3 May 2022 Kate Hedges · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to follow safeguarding policy after disclosure of a serious allegation of inappropriate touching by another patient View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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
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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
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9 Jul 2021 Alan Howard Foster Griffin · Prevention of Future Deaths report Inner North London
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Concerns raised 6
Failure to exercise sufficient scrutiny of allegations and obtain their details and source View source Failure to list and verify allegations before referral View source Failure to provide allegations promptly to the person concerned View source
Failure to use a safeguarding meeting to discuss allegations View source Failure to set out allegations and their sources plainly before prolonged investigation View source Failure to progress safeguarding investigations promptly and independently when external engagement is absent View source See 3 more concerns
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
CSSA Diocese of London Lambeth Palace
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 13
Diocese of London and Lambeth Palace
Appoint an experienced independent reviewer to provide external scrutiny of diocesan safeguarding systems and processes.
View source
Diocese of London and Lambeth Palace
Design and implement improved systems for capturing, triaging, recording, assessing and appropriately sharing safeguarding and conduct information.
View source
Diocese of London and Lambeth Palace
Develop a supervised referral and triage process that assigns case holders and maintains initial and ongoing risk assessments, including mental health.
View source
Diocese of London and Lambeth Palace
Develop casework tracking and structured review systems to record progress against milestones and monitor actions throughout each case.
View source
Diocese of London and Lambeth Palace
Update and reissue the concern reporting form to prompt complete disclosures, including information about relevant evidence and witnesses.
View source
CSSA
Develop a casework meeting template prompting reflection and critical thinking.
View source
CSSA
Update and issue practice guidance on clarifying, verifying and escalating allegations and concerns.
View source
CSSA
Develop and roll out mandatory safeguarding leadership training on professional curiosity, reflection and support for respondents.
View source
Diocese of London and Lambeth Palace
Ensure relevant clergy background information and training records are accessible to safeguarding staff, with improved tracking of file access and transfer.
View source
CSSA
Launch national Safeguarding Standards requiring information, pastoral, professional and legal support for respondents.
View source
CSSA
Update practice guidance to emphasise prompt notification, timely investigations and ongoing support for respondents.
View source
Diocese of London and Lambeth Palace
Conduct an independent external Lessons Learned Review of safeguarding and conduct handling, including information management, risk assessment, casework and inter-church sharing.
View source
CSSA
Change the minimum case-management supervision standard to monthly, with more frequent supervision when required.
View source See 10 more actions
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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.
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× 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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Actions and positions describe what organisations say in published responses. Implementation is not independently verified.