Natasha Hill
1 May 2026 · Coroner Julian Morris · Inner South London
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of formal review of teenagers approaching 18 by adult safeguarding team and independent reviewing officer
“Anyone requiring/ needing/suffering o Safeguarding o Domestic violence o Controlling/ coercive behaviour”
2. absence of dedicated young person's safeguarding team
“Thought should be given to creating a young person's team covering the transition from under 18 (MACE) to adult safeguarding teams e.g. For the period 18-22”
3. no extension of CAWN for young persons at risk
“Thought should be given to the creation of a young person's protection by way of creation of an extension to the CAWN for the young person, against the adult creating that safeguarding risk e.g. young person's abuse warning notice”
4. fragmented national policy on child sexual exploitation
“The creation of one single national policy for policing and child sexual exploitation following the groundwork laid down by Operation Hydrant and local Forces”
5. inconsistent offender management and guidance
“Re safeguarding offender management, the use of VOO's and the creation of POETs/ DAPST and RMUs: Consideration should be given to the creation of one set of criteria with one name whose role it is to cover and create a central guidance”
6. limited national dissemination of local protocols
“To consider the wider dissemination of existing local protocols nationally, for example the London Exploitation Protocol”
7. inadequate guidance for missing persons and return interviews
“The provision of guidance in respect of missing persons/ runaways and the return to home interviews to assist the actions of the police and local councils”
Linked reports
Closely relatedConfidence 0.70 · moderate
Earlier report
“In issuing, the CAWN there was no evidence that his known vulnerability had been taken into account. A risk assessment had not been carried out.”
This report
“Thought should be given to the creation of a young person's protection by way of creation of an extension to the CAWN for the young person, against the adult creating that safeguarding risk e.g. young person's abuse warning notice.”