The Governance Gap in Safeguarding Systems
Why Institutional Fragmentation Weakens Protection for Victims of Abuse
Author: Samantha Avril-Andreassen
Founder, SAFECHAIN™
© 2026 Samantha Avril-Andreassen. All rights reserved.
Safeguarding systems across police, courts, housing, and healthcare often operate in fragmented institutional silos. This report examines the governance gap in safeguarding systems and proposes structural reforms to improve accountability, coordination, and victim protection.
Executive Summary
Safeguarding systems across modern institutions face a persistent governance challenge.
While governments have introduced stronger legal frameworks to address domestic abuse, coercive control, and victim protection, the institutional systems responsible for implementing these protections often remain fragmented.
Police services, family courts, healthcare providers, housing authorities, and specialist support organisations each perform vital safeguarding roles. However, these institutions frequently operate within separate professional frameworks, documentation systems, and decision-making structures.
The absence of coordinated governance across these institutions can produce a safeguarding gap, where relevant information exists across multiple agencies yet fails to form a coherent understanding of risk.
This fragmentation can have serious consequences.
Patterns of coercive control may remain partially visible within different institutional systems. Survivors may be required to repeat their experiences across agencies. Professionals may make safeguarding decisions based on incomplete information.
This report examines the governance gap within safeguarding systems and explores how structural reform could strengthen institutional coordination, accountability, and victim protection.
It also introduces SAFECHAIN™, a safeguarding interoperability framework designed to improve continuity across institutional safeguarding responses.
Introduction: Safeguarding in a Multi-Institutional Environment
Safeguarding responsibilities rarely fall within the authority of a single institution.
Domestic abuse cases frequently involve complex interactions between several public authorities and professional services. These can include police forces investigating criminal allegations, family courts adjudicating disputes involving children, housing authorities responding to accommodation issues, healthcare providers treating trauma-related harm, and specialist advocacy organisations supporting victims.
Each institution operates under its own statutory obligations and professional mandates.
Police investigate criminal conduct. Courts adjudicate legal disputes. Healthcare providers address physical and psychological harm. Housing authorities respond to accommodation and tenancy issues.
Individually, these institutions may fulfil their roles effectively.
However, domestic abuse frequently unfolds across multiple domains simultaneously. Psychological intimidation, financial manipulation, legal coercion, and social isolation may interact in ways that span different institutional jurisdictions.
When safeguarding systems lack mechanisms for coordination, these dynamics may remain fragmented across institutional boundaries.
The result is a safeguarding landscape in which risk is distributed across agencies but rarely integrated into a unified safeguarding picture.
Understanding the Governance Gap
The governance gap in safeguarding systems arises when institutional structures fail to support coordinated responses to complex harm.
This gap does not necessarily reflect a lack of professional commitment or competence among practitioners. Rather, it reflects structural limitations in how institutions communicate, share safeguarding insights, and assess risk collectively.
In fragmented systems, different agencies may possess partial information about a survivor’s circumstances.
For example:
A police force may record reports of harassment or intimidation.
Healthcare providers may treat symptoms associated with trauma or stress.
Housing authorities may observe financial instability linked to coercive control.
Family courts may address legal disputes relating to children or property.
Each of these observations contributes to understanding the broader context of abuse.
Yet when these insights remain confined within separate institutional systems, the cumulative pattern of harm may be difficult to identify.
Safeguarding decisions therefore risk being made based on incomplete institutional visibility.
The Structural Complexity of Domestic Abuse
Domestic abuse often involves patterns of behaviour that extend beyond isolated incidents.
The recognition of coercive and controlling behaviour under Section 76 of the Serious Crime Act 2015 marked an important legal acknowledgement of this reality. Rather than focusing solely on acts of violence, the law now recognises that abuse may occur through sustained patterns of domination and manipulation.
The Domestic Abuse Act 2021 further expanded the statutory definition of domestic abuse to include emotional, psychological, and economic harm.
These legislative developments reflect a deeper understanding of the complexity of abuse.
However, recognising these patterns in practice requires safeguarding systems capable of identifying how different forms of harm interact across multiple aspects of a person’s life.
Economic abuse may affect housing stability.
Psychological intimidation may influence healthcare outcomes.
Legal manipulation may arise within court proceedings.
Harassment or stalking may involve police investigation.
When institutional systems assess these issues independently, the cumulative pattern of abuse may remain partially obscured.
Institutional Silos and Information Discontinuity
Institutional silos are a common feature of complex governance systems.
Public authorities often operate under statutory mandates that define the scope of their responsibilities and the limits of their jurisdiction. While such structures help maintain accountability and procedural integrity, they can also create barriers to coordinated safeguarding responses.
Information relevant to victim protection may exist within separate institutional records that are not routinely connected.
For instance, a police officer responding to a harassment complaint may not have visibility of relevant housing authority records. A healthcare professional treating trauma symptoms may not be aware of ongoing legal disputes involving coercive behaviour. A family court may focus on parental arrangements without access to broader safeguarding documentation.
The absence of structured communication pathways between these institutions contributes to information discontinuity.
As a result, professionals working in different sectors may observe aspects of the same safeguarding problem without recognising the full pattern of harm.
Procedural Burdens on Survivors
Institutional fragmentation can place significant procedural burdens on survivors.
Individuals navigating domestic abuse proceedings often encounter multiple institutions simultaneously. They may be required to report incidents to police, attend court hearings, communicate with housing authorities, and seek medical or psychological care.
In the absence of coordinated safeguarding systems, survivors frequently find themselves repeating their experiences across agencies.
They may also need to compile documentation from different institutions, explain the broader context of abuse repeatedly, and attempt to ensure that professionals understand the wider safeguarding picture.
For individuals already coping with trauma, financial instability, and personal safety concerns, these procedural demands can be overwhelming.
Safeguarding systems designed to protect vulnerable individuals should not depend on survivors performing the role of institutional coordinators.
Governance Accountability in Safeguarding Systems
Effective safeguarding systems depend not only on legal frameworks but also on governance structures that ensure accountability across institutions.
Governance involves the mechanisms through which organisations coordinate their activities, manage risk, and ensure that responsibilities are fulfilled effectively.
In safeguarding environments, governance structures must support collaboration between institutions responsible for protecting vulnerable individuals.
Without such structures, safeguarding responsibilities may become dispersed across agencies without clear mechanisms for coordination or oversight.
Strengthening governance frameworks therefore represents a critical step in improving safeguarding outcomes.
The Role of Structural Reform
Addressing the governance gap in safeguarding systems requires structural reform.
Such reform does not necessarily require the creation of new institutions. Instead, it involves strengthening the connective infrastructure that allows existing institutions to operate cohesively.
Structural reform may include:
• improved safeguarding data governance
• cross-agency communication protocols
• trauma-informed operational frameworks
• institutional accountability standards
• coordinated safeguarding documentation systems
These mechanisms can help ensure that relevant safeguarding information is visible across institutional boundaries while maintaining appropriate safeguards for privacy and legal compliance.
SAFECHAIN™ and Safeguarding Interoperability
SAFECHAIN™ was developed as a conceptual framework designed to address the governance gap in safeguarding systems.
The framework focuses on strengthening interoperability between institutions responsible for safeguarding vulnerable individuals.
Interoperability refers to the capacity of different organisations to exchange information, recognise risk indicators consistently, and maintain continuity in safeguarding documentation.
SAFECHAIN™ proposes governance mechanisms that support:
• safeguarding documentation continuity
• structured cross-agency communication pathways
• trauma-informed operational protocols
• enhanced procedural accountability
• improved institutional visibility of risk patterns
The framework does not seek to centralise control or replace existing institutions.
Instead, it focuses on strengthening how institutions collaborate within existing safeguarding systems.
Human Rights and Institutional Responsibility
Safeguarding systems also operate within broader human rights frameworks.
The Human Rights Act 1998 places obligations on public authorities to protect individuals from harm and ensure fairness within legal processes.
When safeguarding systems fail to recognise patterns of abuse due to institutional fragmentation, these obligations may be undermined.
Similarly, the Macpherson Report (1999) emphasised that institutional failures can arise from structural weaknesses rather than solely from individual misconduct.
Strengthening safeguarding governance therefore aligns with broader principles of institutional accountability and human rights protection.
Toward Integrated Safeguarding Systems
Improving safeguarding governance requires recognising that domestic abuse often unfolds across multiple institutional environments.
Professionals working within police services, courts, healthcare systems, housing authorities, and support organisations may each observe aspects of a victim’s experience.
Integrating these insights into a coherent safeguarding picture requires systems that support structured collaboration.
Integrated safeguarding systems can help ensure that risk indicators are recognised more effectively, professionals have access to relevant contextual information, and survivors are not required to navigate fragmented institutional processes alone.
Conclusion
Domestic abuse safeguarding has progressed significantly in recent years.
Legislation now recognises coercive control, psychological abuse, and economic harm as serious forms of violence. Public awareness has increased, and safeguarding institutions continue to develop professional expertise in responding to complex cases.
Yet structural challenges remain.
Institutional fragmentation continues to limit the ability of safeguarding systems to recognise patterns of harm that unfold across multiple agencies.
Addressing this governance gap requires strengthening the connective infrastructure that allows safeguarding institutions to operate cohesively.
Frameworks such as SAFECHAIN™ represent one approach to exploring how safeguarding interoperability, documentation continuity, and institutional accountability might evolve.
Ultimately, safeguarding systems must ensure that survivors encounter coordinated protection rather than fragmented responses.
Closing the governance gap is therefore an essential step toward building safeguarding systems capable of delivering the protection victims deserve.
© 2026 Samantha Avril-Andreassen. All rights reserved.
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