Recurring concern

Safeguarding systems failing to identify and respond to neglect

First to latest report 16 Sep 2021 — 4 Jul 2023

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
6

What this concern includes

Includes failures of safeguarding arrangements dedicated to identifying, referring, triaging, investigating or responding to suspected neglect, including omissions from safeguarding guidance where those omissions affect recognition of neglect.

What is not included
  • Excludes generic clinical, communication, documentation or staffing failures unless the report explicitly ties them to safeguarding identification or response.
  • Excludes safeguarding concerns unrelated to neglect, such as abuse allegations without a supported neglect-identification or neglect-response issue.
  • Excludes general failures in health or social care that do not concern a safeguarding process or control.

Reports and published responses 4 reports

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

  1. South Wales Central

    AI-generated summary

    Stella Ann JAMES · 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

    Stella Ann James, aged 40, died at the Royal Glamorgan Hospital on 20 January 2021 after being admitted with severe pneumonia and sepsis following severe food restriction, malnutrition and very low body weight. The principal concerns were that she appeared to meet the criteria for an adult at risk of neglect, without an apparent mechanism for Social Services to be aware of her status, and whether a register or anonymous referral mechanism could support unannounced social-work visits.

    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 a mechanism for Social Services to become aware of adults at risk of neglect

    Wider context from the report

    “(1) Stella appeared to meet the criteria as an ‘adult at risk of neglect’ due to her food avoidance and very low body weight, yet there was no apparent mechanism for Social Services to be aware of Stella’s status. Stella was very secretive and formally had capacity when assessed months before her death, although it is noted that this can fluctuate. (2) Could there be a register to include a person in Stella’s position, whereby unannounced house visits from a social worker can be an option? Perhaps involving a mechanism for anonymous referral? ”

    Source location

    Stella Ann JAMES · 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

    Review current multi-agency referral and monitoring arrangements for vulnerable adults.

    Verbatim wording from the response

    “In this case the decision not to refer for social worker involvement was the correct one and, having reviewed current arrangements, all partners are confident that should such a referral be assessed as needed in a future case then the process is clear and unambiguous. There is also the potential that the creation of a much wider vulnerable adults list would give the misguided impression to someone referring an individual onto the register, that the individual would be safeguarded.”

    Source location

    Response from Cardiff Council
    Page 3 · response
    Published 2 July 2026

    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

    The decision not to refer for social work involvement was considered correct because existing referral processes were clear and appropriate.

    Verbatim wording from the response

    “In this case the decision not to refer for social worker involvement was the correct one and, having reviewed current arrangements, all partners are confident that should such a referral be assessed as needed in a future case then the process is clear and unambiguous. There is also the potential that the creation of a much wider vulnerable adults list would give the misguided impression to someone referring an individual onto the register, that the individual would be safeguarded.”

    Source location

    Response from Cardiff Council
    Page 3 · response
    Published 2 July 2026

    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

    A separate vulnerable-adults register was considered unnecessary because existing multi-agency monitoring and referral arrangements were sufficient and clearer.

    Verbatim wording from the response

    “In terms of holding a register of vulnerable adults more generally, we think that this could potentially negatively impact on the existing arrangements in place for appropriate multi agency involvement in future complex cases.”

    Source location

    Response from Cardiff Council
    Page 3 · response
    Published 2 July 2026

    Open published response

  2. Lincolnshire

    AI-generated summary

    Dainton Harley Hill Cressell GITTOS · 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

    Dainton Harley Hill, an 11-year-old vulnerable child with cerebral palsy who could not speak, bear his own weight, or call for help, was left unsupervised in a bath on 22 January 2021 and was later found unresponsive. The inquest concluded that parental neglect in failing to supervise him contributed directly to his death, which was consistent with drowning. Concerns were raised about the lack of supervision, failure to use a non-slip bath mattress, prior social services records concerning neglect and emotional harm, and the decision not to bring charges.

    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 adequately test evidence and reconsider charging criteria in suspected child neglect cases

    Wider context from the report

    “I refer to all the evidence heard at the Inquest particularly, that of DC ████████ and the Police’s own expert Dr. ████████, (recited above) and do not accept why any charges have not been brought against either or both parents focusing on s1(1) Children and Young Persons Act 1933 The police are asked to review their file again in view of the many concessions made by CPS and the findings as to cause of death now made in the Coroner’s Court (admittedly on a different standard of proof but they are still findings after hearing evidence). Neglect runs right through this case and irrespective of the parent’s allegations against each other in the Coroner’s Court the belief is that the evidence needs to be tested and if agreed charging criteria reconsidered as there are 3 other siblings. A vulnerable child aged 11 is dead. ”

    Source location

    Dainton Harley Hill Cressell GITTOS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester City

    AI-generated summary

    Adrian Vincent Balog · 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

    Adrian Vincent Balog died at age 13 on 2 April 2015 at Royal Manchester Children’s Hospital after longstanding morbid obesity, dilated cardiomyopathy and heparin-induced thrombocytopenia. His obesity made him ineligible for heart transplantation and interim mechanical support, and the inquest concluded that it significantly contributed to his death. A principal concern was that national safeguarding guidance did not identify obesity as a sign or symptom of neglect, unlike malnourishment or being underweight.

    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 national safeguarding guidance to identify childhood obesity as a sign or symptom of neglect

    Wider context from the report

    “In the two government documents there is no reference to ‘obesity’ relating to signs and symptoms of neglect in children. The absence of such a reference is a matter of concern as to how obesity in children is viewed as a public health issue in comparison to malnourished or underweight children (which are both referenced as signs and symptoms of neglect). The consensus from the public health witnesses was that obesity should be included within national guidance as a sign of symptom of neglect in order to protect children at risk. ”

    Source location

    Adrian Vincent Balog · 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

    Consider the Review’s recommendations, including the matters raised in the coroner’s report.

    Verbatim wording from the response

    “We will need to consider the detail of the recommendations and we will work with experts in the sector to develop our response to the report with a view to publish a detailed and ambitious implementation strategy later this year. I will ensure that the matters you have raised in your report are considered in the context of the recommendations made in the Review and I hope that my response provides the reassurance you need that this matter will be looked at soon.”

    Source location

    Response from Secretary of State for the Department for Education
    Page 3 · response
    Published 24 February 2022

    Open published response

  4. Manchester South

    AI-generated summary

    Irene Ann Esaw · 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

    Irene Ann Esaw, who had dementia and was dependent on her grandson for all nutritional, mobility, hygiene and personal care, was discharged from hospital without a formal care package or community referrals. She was later found deceased at home in an emaciated state, with severe untreated pressure sores, tissue damage and widespread sepsis. The principal concerns were failures to assess mental capacity, recognise clinical signs of neglect, and ensure effective multi-agency assessment and working.

    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 recognise clinical indicators of neglect as safeguarding concerns

    Wider context from the report

    “2. Recognising the Clinical Signs of Neglect – My findings indicate that in 2018 there was no adequate consideration by the clinical or nursing staff that Mrs. Esaw’s clinical presentation in of itself indicated neglect and therefore a safeguarding concern. The Trust’s Safeguarding Lead ████████ told me that following on from the Domestic Homicide Review, the Trust recognises that more work needs to be done around the recognition of what is neglect and those medical indicators of neglect. She recognised that there needs to be a strengthening of recognition in staff of safety concerns. I understand that this is part of the Safeguarding Lead’s portfolio, but I am concerned that this still needs to be addressed. ”

    Source location

    Irene Ann Esaw · 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

    Deliver a continuing Trust-wide Mental Capacity Act learning and awareness programme using masterclasses, e-learning, briefings, podcasts, animations and related resources.

    Verbatim wording from the response

    “- Training and development The Trust has a focused month on safeguarding throughout the month of November 2021. As part of this whole month of focus there is a Mental Capacity Act Masterclass entitled “back to basics” which will work in parallel with our community and social care partners as a multi-agency plan. In addition to this, a proposal for the inaugural integrated safeguarding conference has also been approved to be held in Spring 2022, hosted by the Trust, with invitations to multi-agency colleagues to promote a culture in which teams collaborate work and learn together.”

    Source location

    Response from Tameside and Glossop NHS England
    Page 2 · response
    Published 17 September 2021

    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

    Include Betty’s Story and its learning in recurrent multi-professional induction and training, and develop a live-play version for organisational dissemination.

    Verbatim wording from the response

    “We have liaised with teams who coordinate multi-professional inductions for staff across the Trust, all have committed to including Betty’s story and the learning from this to develop a recurrent programme of training.”

    Source location

    Response from Tameside and Glossop NHS England
    Page 5 · response
    Published 17 September 2021

    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

    Establish a specialist team to advise clinicians on recognising clinical signs of neglect.

    Verbatim wording from the response

    “The Trust’s Safeguarding Lead, ████████, has continued to focus on this project with the support of the senior nurse and medical leadership team to ascertain how this can be factored into all areas of clinical practice. In addition to this, the Clinical Director for the Emergency Department is establishing a specialist team to provide advice on the clinical signs of neglect. He has requested a nomination from a Divisional team with the advice and support of ████████, who is the Clinical Director for Integration and Consultant Geriatrician, building on a model used by paediatric colleagues.”

    Source location

    Response from Tameside and Glossop NHS England
    Page 5 · response
    Published 17 September 2021

    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

    Implement the Safeguarding Lead’s programme of learning, case-file audits, learning reviews, staff consultation and feedback to strengthen professional curiosity.

    Verbatim wording from the response

    “The Safeguarding Lead started in their role on the 13 September 2021, they are responsible for the implementation of the new Safeguarding Policy and Procedure within Tameside Adult Services. One of the priorities that will run throughout all of their work will be to ensure staff feel confident and equipped to be more ‘professionally curious’. This is recognised safeguarding training and the toolkit, advises that social workers can become more professionally curious and respectfully uncertain by following the points below:”

    Source location

    Response from Tameside and Glossop NHS England
    Page 9 · response
    Published 17 September 2021

    Open published response

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