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IICSA published its final Report in October 2022. This website was last updated in January 2023.

IICSA Independent Inquiry into Child Sexual Abuse

The Anglican Church Investigation Report


Annex 3: Expert analysis of safeguarding case files


1. The Inquiry instructed Mrs Edina Carmi (an independent safeguarding consultant, who has previously undertaken independent reviews of the Church of England and safeguarding audits on behalf of SCIE) to provide an expert report examining the recent management of safeguarding in both the Church of England and the Church in Wales.

2. Mrs Carmi analysed a number of case files from four of the 42 dioceses in the Church of England:

  • the Diocese of London;
  • the Diocese of Sheffield;
  • the Diocese of Worcester; and
  • the Diocese of York.

These dioceses were chosen by the Inquiry to represent a spread of geographic locations and sizes. To ensure a representative sample, the Inquiry obtained a full list of all safeguarding casework undertaken by those dioceses between April 2017 and April 2018 and selected a sample of cases to be considered by Mrs Carmi.

3. As regards the Church in Wales, the Inquiry obtained a full list of all safeguarding casework undertaken between April 2017 and April 2018. One case was selected from each of the six dioceses, with each case reflecting a different issue.

The Church of England

Diocese of London

Safeguarding resources

4. The Diocese of London covers a large area with a diverse population and more than 500 worshipping communities.

5. The diocesan safeguarding team is presently made up of three diocesan safeguarding advisers (DSAs) and a safeguarding manager. In addition, one bishop within the diocese oversees safeguarding together with the Bishop of London.[1]

6. The Diocese of London has seen a significant increase in its safeguarding budget, from £50,000 in 2013 to £281,000 in 2019.[2] Of the safeguarding cases seen each year by the diocese, 25 percent relate to children.[3]

London sample cases


7. In this sample case, it was alleged in 2017 that L1, who was a volunteer at a ‘kids club’, hugged an eight-year-old girl and pinched her bottom. When the police and the local authority designated officer (LADO)[4] decided to take no action, an internal investigation was recommended. That investigation, carried out by the DSA, involved meeting with the alleged perpetrator but did not include meeting with the complainant.[5] The allegation was found to be unsubstantiated.


8. The L2 case involved a perpetrator who was convicted in 2007 of child sexual offences. He worshipped for seven or eight years in a London church without any safeguarding agreement or risk assessment in place.

9. Church policy was that the offender should have been referred to the DSA for risk assessment and offender agreements. The DSA only became aware of the conviction in 2017, when she was contacted by the perpetrator’s offender manager in the probation service.[6] The DSA then put in place a safeguarding agreement to ensure the perpetrator had no contact with children.[7]

10. Mrs Carmi described as “worrying practice” that the individuals in this case “didn’t recognise, either eight years ago or at any time since, that the DSA needed to be informed about this and there needed to be a safeguarding agreement in place”.[8]

11. A current DSA for the Diocese of London, Ms Margaret McMahon, agreed that it was “really concerning that in the current climate people were not coming to us with that information”.[9] She did not think that this would be an isolated case and there could be other perpetrators worshipping within congregations of which they were not aware.


12. The L3 case involved a three-year-old boy. In July 2018, while visiting the family home, it was alleged that a church employee, AN-F23 (who also ran activities for children on behalf of the church), had been “rough wrestling” with the child on a trampoline. The child reported that they had both had their penises out on the trampoline and touched their penises together. AN-F23’s belt was seen by the parents to be undone when he climbed off the trampoline. The parents also saw the child lick AN-F23’s tongue.[10]

13. This was reported by the parents to the rector and his wife, who in turn reported it to the DSA. On the advice of the DSA, AN-F23 was immediately suspended from duty. The police and the LADO were also informed.[11]

14. When no further action was taken by the police or the LADO, an internal investigation was carried out on behalf of the parish. AN-X2, a part-time priest within the parish, conducted the investigation. He had some relevant experience but was not a specialist in safeguarding or in risk assessments. The investigation was a fact-finding exercise, to inform a decision on whether or not disciplinary action would be required.[12] This was treated as a disciplinary matter, not a safeguarding investigation.[13]

15. AN-X2 interviewed AN-F23, the parents of the child, and the rector and his wife. He could not be satisfied that any “touching of penises” had taken place. However, he was satisfied that there had been “rough play on the trampoline” and “touching of tongues in the kitchen of the family house”. His conclusion was that these acts were “infantile” and “not very pleasant” rather than sexual.[14] As a result, no disciplinary hearing was required. AN-X2 did note that, despite being employed by the parish to run children’s activities, AN-F23 had not received formal church safeguarding training. He therefore recommended that AN-F23 undertake safeguarding training before he would be permitted to return to work.[15]

16. AN-X2’s report was praised by the local authority but Mrs Carmi questioned whether AN-X2 was the right person to have done the investigation because he was a priest and had no specialist knowledge of safeguarding.[16] Mrs Carmi said that the Church must distinguish between a safeguarding and a disciplinary investigation. Disciplinary processes are separate from the need to carry out a risk assessment.[17] AN-X2 agreed that it would have been preferable for the whole investigation to have been carried out by the DSA.[18]

Diocese of Sheffield

Safeguarding resources

17. The Diocese of Sheffield includes 175 parishes.[19] The Bishop of Sheffield is responsible for safeguarding practice in the diocese but has delegated the day-to-day management of safeguarding to the Archdeacon of Doncaster, who also manages the DSA. The Bishop of Sheffield is notified of any allegation against a church officer.[20]

18. The diocesan safeguarding team includes a full-time DSA, an assistant DSA (ADSA, who also acts as the safeguarding adviser for Sheffield Cathedral), a full-time training officer and a part-time member of staff responsible for DBS checks of criminal records and training administration. The diocese has external support via agency workers for administrative tasks and Thirtyone:eight (an independent safeguarding charity which works predominantly with Christian organisations) provides out-of-hours and leave cover.[21]

19. The funding of safeguarding in the Diocese of Sheffield has been increasing since 2009, rising from £79,103 in 2016 to £183,337 in 2018.[22]

Sheffield sample cases


20. The perpetrator in sample case S1 was a high-risk offender. He was first convicted of sexual offences when he was 14 years old. He reoffended on a number of occasions and breached a sexual harm prevention order. Following his release from prison in 2017, the Church put in place a safeguarding agreement to manage his attendance at the parish church. The safeguarding agreement placed little restriction upon his activities; it allowed him to attend all services, social activities and house groups.[23]

21. The DSA was not informed by the Probation Service when the perpetrator was recalled to prison for breaching his sexual harm prevention order. She found out through a chance encounter some months later.[24] Mrs Carmi observed that “statutory authorities … are not recognising that churches need to know this”.[25] In addition, the DSA was not informed by churchwardens that the perpetrator, upon release, began attending community meals at which children would be present. It only came to the DSA’s attention when she was contacted by the perpetrator’s probation officer to raise a concern. It took phone calls to the churchwarden, the parish safeguarding officer (PSO), a deputy PSO and an archdeacon before she was able to establish what was happening and try to put safeguarding measures in place.[26]

22. While the DSA used the correct Church of England risk assessment templates, Mrs Carmi criticised the quality of those templates, which in her view focussed on the management of risk and the deployment of practical steps at the expense of a real and detailed assessment of the risk that might be posed.[27] Mrs Carmi said “it is important to try to obtain any relevant history and risk assessments from statutory agencies that have been involved”.[28]


23. In the sample case of S2 the perpetrator was a former headteacher, churchwarden and youth leader who was convicted of possessing indecent images of children, including extreme images. While under police investigation for further offences, he wished to join church home group meetings (where worship occurs in parishioners’ homes). When this was raised with the PSO and the local priest, they refused to allow the perpetrator to attend until a safeguarding agreement was in place. When consulted, the DSA advised that – as home group meetings provided access to children – it would not be safe for the perpetrator to attend. The perpetrator refused to engage with a risk management agreement and left the diocese.[29]

24. When attempting to assess the risk posed by the perpetrator, the DSA contacted (with permission) Derbyshire Police about the ongoing investigation. The lead officer refused to share any information with her. The Diocese of Derby had not previously had difficulties in getting information from Derbyshire Police.[30] It may have been because the Diocese of Sheffield did not have an information-sharing agreement with that particular force. In Mrs Carmi’s view, the DSA should have escalated this difficulty in information-sharing.[31] The National Police Chiefs’ Council (NPCC) accepted that there were no information-sharing templates for police forces in existence at the time of the hearing.[32] The NPCC has since prepared such a template and further guidance on its use, which was circulated to all chief officers in June 2020.[33]


25. In the case of S4, a youth worker at a church youth group learned that a 13-year-old girl was in a sexual relationship with a 17-year-old boy. The youth worker initially informed the boy that if he promised not to have sex with the girl” then he would not tell her parents.[34] Mrs Carmi considered that this was “clearly totally inappropriate.[35]

26. When volunteers became aware that the two were having sex and that the boy may have been coercing the young girl, it was reported to the DSA by the head of the youth group. The DSA provided advice over the phone and via email. As a result, the girl’s parents were informed and the matter was referred to the police. The DSA did not, however, advise on whether a safeguarding agreement should be put in place.

27. Mrs Carmi commented that it was difficult for professionals and volunteers to identify when to report concerns about adolescent sexual relationships, and to identify appropriate relationships between children.[36] The DSA also noted that there was no guidance from the Church of England on harmful sexual behaviour between children.[37] There was also no specific guidance as to whether or not it was appropriate for safeguarding agreements to be put in place for alleged perpetrators under 18 years old.[38]

Diocese of Worcester

Safeguarding resources

28. The Diocese of Worcester has 169 parishes. The Bishop of Dudley is Lead Bishop on Safeguarding within the diocese and manages the DSA. There is a full-time DSA and an ADSA. They receive administrative support from the HR and safeguarding coordinator as well as the Disclosure and Barring Service (DBS) and training administrator. There is also a diocesan youth officer and a diocesan children’s officer.

29. The diocesan budget for safeguarding was £55,000 in 2014. In 2018, it had increased to £109,000.[39]

Worcester sample cases


30. A parish priest, AN-X3, was contacted by parents who reported that an older parishioner had been sending inappropriate, potentially grooming, text messages to their teenage daughter (AN-A138).

31. AN-X3 took action immediately, over a weekend, contacting the diocesan safeguarding team and speaking to the ADSA. He met with AN-A138 and her parents, and took safeguarding measures to prevent the alleged perpetrator having any contact with the complainant.[40] He had been prepared to insist that the alleged perpetrator attend a different service to avoid meeting AN-A138’s family, but this was not necessary as the family offered to change their worshipping arrangements.[41] AN-X3 advised AN-A138 that she could contact him or the ADSA directly if she wished.[42]

32. AN-X3 had no further discussions with AN-A138 and spoke only to her father. Mrs Carmi emphasised that it may have been beneficial to meet with AN-A138 alone, as this could have elicited further relevant details about the allegation.[43] The matter was reported to the LADO but, when the LADO was slow to act, it was the ADSA who pursued the matter to arrange a ‘positions of trust meeting’.

33. Mrs Carmi noted that this was not the only case in which she had seen delay on behalf of the statutory agencies. She thought that it occurred when they did not see the case as urgent, within the context of the more serious cases they were dealing with.[44] In Mrs Carmi’s view, the information-sharing from the LADO was not good enough. The alleged perpetrator worked with children as a coach for a national sports organisation, but the LADO did not share this information with the ADSA.[45]

34. It was five months from the allegation being made to the ADSA visiting the alleged perpetrator, and a further two months before she met with the complainant’s family. In total it was nine months before a formal safeguarding agreement was put in place. The delays were caused by a combination of factors. AN-X3 was very busy at that time both professionally and personally, and the ADSA was dealing with a heavy workload.[46] Mrs Carmi considered that:

there could be sometimes, perhaps, more direct communications between the DSAs and the people they are dealing with, rather than always doing it via the vicars or somebody else in the local church”.[47]

35. In Mrs Carmi’s view, the record-keeping in the Worcester cases was “very good”. A complete case log was maintained, recording what had been done and why.[48]


36. In this case, a safeguarding agreement was required for a congregant who held a number of voluntary roles within the parish but had convictions for child sexual offences from more than 35 years before. Contrary to national policy, the PSO (who was the congregant’s brother) did not inform the DSA of the convictions until the congregant wished to take on a pastoral role which required a DBS check (which would reveal the fact of the convictions). This was despite the congregant’s existing voluntary roles bringing him into contact with children, although he was not alone with them.[49] When a safeguarding agreement was put in place for the perpetrator, it was, effectively, managed solely by his brother.[50]

37. Mrs Carmi recognised that finding individuals to manage safeguarding agreements was difficult in small parishes but she concluded there was a clear conflict of interest in the PSO acting as the parish’s representative in this case.[51]

Diocese of York

Safeguarding resources

38. The Diocese of York is made up of 472 parishes. The diocesan safeguarding team now includes a full-time DSA, a full-time ADSA and a part-time ADSA. They are assisted by a part-time DSA administrator and an events coordinator. In addition, the diocesan training team assists with the delivery of theological and pastoral aspects of the safeguarding training.

39. As he is both the Archbishop of the Province of York and the diocesan bishop of the Diocese of York, the Archbishop of York has delegated his safeguarding responsibility to the diocesan secretary, who also acts as line manager for the DSA.[52] The diocesan safeguarding budget increased from £118,878 in 2017 to £191,049 in 2019.

York sample cases


40. In this case, the DSA responded to the arrest of a volunteer server for indecent assault on a child the server met through the church. The DSA became aware of the arrest in June 2017, three months before the trial, when the alleged perpetrator himself disclosed it. There had been no contact from the police.[53] As soon as the allegations were disclosed, a plan was put in place to limit the alleged perpetrator’s contact with children.[54]

41. The DSA interpreted broadly the term ‘church officer’ in the relevant guidance, focussing on:

the point of view of a child sitting at the front of a congregation: would a child look at an individual and think that they were part of the church and, therefore, might they assume that the individual was ‘safe’”.[55]

As a result, the DSA initiated a core group even though the members of the group doubted it was required.[56]

42. Mrs Carmi considered that the approach taken by the DSA to the question of who is a church officer was insightful and the decision to convene a core group was one of the reasons why the case was handled so well.[57]

43. A risk assessment was carried out promptly (prior to the criminal trial) and measures were put in place to restrict the alleged perpetrator’s access to children. The police refused to provide any information about the allegations, so the DSA relied upon information provided by the alleged perpetrator himself.[58]

44. The DSA arranged for someone to attend every day of the trial and, when the alleged perpetrator was acquitted, another risk assessment was carried out based upon what she had heard during that trial.[59] Mrs Carmi considered this case to demonstrate very good practice.[60]


45. A congregant (AN-F71) was convicted in 1997 of indecent assault on a child. In 2011, a complainant contacted the parish priest (AN-X7) and requested a meeting to discuss further allegations of grooming behaviour that occurred in 1999.[61]

46. A very brief written agreement was put in place by AN-X7, on the advice of the Archdeacon of Cleveland and the DSA then in post. This was not sufficiently detailed and lacked clarity about what was expected of AN-F71.[62] Though the Church’s actions in 2011 were not the focus of Mrs Carmi’s analysis, she observed that the response of church officers was “hostile, inappropriate and unsafe” and that they were focussed on protecting AN-F71’s emotional welfare.[63] AN-X7 agreed that his response in 2011 had been inappropriate but denied being hostile or unsafe.[64]

47. Between 2011 and 2017, AN-F71 held a number of roles within his parish, including leading a house group, in which worship is led at an individual’s home, and being a member of the parochial church council (PCC).

48. In 2016, the Church’s national guidance was changed so that PCC members were required to have a DBS certificate and to complete a confidential declaration form. It was only as a result of AN-F71’s confidential declaration that, in 2017, the DSA then in post became aware of the conviction, the 2011 allegations and the written agreement.

49. When the DSA informed AN-X7 that she wished to conduct a risk assessment, he resisted. He said that a risk assessment was not necessary because the risk had already been managed and it would make AN-F71 extremely upset.[65] The DSA agreed to wait until the DBS certificate had been received, because they usually came through quickly.[66] However, the DBS certificate was not received until January 2018, as AN-F71 said he had struggled to find any documents with his address. During this 12-month period, contrary to the Church’s Safer Recruitment guidance, AN-F71 continued on the PCC.[67] Whenever the DSA contacted AN-X7 to chase this up, he repeated his view that the risk assessment was not necessary.[68]

50. In February 2018, the DSA realised that – regardless of the outcome of any risk assessment – AN-F71 was precluded from being on the PCC because of his conviction.[69] When AN-X7 was informed, he did not immediately follow the advice of the DSA or comply with the Safer Recruitment guidance to remove AN-F71 from the PCC.[70] Instead AN-X7 asked that AN-F71 remain on the PCC for its final meeting of the year and then be allowed to withdraw without bringing attention to himself. The DSA remained firm in her advice.

51. AN-X7 denied contributing to any delay or acting as an obstacle. In his view he was acting pastorally towards AN-F71 but he accepted pastoral support for AN-F71 cannot be placed above safeguarding.[71]

52. In February 2018, the DSA referred the case to the Archdeacon of Cleveland and the Bishop of Whitby. Separately, they reinforced the position that AN-F71 must step down immediately. AN-X7 was very upset, as the DSA recalled:

He reflected on the challenges of supporting somebody who had he felt had been redeemed, had gone on a redemption journey, and how that sat against the safeguarding process, and he felt quite strongly that the individual had changed and the decisions we were making were unfair.[72]

In the meantime, AN-F71 left the parish. It is unclear whether he is worshipping elsewhere and, if so, whether steps have been taken to manage any risk he may pose.

53. Mrs Carmi described AN-X7 as “very, very protective of AN-F71 throughout the risk assessment process,[73] objecting to the advice of the DSA at every stage and obstructing her attempts to follow the requirements of national safeguarding policy. The DSA accepted that she was partly responsible for the delays in this case, and that she could have handled it differently.[74] At the time, she was new in post and was not familiar with “church structure and church process”. She said that she felt “stuck” in her attempts to progress discussions with AN-X7, which always “revisited a position of, ‘Is this necessary? Do we have to undertake this?[75]

54. Mrs Carmi thought this case highlighted the need for more effective support for the DSA, particularly when their advice is not followed. Mrs Carmi would have expected senior clergy involved to have considered the use of disciplinary proceedings rather than persuasion to get the risk assessment done expeditiously.[76]

The Church in Wales

Sample cases


55. The first sample case, Wa1, related to an allegation made by a 17-year-old boy that he was raped by his former choirmaster at the choirmaster’s church-owned home. The matter was investigated by the police, who took no further action. The choirmaster was not suspended during the police investigation.

56. Without informing the Provincial Safeguarding Team, AN-X8 met with the choirmaster together with a member of the PCC to discuss the incident. AN-X8 claimed that they carried out a risk assessment but no safeguarding agreement was signed. AN-X8 wrote to the choirmaster to say that he must not entertain children under 18 years old in his home.

57. When the matter was referred to the Provincial Safeguarding Panel, it recommended suspension, a risk assessment and a safeguarding agreement.[77] AN-X8 declined to suspend the choirmaster and considered it might harm the choirmaster’s career unnecessarily as well as risk the allegations being made public,[78] despite the fact that the choirmaster admitted that he had engaged in oral sex with a 17-year-old (AN-A145) but denied any non-consensual sexual activity. AN-X8 also thought it was sufficient to have agreed informally that the choirmaster would not be alone with children.[79] According to Ms Fay Howe (a PSO for the Church in Wales), AN-X8 wrote directly to the diocesan bishop and threatened to resign should the Provincial Safeguarding Team insist on suspension.[80] The diocesan bishop tried to mediate and suggest a safeguarding agreement could be drafted without the need for an independent risk assessment but the Provincial Safeguarding Panel confirmed its recommendation was unchanged. This was reinforced by a letter to the diocesan bishop from the Church in Wales legal department.[81]

58. AN-X8 felt bullied by the Provincial Safeguarding Team and its insistence upon suspension and a formal risk assessment. AN-X8 also felt that the Provincial Safeguarding Team was slow to act upon its own recommendations.[82] Mrs Carmi noted that the discussion around suspending the choirmaster had been dominated by his being ‘key’ to a forthcoming music festival, AN-X8 denied that their decision had anything to do with any music festival.[83]

59. It took six months for a safeguarding agreement to be put in place and almost nine months for a risk assessment to be carried out. This was, in part, because the external organisations which undertake those risk assessments would not do so until the individual had been suspended from post.[84] When that risk assessment recommended safeguarding training for the choirmaster, he avoided completing this despite being offered four different dates and it took nearly two years for the training to be completed. The choirmaster stayed in post throughout.[85] As the complainant was no longer a member of the parish, though he had been in the choir just two years before, no attempt was made to contact him or provide him with any pastoral support. Mrs Carmi considered this to be a “significant omission”.[86]

60. Mrs Carmi thought that the overall delay in the parish agreeing the safeguarding response was “inappropriate and inadequate”. The actions of AN-X8 contributed directly to that delay. The Church in Wales procedures expressly provide that “Where appropriate the Diocesan Bishop will invoke Disciplinary Procedures but that did not happen in this case.[87] Safeguarding advice should have been followed and the priest should have been suspended.[88]

61. The Church in Wales is examining whether there should be a specific disciplinary heading for failure to comply with professional advice from the provincial safeguarding officers or recommendations from the safeguarding panel.[89]


62. In the Wa2 case, a former priest and convicted perpetrator Ian Galt was convicted in 1999 of assaulting a young boy, at which time his permission to officiate was removed. He was convicted again of child sexual offences in 2013 and a safeguarding agreement was put in place which restricted him to a specific church and prohibited him from being alone with or in the immediate vicinity of a child. When Reverend Christopher Watkins took over the parish, he was told that the safeguarding agreement was in place but he did not see a copy of it. There was no copy saved in the parish. The attendance agreement was reviewed by Reverend Watkins in 2015 and renewed. It was, in the main, easy to enforce and when Ian Galt tried to circumvent it, Reverend Watkins remained firm and would allow no exceptions.[90]

63. In 2017, a parishioner disclosed a further allegation to Reverend Watkins, of which Ian Galt was subsequently convicted. As soon as he heard the allegation, Reverend Watkins contacted the provincial safeguarding officer and then Ian Galt. He told him that he was not allowed to attend church at all. The diocesan bishop was informed within 48 hours. Reverend Watkins forbade Ian Galt from attending church throughout the police investigation and instead arranged for someone to minister to him at home, and subsequently in hospital. Reverend Watkins did so because he thought it presented too great a risk, because he could never know whether a family would attend church out of the blue.[91] Mrs Carmi considered the practice in this case to have been good, and to have shown good communication between the parish priest and the provincial safeguarding officer.[92]


64. The Wa3 case related to a bell ringer (AN-F26), against whom there had been allegations of, but no convictions for, inappropriate behaviour towards teenage bell ringers in the Church of England which included inappropriate jokes, conversations about sex and social media communications. As a result, a detailed risk assessment had been conducted by the Church of England. When AN-F26 moved to the Church in Wales, the Church of England’s DSAs informed the provincial safeguarding officers. Both the risk assessments and the safeguarding agreements were shared. The provincial safeguarding officers spoke with the relevant parishes in Wales and safeguarding arrangements were put in place. The case was reviewed by both the Church of England DSAs and the Church in Wales, including the Provincial Safeguarding Panel, when formal agreements were no longer considered necessary.[93]

65. Mrs Carmi thought that the actions were consistent with the policies of both the Church of England and the Church in Wales. In particular, she praised the liaison between the Church of England DSAs and the Church in Wales provincial safeguarding officers.



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