Recurring concern
Failure to act appropriately on safeguarding referrals and notices
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Request correctionFirst reported 12 Sep 2014•Latest report 5 Mar 2026
What this concern includes
Includes failures of the end-to-end safeguarding response involving safeguarding notices, referrals or identified safeguarding concerns, including inadequate assignment, follow-up, escalation, investigation or protective action.
Not included
- Excludes generic communication, documentation or staffing deficiencies unless they are directly tied to the safeguarding response.
- Excludes failures concerning clinical referrals or other service referrals without an explicit safeguarding concern.
- Excludes failures to issue general warnings or safety notices that are not safeguarding notices.
- Reports
- 39
- Individual concerns
- 44
- Date range
- 2014–2026
- Stated actions
- 74
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to appropriately identify and refer safeguarding concerns
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Provide practical safeguarding and whistleblowing training, including scenario-based exercises, and discuss the Night Working Policy at staff meetings.
Stated by Broadland View Care Home -
Action
Report medication near misses as safeguarding concerns going forward.
Stated by Broadland View Care Home
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The medication events were near misses, not medication errors, and residents received the medication safely.
Stated by Broadland View Care Home
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Concerns raised1
Lack of an audit system for non-escalation following referrals
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Review all gas repairs closed outside the agreed service level without reference back, tracing records and identifying closure reasons.
Stated by London & Quadrant Housing Trust -
Action
Record relevant calls centrally and track every repair through the internal housing management system to maintain an auditable trail.
Stated by London & Quadrant Housing Trust -
Action
Hold weekly contractor meetings, reconcile work-in-progress reports with internal records, and review every repair to prevent unauthorised abortion without escalation.
Stated by London & Quadrant Housing Trust
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Concerns raised2
Failure of systems to make involved agencies aware of safeguarding referrals and concerns
Delays in review and triage of safeguarding referrals
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Implement the One Team community mental health model with multi-agency working, clear safety plans, named workers, feedback, and wider community support.
Stated by Berkshire Healthcare NHS Foundation Trust -
Action
Make the Integrated Multi-Disciplinary Team operational to discuss complex cases, share information, formulate risk, and determine suitable pathways and care plans.
Stated by Berkshire Healthcare NHS Foundation Trust -
Action
Add priority flags to safeguarding contacts indicating suicidal ideation or significant self-harm risk.
Stated by Reading Borough Council
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Action
Hold daily consultations between the Safeguarding Team and Customer Contact Centre to support referral processes and priority flagging.
Stated by Reading Borough Council -
Action
Increase dedicated safeguarding referral capacity by appointing three additional full-time safeguarding staff.
Stated by Reading Borough Council
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Concerns raised2
Failure to take safeguarding action to mitigate identified risks
Premature closure of section 42 safeguarding enquiries without gathering material information
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
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Position
The toxicology report would not have affected whether the safeguarding enquiry should be reopened because no provider concerns were identified.
Stated by Lincolnshire County Council
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Position
The Commercial Team and, where appropriate, CQC decide assurance actions after limited safeguarding fact-finding.
Stated by Lincolnshire County Council -
Position
Existing council quality-assurance and multi-agency arrangements provide appropriate assurance about risks to other individuals.
Stated by Lincolnshire County Council -
Position
The statutory safeguarding duty did not apply to a deceased individual, so a section 42 enquiry was inappropriate in these circumstances.
Stated by Lincolnshire County Council -
Position
Reopening the enquiry could not determine which evidence was reliable or whether the provider acted inappropriately.
Stated by Lincolnshire County Council
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Concerns raised1
Failure to adequately investigate safeguarding explanations and evidence
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Share safeguarding learning with staff and introduce automatic internal safeguarding-team escalation for relevant incidents.
Stated by Central London Community Healthcare NHS Trust -
Action
Identify potential conflicts of interest when interviewing the organisation’s care staff.
Stated by Kapital Care (UK) Limited -
Action
Discuss potential interview conflicts of interest with the Local Authority to identify the appropriate interviewing lead.
Stated by Kapital Care (UK) Limited
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Action
Revise safeguarding supervision practice to assess whether conversations should be delegated or conducted directly, including conflicts of interest.
Stated by Westminster City Council -
Action
Identify potential conflicts of interest when interviewing care staff and discuss appropriate interview leadership with the Local Authority.
Stated by Kapital Care (UK) Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
Stated by University College London Hospitals NHS Foundation Trust
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Position
The Local Authority should determine which person or agency is most appropriate to lead interviews where Kapital Care has a potential conflict of interest.
Stated by Kapital Care (UK) Limited
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Concerns raised1
Failure of the welfare case management system to ensure follow-up of safeguarding alerts
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Implement case-management mitigations, including welfare tracking, safe voicemail referral storage, staff reminders, procedural guidance and individual training support.
Stated by University of Exeter -
Action
Procure and integrate a replacement welfare case-management system for operation during the 2023/24 academic year.
Stated by University of Exeter
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Concerns raised1
Failure to follow safeguarding policy after disclosure of a serious allegation of inappropriate touching by another patient
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Implement twice-weekly patient safety meetings and include sexual safety as a standing topic in meetings and staff supervision.
Stated by Greater Manchester Mental Health NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Staff followed safeguarding processes after the reported sexual harassment, although the team acknowledged that transfer to a single-sex ward should have been considered.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Failure to consider safeguarding referral and assessment for vulnerable adults with serious mental disorder
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to properly investigate safeguarding referrals
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to take safeguarding action following significant safety concerns
Failure to make an in-person visit after unanswered safeguarding contact attempts
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Complete a systematic review of safeguarding adults self-neglect policies and procedures to clarify roles, responsibilities and duties.
Stated by Cumbria County Council -
Action
Review and revise operational guidance for self-neglect concerns to require face-to-face visits for assessment and safety assurance.
Stated by Cumbria County Council -
Action
Implement a countywide operational Safeguarding Adults service with a dedicated team providing consistent responses to safeguarding concerns.
Stated by Cumbria County Council
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Action
Deliver training sessions across partner organisations to embed revised self-neglect policy, procedure and guidance.
Stated by Cumbria County Council -
Action
Undertake a practice learning session with the involved team to establish a clear operational response to self-neglect concerns.
Stated by Cumbria County Council
Data last updated 7 September 2026