies, social services and the police in the event of child protection …
Unknown
LAMI-90 — Ensure child protection training for liaison staff and audit policy compliance.
Recommendation: Liaison between hospitals and community health services plays an important part in protecting children from deliberate harm. The Department of Health must ensure that those working in such liaison roles receive child protection training. Compliance with child protection policies and …
Unknown
LAMI-91 — Require child assessment before police protection, except in exceptional circumstances.
Recommendation: Save in exceptional circumstances, no child is to be taken into police protection until he or she has been seen and an assessment of his or her circumstances has been undertaken.
Unknown
LAMI-92 — Ensure prompt, efficient investigation of child victim crimes to adult standards.
Recommendation: Chief constables must ensure that crimes involving a child victim are dealt with promptly and efficiently, and to the same standard as equivalent crimes against adults.
Unknown
LAMI-93 — Require manager involvement from both agencies in joint child harm investigations.
Recommendation: Whenever a joint investigation by police and social services is required into possible injury or harm to a child, a manager from each agency should always be involved at the referral stage, and in any further strategy discussion.
Unknown
LAMI-94 — Require supervisory officers to actively ensure proper investigation of serious child crimes.
Recommendation: In cases of serious crime against children, supervisory officers must, from the beginning, take an active role in ensuring that a proper investigation is carried out.
Unknown
LAMI-95 — ACPO must produce and implement standards-based child protection service.
Recommendation: The Association of Chief Police Officers must produce and implement the standards-based service, as recommended by Her Majesty’s Inspectorate of Constabulary in the 1999 thematic inspection report, Child Protection.
Unknown
LAMI-96 — Review police protection systems for Children Act compliance and designated inspector officer.
Recommendation: Police forces must review their systems for taking children into police protection and ensure they comply with the Children Act 1989 and Home Office guidelines. In particular, they must ensure that an independent officer of at least inspector rank acts …
Unknown
LAMI-97 — Ensure child crime investigation is equal to other serious crime investigations.
Recommendation: Chief constables must ensure that the investigation of crime against children is as important as the investigation of any other form of serious crime. Any suggestion that child protection policing is of a lower status than other forms of policing …
Unknown
LAMI-98 — Social services must inform police immediately of child criminal offence referrals.
Recommendation: The guideline set out at paragraph 5.8 of Working Together must be strictly adhered to: whenever social services receive a referral which may constitute a criminal offence against a child, they must inform the police at the earliest opportunity.
Unknown
LAMI-99 — Amend Working Together for police to exclusively conduct child criminal investigations.
Recommendation: The Working Together arrangements must be amended to ensure the police carry out completely, and exclusively, any criminal investigation elements in a case of suspected injury or harm to a child, including the evidential interview with a child victim. This …
Unknown
PFD Reports (45)
Evelyn Rae Le Masurier-O’Sullivan
Concerns: Midwifery staff failed to elicit and act upon parental concerns about a baby's breathing and crying during postnatal contacts, leading to missed neonatal assessments and escalation.
Overdue
Alexander Eastwood
Concerns: There is a lack of guidance and regulation for children's contact sports, particularly for unofficial matches, leading to an absence of minimum standards for safeguarding, medical support, and risk management.
Responded
Janet Scott
Concerns: The "safeguarding is everyone's responsibility" message is not fully embedded, with agencies potentially failing to make referrals if they believe others are informed, risking a fragmented multi-agency approach.
Responded
Ella Murray
Concerns: Failures in urgent safeguarding, lack of shared information access between health, social care, and education agencies, and an inability to convene urgent multi-agency meetings, meant a vulnerable child was left in an unsafe home environment.
Overdue
Mazeedat Adeoye
Concerns: The National Police Air Service discounted a critical heat signature during a search. London Borough of Newham's child services demonstrated unprofessional, hostile behaviour, poor management, inadequate supervision, and substandard note-keeping, risking sub-optimal care for vulnerable individuals.
Responded
Henry Grierson
Concerns: The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication breakdown between the college and mental health organizations.
Responded
Lee-Ann Ince
Concerns: Agencies supporting the victim lacked understanding of coercive control and the impact of "love bombing." Children's concerns were overlooked, and the victim's physical health vulnerability was not recognised, increasing her risk.
Responded
Jacob Shorter
Concerns: Crucial information about previous suicidal ideation was not shared with foster carers. Calderdale Council lacks clear training and escalation routes for mental health concerns, creating a risk of future deaths.
Responded
Karen Thomason
Concerns: Hospital safeguarding procedures were flawed, treating forms as a tick-box exercise and failing to communicate with support agencies. There was also a misinterpretation of patient capacity leading to unaddressed obvious vulnerability.
Responded
Michaela Hall
Concerns: Children and Adult Services failed to consider the family as a whole, lacked written rationale for care needs and safeguarding decisions, and neglected health-related enquiries despite signs of mental impairment.
Responded
Christopher Vickers
Concerns: There were multiple missed opportunities to coordinate care through multi-disciplinary meetings and to make safeguarding referrals despite the deceased's known escalating risks.
Responded
Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent
Concerns: Probation Service offender records lacked clear, prominent recording of critical risk information, leading to unread vital details and insufficient domestic abuse and child safeguarding checks. Systemic issues contributed to ongoing risks.
Overdue
Jacqueline Carrey
Concerns: The patient's medical record lacked clear indication of potential abuse risk, and this crucial information was not flagged to staff before discharge, highlighting failures in record-keeping and communication.
Responded
Sylvia Pollitt
Concerns: The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed to monitor referral outcomes, missing crucial safety oversight for vulnerable adults.
Responded
Lucy Walles
Concerns: Systemic issues in safeguarding, mental health provision, and inter-agency communication led to inadequate support for a vulnerable person. Concerns include slow safeguarding referrals, insufficient staff training, and resource adequacy across council and health services.
Responded
Nicholas Stout
Concerns: Mental health crisis assessments are often delayed, essential Triage Tools and Safety Plans are not consistently completed, and safeguarding referrals for children are frequently missed.
Responded
Melsadie Parris
Concerns: Social work failed to conduct renewed home visits or liaise with mental health teams regarding a carer's admitted psychosis, relying on old assessments and missing critical information about the carer's deteriorating mental state.
Responded
Harper Denton
Concerns: Police forces failed to adopt guidance for managing violent offenders and lacked proactive information sharing to protect children. Additionally, a national register for child cruelty offenders is missing, and health visitor safeguarding assessments are not mandatory.
Responded
Joan Prescott
Concerns: Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare visit. This represented a missed opportunity to formally address broader safeguarding concerns.
Overdue
Marc Bennett
Concerns: There is a critical need for Devon Partnership Trust staff to improve communication with Children's Services, especially regarding child protection investigations and providing appropriate mental health support to parents.
Overdue
Lily-Mai George
Concerns: Haringey Children's Services facilitated a child's discharge into unsupervised parental care despite professional concerns, leading to fatal injuries before a planned safe placement could occur.
Overdue
Christopher Smith
Concerns: The hospital failed to complete a home assessment or ensure proper discharge planning, leading to incorrect next of kin notification, unaddressed complex care needs, and the patient being discharged to unsafe living conditions.
Overdue
Roy Curtis
Concerns: Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.
Responded
Chelsie Greatorex
Concerns: The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.
Responded
Xuanze Piao
Concerns: The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal risk, revealing a lack of clear communication policy.
Responded
Avis Addison
Concerns: Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.
Responded
Shneur Kaye
Concerns: Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.
Responded
Archie Spriggs
Concerns: Systemic failures in child safeguarding include unclear referral pathways, delayed responses to urgent concerns, insufficient multi-agency understanding of complex family dynamics, and inadequate information sharing regarding children's welfare in private law proceedings.
Overdue
Caspian Thorn
Concerns: Poor communication between midwifery and social work teams, undocumented calls, and delayed review of pathological CTGs contributed to missed opportunities for monitoring a vulnerable baby and identifying early sepsis.
Overdue
Janie McFadyen
Concerns: No specific concerns were detailed in the provided text.
Responded
Edward Joyce
Concerns: A child's critical high temperature following a burn was missed by the GP and not recorded or acted upon by hospital staff, highlighting inadequate awareness of burn complications and follow-up advice.
Responded
Ellie Butler
Concerns: No specific concerns were detailed in the provided text, only a reference to appended concerns.
Overdue
Sofia Legg
Concerns: Concerns include a high CAMHS referral threshold, a six-month wait for CBT, and the care co-ordinator's failure to ensure urgent psychiatric input. Critical safeguarding advice, like not leaving the patient alone, was not properly documented or communicated.
Responded
Terry Latimer
Concerns: A safeguarding notice with a request for Mental Health Services referral was not actioned. There was a lack of clarity among staff on whether such notices required follow-up or were just for information.
Overdue
Chadrack Mulo
Concerns: School procedures for unexplained absences were inadequate, with limited emergency contacts and delayed responses to non-attendance, revealing a need for wider adoption of immediate welfare checks.
Responded
Carol Leesley
Concerns: A safeguarding report made by a GP was not acted upon, despite automated acknowledgment, due to an unknown systemic or IT error, leaving a patient vulnerable.
Responded
Karnel Haughton
Concerns: Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support for parents, risking further injuries and deaths.
Overdue
Harry Mellor
Concerns: There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with chronic health needs, as specialist teams are not informed.
Overdue
Solomon Bealey
Concerns: Despite initial concerns about a patient's suicidal ideation and a history of self-harm, no effective follow-up action was taken after failed contact attempts.
Responded
Kesia Leatherbarrow
Concerns: Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team case, led to a lack of support for a high-risk young person.
Overdue
Bradley Griffiths
Concerns: Health visitor services failed to maintain contact and track a child after the mother moved without providing new GP or address details, leading to lost records.
Responded
Alex Kelly
Concerns: A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic approach or consult outside agencies. A social worker allocation was also significantly delayed.
Responded
Lauren Barfoot
Concerns: Failures in information sharing between Social Services and the Missing Person's Unit led to an inadequate risk classification and an ineffective search for the deceased. Social Services also failed to maintain comprehensive contact lists and hold timely strategy meetings.
Responded
Andrew Cairns, Rachael Slack and Auden Slack
Concerns: Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of a recent mental health assessment; an existing information-sharing policy was also undisclosed.
Overdue
Samantha Gould and Christine Gould
Concerns: Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance for police on communicating with such vulnerable minors.
Pending