Alan Griffin

Regulation 28:  Prevention of Future Deaths report 

Alan Howard Foster GRIFFIN (died 08.11.20) 

THIS REPORT IS BEING SENT TO: 

1. 

Chair 
Catholic Standards Safeguarding Agency 
39 Eccleston Square 
London SW1V 1BX 

1 

CORONER 

I am:   Coroner ME Hassell 
           Senior Coroner  
           Inner North London 
           St Pancras Coroner’s Court 
           Camley Street 
           London  N1C 4PP 

2 

CORONER’S LEGAL POWERS 

I make this report under the Coroners and Justice Act 2009,  
paragraph 7, Schedule 5, and  
The Coroners (Investigations) Regulations 2013, 
regulations 28 and 29. 

3 

INVESTIGATION and INQUEST 

On  12  November  2020,  one  of  my  assistant  coroners,  Sarah  Bourke, 
commenced  an  investigation  into  the  death  of  Alan  Howard  Foster 
Griffin,  aged  76  years.  The  investigation  concluded  at  the  end  of  the 
inquest on 2 July 2021.  I made a narrative determination as follows. 

“Alan Griffin hanged himself at home on Sunday, 8 November 2020.   

He killed himself because he could not cope with an investigation into his 
conduct, the detail of and the source for which he had never been told.  
The  investigation  had  been  ongoing  for  over  a  year  and  was  being 
conducted by his former Church of England diocese and subsequently 
also  by  his  current  Roman  Catholic  diocese  (to  whom  the  Church  of 
England  had  passed  a  short,  written  summary  of  allegations  that 
contained  inaccuracies  and  omitted  mention  of  Father  Griffin’s  earlier 
suicide attempt on learning of his HIV status).   

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Father Griffin did not abuse children.  He did not have sex with young 
people  under  the  age  of  18.    He  did  not  visit  prostitutes.    He  did  not 
endanger the lives of others by having sex with people whilst an HIV risk.  
And there was no evidence that he did any of these things.  He was an 
HIV positive (viral load undetectable) gay priest.   

Death by suicide.” 

4 

CIRCUMSTANCES OF THE DEATH 

Information  was  passed  to  a  diocesan  safeguarding  adviser  of  the 
Roman  Catholic  Diocese  of  Westminster,  by  a  diocesan  safeguarding 
adviser  of  the  Church  of  England  Diocese  of  London  &  Westminster, 
regarding Alan Griffin.  Father Griffin had  previously left the Church of 
England and had taken holy orders in the Roman Catholic Church.  After 
receipt  of  some  information,  the  Roman  Catholic  safeguarding  team 
investigated. 

5 

CORONER’S CONCERNS 

During the course of the inquest, the evidence revealed matters giving 
rise to concern. In my opinion, there is a risk that future deaths will occur 
unless  action  is  taken.  In  the  circumstances,  it  is  my  statutory  duty  to 
report to you. 

The MATTERS OF CONCERN are as follows.  

1.  The  safeguarding  team  of  the  Roman  Catholic  Diocese  of 
Westminster did not exercise sufficient professional scrutiny of the 
allegations  that  came  to  them  from  the  Anglican  safeguarding 
team.    This  was  partly  because  they  gained  a  false  sense  of 
security from the fact that the allegations came from the Church 
of England.   

However, there was more that could have been done to establish 
the  exact  nature  of  the  allegations  and  whether  these  were 
credible.    The  Catholic  safeguarding  team  asked  for  disclosure 
from the Anglican safeguarding team and most particularly for the 
source  of  the  allegations.    When  they  did  not  receive  either  of 
these, they should have insisted.   

2.  The  Catholic  safeguarding  team  met  with  Father  Griffin  on  23 
June 2020 to discuss his DBS check.  That would have been an 
ideal opportunity to discuss the Church of England allegations that 
the 
would  have  shortened 
opportunity was lost. 

the  process  considerably  and 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  Father  Griffin  then  asked  to  know  the  allegations  against  him 
before  he  attended  another  meeting  with 
the  Catholic 
safeguarding  team.    The  safeguarding  team  felt  that  the 
information  was  not  theirs  to  give  because  it  came  from  the 
Church of England, but Father Griffin should have been provided 
with a note of the allegations promptly. 

4.  The  Roman  Catholic  Diocese  of  Westminster  was  unaware  of 
Father Griffin’s attempted suicide nine years earlier.  However, it 
could still have been more proactive than it was in ensuring that 
he had maximum pastoral support. 

5.  The Catholic safeguarding team volunteered at inquest that they 
did not deal with the investigation into Father Griffin promptly and 
they apologised for this.  The very first telephone call was placed 
to  the  Catholic  safeguarding  adviser  on  30  October  2019.    The 
delay was therefore significant and it was harmful. 

This  was  in  part  because  the  Catholic  safeguarding  team  were 
waiting for the engagement of the Anglican safeguarding team to 
enable a joint approach to be taken.  When it was clear that such 
engagement  was  not  forthcoming  (whether  for  reasons  of 
sickness or anything else), the Catholic safeguarding team should 
have  gone  back  to  the  local  authority  designated  officer  (the 
LADO) and recommended that they continue without further input 
from the Church of England. 

6 

ACTION SHOULD BE TAKEN 

In  my  opinion,  action  should  be  taken  to  prevent  future  deaths  and  I 
believe that you have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date 
of this report, namely by 3 September 2021.  I, the coroner, may extend 
the period. 

Your  response  must  contain  details  of  action  taken  or proposed  to  be 
taken, setting out the timetable for action. Otherwise you must explain 
why no action is proposed. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the following. 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 , sister in law of Father Griffin 

, partner of Father Griffin 
, friends 

• 
• 
• 
•  Most Revd Justin Welby, CofE Archbishop of Canterbury 
• 
• 
•  Cardinal Vincent Nichols, RC Archbishop of Westminster 
•  HHJ Thomas Teague QC, Chief Coroner of England & Wales 

, formerly of the CofE Diocese 
, formerly of the CofE Diocese 

I  am  also  under  a  duty  to  send  a  copy  of  your  response  to  the  Chief 
Coroner and all interested persons who in my opinion should receive it.  
I  may  also  send  a  copy  of  your  response  to  any  other  person  who  I 
believe may find it useful or of interest.  

The Chief Coroner may publish either or both in a complete or redacted 
or summary form. He may send a copy of this report to any person who 
he  believes  may  find  it  useful  or  of  interest.  You  may  make 
representations to me, the coroner, at the time of your response, about 
the release or the publication of your response. 

9 

DATE                                                  SIGNED BY SENIOR CORONER 

09.07.21                                              ME Hassell 

4

Coroner ME Hassell  
Senior Coroner  
Inner North London  
St Pancras Coroner’s Court 
Camley Street  
London  
N1C 4PP  

Dear Madam 

29th November 2021 

This letter is sent in response to the Regulation 28: Prevention of Future Deaths report, regarding Father 
Alan Howard Foster Griffin, issued on 9th July 2021. 

You will recall I wrote on 26th August 2021 to explain the process that the CSSA would follow to review 
this case and respond to your report, and you kindly agreed to an extension to 30th November 2021 to 
submit the CSSA’s response. 

We have reviewed a range of documentary evidence, held interviews with key persons, and are in the 
process of producing a report of our review. Our review will also take into account the findings of an 
internal review being undertaken by the Archdiocese of Westminster and those of an independent 
review commissioned by the Church of England.   

At the outset, I must state that the CSSA shares the concerns you have raised and, as the newly 
established safeguarding regulator for Catholic dioceses and religious life groups in England and Wales, 
we are determined to do all we can to prevent similar situations from occurring in the future. I 
summarise below the action we have taken, or are intending to take, specifically to address your 
concerns.  

Area of Concern 1: Professional Scrutiny of Allegations 

The safeguarding team of the Roman Catholic Diocese of Westminster did not exercise sufficient 
professional scrutiny of the allegations that came to them from the Anglican safeguarding team. 

Response of the CSSA 

National Safeguarding Policy and Practice Guidance 
a. Whilst national safeguarding policies and practice guidance are issued by the CSSA, these do not

remove the need for safeguarding practitioners to exercise proper scrutiny and to apply professional

Catholic Safeguarding Agency Ltd 

www.catholicsafeguarding.org.uk 

39 Eccleston Square 
London, SW1V 1BX 

Catholic Safeguarding Standards Agency is a trading name of Catholic Safeguarding Agency Ltd. 

Registered in England & Wales, Company Reg 13182385 

 judgement in responding to allegations or concerns that are raised. To support the 
training being developed the CSSA is producing professional development 
resources.  

b.  To support reflection and critical thinking in intra-agency or inter-agency meetings, the CSSA is 

developing a template form to be used in casework meetings. The template will include all areas 
that need to be considered and addressed and will act as a prompt to safeguarding practitioners.   

c.  The CSSA is updating its practice guidance on the management of allegations and concerns, to 
provide for situations where concerns are raised but the information cannot immediately be 
clarified or verified. The guidance will give a timescale within which the information must be 
clarified or verified, what action must be taken if this cannot be achieved (i.e., escalation to the 
Safeguarding Sub-Committee for consideration and decision as to next steps).  

The practice guidance developed in each of these areas will be considered by the CSSA Board in 
December 2021 and February 2022 with a view to being issued to Church bodies by the end of March 
2022. 

Training 
The CSSA national training lead is developing a suite of training for those in leadership and management 
in safeguarding roles within Church bodies. Work has commenced and the training modules, which will 
include mandatory modules on reflection and professional curiosity and on the provision of support to 
those about whom allegations or concerns have been raised, and they will be rolled out over the course 
of 2022.  

Area of Concern 2: Management of allegations and support for those against whom allegations have 
been made 

▪  Father Griffin should have been provided with a note of the allegations promptly.  
▪  The Catholic safeguarding team did not deal with the investigation into Father Griffin promptly. The 

delay was significant, and it was harmful. 

▪  The Roman Catholic Diocese of Westminster could have been more proactive than it was in ensuring 

that Father Griffin had maximum pastoral support.  

Response of the CSSA 

National Safeguarding Standards 
On 27th October 2021, the CSSA launched its new national Safeguarding Standards, which can be 
viewed at: https://www.catholicsafeguarding.org.uk/national-safeguarding-standards/the-standards/ 
Standard 5 relates specifically to the management and support of those who are the subject of 
allegations and concerns, and requires church bodies to: 
▪  Adhere to national policies and/or practice guidance that set out how a respondent is to be informed 

when an allegation has been made and supported thereafter; 

▪  Be mindful of the impact on the wellbeing of the respondent and appoint a support person with the 

responsibility for listening to and addressing the pastoral needs of the respondent; 

Catholic Safeguarding Agency Ltd 

www.catholicsafeguarding.org.uk 

39 Eccleston Square 
London, SW1V 1BX 

Catholic Safeguarding Standards Agency is a trading name of Catholic Safeguarding Agency Ltd. 

Registered in England & Wales, Company Reg 13182385 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ▪  Access suitably accredited professionals to deliver professional mental health and 

other appropriate support when required; 

▪  Ensure that the respondent has access to suitable legal representation when 

subject to statutory/canonical investigation. 

CSSA Audit Programme 
The CSSA is preparing its audit programme for 2022, and the Diocese of Westminster will be audited 
during the year. Compliance with Standard 5 will be tested through robust audit processes. Where it is 
found that improvements need to be made, the CSSA will ensure that action plans are implemented, 
and progress will be monitored. 

National Safeguarding Policy and Practice Guidance 
There is considerable existing practice guidance on Church bodies’ responsibilities towards clergy and 
religious against whom allegations have been made, including on conducting an initial meeting with an 
individual against whom allegations have been made. In view of this case, that guidance will be updated 
to emphasise the importance of promptly informing individuals of allegations made against them, of 
completing safeguarding investigations in a timely manner, and of ensuring that support needs are 
identified and met throughout.  

Training 
Training on Mental Health First Aid will be made available as part of the national training programme, to 
teach safeguarding personnel how to spot signs and symptoms of mental ill health and feel confident in 
guiding them to the appropriate support. This training will be part of the national training programme 
rolled out throughout 2022. 

Additional Areas of Concern and CSSA Actions 

During our review, we have identified some additional areas of concern relating to the outcome of inter-
agency meetings and the supervision of casework. I set out below the actions we are taking to address 
these concerns. 

Inter-agency working 
The CSSA has consulted with the Church of England National Safeguarding Team and agreed that we will 
collaborate on creating and implementing an Information Sharing Agreement between the two 
denominations, and a process for escalation of concerns where matters cannot be resolved by the 
respective safeguarding teams. 

Case supervision 
There is already national practice guidance in relation to induction, supervision, and support. Currently, 
the requirement is for case management supervision to be undertaken regularly. The standard will be 
changed to monthly (pro-rata for non-full-time roles) as a minimum with the requirement for more 
frequently if there are obstacles or changes that require resolution. 

Catholic Safeguarding Agency Ltd 

www.catholicsafeguarding.org.uk 

39 Eccleston Square 
London, SW1V 1BX 

Catholic Safeguarding Standards Agency is a trading name of Catholic Safeguarding Agency Ltd. 

Registered in England & Wales, Company Reg 13182385 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Casework oversight 
Already in progress is the development of a formal Case Consultation Committee 
(CCC). This has always been part of the remit of the CSSA and the proposal for it is 
based on a recognition of the benefits that can result from accessing high quality advice when faced 
with unusually challenging cases. The CCC will enable the CSSA to provide a range of expert advice on 
complex cases and will represent a formal means by which advice and guidance can be provided to 
Church bodies who wish to seek it from the CSSA. The CCC will be made up of professionals with specific 
expertise who meet to review a case and offer recommendations as to how it should be managed.  

The CCC will create a record of the advice which will be provided to the referring body along with details 
of the assessment of the case and the recommendations for future management. The CCC may agree a 
date to review progress in the case if this is considered necessary. 

Learning lessons 
Once our review is completed, the CSSA will arrange events to share learning across the Church bodies. 

I hope this response demonstrates the seriousness with which the CSSA has taken your report, and 
importance that we place on supporting safeguarding practice improvements to ensure that allegations 
and concerns are subjected to proper scrutiny, safeguarding investigations are conducted promptly and 
professionally; and that appropriate support is put in place for those who are the subject of allegations 
to prevent future deaths.  

Yours sincerely  

Chair 

Catholic Safeguarding Agency Ltd 

www.catholicsafeguarding.org.uk 

39 Eccleston Square 
London, SW1V 1BX 

Catholic Safeguarding Standards Agency is a trading name of Catholic Safeguarding Agency Ltd. 

Registered in England & Wales, Company Reg 13182385

Response by the Diocese of London and Lambeth Palace to the 
Regulation 28 Report (9 July 2021) to the Church of England in relation 
to the death by suicide of Fr Alan Griffin on 8 November 2020. 

1.

Introduction

The Diocese of London and Lambeth Palace wish to thank the Coroner for writing to the Archbishop 
of Canterbury and bringing to our attention the various matters of concern that were prompted by her 
investigation into the tragic death of Father Alan Griffin.  

Those concerns have been shared with and considered carefully by the various Church Institutions. 
We have formed a Case Steering Group, with representatives including the Diocese of London, the 
National Safeguarding Team (NST), Lambeth Palace, and an independent professional member of 
the Diocese of London’s Safeguarding Steering Group to oversee both this response and our next 
steps.  

This report is our collective response on behalf of the Church of England to your Report to Prevent 
Future Deaths dated 9 July 2021, in accordance with the provisions of the Coroners and Justice Act 
2009.  

2.

Aims

The Diocese of London and Lambeth Palace express their deep regret and sorrow at the death of Fr 
Alan Griffin. We acknowledge that there were either poor processes or systems, or mistakes, that led 
to unreasonable pressures on Fr Alan and we take responsibility for what went wrong. This response 
is prepared to assure the Chief Coroner of the Diocese’s commitment to change, ongoing learning 
and improvement. 

We will seek to respond to the key points that have been raised by the Coroner in criticism of the 
Diocese of London’s handling of the concerns relating to Fr Alan, to set out current and future actions 
to improve our handling of conduct and safeguarding concerns, and to set out measures to mitigate 
the risk of any future suicide by someone who is the subject of such concerns within the Church of 
England.  

We are also committed to undertaking a Lessons Learned Review and implementing any necessary 
actions (see section 5).  

3.

Other parties

We are committed to doing whatever we can in partnership with our colleagues in the Roman Catholic 
Church to improve our joint management of matters that affect people within both our Churches.  

4.

Immediate first steps

We had already made a Serious Incident Report to the Charity Commission, and this has been 
updated since the publication of the R28 Report. 

As a result of the concerns that the Coroner raised in her report, we have revised the terms of 
reference initially proposed for the Lessons Learned Review and have taken steps towards appointing 

1 

 an experienced, independent reviewer,1 not previously known to or associated with the Diocese of 
London, who is able to give rigorous external scrutiny to the safeguarding systems and processes of 
the Diocese of London as applied in this case.  

To ensure good process, we have consulted the independent professional members of the Diocese of 
London’s Safeguarding Steering Group (part of the governance of the Diocese of London) and are 
engaging with the close family and friends of Fr Griffin who were registered as Interested Parties for 
the purposes of the Inquest, about these Terms of Reference.  

5. 

Lessons Learned Review  

We aim to agree the Terms of Reference by early September with the intention of the Lessons 
Learned Review (“the Review”) beginning in September 2021.   The purpose and objectives of the 
Review are currently as follows: 

5.1  This Review will examine the Diocese of London’s handling of information relating to the 
late Fr Alan Griffin in the light of the ten specific concerns and three further issues set out 
in Section 5 of the Coroner’s Regulation 28 Report. The Review will set out a simple and 
accessible chronology of events.  
It will identify lessons to be learned and how they should be acted on, which will enable 
the Diocese of London and the Church of England to take steps to enhance and improve 
their handling of matters relating to conduct and safeguarding.  

5.2 

5.3  The Review will consider the effectiveness of procedures, areas of service improvement 

and development needs and will establish what lessons can be learned regarding the 
way in which information is responded to, recorded, assessed, shared, and managed.  
5.4  The overall purpose of the Review is to promote learning and improve practice, not to 

5.5 

apportion blame. 
It will make recommendations about what could be done better in the Church of England 
to help prevent such a death taking place again.  

5.6  With the cooperation of the Roman Catholic Diocese of Westminster, it will seek to 

understand how information was shared and acted upon between the Diocese of London 
and the Roman Catholic Diocese of Westminster and set out lessons that should be 
learned to improve this.   

The full Terms of Reference (subject to consultation) will be published on the Diocese of London 
website when consultations are complete (anticipated early September 2021). 

6. 

Initial actions 

Although we do not wish to pre-empt the findings of the independent Lessons Learned Review, and 
appreciate that we will need to make decisions about any recommendations that the Reviewer makes, 
we have recognized and are making the following early improvements to our capacity, capability, and 
practice: 

In the Diocese of London: 

•  The newly appointed Head of Safeguarding began in post at the beginning of August. He has 
over 30 years policing experience and extensive experience of safeguarding, multi-agency 
working, leadership and systems and performance improvement. 

• 

In September 2021 a new Diocesan Safeguarding Advisor (DSA) will begin, filling the 
remaining vacant post. An additional Safeguarding Advisor has also been appointed who will 
begin in October, taking our DSA headcount from 3.6 to 4.6 FTE. 

1 This will not now be the Independent Chair of the Diocese of Exeter Safeguarding Steering Group as set out in 
the Diocese’s legal submissions of 28 June 2021 to the Coroner. 

2 

 
 
 
 
 •  Our new Head of Safeguarding has already started working with the team to design and 
implement new systems of information capture, triage, recording, assessment and 
appropriate sharing of safeguarding and conduct matters. These issues will form part of our 
overarching improvement plan. 

•  Specific initial actions include:  

1.  Ensuring a single safeguarding referral line and inbox, to enable capture and triage of 

information.  

2.  The development of a referral/triage system, with supervision from the Head of 
Safeguarding, to ensure that matters are separated out into safeguarding, non-
safeguarding conduct, and “other” issues, ensuring an initial and ongoing assessment 
of risk (including mental health) and with appropriate follow up action by a designated 
case holder.  

3.  The development of a casework management tracking system for all referrals into the 
safeguarding team to record timely progress against key milestones and ensure a 
structured review process (including risk and mental health) during the lifetime of a 
case. 

4.  Delivering additional GDPR training specific to safeguarding to ensure staff in the 

Diocesan Safeguarding Team are competent and confident to ensure information that 
is shared is recorded and audited, and that the principles of information sharing are 
applied lawfully and proportionately. In due course this will be delivered to senior staff 
involved in handling personal and safeguarding related data to support their practice 
and decision making. 

5.  A protocol for the management of possible serious incidents, both by the Diocesan 

Safeguarding Team and the Diocese as a whole. 

• 

• 

• 

• 

The Head of Safeguarding will also be working with the Director of HR and Safeguarding to 
identify additional resource requirements to ensure necessary support for these areas of 
activity and improvement.  

The role of Head of Operations for the Two Cities Area was restructured prior to the 
appointment of a new Operations Manager. This now ensures that the post holder relates only 
to financial and property matters, with clear accountability and supervision.  

Informed by these initiatives and by our own experience, the Diocese of London has 
continued to develop our approach to clergy wellbeing. A range of support groups, sources of 
therapeutic support, (and grants to pay for it) have been made available, and we have 
developed web resources relating to physical and mental wellbeing for clergy and their 
households https://www.london.anglican.org/clergy-wellbeing/.  

In addition to diocesan support, the Diocese has offered parishes a framework for supporting 
their clergy https://www.london.anglican.org/clergy-
wellbeing/#2_Tools_for_Reflection_and_Action_on_Clergy_Wellbeing. 

This has been communicated via focussed messages from the Bishop to her clergy, and via 
training events, especially during the pandemic. We know that we have more to do and 
recognise the need to develop these tools with our clergy. Our website invites those making 
use of the resources to suggest additions and amendments.  

The specific circumstances of this case were such that Fr Griffin no longer considered himself 
to be a member of the Church of England and had retired from the Diocese of London in 
2011. As a result, is it is hard to say whether these improvements would have been accessed 
by Fr Alan, nevertheless, the wider Church has instigated a number of support tools which are 
accessible to all clergy. We will continue to work with clergy to improve our support for clergy 
about whom concerns are raised.  

3 

 
 
 
 
 
 
 
 •  Over the last two years, the Diocese of London, along with all other dioceses in the Church of 
England, have been undertaking a Past Cases Review of safeguarding cases in line with the 
House of Bishop’s Practice Guidance. In total, over 5000 files have been reviewed in the 
Diocese of London: in parishes, in diocesan offices, and those held by the Diocesan 
Safeguarding Team. We are investigating any information or allegations that appear not to 
have been dealt with satisfactorily in the past, and, where possible, providing support for both 
those about whom concerns have been raised and those who are survivors of or 
complainants about historic abuse. Following implementation of the initial actions by the new 
Head of Safeguarding relating to this matter, we aim to ensure good management of these 
cases. 

Our project team, working with an Independent Reviewer, has gathered data about casework 
management and practice and has made recommendations that will be reviewed by the new 
Head of Safeguarding as we develop an Improvement Plan. Key areas for improvement 
include consistency of practice, ongoing risk management and oversight, and ensuring 
ongoing timely progress regarding the management of cases.  

In and with the National Safeguarding Team: 

The National Safeguarding Team (NST) has responsibility for delivering and improving safeguarding 
across the Church of England.  The NST is leading on several projects which will address some of the 
issues raised in the R28 report.   

•  National Casework Management System 

A national case management system which has a wide range of specifications which will bring the 
following benefits to how safeguarding information/investigations are recorded and managed. 

o  A consistent approach to quality case work practice and recording in line with agreed House 

of Bishops’ expectations. 

o 

Identify and record risks and support required for victims/survivors and those that have been 
accused. 

o 

Integration with the clergy data from the HR system to ensure accurate records. 

o  The ability to improve the information available to key safeguarding professionals in relation to 

individuals and any risk issues that are identified. 

The pilot phase for this project starts in November 2021 and will be implemented across the Church of 
England in 2022.   

• 

Information Sharing Project  

This project seeks to strengthen information sharing arrangements by putting in place an information 
sharing protocol and information sharing agreement in place for safeguarding information.  The 
project was established as a result of a recommendation from the Independent Inquiry into Child 
Sexual Abuse (IICSA) to focus on sharing information with the Church of Wales and statutory 
agencies.  We will work with the Roman Catholic Church to implement a similar information sharing 
agreement.   

•  Engagement with Diocesan Safeguarding Advisors 

Learning from Fr Griffin’s death has been shared with Diocesan Safeguarding Advisors along with a 
reminder of the House of Bishops’ Safeguarding guidance and support that is available for people 
who are vulnerable or at risk of suicide.   

4 

 
 
 
 
 
 
 
 •  Engagement with Diocesan Bishops  

The National Safeguarding Team will write to all Diocesan Bishops and Chairs of Diocesan 
Independent Safeguarding Panels in England to remind them that they should be meeting together at 
least once a year and, among other matters, receiving assurance that safeguarding processes are 
working well.  

•  Policy Review  

The NST is in the process of reviewing the suite of safeguarding policies which includes the policy 
covering the management of actions to be taken when safeguarding concerns are received. The 
current managing allegation policy does detail the support offered to a respondent in a safeguarding 
investigation Responding PG V2.pdf (churchofengland.org) 

7. 

A note on IICSA and our response in the context of its findings 

The Independent Inquiry Child Sexual Abuse (IICSA) was a wide-ranging inquiry into many British 
Institutions. Its conclusions pertain not only to the protection of children but to all aspects of the 
safeguarding of children and vulnerable adults. It reported in October 2020 in relation to Safeguarding 
in the Church of England and Church in Wales The Anglican Church - Safeguarding in the Church of 
England and the Church in Wales - Investigation Report | IICSA Independent Inquiry into Child Sexual 
Abuse.   

The Church of England accepted the recommendations made by the inquiry in full. The Church of 
England has published a detailed response to the recommendations focusing on response to victims 
and survivors including redress, structure and independence, information sharing, revision of the 
Clergy Discipline Measure and external audits. 15.04 IICSA - Response to recommendations FINAL 
AC Council.pdf (churchofengland.org) 2 To deliver these recommendations successfully, an IICSA 
safeguarding programme has been set up by the National Safeguarding Team.  

The implications of these recommendations for the matters considered in this response are important. 
Both the IICSA recommendations and the existing House of Bishop’s Guidance to clergy are strong 
and clear in their instruction that all safeguarding concerns or allegations should be reported to the 
Diocesan Safeguarding Team in the first instance and in any event within 24 hours, and that it is 
those professionals who should decide, independently, whether investigation or action needs to 
follow.  

This is to ensure untrained clergy are not investigating or using their own judgement, and to establish 
consistency of process. Although elements of our response to and handling of the concerns about Fr 
Griffin fell well short of good practice and need improvement, the principle of reporting, without 
investigation or filtering, of safeguarding concerns to qualified professionals, is one which is well 
established and one which we defend. See also section 7, additional matters.  

2 IICSA Response: Recommendation 1, Part 1, role of the Diocesan Safeguarding Officer. P1.  

Responding to Safeguarding Concerns or Allegations that relate to Children, Young People and Vulnerable 
Adults 2018. “Inform DSA/nominated safeguarding officer and seek advice within 24 hours. Record all 
conversations and actions taken and retain securely.” P19 

5 

 
 
 
 
 
 
 
 
 
 
 
 8. 

 Initial responses to the Coroner’s Criticisms 

Although we do not wish to pre-empt the findings of the Lessons Learned Review as we are 
committed to learning from the Reviewer’s findings and recommendations, it is important that we offer 
an initial factual response to the Coroner’s findings, both to acknowledge obvious failings and to 
correct any misperceptions which may be barriers to full learning.  

The Coroner’s key points are summarized here, and the full table can be found in her Regulation 28 
Report.   

Action already completed  Action proposed 
We have created a single 
safeguarding referral line 
and inbox, to enable 
capture and triage of 
information and to ensure 
that these are the single 
points of entry for referrals 
into the safeguarding 
team.  

The concern reporting form is 
being updated and will be 
reissued shortly. This will 
prompt full disclosures 
including pointing to relevant 
evidence and witnesses. 

We will identify additional 
training and communications 
for the safeguarding team 
and senior staff regarding the 
handling of safeguarding 
disclosures or receipt of 
safeguarding concerns. 

Further actions will be 
informed by the Review and 
will be developed by the new 
Head of Safeguarding, who 
has extensive experience of 
managing allegations, 
supervising staff, and 
keeping track of casework.  

We now make sole use of 
the safeguarding inbox for 
referrals, preventing 
information being sent to 
individual recipient’s 
inboxes. 

Both of these actions will 
ensure better oversight of 
any potential 
safeguarding referral, and 
ensure appropriate 
handling, including 
seeking evidence and 
witnesses.  

Coroner’s finding - summary 
1. The purpose of the meetings 
with the Head of Operations was 
not made clear to all who 
attended. The nature and origin of 
the allegations was not clear, and 
they were not evidenced/ 
witnessed. 

Response  
The purpose of the 
meetings was stated in 
the meetings and the 
notes of those meetings. 
However, it is accepted 
that not all those present 
may have understood 
this.  

Although some of the 
concerns relating to other 
people were evidenced 
and had been dealt with, 
we accept that the 
concerns raised in respect 
of Fr Griffin were 
unsubstantiated. 

6 

 
 
 
 
 
 
  
 
  
 
 
 2. The Head of Operations’ 
allegations were never clearly 
listed at the outset or 
appropriately verified with him, yet 
were passed on to the Roman 
Catholic Church 

We accept that the 
information shared by the 
Head of Operations was 
not verified with him. 

We accept that good 
practice around evidence 
gathering, verification, 
and evaluation of 
information prior to action 
was lacking. 

We have recruited a new 
Head of Safeguarding 
with high level experience 
of investigation, 
supervision, and quality 
assurance. 

Legal advice has been 
taken on Data Protection 
issues arising. 

GDPR training is being 
given to the safeguarding 
team in September 2021 
by the National Church 
Institutions. 

3. Lack of clarity about the use of 
the term “rent boys”.  

Whilst this was the term 
used in the initial 
disclosure, it is 
unacceptable for it to 
have been used in 
subsequent 
communications; we 
should have challenged 
and corrected its use.  

We accept that there was 
clarification neither of the 
term used nor of its origin 
(ie by whom it was used) 
in the meetings that took 
place. 

The single referral form 
for all safeguarding 
concerns will prompt 
those recording 
disclosures to be clear, as 
much as is practicably 
possible, as to the origin 
of information and to take 
steps to ensure that it is 
appropriately verified or 
investigated by the 
safeguarding team. We 
will also ensure that 
appropriate terminology is 
used. 

The Head of Safeguarding 
will ensure staff are 
competent and confident to 
risk assess any information 
to be shared and that future 
decisions are recorded and 
audited. 

The National Safeguarding 
Team have been developing 
formal information sharing 
protocols for all dioceses. 
These will be implemented in 
the Diocese of London once 
completed and will facilitate 
appropriate sharing of 
information with statutory 
services and also other 
trusted partners, such as 
faith organisations. 

Further actions will be 
informed by the Review and 
will be developed by the new 
Head of Safeguarding. 
We will continue to ensure 
that any relevant background 
information stored on clergy 
blue (HR) files is made 
available to members of the 
safeguarding team, that DBS 
and safeguarding training 
records are up to date and 
accessible, and that we have 
better systems for tracking 
file access and transfer. 

7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4. Lack of interrogation of the 
Head of Operations’ recollections, 
leading to lack of clarity about 
allegations, sources, or evidence.  

5. No one took responsibility for 
triaging, verifying, or assessing 
the allegations and deciding how 
they should be acted upon.   

6. The introduction of an error 
recording “concerns of possible 
child exploitation.” 

7. That no one took legal advice 
before proceeding and that no 
one developed an overarching, 
coherent strategy for dealing with 
the concerns relating to Father 
Alan.  

New Leadership and 
Senior Leadership 
Development Pathway 
training equips leaders 
better for handling 
disclosures and 
discerning how 
professional judgement 
might best be exercised. 
This is currently being 
delivered in the Diocese 
of London as part of the 
delivery across all 
dioceses. 

This process will be 
further commented on by 
the Review but is 
informed by the Church of 
England’s response to 
IICSA findings and 
remains wider Church of 
England policy. 

In addition, see above re 
skillset of new Head of 
Safeguarding.  
A case work tracking 
system has been 
developed for all referrals 
into the safeguarding 
team. This includes a 
clear process for the 
receipt and triage of 
allegations and concerns, 
and for recording timely 
progress against key 
milestones. 
It is not possible to quality 
assure all internal 
documents; however, we 
will ensure good working 
practices and closer 
supervision are 
established. 

We acknowledge the 
inherent challenge in 
deciding what is a 
safeguarding concern, 
and what degree of 
evidence is needed in 
order to investigate. 
However, the Diocese of 
London and Church of 
England is bound by 
House of Bishops’ 
Guidance which signposts 
all safeguarding concerns 
to the Diocesan 
Safeguarding Team 
(DST). The presumption 
in favour of reporting to a 
safeguarding professional 
is strong.  

We fully accept that there 
was no subsequent 
verification of the 
information shared by/with 
the Head of Operations. 

We agree there was not a 
clear system for tracking 
progress or assigning 
responsibility for 
oversight. This must be 
corrected.  

We agree this was 
mistake and is a matter of 
regret. This description 
was entered into the 
spreadsheet referred to 
above as part of the Two 
Cities report, which was 
an internal document. It 
was not shared with the 
RC church as part of the 
referral.  
We agree that this did not 
happen. It had been 
recommended that legal 
advice should be taken, 
but this was not followed 
up. 

8 

Further actions will be 
informed by the Review and 
will be developed by the new 
Head of Safeguarding. 

We will further develop 
systems for tracking and 
monitoring actions. Further 
actions will be informed by 
the Review and will be 
developed by the new Head 
of Safeguarding. 

We will ensure the 
appropriate resourcing of the 
safeguarding team to enable 
this to take place. 

See section 2 above 

This will also prompt the 
offer/provision of support for 
those about whom concerns 
have been raised. 

We will further develop 
systems for tracking and 
monitoring actions.  

 
 
 
 
 
 
 
 8. That the Diocese of London 
DSA referred information about Fr 
Griffin to the Roman Catholic 
Church, including disclosure of his 
HIV status. That checking of this 
referral took place by the 
Safeguarding Manager and 
Archdeacon, but no one 
recognized this passing on of 
information as inappropriate.    

9. That welfare and investigation 
were confused in the DSA’s 
referral to the Roman Catholic 
Church.  

Legal advice has been 
taken on Data Protection 
issues arising and 
learning from this has 
been identified. 

GDPR training is being 
given to the safeguarding 
team in October 2021 by 
the data protection lead 
from the National Church 
Institutions (NCIs). 

The National 
Safeguarding Team has 
been developing 
information sharing 
protocols between 
dioceses, statutory 
services, and other faith 
organisations which will 
form a basis for practice 
across the Church of 
England including the 
Diocese of London. 
We have recruited a new 
Head of Safeguarding 
with high level experience 
of investigation, 
supervision, and quality 
assurance. 

Oversight from the Head 
of Safeguarding will 
ensure that DSAs are 
more closely supervised, 
and clear case 
management strategies 
are put in place.  

We fully accept that 
further steps should have 
been taken to verify this 
Information before it was 
shared, even though it 
was being shared with a 
trusted safeguarding 
professional in the Roman 
Catholic Church. We 
accept that there was no 
written record of a risk 
assessment or of the 
wellbeing issues arising.  

Legal advice was not 
taken regarding the detail 
of the disclosure, and we 
also recognize that no 
information sharing 
protocol was in place that 
would have prompted 
further reflection. 

Whilst planning 
conversations did take 
place between the 
Diocese of London and 
the Roman Catholic 
Diocese of Westminster 
prior to the proposed 
meeting with Fr Griffin to 
agree the nature of that 
meeting (which was in 
part to verify the 
information which had 
been passed on), this was 
not recorded. 
Opportunities to establish 
a clear plan for joint 
investigation and pastoral 
care between the two 
denominations were 
missed.  

We will ensure development 
of a Diocesan Suicide Action 
Plan and ensure that this is 
actioned as appropriate. 

Agreement to be developed 
about good practice for joint 
investigations between 
denominations. 

Record keeping needs to be 
further improved and 
practices will be overseen by 
the new Head of 
Safeguarding.  

Improved plans developed 
for ensuring pastoral care 

9 

 
 
 
 
 
 
 
 
 
 10. That the allegations passed 
on had no complainant, no 
witness, and no accuser; that no 
concern had been raised by a 
victim of abuse, a child, parent, 
teacher, youth worker, or other 
witness; and that these led to an 
investigation lasting over a year, 
with the allegations and their 
source never being plainly put to 
Fr Griffin.  

Case management and 
tracking need to be further 
improved to ensure timely 
handling, communications, 
and resolution.   

Further actions will be 
informed by the Review and 
will be developed by the new 
Head of Safeguarding. 

We are further reviewing 
resource requirements to 
ensure future resilience. 

The way the information 
was documented and 
passed to the Roman 
Catholic church is a 
matter of deep regret for 
the Diocese of London. 

Whilst initial actions were 
completed in a timely 
way, we recognise the 
contribution of the 
Diocese of London to 
subsequent delays once 
Father Alan had been 
made aware of this 
matter.  

We also recognise that 
the strategy for managing 
the case was not clear. 

The single Referral Form 
coupled with the process 
for triage and 
safeguarding verification 
will support improvement, 
together with the 
information sharing 
protocols and training 
referred to above 

See above comments in 
section 9. 

There have been 
resilience and capacity 
issues in the Diocesan 
Safeguarding Team, 
relating to illness, 
bereavement, and the 
pandemic, which are 
being addressed. 

Once the new Diocesan 
Safeguarding Advisors 
begin in September and 
October, there will be 
increased safeguarding 
team capacity.  

Additional matters 

In addition to the ten matters of concern set out above, the coroner made specific criticisms in respect 
of the following matters to which the Diocese of London offers responses as follows: 

•  The Diocese of London’s lack of engagement with the inquest process until June 2021 

We apologise for the delay and for the points at which we did not engage as effectively as we could 
have done. Whilst we had initially confirmed to the Coroner’s office that a legal representative was 
being instructed, we now recognise that the details were not subsequently confirmed to them. This 
was an oversight. As a result, we did not request Interested Party status until 3 June 2021. Despite 
this, we were actively engaged in preparation for the Inquest. We will ensure that learning is drawn 
from this, and appropriate actions taken. 

•  Lack of any meaningful attempt at improvement until later June 2021. 

It is a matter of significant regret that, even following the death of Father Griffin, there were a number 
of lost opportunities to review learning from the handling of this case prior to the Inquest. By the time 
of the inquest, the Diocese of London had agreed a Lessons Learned Review and had begun the 
process of drafting Terms of Reference. The scope of that review has now been extended and the 
Diocese of London has taken steps towards appointing an experienced, independent reviewer who is 
able to give rigorous external scrutiny both to this case and to any attendant issues within the 
safeguarding systems and processes of the Diocese of London.  

•  Finally, the coroner responded to the legal submissions made on 28 June 2021 in these terms: 

I then received submissions on behalf of the Church of England regarding any prevention of 
future deaths report. These submissions impressed upon me that referrals to child protection 
and safeguarding professionals must not be reduced and urged me not to include any 

10 

 
 
 
 
 
 
 
 
 
 
 
 concerns that may be taken as a criticism of clerics or staff for not filtering or verifying 
allegation.   

The aim of making this submission to the Coroner was not to deflect criticism away from clergy or staff 
if they had acted inappropriately. It was made in the context of the IICSA recommendations and in the 
light of existing House of Bishop’s Guidance to the clergy that state that clergy must refer all 
safeguarding concerns or allegations to the Diocesan Safeguarding Team in the first instance and in 
any event within 24 hours (see 6, above). This is to ensure untrained clergy are not investigating or 
using their own judgement, and to establish consistency of process. We believe that our clergy and 
staff acted in accordance with this Guidance and we were concerned that any criticism of them for 
following it might deter others from the appropriate reporting of safeguarding concerns 

Our submission, therefore, was intended to ask the Coroner to bear in mind when making her findings 
that all clergy and staff are obliged to follow this Guidance. The Guidance is clear that it is 
inappropriate for clergy and staff to filter or investigate any apparent or alleged safeguarding related 
concerns and instructs them to refer these directly to safeguarding professionals. The Church of 
England has worked hard to ensure that all clergy and staff are clear about their reporting obligations. 
We were and are keen that this good work is not undermined.   

For completeness the relevant Diocese of London submission is included here:    

If, despite these submissions, the learned coroner remains minded to issue a regulation 28 
report, she is urged not to include any concerns that may be taken as a criticism of clerics or 
staff for not filtering or verifying allegations. The learned Coroner has heard that the events in 
question took place in the context of the Independent Inquiry into Child Sexual Abuse (IICSA). 
The purpose of the Inquiry, as set out in its terms of reference, is to consider the extent to 
which State and non-State institutions have failed in their duty of care to protect children from 
sexual abuse and exploitation. The Diocese of London is deeply committed to child protection 
and wishes to avoid anything that may have the unintended consequences of reducing 
referrals to child protection and safeguarding professionals. 

Case Steering Group: 

, General Secretary of the Diocese of London  
, Bishop of Stepney 

, Interim National Director of Safeguarding 
, Bishop at Lambeth (alternate 

) 

, independent member of the London Diocesan Safeguarding Steering Group  

Date: 24 August 2021 

11 

 
 
 
 
 
 
 
 
 Appendix 1 

Church of England Structures and Safeguarding Policy 

This information is offered to demonstrate the Church of England and each individual diocese’s 
framework for dealing with safeguarding and conduct matters. It explains how leadership is exercised 
in the Church and sets individual actions in Fr Griffin’s case in the light of church structures and 
policies.  

The Church of England is made up of 42 dioceses. Each diocese has a lead bishop, known as a 
diocesan bishop, who works alongside a diocesan synod and a structure of boards and councils 
responsible for different aspects of the diocese’s work including ministry, mission, and education. 
Each diocese, including the Diocese of London, is a separate structure. The London Diocesan 
Fund (LDF) exists as the legal entity for the management of the assets and operations of the 
Diocese and is an independent charity.  

The General Synod is an assembly of bishops, clergy, and laity, which meets at least twice a year to 
debate and decide the Church’s laws and to discuss matters of public interest. The General Synod is 
a legislative body whose Measures when passed by the Ecclesiastical Committee of Parliament 
become statute. The House of Bishops is one of the three houses of the General Synod. All diocesan 
bishops are members of the House of Bishops, along with a small number of other elected bishops.  

Seven National Church Institutions work together to support the mission and ministries of the Church. 
See https://www.churchofengland.org/about/leadership-and-governance/national-church-institutions 
and https://www.churchofengland.org/sites/default/files/2021-01/NCI%20structure%20chart%20-
%20Jan%202021%20-%20website.jpg. 

Safeguarding in the Church of England centrally is led by the NST, under the oversight of the 
Archbishops’ Council. See https://www.churchofengland.org/safeguarding/reporting-abuse-and-
finding-support. The NST plays a key role in developing strategy, policy, and training, and 
overseeing casework which has national implications, crosses diocesan boundaries, or involves 
bishops. They work in supportive partnership with dioceses as they manage their own casework.   

Safeguarding policy and practice guidance is developed by the NST but is approved by the House 
of Bishops and must, where relevant, be followed by all church bodies and church officers. In 
particular, all clergy have a duty to operate within and pay due regard to the policy and practice 
guidance and to disclose any safeguarding related concerns to diocesan or national safeguarding 
staff. Indeed, failure to do so by a member of clergy could be considered grounds for a complaint 
under the Clergy Disciplinary Measure. 

Each diocese has its own Safeguarding Team, made up of professionals with appropriate 
safeguarding experience, drawn from social work, police, probation services, or similar backgrounds, 
and with administrative support. It is the Safeguarding Team that handles all safeguarding related 
case work. Senior clergy, e.g. Bishops of a diocese have oversight of ministry generally and specific 
clergy such as Archdeacons work closely with the team on matters of safeguarding and potential 
clergy misconduct. However, it is the safeguarding team (along with a Core Group where appropriate) 
that has operational responsibility for cases and would make decisions/form judgements about the 
progression of safeguarding matters with appropriate consultation with senior staff.  

12