Recurring concern

Unreliable social care referral pathways

First to latest report 16 Jan 2015 — 30 Jan 2026

Reports that mention this concern
15
Times this concern has been raised
19
Stated actions linked to this concern
35

What this concern includes

Includes dedicated failures in social care referral pathways, including referral identification, initiation, form or information requirements, allocation, prioritisation and response, where the failure risks a needed social care referral being delayed, misdirected or omitted.

What is not included
  • Excludes generic workforce training deficiencies unless the training is specifically required for operating or safeguarding the social care referral pathway.
  • Excludes general social care capacity, placement or discharge-provision shortages that are not failures of the referral pathway.
  • Excludes referrals to unrelated services, including healthcare or mental health services, unless the assertion concerns a social care referral pathway.

Reports and published responses 15 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester North

    AI-generated summary

    Shneur Zalman Kaye · 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

    Shneur Zalman Kaye died at home on 24 August 2018, aged 14, from suffocation caused by inhalation of helium. The report raises concerns that a safeguarding referral was closed without contacting Shneur or his parents and that the referral and reasons for it were not shared with relevant third parties or agencies, potentially limiting assessment and protective action.

    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 contact parents before closing a referral where no safeguarding or legal reason prevents contact

    Wider context from the report

    “1. The decision to close a referral without prior contact with parents (where there is no safeguarding or legal reason why such contact should not be made) potentially deprives the Social Worker of the opportunity to contextualise the event or concern which has triggered the referral, and of forming an informed view of the welfare of the child to whom the referral relates; ”

    Source location

    Shneur Zalman Kaye · Prevention of Future Deaths report
    Page 1 · 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

    Make speaking with parents or carers part of MASH referral practice unless a safeguarding or legal reason prevents contact.

    Verbatim wording from the response

    “Strength based practice within the MASH, working alongside parents/carers and seeing them as an expert in their own right is standard practice and unless there is a safeguarding or legal reason not to, it is an expectation that parents/carers are spoken with as part of the process.”

    Source location

    Response from Bury Council
    Page 2 · response
    Published 8 February 2020

    Open published response

  2. 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

    Failure to apply and document a clear referral and decision-making process

    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

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays or lack of child-centred response by Children’s Social Care to urgent concern information

    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 1 · 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 of professionals to understand referral of urgent concerns in open social care cases

    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

  3. Manchester City

    AI-generated summary

    Mr Brian MacLean · 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

    Mr Brian MacLean died on 19 March 2016 from smoke inhalation contributed to by alcohol toxicity after a fire started while he was smoking on his sofa. The report raised concerns about insufficiently proactive social services involvement, failure to identify and refer him as being at risk of fire, and the absence of automatic processes for fire-risk assessment, referrals, sprinklers and other preventive measures.

    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 of Social Services to proactively pursue referrals and understand fire risks through joined-up interagency working

    Wider context from the report

    “1. That Social Services did not take a more proactive role in pursuing any referral and understanding the risks presented by the deceased. This requires joined up thinking and working with GPs, the NHS locally, the housing provider and finally GMFRS. ”

    Source location

    Mr Brian MacLean · Prevention of Future Deaths report
    Page 3 · 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

    Review contacts closed or classified as non-urgent by the two officers.

    Verbatim wording from the response

    “1. All contacts which have been closed or viewed as non-urgent by Officers A and B have been reviewed.”

    Source location

    2017-0233-Response-by-Manchester-City-Council
    Page 3 · response
    Published 24 September 2017

    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

    Audit 20% of Contact Centre contacts classified as No Further Action between July and September 2017.

    Verbatim wording from the response

    “2. An audit of 20% of all contacts classed as “NFA” (No Further Action) by the Contact Centre between July 2017 and September 2017 is being undertaken”

    Source location

    2017-0233-Response-by-Manchester-City-Council
    Page 3 · response
    Published 24 September 2017

    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

    Undertake regular audits of Contact Centre work through the Quality Assurance Team.

    Verbatim wording from the response

    “4. The Quality Assurance Team are to undertake regular audits of the work undertaken by the Contact Centre.”

    Source location

    2017-0233-Response-by-Manchester-City-Council
    Page 3 · response
    Published 24 September 2017

    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

    Explore increasing social work supervision and oversight of Contact Centre officers.

    Verbatim wording from the response

    “5. MCC is currently exploring increasing social work supervision and oversight of the Contact Centre officers”

    Source location

    2017-0233-Response-by-Manchester-City-Council
    Page 3 · response
    Published 24 September 2017

    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

    Continue raising adult social care staff awareness of Greater Manchester Fire and Rescue Service offerings through partnership meetings and consideration of extended partnership working.

    Verbatim wording from the response

    “6. MCC has considered the recommendations of the GMFRS report and will continue with the work currently underway to raise the awareness of the services offered by GMFRS among adult social care staff. There are regular meeting between the Community Safety Officer from GMFRS and MCC to ensure that all options for extending partnership working are considered.”

    Source location

    2017-0233-Response-by-Manchester-City-Council
    Page 3 · response
    Published 24 September 2017

    Open published response

  4. Warwickshire

    AI-generated summary

    Peter Embra · 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

    Peter Embra’s death was investigated, with the inquest concluding with a Narrative Verdict. The principal concern was that the local authority failed to act on an urgent referral from a GP, resulting in an approximately seven-week delay before a social worker visited him.

    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 act promptly on urgent referrals for assessment

    Wider context from the report

    “The local authority failed to act on an urgent referral from a GP. ████████(GP) visited Mr Embra at his home on 9 March 2015 and contacted the local authority asking for an urgent assessment. On 16 March he made a written referral to the local authority asking for an urgent assessment preferably that day. There was an approximately 7 week delay before a Social Worker visited Mr Embra. ”

    Source location

    Peter Embra · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Norfolk

    AI-generated summary

    Mark Robert Anstice · 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

    Mark Robert Anstice, who had a history of mental health and social problems and previous self-harm, was found hanged on 27 September 2014. Concerns included that recommended support-worker or care-coordinator provision was not actioned, uncertainty about a carer’s assessment referral, gaps in team awareness of appointments, and difficulties supporting his attendance at group sessions due to lack of transport or means.

    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 recommended carer’s assessment referrals

    Wider context from the report

    “(1) On 12 August 2014 Psychiatrist recommended Mr Anstice would benefit from a Support Worker and/or Care Co-ordinator – this was not actioned. The reason for this is not known – it was indicated this may be due to an administrative problem; (2) It was recommended a referral be made for a Carer’s Assessment on 1 September 2014. It is not clear this referral was made. Even if it had been made there would be difficulties with assessment and provision of the service in view of the fact Mr Anstice resided in Norfolk and the service would be provided by Suffolk MH Team (3) The appointment arranged with the Psychiatrist for 12 November 2014 was not known by other members of the Team, despite Team Meetings being in place to discuss Mr Anstice’s care. (4) It was recommended to Mr Anstice he attend Group sessions to help overcome feelings of social isolation, whilst being unaware as to whether Mr Anstice was physically able to attend those Group sessions. He did not have the transport or means to attend such groups. (5) When it became known to the IDT that Mr Anstice did not have the transport or means to attend the Groups, consideration was given as to how to help him overcome those practical difficulties but Mr Anstice was not informed that help was being considered. (6) Mr Anstice was discharged from Bury North IDT on 17 September 2014, being invited to attend Groups and having attended one on the 5 September 2014. However IDT were unable to speak with Mr Anstice by telephone on 5 September 2014, 8 September 2014 (tried 3 times) and he did not attend Group session on 12 September 2014. (7) At the time of Mr Anstice’s discharge from Bury North IDT, IDT were unaware Mr Anstice had an appointment with a Psychiatrist on 12 November 2014. ”

    Source location

    Mark Robert Anstice · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026