Cancelled appointment follow-up
Hospital policies for cancelled appointments lacking clinical input to assess individual patient urgency, risking vulnerable patients.
Source spread
Where this theme appears
This theme appears across 15 independent accountability sources, so the source mix matters as much as the headline total.
22 PFD reports
5 committee recs
2 HSSIB recs
27 CQC actions
4 PPO recs
15 IMB recs
3 IMB reports
1 Article 2 learning point
47 DHR recs
25 PHSO decisions
69 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(22)
Amanda Hawkins
Concerns: The coroner noted increased vulnerability following changes in services and funding. Additionally, hospital appointments sent to the patient's home were not followed up due to her insufficient understanding to deal with correspondence and care co-ordinators not being informed of missed appointments.
Response (Dudley Walsall NHS Trust): • The Trust confirmed that outpatient letters from the North Community Recovery Service medical teams are now copied to the care coordinator. • A Working Group has been convened to … (AI summary)
Responded
Suzanne Greenwood
Concerns: The coroner identified a lack of systems at The Priory Hospital, Altrincham, for contacting patients who repeatedly miss appointments, informing GPs about non-attendance or discharge, and ensuring appropriate review before medication changes are made.
Response (Priory Group): • The organisation reviewed its systems and amended Policy H105: Practising Privileges for Independent Doctors. • The amended policy requires independent doctors to send final letters to patients for repeated … (AI summary)
Responded
Shelia Stokes
Concerns: Concerns include administrative delays in patient follow-up and acting on alerts, alongside the lack of a clear protocol for obtaining custom-made grafts. The adequacy of the trust's internal investigation and the completeness of witness statements were also noted.
Response (Sherwood Forest Hospitals NHS Trust): • The Trust re-launched its DNA process in June 2016 to ensure consistent handling and clinician action, and conducts regular DNA audits. • Upgrades to the EMRAD systems are underway … (AI summary)
Response (Radiology Department): • The Radiology Department outlined its existing 'XXXX POLICY' for communicating critical, urgent, and significant unexpected radiological findings. • The 'XXXX POLICY' will be reviewed and modified to incorporate electronic … (AI summary)
Response (Sherwood Forest Hospitals NHS Trust): • The Trust re-launched its DNA process in June 2016, implementing new procedures for managing missed appointments, including regular audits, and is planning to pilot scanning reconciliation slips. • Upgrades … (AI summary)
Responded
Ann Hardman
Concerns: The coroner noted that the current protocol for negative DVT scans at St Mary's Hospital relies on GP re-referral for follow-up, which risks patients not re-attending. An automatic re-attendance system, with GP discretion to cancel, would be preferable.
Response (Isle of Wight NHS Trust): • The Ultrasound department now automatically books a repeat scan for patients with a D-Dimer positive blood result and a negative initial ultrasound, to occur 6-8 days later. • If … (AI summary)
Responded
Luke Moulding
Concerns: The coroner identified that an 'opt-in' letter, deemed necessary for the deceased, was not sent. There were also concerns about the 10-day delay in sending such letters and the requirement for a typed letter rather than a more efficient pre-printed option.
Response (East London NHS Trust): • A Serious Incident Review identified a delay in sending opt-in letters as a care delivery problem. • The Operational Policy was updated to require opt-in letters to be sent … (AI summary)
Responded
Michael Halfpenny
Concerns: The coroner raised concerns about a GP's incorrect referral for vascular screening and a lack of a hospital system to direct such requests, leading to refusal. Issues also included GP uncertainty regarding the screening programme criteria.
Response (Glenfield Surgery): • The practice conducted a significant event analysis, discussed the case with all practitioners, and escalated the incident to a serious incident with the Clinical Commissioning Group (CCG). • The … (AI summary)
Response (University Hospitals of Leicester NHS Trust): • The Trust confirmed it had implemented a new system for redirecting imaging referrals sent to incorrect teams. • The Trust stated it would update the guideline for rejecting imaging … (AI summary)
Response (East Leicestershire and Rutland Clincial Commisioning Group): • The signed final report regarding the Serious Incident investigation has been enclosed. • The family has been contacted to share the report. • The final report will be shared … (AI summary)
Responded
Robert Power
Concerns: The coroner identified a risk that patients treated as outpatients could be lost to follow-up care, noting that one patient was not followed up for eight years without explanation.
Response (North Bristol NHS Trust): • The Trust confirmed it operates under different systems compared to 2008. • The Trust stated that processes have been introduced to arrange follow-up appointments. • The Trust stated that … (AI summary)
Responded
John Lee
Concerns: Ambiguous language used for urgent referrals is open to misinterpretation, and there is no provision for direct clinical staff input in setting urgent appointments or a checking procedure to guard against errors.
Overdue
Connor Davies
Concerns: The coroner noted a lack of clinical input when patient appointments are cancelled, which means individual needs for urgent referrals are not assessed, posing a risk that patients in serious need may be missed.
Response: • The Health Board developed an action plan to address the matters raised. • Actions to address the issues are currently being implemented by the Mental Health Directorate. • The … (AI summary)
Responded
Gemma Azhar
Concerns: The TTT service's repeated cancellations led to individuals being discharged without clinical assessment of their mental state. The procedure for re-engagement after cancellations is informal, lacks written policy, and inconsistent across staff areas.
Response (Sussex Community NHS Foundation Trust): • A Standard Operating Procedure (SOP) was created to confirm processes for service-cancelled appointments, and an existing SOP for patient-cancelled appointments was updated. • The new SOP ensures administrative staff … (AI summary)
Responded
Imre Thomas
Concerns: Cancelled hospital appointments for vulnerable prisoners place them at risk. The coroner suggested investigating the possibility of special prison clinics with visiting consultants to address this.
Overdue
Hannah Bampfylde
Concerns: The coroner identified a lack of clear protocols and communication regarding newly referred patients who do not engage with mental health services, specifically noting that GPs were not made aware of missed appointments. Concerns were raised about the existing policy for non-attendance, which lacked clarity on re-booking appointments and escalation procedures.
Response (Sussex Partnership NHS Foundation Trust): • The Trust confirmed that since September 2020, the Referral Co-ordinator is responsible for booking further initial assessment appointments. • The Trust stated that its Active Engagement Did Not Attend … (AI summary)
Responded
Stephen Barton
Concerns: The coroner noted the absence of a system for tracking missed outpatient appointments in non-cancer NHS cases, which could prevent unnecessary deaths and save administrative time if introduced.
Overdue
Hugo Carlos
Concerns: The GP practice's EMIS system lacks a scheduled task feature or prominent alerts for future follow-up, placing responsibility on patients to initiate contact and risking missed necessary investigations.
Overdue
Rachelle Ross
Concerns: GP practice IT systems lack an automatic flag for patients who do not respond to National Screening Service smear test invitations, meaning GPs must manually add warnings. An automatic system could standardise care and increase patient safety.
Response (Response NHS England): • GP IT software systems include automatic alerts for overdue cervical screening, which appear in a patient's record without manual input from age 25. • These alerts remain present even … (AI summary)
Response (TPP LTD): • SystmOne includes a built-in report that alerts general practitioners when a patient is due for a cervical smear. • The system provides a list of patients requiring a smear, … (AI summary)
Response (EMIS): • EMIS stated that its system displays an automatic alert, 'Cervical Smear due or outstanding,' each time a patient's record is opened if a cervical screening event is outstanding. • … (AI summary)
Response (Department of Health and Social Care): • NHS England is developing a new IT Cervical Screening Management System (CSMS) to enable general practices to identify and proactively contact non-responders for cervical screening. • The Care Quality … (AI summary)
Responded
Jacqueline Cobain
Concerns: The coroner identified a lack of a system or protocol to alert clinicians to review concerning responses to an automated questionnaire when a patient has cancelled their appointment or the assessment appointment is not for several days/weeks.
Response (South London and Maudsley NHS Foundation Trust): • The Trust added a message to its automatic webform, stating that questionnaires are an aid to monitoring progress and not for urgent support, and will only be viewed at … (AI summary)
Responded
Paul Bradley
Concerns: The coroner identified a lack of clear systems for following up missed urology appointments and for inter-team communication between departments involved in patient care. Concerns were also raised regarding an inappropriate telephone appointment offered to a patient with documented hearing difficulties.
Response (Worcestershire Acute Hospitals): • The Trust has undertaken work to raise awareness of supporting patients with hearing impairment and developed British Sign Language flyers. • Following a Round Table review, the Trust agreed … (AI summary)
Responded
Sara Grinnell
Concerns: Extensive delays in contacting a patient for an urgent gynaecology appointment were noted, due to reliance on written correspondence. Re-referrals did not adequately consider previous delays, resulting in a 24-month delay to diagnosis.
Response (Cwm Taf Morgannwg University Health Board): • The Health Board developed an improvement plan for Urgent Suspected Cancer referrals. (AI summary)
Responded
Lady Lola Crouch
Concerns: A patient was not informed of potential malignancy findings from a CT scan, and this information was not followed up or included in her medical history. Additionally, a medical emergency call was not triggered, and doctor review was delayed due to staffing levels.
Response (Mid South Essex NHS Trust): • The Trust signed up to the ‘NHS App’ radiology reporting service, allowing patients to receive copies of their imaging reports. • Learning from the case, including the need for … (AI summary)
Responded
Joseph Powell
Concerns: The coroner noted that some GPs do not book follow-up appointments for patients with mental health difficulties, instead requiring patients to book their own. This practice can prevent patients from receiving necessary follow-up care or medication.
Response (Royal College of General Practitioners): • The Royal College of General Practitioners will highlight this case to its Mental Health Special Interest Group. • The College will support further promotion of safety planning in suicide … (AI summary)
Responded
Milos Jankovic
Concerns: The coroner raises concerns about inadequate follow-up processes for patients diagnosed with Barrett's oesophagus, particularly in primary care, leading to a risk of developing oesophageal cancer due to missed surveillance. There is no recall system and no prompts for GPs to consider endoscopy or surveillance.
Response (Health and Social Services of Wales): • The Health and Social Services of Wales stated that secondary care teams manage surveillance procedures for Barrett’s Oesophagus. • The Health and Social Services of Wales stated that health … (AI summary)
Response (Cardiff and Vale University Health Board): • A Standard Operating Procedure for Surveillance has been fully implemented, ensuring clerical validation of all surveillance waiting lists. • The total endoscopy waiting list has decreased, supported by temporary … (AI summary)
Responded
Caitlin Imber
Concerns: The coroner noted a CAMHS referral was closed due to missing contact numbers without further enquiries being made to obtain the information. There are concerns that this lack of effort to progress referrals could risk future deaths.
Response (Betsi Cadwaladr University Health Board): • Child and Adolescent Mental Health Services (CAMHS) changed its standard operating procedure to ensure appointments are offered even when contact numbers are not provided. • The service is undertaking … (AI summary)
Responded
Select committee recommendations(5)
#12 — NHS England failed to reduce outpatient follow-up appointments, abandoning its 25% target
Recommendation: NHSE has aimed to free up capacity in outpatient services to allow more patients from the waiting list to be seen. In 2022, NHSE set a target to reduce outpatient follow-up appointments by 25% compared with 2019–20 levels by March …
Response attribution not verified
#9 —
Recommendation: Older prisoners are disproportionately affected by cancellations to external medical appointments, and their health can be seriously impacted by non-attendance. While increasing the number and availability of prison staff to escort prisoners to appointments is important, we also recommend that …
Response attribution not verified
#3 —
Recommendation: The pandemic has placed an unprecedented burden on the delivery of core NHS and care services. This has resulted in the delay, suspension or cancellation of services which in turn has inevitably led to a significant increase in waiting times, …
Response attribution not verified
#9 —
Recommendation: It is not acceptable for patients awaiting planned treatment or feeling the debilitating effects of long covid to feel “abandoned” by the NHS. We appreciate the uncertainty about the length of future waiting lists, but this is no excuse for …
Response attribution not verified
#14 —
Recommendation: The Department and NHSE&I are now managing a large, growing and diverse set of challenges to elective and cancer care on top of the ongoing pandemic. We asked how the Department and NHSE&I expected the accelerated and expanded vaccine booster …
Response attribution not verified
HSSIB safety recommendations(2)
Potential under-recognised risk of harm from the use of propranolol
The Practice carried out an audit of all patients on antidepressants and invited them for a review appointment. The Practice now sends text/call reminders to patients who do not attend appointments and also have depression.
Safety Action
Outpatient appointments intended but not booked after inpatient stays
HSIB recommends that NHS England and NHS Improvement develops standards and an operating framework that describes the assurance required for all outpatient appointment booking processes, including after an inpatient stay. The assurance should include feedback mechanisms which provide safeguards that …
Safety Recommendation
NCEPOD recommendations(3)
CQC inspection actions(27)
Kidderminster Hospital and Treatment Centre
Ensure that all patients who have their surgery cancelled are rebooked within 28 days.
Should Do
Kidderminster Hospital and Treatment Centre
Ensure that all patients who have theirs surgery cancelled are rebooked within 28 days.
Should Do
Kidderminster Hospital and Treatment Centre
Ensure that all patients who have their surgery cancelled are rebooked within 28 days.
Should Do
Kettering General Hospital
The service should ensure processes are in place to re-book cancelled operations within set timeframes.
Should Do
Fleetwood Hospital
The trust should ensure cancelled appointments are kept to a minimum; particularly within those specialities with high cancellation rates (such as general medicine, cardiology, dermatology, gastroenterology, colorectal, geriatric medicine, and clinical haematology).
Should Do
Fairfield General Hospital
The service should ensure it improves theatre utilisation rates and reduces the number of cancelled operations for non-clinical reasons.
Should Do
Moorcroft Medical Centre
Develop a strategy for non-compliant patient attendance when required for medicines and/or long-term condition monitoring.
Should Do
Durham Diagnostics and Treatment Centre
The service should consider working to reduce the number of patients without a review appointment across all specialties and sites within the trust and continue thorough oversight of all patients waiting for appointments.
Should Do
Durham Diagnostics and Treatment Centre
The service should continue working to reduce the number of patients without a review appointment across all specialties and sites within the trust and continue thorough oversight of all patients waiting for appointments.
Should Do
Bridlington Hospital
The service should consider ways to reduce the number of cancelled clinics in outpatients.
Should Do
Bridlington Hospital
The service should consider ways to reduce the number of cancelled clinics in outpatients.
Should Do
Diana Princess of Wales Hospital
The service must continue to address the challenges regarding overdue new and follow up appointments and ensure patients receive their appointment in a timely way across outpatient specialties.
Must Do
St Benedict's Hospice
The trust should ensure that there are robust systems in place to monitor patients on waiting lists and review waiting times for access to assessment and treatment.
Should Do
St Benedict's Hospice
The service should consider working to reduce the number of patients without a review appointment across all specialties and sites within the trust and continue thorough oversight of all patients waiting for appointments.
Should Do
St Benedict's Hospice
The service should continue working to reduce the number of patients without a review appointment across all specialties and sites within the trust and continue thorough oversight of all patients waiting for appointments.
Should Do
St Benedict's Hospice
The service should continue to ensure the waiting time for urgent appointments and cancer appointments at Sunderland Royal Hospital meet national requirements.
Should Do
St Benedict's Hospice
The service should continue working to reduce the number of patients overdue their review appointment across all specialties and sites within the trust and continue thorough oversight of all patients waiting for appointments.
Should Do
Bridlington Hospital
The service should ensure the services assess risk in patients waiting beyond the recommended appointment dates.
Should Do
Bridlington Hospital
The service should ensure that they continue their work to improve patient access and flow to reduce referral to treatment times and patient cancellation rates.
Should Do
Birmingham
The service should ensure delays and disruption to clinics are consistently managed and communicated to patients. Regulation 17.
Should Do
Princes Medical Centre
Continue to monitor and take action to address backlogs to patient reviews.
Should Do
St Benedict's Hospice
The service should consider patient needs when appointments are rearranged at short notice and at a different site from their original appointment.
Should Do
Clifton Hospital
The trust should ensure cancelled appointments are kept to a minimum; particularly within those specialities with high cancellation rates (such as general medicine, cardiology, dermatology, gastroenterology, colorectal, geriatric medicine, and clinical haematology).
Should Do
Clifton Hospital
The trust should consider processes to reduce the number of missed appointments.
Should Do
Bridlington Hospital
The service must ensure the backlogs and overdue appointments in the trust is addressed and improved.
Must Do
Bridlington Hospital
The service must ensure the backlogs and overdue appointments in the trust is addressed and improved.
Must Do
Linden Road Surgery
Follow-up patients who have had a flare up of asthma in line with national guidance.
Should Do
PPO death in custody recommendations(4)
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff follow up prisoners’ non-attendance at medical appointments and document the reasons.
The Head of Healthcare
The Head of Healthcare should discuss with Leicester Royal Infirmary the process for obtaining chemotherapy appointment letters, to ensure that patients do not miss important treatments.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should agree protocols for recording the reasons for missed clinical appointments, audit these and appropriately address any emerging issues.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff chase up cancer follow up appointments promptly if they have not been received when due.
IMB annual reports(3)
Buckley Hall (2020)
HMP Buckley Hall, a Category C training prison with an operational capacity of 459, received positive HMIP inspection results and was ranked highly among UK prisons. Staff efforts to keep prisoners safe during the COVID-19 lockdown were commended, with minimal positive cases. Key concerns included high rates of cancelled external medical appointments, under-completion of key worker sessions due to staffing pressures, and the lack of in-cell telephones. The regime was significantly restricted during lockdown, causing boredom, though out-of-cell time increased by the reporting year's end.
PRISON
Key concerns
Deerbolt (2020)
HMP & YOI Deerbolt experienced a significant improvement in atmosphere and performance following staff shortages and a change in management, aided by a reduced operational capacity. The COVID-19 lockdown led to a reduction in violence and improved safety perceptions for vulnerable prisoners, but severely curtailed all rehabilitative and educational activities. Key concerns include the lack of rehabilitation during lockdown, the need for better remote learning, and systemic issues around gang-related transfers and appropriate facilities for segregation reviews.
PRISON
Key concerns
Forest Bank (2020)
HMP Forest Bank, a Category B male prison, faced significant challenges during its transition to a main Reception prison and the COVID-19 pandemic. The Board commended staff and management for their efforts in maintaining safety and humane treatment amidst staffing shortages and a heavily restricted regime. While healthcare provision was generally good and education adapted well to in-cell learning, concerns remained regarding the impact of restrictions on purposeful activity, appropriate transfers for long-term prisoners, property issues, and increased drug smuggling.
PRISON
Key concerns
IMB individual recommendations(15)
Berwyn (2020)
Did not attend appointments, DNA
NHS / Healthcare Provider
In Progress
Wormwood Scrubs (2020)
Will the minister instigate, at a national level, a policy which will ensure that prisoners who have had their hospital appointments cancelled, through no fault of their own, are not returned to the start of the appointments process?
Ministry of Justice
In Progress
Buckley Hall (2020)
Reduce the number of cancelled outside medical appointments (see paragraph 6.1.4)
Governor / Director
Bedford (2021)
Over a quarter of health appointments were missed because the prison was unable to deliver prisoners to the healthcare area, which is both a waste of healthcare resources and really unhelpful for prisoners.
Governor / Director
Foston Hall (2023)
A significant number of healthcare appointments are missed. What can be done to improve communication to prisoners about appointments and enable their attendance?
Governor / Director
Wymott (2020)
The Board remains concerned about the regular cancellation of prisoner forums, particularly the healthcare forum (see also section 3.4).
Governor / Director
Berwyn (2023)
The Board would like to see measures to improve attendance at medical appointments.
Governor / Director
Swaleside (2020)
There is an unacceptable number of cancelled outside hospital appointments which, apart from the distress that it causes patients, places a burden on the public purse and wastes NHS time which could usefully be used for other patients (see section 6.1).
HMPPS
In Progress
Ranby (2020)
What action will the Governor take to reduce the level of missed healthcare appointments?
Governor / Director
Parc (2022)
There continued to be a high level of failed appointments for healthcare, again indicating a need to examine the appointments system to establish where the process is failing.
Governor / Director
Thorn Cross (2024)
To continue to reduce the number of men who do not turn up for their healthcare appointments.
Governor / Director
Hollesley Bay (2024)
DNAs (did not attends) continue to be a problem for the healthcare department. The Board requests that a further review of the management of the appointments process is undertaken.
Governor / Director
Noted
Foston Hall (2024)
What else can be done to reduce the number of missed internal healthcare appointments?
Governor / Director
Erlestoke (2025)
What guarantees can be given that there will be sufficient funding for escorts to take prisoners to hospital appointments, to avoid the numerous cancellations that have taken place over the last year?
HMPPS
In Progress
Wormwood Scrubs (2020)
Given the Board’s concerns relating to the provision of healthcare services, will the Governor ensure: (i) regular meetings of the strategic healthcare partnership? (ii) a fit-for-purpose healthcare complaints system, delivering timely and appropriate responses, with agreed deadlines? (iii) a significant reduction in the number of cancelled hospital appointments?
Governor / Director
Health investigations(43)
*Mental health homicide investigation legacy report into the care and … — Rec L3
The trust should ensure that all staff adhere to the trust’s policy and procedure for managing formal and informal service users’ non-compliance with treatment and managing DNA (did not attend) or cancelled appointments.
south_east
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (xi)
The Trust should carry out a review of the appointments system in the Out-patient Clinic so as to achieve so far as practicable consistency between the recommended and actual intervals and expeditious follow up in the event of non-attendance.
london
Independent investigation: Simon Breed, Wood Green (2004) — Rec R2
The current trust non-attendance policy should be critically reviewed in the light of our findings. The trust should ensure that, where necessary, it is strengthened to ensure non-attendance is discussed with a named senior clinician and that nominated individuals are identified to carry out the agreed action plan which should …
london
Independent investigation: Richard Marden, Towcester (1999) — Rec 10
That, in the event that a patient of the mental health services who has been newly referred or newly re-referred to the secondary services, or who is considered to carry significant risk, fails to attend an out-patient's appointment: (i) There should be a letter from the secondary mental health services …
midlands
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 14
A robust system must be put in place to ensure that appropriate action is taken to respond to failed appointments. Primary responsibility for this should remain with the individual with whom the appointment was scheduled. The care coordinator or, if none has been appointed, the team manager, must be informed …
north_east_yorkshire
Independent investigation: Valerie Jozunas, Wimbish, Saffron Walden (2020) — Rec 6
EPUT should ensure that communication with mental health patients about prospective or missed appointments takes into account the potential that the patient may be vulnerable due to mental disorder and may have difficulty in engaging and forming relationships with service providers and as a result may need more assistance/support to …
east_of_england
Independent investigation: Steven Hoskin, St. Austell (2006) — Rec R2
Northamptonshire Healthcare NHS Trust and Cornwall Partnership NHS Trust should assure their commissioners that patients who do not attend outpatient appointments are risk assessed and plans to re-engage or discharge are based on the outcome of the risk assessment as outlined in their respective trust policies.
south_west
Independent investigation: Simon Sutton, Birkenhead (2007) — Rec R8
The trust should ensure that all staff adhere to the trust’s policy and procedure for managing informal service users’ non-compliance with treatment and managing DNA (did not attend) or cancelled appointments.
north_west
Independent investigation: Richard Baker (Mr G), Hastings (2003) — Rec Two
It is recommended that the Trust audit the operation and effectiveness of the policy on Managing DNA or Cancelled Appointments implemented in the Autumn 2005. This is to ensure that there is an effective follow up of people who do not attend for appointments.
south_east
Independent investigation: Peter Grimshaw, Colchester (2005) — Rec R2
The Commissioners should ask provider trusts to review their DNA policies and procedures to ensure they are fit for purpose. Trusts should include audits in their clinical audit programmes to assure compliance with DNA policies.
east_of_england
Independent investigation: Pamela Hardy, Wombwell (2010) — Rec 1
The ‘Did not attend, not available for a planned appointment’ policy currently in place within South West Yorkshire Partnership Foundation NHS Trust Although the Trust was not the responsible provider of mental health services at the time of the JK incident, the Independent Team recommends that the Trust reviews its …
north_east_yorkshire
Independent investigation: Michael Bird, Braintree (2005) — Rec R2
The Commissioners should ask provider trusts to review their DNA policies and procedures to ensure they are fit for purpose. Trusts should include audits in their clinical audit programmes to assure compliance with DNA policies.
east_of_england
Independent investigation: Mark Berry, Dewsbury (2005) — Rec 2.3
The Trust should review methods of reducing DNA rates of both new and follow up patients.
north_east_yorkshire
Independent investigation: Marcus Witham, Colchester (2006) — Rec R2
Primary care trusts should ask provider trusts to review their DNA policies and procedures to ensure they are fit for purpose. Trusts should include audits in their clinical audit programmes to assure compliance with DNA policies.
east_of_england
Independent investigation: Lisa Sullivan, Walton on the Naze (2005) — Rec 6
Where there is irregular attendance and a number of missed appointments by a service user to outpatient appointments it is particularly important that there is a clear plan, which has been discussed between the medical staff and at least one other member of the CMHT, for either the continuation of …
east_of_england
Independent investigation: Lesley Wright, Tooting (2006) — Rec R2
The trust should monitor compliance with its policy on notifying primary care services when patients do not attend appointments (the DNA policy).
london
Independent investigation: John TaylorBeverley Taylor, Skipton (2021) — Rec 1
There were weaknesses in the application of the Failure to Attend Policy. The Trust must strengthen their response to patient non-engagement by: • identifying patients at risk of non-engagement who are on CPA, and entitled to Section 117 aftercare; • monitoring and prioritising those patients; • ensuring that these patients …
north_east_yorkshire
Independent investigation: John Redhead, Potters Bar (2007) — Rec 2
Where alternative communication mechanisms and technologies are used to communicate with, and inform, service users of appointments, the efficacy of these should be evaluated.
east_of_england
Independent investigation: Joanne Butler, East Shilton, Leics (2006) — Rec R8
The trust should ensure that all clinicians are fully aware of the DNA policy, implement it appropriately and notify other stakeholders of DNA issues (A).
midlands
Independent investigation: Joanne Butler, East Shilton, Leics (2006) — Rec R3
The trust should ensure that care coordination through the outpatient system is sufficiently rigorous and that service-users who do not attend are followed up appropriately (the DNA policy) (A).
midlands
Independent investigation: Jayne Poppy, Leigh on Sea (2002) — Rec 3
The Trust should ensure that there is a system in place for a client's failure to attend an outpatient appointment to be recorded and brought to a Consultant's attention.
east_of_england
Independent investigation: Hugh McCaffrey, Willesden — Rec 4.80
Patients seen as unable or unwilling to attend appointments should be afforded greater flexibility and extra efforts should be provided to meet their needs.
london
Independent investigation: Harry Upton, Culcheth, Warrington (2002) — Rec 9.4
The RCA team recommends that the Trust conducts a review of its referral process to assess whether the ‘opt in’ system is the most appropriate arrangement for both new and existing service user populations. It should consider whether non-attendance is an appropriate indicator for ‘case closure’ or whether a more …
north_west
Report of a review in respect of: Mr N and … — Rec 8
Abertawe Bro Morgannwg University Health Board, Aneurin Bevan University Health Board and Cardiff and Vale University Health Board should develop clear lines of accountability regarding the responsibility for attempting to engage with individuals who regularly do not attend appointments.
wales
Independent investigation: Ben Cargill (Mr D), Chesham, Bucks (2004) — Rec four
It is recommended that the Trust develop a Policy on Managing DNA or Cancelled Appointments as detailed on the internal review’s recommendation to ensure that there is an effective follow up of people who do not attend for appointments. It is further recommended that once the Policy is implemented that …
south_east
*Mental health homicide investigation legacy report into the care and … — Rec L3
The trust should ensure that all staff adhere to its policy and procedure for managing formal and informal service users’ non-compliance with treatment and managing DNA (did not attend) or cancelled appointments.
south_east
*Independent investigation into the care and treatment of Patient C: … — Rec 12
There is full compliance with policies dealing with non-attendance and, in particular, that any referrer is consulted in order to re-assess the situation and formulate an appropriate action plan.
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Accepted
*Independent investigation into the care and treatment of Mr A: … — Rec 7
HPFT should conduct an audit to ensure that patients who are discharged from care are the subject of multidisciplinary review as a result of a failure to attend appointments.
Hertfordshire Partnership University NHS Foundation Trust
east_of_england
An independent investigation into the care and treatment of patient … — Rec 1
There were weaknesses in the application of the Failure to Attend Policy. The Trust must strengthen their response to patient non-engagement by: • identifying patients at risk of non-engagement who are on CPA, and entitled to Section 117 aftercare; • monitoring and prioritising those patients; • ensuring that these patients …
north_east_yorkshire
An independent external quality assurance review of the internal investigation … — Rec 10
Failure in the application of the DNA policy. A quality peer review team will review the function of the recovery team (as above).
north_west
Independent investigation: Simon Breed, Wood Green (2004) — Rec R1
The current system of offering outpatient appointments should be thoroughly scrutinised through audit. Appointments should be made and letters of confirmation should be sent to all patients offered outpatient appointments.
london
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 13
The frequency of follow up appointments for recently discharged patients should be prescribed.
north_west
Independent investigation: Sean Hand, Basildon (2003) — Rec 105.1
That the Trust be asked to confirm that its internal review panel's recommendations covering the matters listed below have been implemented, with the reasonable expectation that problems connected with those matters should not occur in any future case. The matters in question are: a. Procedures for keeping track of clients …
east_of_england
Independent investigation: Peter Grimshaw, Colchester (2005) — Rec R1
The trust should assure itself and commissioners that there is now a robust process in place for CPA which includes care planning, risk assessment, risk management planning and non attendance at appointments. The trust should also assure itself or the PCT that it has a robust policy on safeguarding.
east_of_england
Independent investigation: Michael Bird, Braintree (2005) — Rec R1
The trust should assure itself and commissioners that there is now a robust process in place for CPA which includes care planning, risk assessment, risk management planning and non attendance at appointments. The trust should also assure itself or the PCT that it has a robust policy on safeguarding.
east_of_england
Independent investigation: Mandlemkosi Nelya (Mandla Leya), Cambridge (2006) — Rec R2
Primary care trusts should ask provider trusts to review their DNA policies and procedures to ensure they are fit for purpose. Trusts should include audits in their clinical audit programmes to assure compliance with DNA policies.
east_of_england
Independent investigation: John Rees, Pen Y Graig, Rhondda (2020) — Rec 2
Ann’s serial “Did Not Attend” appointments resulted in her case being closed to the Domestic Violence service. When Ann was in hospital there were two occasions when she Did Not Attend outpatient appointments (because outpatients had not been informed that Ann was an inpatient) resulting in her discharge from outpatients, …
wales
*Independent investigation into the care and treatment of Patient G: … — Rec 15
Trusts should consider more diverse methods of contacting patients, e.g. by the use of mobile phones or text message to better promote attendance at appointments.
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Accepted
An independent investigation into the care and treatment of patient … — Rec 8
a: CMHT care planning for erratic and sporadic patient engagement When Patient E was not engaging in the autumn of 2021 there was no contingency/care plan to guide the service response as required by Trust policy. The Trust must provide assurance to the appropriate sub-committee of the Board that CMHTs …
north_east_yorkshire
Independent investigation: Beata Slomiana, Finchley (2010) — Rec R1
The trust should ensure that guidelines for the use of opt-in forms should set out when additional processes such as phone follow-up are needed to effectively assess a person’s willingness to engage with the service. Opt-in forms must be clearly written and available in other relevant languages.
london
Independent investigation report into the care and treatment of Mr … — Rec 12
The GP practice must ensure that when the practice is informed that a patient has been admitted to hospital, a review of that patient’s appointments and repeat medications is undertaken.
midlands
Independent investigation into the care and treatment of Mr M … — Rec 6
EPUT should ensure that communication with mental health patients about prospective or missed appointments takes into account the potential that the patient may be vulnerable due to mental disorder and may have difficulty in engaging and forming relationships with service providers and as a result may need more assistance/support to …
east_of_england
An independent investigation into the care and treatment of patient … — Rec 2
There were weaknesses in the way the IHTT and the CMHT communicate to each other about persistently non-engaging patients. The Trust must provide guidelines to IHTT so that they know when and why to feedback to CMHTs about referred patients who are persistently not engaging.
north_east_yorkshire
Independent reviews(3)
Paterson Inquiry — Rec 9
We recommend that a national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated. This framework or protocol should specify that the process is centred around the patient's needs, provide advice on how recall decisions are made, and advise what resource is …
Health & Social Care
Paterson Inquiry — Rec 8
We recommend that Spire should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in the same way that has been provided for patients in the …
Health & Social Care
Paterson Inquiry — Rec 7
We recommend that the University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen.
Health & Social Care
PHSO casework decisions(25)
P-002678 — A practice in the Norfolk area
The Practice delayed her fertility referral for approximately seven months, causing significant distress and reducing her chances of successful treatment.
NHS in England
Partly Upheld
Jun 2024
P-003442 — A dental practice in the Trafford area
Mr A complained a dental practice repeatedly cancelled his appointments without prior notice and refused to complete his treatment plan, delaying root canal treatment and causing distress.
NHS in England
Mar 2025
P-003529 — A practice in the Croydon area
Ms O complained the Practice incorrectly sent her thyroid referral, causing a 10-month delay, distress, heart palpitations, and an underactive thyroid diagnosis.
NHS in England
Not Upheld
Apr 2025
P-004361 — University Hospitals Birmingham NHS Foundation Trust
The Trust wrongly removed Mr A from an ENT waiting list and gave conflicting information about his re-listing, causing distress and delaying surgery.
NHS in England
Nov 2025
P-004613 — Whittington Health NHS Trust
A trust's podiatry services repeatedly rejected referrals and failed to assess his need for toenail trimming, causing him pain, mobility issues, and exacerbating depression.
NHS in England
Jan 2026
P-001437 — Hampshire Hospitals NHS Foundation Trust
Mr A complained the Trust repeatedly cancelled his discectomies and provided conflicting information about MRI scans, causing prolonged severe physical pain, mental health deterioration, and family distress.
NHS in England
Partly Upheld
Jun 2022
P-001822 — Ashford and St Peter's Hospitals NHS Foundation Trust
Dr O complained the Trust failed to order agreed urgent gastrological investigations, causing her health to deteriorate and worsening symptoms.
NHS in England
Feb 2023
P-001905 — County Durham and Darlington NHS Foundation Trust
Miss O complained a practice misdiagnosed pelvic pain, delaying treatment for infection and causing infertility. She also cited a Trust secretary's error delaying a laparoscopy.
NHS in England
Mar 2023
P-002580 — A practice in the Liverpool area
Mrs B complained the Practice did not provide a timely referral to hospital after a pharmacist identified a possible cancerous growth on her face, causing delayed diagnosis and treatment.
NHS in England
May 2024
P-002633 — An independent provider in the West Berkshire area
Mr A complained about the Practice's failure to book timely appointments and provide adequate pain relief for dental pain, resulting in an abscess, emergency surgery, and removal of four teeth.
NHS in England
May 2024
P-002687 — A practice in the Kent area
The Practice failed to process Mrs L's rheumatology referral correctly, causing her pain, mental health issues, and impacting her ability to work.
NHS in England
Jun 2024
P-002694 — Kent Community Health NHS Foundation Trust
Mrs P complained MTWT cancelled and performed unsuccessful leg surgery on her daughter, and KCHT delayed and inadequately provided post-operative physiotherapy, leading to increased pain and inability to walk.
NHS in England
Partly Upheld
Jun 2024
P-002968 — A practice in the Kent area
The Practice failed to inform Mrs U her orthopaedic referral was rejected for over a year, causing missed treatment, severe pain, and mental health deterioration.
NHS in England
Sep 2024
P-003415 — A practice in the Barnet area
Mr B complained the GP practice delayed a specialist referral and provided insufficient information, causing a year-long delay, prolonged pain, and stress.
NHS in England
Mar 2025
P-002669 — A practice in the Suffolk area (the Surgery)
Mrs A complained multiple NHS organisations provided inadequate care to her late mother, including delayed cancer treatment, poor follow-up, and communication failures.
NHS in England
Jun 2024
P-002672 — A practice in the Lincolnshire area
Ms R complained the Practice ignored appointment requests, delayed acting on test results, dismissed spinal symptoms as psychosomatic, and altered her medical records, worsening her health.
NHS in England
Jun 2024
P-002957 — An independent provider in the East Riding of …
Mr R complained the Hospital failed to follow procedures checking his BMI and smoking status for spine surgery. This led to his surgery being cancelled, causing distress and requiring him to pay privately.
NHS in England
Sep 2024
P-003240 — Manchester University NHS Foundation Trust
Mr T complained the Trust held an incorrect phone number, failed to notify him of a cancelled appointment, delayed referrals, and sent unnecessary letters, causing treatment delays and tooth loss.
NHS in England
Dec 2024
P-003323 — The Royal Wolverhampton NHS Trust
Mrs O complained the Trust discharged her from gynaecology after she missed a cancellation appointment, forcing her to restart the referral process and endure ongoing pain and discomfort.
NHS in England
Feb 2025
P-003493 — An independent provider in the Sheffield area
Ms L complained the Trust incorrectly cancelled her hysterectomy surgery and communicated poorly about the cancellation, causing stress, pain, bleeding, and financial impact.
NHS in England
Apr 2025
P-002621 — A practice in the Cambridgeshire area
Mrs E complained a GP practice failed to act on a scan report identifying a 10cm dermoid cyst and did not provide a formal response to her complaint.
NHS in England
May 2024
P-004154 — University Hospitals of North Midlands NHS Trust
Mrs G complained about delayed follow-up, an inappropriate virtual appointment, and failure to act on her husband's symptoms, which she believes led to his avoidable death.
NHS in England
Oct 2025
P-004459 — Northern Care Alliance NHS Foundation Trust
Mrs B complained the Trust provided inappropriate care to her husband, Mr B, alleging issues like mixed records, cancelled tests, and poor communication, which she believes contributed to his death.
NHS in England
Dec 2025
P-002358 — Harrogate and District NHS Foundation Trust
Mrs U complained the Trust failed to properly assess and treat her knee injury, delayed appointments, and caused further damage, resulting in prolonged pain and distress.
NHS in England
Dec 2023
P-002381 — University Hospital Southampton NHS Foundation Trust
Mrs E complained about delayed X-ray, lack of ice after knee surgery, unwanted catheter insertion, and a delayed referral for ankle surgery, impacting her recovery and wellbeing.
NHS in England
Dec 2023
LGO / SPSO decisions(69)
NIPSO-202002974 — South Eastern Health and Social Care Trust
A man’s cancer treatment was interrupted by the Covid pandemic in March 2020. We found that he should have been reviewed by clinicians as soon as possible after the resumption of face-to-face appointments.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Sep 2024
21-011-833 — Sheffield City Council
Summary: We will not investigate this complaint about a cancelled pest control appointment and incorrect advice about when a refund for that service would be made. This is because the Council has resolved the matter to the satisfaction of the complainant.
LGO (Local Government & …
Environment And Regulation
Upheld
Feb 2022
201204744 — Forth Valley NHS Board
Mr C, who is a prisoner, complained that he was not seen by the prison dental hygienist after being advised that he would be seen again in three months. He was also unhappy that it took nearly four months for him to see the dentist after he reported that a …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2013
201600464 — Lothian NHS Board - Acute Division
Mr C was referred by his GP for a possible hernia operation. Mr C complained to us that the board failed to arrange his operation within the 12-week treatment time guarantee under the Patients Rights (Scotland) Act and that they failed to advise him of his rights under that Act. …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2016
201508175 — Lanarkshire NHS Board
Mrs C complained about the care that her late husband (Mr A) received at Monklands Hospital after attending the emergency department. Mr A was to be admitted to a private room but none was available. He remained in A&E until a suitable room was found. Mr A was later moved …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2016
201602805 — Highland NHS Board
Mr C was referred to a urologist at Raigmore Hospital to have his history of erectile dysfunction and low testosterone investigated. Mr C raised a complaint nine months later as he had not received an appointment and was distressed by his ongoing symptoms. The board informed Mr C that there …
SPSO (Scottish Public Se…
Health
Upheld
May 2017
PSOW-202200121 — Betsi Cadwaladr University Health Board
Miss X complained although she had complained about the treatment she received in hospital back in February 2022, she had not received a response. The Ombudsman was concerned that Miss X had not yet received a response to her concerns, and she contacted the Health Board. As an alternative to …
PSOW (Public Services Om…
Health
May 2022
PSOW-202400587 — Swansea Bay University Health Board
Mr A complained that he had waited for 6 years for knee replacement surgery from the Health Board and that it had not replied to his complaint. The investigation found that it was unclear whether the Health Board had received Mr A’s complaint and that it had not been investigated …
PSOW (Public Services Om…
Health
Jun 2024
PSOW-202401319 — Betsi Cadwaladr University Health Board
Mr C complained about the care and treatment he received from Betsi Cadwaladr University Health Board (“the Health Board”). Specifically, whether his colorectal prolapse had been managed appropriately by the Colorectal Team from the time of initial referral in February 2022 to May 2024. The investigation found that Mr C’s …
PSOW (Public Services Om…
Health
Not Upheld
Jul 2025
PSOW-202502124 — Cardiff and Vale University Health Board
Mr A complained that the Cardiff and Vale University Health Board failed to send referral letters to his new GP so that he could continue his treatment outside of Wales. The Ombudsman found that the Health Board issued a referral letter to Mr A’s new GP in March 2025 but …
PSOW (Public Services Om…
Health
Aug 2025
201004170 — A medical practice, Greater Glasgow and Clyde NHS …
Ms C made a GP appointment for her daughter, who was unwell. When, however, her daughter became more unwell Ms C phoned to request a GP home visit on an earlier date. She did not specifically cancel the booked appointment. As their records showed that she had not kept an …
SPSO (Scottish Public Se…
Health
Jun 2011
201201028 — A Medical Practice in the Lanarkshire NHS Board …
Mr C complained that his medical practice failed to provide appropriate care and treatment when he had an eye infection and unreasonably refused to allow him to see a GP. Mr C developed an eye infection, and called his practice on a Friday to request an appointment. He was told …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2013
201605507 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C complained that there was an unreasonable delay in the board providing him with treatment on his right eye. Mr C is diabetic and was referred to Gartnavel General Eye Hospital when he began having problems with the vision in his right eye. Mr C was seen by the …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2017
201602519 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C complained about delays in being seen by the gastroenterology (medicine of the digestive system) department at the New Victoria Hospital. He considered that there was an unreasonable delay in contacting him after he was referred by his GP and that the board's communication in relation to appointments was …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2017
201702683 — Golden Jubilee National Hospital
Mr C had a scan at the Golden Jubilee National Hospital. A mass was discovered on his lung, which could have been either a spread of his existing bowel cancer or a new lung cancer. His consultant arranged some tests to help determine which it was, but because they were …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2018
201606971 — Shetland NHS Board
Miss C complained that the board unreasonably removed her from a waiting list for orthodontic treatment. She also complained that they had failed to tell her that she had been removed from the waiting list and had not provided her with a reasonable explanation of why she had been removed. …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jan 2018
201802999 — An NHS Board
Ms C complained about the board's assessment of a referral that was made for her child (Child A) to the child and adolescent mental health services. Ms C considered that it was clear from the referral that Child A had not been appropriately assessed by the GP and that the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2019
PSOW-202104566 — Cardiff and Vale University Health Board
Mr P complained that Cardiff and Vale University Health Board did not manage a neurodevelopmental referral in respect of his daughter, B, appropriately. He was also concerned that the Health Board had failed to provide him with adequate information about the referral process and B’s place on the waiting list. …
PSOW (Public Services Om…
Health
Jan 2022
PSOW-202300457 — Cardiff and Vale University Health Board
Mr X complained that Cardiff and Vale University Health Board had failed to provide him with further surgery and had not issued a formal complaint response. The Ombudsman decided that the Health Board had failed to provide Mr X with a formal complaint response, which caused frustration to Mr X …
PSOW (Public Services Om…
Health
Jun 2023
PSOW-202404527 — Betsi Cadwaladr University Health Board
Mr A complained about the care and treatment given to him by Betsi Cadwaladr University Health Board (“the Health Board”). He said that although he attended hospital for planned treatment, this did not take place. Mr A said that his condition has deteriorated and causes discomfort and pain. Mr A …
PSOW (Public Services Om…
Health
Oct 2024
PSOW-202404816 — Betsi Cadwaladr University Health Board
Mr H complained about not receiving a medical appointment to remove a lump from his head. Mr H complained to the Health Board noting on the top of his letter that it was a formal complaint. The Ombudsman found that Mr H had been referred as a routine patient and …
PSOW (Public Services Om…
Health
Oct 2024
PSOW-202502465 — Cardiff and Vale University Health Board
Miss G complained that Cardiff and Vale University Health Board failed to address one aspect of her complaint, relating to issues with contacting it, made in June 2025. The Ombudsman found that the Health Board failed to address this aspect of her complaint. This caused additional frustration and uncertainty for …
PSOW (Public Services Om…
Health
Sep 2025
PSOW-202505683 — Powys Teaching Health Board
Mrs A complained to Powys Teaching Health Board regarding the impact a policy change had on her. The Ombudsman found that the Health Board had not directly responded to Mrs A and did not address every issue she had raised. The Ombudsman considered that this caused Mrs A frustration due …
PSOW (Public Services Om…
Health
Nov 2025
PSOW-202504920 — Swansea Bay University Health Board
Mr A complained that his place on the waiting list for surgery was reset when he rearranged an appointment. The Ombudsman recognised the language used in the complaint response may have led to confusion. However, as Mr A gave prior notice of his inability to attend a mutually agreed appointment, …
PSOW (Public Services Om…
Health
Jan 2026
201102499 — Lothian NHS Board
Mrs C had worsening hearing loss in both ears, with narrow ear canals that made use of in-ear hearing aids painful and intolerable. She complained that the board failed to refer her to the correct consultant at the right time, and that there was an unreasonable delay of a year …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2012
201202345 — Lothian NHS Board
Mrs C complained that she experienced an unreasonable delay in receiving appointment notification letters from the board. After she was referred to a respiratory clinic by her GP, the board wrote inviting her to an appointment at the clinic. Mrs C did not receive this letter until after the time …
SPSO (Scottish Public Se…
Health
Upheld
May 2013
201204300 — Lothian NHS Board
Ms C's dentist referred her to the board's dental institute for treatment to remove the roots of a broken wisdom tooth. Ms C complained that there was unacceptable delay in providing an appointment at the institute; and that the lack of communication about the waiting time was unreasonable. After investigating, …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2013
201508735 — Tayside NHS Board
Mrs C learned that she had a gene mutation which increased the risk of breast and ovarian cancer. She decided to have surgery to remove both breasts to reduce the risk of developing breast cancer, and reconstruction surgery. Her surgery was cancelled on the morning she was due to be …
SPSO (Scottish Public Se…
Health
Jun 2016
201606782 — A Medical Practice in the Greater Glasgow and …
Mr C complained that his GP practice failed to provide him with a GP appointment and a medical certificate for sickness absence. Mr C said he could not get a same day appointment when he phoned the practice in the mornings. We found there were other means of getting an …
SPSO (Scottish Public Se…
Health
Not Upheld
Oct 2017
201608877 — Fife NHS Board
Mr C complained about the length of time it had taken the board to provide him with treatment for varicose veins. Mr C was referred to vascular surgery at Victoria Hospital by his GP. Around four months later he saw a vascular consultant who said that he needed a special …
SPSO (Scottish Public Se…
Health
Partly Upheld
Feb 2018
201700482 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C complained that the board failed to provide him with clinic appointments within a reasonable timescale. He also raised concern that the board failed to provide him with adequate notice of the cancellation and rescheduling of appointments, and he was unhappy with the board's handling of his complaint. The …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2018
201609412 — Lanarkshire NHS Board
Mrs C, who is an advocacy and support worker, complained on behalf of her client (Mrs A). Mrs A was unhappy about delays in getting confirmation of an appointment with a consultant ophthalmologist (a doctor who deals with injuries and conditions in and around the eye). Mrs A was also …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2018
201708551 — Tayside NHS Board
Mrs C was referred by her GP to the orthopaedic department (the area of medicine which deals with the musculoskeletal system) at Ninewells Hospital for consideration of knee replacement surgery. However, there were problems with the communications from the board which resulted in her missing a scheduled out-patient clinic appointment. …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2018
201700671 — Ayrshire and Arran NHS Board
Mr C attended University Hospital Crosshouse after sustaining a tear in the anterior cruciate ligament (a ligament in the knee) and damaged cartilage (connective tissue). Mr C complained that the board took too long to provide appropriate treatment following a referral from his GP, failed to provide a reasonable standard …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2018
201804379 — Tayside NHS Board
Ms C complained that Ninewells Hospital failed to provide her with reasonable care and treatment when she was admitted for investigations by the gastroenterology (branch of medicine which deals with disorders of the stomach and intestines) team. We took independent advice from a consultant gastroenterologist. We found that the treatment …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2019
201900596 — Grampian NHS Board
Ms C complained that the board delayed in arranging the surgery she needed. She was entered onto the list for surgery at a gynaecology (medicine of the female genital tract and its disorders) out-patient clinic, but said that she was told months later that they were only carrying out surgery …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2020
201908887 — Highland NHS Board
C complained on behalf of their child (A) who has a background of low mood and anxiety. C complained about the assessments of A by two paediatric consultants. C also complained that the Child Adolescent Mental Health Service (CAMHS) unreasonably rejected referrals from A’s GP due to social work’s involvement …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2021
201810251 — Highland NHS Board
C complained that the board failed to provide their child (A) with orthognathic treatment (orthognathics is a specialist subset of dentistry which involves surgical correction of growth issues with the jaw and lower face) within a reasonable timescale. A's teeth were overcrowded to the extent that they caused pain in …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2021
201907379 — Lothian NHS Board - Acute Division
C complained about delays in treatment that was meant to be provided to their late spouse (A). They told us that A had been referred to the board from another area for heart surgery, but that this took so long to arrange, A's condition deteriorated to a point that surgery …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2022
202004806 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about their waiting time for hip replacement surgery. C was initially added onto the waiting list for surgery but was later removed after C advised the board of their personal circumstances. A couple of months later, C was added back onto the waiting list for surgery but, after …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2022
202302835 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment received by their young child (A). A had a complex congenital (from birth) heart condition. C complained to the board after A received heart surgery, which had been part of the treatment planned for A. C complained that the board did not reasonably …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2024
202303181 — Forth Valley NHS Board
C complained about delays in the care and treatment provided to their spouse (A) who was diagnosed with lung cancer following an abnormal chest X-ray. C said that there was a delay in A being provided with a CT scan result by the respiratory consultant, and a further wait to …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2025
NIPSO-gp-practice-addresses-appointment-booking-system-after-patients — GP
NIPSO (NI Public Service…
Health & Social Care
Apr 2021
PSOW-202305250 — Aneurin Bevan University Health Board
Mr A complained that the Health Board refused to warn patients referred to the Erectile Dysfunction Therapy clinic in advance that they would be expected to be examined and counselled by female clinicians. He said that the Health Board hid the fact that it would be a female clinician by …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202301069 — Aneurin Bevan University Health Board
Mrs X complained that Aneurin Bevan University Health Board (“the Health Board”) failed to offer her treatment with the drug fampridine after its approval for NHS use in Wales in December 2019. Fampridine may help certain patients who have multiple sclerosis. I upheld the complaint. My investigation found that, despite …
PSOW (Public Services Om…
Health
Feb 2024
PSOW-202310379 — Betsi Cadwaladr University Health Board
Mr A complained that Betsi Cadwaladr University Health Board failed to respond to the complaint he made to it in June 2023. The Ombudsman decided that there had been a significant delay by the Health Board to respond to Mr A’s concerns and this had caused inconvenience and frustration for …
PSOW (Public Services Om…
Health
Apr 2024
PSOW-202400981 — Hywel Dda University Health Board
Ms B complained, with the help of a Complaints Advocate, about the standard of care provided by the Health Board. The investigation considered whether the care and treatment provided at the Early Pregnancy Assessment Unit (“EPAU”) on 21 March 2023 was clinically appropriate, and whether the subsequent Community Midwife Team …
PSOW (Public Services Om…
Health
Upheld
Jan 2025
PSOW-202407137 — Hywel Dda University Health Board
Mrs A complained about Hywel Dda University Health Board (“the Health Board’s”) failure to provide her mother with timely Ophthalmology clinic appointments to treat her age-related eye disease. The Ombudsman noted that whilst the Health Board in its complaint response had provided an explanation about the timing of appointments and …
PSOW (Public Services Om…
Health
Feb 2025
201204154 — Tayside NHS Board
Mr C is unable to cut his own toenails, and complained that the board failed to provide him with an appropriate regular service for this. He explained that delays in having his toenails cut impacted on his mobility and caused him discomfort. Our independent medical adviser noted that it was …
SPSO (Scottish Public Se…
Health
Not Upheld
Apr 2013
201508820 — Golden Jubilee National Hospital
Mrs C complained about a decision taken by the board to cancel her heart surgery and the lack of communication to her about this decision. She was also concerned that her complaint had not been dealt with appropriately because members of the complaints team had been involved with the decision …
SPSO (Scottish Public Se…
Health
Partly Upheld
Sep 2016
Domestic Homicide Reviews(47)
Sheffield — recommendation SCCG 1
Sheffield CCG to encourage GP Practice staff to adapt their ‘did not attend’ policy to consider the impact of not accessing health care appointments on the health of adults who may lack capacity and children.
Sheffield ICB
Sheffield — recommendation 8
As part of the ongoing review of ‘Did Not Attend’ strategy and policies, Sheffield CCG to consider whether they have the capacity to review the risk where patients demonstrate a consistent lack of engagement.
Sheffield ICB
Swindon — recommendation 28
All personnel should be reminded of the policy that: 1. The “Missed Appointment Matrix” is to be followed for all clients – especially prior to closing. 2. Workers to double check hard copy file for client’s preferred method of contact and follow this course of action first. 3. If paperwork …
Swindon Drug and Alcohol Service (CGL)
Newcastle upon Tyne — recommendation 6
Policy and procedures to follow up missed appointments following CAHMS referrals to G.P. put into place
ICB
North Tyneside — recommendation 2
Community Safety Partnership to work with Safeguarding Adults Board to ask Partners to review their policy and procedures when clients default from service provision (Do Not Attend) to ensure that the vulnerability of the patient is taken into consideration when deciding what action (if any) needs to be taken.
Community Safety Partnership | Safeguarding Adults …
Safeguarding Adults Board
North Tyneside — recommendation 1
North Tyneside CCG advise all partners to discuss the overall vulnerability of adult patients when considering what follow up actions should be taken in the case of DNAs in any area of the partnership.
North Tyneside ICB
St Helens — recommendation 6
Policy and procedures to follow up missed appointments put into in place
ICB
Norfolk — recommendation 7
GP Practices to ensure that they have a process in place when patients do not respond to requests to attend for a monitoring check, related to their medication – for example a blood test or blood pressure check.
Norfolk and Waveney Integrated Care Board
NHS Norfolk and Waveney …
Norfolk — recommendation 3
An in-house process introduced for Practices, for communication regarding disengaging patients in primary care by notification to the Safeguarding Lead GP for the Practice, or the responsible GP for the patient.
Norfolk and Waveney Integrated Care Board
NHS Norfolk and Waveney …
Norfolk — recommendation 1
Creation of a standalone Missed Appointments Policy/Process for adult patients, which includes guidance for specialist clinics for when a patient does not attend successive appointments.
Cambridge University Hospitals NHS Foundation Trust
Cambridge University Hospitals NHS …
Somerset — recommendation 7.2.5
When someone with complex presentation does not return initial attempts to make contact for a medication review that may impact on the risk that person may be exposed to as a result of lack of the review, further attempts to establish contact should be evidenced by the GP practice.
NHS Somerset ICB
NHS Somerset ICB
Buckinghamshire — recommendation ORB-6
Service users / patients should be reminded of the need to attend appointments and to fully participate in their recovery programme. Full compliance with the ORB ‘Did Not Attend ‘SOP.
One Recovery Bucks (Midlands Partnership NHS …
Norfolk — recommendation 30
A piece of work should take place looking at and considering the development of a risk assessment relating to patients who do not attend appointments, or cancellations are made by people other than the patient themselves or there are safeguarding concerns. This could become part of the Safeguarding Adults Policy. …
Norfolk Community Health & Care NHS …
Norfolk Community Health & …
Norfolk — recommendation 29
A message should be included as part of the Norfolk Community Health and Care NHS Trust Safeguarding Newsletter to remind staff and raise awareness to be professionally curious when appointments are repeatedly cancelled/not attended and the source of information for the cancellation is not the patient. Staff should not automatically …
Norfolk Community Health & Care NHS …
Norfolk Community Health & …
Norfolk — recommendation 30
A piece of work should take place looking at and considering the development of a risk assessment relating to patients who do not attend appointments, or cancellations are made by people other than the patient themselves or there are safeguarding concerns. This could become part of the Safeguarding Adults Policy. …
Norfolk Community Health & Care NHS …
Norfolk Community Health & …
Norfolk — recommendation 29
A message should be included as part of the Norfolk Community Health and Care NHS Trust Safeguarding Newsletter to remind staff and raise awareness to be professionally curious when appointments are repeatedly cancelled/not attended and the source of information for the cancellation is not the patient. Staff should not automatically …
Norfolk Community Health & Care NHS …
Norfolk Community Health & …
Somerset — recommendation 6
Change how Patient Liaison Team (with A&E) follow up to patients referred to the PLT but leave the hospital without being seen
Somerset NHS Foundation Trust
Taunton and Somerset NHS …
Brent — recommendation 7.1.17
Criminal Justice ‘Follow up appointment’ – The criminal justice team have been advised that all service users who come through the Criminal Justice route should be offered both the compulsory ‘Initial Assessment’ and a ‘Follow Up Appointment’. Service users will be breached if they fail to attend either of these …
Westminster Drug Project
Sandwell — recommendation 1
To ensure that discharges are appropriate, both for the patient’s well-being and that of their family and the wider community, the DNA (did not attend) policy to be revised and re-launched and compliance monitored
Black Country Partnership NHS Foundation Trust
Black Country Partnership NHS …
Norfolk — recommendation 13
It is recommended that DNA (Did Not Attend) processes in GP surgeries are reviewed to ensure their effectiveness for safeguarding purposes
NHS Norfolk and Waveney ICB
NHS Norfolk and Waveney …
Norfolk — recommendation 12
It is recommended that the pack provided to locum GPs by a practice includes information on how they can make sure patients ‘of concern’ are followed up. For example, where to direct a ‘patient task’ to make sure a follow up in the case of a DNA (Did Not Attend)
NHS Norfolk and Waveney ICB
NHS Norfolk and Waveney …
Manchester — recommendation 7.8.3
To review the effectiveness of changes to the system where Deputy Head Pastoral reviews all counselling appointments every week to check who has attended and who hasn’t. There should be a system of follow-up as necessary.
Robert’s school
Kirklees — recommendation 8
That KNH look into enabling a system prompt to ensure that failed initial tenancy visits are followed up with further communication with the tenant, to ensure appropriate welfare checks are made as appropriate.
Kirklees Neighbourhood Housing
Hammersmith and Fulham — recommendation WLT11
The service should adhere to a DNA policy that is understood by all members of staff that outlines clearly, expectations in relation to follow up of patients who Do Not Attend (DNA) appointments (to include nursing, medical, psychological and/or social work appointments
West London NHS Trust
West London NHS Trust
Hammersmith and Fulham — recommendation 11
West London NHS Trust and Victim Support to review their DNA policy to include a more flexible approach, to consider checking contact details are accurate at each successful contact and / or to attempt more assertive outreach on the third attempt.
West London NHS Trust | Victim …
West London NHS Trust
Northampton — recommendation 2
Cancellation of appointments by known vulnerable people should not be accepted on face value and should be checked and confirmed, especially when a family member is expressing concerns regarding the behaviour and demeanour of the vulnerable person.
All agencies
South Cambridgeshire — recommendation 3
Vulnerable patients should be booked in directly by the clinician at the end of the appointment, rather than being sent to book a routine appointment at reception. A ‘task to self’ could then be scheduled by the clinician booking the appointment to check attendance.
GP Practices
South Cambridgeshire — recommendation 2
Follow up of persistent non-attenders or those considered at risk, not just by text as currently occurs, but also by phone. Consider telephone follow ups on vulnerable patients such as the victim when they do not attend their appointments. This is currently the recommended protocol when children do not attend …
GP Practices
South Cambridgeshire — recommendation 1
Consider running reports through Systm1 on patients that have failed to attend more than 3 appointments in 3 months and contrast this to any identified vulnerabilities to compile a report and take appropriate actions.
GP Practices
Middlesbrough — recommendation 19.21
Ensure community teams are following up none attendance via the Did not Attend policy.
Middlesbrough Recovering Together
Nottingham — recommendation 2
GP Services to apply a did not attend process for high risk/vulnerable patients with support of the CCG linking with primary care.
GP Services | NHS Nottingham and …
GP
South Worcestershire — recommendation 4
NHS England will alert GPs locally to ensure any non-attendance of appointments are robustly followed up through the organisations ‘Did Not Attend/Was not brought Policy ‘ . GPs should ensure their Practice has a documented process in place to liaise with HV/SN’s about transfers in or out of their Practice …
NHS England | GPs
NHS England
Newcastle upon Tyne — recommendation 3
For a patient subject to MARAC, referring services must be informed , when engagement concludes or there is disengagement; • Cancelling of appointments by partners in known domestic abuse cases, subject to MARAC, must be followed up immediately and information shared with other agencies; and • Background information and history …
Health Agencies
Sheffield — recommendation 1
Non-response to annual health checks, cancer screening programmes and immunisations: Sheffield CCG requests that GP practices review their policies regarding non-response to annual health checks, cancer screening programmes and immunisations. Practices should ensure that capacity to decline the appointment is assessed and that reasonable adjustments are made for those who …
Sheffield ICB
Bassetlaw — recommendation 7.4
Where patients do not have the capacity to bring themselves to appointments as they are dependent upon carers, GP practices should ensure that there is a robust process for following up non-attendance for required health checks.
GP practices
Barking and Dagenham — recommendation 28
Where a patient known to have a debilitating or life limiting illness fails to attend hospital appointments more than once there should be follow up including a home visit, to ensure that the patient knows they have an appointment, has the means to attend, and are not being prevented from …
GP Practice
Barking and Dagenham — recommendation 37
Barking, Havering & Redbridge University Hospitals NHS Trust to strengthen their Patient Access Policy section on Did Not Attend with the addition of issues to consider when vulnerable adults Do Not Attend, and guidance to staff of steps to take when they have concerns.
Barking, Havering & Redbridge University Hospitals …
Barking, Havering and Redbridge …
North East Lincolnshire — recommendation 2
Each GP practice should have appropriate arrangements in place to ensure robust follow-up arrangements where patients do not attend appointments. This should include a relevant “did not attend/was not brought” policy and consideration of wider vulnerability factors which inform any risk assessment and escalation processes.
North East Lincolnshire Health and Care …
Dudley — recommendation 5
Black Country Integrated Care Board and Dudley Group to review the communication pathway to ensure that all notifications concerning ‘did not attend’ issued by the hospital are being received and, where necessary, followed up by primary care.
Black Country Integrated Care Board | …
NHS Black Country ICB
Manchester — recommendation A.3
For GPs to routinely enquire as to the reason for any persistent or frequent non-attendance at hospital appointments and consider the safeguarding impact to the patient by following their non-attendance / ‘was not brought’ policies.
Greater Manchester Integrated Care Board
NHS Greater Manchester ICB
Derbyshire Dales — recommendation 3
Derbyshire Recovery Partnership should introduce a written policy for Did Not Attend, to formalise their new working practices where a service user misses appointments. The policy should also outline factors to consider in relation to the impact on carers or family members of the individual who has not engaged and …
Derbyshire Recovery Partnership
Braintree — recommendation 5.4
That all health agencies are reminded of the significance of information sharing with primary care services (GPs) to ensure clarity of information and continuity of care. It would be helpful if GPs are made aware when patients do not attend (DNA) appointments with other services.
EPUT | Mid Essex Clinical Commissioning …
Essex Partnership University NHS …
Salford — recommendation 2
Agencies to review no reply policies and ensure that they are fit for purpose and include escalation routes. This aims to address the importance of regular and timely care coordination visits in accordance with the presenting needs of service users.
Community Safety Partnership | Salford Safeguarding …
Safeguarding Adults Board
West Cumbria — recommendation North Cumbria Integr
To complete a review to be completed of current pathway and follow up for patients who leave A&E prior to completing treatment.
North Cumbria Integrated Care NHS Foundation …
North Cumbria Integrated Care …
Bromley — recommendation 2.1.4
The IAPT clinical lead to ensure that all IAPT staff are familiar with the No Access Visit including Did Not Attend Adult Policy.
Bromley Healthcare
Bromley Healthcare
Kingston upon Thames — recommendation 11
Where a patient on the serious mental illness register suddenly disengages from a service, such as ceasing to collect repeat prescriptions of essential medication, or failure to attend reviews, processes should be put in place to contact the patient for review as quickly as possible. An escalation policy should be …
Kingston Clinical Commissioning Group
Bristol Clinical Commissioning Group
Lincoln — recommendation 4
In relation to finding 6, there should be an immediate Trust-wide review of patient service contracts and policies in how they engage patients who present with risks to self, to others and from others, who are unwilling or unable to attend planned appointments. An action plan in response to this …
LPFT
Lincolnshire Partnership NHS Foundation …