Recurring concern

Unreliable child safeguarding referral processes

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First reported 16 Apr 2015•Latest report 3 Sep 2025

Definition

What this concern includes

Includes failures in child safeguarding referral arrangements, including unclear referral thresholds or routes, absent or inconsistent guidance, failure to make required referrals, and materially incomplete or insufficient referral information.

Not included

Excludes generic social-care referral failures where no child safeguarding concern or child-in-need referral process is identified.
Excludes child-safeguarding assessment, investigation or protective-action failures occurring after a referral has been reliably made and received.
Excludes generic training, communication or documentation deficiencies unless they directly impair a child safeguarding referral.
Excludes referrals for adults or non-safeguarding services.

Reports: 4
Individual concerns: 5
Date range: 2015–2025
Stated actions: 12

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Cafcass1

Crown Prosecution Service1

Department for Education1

Department of Health and Social Care1

Greater Manchester Combined Authority1

Greater Manchester Police1

Home Office1

Lancashire County Council1

Medacs Healthcare Limited1

Ministry of Housing, Communities and Local Government1

National Police Chiefs’ Council1

Pennine Care NHS Foundation Trust1

Shropshire Safeguarding Children's Board1

Shropshire Safeguarding Partnership1

Tameside Borough Council1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

3 Sep2025
Hampshire, Portsmouth and Southampton
Concerns raised1
1. Lack of national guidance and standards for safeguarding referrals
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Deliver Families First Partnership reforms, including multi-agency child protection teams and integrated front-door models for triaging contacts and referrals.
  Stated by Department for EducationStated in progress
2. Action
  Update and publish Keeping Children Safe in Education guidance to support consistent recognition, referral and response to safeguarding concerns.
  Stated by Department for EducationStated completed
AI-generated summary

Lucy-Anne DYSON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Lucy Rushton died on 23 June 2019 in the early hours of the morning following a prolonged, severe and brutal attack, with multiple blunt force injuries; the narrative conclusion recorded that she was unlawfully killed. The principal concerns were the lack of a national interface for sharing safeguarding information between schools and relevant agencies, and the lack of national guidance or standards governing safeguarding referrals.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of national guidance and standards for safeguarding referrals
Wider context from the report
“2. The lack of national guidance/standards means agencies with safeguarding duties for children are receiving referrals that either rely too heavily on the individual referrer’s judgement about what should be included, or where no referral is made at all. ”
Source location
Lucy-Anne DYSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver Families First Partnership reforms, including multi-agency child protection teams and integrated front-door models for triaging contacts and referrals.

Verbatim wording from the response
“• Families First Partnership Programme Through this programme, we are delivering national reforms to Family Help, multi-agency child protection, and Family Group Decision Making. The reforms include establishing multi-agency child protection teams that bring together education, police, health, and social care professionals to take decisive action where significant harm is identified. The programme also promotes integrated ‘front door’ models for triaging contacts and referrals, ensuring concerns are directed appropriately and consistently.”

Source location
Response from Department for Education
Page 3 · response
Published 19 January 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update and publish Keeping Children Safe in Education guidance to support consistent recognition, referral and response to safeguarding concerns.

Verbatim wording from the response
“• Keeping Children Safe in Education (KCSIE) (2024) Schools and colleges have a critical role to play in protecting children and keeping them safe. The Department publishes the statutory safeguarding guidance Keeping Children Safe in Education (KCSIE) to support schools and colleges in carrying out their duties to safeguard and promote the welfare of children. KCSIE makes clear that every school must have a Designated Safeguarding Lead who takes lead responsibility for safeguarding and child protection. Part 1 of the guidance, which should be read by all staff who work directly with children, sets out that all staff should know what to do if they have concerns about a child and should be aware of the process for making referrals to local authority children’s social care and for statutory assessments under the Children Act 1989.”

Source location
Response from Department for Education
Page 4 · response
Published 19 January 2026
Open published response
15 Jun2023
County Durham and Darlington
Concerns raised1
1. Failure to make safeguarding referrals for children in all warranted situations
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 10
1. Action
  Provide additional training on the Parental Mental Ill Health and Children tool to support safeguarding-referral decisions.
  Stated by The TrustStated completed
2. Action
  Discuss safeguarding concerns daily in community and crisis huddles, assign actions, and share incident learning and review findings with teams.
  Stated by The TrustStated completed
3. Action
  Allocate safeguarding-team links to clinical areas to provide safeguarding support and guidance.
  Stated by The TrustStated completed
1. Action
  Enhance QA5 auditing to assess PAMIC completion, safeguarding identification, and completion of appropriate safeguarding actions.
  Stated by The TrustStated completed
2. Action
  Allocate safeguarding duty workers to provide immediate advice and support during core working hours.
  Stated by The TrustStated completed
3. Action
  Provide additional staff training on the PAMIC tool to support recognition and referral of safeguarding concerns affecting children.
  Stated by Tees, Esk and Wear Valleys NHS FTStated completed
4. Action
  Make safeguarding concerns a daily community and crisis-huddle agenda item, assign resulting actions and share incident learning with teams.
  Stated by Tees, Esk and Wear Valleys NHS FTStated completed
5. Action
  Assign safeguarding-team links to clinical areas to provide teams with additional safeguarding support and guidance.
  Stated by Tees, Esk and Wear Valleys NHS FTStated completed
6. Action
  Expand QA5 audits to review PAMIC completion, safeguarding identification and completion of appropriate safeguarding actions.
  Stated by Tees, Esk and Wear Valleys NHS FTStated completed
7. Action
  Allocate safeguarding duty workers to provide immediate advice and support during core working hours.
  Stated by Tees, Esk and Wear Valleys NHS FTStated completed
AI-generated summary

Nicholas James STOUT · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Nicholas “Nicky” Stout died at Darlington Memorial Hospital on 26 July 2021 after consuming a large quantity of cocaine, with acute cocaine toxicity and coronary artery atheroma recorded as factors. The report raised concerns about delays in mental health crisis assessment, incomplete crisis-team triage tools, safeguarding referrals for children, and the absence or incomplete use of safety plans.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to make safeguarding referrals for children in all warranted situations
Wider context from the report
“3. In relation to making safeguarding referrals for children, the evidence I heard was in this particular case a referral should have been made and was not. I was told training had been undertaken to make all staff aware of what action to take. However, I was told in the majority of occasions it was believed a referral would be made. It is of concern in terms of protecting children that I was not satisfied that a referral was made in all situations that warranted such a referral. ”
Source location
Nicholas James STOUT · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide additional training on the Parental Mental Ill Health and Children tool to support safeguarding-referral decisions.

Verbatim wording from the response
“In evidence, ████████ confirmed that since this incident, staff have received additional training in relation to the Parental mental ill health on children tool (PAMIC). ████████ confirmed that the tool considers how a parent’s mental health may impact on a child and supports the clinician completing the tool to consider whether a referral to the local authority for safeguarding teams should be completed and actions that should be considered to safeguard the child/children.”

Source location
Response from Tees Esk and Wear Valleys NHS Foundation Trust
Page 4 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Discuss safeguarding concerns daily in community and crisis huddles, assign actions, and share incident learning and review findings with teams.

Verbatim wording from the response
“As a Trust we are committed to learning from this incident and have implemented the necessary improvements to prevent such incidents from happening in the future. Safeguarding concerns are now a standard agenda item discussed daily within community and crisis huddles, attended by all members of the multi-disciplinary team. Any identified actions are promptly acted upon, with individual clinicians taking responsibility for allocated tasks. The learning in relation to this incident has been discussed within team meetings, and the review from the incident has been shared with the team to ensure widespread awareness.”

Source location
Response from Tees Esk and Wear Valleys NHS Foundation Trust
Page 4 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Allocate safeguarding-team links to clinical areas to provide safeguarding support and guidance.

Verbatim wording from the response
“To strengthen safeguarding practices across the organisation, the Trust safeguarding team allocate members of the team to link in with different clinical areas across the Trust. This provides increased support and guidance within the teams, enabling timely and effective handling of safeguarding concerns. The organisation has also issued a Patient Safety Briefing following this incident, this briefing has been shared throughout the wider organisation to ensure that the learning from the incident has been communicated and lessons learnt across the Trust.”

Source location
Response from Tees Esk and Wear Valleys NHS Foundation Trust
Page 4 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Enhance QA5 auditing to assess PAMIC completion, safeguarding identification, and completion of appropriate safeguarding actions.

Verbatim wording from the response
“To provide assurance and to maintain consistent monitoring across the organisation, the Trust has enhanced its quality assurance schedule and has introduced the QA5 audit detailed earlier in this response. A recent addition to the audit tool includes reviewing compliance against PAMIC tool completion, whether a safeguarding concern has been identified in the past month, and whether appropriate actions have been undertaken when a safeguarding concern has been identified. This audit helps us to ensure agreed policies and procedures are being followed and to take corrective action where necessary to ensure safeguarding procedures are being followed.”

Source location
Response from Tees Esk and Wear Valleys NHS Foundation Trust
Page 4 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Allocate safeguarding duty workers to provide immediate advice and support during core working hours.

Verbatim wording from the response
“Additionally, to provide immediate support and advice during core working hours, the Trust have allocated safeguarding duty workers. This professional lead is available to discuss any safeguarding concerns and to offer guidance on how to address concerns safely, ensuring a child’s welfare remains a central priority. Outside of regular working hours, the Trust safeguarding policy directs staff to contact the local authority safeguarding team to ensure that concerns are promptly discussed and addressed as required.”

Source location
Response from Tees Esk and Wear Valleys NHS Foundation Trust
Page 4 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide additional staff training on the PAMIC tool to support recognition and referral of safeguarding concerns affecting children.

Verbatim wording from the response
“In evidence, ████████ confirmed that since this incident, staff have received additional training in relation to the Parental mental ill health on children tool (PAMIC). ████████ confirmed that the tool considers how a parent’s mental health may impact on a child and supports the clinician completing the tool to consider whether a referral to the local authority for safeguarding teams should be completed and actions that should be considered to safeguard the child/children.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
Page 4 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Make safeguarding concerns a daily community and crisis-huddle agenda item, assign resulting actions and share incident learning with teams.

Verbatim wording from the response
“As a Trust we are committed to learning from this incident and have implemented the necessary improvements to prevent such incidents from happening in the future. Safeguarding concerns are now a standard agenda item discussed daily within community and crisis huddles, attended by all members of the multi-disciplinary team. Any identified actions are promptly acted upon, with individual clinicians taking responsibility for allocated tasks. The learning in relation to this incident has been discussed within team meetings, and the review from the incident has been shared with the team to ensure widespread awareness.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
Page 4 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Assign safeguarding-team links to clinical areas to provide teams with additional safeguarding support and guidance.

Verbatim wording from the response
“To strengthen safeguarding practices across the organisation, the Trust safeguarding team allocate members of the team to link in with different clinical areas across the Trust. This provides increased support and guidance within the teams, enabling timely and effective handling of safeguarding concerns. The organisation has also issued a Patient Safety Briefing following this incident, this briefing has been shared throughout the wider organisation to ensure that the learning from the incident has been communicated and lessons learnt across the Trust.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
Page 4 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Expand QA5 audits to review PAMIC completion, safeguarding identification and completion of appropriate safeguarding actions.

Verbatim wording from the response
“To provide assurance and to maintain consistent monitoring across the organisation, the Trust has enhanced its quality assurance schedule and has introduced the QA5 audit detailed earlier in this response. A recent addition to the audit tool includes reviewing compliance against PAMIC tool completion, whether a safeguarding concern has been identified in the past month, and whether appropriate actions have been undertaken when a safeguarding concern has been identified. This audit helps us to ensure agreed policies and procedures are being followed and to take corrective action where necessary to ensure safeguarding procedures are being followed.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
Page 4 · response
Published 6 September 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Allocate safeguarding duty workers to provide immediate advice and support during core working hours.

Verbatim wording from the response
“Additionally, to provide immediate support and advice during core working hours, the Trust have allocated safeguarding duty workers. This professional lead is available to discuss any safeguarding concerns and to offer guidance on how to address concerns safely, ensuring a child’s welfare remains a central priority. Outside of regular working hours, the Trust safeguarding policy directs staff to contact the local authority safeguarding team to ensure that concerns are promptly discussed and addressed as required.”

Source location
Response from Tees, Esk and Wear Valleys NHS Foundation Trust 2
Page 4 · response
Published 6 September 2023
Open published response
2 Dec2019
Shropshire, Telford and Wrekin
Concerns raised1
1. Lack of clear policy on when and how child-in-need safeguarding referrals should be made
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Archie David SPRIGGS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Archie David Spriggs was murdered by his mother on the morning of 21 September 2017, during a bitter dispute between his parents and on the day of a scheduled child arrangements hearing. The report’s concerns, based on a Serious Case Review, included referral and decision-making processes, responses to urgent safeguarding information, the impact of prolonged private law proceedings, assessment of separated-parent cases and allegations of domestic abuse, and multi-agency working with fathers and families.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clear policy on when and how child-in-need safeguarding referrals should be made
Wider context from the report
“a) SSCB to clarify, and subsequently audit the application of the referral pathway and decision-making process for referrals to Early Help and Children’s Social Care. This should include the use and quality of written referral forms and feedback to referrers. b) SSCB to seek regular assurance that: i. Professionals understand how to refer urgent concerns in respect of cases open to Children’s Social Care; ii. Children’s Social Care provide a timely and child centred response to this information. c) SSCB to provide the multi-agency workforce with the knowledge and understanding of i. the impact of protracted private law proceedings on children’s emotional wellbeing; ii. the factors to be considered and assessed in circumstances whereby separated parents make allegations about the welfare of their children iii. the features of filicide cases. d) To test the impact of recommendation (c) SSCB to conduct a multi-agency audit of the services provided to children referred to Children’s Social Care whose parents are separated and where private law proceedings have taken place. The audit should consider the completion of whole family assessments and the response to safeguarding concerns and allegations of domestic abuse. e) SSCB to work with Local Family Justice Board (LFJB) and CAFCASS to review the notification process for Section 37 reports to ensure timely and consistent arrangements. f) CAFCASS to update their Child Protection Policy to include when and how safeguarding referrals (child in need) should be made. g) SSCB to engage with multi-agency frontline staff as well as parents/carers to explore their experiences, and any barriers, to working with fathers. The findings of this work should be considered and acted on by SSCB. h) SSCB to create learning opportunities for the multi-agency workforce to come together and reflect on their approach to providing a whole family focus; including how they consider the impact of parenting capacity on children. ”
Source location
Archie David SPRIGGS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Apr2015
Manchester South
Concerns raised2
1. Failure to make safeguarding referrals from custody medical information
2. Failure to route domestic violence cases involving 17-year-old children to child protection review
This report raised 26 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to make safeguarding referrals from custody medical information
Wider context from the report
“Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use. ”
Source location
Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Page 7 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to route domestic violence cases involving 17-year-old children to child protection review
Wider context from the report
“For domestic violence incidents the closing code relates to people over the age of 16 as being adults. This means that the case is not then automatically passed through to the Child Protection Team within Greater Manchester Police for a review even if one of the people involved is still a child - i.e. is 17 years of age. ”
Source location
Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
Page 7 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of national guidance and standards for safeguarding referrals

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to make safeguarding referrals for children in all warranted situations

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10

Concerns raised1

Lack of clear policy on when and how child-in-need safeguarding referrals should be made

Concerns raised2

Failure to make safeguarding referrals from custody medical information

Failure to route domestic violence cases involving 17-year-old children to child protection review

Actions described in response 2

Actions described in response 10