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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


B.1.5: Reviews of safeguarding practice

93. There have been a number of reviews of the Church of England’s safeguarding practice since 2007.

Past Cases Review

94. During the mid to late 2000s, a number of clergy and Church officials were prosecuted for child sexual abuse offences. In the course of the high-profile criminal trials, it became clear that the Church had often failed to act or to act appropriately in response to allegations.

The Past Cases Review 2007–2009

95. These events led to the establishment of a Past Cases Review (PCR) working group in 2007. The PCR was intended to:

ensure that in every case, the current risk, if any, is identified, and appropriate plans are made to manage the identified risk to children and young people and take any action necessary in the light of current statutory and other best practice guidance”.[1]

96. The PCR involved an examination of a ‘Known Cases List’ by a “suitably qualified independent reviewer (appointed by each diocese). A list was prepared in each diocese, based on a proforma, of all cases “involving any clergy, employees, readers and licensed lay workers or volunteers in the Church about whom information of concern exists”.[2] The reviewer also scrutinised the personnel files of clergy (known as blue files) and employees in contact with children.[3] Any safeguarding issues were referred to the Diocesan Child Protection Management Group, which prepared a report for the diocesan bishop.[4] A copy of each diocesan report, together with an anonymised version of the Known Cases List and a statistical report, were sent to the national safeguarding adviser.

97. The PCR was completed in 2009, and was described by the Church as “the most comprehensive of its type”.[5] More than 40,000 files were reviewed, but only 13 cases were identified as requiring formal action, of which 11 were referred to statutory agencies. In the other two cases, the independent reviewers deemed that formal disciplinary action by the Church was appropriate.[6] As Lord Williams (Archbishop of Canterbury at the time of the review) stated, it “gave the Church a clearer bill of health than was really appropriate and failed to “look carefully enough at how those making allegations of abuse were understood and treated.[7]

Independent scrutiny of the Past Cases Review 2016–2018

98. In 2016, the Church commissioned an independent scrutiny team of safeguarding experts (led by Sir Roger Singleton, a safeguarding specialist[8]) to review the process and content of the PCR and to assess the extent to which it was conducted effectively in each diocese.

99. The team’s 2018 report summarised the PCR as “A Curate’s Egg”,[9] ie “a thing that is partly good and partly bad”.[10] While it was “a thoughtful and well-intentioned piece of work”, the team concluded that the PCR was “essentially a retrospective desk review with a number of flaws and limitations”.[11] It identified a number of inadequacies, including:

  • a lack of clarity about which roles were included within the scope”, for example whether parish employees and volunteers were within the scope of the PCR;[12]
  • there were some difficulties “in locating files” within dioceses and those reviewing the files “commented adversely on the quality of case recording”;[13]
  • little, if any, work was undertaken with victims and survivors during and after the review, which “had a constraining impact on the value of the initiative … by not including them, their views were absent from the review and perhaps particularly from the lessons learned”;[14] and
  • there were “considerable inconsistencies” in the completion of the statistical returns by dioceses; for example, some were only partially completed. The form was only available after many dioceses had begun or almost completed their reviews, and was itself confusing, while the accompanying instructions contained ambiguities.[15]

The Church’s oversight was limited to responding to questions and seeking reports, with little interrogation of what had been found and whether it looked accurate or comprehensive. Its reporting of the PCR also “failed to reflect the true extent of the issues which needed to be addressed”, which could “expose the Church to the accusation that it did not report the full picture”.[16]

100. The team made a number of recommendations, including:

  • All dioceses should conduct an independent review of any files not included in the PCR, with the DSA dealing with any concerns as if they were new referrals.
  • Dioceses should check with every parish that all safeguarding concerns about the behaviour of any parish employee or volunteer towards children have been notified to the DSA.
  • All dioceses should focus on maintaining improvements in record-keeping, file maintenance and cross-referencing of safeguarding issues.
  • An “updated version” of the PCR should be conducted in the dioceses of Ely, Lichfield, Rochester, Salisbury, Sheffield, Winchester, and Sodor and Man given “the absence of evidence that the Past Cases Review had been carried out competently in these dioceses”.[17]
  • The NST and diocesan safeguarding teams should prioritise their plans to improve the Church’s response to victims and survivors.

These recommendations were intended to help protect children from persons of previously unidentified or unmanaged risk, and to improve the Church’s response to the needs of victims and survivors.[18]

101. The NSSG agreed in April 2018 that a further review – Past Cases Review: Part Two (PCR-2) – would take place covering 2007 to the present day.[19]

Past Cases Review: Part Two (PCR-2)

102. PCR-2 is expected to be completed in 2022. A project management board was established in July 2018.[20] By the end of the PCR-2 process, it is intended that:

any file that could contain information regarding a concern, allegation or conviction in relation to abuse by a living member of the clergy or church officer (whether still in that position or not) will have been identified, read and analysed by an independent safeguarding professional”.[21]

As a result, its objectives include:

  • identifying all cases of concern relating to clergy or church officers causing harm to children or adults (including where domestic abuse is alleged) and ensuring they have been independently reviewed;
  • ensuring that all identifiable safeguarding concerns relating to living clergy or church officers have been referred to the DSAs;
  • ensuring any allegation made since the original PCR took place have been handled appropriately and proportionately to the level of risk identified and that the support needs of survivors have been considered; and
  • ensuring that cases meeting the relevant thresholds have been referred to statutory agencies and that all cases have been managed in line with current safeguarding practice guidance.[22]

103. An overview report regarding the outcome of PCR-2, including recommendations and proposals for practice improvement where necessary, will be submitted to the NSSG and to this Inquiry.[23] Dioceses will complete their work on PCR-2 in 2021, and the final overview report is expected to be published within one year of completion.[24]


104. Following a consultation with bishops, senior staff and DSAs, the NST sought the approval of the House of Bishops for a quality assurance package to be applied throughout the Church of England.[25] It comprised:

  • an annual safeguarding data return by each diocese to be collated by the Church;
  • a safeguarding self-audit by each diocese;
  • parish self-audits;
  • peer reviews of the work of individual dioceses; and
  • an independent safeguarding audit of each diocese every five years.

Independent safeguarding audits: dioceses

105. In May 2015, SCIE was commissioned by the Church to deliver a national programme of diocesan safeguarding audits given “the differences in the quality of safeguarding policies and processes across dioceses”.[26] This is “the main means for externally monitoring compliance with House of Bishops policy and guidance on safeguarding”.[27]

106. SCIE undertook 42 audits between 2016 and 2019, led by Mrs Carmi. Case records and recruitment files were examined. Meetings were also held with key diocesan staff, clergy and parish representatives to seek their individual perspectives. Three days were spent in each diocese, which Mrs Carmi said enabled “a good understanding of the main strengths and weaknesses of safeguarding practice in each diocese”.[28]

107. In April 2019, SCIE published its final overview report.[29]

107.1. Part One provided an overview of findings from the diocesan safeguarding audits and set out considerations for further action by the Church. It reached two key conclusions:

  • There had been a “major improvement” between 2015 and 2018 in the Church’s safeguarding resources, policies and safeguarding training courses. Those developments were enabled by an increase in staffing levels and the extensive revision of practice guidance, which now benefits from “increased clarity, less duplication and more consistency than the procedures that have been replaced”. The NST had strengthened consistency of practice by, for example, the introduction of core groups and risk assessment training.[30]
  • However, there were a series of “systemic underlying vulnerabilities[31]arising from the organisation, structure and management of safeguarding. Diocesan bishops were largely autonomous so could overrule the decisions of their advisers. As a result, safeguarding “remains locally managed and led by those without any requirement to have safeguarding knowledge and expertise”.[32]

107.2. Part Two presented the results of a confidential survey designed by SCIE in consultation with the survivor support organisation MACSAS (Minister and Clergy Sexual Abuse Survivors).[33] It analysed 58 survey submissions from victims and survivors,[34] the overwhelming majority of whom were dissatisfied with the Church’s response to their disclosures of abuse, in terms of both timeliness and quality.[35] The issues included:[36]

  • the importance of telling difficult stories about abusers and abuse during safeguarding training;
  • recognising the contributions of survivors in public narratives about the safeguarding journey of the Church;
  • positive senior role models being seen to hold their hands up to having got it wrong;
  • recognising the need for long-term support; and
  • taking a person-centred approach in safeguarding policy and practice, and keeping the victim at the heart of the Church response.

108. SCIE audits do not include recommendations, as SCIE sees its role as being to “shed light on the nature of the systemic vulnerabilities”, identifying improvements and providing an understanding of the nature of the problems.[37] The final overview report therefore posed a series of questions intended to help the Church decide how to address its findings and to allow the Church to “engage survivors of abuse and others in what the best solutions might be, and generate ownership within the Church of the strategies and actions agreed”.[38] The issues raised concerned:

  • Leadership and culture: SCIE reflected the view of survivors that the Church does not attach adequate value to the contributions of survivors. It often reacts defensively when presented with evidence of its safeguarding failures, which inhibits the growth of an open and transparent learning environment.[39]
  • Church processes for the management of allegations: Survivors told SCIE that processes do not currently support a “person-centred approach”. Recent revisions to policy and guidance do not yet constitute “a strong golden thread about keeping the person who has come forward at the heart of everything”.[40]
  • The term ‘practice guidance’: Survivors considered that using this as an umbrella term to cover policy, procedures and guidance leads to confusion for the reader. It is “inadvertently encouraging inconsistency, as guidance suggests advice as opposed to procedures that must be followed”.[41]

109. SCIE concluded that there remained a key role for bishops in “the spiritual or theological leadership” of safeguarding in dioceses on matters specifically linked to faith. In the view of Dr Sheila Fish (Head of Learning Together at SCIE), clergy should not play “any role at all” in the operational management of safeguarding.[42] However, senior leaders within dioceses also have a role to play in terms of strategic leadership on safeguarding, although safeguarding expertise will be needed, such as through a requirement for the DSA to report into that group.

110. A further round of independent safeguarding audits will be undertaken from 2021, as agreed by the House of Bishops in December 2016.[43]

Independent safeguarding audits: cathedrals

111. In December 2016, the House of Bishops agreed to extend the independent safeguarding audits to cathedrals. The cathedral safeguarding audit programme began in October 2018. Of the Church’s 42 cathedrals, as of April 2020, 24 have been audited or have an audit in progress.[44] Dean Lake described the audits as “comprehensive, covering a range of activities and arrangements within the life of the cathedral”.[45] They included casework and information-sharing, training, recruitment and the application of safeguarding policies.

112. From the audits completed by SCIE, Dr Fish identified three overarching challenges for all cathedrals.

112.1. The dean and chapter are responsible for all three strands of leadership: strategic, operational and theological. This means that they are “often wearing different hats at different times”.[46]

112.2. Cathedrals have a largely volunteer workforce. Key safeguarding roles are likely to be filled by volunteers rather than Church employees. This “creates the need for very good links and communication with the professional safeguarding role situated in the linked dioceses”.[47]

112.3. Cathedrals are places, rather than networks. They may have “particular challenges about managing the boundary between pastoral care and safeguarding, and referring to external agencies where necessary”.[48]

Internal safeguarding self-assessments for dioceses

113. In December 2016, the House of Bishops agreed that each diocese must complete an annual safeguarding self-assessment administered by the NST. The self-assessments included questions about safeguarding arrangements, recruitment, training and record-keeping in the diocese in the previous year.[49] Its purpose was to enable the DSA and senior leadership team “to assess diocesan safeguarding arrangements against national government and church guidance expectations, identify areas of good practice and areas that need further work”.[50]

114. The NSSG considered the results in July 2018, together with an analysis of the safeguarding position in the dioceses in 2015 and 2016. It concluded that an “urgent deep dive file review” should be undertaken in a sample of dioceses, to further explore the key issues that were identified in the self-assessments, including:

  • a variation across dioceses in the use of risk assessments and safeguarding agreements;
  • a significant disparity between dioceses in recorded numbers of reporting cases to statutory authorities; and
  • a limited use of disciplinary action in safeguarding cases and referrals to the DBS.[51]

115. To determine the current state of safeguarding in the Church, an extensive report on data arising from annual diocesan self-assessments of safeguarding activity in 2015, 2016 and 2017 was then considered by the NSSG in April 2019.[52] As at 2018, the key findings included:[53]

  • 38 of 42 dioceses had Diocesan Safeguarding Advisory Panels, which were compliant with the House of Bishops’ safeguarding guidance. All panels included senior clergy representatives.
  • 33 of 42 dioceses had formal safeguarding arrangements in place with their cathedrals.
  • 41 of 42 dioceses employed a DSA, of which 15 were from social work backgrounds, 9 from police backgrounds and the remaining from professional disciplines including probation and health.
  • 34 of 42 dioceses had protocols in place to enable routine engagement between the DSA and the diocesan bishop.
  • DSAs in all dioceses had access to clergy personnel files.
  • Less than one third of dioceses had information-sharing agreements in place with key statutory agencies.
  • 39 of 42 dioceses had arrangements in place to monitor safeguarding in parishes.

116. The NST recommended to the NSSG that ‘deep-dive’ audits are undertaken with sample dioceses in respect of the following areas:[54]

  • safeguarding concerns and allegations reported to the dioceses;
  • reporting of safeguarding concerns and allegations by dioceses to statutory partners;
  • completion of standard risk assessments and use of safeguarding agreements;
  • use of disciplinary processes such as the CDM; and
  • reporting to the DBS.

Monitoring of safeguarding in parishes

117. Each diocese has an archdeaconry, presided over by one or more archdeacons who assist the diocesan bishop and ensure that the duties of church officers are performed diligently. Their safeguarding responsibilities, set out in the Key Roles Guidance 2017, include “working with the DSA to assist in monitoring good safeguarding practice in parishes”.[55]

118. This is achieved by yearly visitations by the archdeacon to each parish.[56] Churchwardens in each parish, its principal lay representatives, are responsible for completing the archdeacon’s Articles of Enquiry, a list of questions sent to the parish prior to each visitation to assess the implementation of diocesan policy in parishes.[57]

119. As set out in its Final Overview Report, SCIE found that while archdeacons are aware of their responsibility to monitor safeguarding in the parishes, there are inconsistencies amongst dioceses in how this task is carried out.[58]

119.1. In the Diocese of York, for example, Articles of Enquiry “are used but not always every year” and “safeguarding is not always in the Articles”.[59]

119.2. In the Diocese of Coventry, the Articles include safeguarding questions but “the questions asked do not judge the depth of understanding of what is required, or the exact level of compliance”.[60]

119.3. Archdeacons in the Diocese of Manchester conduct visitations only once every five years, which were described as “a useful if infrequent check on parish safeguarding arrangements”.[61]

120. There is no national standard for the means by which dioceses monitor the state of safeguarding within parishes. Several dioceses are developing their own processes, which include independent case reviews and case peer review between neighbouring DSAs.

120.1. The Diocese of Worcester has collected parish-level data by questionnaire since 2003.[62] In 2016, it introduced a parish self-audit (known as the Parish Toolkit) which requires each parish to self-assess, including in relation to safer recruitment, adoption of policies and the role of the parish safeguarding officer. It also seeks numerical data about allegations and safeguarding agreements. SCIE commented that the Parish Toolkit provides “a wealth of information about safeguarding at the grassroots level”.[63]

120.2. Parish Safeguarding Dashboards were initially developed in the Dioceses of Canterbury and Coventry, and are now used in 10 dioceses across the East and West Midlands region.[64] The dashboards “show the status of safeguarding in the parish at a glance, through the use of simple checkpoints that reflect the requirements of national policy and practice guidance”.[65]

120.3. The Simple Quality Protects process, used by the Diocese of Chichester in each of its parishes, is an online tool for community organisations to demonstrate compliance with certain standards. SCIE considered that the process has the potential to provide a systemic and detailed picture of safeguarding in the parishes, and identify where effort is needed in terms of training, parochial safeguarding policies and other measures”. It could be improved by prompting parishes to require safeguarding agreements for convicted perpetrators and any individual about whom there may be safeguarding concerns.[66]

120.4. In 2019, all parishes in the Diocese of York received a parish safeguarding audit on a number of key safeguarding areas to demonstrate compliance with the House of Bishops’ practice guidance. Where parishes were not compliant, they were asked to provide action plans to address any deficiencies. Subsequently, each parish was provided with feedback and recommendations for learning and improvement.[67]

120.5. In addition, some dioceses, parishes and cathedrals have commissioned external auditors and reviews on an ad hoc basis. For example, ThirtyOne:Eight (an independent safeguarding charity that works predominantly with Christian organisations to provide training courses, policy advice and consultancy assignments for complex safeguarding issues[68]) has undertaken 41 separate pieces of commissioned work across the Church of England since January 2018.[69]

Samples of recent safeguarding casework

121. As referred to in the Chichester/Peter Ball Investigation Report, there is often a difference between safeguarding policy and safeguarding practice in the Church of England. In 2019, the Inquiry commissioned an expert analysis of case files to assess how safeguarding is managed in practice by the Church. This analysis was conducted by Mrs Carmi.[70]


122. Mrs Carmi was instructed to review case files from four dioceses in the Church of England, chosen to represent varying geographic locations and sizes. These were:

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

To ensure a representative sample, the Inquiry obtained a full list of all safeguarding casework undertaken by the dioceses between April 2017 and April 2018. Four cases were then selected from each diocese for analysis, in order to provide a recent ‘snapshot’ of various aspects of safeguarding in practice.

123. Mrs Carmi’s review was based on a desktop audit of the dioceses’ written safeguarding records, with reference to the relevant Church guidance that was in place at that time.[71] Her report sets out her expert opinion on the quality of this guidance, the extent to which it was followed by dioceses and the adequacy of the steps taken by each diocese in response to the sample cases. The report also notes that she was not able to speak to victims and survivors or those engaged with the safeguarding processes.

124. Detailed summaries of all sample cases can be found in Annex 3 of this report. For ease of reference, the individual cases are identified by initials only. For example, ‘L1’ is used to refer to the first sample case from the Diocese of London.

Summary of findings

125. Based on the 16 sample cases and drawing on her expertise, Mrs Carmi made a number of observations about the Church’s response to allegations of child sexual abuse.

125.1. The Church must distinguish between safeguarding and disciplinary investigations. Disciplinary investigations are separate from risk assessments, although disciplinary conclusions may contribute to the risk assessment.[72] Mrs Carmi thought that many cases that require a disciplinary investigation will also require an assessment of the risk to children or other vulnerable people.

125.2. Mrs Carmi thought that allegations against church officers receive a “more thorough response”.[73] Church safeguarding policy requires a core group (from the diocesan team and the parish) to be convened where safeguarding allegations are made against church officers, as defined by Church of England policy.[74] A core group was not convened in two cases sampled because neither individual fell within the definition of a ‘church officer’ but both were involved in children’s activities on behalf of the Church (one in a paid capacity and the other as a volunteer). Mrs Carmi concluded that the Church’s response should focus on the individual circumstances of each case, including the level of risk, rather than on the role of the individual.[75] Mr Tilby agreed that additional guidance may be useful.[76]

125.3. Clergy in parishes receive disclosures from perpetrators, complainants, victims and survivors. They are also responsible for managing the risk posed by perpetrators who worship within their parish. Safeguarding for parish priests, however, is only one aspect of their roles. For example, we heard from a parish priest of 34 years’ experience who had only dealt with one safeguarding case.[77] In these circumstances, Mrs Carmi emphasised that it is crucial that a DSA’s safeguarding advice is followed. Where a DSA proposes a risk assessment, there should be a risk assessment. A member of the clergy should not attempt to delay or obstruct good safeguarding practice, or to put pressure on the DSA to adopt a position contrary to national guidance. In Mrs Carmi’s view, this was closely linked to “the way the Church of England is structured and the limited options available to DSAs to enforce safe practice on individual incumbents.[78]

125.4. Where the advice of a DSA is not followed, Mrs Carmi said he or she will require “more effective support”, including the use of disciplinary processes should individuals attempt to hinder the implementation of safe practice.[79] The Archbishops’ Council accepted that further work is required on the Church’s capability processes.[80]

125.5. In Mrs Carmi’s view, the PSOs were “largely invisible” in the sample cases.[81] She thought that PSOs should be given a larger role, with more responsibility (for example monitoring safeguarding agreements), despite the PSO being in a voluntary role, because this would ease the burdens on parish priests who often try to provide support for both alleged perpetrators and complainants. This would require more knowledge on their part and more direct communication with the DSA.

125.6. The Church’s risk assessment templates focus on the management of risk, rather than the assessment of risk. In three sample cases in Sheffield, this led to “an identical plan being made in all cases” without first exploring the specific risk-level posed by an individual and to whom.[82] The Church has now introduced a new national standard risk analysis assessment template alongside a modular risk assessment training course, risk-level guidance and a safeguarding agreement template.[83]

125.7. There were varying levels of success in obtaining “relevant history and risk assessments from statutory agencies that have been involved”.[84] The refusal to share information presented an obstacle to effective safeguarding. Diocesan safeguarding teams require good information-sharing channels with local authorities, probation services and the police.

125.8. Complete case logs should be maintained, recording actions and reasons.[85] In Mrs Carmi’s view, the record-keeping in the Diocese of Worcester cases was “very, very good”.[86]


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