Recurring concern

Failure to assess and respond to mental-health risks arising during child protection and care proceedings

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First reported 2 Dec 2019•Latest report 30 May 2024

Definition

What this concern includes

Includes failures in child protection, public-law or private-law care-proceedings processes to identify, assess, communicate or respond to mental-health risks arising from the proceedings or related welfare decisions, including workforce understanding of those impacts and risk assessment at proceedings-related notifications.

Not included

  • Excludes generic safeguarding, workforce training or communication deficiencies that are not specifically tied to mental-health risks arising during child protection or care proceedings.
  • Excludes general delays or procedural failures in family or care proceedings where no mental-health or emotional-wellbeing risk is identified.
  • Excludes clinical mental-health assessment and treatment failures unrelated to child protection, care proceedings or proceedings-related welfare decisions.
  • Excludes risks concerning children or parents that are unrelated to the impact of proceedings or associated safeguarding decisions.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2019–2024

First to latest report issue date

Stated actions
5

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Cafcass1
Department of Health and Social Care1
Home Office1
Ministry of Justice1
NHS Norfolk and Suffolk Integrated Care Board1
NHS Norfolk and Waveney Integrated Care Board1
Norfolk and Suffolk NHS Foundation Trust1
Shropshire Safeguarding Children's Board1
Shropshire Safeguarding Partnership1
Suffolk Constabulary1
Suffolk County Council1
Surrey County Council1
Surrey Police1

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.

  1. Suffolk

    AI-generated summary

    Katie MADDEN · 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

    Katie Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.

    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 risk assessment of vulnerable parents’ mental health and physical wellbeing at Public Law Outline notification

    Wider context from the report

    “2. It was identified that when Kate was informed there may be an application to the Family Court to place her children into care (using the Public Law Outline process), the impact of such a decision on her mental health, or physical wellbeing was not taken into consideration. As a recipient of a ‘Claires Law’ Domestic Violence Disclosure, it was acknowledged that she was of greater vulnerability, but no system is currently in place which allows a risk assessment to be undertaken at the time the Public Law Outline notification is given to a parent. The day after Kate was told of the Public Law Outline notification, she had intentionally crashed her car in an unsuccessful attempt to end her life, requiring 4 weeks in an Intensive Treatment Unit to recover from the serious injuries she received. ”

    Source location

    Katie MADDEN · 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

    Refer parents needing additional support during PLO proceedings to Adult Social Care for eligibility assessment and services.

    Verbatim wording from the response

    “CYP staff were aware of the “Claire’s Law” disclosure recorded having had access to all safeguarding referrals relating to the family. However, SCC accept that if a parent demonstrates that they are in need of additional support as a result of the onset of PLO proceedings then CYP staff should make a referral to ASC by way of a referral to its Customer First Team in addition to any support they may already be receiving from other agencies. This is particularly pertinent, in cases such as Katie’s, where a parent has an established history of rumination and behaving unpredictably during stressful life events. The purpose of the referral would be to determine eligibility for assessment and services in accordance with the Care Act 2014. This activity may result in further signposting, including to primary or secondary mental health services.”

    Source location

    Response from SCC
    Page 2 · response
    Published 6 June 2024

    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 referral practice and recognition of significant mental-health issues a dedicated focus of annual PLO training, informed by parent and carer experience.

    Verbatim wording from the response

    “Whilst a referral of this type is wholly dependent on the person’s consent and may not always result in the aforementioned assessment(s) staff will be reminded that a referral ought to be made, nonetheless. This aspect of identified learning shall become a dedicated focus within our annual PLO training for CYP colleagues working across our operational services to raise awareness of presenting significant MH issues, recognising that SW are not able to undertake specific MH assessments. The voice of parent/carers as “experts by experience” will inform our PLO training programme. We shall work alongside our judiciary partners such as CAFCASS to raise awareness and promote”

    Source location

    Response from SCC
    Page 2 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Children’s social workers cannot undertake specific mental health assessments, requiring referral or signposting to appropriate services.

    Verbatim wording from the response

    “Whilst a referral of this type is wholly dependent on the person’s consent and may not always result in the aforementioned assessment(s) staff will be reminded that a referral ought to be made, nonetheless. This aspect of identified learning shall become a dedicated focus within our annual PLO training for CYP colleagues working across our operational services to raise awareness of presenting significant MH issues, recognising that SW are not able to undertake specific MH assessments. The voice of parent/carers as “experts by experience” will inform our PLO training programme. We shall work alongside our judiciary partners such as CAFCASS to raise awareness and promote”

    Source location

    Response from SCC
    Page 2 · response
    Published 6 June 2024

    Open published response

  2. Surrey

    AI-generated summary

    Name not published · 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

    The deceased died at home on 29 November 2017 after consuming considerable amounts of alcohol and cocaine and hanging herself with a ligature. Concerns included limited communication between the MARAC process and her general practitioner about domestic abuse risks and safeguarding measures, and the GP not being informed about her children being removed from her care and subsequent care proceedings, or the associated mental health stressors.

    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 inform the general practitioner of children’s removal and care proceedings

    Wider context from the report

    “6. ████████ children were removed from her care in ████████ and she was then involved in care proceedings. Her general practitioner was not made aware of this although it would have been a further significant stressor so far as her mental health was concerned. ”

    Source location

    Name not published · 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

    Implement the Children’s Services Improvement Plan to strengthen information sharing with partner agencies.

    Verbatim wording from the response

    “In relation to Point 6, Surrey County Council recognises the importance of informing agencies involved with a family about the removal of a child. Our practice has strengthened considerably since 2017 and Children's Services has implemented an Improvement Plan in order to secure continuing improvement over time. This includes improving the way in which information is shared with partner agencies. When a child moves into our care we routinely notify our health colleagues and this would ensure that the GP would now be informed. However, this would be the GP for the children, rather than the GP for the parents and we recognise the focus in this situation was on the needs of the mother and her increased vulnerability in the light of the removal of her children.”

    Source location

    Response to Surrey coroner area - Prevention of future deaths report
    Page 1 · response
    Published 7 October 2022

    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

    Share Domestic Homicide Review learning across Children’s Services.

    Verbatim wording from the response

    “This was a point of learning identified early within the Domestic Homicide Review and action was taken immediately to share this learning across our service and to strengthen practice. We now ensure that when we are making plans to remove children into our care we consider how to manage any increased risk to the parents. If the agencies working with them are part of the children’s core group we would always contact them. If they are not we would ask the consent of the parents to contact them, or support them to make contact with them themselves. This would include GPs as well as domestic abuse services or adult services.”

    Source location

    Response to Surrey coroner area - Prevention of future deaths report
    Page 1 · response
    Published 7 October 2022

    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

    Assess increased parental risk during child-removal planning and contact or support contact with relevant agencies, including GPs and specialist services.

    Verbatim wording from the response

    “This was a point of learning identified early within the Domestic Homicide Review and action was taken immediately to share this learning across our service and to strengthen practice. We now ensure that when we are making plans to remove children into our care we consider how to manage any increased risk to the parents. If the agencies working with them are part of the children’s core group we would always contact them. If they are not we would ask the consent of the parents to contact them, or support them to make contact with them themselves. This would include GPs as well as domestic abuse services or adult services.”

    Source location

    Response to Surrey coroner area - Prevention of future deaths report
    Page 1 · response
    Published 7 October 2022

    Open published response

  3. Shropshire, Telford and Wrekin

    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

    Insufficient workforce understanding of the impact of protracted private law proceedings on children’s emotional wellbeing

    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
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Data last updated 7 September 2026