Recurring concern

Unreliable interagency sharing of safeguarding risk information

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First reported 18 Dec 2013•Latest report 3 Sep 2025

Definition

What this concern includes

Includes failures of the interagency safeguarding-information-sharing process, including obtaining relevant information, securing or recording appropriate consent for disclosure, communicating risk information across agencies, and ensuring that receiving agencies obtain complete and accurate information.

Not included

  • Excludes generic communication or information-management failures not materially connected to safeguarding risk information or interagency care.
  • Excludes failures confined to disclosure to a court, coroner or other legal inquiry rather than safeguarding or care coordination.
  • Excludes failures in making safeguarding referrals where the concern is the referral decision itself rather than the sharing of information between agencies.
  • Excludes clinical assessment, care ownership or discharge failures unless the unsafe condition is specifically the failure to share relevant safeguarding risk information between agencies.
Reports
23

Distinct published reports

Individual concerns
26

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
45

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 Care7
Home Office4
Department for Education3
NHS Greater Manchester Integrated Care Board3
Crown Prosecution Service2
Greater Manchester Police2
Ministry of Justice2
NHS England2
Pennine Care NHS Foundation Trust2
Surrey County Council2
Berkshire Healthcare NHS Foundation Trust1
Bury Borough Council1
Catholic Safeguarding Standards Agency1
Church of England1
College of Policing1

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. West Yorkshire (East)

    AI-generated summary

    Irene Scholey · 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

    Irene Scholey, an elderly and vulnerable 73-year-old woman, died from pneumonia and empyema after living permanently with two daughters in a household described as dysfunctional and inappropriate for her wellbeing. The report identified concerns that her wellbeing would have been safeguarded if relevant agencies had been able to access and share information about her home environment, and noted the potential benefit of extending the Multi Agency Safeguarding Hub to elderly and vulnerable adults.

    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 relevant agencies to access and share information about vulnerable adults’ home environments

    Wider context from the report

    “(3) The household was dysfunctional, was an inappropriate environment for Irene Scholey to be living in, and was a risk to her physical and emotional wellbeing. (4) A safeguarding alert was raised in respect of Mrs Scholey in April/May 2012. (5) Her wellbeing would have been safeguarded had all relevant agencies been able to access, and to share, information relating to the home environment in which Mrs Scholey was living. ”

    Source location

    Irene Scholey · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. 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

    Lack of interagency understanding for sharing safeguarding information between police and CPS

    Wider context from the report

    “There was a lack of understanding between GMP and the CPS as to how such important information should be shared between agencies. ”

    Source location

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

    Open source report

  3. 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