Managing allegations against people in positions of trust (PiPoT) procedure

1 Policy summary

This policy is based on the Care Act (2014) and the Care and Support Statutory Guidance (2015) to provide a framework for managing allegations made against a person in a position of trust (PiPoT). As with all safeguarding concerns, it is everybody’s responsibility to report. This policy applies whether the incident is current or historical and whether the person in a position of trust is in paid or unpaid work.

2 Introduction

This procedure provides the framework for managing cases where allegations have been made against a person in a position of trust (PiPoT) and is focussed on the management of risk. It provides guidance to ensure appropriate actions are taken to manage allegations against people who are employed, or volunteer for the trust.

This policy is based on the Care Act (2014) which requires that partner agencies and commissioners of services should have clear recording and information sharing guidance set explicit timescales for action and are aware of the need to preserve evidence.

This procedure builds upon the existing statutory provision and local safeguarding adults board procedures.

The trust recognises its responsibility to ensure safe working systems are in place for colleagues working with children and adults. Having a clear process in place to manage allegations against persons in positions of trust forms one part of this process but needs to sit alongside safe recruitment and selection policies, robust disclosure procedures and training for colleagues to ensure they understand their responsibilities in terms of safeguarding. As such, this guidance should be read in conjunction with the following trust policies:

This is not an exhaustive list and reference to additional policies will need to be considered on a case-by-case basis.

In addition, each local safeguarding adults board have their own local person in a position of trust policies and procedures, and these can be found below:

3 Purpose

Set out clear reporting requirements and the arrangements for the management of allegations against persons in positions of trust, with concise recording, information sharing arrangements and explicit timescales for action.
Ensure that allegations are dealt with expeditiously and in a fair, proportionate and transparent way, adopting the just culture principles.
Ensure that appropriate systems are in place to support and provide regular updates to the employee concerned in respect of any investigation.
Ensure that the control of information in respect of individual cases is in accordance with data protection and confidentiality requirements in line with the General Data Protection Regulations (GDPR).
Ensure that where colleagues, students and volunteers are found to have had allegations substantiated against them, appropriate governance procedures are followed, including a referral to the individual’s professional body.

This guidance must be applied when concerns are raised about a person in a position of trust in a work (professional) context and if any relevant concerns arise from a person’s personal life, if there are implications for the safety of people with care and support needs. This guidance applies whether the allegation or concern is current or historical.

When considering a referral relating to a person in a position of trust, a distinction should be made between an allegation, a concern about a person’s quality of care or practice and a complaint.

Where there are potential risks to adults with care and support needs who use the trust’s services, these risks need to be assessed, and if necessary, action should be taken to safeguard those adults.

Examples of concerns that can arise either in a professional or personal context:

person has behaved in a way that has harmed or may have harmed an adult or child
person has committed a criminal offence against, or related to, an adult or child
person has behaved towards an adult or child in a way that indicates they may pose a risk of harm to adults with care and support needs
person may be subject to an investigation by police as a perpetrator of domestic harm
a person has behaved (or is alleged to have behaved) towards children in a way that indicates that they may pose a risk of harm to adults with care and support needs
a person is subject of a formal safeguarding enquiry into allegations of abuse or neglect which have occurred in one setting. However, there are also concerns that the person is employed, volunteers or is a student in another setting where there are adults with care and support needs who may also be at risk of harm

4 Scope

As a relevant partner to several local authorities and an organisation providing care and support services to adults; the trust is required to have a clear process in place for dealing with allegations against persons in positions of trust.

The Care Act (2014) defines people in positions of trust as:

“People who work, in either a paid or unpaid capacity with adults with care and support needs.”

Therefore, although this guidance uses the words “employee”, “employees” and “colleagues” this guidance applies to all colleagues, volunteers and students working at the trust, who have contact with adults with care and support needs.

4.1 What is excluded from the procedure?

Section 14 of the Care Act and support statutory guidance states safeguarding is not a substitute for:

the providers’ responsibility to provide safe and high-quality care and support
the commissioners regularly assuring themselves of the safety and effectiveness of commissioned services
the Care Quality Commission to ensure providers comply with the standards of care or by taking enforcement action
the core duties of the police to prevent and detect crime, and protect life and property

Therefore, careful consideration should be given to distinguish clearly between:

a complaint about a professional or volunteer
concerns raised about the quality of practice provided by a person in a position of trust that do not meet the criteria for a safeguarding enquiry

Other relevant bodies and their procedures should be used to recognise, respond to and resolve these issues.

5 Procedure

5.1 Manager becomes aware of an allegation involving children

The manager must ensure the safety of all involved; in cases of immediate danger the police should be called on 999. The manager must notify the nurse director of the relevant care group; head of the Safeguarding and People Experience team and complete an incident report using the trusts incident reporting system. If the allegation is raised out of hours, then the matter should be escalated to the on-call manager.

If the colleague whom the allegation has been made has children, then consideration must be given for making a safeguarding children referral to protect those children.

The local authority designated officer (LADO) is responsible for managing and overseeing allegations against adults who work with children. This involves working with police, children’s social care, employers and other involved professionals.

The local authority designated officer must be contacted within one working day in respect of all cases in which it is alleged that a person who works with children has:

behaved in a way that has harmed, or may have harmed a child
possibly committed a criminal offence against or related to a child
behaved towards a child or children in a way that indicates they may pose a risk of harm to children
behaved in a way which raises concerns as to their suitability to work with children

The local authority designated officer is responsible for:

providing advice, information and guidance to employers and voluntary organisations around allegations and concerns regarding paid and unpaid workers
managing and overseeing individual cases from all partner agencies
ensuring the child’s voice is heard and that they are safeguarded
ensuring there is a consistent, fair and thorough process for all adults working with children and young people against whom an allegation is made
monitoring the progress of cases to ensure they are dealt with as quickly as possible
recommending a referral and chairing the strategy meeting in cases where the allegation requires investigation by police and, or social care

In order to provide safeguarding oversight, the head of safeguarding must be notified and consulted at every stage of the process. Next steps will be agreed at the strategy meeting where decisions will be made regarding any investigations and associated timescales. The responsibility for notifying the colleague whom against the allegation has been made sits with the employer, in this case, the trust.

If the local authority designated officer advises that an internal investigation should be commissioned:

an investigation manager and member of the People Experience team is appointed and terms of reference (ToR) agreed.
the head of safeguarding or a member of the safeguarding team will be appointed to provide safeguarding oversight, ensuring that correct safeguarding policies and procedures are followed.
The local authority designated officer is involved from the initial phase of the allegation through to the conclusion of the case. The local authority designated officer contacts for each area can be found below:

5.2 Manager becomes aware of an allegation involving adults

The manager must ensure the safety of all involved; in cases of immediate danger the police should be called on 999. The manager must notify the nurse director of the relevant care group and People Experience team and complete an incident report using the trusts incident reporting system. If the allegation is raised out of hours, then the matter should be escalated to the on-call manager.

A person in a position of trust (PiPoT) referral form should be completed and sent to rdash.safeguardingadults@nhs.net. The safeguarding team will then forward to the deputy chief nurse, director of nursing backbone services and head of safeguarding for a decision to be made whether the person in a position of trust threshold has been met If so, a person in a position of trust meeting should be convened within 3 working days.

The person in a position of trust meeting will be chaired by either the deputy chief nurse, nurse director for backbone services or head of safeguarding and attended by the nurse director of the relevant care croup, People Experience team representative and the person in a position of trusts manager. If the head of safeguarding is unavailable, then there will be representation from a named nurse or professional for safeguarding in order to provide safeguarding expertise.

The purpose of the meeting is to review the allegation and assess the risk of harm to the adult and other adults under the care of the person in the position of trust. This should include transferable risk to children.

Key actions for consideration include:

consideration of a safeguarding children referral and, or safeguarding adult concern to the local authority
in cases where the colleague works with or has contact with children in their role, this should include a referral to the local authority designated officer (LADO) for all allegations relating to a child; a local authority designated officer referral must be made within one working day of the initial concerns
consideration of reporting the concern to the Police; the internal management of the investigation must not jeopardise a criminal investigation and the management of any internal investigation must be discussed with the Police
consideration should be given whether there have been practice issues raised in the past including any previous allegations made against the individual
a decision on suspension or redeployment to non-clinical tasks whilst the allegation is being investigation
a decision on a person in a position of trust investigation or human resources action which may include disciplinary procedures
a decision around who will inform the colleague about which the allegation has been made
support for the colleague about which the allegation has been made
consideration of a report to the relevant professional body
consideration of a report to the Disclosure and Barring Service if the allegation is substantiated
any possible public interest and media coverage; if there is potential for public interest, then this should be escalated to the Chief Nursing Officer for consideration and action

5.3 Person in a position of trust (PiPoT) investigation commissioned

An investigation manager and member of the People Experience team is appointed by the Care Group Senior Leadership team and terms of reference agreed.

The head of safeguarding or a member of the safeguarding team will be appointed to provide safeguarding oversight to ensure that correct safeguarding policies and procedures are followed.

5.4 Support for the colleague against whom the allegation has been made

Alongside the trust’s duty of care to the adult at risk, there is a duty to support the individual who is subject to a person in a position of trust investigation, including:

supporting them to understand the process and updating them on progress
ensuring they have a point of contact
providing the opportunity to respond to an allegation
offering a referral to occupational health
advising them to seek support from their union
maintaining an impartial and unbiased approach

5.5 Post investigation outcome and action

A meeting must be convened which includes deputy chief nurse, nurse director for backbone services or head of safeguarding and attended by the nurse director of the relevant care group and representative of the People Experience team to review the case and determine the outcome of:

any police investigation
adult social care enquiry
local authority designated officer enquiry
person in a position of trust investigation

A decision should be recorded on the person in a position of trust closure form (appendix D) whether the allegation is deemed to be:

substantiated: there is sufficient evidence to prove the allegation
unsubstantiated: there is insufficient evidence to either prove or disprove the allegation, it does not imply guilt or innocence
unfounded: there is no evidence or proper basis which supports the allegation being made, it might indicate that the person misinterpreted the incident or was mistaken about what they saw
malicious: there is clear evidence to prove there has been a deliberate act to deceive, and the allegation is entirely false
false: there is sufficient evidence to disprove the allegation.
The decision should centre on the threshold of balance of probabilities rather than the legal threshold of beyond all reasonable doubt

If it is found that there is a case to answer, a disciplinary hearing will be arranged in line with the trusts disciplinary policy.

It should be noted that a lack of criminal investigation, charge or conviction is not an adequate defence for the adult who is subject of a disciplinary hearing due to the differing thresholds. There may be elements of an allegation which suggest a breach of expected or appropriate standards of behaviour even when no criminal activity is identified.

5.6 Reporting and managing allegations involving non-directly employed colleagues

Allegations made against NHS Professional colleagues must be reported to NHSP at how do I make a complaint, compliment or give feedback to NHS Professionals.

Allegations made against colleagues seconded or embedded within services from another employer must be reported to the relevant employer.

Allegations made against volunteers undertaking duties on behalf of the trust must be reported to the voluntary body the person is volunteering with.

5.7 Disclosure and Barring Service (DBS)

As a trust delivering regulated activities, there is a legal duty to refer concerns to the Disclosure and Barring Service (DBS) in accordance with the Safeguarding Vulnerable Groups Act (2006). The responsibility for taking this action will be decided in the person in a position of trust meeting.

An individual must be referred to the Disclosure and Barring Service if:

they have been permanently removed from regulated activity through dismissal or permanent transfer
they would have been removed or transferred if they had not left, resigned, retired or been made redundant
they are believed to have engaged in relevant conduct (been involved in an action or inaction that has harmed a child or vulnerable adult or put them at risk of harm
they have satisfied the harm test (no action or inaction was found to have occurred, but a significant risk remains that it could occur
they have received a caution or conviction for a relevant offence (involving automatic barring)

The Disclosure and Barring Service has no investigative powers and bases its decisions on the evidence supplied to it.

The duty to make a referral may not be triggered by temporary suspension and depends on whether there is sufficient information to meet the referral criteria.

In addition, where appropriate, employers should report workers to the statutory and other bodies responsible for professional regulation such as the General Medical Council, Nursing and Midwifery Council, Health and Care Professions Council and Social Work England. The individual must be informed of any action undertaken against them.

5.8 Resignation during the investigation

If a person subject to a person in a position of trust investigation attempts to leave their employment by resigning in an effort to avoid the investigation or disciplinary process, the employer is entitled not to accept that resignation, conclude whatever process has been utilised and, if the outcome warrants it, dismiss the employee or volunteer instead.
This would also be the case where the person intends to take up legitimate employment or a course of study. A referral to the Disclosure and Barring Service must be made if it is not possible to complete the disciplinary process.

The fact that a person tenders their resignation or ceases to provide their services must not prevent an allegation from being followed up in accordance with this policy and a conclusion reached.
If a person tenders their resignation the trust will ensure that any letters of reference will declare that the individual resigned whilst an investigation was ongoing.

5.9 Information sharing and confidentiality

Information sharing should comply with the trust’s legal obligations, including under the General Data Protection Regulations (GDPR) and the Data Protection Act (2018) (principally that sharing should be fair and lawful, but the legislation should not be a barrier to sharing information where a failure to do so would cause the safety or well-being of a child or adult to be at risk).

To maintain the confidentiality of all parties, no matters related to the person in a position of trust should be discussed outside the process.

5.10 Record keeping

A referral form must be fully completed, and any relevant information gathered before a case can be a presented at a person in a position of trust meeting.

A clear and comprehensive record of the case should be kept on the colleague’s confidential personnel file. The safeguarding team also keep all records relating to person in a position of trust and child local authority designated officer in a confidential file on the “L: Drive”. All records will be kept in accordance with the trust’s record keeping policies.

5.11 Lessons learned

The head of safeguarding will review any key themes and trends regarding allegations made against person in a position of trust and ensure that the learning is embedded into front line practice via ongoing training, supervision and sharing across the organisation through established groups.

6 Internal and external governance

The head of safeguarding will ensure that data from person in a position of trust activity will be reported to the Safeguarding and Mental Capacity Act meeting on a quarterly basis and to the respective safeguarding adults board as and when required.

7 Training implications

7.1 All colleagues

Training or course name: included within L3 core safeguarding adult training
Frequency: 3 hours every year.
Length of training: 3 hours.
Delivery method: eLearning and face to face.
Training delivered by whom: Safeguarding team.
Where are the records of attendance held: electronic staff record.
Employee groups requiring training: all colleagues requiring L3 safeguarding adults training

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 Indicate how this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all colleagues working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason, all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected, and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 Indicate how this will be achieved

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

9 Associated documents

This list is not exhaustive, refer to trust intranet.

11 References

Care Act (2014) Section 42 to 47

12 Appendices

12.1 Appendix A responsibilities, accountabilities and duties

Safeguarding adults and children is everybody’s responsibility whatever role you may have within work or outside work.

12.1.1 How might a person in position of trust (PiPoT) concern be identified?

Concerns about a person in position of trust’s behaviour may be identified by the following people or procedures:

police intervention
providers alerting commissioners investigation of services
whistleblowing disclosure
commissioner’s contract
safeguarding adults enquiry monitoring activity
safeguarding children
Safeguarding Adults Board (SAB) partner investigation
Care Quality Commission (CQC)
complaints
any other source of reports from members of the public

12.1.2 Employee

12.1.2.1 When an employee of the trust raises a concern

Employees are responsible for conducting themselves in a professional manner at all times to patients, relatives, colleagues, and any other individuals they may come into contact with during the course of their work for the trust.

Any colleague with knowledge or information that an individual is involved in the actual or potential abuse of an adult or a child, whether in the course of their work, or leisure and personal time, or their family and carer responsibilities, must report it to their line manager or on call manager and the Safeguarding team.

Some employees may feel uncomfortable doing this, however, the needs of the adult or child should be paramount. For professional colleagues this duty will also fall under their professional code of conduct. It should be noted that failure to report concerns could indicate collusion; along with malicious allegations, this would be viewed seriously by the trust, and the police may need to be informed.

Employees disclosing information should be listened to and advised that their concern will need to be taken further, where appropriate. Employees should be aware that it may not be possible for their anonymity to be maintained.

12.1.3 Line managers

12.1.3.1 Line managers of employees raising concerns

Line managers of employees raising concerns are responsible for:

ensuring that any concern raised with them is listened to and taken seriously
informing employees that it may not be possible for their anonymity to be maintained
documenting the concern
referring to the trust’s Safeguarding team as soon as possible

Line managers will be responsible for populating the person in position of trust referral form and gathering all information, prior to the scoping meeting which may have a bearing on the allegation for example, any previous concerns. This information is to readily accessible during the meeting.

12.1.3.2 Line manager of an individual who is the subject of a concern or allegation

The manager will attend any meetings as appropriate.
The manager will liaise with the head of safeguarding, nurse director and People Experience team.
The manager will be responsible for notifying and supporting the individual against whom the allegation has been made.

12.1.4 Safeguarding team

On receiving the person in position of trust referral form, the Safeguarding team will:

forward the referral to the head of safeguarding, nurse director for backbone services and deputy chief nursing officer to be triaged
the safeguarding administrator will record the data in a secure folder
following the approval for a meeting to be convened, the Safeguarding team administrator will then liaise with the care group or corporate nurse director, line manager, People and Organisation Development team and any other relevant personnel in order to instigate a person in position of trust meeting within 3 working days
if the concern is raised out of hours, then advice is to be sought from the manager on call and action taken accordingly
if the concern involves children, then the local authority designated officer (LADO) should be informed within 1 working day
if the adult or child who is the subject of the concern is believed to be at risk of immediate harm, then steps should be taken to safeguard the individual concerned, and the police should be informed without delay on 999

12.1.5 Person in position of trust lead (deputy director of nursing delegated to the head of safeguarding)

The person in position of trust (PiPoT) lead will have the overarching responsibility for the management of the investigation into the allegations and will delegate responsibility for actions to be undertaken.

The responsibilities include:

ensuring colleagues and managers have access to expert advice and guidance to enable them to fulfil their responsibilities when responding to allegations, which may include legal and people experience policies and guidance
escalating to the chief nursing officer
responding promptly to allegations regarding colleagues and for undertaking necessary action in line with internal processes and agreed timescales
the communication strategy if the allegations is in the public domain
reviewing the information gathered to assess if the allegations are substantiated or not
ensure that the appropriate person is identified to inform the police as appropriate
ensure the appropriate person is identified to inform the necessary regulatory body for example, The Nursing and Midwifery Council, General Medical Council, Health and Care Professions Council
and Social Work England
triaging the person in position of trust referral and ensuring that a person in position of trust meeting is arranged within 3 working days
monitoring the progress of cases to ensure they are dealt with as quickly as possible, with a consistent, thorough, fair and transparent process
ensuring appropriate recording systems are in place to provide a clear audit trail about the decision-making process and any recommendations arising from an investigation and subsequent actions

12.2 Appendix B monitoring arrangement

12.2.1 Adherence to policy and process

How: clinical audit.
Who by: Safeguarding team.
Reported to: safeguarding and Mental Capacity Act meeting.
Frequency: quarterly.

12.2.2 Number and themes of person in positions of trust (PiPoT) cases

How: audit.
Who by: Safeguarding team.
Reported to: safeguarding and Mental Capacity Act meeting.
Frequency: quarterly.

12.3 Appendix C decision-making support tool for making a person in positions of trust (PiPoT) referral

Refer to appendix C: decision-making support tool for making a person in positions of trust (PiPoT) referral (staff access only).

12.7 Appendix G summary of person in positions of trust (PiPoT) process

Concern raised by colleague member, patient, partner agency, local authority designated officer, member of the public (the list is not exhaustive).
Manager to notify the nurse director of the relevant care group, People Experience team and complete an incident report using the trusts incident reporting system.
Safeguarding team to be notified, person in positions of trust referral form to be completed and forwarded to rdash.safeguardingadults@nhs.net.
Safeguarding team will send the person in positions of trust referral to the head of safeguarding, nurse director backbone services and deputy chief nursing officer for triage.
If the person in positions of trust threshold has been met a person in positions of trust meeting will be arranged within 3 working days.
The person in positions of trust meeting will be chaired by either the head of safeguarding, nurse director backbone services or deputy chief nursing officer.
Quoracy will be achieved with the attendance of:
- head of safeguarding, nurse director backbone services or deputy chief nursing officer
- named nurse or professional for safeguarding if the head of safeguarding is unavailable
- care croup nurse director or member of the Care Group Senior Leadership team
- member of the People Experience team
Person in positions of trust outcome meeting to be convened to review the findings of any investigation and safeguarding enquiry. One of the following outcomes should be clearly documented in order to conclude the process:
- False
- Unsubstantiated
- Malicious
- Substantiated
All actions identified from the person in positions of trust outcome meeting to be completed
Head of safeguarding to review any key learning points and disseminate at the safeguarding and Mental Capacity Act meeting.
Person in positions of trust data to be reported to the respective Safeguarding Adults Board on request and the safeguarding and Mental Capacity Act meeting every quarter.

Document control

Version: 4.
Unique reference number: 502.
Approved by: clinical effectiveness meeting.
Date approved: 3 February 2026.
Document author: head of safeguarding.
Title of accountable director: chief nursing officer
Date issued: 28 April 2026.
Review by date: 30 April 2029.

Page last reviewed: April 28, 2026
Next review due: April 28, 2027

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