First reported 4 Aug 2015•Latest report 2 Oct 2025
Definition
What this concern includes
Includes failures in safeguarding review processes, including identifying and referring relevant incidents, conducting sufficiently thorough and evidence-based reviews, recording the review, involving relevant people, communicating findings and recommendations, and using the learning to prevent recurrence.
Not included
Excludes generic incident investigation or organisational-learning failures where no safeguarding review or safeguarding incident is identified.
Excludes safeguarding assessment, referral or protective-action failures that do not concern the subsequent safeguarding review and learning process.
Excludes generic communication, documentation or family-involvement deficiencies unless they directly impair a safeguarding review.
Excludes failures to implement unrelated clinical, operational or infrastructure actions after a review where the safeguarding review and its learning were otherwise reliable.
Reports
8
Distinct published reports
Individual concerns
16
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
19
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.
Care Quality Commission2
College of Policing1
Community Health Care1
Crawley Borough Council1
Department for Education1
Department of Health and Social Care1
East Riding of Yorkshire Council1
Greater Manchester Mental Health NHS Foundation Trust1
Harbour Healthcare Ltd.1
Milton Keynes City Council1
NHS Greater Manchester Integrated Care Board1
Saffronland Homes Limited1
Surrey County Council1
West Sussex County Council1
English county council2
English unitary authority2
Health and social care service regulator2
Private limited company2
English district council1
Integrated care board1
Ministerial department1
Multi-service care provider1
National policing body1
NHS trust1
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.
Cumbria
Concerns raised1
Lack of effective internal investigation and organisational learning from safeguarding incidents
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.5
Action
Complete a Serious Untoward Incident root cause analysis with Human Resources support.
Stated by Harbour Healthcare Ltd.Stated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
Action
Operate a governance process and tracker for new Serious Untoward Incidents, reviewing root-cause findings, learning, actions and trends.
Stated by Harbour Healthcare Ltd.Stated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
Action
Record actions in the Service Improvement Plan and share learning through Clinical Governance Meetings.
Stated by Harbour Healthcare Ltd.Stated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
Action
Operate a monthly Coroners Learning Forum to share inquest and serious-incident outcomes and associated lessons across the organisation.
Stated by Harbour Healthcare Ltd.Stated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
Action
Cascade Riverside Court’s inquest outcome and lessons learned across the company.
Stated by Harbour Healthcare Ltd.Stated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
East Riding and Hull
Concerns raised7
Failure to provide Safeguarding Adult Review outcomes and recommendations to review subjects
Failure to appropriately probe responses during Safeguarding Adult Reviews
Failure to document the full Safeguarding Adult Review process properly
Lack of adequate Safeguarding Adult Review quality
Failure to record family input in Safeguarding Adult Reviews
Failure to follow the full Safeguarding Adult Review process
Hasty Safeguarding Adult Review processes
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.4
Action
Implemented new forms guiding practitioners to undertake and record safeguarding concerns and Section 42 enquiries, including person and family voices and outcome-sharing records.
Stated by East Riding of Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.
Action
Disseminated lessons learned from the identified enquiry practice issues across the safeguarding team.
Stated by East Riding of Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.
Action
Delivered training, learning and guidance to strengthen practitioners’ completion of safeguarding forms, professional curiosity and thorough enquiry practice.
Stated by East Riding of Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.
Action
Implemented practice workshops and a weekly safeguarding hub forum providing case discussion and leadership guidance.
Stated by East Riding of Yorkshire CouncilStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.
Manchester South
Concerns raised1
Failure to obtain input from key people involved in care during safeguarding reviews
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.
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 the Safeguarding Adult Review, including a multi-agency practitioner learning event and production of the review report.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
CQC previously had no remit over local authorities’ safeguarding reviews, although it now assesses local authorities’ safety duties.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Manchester City
Concerns raised1
Lack of appropriate safeguarding review
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Unclear dissemination of safeguarding investigation lessons beyond the local area
This report raised 14 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised3
Failure to conduct an adequate safeguarding enquiry
Failure to involve family in safeguarding review
Failure to produce an adequate s42 report
This report raised 9 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.5
Action
Improve systems to identify long-running adult safeguarding enquiries and bring them to satisfactory conclusions.
Stated by Surrey County CouncilStated completedThe respondent said that this action was complete when they made their response on 22 December 2017.
Action
Implement a revised quality assurance auditing programme for adult safeguarding work.
Stated by Surrey County CouncilStated completedThe respondent said that this action was complete when they made their response on 22 December 2017.
Action
Revise adult safeguarding policies and procedures with clearer expectations for planning, family involvement, organisational contributions, responsibility and timeliness.
Stated by Surrey County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 22 December 2017.
Action
Deliver a learning and development programme to help staff meet revised adult safeguarding expectations.
Stated by Surrey County CouncilStated plannedThe respondent said that this action was planned when they made their response on 22 December 2017.
Action
Review systems to support expected adult safeguarding practice and produce better management information for oversight.
Stated by Surrey County CouncilStated plannedThe respondent said that this action was planned when they made their response on 22 December 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The employing provider had first responsibility to complete the safeguarding enquiry, subject to the Council assuring its sufficiency and following up if necessary.
Stated by Surrey County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Milton Keynes
Concerns raised1
Failure to refer incidents for safeguarding review and learning
This report raised 6 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
Commission a multi-agency learning review to identify lessons, improve practice and reduce the likelihood of similar cases.
Stated by Milton Keynes Safeguarding BoardStated completedThe respondent said that this action was complete when they made their response on 31 August 2017.
Action
Undertake the multi-agency learning review, including practitioner engagement, case-report analysis, concern analysis and a practice-improvement report with dissemination recommendations.
Stated by Milton Keynes Safeguarding BoardStated plannedThe respondent said that this action was planned when they made their response on 31 August 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The case did not meet statutory criteria for a Safeguarding Adults Review, so that review could not be conducted.
Stated by Milton Keynes Safeguarding BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West Sussex
Concerns raised1
Lack of formal review of safeguarding-related deaths
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.2
Action
Follow and report safeguarding alerts to senior managers and immediately review future deaths involving such alerts.
Stated by the CouncilStated completedThe respondent said that this action was complete when they made their response on 4 August 2015.
Action
Complete a detailed review of the circumstances surrounding Mr Warren’s involvement with the Council.
Stated by West Sussex County CouncilStated completedThe respondent said that this action was complete when they made their response on 4 August 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Council disputes that its review and recommendations were absent, stating they arose from an earlier case review.
Stated by the CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures in safeguarding review processes, including identifying and referring relevant incidents, conducting sufficiently thorough and evidence-based reviews, recording the review, involving relevant people, communicating findings and recommendations, and using the learning to prevent recurrence.
