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
NHS trust13
English county council7
Private limited company6
English metropolitan district council5
English unitary authority5
Ministerial department5
Police force5
Executive non-departmental public body3
Health and social care service regulator3
Healthcare site3
London borough council3
Other public body3
Residential care home3
Registered provider of social housing2
Type not available2
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.
East London
Concerns raised1
Absence of safeguarding referrals for parents at risk of adult child to parent domestic abuse
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 concerns
Each 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
Action
Strengthen mandatory Level 3 safeguarding training to address intergenerational domestic abuse, parental vulnerability, and risks to family members.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.
Action
Update Tower Hamlets’ admissions checklist to include intergenerational safeguarding concerns.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 March 2026.
City of London
Concerns raised1
Failure to involve Crisis or Home Treatment teams for immediate safeguarding follow-up
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 concerns
Each 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.1
Position
Doctor referral was not initially indicated because the established pathway covered admission, medication changes and other clinical complexities, with senior psychiatric doctors available continuously.
Stated by South London and Maudsley NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Wiltshire and Swindon
Concerns raised1
Failure to have a safeguarding policy and process for acting on resident risk without relying solely on consent
Responses linked to these concerns
Each 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.7
Action
Continue consulting mental health, pharmacy and substance-misuse agencies on safeguarding responses to medication stockpiling.
Stated by Home Group LimitedStated in progressThe respondent said that this action was in progress when they made their response on 23 July 2025.
Action
Review and update the Support Practice Policy, consulting customers, partner agencies and stakeholders and considering inquest learning on risk management.
Stated by Home Group LimitedStated plannedThe respondent said that this action was planned when they made their response on 23 July 2025.
Action
Review and refresh the LIFE support practice model to strengthen risk assessment and management for people at risk of self-harm or suicide.
Stated by Home Group LimitedStated in progressThe respondent said that this action was in progress when they made their response on 23 July 2025.
Action
Review the Tenure Policy, including standards governing house rules and room access in suspected medication-stockpiling situations.
Stated by Home Group LimitedStated plannedThe respondent said that this action was planned when they made their response on 23 July 2025.
Action
Review and update risk-assessment templates, risk-management plans, training resources and quality-assurance checks for medication-stockpiling concerns.
Stated by Home Group LimitedStated plannedThe respondent said that this action was planned when they made their response on 23 July 2025.
Action
Develop and pilot a medication-stockpiling risk-assessment checklist with accompanying staff guidance and training.
Stated by Home Group LimitedStated in progressThe respondent said that this action was in progress when they made their response on 23 July 2025.
Action
Use manager oversight and quality-assurance review to document and follow up staff concerns recorded through the medication-stockpiling checklist.
Stated by Home Group LimitedStated plannedThe respondent said that this action was planned when they made their response on 23 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responsibility for handling or administering medication in these services lies with Change Grow Live, not the supported housing provider.
Stated by Home Group LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Where a service user has capacity, medication cannot be removed without authority, and controlled drugs cannot lawfully be retained or stored on the premises.
Stated by Home Group LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised1
Failure to respond substantively to safeguarding and carer’s assessment referrals
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Increase safeguarding triage capacity and screen every alert before progressing qualifying referrals for further enquiry.
Stated by Essex County CouncilStated completedThe respondent said that this action was complete when they made their response on 28 April 2025.
Action
Introduce carers practice guidance and core practice guidance covering assessments, reviews, support planning and safeguarding.
Stated by Essex County CouncilStated completedThe respondent said that this action was complete when they made their response on 28 April 2025.
Action
Implement recommendations from the external end-to-end safeguarding-process review to improve safeguarding practice and the customer journey.
Stated by Essex County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 28 April 2025.
Cumbria
Concerns raised1
Failure to make safeguarding referrals when other agencies are thought to be aware
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 concerns
Each 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
Action
Audit cases involving self-neglect risk, assess referral, escalation and management oversight, and share findings with partners for practice review.
Stated by Northumberland Children and Adults Safeguarding PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2025.
Action
Introduce a multi-agency risk management framework within six months for earlier intervention and referrals involving adults with complex needs and serious-risk concerns.
Stated by Northumberland Children and Adults Safeguarding PartnershipStated plannedThe respondent said that this action was planned when they made their response on 27 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Integrated Care Board is leading work to ensure escalation processes and safeguarding responsibilities are understood across primary care services.
Stated by Northumberland Children and Adults Safeguarding PartnershipRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Mid Kent and Medway
Concerns raised1
Failure to take urgent safeguarding steps to remove children from an unsafe family home
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 concerns
Each 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.3
Position
NHS England and the integrated care board are responsible for addressing the local concerns and explaining missing safeguarding action and mitigations.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Actions taken by the Integrated Care Board, social services and local authority fall outside the national policy or programme remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Integrated Care Board is responsible for providing a separate system-level response detailing local actions taken.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to investigate the care provided to residents following safeguarding concerns
Responses linked to these concerns
Each 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
Action
Complete a root cause analysis, full investigation and candid lessons learned for every death referred to the Coroner, with central monitoring.
Stated by Harbour Healthcare Ltd.Stated plannedThe respondent said that this action was planned when they made their response on 9 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The records indicate required care was delivered and do not support the description of Mr Good as dirty, unkempt, or neglected.
Stated by Harbour Healthcare Ltd.Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
An internal investigation was not considered usual without a specific reason, which was absent because the death was expected and notification was delayed.
Stated by Harbour Healthcare Ltd.No action considered necessaryThe respondent said that no further action was needed.
East London
Concerns raised1
Insufficiently detailed safeguarding reports failing to trigger further investigation
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 concerns
Each 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.4
Action
Deliver quarterly safeguarding adults training for Newham Community Health Services staff, including guidance on completing high-quality referrals.
Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 March 2024.
Action
Remind Newham Community Health Services staff to follow the internal safeguarding escalation pathway and escalate barriers without waiting for monthly forums.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 March 2024.
Action
Add mandatory pressure-care refresher training, including reporting, notification and safeguarding interfaces, to the 2024/25 training plan for operational adult social care staff.
Stated by London Borough of NewhamStated plannedThe respondent said that this action was planned when they made their response on 25 March 2024.
Action
Maintain regular safeguarding meetings between ELFT Community Health Newham and Council neighbourhood teams to address referral quality, thresholds and recurring safeguarding themes.
Stated by London Borough of NewhamStated completedThe respondent said that this action was complete when they made their response on 25 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The safeguarding referral’s insufficient detail did not cause the investigation failure; LBN’s backlog delayed the safeguarding enquiry.
Stated by East London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Gateshead and South Tyneside
Concerns raised1
Failure to make safeguarding referrals for formal safeguarding supervision
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 concerns
Each 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.9
Action
Establish a daily multi-agency Police Triage Process to review Police Concern Notifications, share information and determine safeguarding actions.
Stated by South Tyneside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Launch the Safeguarding Adults Threshold Guidance Tool across adult social care teams, provide training and require recorded rationale for safeguarding decisions.
Stated by South Tyneside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Establish the Multi-Agency Safeguarding Hub to screen all safeguarding contacts and referrals through integrated multi-agency information gathering and decision-making.
Stated by South Tyneside Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
Action
Deliver bespoke training, email communications and team meetings to improve staff awareness and skills regarding safeguarding referrals and procedures.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Conduct weekly telephone-triage reviews of selected crisis contacts to assess contact quality, safeguarding actions and whether multi-agency meetings were required.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Use a safeguarding incident-reporting template to support consistent practitioner advice on referrals and multi-agency communication, with recommended actions monitored by managers.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Update and circulate the domestic abuse policy, including guidance on identifying abuse risk and requesting MARAC referrals.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Review the domestic violence policy to incorporate inquest and incident learning and clarify staff roles and responsibilities for safeguarding referrals.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
Action
Conduct compliance audits against the domestic abuse policy to check that MARAC referrals are actioned in line with safeguarding advice.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
Plymouth, Torbay and South Devon
Concerns raised1
Failure to acknowledge safeguarding referrals and communicate action taken
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 concerns
Each 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.1
Position
The Disclosure and Barring Service concern could not be answered by the Trust and should be raised directly with that Service.
Stated by Torbay and South Devon NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
