Recurring concern

Inadequate multi-agency safeguarding coordination

First to latest report 18 Dec 2013 — 5 Mar 2026

Reports that mention this concern
24
Times this concern has been raised
26
Stated actions linked to this concern
48

What this concern includes

Includes failures of the dedicated multi-agency safeguarding coordination process, including delayed or absent strategy meetings, inadequate case coordination, and failures to share relevant information when safeguarding risks require joint action.

What is not included
  • Excludes generic communication, record-keeping or staffing deficiencies not explicitly tied to multi-agency safeguarding coordination.
  • Excludes single-agency assessments, treatment decisions or operational failures unless they concern the multi-agency safeguarding coordination process.
  • Excludes coordination for non-safeguarding services or general discharge planning unless the report explicitly links it to safeguarding risk.

Reports and published responses 24 reports

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

  1. Suffolk

    AI-generated summary

    May Adalaid Miller · 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

    May Adalaid Miller, aged 95, was attacked by another resident while asleep at Beech House Residential Care Home on 9 February 2020 and died from natural causes precipitated by the assault. The report raised concerns about the lack of safeguarding information sharing between agencies and care facilities, including the absence of a system to share information about the other resident’s risk factors.

    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 obtain consent for disclosure of safeguarding information to other agencies

    Wider context from the report

    “In light of the data sharing and confidentiality requirements under GDPR, the GP was unable to disclose full information to the Limes or to Beech House about any previous conduct or assessments of ████████. At no time was the family of Mr ████████ asked to sign a letter giving consent to disclosure to other agencies before or after the residency. It was not known whether the GP could have been the central point of contact for all investigative agencies and the Care Homes. It was established during the evidence that multiple investigative agencies may have been aware of Mr ████████’s risk factors but that due to his not having been admitted to Beech House from a registered facility, that information sharing was not possible. Had there been in place a system for sharing safeguarding information with the Limes and Beech House, there may have been an opportunity to safeguard May Miller. ”

    Source location

    May Adalaid Miller · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    GP confidentiality means the suitability information received about prospective residents is very limited.

    Verbatim wording from the response

    “Prospective residents are interviewed by the warden and the manager. A letter of suitability is always obtained from the G.P. but they seemed to be bound by confidentiality and the information is received is very limited.”

    Source location

    2020-0201-Response-from-the-Limes-Residence-Association_Redacted.pdf
    Page 1 · response
    Published 1 December 2020

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Mr. Thomas REILLY · 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 Thomas REILLY visited Beachy Head on 1 October 2019 intending to jump, but changed his mind after receiving support. A safeguarding alert was delayed and then sent to an individual mailbox rather than the appropriate generic mailbox; it was actioned after Mr Reilly had been found dead early on 3 October. The report identified a missed opportunity to prevent his suicide and stated that the safeguarding system was fundamentally flawed and needed urgent review.

    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

    Delays in processing medium-risk safeguarding alerts

    Wider context from the report

    “When the police officer arrived back at Eastbourne police station he raised a safeguarding alert. This alert was sent to the Multi-Agency Safeguarding Hub (MASH). When received there it should have triggered fast onward transmission to the appropriate agency to support Mr Reilly. It was received at MASH at 15.33hrs on the 1st October but, although it had been sent as soon as possible after the incident, it was clear from the evidence that it stood no chance of being dealt with on the 1st. (2) The alerts are graded low, medium and high risk. The high risk alerts stand a chance of being dealt with timeously. This was graded medium which was a reasonable assessment. Everything else will be delayed. Indeed the alert for Mr Reilly was not dealt with until 12:40 hours on Friday, the 4th of October. That is after lunch on a Friday. (3) This alert was not dealt with again until Monday, the 7th of October when it was sent to the mailbox of a named mental health social worker ████████ rather than to the Sussex Partnership Foundation Trust generic mailbox where it would have been actioned on the 7th. As it was, it was received by ████████ on the morning of the 8th. She actioned it at once. Too late, Mr Reilly had been found dead early on the 3rd of October. ”

    Source location

    Mr. Thomas REILLY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. 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 share safeguarding referral information and reasons with relevant third parties, services or agencies

    Wider context from the report

    “2...The evidence received by the Court indicates that the closure of the safeguarding referral marks an end to social services involvement. Despite this no attempt is made to share the fact of the referral or the reasons for it with any third party, service or agency. This may have the unintended result of depriving third parties (including parents) and agencies already participating in the care and welfare of a child from being alerted to the concern and taking appropriate action (including accessing other services) in response to it. The submissions made on behalf of the council indicate these practices are driven by considerations of data protection compliance The practice imperils the precedence to be given to the paramountcy principle and has the potential to undermine the protection of children who are the subject of referral. ”

    Source location

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

    Open source report

  4. Manchester South

    AI-generated summary

    Katie Croft · 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 Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.

    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 ensure case officers attend safeguarding strategy meetings

    Wider context from the report

    “3. At the safeguarding strategy meeting an officer allocated to attend such meetings on behalf of GMP attended rather than an officer allocated to the case. As a result the quality of information sharing and understanding of the allegation was more limited. On the particular police division in question this practice has stopped. It was unclear how common the approach is on a wider basis; ”

    Source location

    Katie Croft · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Cheshire

    AI-generated summary

    Mr Sam Spooner · 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 Sam Spooner died at Leighton Hospital on 31 August 2018 after being found unresponsive following an act intended to end his life. The report identified concerns about inadequate multi-agency information sharing, coordination and intervention despite known suicide risk, and excessive reliance on his family to keep him safe.

    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 adopt an effective multi-agency approach to care during known suicide risk

    Wider context from the report

    “1) There was a lack of multi-agency information sharing, co-operation, co-ordination and effective communication both within and between health care providers which meant that: a) The private counsellor who provided treatment to Mr Spooner did not have adequate information from other health care providers as to his medical/mental health history, diagnosis and treatment by other healthcare professionals. b) There was a failure to adopt an effective multi-agency approach to the care for Mr Spooner from 20th August 2018 when it was known that he was actively considering ending his life. c) There was a failure to adequately intervene from 30th August 2018 when it was known that: (1) Mr Spooner had recently attempted to take his life; and (2) Mr Spooner had subsequently undertaken additional research and made further preparations to enable him to do so. 2) There was an excessive and unreasonable reliance placed upon Mr Spooner's family by health care providers to keep him safe when those providers knew that Mr Spooner's family were not in a position to do so. Health care providers lacked awareness of and/or failed to adequately involve other agencies who may have been able to keep Mr Spooner safe, for example the police who may have been able to exercise their powers under section 136 of the Mental Health Act 1983 to take Mr Spooner to a place of safety. ”

    Source location

    Mr Sam Spooner · 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

    Maintain and publish a national GP curriculum covering assessment and management of mental health problems, including suicide risk and safety planning.

    Verbatim wording from the response

    “The assessment and treatment of patients with mental health difficulties is a core component of being a GP. RCGP has published a detailed curriculum for general practitioners nationally and it is used both to assess doctors aspiring to work as a general practitioner as well as the standards against which we are viewed as qualified GPs. Within this, there is a detailed section on the Care of People with Mental Health Problems. https://www.rcgp.org.uk/training-exams/training/gp-curriculum-overview/online-curriculum-2018/managing-complex-care/3-10-mental-health-problems/3-10-knowledge-and-skills.aspx Key components in this regard are the requirements to:”

    Source location

    2019-0378-Royal-College-of-General-Practitioners
    Page 2 · response
    Published 27 December 2019

    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

    Publish guidance for GPs on assessing, managing and referring patients with suicidal ideation, including a toolkit and quick-reference leaflet.

    Verbatim wording from the response

    “To compliment the above course, we have published guidance to general practitioners on the assessment, immediate management and onward referral for patients with suicidal ideation. This is via a detailed “toolkit” and for ease of reference I have enclosed “Suicide Prevention Top Ten Tips” leaflet which gives general guidance in this area.”

    Source location

    2019-0378-Royal-College-of-General-Practitioners
    Page 2 · response
    Published 27 December 2019

    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

    Support NHS England and devolved health authorities in developing improved mental-health care, including information sharing, case coordination and family-carer support.

    Verbatim wording from the response

    “Additionally, RCGP regularly inputs into national organisations looking to improve the responsiveness and understanding of mental health services. For example, I have personally attended and input into the All Party Parliamentary Group on Suicide and Self Harm. We also regularly support NHS England and devolved nations health authorities in the development of improved care, frequently alongside our sister Royal College, the Royal College of Psychiatrists. Work has included strategies to improve information sharing and case co-ordination as well as support for family members/carers.”

    Source location

    2019-0378-Royal-College-of-General-Practitioners
    Page 2 · response
    Published 27 December 2019

    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

    Amend assessment and consent forms to ask about psychiatric history and obtain consent to contact relevant mental health practitioners.

    Verbatim wording from the response

    “She has spoken to other private psychotherapists and her Clinical Supervisor about their respective practices. Mrs ████████ always asks clients whether they have ever been under Mental Health Services, but she has now amended her assessment and consent forms (which are attached) so that she asks more particular questions about previous psychiatric history. It is also the case that NICE issued guidelines on 10 September 2019 (i.e. after Mr Spooner's death) in relation to multi-agency suicide prevention partnerships and Mrs ████████ has both considered those guidelines and thought about how she might implement some changes in her practice, both as a result of those guidelines and as a result of this case.”

    Source location

    2019-0378-Response-from-Counsellor_Redacted
    Page 2 · response
    Published 27 December 2019

    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

    Existing RCGP mental-health education, guidance and service-improvement work is considered an adequate response to suicide-prevention concerns.

    Verbatim wording from the response

    “From the above, RCGP already undertakes considerable work in this important area as we see it as a key priority. I will ensure that the sad case of Mr Spooner is brought to the attention of our mental health leads and our educational convenors so that we can continue to do what we can to improve services for patients such as Mr Spooner.”

    Source location

    2019-0378-Royal-College-of-General-Practitioners
    Page 3 · response
    Published 27 December 2019

    Open published response

  6. Inner South London

    AI-generated summary

    Ms Donna Williamson · 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

    Donna Williamson, a 44-year-old woman with mental health, alcohol dependence, mobility and domestic abuse vulnerabilities, died from stab wounds to the chest after being assaulted with a knife by her ex-partner. The principal concerns included the failure to secure her insecure door, failure to inform her that the suspect had been released on bail, and weaknesses in the MARAC process for protecting chaotic and non-engaging individuals.

    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 the MARAC process to provide coordinated protection and support for chaotic non-engaging individuals

    Wider context from the report

    “3. The MARAC process was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. Lengthy evidence was heard from the independent chair of the Domestic Homicide Review, who had conducted 23 such reviews. She said that the MARAC system can be good depending on the priority given by each organization. In this case agencies should have worked together to address risks in the context of her life environment and network. Instead her needs were compartmentalised. Her evidence was clear that no MARAC can deliver the needs of chaotic non engaging individuals. She reported that there were arguments for MARAC and other bodies to be put on a statutory footing. Clearly there is an urgent need for national review how the system can afford protection and support for these particularly vulnerable complex individuals or whether changes need to be made to it. ”

    Source location

    Ms Donna Williamson · 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

    Call on Government to assess the effectiveness of the MARAC model and identify improvements, including support and investment for responding agencies.

    Verbatim wording from the response

    “Your report notes that the Multi-Agency-Risk-Assessment-Conference (MARAC) process, in this case, was incapable of facilitating protection and resolution of problems for chaotic non engaging individuals. We support your recommendation for a national review of how the MARAC system can afford protection and support for these particularly vulnerable complex individuals.”

    Source location

    2019-0111-Responses
    Page 3 · response
    Published 9 June 2019

    Open published response

  7. West Sussex

    AI-generated summary

    Paul Lawrence Hanton · 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

    Paul Hanton was an informal patient at Langley Green Mental Health Hospital when he absconded during an escorted walk on 18 April 2016. Eight days later, he jumped in front of a train at Kings Cross Underground Station and died from head injuries. The principal concerns included the information provided during the missing-person call, delays and gaps in police action, inaccessible hospital CCTV, and differing responses to informal and sectioned patients assessed as being at high risk of self-harm or suicide.

    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 joint policy with the Adult Safeguarding Board

    Wider context from the report

    “5) Police to consider joint policy with Adult Safeguarding Board. ”

    Source location

    Paul Lawrence Hanton · Prevention of Future Deaths report
    Page 4 · 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 the jointly agreed absent-without-leave and informal-missing-patients policy through partner-agency consultation, including seeking Safeguarding Board comments and considering coroner recommendations.

    Verbatim wording from the response

    “Point five identifies the need to consider a joint policy with the Adult Safeguarding Board. Sussex Police and Sussex Partnership NHS Foundation have a jointly agreed policy relating to patients absent without leave / informal missing patients which applies to all patients including those detained under the Mental Health Act 1983, subject to Guardianship, Supervised Community Treatment Orders as well as those in hospital informally. The document provides guidance for managers and staff regarding duties, responsibilities and actions to be taken when a patient is absent without leave or provides the legal framework which sets out these duties and responsibilities. This Policy (a copy of which is attached) was due for review in November 2017 and is currently in the process of consultation with all partner agencies prior to the finalisation of any amendments and additions.”

    Source location

    2018-0021-Response-by-Sussex-Police
    Page 2 · response
    Published 14 March 2018

    Open published response

  8. Manchester South

    AI-generated summary

    Russell Charles ROBB · 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

    Russell Charles ROBB died at Manchester Royal Infirmary on 9 April 2016 after taking a fatal combination of prescribed and non-prescribed drugs with alcohol. The report identified inadequate monitoring and lack of regular medication reviews, no apparent guidelines to limit the quantity of drugs available, and limited information sharing between agencies involved in adult safeguarding.

    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 hold strategic safeguarding meetings at an adequate frequency

    Wider context from the report

    “which ultimately led to his death. There was no evidence of regular reviews of his medication. There appeared to be no guidelines in place to reduce the quantity of drugs available to Mr Robb at any one time. (CCG; Secretary of State for Health) 2. There was limited evidence of information sharing between the members of the Trafford Adult Safeguarding Board. This meant that the Local Authority were unaware of volume of interaction between the Police and Mr Robb.(Adult Safeguarding Board).As a result only 1 strategic meeting took place over a 6 year period ”

    Source location

    Russell Charles ROBB · 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

    Redesign the Safeguarding Boards and develop an integrated children-and-adults structure while retaining distinct group focus.

    Verbatim wording from the response

    “At a strategic level, we are in the process of redesigning our Safeguarding Boards and developing a more effective, integrated children and adults structure, whilst ensuring that a unique focus on each group is retained.”

    Source location

    2017-0385-Response-by-Trafford-Safeguarding-Board
    Page 2 · response
    Published 12 February 2018

    Open published response

  9. Shropshire, Telford and Wrekin

    AI-generated summary

    Derrick Edward ROSE-FOWLER · 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

    Derrick Edward ROSE-FOWLER was found hanging by his neck from his prison cell window on 5 June 2015 and was pronounced dead after being transferred to hospital. The concerns included the first attending prison officer not being first-aid trained, the handling of alleged bullying, and the failure to raise concerns about the deceased at a MASH meeting despite several relevant factors.

    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 refer concerns to a MASH meeting when risk indicators are present

    Wider context from the report

    “(4) Regardless of whether the TBB policy was appropriately implemented there was evidence that concerns relating to the deceased should have been raised at a MASH meeting. Factors which should have triggered such a referral were: a. History of self-harm in 2014. b. Recorded diagnoses of anxiety and depression. c. An ACCT opened at HMP Featherstone in October 2014. d. The intelligence report raised by the mental health nurse in March 2015. e. The letter handed by the deceased to a prison officer in April 2015. f. The refusal of the deceased to take prescribed medication. g. The refusal of the deceased to attend scheduled GP appointments. It could not be said that any such referral would have changed the outcome but there was evidence that something would have been done. ”

    Source location

    Derrick Edward ROSE-FOWLER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Manchester South

    AI-generated summary

    Kesia Lena Mary Leatherbarrow · 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

    Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

    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

    Inconsistent safeguarding functions across Manchester Multi-Agency Safeguarding Hubs

    Wider context from the report

    “This was not the system in Manchester and the Court heard evidence that the development of MASHs across Manchester is still ongoing. The Court heard evidence that in Manchester different hubs work differently with different agendas – some relate to domestic violence only and not all of them deal with safeguarding of children. ”

    Source location

    Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
    Page 7 · 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