Themes | Care Quality & Organisational Culture | The Accountability Index

Care and discharge planning

Failure to develop detailed and comprehensive client assessments, recovery plans, and discharge plans.

2,486 items 22 sources 7 inquiries
Source spread

Where this theme appears

This theme appears across 22 independent accountability sources, so the source mix matters as much as the headline total.

19 inquiry recs 523 PFD reports 55 committee recs 48 HSSIB recs 176 CQC actions 82 PPO recs 4 IOPC recs 4 PHSO recs 40 IMB recs 43 IMB reports 5 Scottish FAIs 1 detention investigation rec 113 DHR recs 288 PHSO decisions 455 LGO/SPSO decisions 1 CQC enforcement action

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.

22 sources
Inquiry recommendations(19)
1 — Guidance on long-stay elderly patients in the transition
Whittingham Inquiry
Recommendation: The Department are, we understand, about to issue guidance on the problems of transition from mental illness services based on specialist psychiatric hospitals such as Whittingham to those based on units in general hospitals. Further thought and advice are urgently …
Unknown
R99 — Key individual for resettlement communication
Muckamore Abbey Inquiry
Recommendation: Communication between the HSCTs and/or resettlement service providers and families and people with learning disabilities should be more open and transparent. Each service user/family should have appointed to them a key individual who is responsible for ensuring both the family …
No response yet
R94 — Continuing community support provision
Muckamore Abbey Inquiry
Recommendation: There will be a continuing need, which must be met, for new and ongoing community-based support for young people and adults with learning disabilities and autistic people whose families become unable to cope full time. This means there is a …
No response yet
R92 — Time frame and financial information for families
Muckamore Abbey Inquiry
Recommendation: Families should be provided by the relevant Trust with a time frame for resettlement and relevant financial information. Families should also be afforded an appropriate amount of time to consider resettlement options.
No response yet
R91 — Higher-funded resettlement team for complex needs
Muckamore Abbey Inquiry
Recommendation: There needs to be a recognition that those service users in Northern Ireland yet to be resettled (if there are any by the time of publication of this report) will require a higher level of funding due to their needs …
No response yet
R7 — Independent living skills focus
Muckamore Abbey Inquiry
Recommendation: While patients remain in hospital pending resettlement, there should be a focus on enhancing their independent living skills, tailored to their physical and mental capacity.
No response yet
R6 — Named person approval for transfers
Muckamore Abbey Inquiry
Recommendation: The named person responsible for the care plan must both review and approve the preparation of anyone with a learning disability transferring to a new environment within or external to the Trust in which they are cared for. This approval …
No response yet
R4 — Consultation before patient transfers
Muckamore Abbey Inquiry
Recommendation: Prior to the decision to move a service user to a different facility there must be discussion with the staff regularly caring for them, the relevant multidisciplinary team (MDT), the person's family where practicable and the person themselves where possible, …
No response yet
LAMI-72 — Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Laming Inquiry
Recommendation: No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been …
Unknown
LAMI-71 — Require documented future care plan for discharging children with protection concerns.
Laming Inquiry
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. …
Unknown
LAMI-70 — Require consultant or paediatrician permission for discharging children with protection concerns.
Laming Inquiry
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without the permission of either the consultant in charge of the child’s care or of a paediatrician …
Unknown
R6 — Service change continuity plans
Vale of Leven Inquiry
Recommendation: Scottish Government should ensure that where major changes in patient services are planned there should be clear and effective plans in place for continuity of safe patient care during the period of planning and change.

Words of: Scottish Government, The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report, section 1.3, 18 June 2015

Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
F239 — Continuing responsibility for care
Mid Staffs Inquiry
Recommendation: The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be acceptable for patients to be discharged in the middle of the night, still less so at any time …

Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013

Gov response: Accepted. Discharging patients where it is unsafe, because there is no care and support in place, is clearly a matter of clinical negligence and a breach of the duty of care that professionals have towards …
Accepted
9 — Factors for the Board's reorganisation programme
Whittingham Inquiry
Recommendation: The Board’s programme of reorganising mental illness services should emphasise factors which seem to us not to have been adequately recognised and are essential to the implementation of their policy: (i) the need to provide day places as well as …
Unknown
66 — Meeting and genetic counselling
Alder Hey Inquiry
Recommendation: Following examination of the retained organs or tissue, there should be a meeting between the clinician and parents and referral for genetic counselling or other specialist advice if appropriate.
Unknown
BRIS-20 — Establish comprehensive counselling and support services as integral to patient care
Bristol Heart Inquiry
Recommendation: The provision of counselling and support should be regarded as an integral part of a patient’s care. All hospital trusts should have a well-developed system and a well-trained group of professionals whose task it is to provide this type of …
Unknown
LAMI-56 — Prevent discharge of hospitalised children with concerns until home is safe
Laming Inquiry
Recommendation: Directors of social services must ensure that no child known to social services who is an inpatient in a hospital and about whom there are child protection concerns is allowed to be taken home until it has been established by …
Unknown
F256 — Follow up of patients
Mid Staffs Inquiry
Recommendation: A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a wider range of responses and feedback on their care.

Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013

Gov response: Accepted. A good trust will take every opportunity to seek patient feedback. A good complaints system will recognise that some people will give fuller feedback once they have had time to reflect and therefore it …
Accepted
BRIS-21 — Require every trust to provide a professional bereavement service and online information
Bristol Heart Inquiry
Recommendation: Every trust should have a professional bereavement service. (We also reiterate what was recommended in the Inquiry’s Interim Report: ‘Recommendation 13: As hospitals develop websites, a domain should be created concerned with bereavement in which all the relevant information concerning …
Unknown
Prevention of Future Deaths reports(523)— showing 50 strongest matches
John Fisher
19 Mar 2026 · West Sussex, Brighton and Hove
Concerns: The coroner identified risks of patients receiving incorrect or discontinued medication due to unclear and inaccurate administration records, insufficient information handover between community care providers, and a lack of standard practice for photographic medication records.
Response (Sussex Community NHS Foundation Trust): • Sussex Community NHS Foundation Trust has reviewed and is updating its Medication Administration Record (MAR) chart Standard Operating Procedure to include explicit guidance on discontinued medications and mandatory GP … (AI summary)
Response (Coastal Homecare): • Staff now take photographic records of all medications present in the home at the point of assessment and onboarding for new care packages. • Medication auditing and handover processes … (AI summary)
Responded
Nicola Matthews
20 Aug 2013 · London (South)
Concerns: The coroner identified incomplete documentation of ward round decisions and a lack of clear, documented follow-up arrangements for patients discharged from inpatient care, particularly those at risk of self-harm. This meant staff lacked clarity on discharge plans and medication.
Overdue
John Walker
21 Aug 2013 · West Sussex
Concerns: The risk care plan for Mr Walker was insufficient in scope and depth and was not revisited or revised. There was no clear rationale provided for decreasing observation levels, despite the patient expressing suicidal thoughts.
Response (Sussex Partnership NHS Foundation Trust): • The Trust revised risk care planning documents and confirmed regular audits are completed to ensure adequate standards. • A Nurse Consultant provided training to staff on documenting the rationale … (AI summary)
Responded
Terrance O’Connell
28 Aug 2013 · Bridgend, Glamorgan Valleys & Powys
Concerns: A communication breakdown between the care home, district nurses, and out-of-hours GP meant Mr O'Connell was not seen by clinical staff. There was no direct monitoring of his oral input and urinary output, and no clinical assessment for two days.
Response (Gabbandco): • Monkstone House implemented a policy to send patients to A&E if a health professional does not attend within one hour of being called. • The catheter care policy was … (AI summary)
Response: • The Health Board implemented SBAR (Situation, Background, Assessment, Recommendation) message sheets for switchboard staff to record out-of-hours requests for District Nurses in greater detail. • The Clinical Manager for … (AI summary)
Overdue
Karen Sutton
04 Sep 2013 · Leicester City & South Leicestershire
Concerns: The immunology team was not notified of the patient's hospital admissions, preventing their input into care and discharge. The patient was also discharged without prophylactic antibiotic medication due to a lack of a Trust-wide policy for inter-departmental admission sharing.
Response (University Hospitals of Leicester): • The Medical Director wrote to all Consultants to remind them of their duty to contact specialist teams for complex patients. • The Trust expects to implement software by April … (AI summary)
Responded
Rose Jean Coles
27 Sep 2013 · Avon
Concerns: The coroner identified insufficient communication between the neonatal intensive care unit and the cardiac unit, which was considered unsuited for premature babies, indicating a need for improved protocols or checklists.
Response (University Hospital Bristol): • The Trust provided a composite action plan addressing the matters of concern. • The Trust stated many actions described within the plan were already in hand. • The Trust … (AI summary)
Responded
Douglas Grey
03 Oct 2013 · London (East)
Concerns: The coroner noted a lack of clear written procedure for notifying district nurses about equipment delivery, installation, and performance review. Additionally, carers did not recognise a faulty mattress or follow the home's policy for reporting equipment faults.
Overdue
Rosa Anderson
17 Oct 2013 · Liverpool
Concerns: The patient was discharged without a summary, written information about her laparoscopic operation, contact telephone numbers for advice, or details on matters requiring urgent medical assistance.
Response (Aintree University Hospital): • The hospital confirmed a discharge advice sheet for laparoscopic procedures is in place and provided to relevant patients. • A separate patient information leaflet for hiatus hernia surgery, including … (AI summary)
Responded
Kevin Paul Sutton
14 Nov 2013 · West Somerset
Concerns: The coroner identified that the Trust failed to provide care plans for patients discharged from their wards to other establishments, raising a risk of future deaths.
Overdue
Rosemary Brownyn Ferguson
12 Dec 2013 · South Yorkshire (East)
Concerns: Ms Ferguson's hospital discharge occurred without notifying Social Services, despite their recommendations, and communication with her friend regarding post-discharge supervision lacked clarity. Incomplete hospital notes also hindered tracing key decisions and the precise discharge date.
Overdue
Stephanie Daniels
13 Dec 2013 · Manchester City
Concerns: The coroner identified significant errors in internal Serious Untoward Incident investigations, suggesting independent oversight is needed. Concerns were also raised about inadequate patient handover, particularly a lack of review of recent records for new patients.
Response (Manchester Mental Health NHS): • The Trust stated it would review its Serious Incident Requiring Investigation policy to consider engaging independent investigators and develop further guidance for investigators. • The Trust stated Matrons would … (AI summary)
Response (Manchester Clinical Commissioning Groups): • The Citywide Commissioning, Quality and Safeguarding Team developed a revised governance process, including a monthly Citywide Patient Safety Committee and representation at High Level Investigation Panels to review and … (AI summary)
Response (Department of Health): • The Secretary of State confirmed the concerns were sent to the National Trust Development Authority (NTDA). • The NTDA received an action plan from the Manchester Health and Social … (AI summary)
Responded
Sean Seabourne
17 Dec 2013 · Worcestershire
Concerns: The coroner noted insufficient formal communication and clarity of roles between mental health teams, which meant critical information about a patient's settled plans to kill himself was not adequately shared or acted upon.
Overdue
Christine Williamson
18 Dec 2013 · Shropshire, Telford & Wrekin
Concerns: The coroner identified that the deceased was not assessed as a Vulnerable Adult at risk, which led to insufficient information sharing among professionals and hindered the implementation of preventative measures.
Response (Telford Wrekin Council): • The Council compiled and submitted an action plan in response to the Regulation 28 report. • Most actions within the plan were already under way to implementation. • The … (AI summary)
Response (Telford Wrekin Clinical Commissioning Group): • The Adult Safeguarding Policy and Thresholds, along with domestic abuse guidance, have been recirculated to all GP Practices. • An education and training event for GPs and Practice Nurses, … (AI summary)
Response (West Mercia Police): • West Mercia Police stated it would provide a reminder to all operational staff regarding the requirement to complete DASH risk assessments, crime reports, and vulnerable adult documentation by 31 … (AI summary)
Responded
Michael Longley
19 Dec 2013 · Central & South East Kent
Concerns: The coroner noted difficulties for Integrated Care 24 in contacting the District Nursing Service, indicating a need for improved oral and written communication methods between IC24 and district nurses.
Overdue
James Edward Mansfield
10 Oct 2013 · Cambridgeshire (South and West)
Concerns: The GP surgery experienced delays in receiving and reviewing hospital discharge letters, lacking a method to differentiate between serious and non-serious injuries for prompt attention. Strong painkillers were prescribed over the phone without a face-to-face review, despite the patient's complex medical history and multiple rib fractures.
Overdue
Linda Hudson
24 Sep 2013 · County Durham and Darlington
Concerns: Concerns were raised regarding the hospital's discharge process, specifically that the deceased was discharged with limited medication requiring daily collection due to self-harm risk, her family was not contacted, and the first follow-up nurse visit was scheduled too long after discharge.
Overdue
John Malone
21 Jan 2014 · Manchester (South)
Concerns: The hospital discharge letter sent to the GP lacked vital information, including admission and discharge details, potentially contributing to a patient's fall and subsequent subdural haemorrhage shortly after discharge.
Overdue
Desrae Tucker
23 Jan 2014 · Gwent
Concerns: Concerns included insufficient recording and consideration for anti-embolic stockings in the patient's notes, and the absence of prescribed anti-coagulant medication upon discharge.
Overdue
Michael Irlam
04 Sep 2013 · Manchester South
Concerns: The coroner raised concerns about the waiting time between discharge from crisis services and the first IAPT appointment, and patients not knowing when their next treatment contact would be. It was suggested that follow-up appointments should be arranged before or upon discharge.
Overdue
Ricky Anderson
09 Sep 2013 · Mid Kent and Medway
Concerns: The coroner noted that Mr. Anderson's GP was not informed of his hospital admissions, leading to issues with medication supply. Furthermore, after an early discharge, there was over-reliance on family for information, and no care plan was established to assess his needs.
Overdue
Maureen Leaver
27 Feb 2014 · West Sussex
Concerns: The coroner identified a lack of medical supervision for inpatients and inadequate systems for managing acutely ill elderly patients with complex conditions. There were also concerns about an insufficient understanding of legal duties under the Mental Health Act 1983 and Mental Capacity Act 2005 during patient transfers.
Overdue
Joan Mary Jones
20 Sep 2013 · Leicester City and South Leicestershire
Concerns: The coroner noted that staff did not escalate Mrs Jones' care and failed to communicate all relevant information to healthcare professionals, which led to uninformed decisions and an inappropriate care package.
Response (The Manor): • A memo was issued to all unit leads to ensure family contact and the completion and sharing of communication sheets after visits from healthcare professionals. • The home's manager … (AI summary)
Responded
George Renshaw Brown
16 Sep 2013 · Manchester South
Concerns: The coroner identified a lack of an efficient system for the speedy reassessment and transfer of patients whose condition is rapidly deteriorating, leading to delays in moving individuals to suitable alternative accommodation.
Overdue
Leslie Pates
30 Jan 2014 · Manchester (South)
Concerns: The coroner noted insufficient communication between the hospital, social services, and the family regarding the patient's discharge plan. Concerns were also raised about the patient being discharged home with severe pressure sores and no pressure-relieving mattress.
Response (Tamside Hospital NHS): • The Trust implemented a checklist and monitoring systems to enhance communication and ensure documented engagement between multidisciplinary teams, patients, and families regarding discharge plans. • Processes were established for … (AI summary)
Overdue
Gareth Slater
30 Jan 2014 · Manchester (South)
Concerns: Concerns included inadequate discharge planning for Mr Slater, with no care plan, family involvement, or assessment for independent living. His flat was unsuitable, administrative processes were rushed, and there was a lack of structured support post-discharge.
Overdue
Ryan Chapman
31 Jan 2014 · West Sussex
Concerns: The coroner identified staff's lack of understanding regarding the patient leave policy and the role of support workers as escorts. Concerns were also raised about overdue risk assessments, insufficient information provided to families, and inconsistent visitor security on the ward.
Overdue
Jack Lynn
18 Feb 2014 · North Northumberland
Concerns: The coroner noted the absence of a medication communication sheet at Mr Lynn's home, which prevented reliable checks on medication, and that a 15-minute visit did not include a check on his safety or well-being.
Response (Nightingales Home Help Service): • The service stated it would encourage clients to use medication charts in their communication folders and advise that this is company policy for carers involved in medication services. • … (AI summary)
Responded
Jack William Partington
21 Feb 2013 · Manchester North
Concerns: Concerns noted inadequate neonatal nursing handover, care planning, and isolated treatment decisions. Also, a lack of national policies for paralysing agents in neonates and insufficient ventilatory pressure monitoring post-intubation.
Response (Department of Health): • The Department of Health stated it would notify the British Association of Perinatal Medicine of the case. (AI summary)
Overdue
Alan Stanfield Browning
26 Nov 2013 · Avon
Concerns: Mr. Browning was discharged from Somewhere House without his family being informed of accommodation arrangements, and a Friday discharge limited time to secure proper housing. There was also a lack of clarity regarding routine family involvement in discharge planning.
Overdue
John William Tugwell
01 Dec 2013 · Surrey
Concerns: The coroner noted that a resident identified as a falls risk, with a history of previous falls, was allowed unsupervised access to stairs within the care home.
Overdue
Norma Sheppard
21 Mar 2014 · Staffordshire South
Concerns: The coroner noted considerable confusion regarding Mrs Sheppard’s discharge terms, with the written discharge letter indicating continued subcutaneous fluids while the understanding upon discharge was that she would not receive them. This discrepancy created difficulties in finding a suitable care home.
Overdue
Derrick Plater
21 Mar 2014 · Norfolk
Concerns: The coroner raised concerns that care home visits were not standard practice before placing individuals with complex needs, relying instead on the home's assurances. There was also uncertainty regarding guidelines or protocols for undertaking such visits during the assessment and placement process.
Response: • The organisation stated that a pre-placement visit by a social worker would not be introduced as part of the assessment and placement process. • It explained that social workers … (AI summary)
Responded
Graham Watts
03 Apr 2014 · Brighton & Hove
Concerns: The coroner noted significant flaws in Mr. Watts' hospital discharge procedure, including blank paperwork, a lack of communication with his nursing home and family, and his medical unsuitability for discharge. He returned to the nursing home in a deteriorated state.
Response (Brighton Sussex University Hospitals NHS Trust): • Senior nursing staff confirmed they had emphasized the importance of completing a nurse-to-nurse discharge summary for patients returning to residential or nursing home care. • The Trust is devising … (AI summary)
Responded
Roger Duggan
07 Apr 2014 · Exeter & Greater Devon
Concerns: The coroner noted a lack of clear responsibility between the senior nurse mental health practitioner and night staff for monitoring a patient in a state of heightened anxiety and agitation in the Emergency Department, resulting in him leaving the unit unwatched.
Response (South Western Ambulance Service NHS Foundation Trust): • The Trust conducted an investigation into the ambulance response to calls and disseminated information regarding the correct process for arranging transport. • The Trust upgraded its 'NHS Pathways' system … (AI summary)
Responded
Winifred Dennis
14 Apr 2014 · Kent (North-East)
Concerns: The coroner identified that the transfer of patients between community nursing teams, due to moves between care homes, lacked a formal handover document. This meant important non-clinical information, such as the use of an airflow mattress, was not consistently communicated, potentially reducing optimal patient care.
Response (Kent Community Health NHS Trust): • A formal process for transferring care between community nursing teams has been devised. • A working group has been established to revise policies and procedures and monitor transfer of … (AI summary)
Responded
Andrey Wakefield
22 Apr 2014 · Staffordshire (South)
Concerns: The coroner noted deficiencies in the communication of patient discharge information from the hospital to GPs, particularly for practices outside the immediate area. This issue was highlighted as potentially worsening with the integration of Stafford Hospital into the Trust.
Response (University Hospital of North Staffordshire): • The Trust had implemented an electronic clinical correspondence solution for GP practices in Stoke on Trent and North Staffordshire. • A solution was developed and funded to extend electronic … (AI summary)
Responded
Frank Pope
08 May 2014 · London Inner (North)
Concerns: The coroner noted a lack of a clear 'back-up' process to ensure patients lacking capacity attend follow-up appointments, particularly when family members are not included in correspondence.
Response (Whittington Health NHS): • The Trust described its existing process for placing an alert on the patient administration system to copy appointment letters to family members or representatives for patients lacking capacity, upon … (AI summary)
Overdue
Ross Boyd
23 May 2014 · Milton Keynes
Concerns: The coroner noted an inadequate needs assessment for Ross Boyd prior to his admission to The Willows, which resulted in an inappropriate placement for his care needs.
Response (Milton Keynes Council): • The council stated that Mr. Boyd's needs were assessed by multiple teams on 4 October 2013, and a care package was provided. • The council stated that the decision … (AI summary)
Pending
Jennifer Morrison
02 Jun 2014 · Wirral
Concerns: Missing hospital documentation, including patient observations, was noted to jeopardise post-death investigations. Concerns were also raised about delays in transfer to a High Dependency Unit and in treatment due to bed and staffing shortages after the holiday period.
Response (Wirral University Teaching Hospitals NHS Foundation Trust): • The Trust confirmed it had a Health Records Management Policy, conducted regular audits, and was implementing an electronic patient record system from November 2014. • The Trust stated it … (AI summary)
Responded
William Beckwith
09 Jun 2014 · Derby & Derbyshire
Concerns: The coroner noted a lack of formal assessment for a frail, elderly patient's abilities, home environment, or post-discharge needs before early morning discharge. The department also lacked a formal policy for risk-assessing such discharges.
Response: • The Emergency Department had guidance in place since 2012 for assessing elderly patients presenting after a fall. • A multidisciplinary review of this guidance is currently in progress. • … (AI summary)
Responded
Audrey Garland
17 Jun 2014 · Manchester (South)
Concerns: Concerns included the GP practice's failure to recognise the severity of ulceration and the District Nursing service's inadequate treatment of necrotic ulcers. A lack of organised transport also prevented the patient from attending necessary hospital appointments.
Response: • The District Nursing service strengthened clinical supervision, including daily joint visits with senior nurses and focused support for individual nurses on wound care. • The service implemented quarterly record-keeping … (AI summary)
Overdue
Peter Farebrother
20 Jun 2014 · Shropshire, Telford & Wrekin
Concerns: Concerns involved delayed patient transfer and staff's non-recognition of constant observation status due to inadequate handover, alongside the return of a ligature risk belt. The report also noted an ineffective sloping door designed to prevent hanging and reduced staff risk awareness on the ward.
Overdue
Farres Ikken
02 Jul 2014 · London (North)
Concerns: The coroner noted that hospital staff were unable to directly refer Mr. Ikken to community psychology services upon his discharge from the hospital.
Overdue
Albert Flynn
02 Jul 2014 · Manchester (South)
Concerns: Care staff lacked sufficient training to assess Mr Flynn's condition, leading to a delay in administering food, fluid, and medication for 10 hours. The coroner also identified insufficient staff understanding of prescribed medication's importance and the significance of blood-thinning drugs.
Response (Lester Aldridge LLP): • The organisation stated it would re-emphasise the need to call for qualified assistance during individual staff supervision and new staff induction. • Senior care staff involved in the incident … (AI summary)
Responded
John Wilsher
05 Aug 2014
Concerns: The NNUH discharge letter contained inaccuracies, and there was a lack of awareness regarding prior concerns about the care home's suitability for the patient's deteriorating condition, leading to an inappropriate discharge. Delayed assessments also lacked essential nursing information.
Response (Norfolk Norwich University Hospitals NHS): • The Trust revised the template discharge letter and created a bespoke template for Older People's Medicine patients. • Prompts guiding clinicians and the associated training programme for discharge letter … (AI summary)
Response (Norfolk County Council): • The Multi-Agency Safeguarding Hub and safeguarding manager have been working to embed referrer feedback into the safeguarding process. • Norfolk County Council Community Services continues to work closely with … (AI summary)
Responded
Hilda Thompson
03 Sep 2014 · Surrey
Concerns: An incomplete management plan on admission led to the patient being wrongly identified as not a falls risk, resulting in a 10-day delay for a full falls assessment. The coroner also noted poor record keeping.
Overdue
Gillian Crossley
04 Sep 2014 · Leicester City & South Leicestershire
Concerns: The coroner noted inadequate documentation, insufficient observation and monitoring, and shortcomings in assessing and planning for Mrs. Crossley's discharge, compounded by poor communication among her care providers.
Overdue
Nicholas Megginson
11 Sep 2014 · Powys, Bridgend & Glamorgan Valleys
Concerns: Inconsistent advice was given to patients discharged post-surgery regarding the risks of venous thromboembolism and urgent clinical signs, both orally and in writing.
Overdue
Sybil Roberts
12 Sep 2014 · North Wales (East & Central)
Concerns: The coroner noted no referral to a GP for a falls risk assessment upon admission, despite Mrs. Roberts' declining condition. Additionally, her care plan and falls risk were not reassessed or updated after her return from hospital following a first fall.
Overdue
Ian Page
12 Sep 2014 · Carmarthenshire & Pembrokeshire
Concerns: The coroner noted training needs in communication following patient handover, a lack of falls risk assessment and low bed provision for Mr. Page, and a need to review nursing staff levels.
Overdue
Select committee recommendations(55)— showing 50 strongest matches
#5 —
Public Services Committee
Recommendation: Delays in providing homecare services can negatively impact on patients physical and mental health. For some, impacts can be serious safety issues and include patients being admitted to hospital or requiring surgery.
Response attribution not verified
#1 —
Public Services Committee
Recommendation: Homecare medicines services have significant potential to deliver high-quality care to patients in their homes and reduce pressure on hospitals. They should be a key part of future planning and resourcing for the NHS.
Response attribution not verified
#34 —
Welsh Affairs Committee
Recommendation: We call on the Ministry of Justice and prison leaders to prioritise timely notification of upcoming releases to local authorities and other relevant stakeholders, giving them the best chance to identify suitable accommodation among an already limited stock of options. …
Response status not verified
#9 —
Justice Committee
Recommendation: Accommodation is an important resettlement need for prison leavers, and we welcome the work that the Ministry of Justice and HMPPS have done during the pandemic to ensure that prison leavers have the best access to accommodation as possible. We …
Response attribution not verified
#8 —
Justice Committee
Recommendation: The Committee are pleased to hear about the work the Ministry has done with the DWP to make Universal Credit more accessible to those leaving prisons. We also welcome the increase in the Subsistence Grant for those who are leaving …
Response attribution not verified
#7 —
Justice Committee
Recommendation: At the best of times, release from prison can be a difficult time for many, however, Covid-19 has created a very different environment for those released from prison to enter. Service provision in the community has changed substantially and it …
Response attribution not verified
#19 —
Justice Committee
Recommendation: We are concerned about reports of older prisoners being released without prescription medication or without being registered with a GP. We recommend all older prisoners are supported to register with a GP prior to release; where a prisoner is unable …
Response attribution not verified
#18 —
Justice Committee
Recommendation: Prisons, local authorities, and health and care providers do not always work together effectively to ensure continuity of older prisoners’ health and social care. This can have a detrimental impact on an individual’s health and their efforts to re-integrate into …
Response attribution not verified
#17 —
Justice Committee
Recommendation: There is a shortage of suitable accommodation for older prisoners following their release, which can undermine their rehabilitation and prevent them from successfully re-integrating into society. We are particularly concerned about reports of older individuals being released to no-fixed abode. …
Response attribution not verified
#16 —
Justice Committee
Recommendation: Older prisoners can experience greater levels of institutionalisation and be less able to live independently following their release compared to younger cohorts. Many will require additional support to prepare them to re-join society. Release programmes and guidance that are age …
Response attribution not verified
#15 —
Justice Committee
Recommendation: Prisoners applying for early release on compassionate grounds should have their applications processed in an efficient and timely manner. This is especially important for terminally ill prisoners near the end of their lives. We recommend prisons identify a single member …
Response attribution not verified
#10 —
Justice Committee
Recommendation: The Committee welcome the Government’s decision to temporarily release pregnant women and women in prison with their children, whenever it is safe to do so. The Committee recognise that this cohort of women require specialist support in the community, but …
Gov response: During the pandemic we have operated a scheme under which prisoners in the following groups may be considered for Compassionate Release on Temporary Licence (ROTL): • Pregnant women; • Prisoners with their babies in custody …
Position Not Stated
#6 —
Justice Committee
Recommendation: It is vital that prisoners are able to maintain contact with family and friends, particularly at such an uncertain time. Family contact is essential to a prisoner’s wellbeing and resettlement, and we welcome measures taken to ensure that prisoners are …
Gov response: HMPPS fully recognise the importance of maintaining family contact for prisoners. This is why we quickly introduced video calling when the exceptional circumstances meant social visits were temporarily suspended in March and where they continue …
Position Not Stated
#9 —
Public Accounts Committee
Recommendation: On 17 March the NHS told trusts to discharge urgently all medically fit hospital patients with COVID-19 to maximise inpatient and critical care capacity. On 2 April, the Department told care homes that they needed to make their full capacity …
Response attribution not verified
#15 — Complex patient needs, longer hospital stays, and staff sickness impede NHS productivity recovery.
Public Accounts Committee
Recommendation: We asked witnesses why NHS productivity continues to be lower than before the pandemic. NHSE told us the NHS currently has 19% more staff compared to before the pandemic but is only seeing 14% more patients. It named several factors …
Response attribution not verified
#27 — Accelerate adult social care commission timescale and fully fund sector by Parliament's end
Housing, Communities and Local Government Committee
Recommendation: The timescale for the commission into adult social care should be brought forward, and it must present actionable reforms to the sector as part of its interim findings in 2026. The Government must not wait for the commission to publish …
Response attribution not verified
#26 — Proposed timescale for adult social care commission risks insufficient and delayed reform
Housing, Communities and Local Government Committee
Recommendation: While we support the new independent commission into adult social care led by Baroness Casey, we are concerned that the proposed timescale means that urgent reforms to social care services will not be implemented soon enough to overcome the severity …
Response attribution not verified
#25 — Inaction on adult social care reform creates unsustainable human and financial costs
Housing, Communities and Local Government Committee
Recommendation: We support and echo the conclusions of the recent report Adult Social Care Reform by the Health and Social Care committee. As they have said in the summary of their report, successive Governments have not fully considered the human and …
Response attribution not verified
#18 — Publish annual official estimates of delayed discharge costs to the NHS, broken down by reason
Health and Social Care Committee
Recommendation: We recommend that the Department provides an official estimate of how much delayed discharges are costing the NHS, broken down by the reason for the delay and including costs associated with the beds themselves, staff time and wider activity that …
Response attribution not verified
#17 — Inadequate adult social care system imposing significant costs on the NHS, particularly from delayed discharges
Health and Social Care Committee
Recommendation: Social care is a vital public service in and of itself and should not be valued only for how it supports the NHS. However, the current state of adult social care is imposing significant costs on the NHS. The best …
Response attribution not verified
#15 —
Women and Equalities Committee
Recommendation: We welcome the government’s programmes to increase access to mental health support for people in the homelessness system. We would like to see improved access to referral pathways between health and housing services in areas with high levels of Black …
Response status not verified
#33 —
Welsh Affairs Committee
Recommendation: We were impressed by the large network of partners—including multiple UK and Welsh Government funded housing advisors as well as third sector providers—working hard to ensure Welsh prisoners were released into suitable accommodation and not released into homelessness. However, we …
Response status not verified
#8 —
Public Accounts Committee
Recommendation: NHSE pointed to the large proportion of people with severe frailty living in care homes and how it expected primary care networks to provide support such as weekly ward rounds.14 NHSE recognised that this care needed 8 Q 2 9 …
Response attribution not verified
#6 —
Health and Social Care Committee
Recommendation: As emphasised by Alzheimer’s Society and other key stakeholders, social care reform must be “rooted in the recognition of what good quality care looks like” and 20 Supporting people with dementia and their carers create a system where people with …
Response status not verified
#5 —
Health and Social Care Committee
Recommendation: We recommend the Department of Health and Social Care and NHS England and Improvement use the White Paper to develop clear guidance on the care and support those living with dementia and their carers should expect to receive from diagnosis …
Response status not verified
#4 —
Health and Social Care Committee
Recommendation: However, the evidence we have taken has made it clear that improving diagnosis alone is not sufficient: people living with dementia and their carers need appropriate post- diagnostic support throughout the rest of their life. We are clear that there …
Response status not verified
#19 — Delayed hospital discharges increased by 12% in 2022-23, due to complex patient needs.
Public Accounts Committee
Recommendation: The number of patients staying in hospital despite no longer needing to be there averaged 13,623 across Q4 of 2022–23, an increase of 1,505 or 12% compared with 12,118 during the same period in 2021–22.49 We asked NHS England why …
Response attribution not verified
#4 — Set out actions to address delayed discharges caused by hospital, community, and social care constraints.
Public Accounts Committee
Recommendation: Not enough is being done to tackle delayed discharges, which cause inefficiencies both within hospitals and more widely across the care system. Delays with discharging patients when they are medically fit for discharge reduces available bed capacity, which in turn …
Response attribution not verified
#21 —
Public Accounts Committee
Recommendation: We asked for assurance that there would be enough additional capacity outside of hospitals, given that new community services would be funded separately from the NHP. NHS England told us that this was at the heart of its 10-year plan. …
Response attribution not verified
#20 —
Public Accounts Committee
Recommendation: We asked the Department how it had concluded that the new hospitals required more beds than those they were replacing given that its 10-year health plan aims to shift of care out of hospitals and into the community.41 The Department …
Response attribution not verified
#4 —
Public Accounts Committee
Recommendation: The Department has not yet developed a convincing rationale for the proposed size of new hospitals or how larger hospitals complement aspirations for new models of care and reducing demand in hospitals. Shifting care out of hospitals and into the …
Response attribution not verified
#11 —
Justice Committee
Recommendation: We ask the Government to set out how many prisoners were actively considered for release under the scheme and the principal reasons why just over 5 per cent were in fact released early.
Gov response: As of 15 November, 262 prisoners have been released as part of the End of Custody Temporary Release (ECTR) scheme. The ECTR scheme was aimed at low-risk offenders approaching the end of their sentence, but …
Position Not Stated
#3 —
Public Accounts Committee
Recommendation: This pandemic has shown the tragic impact of delaying much needed social care reform, and instead treating the sector as the NHS’s poor relation. This Committee has highlighted the need for change in the social care sector for many years, …
Response attribution not verified
#20 —
Public Accounts Committee
Recommendation: We asked the Department what the £500 million Adult Social Care Discharge Fund would achieve. It informed us this funding would be used primarily for measures to support discharge from hospitals into social care, with an expectation that much would …
Response attribution not verified
#21 — Facilitate integrated working between health and social care services to reduce delayed discharges.
Public Accounts Committee
Recommendation: We have previously noted that the fragility of the adult social care provider market was exacerbating the difficulties in discharging older patients from hospital.55 NHS England agreed that there is a clear challenge in social care. Different solutions are needed …
Response attribution not verified
#20 — Delayed hospital discharges attributable to four categories, including hospital processes and social care.
Public Accounts Committee
Recommendation: NHS England told us that the reasons why patients might experience delays in leaving hospital could be divided into four categories. For one group of patients, accounting for around 20%, the delays are related directly to activity in the discharging …
Response attribution not verified
#12 — Short-term hospital discharge funding shows positive impact but avoids systemic issues.
Public Accounts Committee
Recommendation: With regard to additional funding for hospital discharge—£600 million in 2023– 24 and £1 billion in 2024–25—the Department told us that delayed discharges had been consistently lower over the last 6 months than the previous year despite an increase in …
Response attribution not verified
#180 —
Science and Technology Committee (Commons)
Recommendation: The lack of available testing for social care was particularly damaging, as we discuss in more detail later in this Report. Crucially, it was not until mid-April that covid-19 testing was made a requirement for people discharged from hospital to …
Response attribution not verified
#180 —
Science and Technology Committee (Commons)
Recommendation: The lack of available testing for social care was particularly damaging, as we discuss in more detail later in this Report. Crucially, it was not until mid-April that covid-19 testing was made a requirement for people discharged from hospital to …
Response attribution not verified
#22 — NHS England's current discharge speed-up processes show inconsistent results across the country.
Public Accounts Committee
Recommendation: NHS England told us it had instructed the NHS to speed up discharge processes, for example by minimising waits for supporting services such as transport and medications. It was also asking hospitals to monitor patients more closely to assess whether …
Response attribution not verified
#18 — Interdependency of urgent and emergency care services creates system-wide bottlenecks from issues.
Public Accounts Committee
Recommendation: The different services for urgent and emergency care are highly connected and interdependent, meaning that issues in one service impacts throughout the rest of the system.46 If the NHS is unable to discharge patients from hospitals when they no longer …
Response attribution not verified
#44 — Publish details of work ensuring continuity of care for women from prison to release.
Justice Committee
Recommendation: Continuity of care for women on short and longer sentences is fundamental to successful resettlement. The MoJ and HMPPS should set out what work they are doing to ensure that women experience continuity of care from prison through to release. …
Response attribution not verified
#15 — Provide updates on IPP prisoner resettlement, detailing Resettlement Passports and pre-release preparation
Justice Committee
Recommendation: We welcome the Government’s commitment to ensuring that all prison leavers leave prison with the basics, such as ID and a bank account, and ask that updates on this programme of work be provided to us. We would also welcome …
Response attribution not verified
#10 — Inadequate regulation of exempt accommodation permits widespread provision of substandard housing.
Public Accounts Committee
Recommendation: Exempt accommodation can provide much-needed homes and support including for people recovering from drug or alcohol dependence; at risk of or transitioning to or from homelessness; or on release from the criminal justice system. However, the NAO found that some …
Response attribution not verified
#27 — Probation Service faces significant increase in demand for resettlement services
Public Accounts Committee
Recommendation: As these additional prisoners progress through their sentences, there will be higher demand for resettlement services. MoJ’s central estimate in its recent modelling work on forecast volumes of prison leavers starting their supervision in the community shows that, while projections …
Response attribution not verified
#22 — Long-term accommodation outcomes for prison leavers remain challenging despite HMPPS investments.
Public Accounts Committee
Recommendation: MoJ told us it is working with HMPPS to better understand what works best on accommodation support for prison leavers.52 Outcomes have remained stable in recent years despite HMPPS’ investments, with 76% of prison leavers from April 2022 to February …
Response attribution not verified
#7 — Inconsistent delivery of prison resettlement services undermines effective support for prison leavers.
Public Accounts Committee
Recommendation: HMPPS told us one of its biggest concerns is whether it can consistently deliver its vision for probation services across all corners of England and Wales.13 In 2022–23, an HMPPS review found 14 out of 27 key events in the …
Response attribution not verified
#58 — Continuity of care is vital; swift Government action needed to improve social care retention.
Health and Social Care Committee
Recommendation: The value of continuity of care in social care settings, particularly for people who rely on non-verbal communication, is undeniable. It is essential that the Government acts swiftly to implement the findings of this report to improve retention in the …
Response attribution not verified
#23 — Stop moving pregnant asylum seekers and new mothers without clinical consent and collect related data.
Women and Equalities Committee
Recommendation: The Home Office must stop moving pregnant women and new mothers between asylum accommodation settings unless clinical advice has been sought and acted on, the mother has consented to a move, and it is in the mother’s and baby’s best …
Response attribution not verified
#22 — Home Office compliance failures endanger pregnant asylum seekers and new mothers during accommodation moves.
Women and Equalities Committee
Recommendation: The Home Office is too often failing to comply with guidance on moving pregnant women and new mothers between asylum accommodation settings. The guidance is clear that such moves are potentially harmful and should only be made where advice on …
Response attribution not verified
HSSIB safety recommendations(48)
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to identify and be able to refer to local diabetes specialist services when patients are discharged home?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation work with other services to help provide co-ordinated care for patients discharged home who need insulin support?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation follow up with patients post discharge, whose insulin regimen has started or been changed while in hospital?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to complete medication checks before patients are discharged home with medications?
Learning Prompt
Transfer of critically ill adults
It is recommended that the Department of Health and Social Care should co-ordinate the development of national guidance, with the arm’s length bodies, for the transfer of critically ill adults, both in planned and emergency situations.
Safety Recommendation
Electronic prescribing and medicines administration systems and safe discharge
It is recommended that NHSX produces guidance for configuring the electronic discharge process, and how electronic prescribing and medicines administration systems should be interfaced with such a process.
Safety Recommendation
The diagnosis of ectopic pregnancy
It is recommended that the Royal College of Emergency Medicine should provide standardised discharge information for clinicians to offer to women following discharge from the emergency department with a problem in early pregnancy and while awaiting further assessment by early …
Safety Recommendation
Unplanned delayed removal of ureteric stents
It is recommended that the British Association of Urological Surgeons encourages members to include information in discharge letters and other communication sent to GPs and patients regarding patients’ stent status, potential complications and the possibility of a retained stent.
Safety Recommendation
Unplanned delayed removal of ureteric stents
It is recommended that the British Association of Urological Surgeons provides guidance for staff working within the stone care pathway to promote consistent advice to patients as part of discharge planning.
Safety Recommendation
Local integrated investigation pilot 1: Incorrect patient identification
‘Electronic prescribing and medicines administration systems and safe discharge’ (Healthcare Safety Investigation Branch, 2019a)
Learning Prompt
Patients at risk of self-harm: continuous observation
Is there a clear and comprehensive process for handing over a patient’s care to staff on the receiving ward?
Learning Prompt
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
Inpatient children and young people’s mental health services can improve patient safety by ensuring that young people, families, and carers are involved, informed and prepared as possible for the young person’s next place of care. This may require increased levels …
Safety Observation
Workforce and patient safety
HSSIB recommends that the NHS England/Department of Health and Social Care, in collaboration with relevant national bodies including the Professional Record Standards Body, adopts user-centred design principles to develop and validate new discharge correspondence templates for primary and community care …
Safety Recommendation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
When transferring or discharging a Service User [patient] from an inpatient or day case or accident and emergency Service, the Provider must within 24 hours following that transfer or discharge issue a Discharge Summary to the Service User’s GP and/or …
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Does your organisation have processes for identifying and prioritising safety and time-critical actions requested by secondary care?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Does your organisation have pathways for primary and community care to troubleshoot incomplete or ambiguous information in discharge correspondence?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation support staff to communicate time-critical actions to providers of ongoing care so they are undertaken within the required time?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Do your staff recognise that capacity and resource issues in primary and community care mean time-critical actions after discharge may be delayed or unable to be actioned?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation ensure discharge correspondence is updated if a patient has further clinical input after the correspondence was written?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation ensure patients and their families/carers (if appropriate) are given an accessible copy of any discharge correspondence?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation know that all required discharge correspondence is reliably produced, sent and received by all necessary recipients, not just GPs?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation support staff to ensure the contents of discharge correspondence meets the needs of all likely recipients and is of high quality?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation ensure important information about medication changes are reliably and accurately described in discharge correspondence?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Do your staff know who are the recipients of and users of your discharge correspondence, particularly discharge summaries?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation ensure staff recognise discharge correspondence as safety-critical information for the clinical handover of care?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
HSSIB recommends that the Department of Health and Social Care, through its future strategic and policy programmes, sets specific expectations for NHS healthcare providers to ensure that: high-quality safety-critical information about patients is accessible after discharge, and processes exist to …
Safety Recommendation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
HSSIB recommends that the NHS England/Department of Health and Social Care, in collaboration with relevant national bodies including the Professional Record Standards Body, adopts user-centred design principles to develop and validate new discharge correspondence templates for primary and community care …
Safety Recommendation
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
Health and care organisations can improve patient safety by allocating a point of contact for patients and/or their carers when people are discharged from services out of normal working hours. This will ensure patients and their carers are able to …
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
The processes for medicines reconciliation in the community would benefit from being reviewed, taking into account the intent for practice-based pharmacists outlined in NHS England’s Long Term Plan (NHS England, 2019). Summary Care Records
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
The National Academic Health Science Networks Medicines Optimisation Network has been commissioned by NHS England to support the roll-out of Transfers of Care Around Medicines across England.
Safety Action
Electronic prescribing and medicines administration systems and safe discharge
There may be benefit for healthcare professionals to receive training in handover communications which should include integrating clinical information with full medicines information, and to share this information with patients and carers in writing and verbally.
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
The practice of documenting only newly prescribed medication on discharge summaries should be reviewed from a patient safety and medicines management perspective.
Safety Observation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
It is recommended that NHS England and NHS Improvement carry out work to understand and further define the work of hospital clinical pharmacy teams, including the period between initial medicine reconciliation and discharge, in consultation with relevant stakeholders.
Safety Recommendation
Harm caused by delays in transferring patients to the right place of care
HSIB recommends that the Department of Health and Social Care conduct an integrated review of the health and social care system to identify risks to patient safety spanning the system arising from challenges in constraints, demand, capacity and flow of …
Safety Recommendation
Positive patient identification
Future improvement programmes considering the risk of patient misidentification can improve patient safety by prioritising high-risk situations and settings, such as handovers and transfers of patient care. Multiple controls may need to be introduced, including new technologies and standardising of …
Safety Observation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
HSSIB recommends that NHS England provides guidance regarding communication of essential safety and risk mitigation information when patients transition from inpatient children and young people’s mental health services due to reaching transition age. This is to safeguard vulnerable people and …
Safety Recommendation
Investigation report: Mental health inpatient settings - out of area placements
Health and social care organisations can improve patient safety by working together and embedding mental health social workers from the local authority in mental health acute hospitals. This can ensure that patients’ holistic health and social care needs are considered …
Safety Observation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Does your organisation have processes for effectively feeding back concerns and incidents to secondary care when discharge communications do not meet your needs?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Does your organisation include digital and clinical input in the training of staff to write discharge correspondence to help them understand what ‘good’ looks like?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation know that its correspondence meets the needs of those receiving and acting on the information?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Primary, community and secondary healthcare providers can improve patient safety by working collaboratively to recognise and mitigate local system challenges and constraints that prevent the: communication of high-quality safety-critical information about patients completion of actions for ongoing patient care within …
Safety Observation
Healthcare provision in prisons: needs assessments and disability access
HSSIB recommends that the Department of Health and Social Care works with local authorities to redesign how the health and social care needs of prisons’ populations are assessed. This is to ensure that appropriate services are commissioned to meet the …
Safety Recommendation
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
Management of risk Although the NHS identified continued provision of maternity services as a priority, operational changes were made to reflect the need to reduce the risk of transmission of infection. In all the cases reviewed, the women and pregnant …
Learning Prompt
HSIB’s local investigation pilot: shared learning for local healthcare systems
HSIB national investigation ‘Harm caused by delays in transferring patients to the right place of care .’
Learning Prompt
Mental health inpatient settings
HSSIB recommends that NHS England provides guidance regarding communication of essential safety and risk mitigation information when patients transition from inpatient children and young people’s mental health services due to reaching transition age. This is to safeguard vulnerable people and …
Safety Recommendation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
When exploring safety accountability, views varied as to whether individual providers or people were accountable, or the integrated care board (ICB). Stakeholders described that accountabilities needed to be clearly defined, with collaboration between providers to ensure processes – such as …
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation assure your internal processes for the administration of correspondence to ensure thoroughness of review while looking to be efficient?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation manage seemingly ‘duplicate’ correspondence to ensure it is not an updated version with further information or actions?
Learning Prompt
NCEPOD recommendations(54)— showing 50 strongest matches
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Testicular Torsion
Wording not shown. See the report on NCEPOD's website.
Testicular Torsion
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
End of Life Care
Wording not shown. See the report on NCEPOD's website.
End of Life Care
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
CQC inspection actions(176)— showing 50 strongest matches
Worthing Hospital
The trust must ensure they have an out of hours discharge policy to reduce risks relating to patients when discharged out of hours.
Must Do
Worcestershire Royal Hospital
The trust should ensure there are suitable arrangements to facilitate the timely discharge of patients who no longer require a critical care bed.
Should Do
William Harvey Hospital
The trust should ensure they make efforts to reduce the number of times patients are moved from one ward to another, and to avoid moving patients outside of regular working hours.
Should Do
Westmorland General Hospital
The trust must take actions to improve average length of patient stay for patients having trauma and orthopaedics surgery.
Must Do
Westmorland General Hospital
The service must ensure that care is provided in line with national performance standards for waiting times from referral to treatment and arrangements to admit, treat and discharge patients.
Must Do
The York Hospital
The trust should ensure that patients discharge plans are commenced on admission to the service so that support is in place where needed on the patients discharge.
Should Do
The York Hospital
The trust should ensure that consultants lead daily ward rounds on the emergency assessment unit to ensure patients are discharged and improve patient flow.
Should Do
The Princess Royal Hospital
The trust should continue to work with partner organisations to improve discharges.
Should Do
The Princess Royal Hospital
The trust should ensure that they audit patient discharges undertaken under the fast track system.
Should Do
The Princess Royal Hospital
The trust should ensure waiting times from referral to treatment and arrangements to admit, treat and discharge patients are in line national standards.
Should Do
The Princess Royal Hospital
The trust should ensure that they audit patient discharges undertaken under the fast track system.
Should Do
Southport & Formby District General Hospital
The trust should continue to improve discharge arrangements to ensure safe patient discharge.
Should Do
Scarborough Hospital
The trust should ensure that patients discharge plans are commenced on admission to the service so that support is in place where needed on the patients discharge.
Should Do
Salford Royal Hospital
The trust must ensure that effective and timely care is provided to improve patient access and flow through the hospital to safe discharge or transfer to inpatients services.
Must Do
Salford Royal Hospital
The service must implement clear plans, with set timescales and actions, to improve patient's access to care and to achieve their timely discharge from hospital.
Must Do
Royal Victoria Infirmary
The service should consider increasing the numbers of discharge co-ordinators across the speciality.
Should Do
Royal Victoria Infirmary
The service should consider increasing the numbers of discharge co-ordinators across the speciality.
Should Do
Royal Victoria Infirmary
The service must ensure that timely care planning takes place where responsibility for care and treatment is shared with, or transferred to others services.
Must Do
Royal Sussex County Hospital
The trust must ensure they have an out of hours discharge policy to reduce risks relating patients when discharged out of hours.
Must Do
Royal Shrewsbury Hospital
The trust should continue to work with partner organisationsto improvedischarges.
Should Do
Royal Shrewsbury Hospital
The trust should ensure that they audit patient discharges undertaken under the fast tracksystem.
Should Do
Royal Shrewsbury Hospital
The trust should ensure waiting times from referral to treatment and arrangements to admit, treat and discharge patients are in line national standards.
Should Do
Royal Shrewsbury Hospital
The trust should ensure that they audit patient discharges undertaken under the fast track system.
Should Do
Rochdale Infirmary
The trust must ensure that effective and timely care is provided to improve patient access and flow through the hospital to safe discharge or transfer to inpatients services.
Must Do
Rochdale Infirmary
The service must implement clear plans, with set timescales and actions, to improve patient's access to care and to achieve their timely discharge from hospital.
Must Do
North Middlesex University Hospital
The service must ensure staff always plan discharges in advance to allow patients to make the necessary preparations, to ensure all appropriate arrangements are ready when required, and to manage bed capacity effectively.
Must Do
North Manchester General Hospital
The trust should ensure that discharge processes are person-centred.
Should Do
North Manchester General Hospital
The trust should ensure it continues to improve the risk of readmission for elective surgery.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that staff are documenting that discharge planning is taking place.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that there is a comprehensive action place in place to improve discharge summaries being sent to GPs within nationally set timescales.
Should Do
Mount Vernon Cancer Centre
The trust should review the rapid discharge guidance and complete audits in line with national recommendations to ensure patient transfers are achieved within national standards.
Should Do
Lister Hospital
The trust must ensure that information sharing and planning with social care providers is timely to ensure safe and timely discharge from the service.
Must Do
Kidderminster Hospital and Treatment Centre
The trust should ensure that there are processes in place to document the actions taken regarding the home first action plans’ length of stay.
Should Do
Kettering General Hospital
The service should review the discharge process, including staffing levels, facilities, and flow to ensure the safety of patients.
Should Do
Kettering General Hospital
The servicemust ensure that discharge passports are issued for all people with complex mental health and social care needs.
Must Do
Ellesmere Port Hospital
The trust must ensure that effective and timely care is provided; to improve patient access and flow through the hospital to safe discharge or transfer to other appropriate services.
Must Do
Ellesmere Port Hospital
The trust must ensure that effective and timely care is provided; to improve patient access and flow through the hospital to safe discharge or transfer to other appropriate services.
Must Do
Clatterbridge Hospital
The services should continue to consider ways to resolve issues with transitional pathways for patients with complex care needs.
Should Do
Clatterbridge Hospital
The services should look at ways of reducing patients re-admitted following an emergency admissions and multiple readmissions of diabetic and epileptic patients.
Should Do
Clatterbridge Hospital
The services should ensure that there is timely access and discharge from services at the hospital.
Should Do
Clatterbridge Hospital
The service must implement clear plans, with set timescales and actions, to improve patients access to care and to achieve their timely discharge from hospital.
Must Do
Clatterbridge Hospital
The service must ensure patients have timely access to care and treatment. It must ensure patient care is planned effectively to reduce length of stay and the number of patients moved between wards at night. It must ensure effective discharge …
Must Do
St Benedict's Hospice
The service should aim to bring waiting times from arrival to treatment and arrangements to admit, treat and discharge patients in line with national standards.
Should Do
Fairfield General Hospital
The trust should consider readmitting babies for phototherapy to paediatric wards rather than maternity.
Should Do
Fairfield General Hospital
The trust must ensure that effective and timely care is provided to improve patient access and flow through the hospital to safe discharge or transfer to inpatients services.
Must Do
Fairfield General Hospital
The service must implement clear plans, with set timescales and actions, to improve patient's access to care and to achieve their timely discharge from hospital.
Must Do
Fairfield General Hospital
The trust should consider a follow-up service for patients.
Should Do
Fairfield General Hospital
The trust should ensure that discharge processes are person-centred.
Should Do
Fairfield General Hospital
The trust should ensure it continues to work towards offering follow-up support and patient diaries to patients.
Should Do
Fairfield General Hospital
The trust should ensure it continues to improve the risk of readmission for elective surgery.
Should Do
PPO death in custody recommendations(82)— showing 50 strongest matches
The Head of Healthcare
The Head of Healthcare to ensure that all patients who have life limiting conditions have an advanced care plan in place in accordance with the National Institute for Health and Care Excellence (NICE) guideline [NG142] for ‘end of life care …
The Head of Healthcare
The Head of Healthcare should undertake an audit of hospital discharge plans to ensure that the agreed plan has been enacted and develop an action plan based on the findings.
The Governors and Heads of Healthcare of HMP Dartmoor and …
The Governors and Heads of Healthcare of HMP Dartmoor and HMP The Verne should ensure that they follow PSI 03/2016 when considering transfers for prisoners receiving local authority care and support.
HMPPS, working in partnership with Ministry of Justice, ADASS, DHSC …
HMPPS, working in partnership with Ministry of Justice, ADASS, DHSC and NHS England, should explore options for developing a pathway for prisoners who have been assessed as needing residential social care to access an appropriate care setting. This work should …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that when a prisoner returns from hospital: • their healthcare needs are assessed if they are in any of the categories at paragraph 4 of Annex D of PSI 07/2015; and • …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that applications for early release on compassionate grounds for prisoners with terminal illnesses are prioritised, and that a record is kept of action taken.
The Head of Healthcare
The Head of Healthcare should ensure that newly arrived prisoners with long-term medical conditions are managed appropriately, including: • prompt referrals to the GP at the prison; • offering a further opportunity for a secondary health screen if a prisoner …
The Head of Healthcare
The Head of Healthcare should ensure that patients with multiple healthcare needs are discussed at the multi professional complex case conference meeting so that the MDT has full oversight of their complex care and multiple care needs.
The Head of Healthcare
The Head of Healthcare should ensure that the appropriate persons are being discussed in the multi professional complex case conference (MPCCC) so that the wider healthcare team have full oversight of their needs.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should implement a process to ensure that healthcare staff are notified when prisoners return from hospital and that all discharge information is shared promptly to inform care planning.
The Head of Healthcare
The Head of Healthcare should ensure that processes and systems are in place regarding release and discharge planning for all prisoners known to healthcare and who require ongoing healthcare input.
The Head of Healthcare
The Head of Healthcare should ensure that a clear plan is documented within the patients SystmOne records following self–discharge from the hospital acute Trust to ensure that all outstanding care/treatment is re-initiated as soon as possible.
The Head of Probation Delivery Unit for Dyfed-Powys
The Head of Probation Delivery Unit for Dyfed-Powys should ensure that when a risk is identified, appropriate referrals are promptly completed to the relevant community services.
The Regional Probation Director
The Regional Probation Director should ensure that accurate and up to date information about a resident’s risk is shared with AP staff prior to their arrival, in line with national instructions.
The Local Delivery Unit Manager of North & Northeast Lincolnshire …
The Local Delivery Unit Manager of North & Northeast Lincolnshire Probation Service should ensure that community offender managers check that necessary referrals have been made to community-based support services prior to release.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that release planning processes are timely, collaborative and robust, including that appropriate referrals are made to community mental health providers for prisoners with complex needs and ongoing self-harming behaviour.
The Head of Healthcare
The Head of Healthcare should engage with a senior clinical hospital colleague in order to improve the discharge information process between the hospital provider and HMP Stafford.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff explore alternative environments for delivering care to prisoners isolating with COVID-19 – including in-cell assessment – to ensure that care is received in a timely manner.
The Head of Healthcare
The Head of Healthcare should ensure that all patients who have a terminal diagnosis (irrespective of prognosis) have an advanced care plan in place in accordance with the NICE guideline [NG142] for ‘end of life care for adults: service delivery’ …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • healthcare staff assess prisoners in reception when they return from hospital; and • there is effective written communication of clinical risks and health needs of prisoners returning from hospital and …
The Director and the Head of Healthcare at Parc
The Director and the Head of Healthcare at Parc should ensure that hospital discharge summaries for prisoners are received in a timely manner and, if this does not happen, that requests are followed up promptly.
The Director and the Head of Healthcare at Parc
The Director and the Head of Healthcare at Parc should ensure that all prisoners are assessed by the healthcare team on their return from hospital.
The Director and the Head of Healthcare at Parc
The Director and the Head of Healthcare at Parc should liaise with the local Health Board to ensure that newly arrived insulin-dependent diabetic prisoners are assessed on their understanding of diabetes management and self-care so that appropriate care is provided …
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff receive training on the Mental Capacity Act and that staff know when and how to assess mental capacity.
The Head of Healthcare
The Head of Healthcare should ensure that there are robust processes in place for communicating with hospitals to ensure that information is appropriately shared and discharge planning is completed.
The Head of Healthcare
The Head of Healthcare should ensure that all prisoners returning from inpatient stays in outside hospital are treated in line with expected standards, including that: • all prisoners returning via Reception are seen and assessed by healthcare staff; and • …
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff undertake a risk assessment when an adult presents with risk factors that make them at increased risk of dehydration and ensure that a plan of care is in place.
The Head of Healthcare
The Head of Healthcare should ensure that staff create care plans for prisoners at risk of cardiovascular disease.
Head of Knowsley and St Helens Probation Delivery Unit
The Head of Knowsley and St Helens Probation Delivery Unit should ensure all COMs understand their responsibilities within release planning and are aware of the need to complete relevant referrals for prisoners with mental health needs.
The Head of Healthcare
The Head of Healthcare should ensure that care plans are created to support in the management of incontinence as per NICE ‘When should I suspect a urinary tract infection in a man’ (2024).
The Head of Healthcare
The Head of Healthcare should ensure that prisoners with epilepsy are referred to a doctor, placed on a long-term care pathway and have a care plan.
The Governor
The Governor should ensure that all newly arrived prisoners receive an ‘Induction to Custody presentation’ in line with the expectations of PSI 07/2015 and that the local induction process is reviewed to ensure support is available for prisoners that arrive …
The Head of Service at East Midlands Probation Delivery Unit
The Head of Service at East Midlands Probation Delivery Unit should ensure that Community Offender Managers complete appropriate referrals to community services in preparation for a prisoner’s release, including when there are licence conditions in place, to allow for continuation …
The Head of Healthcare at Isle of Wight
The Head of Healthcare at Isle of Wight should ensure that healthcare staff arrange a proper handover to the receiving prison where a prisoner has more complex health care needs.
The Governor of HMP Downview
Downview has protocols for support following deaths in custody, but there do not appear to be formalised procedures for deaths following release. Deaths shortly after release are not frequent and so the situation may not have arisen previously, but the …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that there is a process in place to transfer prisoners with a terminal diagnosis or whose medical needs cannot be met at The Verne to a more suitable environment at the earliest …
The Head of Healthcare at HMP Thameside
The Head of Healthcare at HMP Thameside should ensure that prisoners are discharged or transferred with a sufficient supply of their prescribed medications.
The Head of Healthcare
The Head of Healthcare should ensure that a care plan is created for prisoners who are at increased risk of suicide or self-harm.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners with complex care needs are added to the multi-disciplinary team caseload.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should explore alternative options for meeting a prisoner’s care needs when they cannot be met on a standard wing.
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that applications for early release on compassionate grounds contain an up-to-date letter from the relevant hospital consultant, including all of the information required by the Early Release on Compassionate Grounds Policy Framework.
The Head of Healthcare
The Head of Healthcare should ensure that there is an auditable process to manage long-term medical conditions in line with the National Institute for Health and Care Excellence (NICE) guidelines, including: timely and appropriate referrals after reception health screens; implementation …
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff complete all post-operative actions requested in hospital discharge summaries.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff request hospital discharge summaries when they are not routinely provided.
The Head of Healthcare
The Head of Healthcare should ensure that individualised care plans are created for prisoners with acute and complex physical health needs.
The Head of Healthcare
staff use appropriate clinical assessment and monitoring tools.
The Governor and Head of the Offender Management Services at …
The Governor and Head of the Offender Management Services at Bristol will want to consider whether any changes to existing processes would have prevented Mr Andrews being released in error.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners are involved in their end-of-life care where practicably possible and that patient involvement in these discussions is recorded in the clinical notes.
The Commissioner for Health and Justice NHS England South East
The Commissioner for Health and Justice NHS England South East should work collaboratively with commissioned healthcare providers in custodial settings to formulate a regional approach and implement a process on when to recommend cell sharing for prisoners with life-threatening long-term …
The Governor
The Governor should ensure that the review of the prison debt strategy considers care planning for known debtors and ensures that all agreed care plans are recorded on the prisoner’s record and therefore available for all staff to see.
IOPC learning recommendations(4)
PHSO ombudsman recommendations(4)
IMB annual reports(43)
The Verne (2023)
HMP The Verne maintains a generally safe and respectful environment, successfully implementing a new self-harm monitoring system and demonstrating strong staff-prisoner relationships. The Board commends the high-quality physical healthcare provision, including excellent vaccination rates, and welcomes the establishment of a new 16-room social care unit aimed at addressing the long-standing concern for elderly and frail prisoners. However, significant challenges persist, particularly in resettlement provision, severe understaffing in the Offender Management Unit leading to backlogs, and long waiting times for mental health services and external healthcare appointments due to staff shortages.
PRISON Key concerns
Ashfield (2020)
HMP Ashfield continues to be a well-run Category C prison for men serving sentences for sexual offences, known for its safe environment and humane treatment. Despite the significant impact of the COVID-19 pandemic on daily regime and programme delivery, staff were highly commended for their support and resilience. Key concerns include the persistent lack of suitable accommodation for release, issues with property management from other establishments, and the growing backlog for intervention programmes due to COVID-19 restrictions, which could hinder prisoner progression and parole.
PRISON Key concerns
Bedford (2020)
Conditions at HMP/YOI Bedford generally improved over the reporting year, with commendations for the Governor's leadership, particularly during the COVID-19 crisis. While prisoner-on-prisoner assaults and self-harm incidents reduced, staff assaults and use of force remained worryingly high. Significant concerns persist regarding the ACCT process, the physical state of the segregation unit, and the high number of prisoners released without stable accommodation. Healthcare was satisfactory, but the mental health team's working practices require review, and issues with the Victorian estate infrastructure and the perceived unfairness of the IEP scheme need addressing.
PRISON Key concerns
Charter Flight (2020)
The IMB Charter Flight Monitoring Team's 2020 report highlighted grave concerns regarding the inhumane treatment of vulnerable detainees, particularly Dublin Convention returnees who had recently self-harmed, with no health information shared with receiving countries. It noted unacceptably long periods of confinement in vehicles during transfers, lack of privacy during WC use, and inconsistent provision of information and support. The Board welcomed improved HOIE oversight and more consistent information provision by escorts, but reiterated several unaddressed recommendations regarding welfare and procedural fairness.
PRISON Key concerns
Gatwick, Stansted, Luton and Lunar House (2020)
The IMB report for Gatwick, Stansted, Luton Airports and Lunar House covers the period January to December 2020. It notes that while staff generally treated detained individuals fairly and humanely, significant concerns exist regarding the physical limitations of the holding rooms, which lack natural light, fresh air, and adequate washing facilities. A primary concern is the inadequate arrangements for monitoring medical welfare and accessing urgent medication, compounded by the absence of trained medical staff on site. The Board made recommendations to the Home Office and Detention Contractor to address these healthcare deficiencies.
PRISON Key concerns
Thorn Cross (2021)
HMP/YOI Thorn Cross continued to be a safe and respectful environment, despite the challenges of the Covid-19 pandemic. The Board noted good healthcare provision and a strong rehabilitative culture, supported by the welcomed use of mobile phones. Key concerns include the national reduction in open estate places, insufficient resources for prisoners with complex needs, and persistent issues with IT systems and missing property during transfers.
PRISON Key concerns
Dover (2020)
The Independent Monitoring Board for Dover Short-Term Holding Facility reported on the period of January 2019 to December 2020, during which detainee numbers significantly increased. Key concerns included the unsuitability of the facilities for the high volume of detainees and extended stays, particularly for vulnerable individuals and children. The Board highlighted issues with mental health provision, the practicality of COVID-19 measures, and detainees' lack of clear information or external contact, despite staff largely treating detainees with respect.
PRISON Key concerns
Stocken (2021)
HMP Stocken, a category C training prison, experienced significant disruption during the reporting year (May 2020 – April 2021) due to the Covid-19 pandemic, yet managed a commendable response to the outbreak and achieved high vaccination rates. Despite an extended period of restricted regime, the Board found the prison generally safe and commended the leadership and staff. Key concerns include persistent issues with prisoner transfers, resettlement support, and access to programmes.
PRISON Key concerns
The Verne (2021)
HMP The Verne experienced a challenging year due to the COVID-19 pandemic, which caused a major outbreak, significant staff absences, and disruption to the prison regime, including education, work, and visits. Despite these challenges, the prison maintained a very safe environment with low violence, and the Board commended staff dedication and the strong ethos of mutual respect. Key concerns persist regarding the provision of 24-hour social and healthcare for the ageing population, slow progress on a proposed hospital unit, and the need for more purposeful activity.
PRISON Key concerns
Dover (2022)
The Dover Independent Monitoring Board's 2021 report details critical issues at the Tug Haven, Kent Intake Unit (KIU), and Frontier House Short-Term Holding Facilities. While some initial improvements were noted in induction processes and staff interactions, the facilities were largely unsuitable for their purpose, particularly Tug Haven, which routinely held detainees overnight in overcrowded, unheated tents with inadequate sleeping, washing, and food provisions. Significant concerns were raised about poor hygiene, brief and ineffective medical screenings leading to undetected serious injuries, and excessive lengths of stay, causing distress and confusion among detainees, including vulnerable families and children.
PRISON Key concerns
North Sea Camp (2024)
HMP North Sea Camp generally provides a safe and humane environment, with a strong emphasis on humane treatment and a wide range of release preparation programs. Positive developments include improved facilities management, a proactive safer community team, and good healthcare services that receive positive feedback from prisoners. Key concerns include persistent delays in offender management paperwork, the unresolved situation for IPP prisoners, and poor accommodation standards with no plans for replacement or conversion of dormitories. Additionally, issues with prisoner property transfers, lack of on-site end-of-life care, and difficulties for disabled prisoners accessing resettlement opportunities remain.
PRISON Key concerns
Aylesbury (2024)
HMP Aylesbury, a Category C prison, completed its transformation from a YOI this year, adapting to an older population with improved but still sub-standard regime delivery. Significant efforts were made to enhance safety, reduce gang violence, and manage illicit items, though their incursion remains a serious problem. While staffing levels improved, staff inexperience and a lack of purposeful activity remain key challenges impacting prisoner wellbeing, progression, and resettlement, as evidenced by long waiting times for healthcare and inadequate release preparation.
PRISON Key concerns
North Sea Camp (2025)
HMP North Sea Camp is a Category D open prison providing a safe and humane environment with a new Governor making positive regime and community engagement changes. While healthcare and education services receive commendations, significant concerns persist around inadequate accommodation standards, particularly for double rooms and dormitories, and the lack of on-site residential healthcare for complex needs. The Board also highlights issues with delayed Offender Assessment System (OASys) completion by Community Offender Managers and the ongoing lack of progress for IPP prisoners.
PRISON Key concerns
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2020)
This report covers the Glasgow, Edinburgh and Larne House Short-Term Holding Facilities from February 2019 to January 2020. The Board found that detainees are largely treated humanely and respectfully by DCOs across all establishments, noting good practice in various areas. However, significant concerns remain regarding the adequacy of airport Holding Rooms for longer stays, including lack of fresh air, natural light, showering facilities, and exercise opportunities. Other key issues include delays in building work at Glasgow Airport, inadequate separation of female accommodation at Larne House, and problems with accessing prescribed medication for detainees.
PRISON Key concerns
Downview (2020)
HMP/YOI Downview is considered a safe and humane prison where healthcare needs are largely met. However, the Board identified significant challenges including an unsatisfactory induction process, unsuitable long-term segregation for complex cases, and persistent issues with London weighting affecting staff recruitment. Key working remains unimplemented, and both purposeful activity and resettlement efforts are hampered by short sentences and difficulties accessing performance data from service providers like Weston College and the CRC.
PRISON Key concerns
East Sutton Park (2020)
HMP East Sutton Park maintained a safe and supportive environment for women prisoners amidst the COVID-19 pandemic, successfully adapting education and family contact. However, significant concerns remain regarding the insufficient time prisoners have to benefit from resettlement, inconsistent transfers from closed establishments, and pandemic-induced disruptions to sentence planning. Staffing issues in key areas and challenges with dental provision and enabling internet access for distance learning were also highlighted.
PRISON Key concerns
Eastwood Park (2020)
This IMB annual report for HMP/YOI Eastwood Park for the year ending October 2020 highlights the significant impact of the COVID-19 pandemic on prison operations and monitoring. While staff efforts and communication were generally commendable, concerns persist regarding rising self-harm incidents, ongoing violence towards staff, and the continuous flow of illicit substances. The Board remains particularly concerned about the prolonged segregation of a brain-injured prisoner and the lack of appropriate secure specialist facilities for women with complex needs.
PRISON Key concerns
Durham (2020)
HMP Durham transitioned to a reception and resettlement prison for adult males and young offenders in February 2020. The reporting year was significantly impacted by COVID-19, leading to a restricted regime for much of the period. The Board noted positive developments in first night inductions, a reduction in self-harm, and improved healthcare provision by a new contractor. However, persistent concerns include overcrowding, low levels of key workers and Listeners, and the prolonged detention of immigration detainees. The report also highlights challenges with access to purposeful activity for specific prisoner groups and staffing consistency in healthcare.
PRISON Key concerns
Gatwick pre-departure accommodation (2020)
The reporting year 2020 was exceptional due to the COVID-19 pandemic, leading to the Gatwick Pre-departure Accommodation (PDA) being largely closed from March onwards. Only three families were held between January and March, none of whom were removed from the UK; all were released back into the community. Consequently, the Independent Monitoring Board's annual report for this period is necessarily limited in its scope and findings.
PRISON Key concerns
Full Sutton (2020)
HMP Full Sutton's IMB report for 2020 highlights the extensive impact of the COVID-19 pandemic on the prison's operations, with significant regime restrictions in place. Despite these challenges, the prison successfully maintained safety, experienced reductions in self-harm and assaults, and generally treated prisoners humanely. However, opportunities for purposeful activity, education, and progression were severely curtailed, and previous recommendations on these issues remain unaddressed due to the pandemic.
PRISON Key concerns
Brook House (2020)
In 2020, Brook House IRC faced significant challenges due to the COVID-19 pandemic, a contract change to Serco, and a compressed charter flight programme for Dublin Convention removals. The Board found the centre unsafe for vulnerable detainees in the latter months, marked by a dramatic increase in self-harm and suicidal ideation, and inhumane treatment of detainees due to Home Office policies. Delays in Rule 35 assessments, inadequate inductions, and issues with property and communication from the Home Office were key concerns, despite a welcome increase in staff numbers and some improvements in facilities.
PRISON Key concerns
Exeter (2020)
This report presents the findings of the Independent Monitoring Board at HMP Exeter for the year 2020. The prison managed the COVID-19 pandemic well, with a settled atmosphere and low virus transmission, despite severe restrictions curtailing regime activities. While staff provided humane treatment and healthcare met community standards, significant concerns persist regarding the inadequate provision for prisoners with serious mental health issues, challenges in staff recruitment and retention, and the limited opportunities for education and resettlement due to the restricted regime.
PRISON Key concerns
Dungavel House IRC (2020)
Dungavel House IRC successfully managed its operations during the 2020 COVID-19 pandemic, with no detainee infections and staff commended for their resilience. Detainees report feeling safe, benefiting from good healthcare, a relaxed regime, and improved escort services. However, concerns persist regarding the length of detention, roof access, staff training, parking, and gate upgrades.
IRC Key concerns
Swaleside (2021)
HMP Swaleside experienced a challenging year due to COVID-19, but management and staff were commended for their exceptional response and innovative strategies. The prison maintained a positive trajectory with declining violence and improved humane treatment, though concerns persist regarding resettlement provision and the mental health impact of prolonged lockdown. Key issues include kitchen capacity, access to confidential complaints, and disparities in opportunities for vulnerable groups.
PRISON Key concerns
North West and Midlands STHF (2024)
This IMB report for Short-Term Holding Facilities (STHFs) highlights an increase in both Board membership and visits, alongside a rise in the number of people detained during 2023. Key concerns include significant safety risks for female detainees at Manchester RSTHF due to co-location with male Foreign National Offenders and a general lack of essential provisions like hot food, CCTV, and prompt access to prescribed medication in other facilities. The report also notes delays in addressing maintenance issues and reliance on external emergency services for medical needs.
PRISON Key concerns
Rye Hill (2025)
HMP Rye Hill, a privately run Category C training prison for men convicted of sexual offences, successfully managed a significant expansion and recategorisation during the reporting year. The prison saw a considerable reduction in violence, self-harm, and use of force, alongside an 'outstanding' CQC rating for its healthcare provision. Key concerns persist regarding the ongoing injustice of IPP sentences, the complexities of the compassionate release process, and issues with prisoner property and hospital escort availability.
PRISON Key concerns
Erlestoke (2025)
HMP Erlestoke is a Category C training and resettlement prison with an operational capacity of 512. The Board observed improvements in healthcare attendance and use of force scrutiny, alongside a decrease in staff turnover. However, significant concerns remain regarding the deteriorating healthcare building, the pervasive availability of illicit substances, and the inadequate provision for vulnerable prisoners, including the elderly and those requiring essential medication on transfer.
PRISON Key concerns
Channings Wood (2025)
HMP Channings Wood, a Category C prison, experienced an increase in deaths in custody and persistent issues with prisoner property and outstanding infrastructure repairs during the reporting period ending August 2025. Despite improvements in education attendance and some aspects of daily regime, concerns remain regarding out-of-hours healthcare for an ageing population, insufficient purposeful activity, and the negative impact of staffing reductions on key services. The Board highlights the inhumane conditions for IPP prisoners and notes a significant rise in prisoner complaints.
PRISON Key concerns
Leyhill (2020)
HMP Leyhill, a Category D open prison, has demonstrated strong performance driven by a new community-focused dynamic, leading to improvements in facilities and resident engagement. However, the Board highlights persistent issues including significant delays in ablution refurbishment, the slow progression of IPP sentences, and insufficient approved premises hindering Release on Temporary Licence. Concerns also remain regarding night-time staffing levels and the recurring problem of lost prisoner property during transfers.
PRISON Key concerns
Lincoln (2020)
HMP Lincoln, a Category B local prison, generally treats prisoners fairly and humanely, with a predictable regime and improved cleanliness, according to the IMB's report for 2019-2020. Key improvements include reduced violence, better staff-prisoner relationships, and improved healthcare and education provision. However, significant concerns persist regarding the high level of self-harm, prisoner homelessness on release, and ongoing maintenance issues affecting accessibility and facilities.
PRISON Key concerns
Low Newton (2020)
HMP/YOI Low Newton provides a generally safe and humane environment with high staff morale and respectful interactions. Healthcare provision is good for most, but the Board highlights long-standing concerns regarding the detention of mentally ill women due to a lack of community places and delays in hospital transfers. Deteriorating prison infrastructure, particularly leaky roofs, significantly impedes education and work opportunities. Resettlement efforts are hampered by a lack of suitable accommodation for a notable proportion of releases. The Board also raised concerns about drug misuse (Buscopan) and the need for more funding for key support services.
PRISON Key concerns
North Sea Camp (2020)
HMP North Sea Camp is an open Category D prison noted for its rehabilitative culture and generally humane treatment of residents. The Board commends improvements in healthcare and positive staff-resident relationships, alongside community engagement. However, significant concerns remain regarding delays in Offender Management paperwork, inadequate accommodation conditions (including continued use of dormitories), and a lack of specific facilities for end-of-life and dementia care for the prison's increasing elderly population. These issues, alongside property transfer problems and laundry machinery breakdowns, require urgent attention and capital investment.
PRISON Key concerns
Lowdham Grange (2020)
HMP Lowdham Grange generally provides fair and humane treatment, evidenced by a positive regime and improved staffing stability. Violence has decreased, and healthcare provision is seeing significant improvements, although challenges remain with mental health transfers and inadequate accommodation. Concerns persist regarding property loss, the consistency of the key worker scheme, and slow progress for IPP prisoners, along with ongoing issues in education and access to local prisons for release planning.
PRISON Key concerns
Hull (2020)
HMP Hull, a category B local and YOI prison, recorded 8 deaths in custody this year, including four self-inflicted, but generally maintained a safe environment with reductions in violence and substance misuse incidents. While healthcare provision and purposeful activity are largely positive, the Board identified significant concerns including persistent problems with property management, delays in mental health transfers, slow contractor responses to maintenance, and a lack of post-release outcome data. Recommendations address these issues, aiming to improve prisoner experience, particularly for vulnerable individuals and young adults.
PRISON Key concerns
Moorland (2020)
HMP/YOI Moorland, a Category C male resettlement prison, has reported significant improvements in safety metrics, including reductions in violence, self-harm, and drug use during the March 2019 – February 2020 reporting period. The Board noted positive developments in staff-prisoner relationships and the IEP system. However, national shortages in secure mental health beds, limited offending behaviour programmes, and a persistent lack of suitable accommodation for released prisoners remain key concerns.
PRISON Key concerns
Nottingham (2020)
HMP Nottingham saw overall improvements in fairness and safety during the reporting year, including a reduction in violence against staff and deaths in custody. However, self-harm incidents rose significantly, and concerns persist regarding long delays for mental health transfers and the high number of prisoners released without accommodation. The Board also highlighted issues with purposeful activity uptake and the key worker scheme's inconsistent implementation.
PRISON Key concerns
New Hall (2020)
HMP/YOI New Hall received a generally positive assessment from the IMB for the reporting year ending February 2020, with prisoners treated fairly and humanely. The report highlighted improvements such as reduced self-harm, the introduction of in-cell telephony, and an outstanding education success rate of 96.69%. Key concerns, however, included long waits for mental health transfers, insufficient staffing and resources for vulnerable prisoners, and persistent issues with property transfer and resettlement accommodation.
PRISON Key concerns
Drake Hall (2020)
Drake Hall continues to provide a safe and humane environment, with staff and prisoners adapting well to the challenges of the COVID-19 pandemic, maintaining good order and low levels of violence. However, long-standing concerns persist regarding the unfit condition of Richmond and Plymouth houses, and systemic issues with prisoner property transfers. The pandemic's restricted regime has impacted rehabilitation and purposeful activity, raising concerns about the mental health and resettlement prospects of prisoners, especially those shielding.
PRISON Key concerns
Hindley (2020)
The reporting year was largely dominated by the COVID-19 pandemic, leading to significant regime restrictions. Despite these challenges, the Board found HMP/YOI Hindley to be a generally safe and humane environment, commending staff efforts in managing the pandemic and maintaining positive staff-prisoner relationships. Key concerns remain around the cramped and unfit accommodation, the consistency of resettlement support, and the increased availability of illicit substances.
PRISON Key concerns
Littlehey (2020)
HMP Littlehey remains a safe, fair, and decent Category C training prison for men convicted of sexual offenses, despite facing significant challenges. Key issues include persistent overcrowding, ongoing structural and heating problems, and inadequate provision for older prisoners and those with mental health needs, often leading to inappropriate CSU placements. The Board notes improvements in social care and equality monitoring, but highlights concerns regarding regime curtailments for staff training, slow responses to property complaints, and a backlog in offender management.
PRISON Key concerns
Humber (2020)
HMP Humber faced significant challenges in 2020, operating under severe COVID-19 restrictions for nine months. The Governor and staff were highly commended for their professionalism in maintaining safety and minimizing virus spread. However, the Board expressed grave concerns about the long-term impact of extended lock-up on prisoner mental health, progression, and purposeful activity, while persistent issues like property loss and PALS response delays remained problematic.
PRISON Key concerns
Isis (2020)
HMP/YOI Isis operated under a severely restricted regime throughout most of 2020 due to the COVID-19 pandemic, leading to prisoners spending up to 23.5 hours a day in their cells and limited access to education, work, and association. The Board commended the prison leadership for managing these challenges and highlighted improvements in hygiene, but raised significant concerns about the impact of the regime on prisoner well-being, the ongoing issue of housing prisoners with chronic mental health needs in an unsuitable environment, and persistent problems with staff recruitment and property transfers. Despite a drop in overall violence during lockdown, levels began to rise towards the year's end, particularly among young adults.
PRISON Key concerns
Huntercombe (2020)
HMP Huntercombe, a Category C prison for foreign national men, successfully managed the COVID-19 pandemic despite significant regime restrictions, with no deaths in custody and positive commendations for its healthcare team. The Board identified several areas for development, notably the unfairness of telephone charges and lack of in-cell telephony, and the concerning increase in time-served prisoners held under immigration powers. Issues surrounding meaningful vocational training and progression to open conditions for foreign national prisoners were also highlighted as key areas needing attention.
PRISON Key concerns
IMB individual recommendations(40)
Heathrow Immigration Removal Centre (2020)
The Home Office and DET should provide greater guidance for detainees returning to a country where they have not lived for some time, ensuring that they are better equipped for their return.
Home Office
Bedford (2023)
The early identification of release areas by the probation service would be helpful where prisoners, because of the length of time served on remand, have only a week or so before release – better coordination in this area would be really useful.
HMPPS
Bristol (2024)
There appears to be insufficient support for prisoners on release to prevent them returning to prison for short periods of time and/or being recalled due to relatively minor licence breaches. How will the Minister address this?
Ministry of Justice In Progress
Ashfield (2024)
In common with other prisons, a small number of prisoners released from Ashfield in the last 12 months did not have suitable accommodation arranged prior to release. What solution is the Minister proposing to resolve this matter?
Ministry of Justice In Progress
Ranby (2020)
Will the minister explain why 36% of prisoners are released with no fixed abode, and why for the same reason prisoners suitable for home release are not being allowed out of HMP Ranby?
Ministry of Justice In Progress
Leyhill (2020)
In view of the unfairness (and potential for discouragement) created when a lack of spaces in approved premises leads to delay in release on temporary licence (ROTL) and thus the potential timing of release (see paragraph 11.1), what action will the minister take to remedy this situation as a matter of urgency?
Ministry of Justice In Progress
Hindley (2020)
The Board understands the challenges which the COVID-19 pandemic has caused but is concerned about the consistency and availability of the information, advice and guidance provided for prisoners released from HMP/YOI Hindley.
Governor / Director
Leicester (2021)
Does the minister agree that assisting them to make progress to safe discharge should have a higher priority?
Ministry of Justice
Stoke Heath (2023)
Can the process for prisoners to rejoin their community upon release be reviewed, to ensure all prisoners are offered accommodation upon release?
HMPPS
Send (2023)
The shortage of probation officers, both at Send – where four of the six full-time equivalent probation officer posts are currently vacant – and in the community, has had a damaging effect on prisoners’ progression and prospects for successful reintegration into society.
HMPPS
Rye Hill (2023)
The Board remains concerned that the movements from Category B to Category C and then to Category D prisons represent a particular problem for prisoners convicted of sexual offences and with the increasing number of direct releases (54 this year against only 20 in 2019/2020 reporting year) frequently leaves them being released with no specialist support.
HMPPS
Altcourse (2023)
How will the resettlement needs of remand prisoners be addressed, given the lack of provision for this in the current contract?
HMPPS
Altcourse (2023)
What efforts are being made to address the failure of Seetec to deliver on their contract responsibility to deliver a service that supports individuals to find suitable accommodation on release?
HMPPS
Swaleside (2025)
The Board remains concerned that prisoners are being released from Swaleside without proper support. How does the Governor plan to address this issue?
Governor / Director
East Sutton Park (2025)
Could the prison develop comprehensive guidance for prisoners preparing for reintegration into the community, outlining the required steps and associated responsibilities to be completed prior to release, as well as identifying the appropriate contacts for assistance? The Board recommends establishing an orderly role to support prisoners nearing release.
Governor / Director Noted
Doncaster (2025)
The Board remains concerned about the high number of prisoners being released with no fixed abode? What steps will the Minister take to work with the relevant government departments to develop and implement a coordinated plan to address this serious issue?
Other In Progress
Yarl’s Wood (2020)
The Board recommends that upon the release of STHF detainees, their destination addresses are confirmed as a matter of urgency to enable medical records to be forwarded swiftly to their GPs, so allowing access to essential medical care.
Home Office
Usk and Prescoed (2020)
The Board notes that sometimes prisoner records are very slow in reaching the open estate. Assessment records which are locked or unavailable to the receiving establishment cause delay in the smooth transition of prisoners, on a fourfold basis: 1. in terms of liaison with statutory agencies 2. the assessment of risk 3. planning for ROTL and eventual release into the …
HMPPS In Progress
Swaleside (2024)
New prisoners are not receiving adequate induction and the Board is very concerned that prisoners are being released from Swaleside without proper support.
Governor / Director
Portland (2024)
In the Board’s view, the early release scheme (ERS) has been poorly thought through and rolled out, relying on the offender management unit (OMU) to fill the gaps in the resettlement process without the staffing increase to accommodate the extra work. This has had an adverse effect on the quality of the service provided and means that prisoners are not …
HMPPS Implemented
The Mount (2025)
HMPPS should take more action to support IPP prisoners, both leading up to and following release into the community.
HMPPS In Progress
Bronzefield (2020)
The government’s early release and special licence schemes have failed, in large part, owing to the requirement to tag a prisoner to an address. What is the government proposing to do to address this issue while lockdown restrictions continue?
Ministry of Justice Noted
Winchester (2023)
What support can be provided to help remand prisoners with release planning as they are not eligible for probation services?
Ministry of Justice Implemented
Wetherby (2023)
Too many young people continue to be placed further than 50 miles from their home, thus reducing the potential to support family links. Is there anything that can be done to change this?
HMPPS
Preston (2023)
To provide more family engagement in preparation for prisoner’s release.
Governor / Director
Portland (2023)
Need for inter-departmental communication relating to prisoners’ pathways to resettlement
Governor / Director
Moorland (2023)
Can there be a general improvement in sentence progression and resettlement services for prisoners?
Governor / Director
Littlehey (2023)
The Board is concerned that prisoners have been transferred to HMP Littlehey, which does not have a 24-hour healthcare facility, when they were already very unwell. Although the Board recognises that HMP Littlehey provides excellent end of life care, it is concerned that such transfers could be detrimental to the transferring prisoner. The Board would like to understand the criteria …
HMPPS
Heathrow immigration removal centre (2023)
The Home Office has a duty of care for those with mental health problems and to ensure that they are safe in the community they are released into. Robust support is required for detained people with mental health people who are released on bail.
Ministry of Justice
Downview (2023)
delivery of the contracted family engagement resource.
Governor / Director
Dartmoor (2023)
The HMPPS’s Ageing Population Strategy was due to be published this year. Given the high proportion of older prisoners in HMP Dartmoor, when will this Strategy be published and when will initiatives to help older prisoners be announced?
HMPPS
Winchester (2024)
What can be done to support and reduce the high number of men on remand who are released immediately from court on bail, licence or as time served?
Ministry of Justice In Progress
Channings Wood (2024)
Year after year, we have been told that the ageing population strategy is coming soon. As in our previous report, the Board asks, again, when will it arrive and what improvements will it bring to the living conditions and care needs of elderly prisoners?
Ministry of Justice In Progress
Portland (2020)
Checks need to be put in place to ensure that critically unwell prisoners, suffering significant health problems, cannot be unilaterally transferred. Should this ever be necessary, it should not happen without prior negotiation with the receiving establishment and the provision of up to date and comprehensive medical records.
HMPPS Noted
Heathrow Immigration Removal Centre (2021)
C&C should consider working more closely with the healthcare provider to maximise the value of the care suite for respite care for vulnerable detainees.
Governor / Director
Maidstone (2023)
Provide feedback to HMP Maidstone on the effectiveness of activities undertaken to prepare prisoners for release both in the UK and abroad.
HMPPS
Bedford (2023)
Prisoners need to attend the pre-release board and we hope that the prison can facilitate this.
Governor / Director
The Mount (2025)
HMPPS should consider prohibiting the transfer of a prisoner from one establishment to another within, say, three months of their release date unless there is a particular reason for doing so, such as to be nearer to their family.
HMPPS Noted
Maidstone (2023)
Give permission to HMP Maidstone to offer a release on temporary licence.
HMPPS
Leyhill (2023)
What steps will be taken to speed up the work and enhance the efficiency of the community offender managers (COMs) in the external probation service?
HMPPS
Health investigations(482)
Independent investigation: Alan Geddes, Aberdeen (2019) — Rec 5
The Scottish Government should work with services to implement the three day follow up post discharge standard to bring it in line with NCISH recommendations (72 hours).
scotland
Independent investigation: Alan Geddes, Aberdeen (2019) — Rec 3
HSCP/NHS A should carry out a review of the discharge planning paperwork process and undertake an audit to ensure that discharge planning processes are understood and complied with.
scotland
Independent investigation: Sidney Waller, Manchester (2008) — Rec 5
The PCT must be given reassurances in relation to the use of the Mental Health Act (07), its appropriateness and in particular pay attention to evidence to monitor Section 117 aftercare to ensure that services are following individuals and that individuals are not left at risk when moving through services.
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 1
The Trust should ensure that the revised CPA Policy is implemented robustly throughout the organisation. The implementation should include the monitoring of: continual clinical review, particularly with regards to the role of the Care Coordinator; the personalisation of the care plan; work with carers and carer assessments; 117 aftercare planning …
north_west
Independent investigation: Katie Kazmi, Reading (1999) — Rec 11
A local protocol should exist between joint mental health services and housing agencies (at a senior level) to facilitate the CPA and local service provision processes.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 10
Where restricted patients are recalled to hospital social services should ensure that there is a joint assessment of the continuing housing needs including consideration of the appropriateness of the previous placement.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 1
All parties should understand the context in which conditions are attached to restricted patients’ discharge by tribunals, or are added by the Home Office. The Home Office should issue guidance on the standing of conditions when there may be no sanctions in the event of breach.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 4
Where restricted patients are recalled to hospital social services should ensure that there is a joint assessment of the continuing housing needs including consideration of the appropriateness of the previous placement.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 13
The Home Office and the DofH should prepare a model information leaflet for the use of professionals (including housing), family and carers who are involved with conditionally discharged patients. The leaflet should explain the patient’s legal status and contain the names and contact information for both supervisors and those others …
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 13
In its review of Guidance the Home Office should include the recommendation that all conditionally discharged patients are considered by Potentially Dangerous Persons Panels.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 10
The Home Office should require supervisors to undertake an annual case review, with a particular emphasis on long-term goals. Reports of these meetings should be considered by the Home Office at its annual review, together with that year’s CPA and case-conference records.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
The DofH and The Home Office should prepare a model information leaflet for the use of professionals (including housing), family and carers who are involved with conditionally discharged patients. The leaflet should explain the patient’s legal status and contain the names and contact information for both supervisors and those others …
south_east
Independent investigation: Bridget MaclennanElizabeth Valad, Camden — Rec 7
Good practice would indicate that discharge planning (including housing) should begin at admission.
london
Independent investigation: Brian Cherry, Walthamstow (2004) — Rec R1
As has been stated by (Forensic Social Worker 1) and (JHC Psychiatrist 1), it seems appropriate for Mr Bryan to be transferred to an environment of lower security. Mr Bryan needs to move to a more challenging setting to further his rehabilitation.
london
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 1
NHS Trusts and Health Authorities should ensure that there is a clear procedure for the transfer of the statutory after-care duty on mental health services when an individual moves away from an area, together with a standard format for passing on pertinent information on risk management. This should include a …
london
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.3.2
The Division should insist that a formal written risk assessment and risk management plan, including a crisis management plan, is in place, before submitting a recommendation for conditional discharge to the First Minister. It should ensure that the symptoms and signs of the individual’s mental disorder are addressed in such …
scotland
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.1.8
The Health Board must ensure that there are clear readmission arrangements for conditionally discharged patients and that these arrangements have the support of the consultant psychiatrists involved. It must also ensure that these arrangements are clearly understood by any RMO taking over the care of a conditionally discharged patient.
scotland
Independent investigation: Simon Breed, Wood Green (2004) — Rec R14
If a person previously unknown to mental health services is admitted to the PICU and then leaves the unit and immediately returns to the community without being allocated a care coordinator this should be treated as a SUI.
london
Independent investigation: Sarah Jane Coghlan, Middlesbrough (2003) — Rec 1
When discharging patients to the psychiatric care of a GP, the discharge letter should give full information with regard to the future management of the patient, including a review of significant issues of which to be aware, all relevant risk factors that may trigger relapse, steps to take in case …
north_east_yorkshire
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec A
Where a breakdown in a community placement occurs, the existing review systems should be implemented.
east_of_england
Independent investigation: Richard Marden, Towcester (1999) — Rec 11
That the provision to a patient of a copy of his Discharge Summary at the time of his discharge should be considered as a matter of routine whenever a patient is discharged from care as an in-patient.(Para 11.5)
midlands
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.3.b
Inpatient teams, the CMHT, and vice versa. We noted difficulties in communicating information from inpatient to community teams on a patient’s admission and discharge. For example a patient taking their own discharge against medical advice could result in a delay in the transfer of relevant information. Likewise, we were told …
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1.d
Inpatients The use of the phrase ‘the transfer of relevant information’ from hospital team to community-based staff should be re-evaluated. Consideration should be given to itemising information to be made available where a patient is being discharged from an inpatient setting.
london
Independent investigation: Philip Ellison, Preston (2008) — Rec 6
The Trust should ensure that statutory duties under the Act are met: this is particularly relevant to community treatment and supervision and to meeting obligations to provide aftercare under Section 117 Mental Health Act. There should be systems in place to ensure that staff carrying out these responsibilities meet Trust …
north_west
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 24
Trusts should review all policies, formal or informal, that prescribe general rules for discharge from services, and ensure that they are not applied in a formulaic way. Discharge should be dictated not by non attendance per se, or by self evaluation, or by rigidly applying service criteria, but by clinical …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 18
Whilst not all patients who have been in medium secure hospitals require ongoing support from forensic services, mechanisms should be put in place to ensure that such patients are discussed with the local forensic services when they are discharged into the community. Ideally, the forensic services should be invited to …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 15
The panel recognises the pressure that may force psychiatrists to rapidly admit a patient to hospital where there is an urgent need for treatment. However the appropriateness of the placement should be kept under close review, and the trust should ensure that the responsible psychiatrist is supported in finding an …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 4
If a patient is admitted to an independent hospital outside the local area, progress reports are sent to the care coordinator and the funding authority at least every three months.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 3
Formal care planning meetings, involving current and future care providers, must be held prior to a patient being discharged from hospital, and prior to any event that is known to have the potential to result in the patient being discharged ( in this case, the expiry of the Section 38 …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 2
Trusts should ensure that all patients subject to CPA have a designated care coordinator who should be responsible for following the patient throughout stays in hospital whether locally or further afield, within the NHS or within the private sector. It should be the responsibility of the treating hospital to ensure …
north_east_yorkshire
Independent investigation: Liaquat Ali, Bury (1999) — Rec 4.i
We recommend that the three North West Medium Secure Units and the Secure Commissioning Team consider how to manage, from a service perspective, a North West patient admitted to a North West Medium Secure Unit who is out of their catchment area. In our view, the Forensic Service needs to …
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.i
The Trust’s Supervised Discharge Policy needs to be re-written to better reflect the Department of Health’s Guidance. Staff should receive training on the use of supervised discharge and guardianship.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.h
The Trust and the local social services authority must strengthen their Section 117 procedures. Individuals who are entitled to aftercare should not be discharged from hospital before appropriate aftercare facilities have been identified. Once discharged, the patient’s progress must be actively monitored. Regular Section 117 meetings should be held, with …
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.g
The patient’s Responsible Medical Officer should discharge their responsibilities as set out in paragraph 27.6 of the Code, in particular the assessment of any risk to the patient or third parties and the consideration of the criteria for supervised discharge or guardianship.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.f
Aftercare planning, including the granting of leave and discharge arrangements, should comply with paragraph 27.6 of the Code of Practice.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.e
The patient’s nearest relative should be actively involved in aftercare planning, if the patient consents, and their views must be documented and properly taken into consideration by the care team.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.iii.b
Patients who move out of one area to another should remain the active responsibility of the original authority until a formal handover can be arranged. A formal handover implies real team to team discussion, nor merely a paper passing exercise, and which should be timely and include: • Team to …
north_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 34
DPT will audit understanding of and adherence to operational policies and care pathways.
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 32
DPT will complete the service redesign work in preparation for the implementation of PbR cluster pathways in 2013. This will fundamentally change the structure of services and both simplify and clarify care pathways. Implementation will include a communication plan with DPT clinicians and referring clinicians in respect of the new …
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 28
South Devon Healthcare Trust will monitor the implementation of the policy concerning the handover of the care of a mother from one midwifery team to another.
south_west
Independent investigation: Laura Sturla, Gillingham (2003) — Rec 13
The trust should ensure that all patients discharged from an acute inpatient ward have a follow-up appointment arranged prior to discharge.
south_east
Independent investigation: Laura Sturla, Gillingham (2003) — Rec 11
The trust should ensure that discharge planning commences on admission for all patients admitted to an acute inpatient ward.
south_east
Independent investigation: Karen Leonard, Middlesbrough (2009) — Rec 6
(a) The inquiry recommends that the Tees, Esk and Wear Valley NHS Foundation Trust and the Local Authorities that it works in partnership with should review the current policy in relation to Section 117 aftercare and endorse their joint working approach. They should ensure full compliance of their joint responsibilities …
north_east_yorkshire
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 8
The panel recommends that the Trust reviews within three months the current practice of the discharge policy and ensure that the discharge of patients should only take place according to the DoH circular HSG(94)27. (Paragraph 5.14)
east_of_england
Independent investigation: Joan Smythe, Rainham (but SE Coast patient) (2002) — Rec 20.1.d
Current CPA policy and procedures should be amended to take into account the following: Inpatients. The use of the phrase ‘the transfer of relevant information’ from hospital team to community-based staff should be re-evaluated. Consideration should be given to itemising information to be made available where a patient is being …
south_east
Independent investigation: Jenny Morrison (s/w), Balham,S London (1998) — Rec 1
The South West London and St. George’s Mental Health NHS Trust and the London Borough of Wandsworth fully implement and monitor the Guidance issued by the Department of Health in October 1999 entitled, “Effective Care Co-ordination in Mental Health Services”. There should be particular reference to the provisions concerning the …
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 28
No-one should be discharged from the mental health services upon being sentenced to a term of imprisonment unless, as in the case of a lengthy prison sentence, the responsibility for delivering the care plan is transferred to the prison mental health care services, who would then have the responsibility for …
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 20
ADischarge Protocol should be formulated which covers: (cid:2) reasons for discharge (cid:2) arrangements for discharge and aftercare (cid:2) decision making processes in respect of discharge.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 19
When any patient is discharged from in-patient care or goes AWOL, the patient’s GPand any other agency involved in the patient’s care should be notified (preferably by fax) of the discharge as soon as possible and in any event within 24 hours, with details of the aftercare plan and any …
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 17
If a patient is admitted to hospital and then discharged before a CPA meeting can be convened, the meeting should take place as soon as possible after discharge.
london
Scottish Fatal Accident Inquiries(5)
Robert William Marshall
It seems to me that if inmates are discharged from hospital when they are stabilised, as happened to Mr Marshall on numerous occasions, then greater provision for care of a nursing nature may require to be looked at by the relevant authority.
Nov 2011
Christina Anne Wilson
That being said, I think it is important that there should be full dialogue between the lead professional in the patient’s care in the hospital and the care home manager before any patient is transferred from hospital to a care home. This dialogue should include the patient and, if possible, a family member and should be fully documented.
Jan 2019
Roderick McIntosh Donnet
Changes must be made utilising modern technology to end this unacceptable state of affairs to ensure that GPs are made aware as soon as possible, and in any event within no more than seven days, by a doctor who played an active role in the patient's in-patient treatment, what was the basis for the discharge, what was the diagnosis and …
Aug 2007
Lee Russell
In terms of Section 6(1)(e) of the said Act, that the following were further facts relevant to the circumstances of the death namely, in the event of a person who is in custody being seen by a medical practitioner, the reasons for that person being seen by that practitioner and any treatment and medication received by that person should be …
May 2009
Scott Andrew Ross
1. There should be a co-ordinated approach between the hospital and the prison systems in the management of a prisoner’s drug withdrawal. 2. Those managing benzodiazapine withdrawal should consider carefully the proper dosage required for safe discontinuation. Under-prescription in respect of benzodiazapine discontinuation may cause seizures, which can cause brain damage and death; the expert evidence was that overprescription was …
Feb 2024 Custody 4 recs
Detention investigations(1)
Independent reviews(16)
Women’s Justice Board report — Rec 9
Improve resettlement prospects by removing barriers to employment.
Health & Social Care
Carter NHS Productivity Review — Rec 10
DH, NHS England and NHS Improvement, working with local government representatives, to provide a strategy for trusts to ensure that patient care is focussed equally upon their recovery and how they can leave acute hospitals beds, or transfer to a suitable step down facility as soon as their clinical needs …
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 32
Providers and practitioners should provide continuity of care. Patients should be offered appropriate follow-up and after-care, rather than stand-alone procedures.
Health & Social Care
Bubb Report — Rec 10
A 'Life in the Community' Social Investment Fund should be established to facilitate transitions out of inpatient settings and build capacity in community-based services. The Investment Fund, seeded with £30 million from NHS England and/or Government, could leverage some £200 million from other investors to make investment more easily accessible …
Health & Social Care
Bubb Report — Rec 5
The Government should look at ways to protect an individual's home tenancy when they are admitted to hospital, so that people do not lose their homes on admission and end up needing to find new suitable accommodation to enable discharge.
Health & Social Care
Bubb Report — Rec 3
People with learning disabilities and/or autism and their families should be given a 'right to challenge' decisions to admit or continue keeping them in inpatient care. They should receive independent expert support to exercise that right, including high-quality independent advocacy.
Health & Social Care
Wanless Review — Rec 12
The Government should examine the merits of employing financial incentives such as those used in Sweden to help reduce the problems of bed blocking (6.45).
Health & Social Care
Shaw Detention Review — Rec 48
Recommendation 48: Home Office staff should be reminded that, to ensure continuity of care, detainees should not be transferred when there is clinical advice to the contrary.
Immigration
Taylor Youth Justice Review — Rec 32
Local authorities should make sure that all children should know where they are going to live at least two weeks before they leave custody, and if they are in care or will be living away from the family home they should have the opportunity to visit the accommodation, see their …
Justice & Legal
Wessely Review — Rec 73
Discharge planning should be improved, as part of the Care and Treatment Plan during detention, to ensure it is being considered from day one, and should be recorded and updated in the SCP post detention.
Health & Social Care Accepted
Wessely Review — Rec 50
A statutory power should be introduced for IMHAs and Nominated Persons to apply for discharge to the Tribunal on behalf of the patient.
Health & Social Care Accepted
Wessely Review — Rec 47
The tribunal should have the power, during an application for discharge, to grant leave from hospital and direct transfer to a different hospital, as well as a limited power to direct the provision of services in the community.
Health & Social Care Accepted
Wessely Review — Rec 19
NPs and INPs should be consulted about a renewal of a patient's detention, extension of a community treatment order, transfer from one hospital to another, and discharge, rather than simply notified.
Health & Social Care Accepted
Gauke Review — Rec 6.6
Increase the use of Early Release on Compassionate Grounds for suitable older offenders
Justice & Legal
Women’s Justice Board report — Rec 8
Support effective expansion of women's ISCs.
Health & Social Care
Angiolini Review — Rec 89
The College of Policing APP on detention and custody and force training should include guidelines for pre-release risk assessment setting out specific practical steps that should be taken to provide support and protection for those at risk of self-harm on release (for example contacting family/carers before release with the detainee’s …
Policing & Security Accepted
PHSO casework decisions(288)
P-003080 — Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr A complained his wife was prematurely discharged from hospital without a care package or explanation, causing stress that accelerated her deterioration and contributed to her subsequent death.
NHS in England Oct 2024
P-003301 — Malling Health
Mrs S complained Malling Health failed to arrange a welfare check for her father after being unable to contact him, instead discharging him, which she believes led to a missed opportunity for medical care.
NHS in England Upheld Jan 2025
P-003303 — Manchester University NHS Foundation Trust
Mr G said the Trust failed to properly assess his father before discharge, leading to readmission within two hours and death the next day.
NHS in England Jan 2025
P-003611 — East Kent Hospitals University NHS Foundation Trust
Mrs A complained East Kent Hospitals University NHS Foundation Trust discharged her too soon after colon surgery, leading to an undetected wound infection that ruptured, required further surgery, and delayed chemotherapy.
NHS in England Jun 2025
P-004690 — University Hospitals Birmingham NHS Foundation Trust
Mrs A complained her mother was injured by a faulty dialysis chair, the incident was undocumented, and the Trust failed to provide an adequate discharge plan, leading to her mother's fall at home.
NHS in England Jan 2026
P-001089 — Royal United Hospitals Bath NHS Foundation Trust
Miss N complained her mother was unsafely discharged while unwell and disorientated, without family consultation, appropriate support, or correct medication type in place.
NHS in England Upheld Jun 2021
P-001094 — The Royal Bournemouth and Christchurch Hospitals NHS Foundation …
Mrs U complained The Trust provided insufficient continence care for her father, inappropriately discharged him, and failed to communicate his needs to the care home.
NHS in England Not Upheld Aug 2021
P-001229 — University Hospitals Birmingham NHS Foundation Trust
Mr L complained doctors failed to act on his father Mr E's CT scan results and inappropriately discharged him, and that the Trust's complaint responses left questions unanswered.
NHS in England Dec 2021
P-001233 — Buckinghamshire Healthcare NHS Trust
Ms T complained the Trust provided inadequate care for her partner Mr S, including poor hydration, hygiene, and compassion, and failed to communicate his deteriorating health and death.
NHS in England Upheld Dec 2021
P-001293 — United Lincolnshire Hospitals NHS Trust
Ms A complained the Trust inappropriately discharged her client, Mr H, to an empty home instead of a hospice, leading to him being found distressed and dying two days later.
NHS in England Feb 2022
P-001379 — County Durham and Darlington NHS Foundation Trust
Mr G complained he was left unattended for long periods, prescription details weren't sent to his GP, and a cannula was left in his hand on discharge.
NHS in England Apr 2022
P-001468 — The Dudley Group NHS Foundation Trust
Miss K complained her mother was incorrectly discharged while unwell, then discharged to the wrong residential care setting, and received inadequate physiotherapy during her admissions.
NHS in England Not Upheld Jul 2022
P-001454 — Barnsley Hospital NHS Foundation Trust
Mrs E complained hospital staff did not properly account for her husband's dementia, discharged him without adequate care, and he sadly passed away shortly after discharge.
NHS in England Not Upheld Jul 2022
P-001607 — Hull University Teaching Hospitals NHS Trust
Ms T complained about Hull University Teaching Hospitals NHS Trust discharging her mother, Mrs K, without a care plan or notifying her GP/social services. She also cited a fall at another trust and delayed notification.
NHS in England Nov 2022
P-001670 — Sheffield Teaching Hospital NHS Foundation Trust
Mr R complained about premature and incorrect discharge arrangements for his mother, including unactioned care packages, missing discharge notes, and his mother being left to use a pad.
NHS in England Dec 2022
P-001660 — Northern Care Alliance NHS Foundation
The Trust improperly discharged a very unwell COVID-19 patient, had a COVID-positive relative collect her, provided insufficient basic care, restricted visitors, and gave unclear updates.
NHS in England Dec 2022
P-001680 — Gateshead Health NHS Foundation Trust
There was poor communication, medication errors, incorrect NHS numbers on a DNACPR, and unsatisfactory discharge risk assessment during the patient's inpatient stay.
NHS in England Dec 2022
P-001750 — East Suffolk and North Essex NHS Foundation Trust
The Trust failed to include Mr K's manual handling and exercise needs in his discharge summary and care plan, leading to his deterioration and subsequent death.
NHS in England Partly Upheld Jan 2023
P-002013 — Bedfordshire Hospitals NHS Foundation Trust
Mrs C complained the Trust discharged Mr J while he was clinically dehydrated and immobile, leading to distress and readmission. She also cited poor communication of his condition to the family.
NHS in England Partly Upheld Jun 2023
P-003877 — Nottingham University Hospitals NHS Trust
Ms T complained the Trust's care for her mother, Mrs T, failed in individualised care, coordinated planning, and communication, leading to her deterioration and death.
NHS in England Partly Upheld Jul 2023
P-002274 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss B complained the Trust wrongly discharged her father while he was still bleeding severely, which she believes contributed to his death. She also experienced worry and distress.
NHS in England Oct 2023
P-002252 — Royal Cornwall Hospitals NHS Trust
A husband complained the Trust discharged his wife after a misdiagnosis of no hip fracture, delaying her treatment and causing her health to deteriorate.
NHS in England Oct 2023
P-002377 — Barts Health NHS Trust
Mr E complained a Trust failed to properly assess and treat his mother, discharging her unfit, leading to an undiagnosed infection, broken back, and ultimately her death.
NHS in England Dec 2023
P-002466 — University Hospitals Birmingham NHS Foundation Trust
Mrs R complained her grandmother received poor hygiene care, was discharged without a care package or oxygen instructions, and capacity for a DNAR form was questionable.
NHS in England Upheld Feb 2024
P-003682 — Warrington and Halton Hospitals NHS Foundation Trust
Mrs R alleged poor handover of her late husband's gallbladder drain care and delayed removal, contributing to infections and his death.
NHS in England Partly Upheld Aug 2024
P-002965 — The Rotherham NHS Foundation Trust
Miss and Mr G complained the Trust gave opiate medication despite adverse reactions, prematurely discharged their mother, had poor communication, and she contracted COVID-19, leading to her death.
NHS in England Partly Upheld Sep 2024
P-003084 — Sheffield Teaching Hospitals NHS Foundation Trust
Ms N complained the Trust prematurely discharged her autistic, non-verbal brother before his infection cleared, without suitable provisions. She believes his disability and skin colour influenced his care, leading to his death.
NHS in England Oct 2024
P-003169 — Leicestershire Partnership NHS Trust
Complaint against two Trusts for missed heart failure diagnosis, inappropriate discharge, and other care failings concerning Mr R.
NHS in England Nov 2024
P-003297 — Royal Devon University Healthcare NHS Foundation Trust
Mrs E complained Royal Devon University Healthcare NHS Foundation Trust staff failed to communicate with her and her son, inappropriately discharged him without monitoring, and stopped his omeprazole prescription.
NHS in England Partly Upheld Jan 2025
P-003295 — South Tyneside and Sunderland NHS Foundation Trust
Miss U complained the Trust failed to provide her mother adequate hydration and did not communicate its decision to place a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order.
NHS in England Upheld Jan 2025
P-003316 — Herefordshire and Worcestershire Health and Care NHS Trust
Mr and Mrs D complained H&W Trust failed to provide appropriate home care after Mr F's hospital discharges, and WAH Trust discharged him without an adequate care plan. They alleged this led to neglect, sepsis, and his death.
NHS in England Partly Upheld Feb 2025
P-003349 — Mid and South Essex NHS Foundation Trust
Staff allegedly failed to provide adequate nutrition/hydration, ensure physiotherapy, and discharged Mr I when he was unfit, leading to his death after nine days.
NHS in England Partly Upheld Feb 2025
P-003587 — Royal Cornwall Hospitals NHS Trust
Mrs B complained the Trust discharged her husband, Mr A, while he had a fever and couldn't swallow medication, and failed to provide a discharge summary. His subsequent death caused her distress.
NHS in England Jun 2025
P-003598 — Gloucestershire Health and Care NHS Foundation Trust
Mrs N complained the Hospital Trust caused discharge delays and both Trusts failed to assess and provide adequate home care for her terminally ill husband, especially in his narrowboat home.
NHS in England Jun 2025
P-003600 — Rotherham, Doncaster and South Humber NHS Foundation Trust
Mr A complained Rotherham, Doncaster and South Humber NHS Foundation Trust wrongly discharged him from its services, denying him care and treatment for his PTSD, depersonalization disorder, and body dysmorphic disorder.
NHS in England Jun 2025
P-003679 — University Hospitals of North Midlands NHS Trust
Mrs A complained the Trust failed to put her father on end-of-life care, discharged him incorrectly, and had poor family communication, causing her significant distress.
NHS in England Upheld Jul 2025
P-003729 — Portsmouth Hospitals University NHS Trust
Mr O complained the Trust prematurely discharged his wife, mismanaged medication, ignored her broken shoulder, delayed emergency response, and had poor communication, leading to her earlier death.
NHS in England Upheld Jul 2025
P-003701 — University Hospitals Sussex NHS Foundation Trust
Mrs N complained her husband was wrongly discharged from A&E with low oxygen and that a heart clinic later delayed urgent intervention for his angina, contributing to his death.
NHS in England Jul 2025
P-003801 — Central and North West London NHS Foundation Trust
Mr W complained the Trust unsafely discharged his mother and failed to manage her choking risk, or respond appropriately during a choking episode, contributing to her death.
NHS in England Aug 2025
P-003816 — South Warwickshire University NHS Foundation Trust
Mrs K complained two Trusts provided poor care to her father. Allegations included inappropriate discharge without treating jaundice, delayed jaundice treatment, poor communication, and inadequate nursing care, contributing to his death.
NHS in England Aug 2025
P-003942 — Oxford University Hospitals NHS Foundation Trust
Ms T complained the Trust only offered hormone therapy for Mr R's prostate cancer, informed him of brain cancer against his wishes, and provided inappropriate physiotherapy after hip replacement, which she believed led to his deterioration.
NHS in England Upheld Sep 2025
P-004034 — Isle of Wight NHS Trust
Mrs F complained about the Trust's decision to move her father from ICU, his subsequent monitoring, circumstances surrounding his cardiac arrest, and poor communication, believing his death was avoidable.
NHS in England Sep 2025
P-003963 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mrs G complained the Trust failed to adequately monitor her mother's condition, perform risk assessments, give timely antibiotics, perform an angiography, assess fall risk, do a timely ABG test, or provide palliative care, leading to her traumatic death.
NHS in England Partly Upheld Sep 2025
P-004033 — Kettering General Hospital NHS Foundation Trust
Mr L complained about his late father's profound weight loss, unaddressed pressure sore, contracting COVID-19 and C. diff, poor fluid balance, unprogressed mental health referral, and ineffective pain control.
NHS in England Partly Upheld Sep 2025
P-003999 — East Kent Hospitals University NHS Foundation Trust
Mrs E complained the Trust failed to diagnose her father after surgery, poorly managed sepsis, lacked awareness of blood clots, and did not refer his death to the coroner, causing his death.
NHS in England Sep 2025
P-004086 — University Hospitals Sussex NHS Foundation Trust
The Trust provided inadequate care to her husband, including minimal senior review, inappropriate medication, poor pain management, and a fall due to lack of supervision, contributing to his death.
NHS in England Partly Upheld Sep 2025
P-004240 — A practice in the Hastings area
Doctor allegedly gave an end-of-life diagnosis without examination, withheld food/liquids, and excluded family. Mrs A also reported a rude nurse, delayed in-person visits, and reluctance to adjust care.
NHS in England Nov 2025
P-004439 — The Princess Alexandra Hospital NHS Trust
A man complained about his mother-in-law's care, citing poor hygiene, inadequate investigation of deterioration, mistaken morphine administration, and unsuitable discharge.
NHS in England Dec 2025
P-004769 — Worcestershire Acute Hospitals NHS Trust
Mr B complained the Trust prematurely discharged his father and didn't give the family necessary information before they withdrew treatment.
NHS in England Feb 2026
P-004753 — Guy's and St Thomas' NHS Foundation Trust
Mrs O complained about her brother's discharge, including being discharged before he was fit, lack of assessments/referrals, and a delayed complaint response from Guy's and St Thomas' NHS Foundation Trust.
NHS in England Jan 2026
LGO / SPSO decisions(455)
21-017-636 — London Borough of Hillingdon
Summary: We will not investigate Mr X’s complaint about the Council’s handling of a planning matter. This is because the complaint is late and the injustice Mr X claims is not the result of any fault by the Council.
LGO (Local Government & … Planning Mar 2022
21-018-433 — Kirklees Metropolitan Borough Council
Summary: We will not investigate this complaint about how the Council dealt with the complainant’s planning application. This is because the complainant had the right to appeal to the Planning Inspector.
LGO (Local Government & … Planning Mar 2022
21-013-691 — Buckinghamshire Council
Summary: Ms X complains about the Council’s failure to enforce a condition of a planning permission granted by the Planning Inspectorate. There was fault by the Council because of unreasonable delay in dealing with the matter. The Council agreed to act to remedy the injustice.
LGO (Local Government & … Planning Upheld Mar 2022
21-012-644 — Bolton Metropolitan Borough Council
Summary: Mrs X complained about the Council’s decision to approve a large storage facility on land near her home, which she feels affects her amenities. There was some fault in the way the Council made its decision (which it had already agreed to remedy) but this did not cause a …
LGO (Local Government & … Planning Upheld Mar 2022
21-004-337 — Kirklees Metropolitan Borough Council
Summary: Mrs D complains about planning advice provided by the Council. The Ombudsman has discontinued the investigation because there is not enough evidence of fault to warrant further investigation.
LGO (Local Government & … Planning Not Upheld Mar 2022
20-014-193 — Calderdale Metropolitan Borough Council
Summary: Mr C complains about the Council’s response to his reports of breaches of planning control which he says allowed a harmful impact on his family’s residential amenity and led to him spending unnecessary time and trouble in trying to resolve the matter. We have found fault by the Council …
LGO (Local Government & … Planning Upheld Mar 2022
21-018-503 — East Lindsey District Council
Summary: We will not investigate this complaint about how the Council dealt with a planning application. This is because we are unlikely to find fault. The complainant has also not been caused significant injustice as a result of the alleged fault.
LGO (Local Government & … Planning Mar 2022
23-014-300 — Hartlepool Borough Council
Summary: X complained about the Council’s failure to take ownership of land used as a car park under the terms of a legal agreement. X also complained that the evidence they had provided to the Council about anti-social behaviour had not been presented to members of a committee tasked with …
LGO (Local Government & … Planning Upheld Jun 2024
24-020-114 — Isle of Wight Council
Summary: We cannot by law investigate this complaint about an alledged failure by the Council to provide information to the Planning Inspectorate for the purposes of an appeal. This is because we have no legal jurisdiction to investigate a complaint when an appeal has been made to the Planning Inspectorate, …
LGO (Local Government & … Planning Apr 2025
24-021-217 — Havant Borough Council
Summary: We will not investigate Mr X’s complaint about the Council’s handling of a planning enforcement matter. This is because there is not enough evidence of fault by the Council affecting its decision not to take formal enforcement action.
LGO (Local Government & … Planning May 2025
24-020-778 — Huntingdonshire District Council
Summary: We will not investigate this complaint about the Council’s decision not to take formal action regarding the condition of his neighbour’s land. There is not enough evidence of fault in the Council’s decision-making process to warrant us investigating.
LGO (Local Government & … Planning May 2025
25-004-016 — Blackburn with Darwen Council
Summary: We will not investigate this complaint about the way the Council decided the complainant’s planning application. He appealed to the Planning Inspector against the Council’s refusal. This complaint is therefore outside our jurisdiction.
LGO (Local Government & … Planning Aug 2025
25-003-488 — Nottinghamshire County Council
Summary: We will not investigate Mrs X’s complaint about the Council’s involvement as a flood risk consultee on a planning application she made to a different authority.
LGO (Local Government & … Planning Aug 2025
25-014-132 — Winchester City Council
Summary: We will not investigate this complaint about how the Council dealt with a planning application. This is because the complainant had the right to appeal to the Planning Inspector.
LGO (Local Government & … Planning Dec 2025
25-010-201 — North Northamptonshire Council
Summary: We will not investigate this complaint that the Council has refused to engage with complainant about finding a viable use for a listed building he owns. There is insufficient evidence of fault in the way the Council has responded to the request for engagement, and we cannot investigate alleged …
LGO (Local Government & … Planning Dec 2025
202302720 — Forth Valley NHS Board
C complained about their attendance at the A&E after their child (A) had a seizure. C said that A’s observations (to measure vital signs like heart rate, blood pressure, and temperature) had not been taken, but that the nurse had told C that they were. C also raised concerns about …
SPSO (Scottish Public Se… Health Upheld Feb 2025
NIPSO-17984 — Belfast Health and Social Care Trust
The Belfast Health and Social Care Trust has apologized to a patient who was forced to arrange her own care package after being discharged from the Royal Victoria Hospital, Belfast.
NIPSO (NI Public Service… Health & Social Care May 2019
NIPSO-20700 — Belfast Health and Social Care Trust
We found that the Belfast Health and Social Care Trust did not provide a patient with a multi-disciplinary review prior to her discharge from the Royal Victoria Hospital.
NIPSO (NI Public Service… Health & Social Care Feb 2021
PSOW-202500164 — Betsi Cadwaladr University Health Board
Ms A complained about the care and treatment provided to her father, by the Health Board, between November 2023 and September 2024 and that the response provided to her complaint did not address all of her concerns. The Ombudsman found that, although the Health Board had conducted an investigation into …
PSOW (Public Services Om… Health Aug 2025
21-014-981a — HCRG Care Group (21 014 981a)
Summary: We found the Council and HCRG Care Group failed to inform Mr C’s family that the care agency supporting him would be unable to do so on a long-term basis. This meant that, when the care agency withdrew care, Mr C’s family were given very little time to arrange …
LGO (Local Government & … Health Upheld Jul 2022
21-014-334 — London Borough of Enfield
Summary: There was a delay in completing an occupational therapy assessment for Ms Y which caused avoidable inconvenience and frustration. The Council will apologise, make payments of £500 to Ms Y and £150 to Mr X for his avoidable time and trouble. It will also review procedures as described in …
LGO (Local Government & … Adult Care Services Upheld Aug 2022
22-003-374 — Kent County Council
Summary: We will not investigate this complaint about the Council’s social worker provision. This is because there is insufficient evidence of a significant injustice to warrant investigation.
LGO (Local Government & … Adult Care Services Aug 2022
21-005-829a — Warrington & Halton Hospitals NHS Foundation Trust (21 …
Summary: Mrs B complains about what happened when her father, Mr C, was discharged from hospital after attending with a fractured collarbone, and about arrangements for putting a care package in place. We found the Trust was at fault for the lack of information given to Mr C and his …
LGO (Local Government & … Health Upheld Sep 2022
21-013-816b — Bromley Healthcare CIC Ltd (21 013 816b)
Summary: Mrs D complained about the way the Council, the Trust and Bromley Healthcare dealt with her late brother Mr S’s discharge from hospital, wheelchair provision and social care. We have not upheld the complaints about the Council and Bromley Healthcare. Most complaints about the Trust are also not upheld. …
LGO (Local Government & … Health Not Upheld Oct 2022
21-013-816a — Kings College Hospital NHS Foundation Trust (21 013 …
Summary: Mrs D complained about the way the Council, the Trust and Bromley Healthcare dealt with her late brother Mr S’s discharge from hospital, wheelchair provision and social care. We have not upheld the complaints about the Council and Bromley Healthcare. Most complaints about the Trust are also not upheld. …
LGO (Local Government & … Health Upheld Oct 2022
22-003-473 — Surrey County Council
Summary: We will not investigate Mr B’s complaint about the Council’s failure to assess Ms C and charge her for her placement. This is because the Council has acknowledged its failings and remedied the fault.
LGO (Local Government & … Adult Care Services Upheld Oct 2022
21-008-070 — Essex County Council
Summary: Mr L complained about the way the Council supported his son, Mr X’s care needs. Mr L said the Council failed to meet Mr X’s care needs and failed to meet his, and his wife’s needs as carers. The Council delayed in assessing the care and support needs and …
LGO (Local Government & … Adult Care Services Upheld Oct 2022
21-017-310 — Medway Council
Summary: The Council took too long to review Mr B’s financial assessment which allowed arrears to accrue. It also did not properly consider whether he could afford to pay the arrears. The Council has agreed to take the action recommended below.
LGO (Local Government & … Adult Care Services Upheld Oct 2022
20-011-643 — London Borough of Croydon
Summary: Miss X complains the Council has prolonged her stay in residential care, but the evidence shows the Council has made every time to enable a supported return home. Miss X has so far chosen not to pay for the renovations her house requires to be habitable.
LGO (Local Government & … Adult Care Services Not Upheld Oct 2022
23-012-080 — Bournemouth, Christchurch and Poole Council
Summary: Mrs D complained the Council delayed assigning a social worker and completing an assessment of her daughter’s care and support needs. We find the Council was at fault for its delay in assigning a social worker and completing the assessment. The Council has agreed to make a payment to …
LGO (Local Government & … Adult Care Services Upheld May 2024
23-011-466 — Lancashire County Council
Summary: Mrs A has complained about a hospital trust and a council in relation to her mother, Mrs B’s discharge to a care home and the fees her mother was charged. We found fault with the Council and the Trust in relation to the discharge a delay in moving Mrs …
LGO (Local Government & … Adult Care Services Upheld Jul 2024
24-003-689 — New Forest National Park Authority
Summary: We will not investigate this complaint about the Authority’s handling of a planning application for development at a site close to Mr X’s home. This is because we are unlikely to find evidence of fault by the Authority or injustice caused to Mr X sufficient to warrant an investigation.
LGO (Local Government & … Planning Jul 2024
24-004-957 — East Devon District Council
Summary: We will not investigate this complaint about the Council’s building control service. This is because we are unlikely to find fault.
LGO (Local Government & … Planning Jul 2024
24-004-524 — Derbyshire County Council
Summary: We will not investigate this complaint about the response the Council provided to a consultation request for a planning application. This is because we are unlikely to find fault.
LGO (Local Government & … Planning Jul 2024
23-016-286 — Folkestone & Hythe District Council
Summary: Mr D complains the Council delayed seeking compliance with a planning Enforcement Notice. We have not found evidence of fault by the Council and have completed the investigation and not upheld the complaint.
LGO (Local Government & … Planning Not Upheld Jul 2024
23-016-127 — Staffordshire Moorlands District Council
Summary: Mrs X complained the Council has failed to take timely and appropriate action in relation to breaches of planning control at a site next to her home. She complained the new houses loom over and reduce the natural light and privacy to her home. The Council’s failure to properly …
LGO (Local Government & … Planning Upheld Jul 2024
24-006-312 — City of Doncaster Council
Summary: We will not investigate Mr B’s complaint about the Council not taking planning enforcement action against his neighbour. This is because there is not enough evidence of fault to justify an investigation.
LGO (Local Government & … Planning Jul 2024
23-011-152a — Calderdale & Huddersfield NHS Foundation Trust (23 011 …
Summary: Ms D complains about faults by Calderdale Metropolitan Borough Council and Calderdale & Huddersfield NHS Foundation Trust in managing her mother, Mrs X’s, discharge from hospital. We have upheld Ms D’s complaints about assessing Mrs X’s ability to make her own decisions, consent and sharing information about community nursing …
LGO (Local Government & … Health Upheld Aug 2024
24-000-008 — London Borough of Ealing
Summary: Mrs Y complained the Council failed to arrange suitable care for her mother, Mrs X, when she was discharged from hospital. Mrs Y said this meant she and her sister, Ms W, had to provide the care instead. The Council was at fault for delay in arranging a new …
LGO (Local Government & … Adult Care Services Upheld Aug 2024
23-014-778a — Lewisham & Greenwich NHS Trust (23 014 778a)
Summary: We consider London Borough of Lewisham and Lewisham and Greenwich NHS Trust did not appropriately seek the views of Mrs Y’s supported accommodation before deciding she could not return there from hospital. Also, the Council did not carry out a Mental Capacity Act assessment and best interest decision in …
LGO (Local Government & … Health Upheld Sep 2024
23-020-329 — London Borough of Enfield
Summary: We will not investigate this complaint about a lack of action on the complainant’s reports of breaches of planning control and building regulations. There is not enough evidence of fault in the Council’s actions to justify an investigation.
LGO (Local Government & … Planning Sep 2024
24-021-610 — London Borough of Sutton
Summary: We will not investigate this complaint about the way the Council decided to approve a planning application for a new property close to the complainant’s home. We have not seen enough evidence of fault in the decision-making process to justify an investigation. Also, we cannot achieve the outcome the …
LGO (Local Government & … Planning May 2025
24-013-233 — Herefordshire Council
Summary: Ms X complained the Council failed to take enforcement action over planning and licensing breaches from a neighbouring property. She said the breaches resulted in noise and anti-social behaviour, causing her distress. We found the Council took suitable steps to investigate Ms X’s complaints and was not at fault.
LGO (Local Government & … Planning Not Upheld Jul 2025
24-015-474 — Torbay Council
Summary: Mr X complained the Council has not taken planning enforcement action to control a development near his home that does not have planning permission. He said the Council delayed its investigation until four years elapsed since the build, then said the work was immune from enforcement. Mr X said …
LGO (Local Government & … Planning Upheld Aug 2025
25-006-223 — Bury Metropolitan Borough Council
Summary: We will not investigate Mr X’s complaint about the Council not taking action against a property developer. It is unlikely we would find fault.
LGO (Local Government & … Planning Aug 2025
24-019-452 — East Devon District Council
Summary: We will not investigate this complaint about planning advice as there is insufficient evidence of fault by the Council.
LGO (Local Government & … Planning Sep 2025
25-007-008 — Runnymede Borough Council
Summary: We will not investigate this complaint about the Council refusing to take planning enforcement action against an outbuilding, which was not built in accordance with the approved plans. There is insufficient evidence of fault in the way the Council reached its decision on the enforcement case, and an investigation …
LGO (Local Government & … Planning Sep 2025
25-006-435 — Forest of Dean District Council
Summary: We will not investigate this complaint about the Council’s handling of planning matters at a site next to where the complainant lived. This is because: it is reasonable to expect the complainant to have contacted us sooner; there is insufficient evidence of fault; it is reasonable for the complainant …
LGO (Local Government & … Planning Sep 2025
25-005-033 — London Borough of Brent
Summary: We will not investigate this complaint about the conduct of a Council officer during a telephone call with the complainant. We consider there is no worthwhile outcome achievable by our investigation.
LGO (Local Government & … Planning Sep 2025
25-002-990 — London Borough of Southwark
Summary: We will not investigate this complaint about the Council providing incorrect planning advice in 2023. We have not seen enough evidence of fault in the Council’s actions to justify an investigation.
LGO (Local Government & … Planning Sep 2025
Domestic Homicide Reviews(113)— showing 50 strongest matches
Manchester — recommendation Bridges 2
Three-way meeting between client, Bridges IDVA and IDVA service where client relocated to will be embedded into process to ensure transition/ continuation of support.
Bridges Domestic Abuse Support Services
Norfolk — recommendation Q
To improve communication and process between the criminal justice system and the general medical services in Norfolk at the point of release from prison including registration at a new practice, timely transfer of medical records and communication regarding ongoing physical and psychological needs as well as repeat medication.
Norwich GP
Wokingham — recommendation 1
We recommend that a system be put in place for a multi-disciplinary case conference to be held to review and plan care needs where the carer of a person with a life limiting physical or mental illness, in particular dementia, also experiences a life limited or potentially life ending physical …
Wokingham Community Safety Partnership
Wokingham — recommendation R5
RBFT discharge letters to GPs should include referrals made but also if and what referrals were declined
Royal Berkshire NHS Foundation Trust Royal Berkshire NHS Foundation …
Lancaster — recommendation 1.
Update Post Natal Care planning standards [SOP] to include transfer of care information and requirement to document family/household members and social support and who is present at visits.
Bolton NHS Foundation Trust Bolton NHS Trust
Barnet — recommendation 1
It is recommended that the Ministry of Justice review the current Prison release process and include the implementation of a Prison Release Risk Assessment which would be completed prior to every prisoner's release from the Courthouse (including video link court proceedings) thus ensuring notification and referral to appropriate agencies is …
Ministry of Justice Ministry of Justice
Bristol — recommendation 28
Process for people moving on from supported into council stock to include the Housing Officer and floating support worker making contact to establish relationship and ensure joint engagement with new tenant.
Bournemouth Borough Council – Strategic Housing …
South Gloucestershire — recommendation 11
BDP and BSDAS to review procedures for transferring service users from shared care to BSDAS specialist prescribing, to explore whether there are ways of more effectively facilitating service users attendance and engagement with the new team.
Avon and Wiltshire Mental Health Partnership … Avon and Wiltshire NHS …
Leeds — recommendation LYPFT1
Where a patient is being discharged from hospital clear information should be shared with the community service
Leeds & York Partnership Foundation Trust Leeds and York Partnership …
Leeds — recommendation 4.2
Leeds & York Partnership Foundation Trust will ensure that the safety of the victim and any children or adults at risk within the household is explicitly considered as part of discharge planning where domestic abuse is a known issue.
Leeds & York Partnership Foundation Trust Leeds and York Partnership …
Wiltshire — recommendation R40
For the team managing the RiO template documents to formally consider producing a new standard “Discharge to GP” editable letter in RiO that references a “Crisis and Contingency-type” plan. By AWP Clinical Systems Manager by 30 June 2016
Wiltshire Quality Director and Clinical Systems …
Somerset — recommendation 7.2.10
To have a more robust transfer/move-on plan.
Arc Inspire
Rochdale — recommendation 10.2
That the Rochdale Safer Communities Partnership (SCP), with support from the Adult Social Care Service, ensures: o That in all domestic abuse cases, where the victim has care and support needs, to refer the client directly to Adult Care for a needs assessment; o That Rochdale Adult Care, as part …
Rochdale Safer Communities Partnership (SCP) | …
Norfolk — recommendation 4
All local health inpatient and residential social care providers: To review, and revise where necessary, the providers Discharge Policy to ensure it covers consideration of vulnerable persons residing in the accommodation to which the patient/service user is returning; specifically in respect of any risks to others the returning patient/service user …
All local health inpatient and residential …
Norfolk — recommendation 3
NICE guidelines on hospital discharge should be revised to include ensuring consideration of vulnerable persons residing in the accommodation the patient/service user is returning too; specifically in respect of any risks to others the patient/service user may pose to other occupants. The policy must outline the need to undertake and …
National Institute for Clinical Excellence (NICE)
Norfolk — recommendation 4
All local health inpatient and residential social care providers: To review, and revise where necessary, the providers Discharge Policy to ensure it covers consideration of vulnerable persons residing in the accommodation to which the patient/service user is returning; specifically in respect of any risks to others the returning patient/service user …
All local health inpatient and residential …
Norfolk — recommendation 3
NICE guidelines on hospital discharge should be revised to include ensuring consideration of vulnerable persons residing in the accommodation to which the patient/service user is returning; specifically in respect of any risks to others the patient/service user may pose to other occupants. The policy must outline the need to undertake …
National Institute for Clinical Excellence (NICE)
Wolverhampton — recommendation Black Country Partne
Review current discharge communication process with Crisis teams and GP.
Black Country Partnership Black Country Partnership NHS …
Bolton — recommendation 3
Bolton Safeguarding Adults Board will seek assurances from Bolton NHS Foundation Trust and Bolton Council that a review of hospital discharges procedures will be undertaken to ensure where appropriate, voices of the next of kin and carers are included in discharge planning giving consideration to complexity and/or safeguarding issues.
Bolton Safeguarding Adults Board Safeguarding Adults Board
South Norfolk — recommendation 17.8
The Norfolk and Waveney Clinical Commissioning Group to take a lead from the Norfolk and Waveney Sustainability Transformation Partnership in planning continuity of trusted support to people living with dementia and their carers, in line with NICE guidance, for example Admiral nurses.
Norfolk and Waveney Clinical Commissioning Group
Hammersmith and Fulham — recommendation 9
Mental Health Trust discharge letters to GPs to include a summary of the quality of the patient's engagement with the service, a crisis contingency plan, the patient's next of kin (or carer if different) and their level of involvement, whether . a carer's assessment has been completed, and if not …
West London NHS Trust West London NHS Trust
Somerset — recommendation 7.1.3
All referrals into their service for temporary accommodation should be advised to bring identification with them and at least one month’s supply of medication (If medically safe) or a record of the medication in order that support can be ascertained from the new local GP practice for assistance to prevent …
Torbay Domestic Abuse Service
Waverley — recommendation 3
That Waverley CMHRS have process in place, that will ensure that letters are prepared and sent to GPs (or other services) when decisions are made to discharge.
Surrey and Borders Partnership NHS Foundation … Surrey and Borders Partnership …
Bedford — recommendation 13
Bedfordshire CCG to work with GPs to evaluate the impact of the changes to the discharge notifications from local hospitals and ensure that this GPs take follow up action if required.
Bedfordshire Clinical Commissioning Group Bedfordshire Clinical Commissioning Group
Norfolk — recommendation IMR_ASC_HT_5
Management overview of hospital discharge cases where carer’s stress is raised as a concern to be increased, including authorisation of the discharge plan.
Adult Social Care Hospital Team
Norfolk — recommendation IMR_ASC_HT_4
Onward referral for Carer’s Assessment post discharge should always be considered where an informal carer has been identified and their consent given. The process of onward referrals to community professionals – Health and Social Care, to be re-clarified to the Hospital Social Work Team.
Adult Social Care Hospital Team
Stockport — recommendation 14
Stockport NHS Foundation Trust : should revise its admission and discharge documentation to include a prompt regarding carers needs and signposting to a plan of care and an assessment before discharge
Stockport NHS Foundation Trust Stockport NHS Foundation Trust
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 …
Preston — recommendation 1
The CMHT & MAS should include both ‘main carer’ and ‘other significant carers’ for signposting to local authority for carer’s assessments.
Lancashire Care NHS Foundation Trust Lancashire and South Cumbria …
Kent — recommendation 2
In order to support inter-agency working, KMPT must include a section in their inpatient discharge policy that sets out the criteria for requesting Kent Police attendance when visiting patients after discharge. KMPT must consult Kent Police when drafting this section.
KMPT | Kent Police Kent and Medway NHS …
Kent — recommendation 1
KMPT should review existing policies relating to inpatient discharge in order to ensure that in every case, whether by self-discharge or not, the responsibility for further care is decided within 24 hours of the unexpected absence of a patient from a ward. This should apply whether a patient is unexpectedly …
KMPT Kent and Medway NHS …
Wolverhampton — recommendation 16
The Safer Wolverhampton Partnership should require the Black Country Partnership Foundation Trust to demonstrate that, before patients are discharged into the care of a family member, an individual carer’s assessment is offered to the family member to ensure they fully understand and appreciate the consequences of the discharge. If this …
Safer Wolverhampton Partnership
Wolverhampton — recommendation 14
The Safer Wolverhampton Partnership to require the Black Country Partnership Foundation Trust to review its discharge communications to ensure appropriate discharge information is sent to the GP within 48 hours of a patient discharge.
Safer Wolverhampton Partnership
Wolverhampton — recommendation 8
The Safer Wolverhampton Partnership to require health service commissioners to demonstrate that they are commissioning services with appropriate and effective discharge planning procedures in place.
Safer Wolverhampton Partnership
Northampton — recommendation 4
NHFT to review the discharge procedure following an admission under Section 2 Mental Health Act, ensuring a more robust system of communication with GPs to avoid delay and therefore potential loss of timely information as well as providing continuity of care provision.
NHFT
Tower Hamlets — recommendation 5
No patient should be considered for discharge from THCfMH within 24 hours of admission without the agreement of a senior member of staff. Senior members of staff include the following: the borough lead nurse and deputy borough lead nurse, the responsible clinician or duty consultant and the modern matron or …
East London Foundation Trust East London NHS Foundation …
Oxford — recommendation 2
We recommend that OHFT put in place systems to ensure the appointment of a care co-ordinator in the community as early as possible after a person is admitted to hospital. The failure to do so in this case has been highlighted as an omission in the care planning process. The …
Oxford Health NHS Foundation Trust Oxford Health NHS Foundation …
South Warwickshire — recommendation 3
Key learning from this case should be shared and utilised within the Warwickshire area and more widely, with a specific reference to the key learning points relating to:  Hospital discharge planning  Raising awareness about the needs of older and ‘hard to reach’ carers who may refuse help and …
Warwickshire Community Safety Partnership | Warwickshire …
South Warwickshire — recommendation 1
GEH and SWFT should jointly review the issues about discharge planning, referral systems and failures of inter-agency communication, which have been highlighted by this DHR. The Review should aim to:  Establish the facts of what actually occurred, including whether or not the referrals to SWFT (as stated in GEH’s …
George Eliot Hospital NHS Trust | … George Eliot Hospital
Kirklees — recommendation 23
Where the patient has been the victim of an assault or sexual abuse, to ensure that safety risks and social support needs are assessed and that safety and support arrangements are in place prior to discharge from both accident and emergency and inpatient hospital wards
Calderdale and Huddersfield NHS Foundation Trust Calderdale and Huddersfield NHS …
Harrow — recommendation 11
Person to person discussion between Trusts regarding the discharge of a client to the community where serious adult or child safeguarding concerns are identified.
Ealing Hospital Ealing Hospital NHS Trust
Harrow — recommendation 10
(Safe Transfer of Women) STOW project in progress to transfer postnatal discharge information electronically from nhs.net to nhs.net address across London.
Ealing Hospital Ealing Hospital NHS Trust
Hammersmith and Fulham — recommendation WLT6
The service ensures patients requiring care coordination are appropriately allocated as soon as is practicably possible. Capacity issues should be escalated to relevant commissioners.
West London NHS Trust West London NHS Trust
Northampton — recommendation 2
The Trust should work in collaboration with the police to develop a clear protocol to support the effective safety planning of those who leave hospital where concerns for their welfare remain.
Northampton General Hospital NORTHAMPTON GENERAL HOSPITAL NHS …
Central Bedfordshire — recommendation 13
Bedfordshire CCG to work with GPs to monitor the impact of the changes to the discharge notifications from local hospitals and ensure that this GPs take follow up action if required.
Bedfordshire Clinical Commissioning Group Bedfordshire Clinical Commissioning Group
Leicester — recommendation 2
Leicestershire Partnership NHS Trust to use the opportunity of the transformation programme to instil into training and awareness of all staff the need for adherence to the requirements of the Care Programme Approach to assess the risks involved in managing patients who have been detained for treatment and are being …
Leicestershire Partnership NHS Trust Leicestershire Partnership NHS Trust
Waverley — recommendation 5
The CCG and NHS Trust must ensure that practitioners make enquiries with patients, particularly those who are admitted to hospital, as to their home circumstances to establish if they have responsibility to care for another who is at home and who may be at risk due to the patients admission.
ICB | NHS Trust
Cornwall — recommendation 9
We recommend that a process and protocol be put in place across Cornwall to ensure the timely and appropriate notification of GP’s about care plans, current treatment and changes to that, including hospital discharge by secondary care NHS Trust providers.
NHS Kernow | Cornwall Foundation Partnership … NHS Kernow
Somerset — recommendation Recommendation 1.
That a review is undertaken of hospital discharge notices and that all relevant information is sent to the GP e.g. especially including disclosure by the patient of any unusual behaviour or experiences e.g. violence or fear of violence, referrals to specialist agencies for alcohol or substance misuse or DVA advice.
Yeovil District Hospital NHS Foundation Trust Yeovil District Hospital NHS …
Somerset — recommendation Recommendation 5.
That GPs follow up hospital attendance discharge notices with the hospital and or patient. Especially regarding those patients who have a known history of DVA, long term prescription of anti-depressant medication, substance misuse, or mental health issues.
Somerset Clinical Commissioning Group (GP) | … NHS Somerset Clinical Commissioning …
CQC enforcement actions(1)
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