Recurring concern

Failure to disseminate safeguarding protocols and learning reliably

First to latest report 19 Nov 2019 — 1 May 2026

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
0

What this concern includes

Includes failures of processes dedicated to disseminating safeguarding protocols, investigation findings, recommendations or other safety learning across relevant safeguarding services, organisations or geographic areas, including the anchor's limited national dissemination of local safeguarding protocols and failures to disseminate safeguarding investigation lessons beyond the local area.

What is not included
  • Excludes generic organisational-learning or information-sharing failures that are not specifically concerned with disseminating safeguarding protocols, findings, recommendations or lessons.
  • Excludes failures to implement safeguarding actions after relevant protocols or learning have been reliably disseminated, unless dissemination itself was also deficient.
  • Excludes operational safeguarding assessment, referral, investigation or protective-action failures where the dissemination of safeguarding information or learning is not the unsafe condition.
  • Excludes dissemination concerns involving clinical, fire, military or other non-safeguarding protocols and learning unless the assertion explicitly concerns the same safeguarding dissemination process.

Reports and published responses 2 reports

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

  1. Inner South London

    AI-generated summary

    Natasha Hill · 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

    Natasha Hill, who had been in care and was experiencing grooming, exploitation, self-harm, substance misuse and domestic violence, was pronounced dead at her abuser’s home in the early hours of 15 April 2018. The jury concluded that she was unlawfully killed by her abuser. The report raised concerns about safeguarding during the transition to adulthood, protection from exploitation and domestic abuse, and coordination of relevant policing and safeguarding policies.

    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

    Limited national dissemination of local safeguarding protocols

    Wider context from the report

    “• To consider the wider dissemination of existing local protocols nationally, for example the London Exploitation Protocol. ”

    Source location

    Natasha Hill · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. 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

    Unclear dissemination of safeguarding investigation lessons beyond the local area

    Wider context from the report

    “4. It was accepted by witnesses for both the Local Authority and GMP that the voice of the child was not fully heard throughout their investigations. They via the safeguarding board commissioned an independent report whose findings and recommendations have been fully adopted by the safeguarding board. It was unclear what if any steps would be taken to disseminate the lessons pan GM or nationally; ”

    Source location

    Katie Croft · Prevention of Future Deaths report
    Page 2 · 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