Recurring concern

Inadequate child safeguarding assessment

First to latest report 2 Dec 2019 — 7 Feb 2025

Reports that mention this concern
6
Times this concern has been raised
12
Stated actions linked to this concern
10

What this concern includes

Includes failures of an explicitly child-focused safeguarding assessment or reassessment, including inadequate risk information gathering, failure to reassess after new concerns, and omission of relevant parent or co-parent risks.

What is not included
  • Excludes generic failures to conduct home visits where they are not part of a child-safeguarding assessment.
  • Excludes adult safeguarding, clinical risk assessment and general care review concerns that are not explicitly concerned with safeguarding children.
  • Excludes failures of downstream action after an otherwise adequate safeguarding assessment, unless the failure is part of the assessment process itself.

Reports and published responses 6 reports

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

  1. Mid Kent and Medway

    AI-generated summary

    Ella Louise Murray · 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

    Ella Louise Murray was 13 years old when she died at Kings College hospital on 15 November 2023 following an episode of hanging, after a period of self-harm, suicidal ideation and deteriorating mental health. The report raised concerns about the adequacy of her risk assessment and the failure to take urgent protective action, including removing her from home or convening an urgent multi-agency response. It also identified the lack of shared information and records across health, social care and education services.

    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 assessment of risk to children presenting with safeguarding and mental health concerns

    Wider context from the report

    “(3) Whilst there were concerns about the level of risk assessment undertaken on 14 November 2023 senior staff at the Trust gave evidence that she did not meet the criteria for admission to a hospital bed. This was difficult to reconcile with the documentary evidence as she was clearly crying out for help and her school had recognised this. No one agency involved had access to all the relevant information and concerns about Ella across the health, social care and education arenas. Evidence given suggested that shared records would assist but the ability to respond to urgent concerns would require a system change. (4)It was brought to the court’s attention that the new Children’s Wellbeing and Schools bill includes a duty to share information to promote safeguarding. In addition the local authority may convene a strategy meeting under s47 of the Children Act 1989 although the speed of convening a meeting would depend on availability and would obviously not be as swift as for example attending an accident and emergency department. If a multiagency meeting had been convened this may have prevented Ella’s death and such action may reduce the risk of death for other children being in a similar position. ”

    Source location

    Ella Louise Murray · Prevention of Future Deaths report
    Page 5 · 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

    Deliver system-wide learning events on provider learning, family perspectives and inter-agency working following children’s and young people’s suicides.

    Verbatim wording from the response

    “As part of the ICBs response to a number of suicides of children and young people during 2023, a series of learning events have taken place. The first focused on North East London Foundation Trust (NELFT - our children and young people mental health services provider) and their learning as an organisation. The second focused on the patients’ and their families’ perspective to ensure their voices were engaged as part of wider learning. The third focused on system wide/inter agency working in November 2024. This event will culminate in a system wide improvement plan that will include a focus on agency information sharing, risk assessments and decision making among others. Work on a shared risk protocol across system partners has already commenced.”

    Source location

    Response from Kent and Medway Integrated Care Board
    Page 4 · response
    Published 16 April 2025

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    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 system-wide improvement plan addressing agency information sharing, risk assessments and decision-making.

    Verbatim wording from the response

    “As part of the ICBs response to a number of suicides of children and young people during 2023, a series of learning events have taken place. The first focused on North East London Foundation Trust (NELFT - our children and young people mental health services provider) and their learning as an organisation. The second focused on the patients’ and their families’ perspective to ensure their voices were engaged as part of wider learning. The third focused on system wide/inter agency working in November 2024. This event will culminate in a system wide improvement plan that will include a focus on agency information sharing, risk assessments and decision making among others. Work on a shared risk protocol across system partners has already commenced.”

    Source location

    Response from Kent and Medway Integrated Care Board
    Page 4 · response
    Published 16 April 2025

    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 shared risk protocol with system partners.

    Verbatim wording from the response

    “As part of the ICBs response to a number of suicides of children and young people during 2023, a series of learning events have taken place. The first focused on North East London Foundation Trust (NELFT - our children and young people mental health services provider) and their learning as an organisation. The second focused on the patients’ and their families’ perspective to ensure their voices were engaged as part of wider learning. The third focused on system wide/inter agency working in November 2024. This event will culminate in a system wide improvement plan that will include a focus on agency information sharing, risk assessments and decision making among others. Work on a shared risk protocol across system partners has already commenced.”

    Source location

    Response from Kent and Medway Integrated Care Board
    Page 4 · response
    Published 16 April 2025

    Open published response

  2. Suffolk

    AI-generated summary

    Katie MADDEN · 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 Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.

    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 assess additional risks to vulnerable parents in safeguarding referrals concerning their children

    Wider context from the report

    “4. Safeguarding referrals made the Multi-Agency Safeguarding Hub in respect of Kate’s children were viewed in isolation, with no system in place to assess any additional risks posed to Kate herself. There were no additional steps, or risk assessments undertaken in relation to Kate, even though she was a recipient of a ‘Claires Law’ Domestic Violence Disclosure and therefore known to be more vulnerable. ”

    Source location

    Katie MADDEN · 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

    Add guidance to the MASH practice note and Standard Operating Procedure to identify vulnerable adults in safeguarding referrals concerning children.

    Verbatim wording from the response

    “Any referrals related to safeguarding concerns for a parent would be passed to the MASH who will consider any safeguarding actions required in accordance with Section 42 of the Care Act. A practice note and addition to the Standard Operating Procedure for the MASH will be made to remind MASH practitioners of the need to identify the vulnerabilities of any adults involved in safeguarding referrals in respect of children.”

    Source location

    Response from SCC
    Page 2 · response
    Published 6 June 2024

    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 prompts across children’s and adults’ multi-agency referral forms to identify and route related concerns about adults or children.

    Verbatim wording from the response

    “Action is already underway following a Serious Case Review in respect of MANDY for a process of prompts in both children’s and adult Multi Agency Referral Forms. This is for the practitioner to consider, when putting in a referral related to a child, whether there is an adult involved for whom there are also concerns. The practitioner will be prompted at the end of the referral form to direct the practitioner to submit the additional concerns in relation to the adult to the relevant portal for triaging. This process will also be implemented when referrals are received in respect of adults where the practitioner will be prompted to refer any concerns identified in relation to a child to the relevant portal.”

    Source location

    Response from SCC
    Page 2 · response
    Published 6 June 2024

    Open published response

  3. Derby and Derbyshire

    AI-generated summary

    Terri Liz Harris and 3 others · 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

    Terri Liz Harris, her children John-Paul Bennett and Lacey Bennett, and their friend Connie Gent were discovered deceased at Terri’s home on 19 September 2021. They had been murdered by Terri’s partner, Damien Bendall, who inflicted severe head injuries on all four; the report also states that he raped Lacey. The deaths were contributed to by acts and omissions in offender supervision and electronic monitoring, including concerns about risk-recording, domestic abuse and child-safeguarding checks, reporting of threats, and notification of missed treatment appointments.

    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

    Insufficient or absent probation domestic abuse and child safeguarding checks

    Wider context from the report

    “The inquests identified that DA and SG checks were either insufficient or wholly lacking at various stages of Damien Bendall’s offender management. The current evidence is that DA and SG checks remain generally insufficient or are not being done with consequent on-going risks to children and women. Insufficient or absent PS DA and SG checks has been a theme of HM Inspectorate of Probation reports and reviews for at least the last 5 years. On HM Inspectorate of Probation case sampling to determine whether domestic abuse and child safeguarding enquiries were being undertaken when indicated, the HM Inspectorate of Probation Annual Report for 2022/2023 states at page 38:- where inspectors judged that these enquiries needed to be made by the probation practitioner, child safeguarding enquiries were carried out in 55 per cent of cases, domestic abuse enquiries were only carried out in 49 per cent of cases and risk of harm was only properly addressed in 39 per cent. ”

    Source location

    Terri Liz Harris and 3 others · 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 complete domestic abuse and child safeguarding checks before proposing curfew conditions

    Wider context from the report

    “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children. The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases. ”

    Source location

    Terri Liz Harris and 3 others · 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 conduct child safeguarding checks where offenders will live with or access children

    Wider context from the report

    “The PS is not currently conducting SG checks in all cases where an offender will live with or have access to children. The PS has mandated that in all cases where a curfew condition is proposed to the court in a pre-sentence report (PSR) DA and SG checks will be conducted prior to the proposal and submission of the PSR: this is not being done in all cases. I am also unclear whether contact to the address homeowner/lead tenant for a potential curfew condition to discuss the suitability of a curfew condition is being undertaken in all cases. ”

    Source location

    Terri Liz Harris and 3 others · 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

    Issue strengthened messaging requiring compliance with domestic abuse and safeguarding check expectations, including no curfew proposal without completed checks.

    Verbatim wording from the response

    “The Probation Service is committed to conducting child safeguarding checks in all cases where an offender will live with or have access to children, and domestic abuse checks in all cases where there are indicators of concern. We are committed to ensuring that DA, SG, and main occupier checks are completed prior to proposing a curfew condition to the court in all cases. Measures to improve performance have been taken since the inquests and are detailed further below.”

    Source location

    Response from HM Prison and Probation Service
    Page 4 · response
    Published 29 November 2023

    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

    Work with police and children’s services to strengthen safeguarding and domestic-abuse information sharing.

    Verbatim wording from the response

    “We are committed to working with partner agencies such as the police and children’s services.”

    Source location

    Response from HM Prison and Probation Service
    Page 4 · response
    Published 29 November 2023

    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

    Operate weekly regional reviews and monthly senior-leader reporting to assure checks support every recommended curfew.

    Verbatim wording from the response

    “A gatekeeping process is mandated to check every report before it goes to court so that any such recommendation can be changed before the report is submitted to court if the information from enquiries is not available. We have taken further steps since the inquests to add assurance through weekly regional meetings to review the data to assure that all cases where a curfew is recommended are informed by checks and this is further backed up by a monthly report for senior leaders.”

    Source location

    Response from HM Prison and Probation Service
    Page 4 · response
    Published 29 November 2023

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    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Probation Service rejects the concern that it fails to grasp the seriousness of failures to conduct or report safeguarding checks.

    Verbatim wording from the response

    “The Probation Service does grasp the seriousness of this issue and has policies to respond as detailed below.”

    Source location

    Response from HM Prison and Probation Service
    Page 5 · response
    Published 29 November 2023

    Open published response

  4. Buckinghamshire

    AI-generated summary

    Melsadie Adella-Rae Parris · 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

    Melsadie Adella-Rae Parris, aged three, died on 18 February 2019 after being struck by a fast non-stopping train at Taplow Railway Station while being held by her adult carer, who also died in a deliberate act of self-harm. The principal concern was that children’s services did not adequately respond to information about the carer’s deteriorating mental health: they did not renew a home visit, seek updated family information, or liaise with mental health services, despite existing guidance encouraging those actions.

    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 conduct renewed home visits during child-safety reassessment

    Wider context from the report

    “In the course of the investigation and in evidence in the inquest I found that the social work staff in the childrens services were informed on 9th January 2019 by two separate persons, ████████ that the adult with daily care of Melsadie had spoken to Melsadie in terms of describing her as evil. On checking with the adult carer, that person admitted to the social worker that the reports were true. The social work team knew that the adult carer had previously been referred to them by emergency services as a result of genuine and valid concerns about the carer’s mental health such that the carer was suffering from psychosis. The team had removed Melsadie appropriately while awaiting a mental health assessment, which was completed without knowledge of the carer’s remark and before the remark was known to children’s services. The mental health assessment found that the carer was not psychotic, an opinion which was appropriate on the day of assessment. The social work team had earlier conducted an investigation around an older matter of concern involving Melsadie, but this was unrelated to the mental health of her adult carer, and it had arisen two calendar months before the mental health crisis. In respect of that initial concern the social worker had concluded reasonably that there was no evidence to justify the removal of Melsadie nor continuing concern for her safety, but for logistical reasons their file remained open at the time of the new concerns around the carer’s metal health. However the team based their review on investigations conducted some months before the mental health concerns arose and before the remark about evil was made. The team did not conduct a renewed visit to the home, nor seek update information from the family, nor liaise with the mental health team. It is likely that if they had done so they would have discovered more detail of the extent of the carer’s mental illness which was indicative of paranoia with depression, linked to concealment of ongoing episodic psychosis. It is possible that a further mental health assessment would have been sought, and arrangements made to remove Melsadie from the custody of the carer. I found that existing guidance and policy recognised and encouraged the need to engage with family to gather information, to make home visits, to liaise with mental health and to treat assessment decisions and verification of file closure as dynamic processes requiring rigorous scrutiny. However, despite the existence of this guidance, the team placed undue reliance on the opinion of the mental health professionals and on old irrelevant investigations. Furthermore, although the department commissioned an independent review of the case, this found that the death could not have been predicted (which I accept), but tended to emphasise perceived shortcomings in the mental health professionals work, without acknowledging the above concerns. In addition it contained factual inaccuracies, such as a failure to identify the revelations of 9th January 2019. The review report was withheld, following complaints by the family as to matters of fact, but the council decided nonetheless to publish an executive summary which maintained the partial reflection of the review conclusions. I am concerned that by so doing the department will persist in a view that its team did not fail to adhere to its own guidance and good practice. ”

    Source location

    Melsadie Adella-Rae Parris · Prevention of Future Deaths report
    Page 3 · 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 obtain updated information from the family during child-safety reassessment

    Wider context from the report

    “In the course of the investigation and in evidence in the inquest I found that the social work staff in the childrens services were informed on 9th January 2019 by two separate persons, ████████ that the adult with daily care of Melsadie had spoken to Melsadie in terms of describing her as evil. On checking with the adult carer, that person admitted to the social worker that the reports were true. The social work team knew that the adult carer had previously been referred to them by emergency services as a result of genuine and valid concerns about the carer’s mental health such that the carer was suffering from psychosis. The team had removed Melsadie appropriately while awaiting a mental health assessment, which was completed without knowledge of the carer’s remark and before the remark was known to children’s services. The mental health assessment found that the carer was not psychotic, an opinion which was appropriate on the day of assessment. The social work team had earlier conducted an investigation around an older matter of concern involving Melsadie, but this was unrelated to the mental health of her adult carer, and it had arisen two calendar months before the mental health crisis. In respect of that initial concern the social worker had concluded reasonably that there was no evidence to justify the removal of Melsadie nor continuing concern for her safety, but for logistical reasons their file remained open at the time of the new concerns around the carer’s metal health. However the team based their review on investigations conducted some months before the mental health concerns arose and before the remark about evil was made. The team did not conduct a renewed visit to the home, nor seek update information from the family, nor liaise with the mental health team. It is likely that if they had done so they would have discovered more detail of the extent of the carer’s mental illness which was indicative of paranoia with depression, linked to concealment of ongoing episodic psychosis. It is possible that a further mental health assessment would have been sought, and arrangements made to remove Melsadie from the custody of the carer. I found that existing guidance and policy recognised and encouraged the need to engage with family to gather information, to make home visits, to liaise with mental health and to treat assessment decisions and verification of file closure as dynamic processes requiring rigorous scrutiny. However, despite the existence of this guidance, the team placed undue reliance on the opinion of the mental health professionals and on old irrelevant investigations. Furthermore, although the department commissioned an independent review of the case, this found that the death could not have been predicted (which I accept), but tended to emphasise perceived shortcomings in the mental health professionals work, without acknowledging the above concerns. In addition it contained factual inaccuracies, such as a failure to identify the revelations of 9th January 2019. The review report was withheld, following complaints by the family as to matters of fact, but the council decided nonetheless to publish an executive summary which maintained the partial reflection of the review conclusions. I am concerned that by so doing the department will persist in a view that its team did not fail to adhere to its own guidance and good practice. ”

    Source location

    Melsadie Adella-Rae Parris · 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 liaise with the mental health team during child-safety reassessment

    Wider context from the report

    “In the course of the investigation and in evidence in the inquest I found that the social work staff in the childrens services were informed on 9th January 2019 by two separate persons, ████████ that the adult with daily care of Melsadie had spoken to Melsadie in terms of describing her as evil. On checking with the adult carer, that person admitted to the social worker that the reports were true. The social work team knew that the adult carer had previously been referred to them by emergency services as a result of genuine and valid concerns about the carer’s mental health such that the carer was suffering from psychosis. The team had removed Melsadie appropriately while awaiting a mental health assessment, which was completed without knowledge of the carer’s remark and before the remark was known to children’s services. The mental health assessment found that the carer was not psychotic, an opinion which was appropriate on the day of assessment. The social work team had earlier conducted an investigation around an older matter of concern involving Melsadie, but this was unrelated to the mental health of her adult carer, and it had arisen two calendar months before the mental health crisis. In respect of that initial concern the social worker had concluded reasonably that there was no evidence to justify the removal of Melsadie nor continuing concern for her safety, but for logistical reasons their file remained open at the time of the new concerns around the carer’s metal health. However the team based their review on investigations conducted some months before the mental health concerns arose and before the remark about evil was made. The team did not conduct a renewed visit to the home, nor seek update information from the family, nor liaise with the mental health team. It is likely that if they had done so they would have discovered more detail of the extent of the carer’s mental illness which was indicative of paranoia with depression, linked to concealment of ongoing episodic psychosis. It is possible that a further mental health assessment would have been sought, and arrangements made to remove Melsadie from the custody of the carer. I found that existing guidance and policy recognised and encouraged the need to engage with family to gather information, to make home visits, to liaise with mental health and to treat assessment decisions and verification of file closure as dynamic processes requiring rigorous scrutiny. However, despite the existence of this guidance, the team placed undue reliance on the opinion of the mental health professionals and on old irrelevant investigations. Furthermore, although the department commissioned an independent review of the case, this found that the death could not have been predicted (which I accept), but tended to emphasise perceived shortcomings in the mental health professionals work, without acknowledging the above concerns. In addition it contained factual inaccuracies, such as a failure to identify the revelations of 9th January 2019. The review report was withheld, following complaints by the family as to matters of fact, but the council decided nonetheless to publish an executive summary which maintained the partial reflection of the review conclusions. I am concerned that by so doing the department will persist in a view that its team did not fail to adhere to its own guidance and good practice. ”

    Source location

    Melsadie Adella-Rae Parris · Prevention of Future Deaths report
    Page 3 · 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

    Reliance on old irrelevant investigations in child-safety reassessment

    Wider context from the report

    “In the course of the investigation and in evidence in the inquest I found that the social work staff in the childrens services were informed on 9th January 2019 by two separate persons, ████████ that the adult with daily care of Melsadie had spoken to Melsadie in terms of describing her as evil. On checking with the adult carer, that person admitted to the social worker that the reports were true. The social work team knew that the adult carer had previously been referred to them by emergency services as a result of genuine and valid concerns about the carer’s mental health such that the carer was suffering from psychosis. The team had removed Melsadie appropriately while awaiting a mental health assessment, which was completed without knowledge of the carer’s remark and before the remark was known to children’s services. The mental health assessment found that the carer was not psychotic, an opinion which was appropriate on the day of assessment. The social work team had earlier conducted an investigation around an older matter of concern involving Melsadie, but this was unrelated to the mental health of her adult carer, and it had arisen two calendar months before the mental health crisis. In respect of that initial concern the social worker had concluded reasonably that there was no evidence to justify the removal of Melsadie nor continuing concern for her safety, but for logistical reasons their file remained open at the time of the new concerns around the carer’s metal health. However the team based their review on investigations conducted some months before the mental health concerns arose and before the remark about evil was made. The team did not conduct a renewed visit to the home, nor seek update information from the family, nor liaise with the mental health team. It is likely that if they had done so they would have discovered more detail of the extent of the carer’s mental illness which was indicative of paranoia with depression, linked to concealment of ongoing episodic psychosis. It is possible that a further mental health assessment would have been sought, and arrangements made to remove Melsadie from the custody of the carer. I found that existing guidance and policy recognised and encouraged the need to engage with family to gather information, to make home visits, to liaise with mental health and to treat assessment decisions and verification of file closure as dynamic processes requiring rigorous scrutiny. However, despite the existence of this guidance, the team placed undue reliance on the opinion of the mental health professionals and on old irrelevant investigations. Furthermore, although the department commissioned an independent review of the case, this found that the death could not have been predicted (which I accept), but tended to emphasise perceived shortcomings in the mental health professionals work, without acknowledging the above concerns. In addition it contained factual inaccuracies, such as a failure to identify the revelations of 9th January 2019. The review report was withheld, following complaints by the family as to matters of fact, but the council decided nonetheless to publish an executive summary which maintained the partial reflection of the review conclusions. I am concerned that by so doing the department will persist in a view that its team did not fail to adhere to its own guidance and good practice. ”

    Source location

    Melsadie Adella-Rae Parris · 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

    Require line managers closing cases to record outstanding tasks, consider another home visit, and explain why file closure is appropriate and safe.

    Verbatim wording from the response

    “As a statutory children services department, Buckinghamshire Council are fully focussed upon the safety and well-being of all the children and young people who are referred to us. Given the complexity of this work, the fact that every case is different, and that the Assistant Coroner has confirmed the policies and procedures we have are the right ones, our focus will be on ensuring that our staff properly evidence the rationale and decision-making process that informs their professional judgment resulting in the closure of cases going forward.”

    Source location

    Response from Buckinghamshire Council
    Page 3 · response
    Published 8 December 2022

    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 policies and guidance are sufficiently robust, so they will not be revisited as a result of the report.

    Verbatim wording from the response

    “File Closure I am pleased to note that it is recognised by the Assistant Coroner that our existing policies and guidance are deemed sufficiently robust. We do not therefore propose to re-visit those policies and guidance as a result of this PFD, as this does not appear to be the Assistant Coroner’s requirement.”

    Source location

    Response from Buckinghamshire Council
    Page 2 · response
    Published 8 December 2022

    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 legal threshold for further statutory intervention was not evidenced in this case, prompting the file closure.

    Verbatim wording from the response

    “We do consider it important to note for the purposes of our response to the PFD, that in this particular case, the Local Authority consider that the legal test (Threshold) for any further statutory intervention was no longer evidenced and that this is what prompted the closure decision.”

    Source location

    Response from Buckinghamshire Council
    Page 3 · response
    Published 8 December 2022

    Open published response

  5. Bedfordshire and Luton

    AI-generated summary

    Harper DENTON · 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

    Harper DENTON, aged one month, was unlawfully killed by her father, who had previously been convicted of violent offences against a two-year-old child. The inquest found that failures by state agencies to manage the continuing risk he posed contributed to her death. Concerns included police information-sharing and risk-management practices, the absence of an offender register for people convicted of cruelty offences against children, and the non-mandatory nature of full safeguarding assessments by health visitors.

    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 require Health Visitors to conduct full safeguarding assessments of fathers’ or co-parents’ potential risks to children

    Wider context from the report

    “4.The need for a Health Visitor to carry out a full safeguarding assessment of a father’s/co-parent's potential risks to a child is currently only ‘best practice’ and not mandatory. ”

    Source location

    Harper DENTON · 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

    Update and publish resources for health visitor- and school nurse-led services, emphasising family relationship and event chronology assessments for children with additional needs.

    Verbatim wording from the response

    “Health visitors and school nurses as leaders of the Healthy Child Programme have a vital role in keeping children safe. They work with their teams and partners to support local safeguarding arrangements. We are currently updating a set of resources for health visitor and school nurse-led services. This includes emphasising the importance for children who may have additional needs to complete an assessment of family relationships and chronology of events to identify strengths and vulnerabilities. These are due to be published shortly.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 6 October 2022

    Open published response

  6. Shropshire, Telford and Wrekin

    AI-generated summary

    Archie David SPRIGGS · 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

    Archie David Spriggs was murdered by his mother on the morning of 21 September 2017, during a bitter dispute between his parents and on the day of a scheduled child arrangements hearing. The report’s concerns, based on a Serious Case Review, included referral and decision-making processes, responses to urgent safeguarding information, the impact of prolonged private law proceedings, assessment of separated-parent cases and allegations of domestic abuse, and multi-agency working with fathers and families.

    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 provide a whole family focus and consider the impact of parenting capacity on children

    Wider context from the report

    “a) SSCB to clarify, and subsequently audit the application of the referral pathway and decision-making process for referrals to Early Help and Children’s Social Care. This should include the use and quality of written referral forms and feedback to referrers. b) SSCB to seek regular assurance that: i. Professionals understand how to refer urgent concerns in respect of cases open to Children’s Social Care; ii. Children’s Social Care provide a timely and child centred response to this information. c) SSCB to provide the multi-agency workforce with the knowledge and understanding of i. the impact of protracted private law proceedings on children’s emotional wellbeing; ii. the factors to be considered and assessed in circumstances whereby separated parents make allegations about the welfare of their children iii. the features of filicide cases. d) To test the impact of recommendation (c) SSCB to conduct a multi-agency audit of the services provided to children referred to Children’s Social Care whose parents are separated and where private law proceedings have taken place. The audit should consider the completion of whole family assessments and the response to safeguarding concerns and allegations of domestic abuse. e) SSCB to work with Local Family Justice Board (LFJB) and CAFCASS to review the notification process for Section 37 reports to ensure timely and consistent arrangements. f) CAFCASS to update their Child Protection Policy to include when and how safeguarding referrals (child in need) should be made. g) SSCB to engage with multi-agency frontline staff as well as parents/carers to explore their experiences, and any barriers, to working with fathers. The findings of this work should be considered and acted on by SSCB. h) SSCB to create learning opportunities for the multi-agency workforce to come together and reflect on their approach to providing a whole family focus; including how they consider the impact of parenting capacity on children. ”

    Source location

    Archie David SPRIGGS · 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

    Insufficient workforce understanding of factors requiring consideration and assessment when separated parents allege welfare concerns

    Wider context from the report

    “a) SSCB to clarify, and subsequently audit the application of the referral pathway and decision-making process for referrals to Early Help and Children’s Social Care. This should include the use and quality of written referral forms and feedback to referrers. b) SSCB to seek regular assurance that: i. Professionals understand how to refer urgent concerns in respect of cases open to Children’s Social Care; ii. Children’s Social Care provide a timely and child centred response to this information. c) SSCB to provide the multi-agency workforce with the knowledge and understanding of i. the impact of protracted private law proceedings on children’s emotional wellbeing; ii. the factors to be considered and assessed in circumstances whereby separated parents make allegations about the welfare of their children iii. the features of filicide cases. d) To test the impact of recommendation (c) SSCB to conduct a multi-agency audit of the services provided to children referred to Children’s Social Care whose parents are separated and where private law proceedings have taken place. The audit should consider the completion of whole family assessments and the response to safeguarding concerns and allegations of domestic abuse. e) SSCB to work with Local Family Justice Board (LFJB) and CAFCASS to review the notification process for Section 37 reports to ensure timely and consistent arrangements. f) CAFCASS to update their Child Protection Policy to include when and how safeguarding referrals (child in need) should be made. g) SSCB to engage with multi-agency frontline staff as well as parents/carers to explore their experiences, and any barriers, to working with fathers. The findings of this work should be considered and acted on by SSCB. h) SSCB to create learning opportunities for the multi-agency workforce to come together and reflect on their approach to providing a whole family focus; including how they consider the impact of parenting capacity on children. ”

    Source location

    Archie David SPRIGGS · 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