Recurring concern

Failure to establish complete and reliable evidence for safeguarding allegations

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First reported 14 Sep 2015•Latest report 31 Aug 2022

Definition

What this concern includes

Includes failures in safeguarding-allegation processes to obtain, distinguish, source, verify and consider material allegations and supporting accounts before deciding, recording or closing an investigation, including missing signed statements, unclear information origins and failure to obtain relevant details from other professionals.

Not included

Excludes generic poor record-keeping or evidence-gathering failures where no safeguarding allegation or protective-investigation context is identified.
Excludes ordinary criminal, disciplinary, complaint or incident investigations unless the assertion specifically concerns safeguarding allegations or Adult Protection referrals.
Excludes failures to take protective action after allegations have been fully and reliably established when the evidence-gathering and verification process itself was adequate.
Excludes the underlying abuse, neglect or safeguarding risk where no deficiency in establishing the supporting evidence is asserted.

Reports: 3
Individual concerns: 4
Date range: 2015–2022
Stated actions: 8

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Catholic Safeguarding Standards Agency1

Church of England1

Lincolnshire Police1

New Park Residential Home1

Office of the Chief Coroner1

Stoke-on-Trent City Council1

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.

31 Aug2022
Lincolnshire
Concerns raised1
1. Failure to adequately test evidence and reconsider charging criteria in suspected child neglect cases
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Dainton Harley Hill Cressell GITTOS · 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

Dainton Harley Hill, an 11-year-old vulnerable child with cerebral palsy who could not speak, bear his own weight, or call for help, was left unsupervised in a bath on 22 January 2021 and was later found unresponsive. The inquest concluded that parental neglect in failing to supervise him contributed directly to his death, which was consistent with drowning. Concerns were raised about the lack of supervision, failure to use a non-slip bath mattress, prior social services records concerning neglect and emotional harm, and the decision not to bring charges.

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 adequately test evidence and reconsider charging criteria in suspected child neglect cases
Wider context from the report
“I refer to all the evidence heard at the Inquest particularly, that of DC ████████ and the Police’s own expert Dr. ████████, (recited above) and do not accept why any charges have not been brought against either or both parents focusing on s1(1) Children and Young Persons Act 1933 The police are asked to review their file again in view of the many concessions made by CPS and the findings as to cause of death now made in the Coroner’s Court (admittedly on a different standard of proof but they are still findings after hearing evidence). Neglect runs right through this case and irrespective of the parent’s allegations against each other in the Coroner’s Court the belief is that the evidence needs to be tested and if agreed charging criteria reconsidered as there are 3 other siblings. A vulnerable child aged 11 is dead. ”
Source location
Dainton Harley Hill Cressell GITTOS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Jul2021
Inner North London
Concerns raised2
1. Failure to exercise sufficient scrutiny of allegations and obtain their details and source
2. Failure to establish the meaning and source of a key allegation
This report raised 15 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 8
1. Action
  Appoint an experienced independent reviewer to provide external scrutiny of diocesan safeguarding systems and processes.
  Stated by Diocese of London and Lambeth PalaceStated in progress
2. Action
  Design and implement improved systems for capturing, triaging, recording, assessing and appropriately sharing safeguarding and conduct information.
  Stated by Diocese of London and Lambeth PalaceStated in progress
3. Action
  Develop a supervised referral and triage process that assigns case holders and maintains initial and ongoing risk assessments, including mental health.
  Stated by Diocese of London and Lambeth PalaceStated in progress
1. Action
  Develop casework tracking and structured review systems to record progress against milestones and monitor actions throughout each case.
  Stated by Diocese of London and Lambeth PalaceStated in progress
2. Action
  Update and reissue the concern reporting form to prompt complete disclosures, including information about relevant evidence and witnesses.
  Stated by Diocese of London and Lambeth PalaceStated planned
3. Action
  Develop a casework meeting template prompting reflection and critical thinking.
  Stated by CSSAStated in progress
4. Action
  Update and issue practice guidance on clarifying, verifying and escalating allegations and concerns.
  Stated by CSSAStated in progress
5. Action
  Develop and roll out mandatory safeguarding leadership training on professional curiosity, reflection and support for respondents.
  Stated by CSSAStated in progress
AI-generated summary

Alan Howard Foster Griffin · 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

Alan Howard Foster Griffin died by suicide at home on 8 November 2020 while under investigation by his former and current dioceses. The principal concerns were systemic and individual failings in the handling of unverified allegations, including inadequate verification, inaccurate and incomplete information-sharing, unclear responsibility, and failure to seek recommended legal advice.

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 exercise sufficient scrutiny of allegations and obtain their details and source
Wider context from the report
“1. The safeguarding team of the Roman Catholic Diocese of Westminster did not exercise sufficient professional scrutiny of the allegations that came to them from the Anglican safeguarding team. This was partly because they gained a false sense of security from the fact that the allegations came from the Church of England. However, there was more that could have been done to establish the exact nature of the allegations and whether these were credible. The Catholic safeguarding team asked for disclosure from the Anglican safeguarding team and most particularly for the source of the allegations. When they did not receive either of these, they should have insisted. ”
Source location
Alan Howard Foster Griffin · Prevention of Future Deaths report
Page 2 · 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 establish the meaning and source of a key allegation
Wider context from the report
“3. What the head of operations did say in his meetings in 2019 was that Father Griffin had told him he had “used rent boys”, which the head of operations understood to mean he had visited adult male prostitutes. The archdeacon emphasised the importance of this being Father Griffin’s phrase. The phrase appeared repeatedly throughout 2019/20 church documents relating to Father Griffin’s actions. Notwithstanding the view expressed to me by the head of operations that the phrase related to visiting adult male prostitutes, it formed the basis of the allegation of sex with minors. I put it to the director of HR & safeguarding that it is an unusual phrase to hear in 2021, and yet the term rent boys appeared elsewhere in the Two Cities report. She told me that the head of operations had used the phrase from start to finish in the meetings that led to the entries in respect of the 42 members of the clergy in London & Westminster. However, she said in court that, as there was no record anywhere that the head of operations had described Father Griffin himself using this term, she now concluded that the head of operations had not actually said this. I recalled the head of operations on the last day of inquest to ask if it was possible that this had in fact been his own term rather than Father Griffin’s. He immediately said yes, the term was his term and Father Griffin had not used it. He said that Father Griffin had never used the term rent boys. He thought that Father Griffin was generous with hospitality and paid for meals out and perhaps he had misinterpreted that. He said that Father Griffin had never actually said that he had paid for sex. Yet in an investigation lasting over a year, the head of operations did not volunteer these details and nobody obtained them from him. ”
Source location
Alan Howard Foster Griffin · Prevention of Future Deaths report
Page 3 · 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
Appoint an experienced independent reviewer to provide external scrutiny of diocesan safeguarding systems and processes.

Verbatim wording from the response
“As a result of the concerns that the Coroner raised in her report, we have revised the terms of reference initially proposed for the Lessons Learned Review and have taken steps towards appointing”

Source location
2021-0243-Response-from-Church-of-England_Published
Page 1 · response
Published 15 July 2021
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
Design and implement improved systems for capturing, triaging, recording, assessing and appropriately sharing safeguarding and conduct information.

Verbatim wording from the response
“• Our new Head of Safeguarding has already started working with the team to design and implement new systems of information capture, triage, recording, assessment and appropriate sharing of safeguarding and conduct matters. These issues will form part of our overarching improvement plan.”

Source location
2021-0243-Response-from-Church-of-England_Published
Page 3 · response
Published 15 July 2021
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
Develop a supervised referral and triage process that assigns case holders and maintains initial and ongoing risk assessments, including mental health.

Verbatim wording from the response
“2. The development of a referral/triage system, with supervision from the Head of Safeguarding, to ensure that matters are separated out into safeguarding, non-safeguarding conduct, and “other” issues, ensuring an initial and ongoing assessment of risk (including mental health) and with appropriate follow up action by a designated case holder.”

Source location
2021-0243-Response-from-Church-of-England_Published
Page 3 · response
Published 15 July 2021
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
Develop casework tracking and structured review systems to record progress against milestones and monitor actions throughout each case.

Verbatim wording from the response
“3. The development of a casework management tracking system for all referrals into the safeguarding team to record timely progress against key milestones and ensure a structured review process (including risk and mental health) during the lifetime of a case.”

Source location
2021-0243-Response-from-Church-of-England_Published
Page 3 · response
Published 15 July 2021
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
Update and reissue the concern reporting form to prompt complete disclosures, including information about relevant evidence and witnesses.

Verbatim wording from the response
“Both of these actions will ensure better oversight of any potential safeguarding referral, and ensure appropriate handling, including seeking evidence and witnesses. | The concern reporting form is being updated and will be reissued shortly. This will prompt full disclosures including pointing to relevant evidence and witnesses.”

Source location
2021-0243-Response-from-Church-of-England_Published
Page 6 · response
Published 15 July 2021
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
Develop a casework meeting template prompting reflection and critical thinking.

Verbatim wording from the response
“b. To support reflection and critical thinking in intra-agency or inter-agency meetings, the CSSA is developing a template form to be used in casework meetings. The template will include all areas that need to be considered and addressed and will act as a prompt to safeguarding practitioners.”

Source location
2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
Page 2 · response
Published 15 July 2021
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
Update and issue practice guidance on clarifying, verifying and escalating allegations and concerns.

Verbatim wording from the response
“c. The CSSA is updating its practice guidance on the management of allegations and concerns, to provide for situations where concerns are raised but the information cannot immediately be clarified or verified. The guidance will give a timescale within which the information must be clarified or verified, what action must be taken if this cannot be achieved (i.e., escalation to the Safeguarding Sub-Committee for consideration and decision as to next steps).”

Source location
2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
Page 2 · response
Published 15 July 2021
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
Develop and roll out mandatory safeguarding leadership training on professional curiosity, reflection and support for respondents.

Verbatim wording from the response
“Training The CSSA national training lead is developing a suite of training for those in leadership and management in safeguarding roles within Church bodies. Work has commenced and the training modules, which will include mandatory modules on reflection and professional curiosity and on the provision of support to those about whom allegations or concerns have been raised, and they will be rolled out over the course of 2022.”

Source location
2021-0243-Response-from-Catholic-Safeguarding-Standards-Agency_Published
Page 2 · response
Published 15 July 2021
Open published response
14 Sep2015
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Failure to obtain full details before closing Adult Protection investigations
This report raised 15 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 1
1. Position
  The investigation was multi-agency, with social work and safeguarding nursing involvement, rather than a single-agency investigation.
  Stated by Stoke-on-Trent City CouncilDisputes the concern
AI-generated summary

Janine Eugenie Pierrette KAISER · 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

Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing care.

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 obtain full details before closing Adult Protection investigations
Wider context from the report
“9. Single agency staff investigating Adult Protections Referrals had closed their investigation and recorded the allegations as unsubstantiated without obtaining full details of concerns raised by other professionals. ”
Source location
Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 investigation was multi-agency, with social work and safeguarding nursing involvement, rather than a single-agency investigation.

Verbatim wording from the response
“9. Single agency staff investigating Adult Protection Referrals had closed their investigation and recorded the allegations as unsubstantiated without obtaining full details of concerns raised by other professionals.”

Source location
2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Page 5 · response
Published 14 July 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to adequately test evidence and reconsider charging criteria in suspected child neglect cases

Concerns raised2

Failure to exercise sufficient scrutiny of allegations and obtain their details and source

Failure to establish the meaning and source of a key allegation

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.8

Concerns raised1

Failure to obtain full details before closing Adult Protection investigations

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 8

Respondent positions 1