Recurring concern

Inadequate multi-agency safeguarding coordination

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First reported 18 Dec 2013•Latest report 5 Mar 2026

Definition

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.

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
24

Distinct published reports

Individual concerns
26

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
48

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.

Department of Health and Social Care9
Home Office4
National Police Chiefs’ Council3
NHS England3
Birmingham and Solihull Mental Health NHS Foundation Trust2
College of Policing2
Crown Prosecution Service2
Department for Education2
Greater Manchester Police2
Metropolitan Police Service2
Ministry of Housing, Communities and Local Government2
Ministry of Justice2
Pennine Care NHS Foundation Trust2
Surrey and Borders Partnership NHS Foundation Trust2
Sussex Police2

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 West

    AI-generated summary

    Aleysha Martine Karla McLoughlin · 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

    Aleysha Martine Karla McLoughlin, aged 16, died by hanging at her foster home on 3 April 2014 after a history of self-harm, overdoses and assessed ongoing risk of impulsive self-harm. The concerns included training for professionals to recognise self-harm, systems for sharing information when young people self-harm, urgent multi-agency discussions including mental health services, and a formal support pathway for young people who resist engagement.

    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 urgent multi-agency discussions involving all relevant agencies for young people at risk of self-harm

    Wider context from the report

    “(3) That it should be considered that systems such as those now being developed in Bolton should be further developed so as to ensure that multi agency discussions involving all relevant agencies are held urgently for those at risk of self harm and particularly for those who do not engage. Evidence was given that meetings concerning Aleysha Martine Karla McLoughlin did not include the Child and Adolescent Mental Health Services although evidence was given that their input would have been valuable. ”

    Source location

    Aleysha Martine Karla McLoughlin · 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

    Support the Public Service Transformation Network and Early Intervention Foundation in co-designing better outcomes for vulnerable people.

    Verbatim wording from the response

    “Lastly, DCLG is focussed on supporting local services to provide early, integrated support for people who need the most help. Central to this is a need to ensure effective sharing of information between agencies and developing effective multi-agency approaches. The department supports the Public Service Transformation Network and the Early Intervention Foundation to help councils and their local partners in the co-design and co-production of better outcomes for vulnerable people. DCLG also supports local authorities on the delivery of the expanded troubled families programme. This aims to directly help up to 400,000 families over the next five years, transforming lives by improving the way local services operate, crucially joining up and co-ordinating the support they offer these families.”

    Source location

    2015-00136-Response-by-Department-of-Health
    Page 4 · response
    Published 8 April 2015

    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 local authorities in delivering the expanded troubled families programme to improve coordinated services for vulnerable families.

    Verbatim wording from the response

    “Lastly, DCLG is focussed on supporting local services to provide early, integrated support for people who need the most help. Central to this is a need to ensure effective sharing of information between agencies and developing effective multi-agency approaches. The department supports the Public Service Transformation Network and the Early Intervention Foundation to help councils and their local partners in the co-design and co-production of better outcomes for vulnerable people. DCLG also supports local authorities on the delivery of the expanded troubled families programme. This aims to directly help up to 400,000 families over the next five years, transforming lives by improving the way local services operate, crucially joining up and co-ordinating the support they offer these families.”

    Source location

    2015-00136-Response-by-Department-of-Health
    Page 4 · response
    Published 8 April 2015

    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

    Local Safeguarding Children Boards are responsible for safeguarding children and ensuring local agencies’ effectiveness.

    Verbatim wording from the response

    “Provision exists under Section 14 of the Children Act 2004 for Local Safeguarding Children Boards (LSCBs) to have responsibility for safeguarding and promoting the welfare of children and ensuring the effectiveness of local agencies in this respect.”

    Source location

    2015-00136-Response-by-Department-of-Health
    Page 3 · response
    Published 8 April 2015

    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 Association of Independent LSCB Chairs was asked to consider the concerns raised about local safeguarding arrangements.

    Verbatim wording from the response

    “DfE has forwarded a copy of your letter to ████████ of the Association of Independent LSCB Chairs asking him to consider the points you raise. DfE has also introduced a number of reforms of social work practice to protect vulnerable people.”

    Source location

    2015-00136-Response-by-Department-of-Health
    Page 3 · response
    Published 8 April 2015

    Open published response

  2. Mid Kent and Medway

    AI-generated summary

    Alex Kelly · 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

    Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

    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 involve outside agencies and carers in safeguarding

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”

    Source location

    Alex Kelly · 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

    Introduce a more rigorous ACCT quality-assurance process with individual feedback to case managers.

    Verbatim wording from the response

    “As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.”

    Source location

    2014-0555-Response-by-Ministry-of-Justice
    Page 5 · response
    Published 28 December 2014

    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

    Require Cookham Wood case workers to facilitate regular community visits, significant-incident updates, and community and parental participation in ACCT reviews.

    Verbatim wording from the response

    “Point 3,a; The arrangements now in place, require Case Workers at Cookham Wood, to encourage the external YOT and Social Workers (where a Looked After Child (LAC)) to visit young persons in custody at least monthly, to meet with the young”

    Source location

    2014-0555-Response-by-Medway-Youth-Offending-Service
    Page 3 · response
    Published 28 December 2014

    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 ACCT process is not inherently unfit for use with young people; identified implementation deficiencies have been addressed through guidance and quality assurance.

    Verbatim wording from the response

    “As you may be aware, in 2013, following a recommendation from the Prisons and Probation Ombudsman, NOMS established a working group to review the effectiveness of the ACCT process for young people. This included representatives from the Ministry of Justice, Youth Justice Board, Home Office and NHS England. The review found that there is nothing in principle that makes the ACCT process unfit for use within the under 18 estate. However, it found some deficiencies in the implementation of the ACCT process and these were addressed in guidance that was sent to Governors of under 18 YOIs in 2013. In January 2015 a further letter to the Governors of under 18 YOIs set out a number of actions, including a requirement to ensure that a quality assurance process is in place to identify and rectify any deficiencies in the ACCT process.”

    Source location

    2014-0555-Response-by-Ministry-of-Justice
    Page 5 · response
    Published 28 December 2014

    Open published response

  3. Inner South London

    AI-generated summary

    Lauren Barfoot · 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

    Lauren Barfoot was a 14-year-old looked-after child who went missing from Micawber House on 22 June 2012 and was later discovered in the porch of her putative father’s home. The report identified concerns about failures to share information, classify the level of risk, conduct an effective search, and hold a timely strategy meeting. The inquest concluded that her accidental death was contributed to by failures in sharing information and pooling and using resources.

    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 a timely strategy meeting to pool information and resources for an effective search

    Wider context from the report

    “(4) There was a failure by the London Borough of Bexley to hold a timely “strategy meeting” by those concerned in the care for Lauren after she had been missing for several days in order to pool information and resources in order to carry out an effective search for Lauren. ”

    Source location

    Lauren Barfoot · 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

    Prepare risk assessment reports for missing looked-after children’s strategy meetings and pass them to police to inform search-risk and resource decisions.

    Verbatim wording from the response

    “A risk assessment report is required in preparation for any strategy meetings for missing looked after children. A strategy meeting is held within three days of a child going missing. The social worker will provide a risk assessment report to the meeting in accordance with the Bexley Practice Guidance pro-forma for assessing risk. The meeting is chaired by the Independent Reviewing Officer for the child. The risk assessment report requires comprehensive information about all possible contacts and locations where the child may be found, including any information known about risks presenting to the young person. The risk assessment report will be passed to the police at the strategy meeting in order that they can assess the level of risk and resources required so that they can carry out an effective search for the missing young person.”

    Source location

    2014-0385-Response-by-Bexley-Borough-Council
    Page 2 · response
    Published 28 August 2014

    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

    Hold missing looked-after children’s strategy meetings within prescribed timescales, oversee their timeliness, and monitor performance through monthly reports and meetings.

    Verbatim wording from the response

    “Strategy meetings for missing looked after children are held within the timescales set out in the “Children who go missing from Home or Care Practice Guidance” implemented in May 2013. The holding of the strategy meetings are overseen by the manager for the ‘looked after’ Independent Reviewing Officer service. The timeliness of ‘missing’ strategy meetings is tracked in monthly performance reports and meetings, to ensure good practice is maintained.”

    Source location

    2014-0385-Response-by-Bexley-Borough-Council
    Page 2 · response
    Published 28 August 2014

    Open published response

  4. Shropshire, Telford and Wrekin

    AI-generated summary

    Christine Ann 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

    Christine Ann Williamson, aged 62, died following a physical assault by her husband, who had advanced Alzheimer’s dementia and was unaware of his actions or their consequences. The concerns included the absence of an earlier referral and assessment of her as a vulnerable adult at risk, and inadequate information sharing that might have enabled preventative measures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to share significant safeguarding information between concerned professionals

    Wider context from the report

    “(2) Had such an earlier assessment as a Vulnerable Adult been made then discussions would have taken place with all concerned with every having significant information sharing it with others. This would have increased the likelihood that preventative measures would have been put in place as the deceased being better or fully informed as to the increased risk she was putting herself in by continuing to live with her husband whose condition was deteriorating. The best illustration of this lack of shared information is that the evidence given at the Inquest when all relevant witnesses were present, should have taken place in a meeting before the situation became critical. ”

    Source location

    Christine Ann WILLIAMSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026