Recurring concern

Unreliable handling of safeguarding allegations

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First reported 9 Jul 2021•Latest report 3 May 2022

Definition

What this concern includes

Includes failures in the dedicated safeguarding-allegation process involving recording or verifying allegations, communicating them to the person concerned or responsible organisations, preserving their source and progressing related investigations where these controls affect safe safeguarding decisions.

Not included

  • Excludes general safeguarding, complaint-handling or disciplinary deficiencies where no allegation-handling failure is identified.
  • Excludes unsupported allegations or investigation outcomes where the safeguarding-allegation process itself is not deficient.
  • Excludes clinical, criminal or regulatory investigations unless the assertion explicitly concerns the handling of safeguarding allegations.
  • Excludes failures occurring after allegations have been reliably recorded, verified and communicated when the remaining issue is a separate assessment or protective-action failure.
Reports
2

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2021–2022

First to latest report issue date

Stated actions
14

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.

Catholic Safeguarding Standards Agency1
Church of England1
Department of Health and Social Care1
Greater Manchester Mental Health NHS Foundation Trust1

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. Manchester South

    AI-generated summary

    Kate Hedges · 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

    Kate Hedges died at Gatley Station on 27 November 2020 as a consequence of injuries sustained in an event that is redacted in the supplied text. The concerns included separate computerised record-keeping systems that could mean staff lacked relevant information for risk assessments and care plans, and an alleged failure to follow safeguarding policy. The report also raised concerns that mental health services were not consistently trauma-informed and that the ward environment could be distressing and difficult for people who had experienced trauma.

    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 follow safeguarding policy after disclosure of a serious allegation of inappropriate touching by another patient

    Wider context from the report

    “2. It is also a matter of concern that, following disclosure by Ms Hedges at a multidisciplinary meeting of a serious allegation to the effect that she was touched inappropriately by another patient, the Trust’s own safeguarding policy was not followed. ”

    Source location

    Kate Hedges · 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 twice-weekly patient safety meetings and include sexual safety as a standing topic in meetings and staff supervision.

    Verbatim wording from the response

    “GMMH is taking part in the Sexual Safety National Collaborative with the Royal College of Psychiatrists that aims to increase the percentage of service users and staff who feel safe from sexual harm within mental health and learning disabilities services. Bronte Ward has been involved in this project and has implemented changes over the past two years including twice weekly patient safety meetings that have sexual safety on the agenda and give staff and patients opportunity to discuss any concerns or ideas for improvements, and sexual safety is a standard agenda item in staff supervision.”

    Source location

    Response from Greater Manchester Mental Health
    Page 3 · response
    Published 5 May 2022

    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

    Staff followed safeguarding processes after the reported sexual harassment, although the team acknowledged that transfer to a single-sex ward should have been considered.

    Verbatim wording from the response

    “Ms Hedges reported at the multi-disciplinary meeting held on 20th October 2020 that she was being sexually harassed by a male patient on the ward and was considering reporting this to the police. On reviewing Ms Hedges’ clinical record staff were aware of this and had followed Trust safeguarding processes by recording the discussions and putting plans in place with Ms Hedges to address on 18th October 2020. In this instance the male patient was due to be discharged from the ward, this was progressed, and Ms Hedges agreed to be supported by staff with increased observations. Transfer of Ms Hedges to another ward did not happen because Ms Hedges was having leave from the ward and was planning for discharge and the fact the male”

    Source location

    Response from Greater Manchester Mental Health
    Page 2 · response
    Published 5 May 2022

    Open published response
  2. Inner North London

    AI-generated summary

    Alan Howard Foster Griffin · 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

    Alan Howard Foster Griffin died by suicide at home on 8 November 2020 while under investigation by his former and current dioceses. The principal concerns were systemic and individual failings in the handling of unverified allegations, including inadequate verification, inaccurate and incomplete information-sharing, unclear responsibility, and failure to seek recommended legal advice.

    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 exercise sufficient scrutiny of allegations and obtain their details and source

    Wider context from the report

    “1. The safeguarding team of the Roman Catholic Diocese of Westminster did not exercise sufficient professional scrutiny of the allegations that came to them from the Anglican safeguarding team. This was partly because they gained a false sense of security from the fact that the allegations came from the Church of England. However, there was more that could have been done to establish the exact nature of the allegations and whether these were credible. The Catholic safeguarding team asked for disclosure from the Anglican safeguarding team and most particularly for the source of the allegations. When they did not receive either of these, they should have insisted. ”

    Source location

    Alan Howard Foster Griffin · 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

    Failure to list and verify allegations before referral

    Wider context from the report

    “2. The head of operations’ allegations were never clearly listed at the outset and appropriately verified with him. He told me in evidence that he had never alleged that Father Griffin had abused children. He said that he had never alleged that Father Griffin had sex with minors. And he said that he had never alleged that Father Griffin had sex whilst HIV+ and believing himself to be an infection risk. His recollection was confirmed by others who were present. Nevertheless, these were the allegations that were passed on to the Roman Catholic (RC) Church by the CofE. ”

    Source location

    Alan Howard Foster Griffin · 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

    Failure to provide allegations promptly to the person concerned

    Wider context from the report

    “3. Father Griffin then asked to know the allegations against him before he attended another meeting with the Catholic safeguarding team. The safeguarding team felt that the information was not theirs to give because it came from the Church of England, but Father Griffin should have been provided with a note of the allegations promptly. ”

    Source location

    Alan Howard Foster Griffin · Prevention of Future Deaths report
    Page 3 · 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 use a safeguarding meeting to discuss allegations

    Wider context from the report

    “2. The Catholic safeguarding team met with Father Griffin on 23 June 2020 to discuss his DBS check. That would have been an ideal opportunity to discuss the Church of England allegations that would have shortened the process considerably and the opportunity was lost. ”

    Source location

    Alan Howard Foster Griffin · 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

    Failure to set out allegations and their sources plainly before prolonged investigation

    Wider context from the report

    “10. Thus, the allegations against Father Griffin passed on to the Roman Catholic Church were supported by no complainant, no witness and no accuser. There was no concern raised by a victim of abuse, by a child, parent, teacher, youth worker or other witness. No person said they had been the subject of or had witnessed any concerning behaviour, save that Father Griffin had been seen to have dinner with men in an Italian restaurant, for which he might have paid the bill. The CofE safeguarding adviser finally tasked with dealing with the matter did not consider that there was any safeguarding concern. And yet on this basis, Alan Griffin found himself to be under investigation for over a year, without ever having the allegations and their source plainly set out for him. ”

    Source location

    Alan Howard Foster Griffin · Prevention of Future Deaths report
    Page 6 · 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 progress safeguarding investigations promptly and independently when external engagement is absent

    Wider context from the report

    “5. The Catholic safeguarding team volunteered at inquest that they did not deal with the investigation into Father Griffin promptly and they apologised for this. The very first telephone call was placed to the Catholic safeguarding adviser on 30 October 2019. The delay was therefore significant and it was harmful. This was in part because the Catholic safeguarding team were waiting for the engagement of the Anglican safeguarding team to enable a joint approach to be taken. When it was clear that such engagement was not forthcoming (whether for reasons of sickness or anything else), the Catholic safeguarding team should have gone back to the local authority designated officer (the LADO) and recommended that they continue without further input from the Church of England. ”

    Source location

    Alan Howard Foster Griffin · 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

    Appoint an experienced independent reviewer to provide external scrutiny of diocesan safeguarding systems and processes.

    Verbatim wording from the response

    “As a result of the concerns that the Coroner raised in her report, we have revised the terms of reference initially proposed for the Lessons Learned Review and have taken steps towards appointing”

    Source location

    2021-0243-Response-from-Church-of-England_Published
    Page 1 · response
    Published 15 July 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

    Design and implement improved systems for capturing, triaging, recording, assessing and appropriately sharing safeguarding and conduct information.

    Verbatim wording from the response

    “• Our new Head of Safeguarding has already started working with the team to design and implement new systems of information capture, triage, recording, assessment and appropriate sharing of safeguarding and conduct matters. These issues will form part of our overarching improvement plan.”

    Source location

    2021-0243-Response-from-Church-of-England_Published
    Page 3 · response
    Published 15 July 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

    Develop a supervised referral and triage process that assigns case holders and maintains initial and ongoing risk assessments, including mental health.

    Verbatim wording from the response

    “2. The development of a referral/triage system, with supervision from the Head of Safeguarding, to ensure that matters are separated out into safeguarding, non-safeguarding conduct, and “other” issues, ensuring an initial and ongoing assessment of risk (including mental health) and with appropriate follow up action by a designated case holder.”

    Source location

    2021-0243-Response-from-Church-of-England_Published
    Page 3 · response
    Published 15 July 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

    Develop casework tracking and structured review systems to record progress against milestones and monitor actions throughout each case.

    Verbatim wording from the response

    “3. The development of a casework management tracking system for all referrals into the safeguarding team to record timely progress against key milestones and ensure a structured review process (including risk and mental health) during the lifetime of a case.”

    Source location

    2021-0243-Response-from-Church-of-England_Published
    Page 3 · response
    Published 15 July 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

    Update and reissue the concern reporting form to prompt complete disclosures, including information about relevant evidence and witnesses.

    Verbatim wording from the response

    “Both of these actions will ensure better oversight of any potential safeguarding referral, and ensure appropriate handling, including seeking evidence and witnesses. | The concern reporting form is being updated and will be reissued shortly. This will prompt full disclosures including pointing to relevant evidence and witnesses.”

    Source location

    2021-0243-Response-from-Church-of-England_Published
    Page 6 · response
    Published 15 July 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

    Develop a casework meeting template prompting reflection and critical thinking.

    Verbatim wording from the response

    “b. To support reflection and critical thinking in intra-agency or inter-agency meetings, the CSSA is developing a template form to be used in casework meetings. The template will include all areas that need to be considered and addressed and will act as a prompt to safeguarding practitioners.”

    Source location

    2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
    Page 2 · response
    Published 15 July 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

    Update and issue practice guidance on clarifying, verifying and escalating allegations and concerns.

    Verbatim wording from the response

    “c. The CSSA is updating its practice guidance on the management of allegations and concerns, to provide for situations where concerns are raised but the information cannot immediately be clarified or verified. The guidance will give a timescale within which the information must be clarified or verified, what action must be taken if this cannot be achieved (i.e., escalation to the Safeguarding Sub-Committee for consideration and decision as to next steps).”

    Source location

    2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
    Page 2 · response
    Published 15 July 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

    Develop and roll out mandatory safeguarding leadership training on professional curiosity, reflection and support for respondents.

    Verbatim wording from the response

    “Training The CSSA national training lead is developing a suite of training for those in leadership and management in safeguarding roles within Church bodies. Work has commenced and the training modules, which will include mandatory modules on reflection and professional curiosity and on the provision of support to those about whom allegations or concerns have been raised, and they will be rolled out over the course of 2022.”

    Source location

    2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
    Page 2 · response
    Published 15 July 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

    Ensure relevant clergy background information and training records are accessible to safeguarding staff, with improved tracking of file access and transfer.

    Verbatim wording from the response

    “We accept that there was clarification neither of the term used nor of its origin (ie by whom it was used) in the meetings that took place. | The single referral form for all safeguarding concerns will prompt those recording disclosures to be clear, as much as is practicably possible, as to the origin of information and to take steps to ensure that it is appropriately verified or investigated by the safeguarding team. We will also ensure that appropriate terminology is used. | We will continue to ensure that any relevant background information stored on clergy blue (HR) files is made available to members of the safeguarding team, that DBS safeguarding training records are up to date and accessible, and that we have better systems for tracking file access and transfer.”

    Source location

    2021-0243-Response-from-Church-of-England_Published
    Page 7 · response
    Published 15 July 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

    Launch national Safeguarding Standards requiring information, pastoral, professional and legal support for respondents.

    Verbatim wording from the response

    “National Safeguarding Standards On 27th October 2021, the CSSA launched its new national Safeguarding Standards, which can be viewed at: https://www.catholicsafeguarding.org.uk/national-safeguarding-standards/the-standards/ Standard 5 relates specifically to the management and support of those who are the subject of allegations and concerns, and requires church bodies to:”

    Source location

    2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
    Page 2 · response
    Published 15 July 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

    Update practice guidance to emphasise prompt notification, timely investigations and ongoing support for respondents.

    Verbatim wording from the response

    “National Safeguarding Policy and Practice Guidance There is considerable existing practice guidance on Church bodies’ responsibilities towards clergy and religious against whom allegations have been made, including on conducting an initial meeting with an individual against whom allegations have been made. In view of this case, that guidance will be updated to emphasise the importance of promptly informing individuals of allegations made against them, of completing safeguarding investigations in a timely manner, and of ensuring that support needs are identified and met throughout.”

    Source location

    2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
    Page 3 · response
    Published 15 July 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

    Conduct an independent external Lessons Learned Review of safeguarding and conduct handling, including information management, risk assessment, casework and inter-church sharing.

    Verbatim wording from the response

    “We aim to agree the Terms of Reference by early September with the intention of the Lessons Learned Review ("the Review") beginning in September 2021. The purpose and objectives of the Review are currently as follows:”

    Source location

    2021-0243-Response-from-Church-of-England_Published
    Page 2 · response
    Published 15 July 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

    Change the minimum case-management supervision standard to monthly, with more frequent supervision when required.

    Verbatim wording from the response

    “Case supervision There is already national practice guidance in relation to induction, supervision, and support. Currently, the requirement is for case management supervision to be undertaken regularly. The standard will be changed to monthly (pro-rata for non-full-time roles) as a minimum with the requirement for more frequently if there are obstacles or changes that require resolution.”

    Source location

    2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
    Page 3 · response
    Published 15 July 2021

    Open published response
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Data last updated 7 September 2026