Recurring concern

Failure to act appropriately on safeguarding referrals and notices

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First reported 12 Sep 2014•Latest report 5 Mar 2026

Definition

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

Distinct published reports

Individual concerns
44

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
74

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 Care4
Care Quality Commission3
East London NHS Foundation Trust2
Greater Manchester Mental Health NHS Foundation Trust2
Surrey County Council2
Berkshire Healthcare NHS Foundation Trust1
Berrycroft Manor1
Broadland View Care Home1
Cafcass1
Catholic Safeguarding Standards Agency1
Central London Community Healthcare NHS Trust1
Chippenham Community Hospital1
Church of England1
Clifton Court Nursing Home1
Community Health Care1

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. South Yorkshire (Western)

    AI-generated summary

    Mrs Leesley · 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

    Mrs Leesley died in Northern General Hospital on 25 April 2016 from septicaemia and a urinary tract infection. Evidence at the inquest showed that a safeguarding report made by the GP was not acted upon despite an automated acknowledgment, and it was unclear whether this resulted from human or IT error.

    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 act on safeguarding referrals

    Wider context from the report

    “During the inquest, evidence showed the GP made a safeguarding report on 4.3.16, but for reasons unknown, despite there being an automated acknowledgment, the referral was not acted upon. It was unclear whether this was a case of unanimous error or IT error. ”

    Source location

    Mrs Leesley · Prevention of Future Deaths report
    Page 1 · 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

    Amend automated safeguarding-referral acknowledgements to instruct senders to confirm receipt if Adult Access does not respond within two working days.

    Verbatim wording from the response

    “3.1.1 On 9th December 2016, the final day of the inquest, ████████, Advanced Practitioner in the Community Access Prevention Team, amended the wording of the automated response generated when a safeguarding report is received by the Adult Access Team.”

    Source location

    2016-0442-Response-by-Sheffield-City-Council-1
    Page 1 · response
    Published 12 February 2017

    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

    Implement an email-journaling facility to retain audit logs and track emails sent, received, deleted and other mailbox actions.

    Verbatim wording from the response

    “3.1.4 The IT systems operating in the Adult Access Team are designed to prevent emails, including those that contain safeguarding referrals, from being accidentally deleted. To completely delete an email, it would have to be deleted from the inbox folder and then separately deleted from the deleted folder; two distinct actions. The Local Authority is putting in place a Journal function integrated into the IT system that will make it easier to retrieve and track deleted emails. Journal function enables the Local Authority to track every action in a specified mailbox, In this case the Mailbox for the Adult Access Team.”

    Source location

    2016-0442-Response-by-Sheffield-City-Council-1
    Page 2 · response
    Published 12 February 2017

    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

    Remind all Adult Access staff of email-handling procedures to reduce the risk of safeguarding referrals being deleted or left unactioned.

    Verbatim wording from the response

    “3.2.5 However, to further reduce the risk of a report not being actioned, all staff working within Adult Access team have been reminded of the existing procedures and process for handling emails to further reduce the risk of emails being deleted or not actioned correctly.”

    Source location

    2016-0442-Response-by-Sheffield-City-Council-1
    Page 3 · response
    Published 12 February 2017

    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

    Complete the ongoing investigation into the missing safeguarding referral, including the IT audit and Serious Incident review, and produce the resulting incident report.

    Verbatim wording from the response

    “4. IT systems audit”

    Source location

    2016-0442-Response-by-Sheffield-City-Council-1
    Page 4 · response
    Published 12 February 2017

    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

    There is no evidence that the referral was not actioned because of human error, and the circumstances appear isolated.

    Verbatim wording from the response

    “There is no available evidence to suggest that non-action was the result of human error either by action or omission on this occasion.”

    Source location

    2016-0442-Response-by-Sheffield-City-Council-1
    Page 3 · response
    Published 12 February 2017

    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 email-handling procedures and staff reminders have adequately addressed and minimised the risk of received referrals being missed through human error.

    Verbatim wording from the response

    “3.2.5 However, to further reduce the risk of a report not being actioned, all staff working within Adult Access team have been reminded of the existing procedures and process for handling emails to further reduce the risk of emails being deleted or not actioned correctly.”

    Source location

    2016-0442-Response-by-Sheffield-City-Council-1
    Page 3 · response
    Published 12 February 2017

    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 GP surgery must make the request for the forensic report from its NHS mail provider.

    Verbatim wording from the response

    “5.2 ████████ has requested a forensic report and audit log via the Accenture agency responsible for the IT System at the GP surgery used to send the email.”

    Source location

    2016-0442-Response-by-Sheffield-City-Council-1
    Page 5 · response
    Published 12 February 2017

    Open published response

  2. Nottinghamshire

    AI-generated summary

    Olive Wilmott · 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

    Olive Wilmott was found on the floor of a communal area of a residential care home after suffering a hip fracture. The Inquest concluded that she died from the effects of a urine infection and severe dementia, with the hip fracture a contributory factor. Concerns included possible pushing that was not effectively investigated or referred for safeguarding, and a lack of evidence that required 15-minute observations were provided amid insufficient night-shift staffing.

    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 make Safeguarding referrals for suspected abuse or neglect

    Wider context from the report

    “1. That there were references in the medical records to Miss Wilmott possibly having been pushed, but no or no effective investigation of the circumstances was made at the time and no Safeguarding referral was made. ”

    Source location

    Olive Wilmott · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. North Lincolnshire and Grimsby

    AI-generated summary

    Terry Stapleton Latimer · 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

    Terry Stapleton Latimer was found dead by hanging at his home on 27 May 2016, and an inquest determined that he died by suicide. A safeguarding notification submitted after police concerns was not acted upon appropriately, including a request to refer the case to Mental Health Services, with evidence of uncertainty about whether such notices required follow-up.

    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 clarity about whether safeguarding notices require follow-up

    Wider context from the report

    “The safeguarding notice was not acted upon either at all or appropriately. In particular a request accompanying the notice that the case be referred to Mental Health Services was not complied with. Evidence indicates lack of clarity in understanding whether the notice is just for information or should be followed up. ”

    Source location

    Terry Stapleton Latimer · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to act appropriately on safeguarding notices

    Wider context from the report

    “The safeguarding notice was not acted upon either at all or appropriately. In particular a request accompanying the notice that the case be referred to Mental Health Services was not complied with. Evidence indicates lack of clarity in understanding whether the notice is just for information or should be followed up. ”

    Source location

    Terry Stapleton Latimer · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Norfolk

    AI-generated summary

    SOLOMON JAMES BEALEY · 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

    Solomon James Bealey, aged 15, was found in his bedroom on 5 February 2015 with a bag over his head and a cord around his neck, having left a note to his family. Concerns included that no action or follow-up was taken after a nurse and doctor became aware of signs of stress and a previous suicide attempt, and that the doctor did not know letters sent to Solomon’s mother had been received.

    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 communicate receipt and outcome of safeguarding correspondence to the responsible doctor

    Wider context from the report

    “(1) Solomon was taken to see a Nurse at the Walk In Clinic on 1 October 2014 for minor medical matters. The Nurse became concerned at signs of stress and was aware that in 2010 Solomon was found preparing to hang himself, and so arranged for an on call Doctor to see him. No action was taken. The Nurse expressed her concerns to a GP in the practice. A telephone call was made to a number believed to be that of the mother of Solomon, but it was a wrong number. The Doctor wrote to Solomon's mother on two occasions and received no reply. The matter was not pursued any further. (2) Although the letters had been received by Solomon's mother who discussed this with Solomon and his father and it was decided to take no further action, the Doctor was unaware that the letters had been received. (3) No follow up action was taken. ”

    Source location

    SOLOMON JAMES BEALEY · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Cornwall

    AI-generated summary

    Miriam Joyce Smith-Cox · 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

    Miriam Smith-Cox was found dead on 4 March 2015 at the bottom of stairs, with injuries consistent with a fall. A safeguarding concern about the suitability of her accommodation and living conditions had been raised in December 2014 but was reportedly not received or acted upon, and the reason for her fall was unknown.

    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 receive or act upon safeguarding concerns about accommodation and living conditions

    Wider context from the report

    “That████████, ████████████████████ with Pluss Work Choice Programme Cornwall raised a safeguarding concern about the suitability of Ms Smith-Cox accommodation and living conditions in December 2014 (see attached letter to ████████ dated 4.12.14 and report) which ████████ gave evidence she did not receive or act upon. ████████ was a key stakeholder in the support of Ms Smith-Cox. Ms Smith-Cox fell down the stairs for unknown reason as raised as a concern by ████████ and this fall led to her death. ”

    Source location

    Miriam Joyce Smith-Cox · 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

    Provide all Pluss staff with a safeguarding case study to raise awareness and reinforce understanding of safeguarding responsibilities.

    Verbatim wording from the response

    “As an organisation we will be utilising the learning from this unfortunate episode to provide a case study to raise awareness with all Pluss staff,”

    Source location

    2015-0475-Response-from-PLUSS_Redacted.pdf
    Page 1 · response
    Published 15 July 2020

    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

    Deliver additional safeguarding, Alerters and lone-working training to the Truro team with the company specialist.

    Verbatim wording from the response

    “We will also be carrying out additional Safeguarding, Alerters and Lone Working training with the Truro Team with the company specialist within September.”

    Source location

    2015-0475-Response-from-PLUSS_Redacted.pdf
    Page 2 · response
    Published 15 July 2020

    Open published response

  6. South Yorkshire (Eastern)

    AI-generated summary

    Phyllis Broomhead · 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

    Phyllis Broomhead, who had dementia and lived at Lord Hardy Court EMI Residential Home, suffered repeated falls, including three significant falls requiring hospitalisation. On 9 June 2013 she fell from her bed while trying to reach the toilet, sustained a head injury and died later that day from a traumatic left-sided subdural haemorrhage. Concerns included incomplete implementation of measures, staff training and record keeping, safeguarding screening, and the lack of closer monitoring or alternative placement for residents at high risk of serious injury.

    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 initial safeguarding referral screening to be sufficiently detailed and objective

    Wider context from the report

    “(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to: i. the head injury protocol, how this should be followed and the importance of doing so. ii. record keeping. iii. indicators and triggers to seek social worker input. (2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home. ”

    Source location

    Phyllis Broomhead · Prevention of Future Deaths report
    Page 1 · 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

    Re-engineer safeguarding documentation to capture the customer journey and provide detailed screening guidance for informed exit decisions.

    Verbatim wording from the response

    “Work Completed Safeguarding documentation has been re-engineered to be Care Act compliant and to ensure the customer journey is captured and recorded. More detailed guidance and standard practice to confirm what documents have been screened, dates spoken to during the screening stage to enable the decision maker to make informed decisions before exiting.”

    Source location

    2015-0290-Response-by-Rotherham-Borough-Council
    Page 4 · response
    Published 6 July 2015

    Open published response

  7. Manchester South

    AI-generated summary

    Sidney Barnett · 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

    Sidney Barnett, a care home resident whose health was gradually declining, was found inadequately clothed and cared for, struggling to eat alone and unattended, and later died in hospital from pneumonia on 3 January 2015. The principal concerns were inadequate observation and general welfare, unclear rules about open windows, and inadequate and insufficiently structured safeguarding investigations.

    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

    Inadequate and unstructured safeguarding investigation processes

    Wider context from the report

    “4. As a result of these matters a safeguarding alert was raised by the hospital team, and this was investigated by the Adult Safeguarding Team at the Council. Both a member of that investigation and the Chairperson of the meetings, agreed that the level of inquiry had been inadequate and that they ought not to have concluded that the ‘complaint’ was unsubstantiated. 5. The system for looking into these matters is vague and unstructured and will inevitably lead to an insufficiency of investigation. Too much reliance is placed on what the “Care home” employees say, without testing that and further querying what actually happened. ”

    Source location

    Sidney Barnett · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. 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

    Failure to make safeguarding referrals from custody medical information

    Wider context from the report

    “Similarly the Court heard that no safeguarding referral was made about Kesia despite information about her self-harming, drug and alcohol use. ”

    Source location

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

    Open source report

  9. Isle of Wight

    AI-generated summary

    Barbara Monica May Cooke · 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

    Barbara Monica May Cooke, an 84-year-old resident of Waxham House Residential Care Home, developed severe pressure ulcers, sepsis and multiple organ failure, and died in hospital on 11 April 2014. The report raised concerns about inadequate staffing, delays in toileting and cleaning, failure to recognise and manage infection risks associated with pressure sores, and gaps in communication and safeguarding procedures after her admission and death.

    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 automatic safeguarding-team notification of deaths of inpatients subject to open safeguarding alerts

    Wider context from the report

    “6. I am concerned that there is currently no system in place at St Mary’s Hospital to automatically notify the IOW Safeguarding Team if someone who is the subject of an open safeguarding alert dies whilst an inpatient in the Hospital. ”

    Source location

    Barbara Monica May Cooke · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report
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Data last updated 7 September 2026