Care plan failures
Care plans not accurately reflecting individual needs or care provided, and ineffective systems for quality assurance and continuous improvement.
Source spread
Where this theme appears
This theme appears across 19 independent accountability sources, so the source mix matters as much as the headline total.
39 inquiry recs
160 PFD reports
43 committee recs
31 HSSIB recs
335 CQC actions
22 PPO recs
57 IMB recs
11 Scottish FAIs
1 Article 2 learning point
337 DHR recs
436 PHSO decisions
3629 LGO/SPSO decisions
10 CQC enforcement actions
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.
Inquiry recommendations(39)
120 — Interviewers involved in care decisions
Recommendation: Interviewers should be involved in decisions relating to the care of the children while they are in places of safety and the extent of their involvement should be defined (17.60).
Unknown
R6 — Named person approval for transfers
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
R5 — Named person for care plans
Recommendation: Any service user with a learning disability should have a named person (a key individual) responsible for their care plans and this person should be involved in and record the discussion with the family and the discussion with any relevant …
No response yet
WATE-(33) — Base care plans on comprehensive assessment, prepared with child consultation
Recommendation: The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Unknown
WATE-(32) — Follow emergency child admissions with comprehensive assessment within prescribed period
Recommendation: All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Unknown
WATE-(31) — Require comprehensive child needs assessment before admission to care
Recommendation: Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Unknown
LAMI-64 — Ensure nursing care plans account for suspected deliberate harm in hospitalised children.
Recommendation: When a child is admitted to hospital and deliberate harm is suspected, the nursing care plan must take full account of this diagnosis.
Unknown
R16 — Missed care incident reporting
Recommendation: If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using the Trust’s or organisation’s incident reporting system.
No response yet
R15 — Independent care plan reviews
Recommendation: Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and should include formal, documented input from the service user themselves (where appropriate) and families. Additionally, there should be …
No response yet
R12 — Person-centred care plans with family involvement
Recommendation: Care plans must be live, person-centred documents. This requires joint ownership with people with learning disabilities and their families rather than simply professional records. While professionals necessarily lead assessments, families should be actively involved in identifying needs. Resulting care plans …
No response yet
COVID-M3.9 — Standardised Advance Care Planning
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for …
Gov response: For the reasons set out above, while we will continue to take action to improve outcomes, the government does not specifically intend to introduce, at this time, a standard process across the UK and the …
Not accepted
WATE-(38) — Extend local authority duty to provide parental-level support for care leavers
Recommendation: The duty upon local authorities under section 24(1) of the Children Act 1989 to advise, assist and befriend a child with a view to promoting his welfare when he ceases to be looked after by them should be extended so …
Unknown
WATE-(37) — Prepare and periodically review leaving care plans for all looked after children
Recommendation: A leaving care plan should be prepared for each looked after child, in consultation with that child, a year in advance of the event and should be reviewed periodically thereafter until the child ceases to require or be eligible for …
Unknown
WATE-(34) — Designate social worker responsible for care plan implementation and child supervision
Recommendation: An appropriate social worker should be designated as the person responsible for the implementation of the care plan and supervision of the looked after child.
Unknown
R30 — Fluid balance monitoring
Recommendation: Health Boards should ensure that where patients require fluid monitoring as part of their clinical care, nursing staff complete fluid balance charts as accurately as possible and sign them off at the end of each 24-hour period.
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
R27 — Positional change records
Recommendation: Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent. Compliance should be monitored by a system of audit.
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
R26 — Wound documentation
Recommendation: Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of the wound or damage in accordance with best practice guidance, including the cause, grade, size and colour of …
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
R24 — TVN instructions recorded
Recommendation: Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the patient notes and care plan of the instructions given for management of the patient.
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
R22 — Relative discussions recorded
Recommendation: Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient’s continuing care is recorded in the patient’s notes to ensure that those caring for the …
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
R18 — Care planning system
Recommendation: Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff. Where appropriate they should introduce pro forma care plans to assist nurses with care …
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
99 — Agreement terms available to foster carers
Recommendation: Where children are placed with foster carers belonging to another local authority, a copy of the terms of the agreement between the two authorities regarding the placement should be available to the foster carer so that lines of support and …
Unknown
98 — Keep foster carers informed
Recommendation: Foster carers should be kept informed of any developments regarding any child in their care and of any course of action being taken with the child (17.35).
Unknown
97 — Written report for foster carers
Recommendation: Foster carers should be given a written report at the time when the child is placed, or as soon as practicable thereafter, with as much personal information about the child as possible (17.34).
Unknown
67 — Information for the child's carer
Recommendation: The fullest possible information about the background of the child should be made available to the child’s carer together with such administrative detail as the carer will require for the well-being of the child (16.41).
Unknown
3 — Bereavement care
Recommendation: The National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027.
Gov response: And I agree with the report that, when the very worst happens and parents face bereavement, they need to be supported to the best of our ability. The report recommends the national bereavement care pathway …
Accepted
WATE-(45) — Require social worker assessment and inter-departmental consultation before residential school placement
Recommendation: Any placement of a child by a local education department or by a social services department in a residential school should be preceded by: (a) consultation between the departments as to whether an assessment by an appropriate social worker of …
Unknown
WATE-(40) — Develop key indicators to monitor compliance with safeguards for looked after children
Recommendation: Appropriate key indicators of compliance with safeguards for looked after children should be developed, covering particularly:34, 62(i) (a) the allocation of a designated social worker to each looked after child; (b) compliance with fostering and placement regulations; (c) statutory review …
Unknown
WATE-(39) — Require fostering services to monitor, analyse, and report placement breakdowns periodically
Recommendation: Every local authority's fostering service, whether provided directly or by another agency, should monitor breakdowns in placements with a view to analysing the causes and remedying any faults in the service and should report upon them periodically to the Director …
Unknown
WATE-(36) — Provide facilities and encourage acquisition of independent living skills in care settings
Recommendation: The daily regime in residential establishments and foster homes should encourage and provide facilities for the acquisition of skills necessary for independent living.
Unknown
R39 — DNAR decision awareness
Recommendation: Health Boards should ensure that medical and nursing staff are aware that a DNAR decision is an important aspect of care. The decision should involve the patient where possible, nursing staff, the consultant in charge and, where appropriate, relatives. The …
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
6 — Draw up maternity risk assessment protocol
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
WATE-(35) — Ensure foster carers receive continuing support and access to specialist services
Recommendation: Foster carers should receive continuing support and have access as necessary to specialist services. In this context we endorse the recommendations of Sir William Utting in relation to training in "People Like Us"919.
Unknown
R28 — Nutritional screening
Recommendation: Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool. Where nutritional problems are identified further assessment should be undertaken to determine an individual care plan. Appropriate …
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
F236 — Identification of who is responsible for the patient
Recommendation: Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient's case, so that patients and their supporters are clear who is in overall charge of a patient's care.
Gov response: Accepted. In his speech on patient safety on 21 June 2013, the Secretary of State for Health signalled his support for the practice of hospitals identifying a named consultant who is responsible for a patient’s …
Accepted
7 — Audit maternity and paediatric services
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
WATE-(12) — Safeguard field social worker's responsibilities for placement supervision and care planning
Recommendation: Any arrangements made for the provision of residential care or fostering services should expressly safeguard the field social worker's continuing responsibilities for supervision of the placement and care planning.
Unknown
IBI-10a(iv) — Thalassaemia Society Support
Recommendation: Particular consideration be given, together with the UK Thalassaemia Society and the Sickle Cell Society, to how the needs of patients with thalassaemia or sickle cell disease can best holistically be addressed.
Gov response: NHS England has successfully established a comprehensive programme of work to prioritise reduction of clinical risk, increase support and care in the community, digitise care plans and step up prevention activities following their review of …
Accepted in part
IBI-9d — Haemophilia Centre Resources
Recommendation: The necessary administrative and clinical resources should be provided by hospital trusts and boards, integrated care boards, and service commissioners to facilitate multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders care, provided they …
Gov response: Recommendation 9d: The need to develop and strengthen multi-disciplinary regional networks to discuss policy and practice in haemophilia and other inherited bleeding disorders to improve patient care and support standardisation is supported by the clinical …
Accepted in part
IBI-2c — Community Support Events
Recommendation: There should be at least three events, approximately six months apart, drawing together those infected and affected, the nature and timing of which should be determined by a working party as described above, facilitated by some central funding.
Gov response: The Inquiry’s report emphasised the need for public recognition and a formal apology for all of those impacted. The previous and current UK governments have issued unequivocal apologies for what happened on behalf of the …
Accepted
Prevention of Future Deaths reports(160)— showing 50 strongest matches
Derek Edward Bartlett Twivey
Concerns: The coroner noted that a falls risk assessment for a patient with a known high falls risk was not conducted within the anticipated 24 hours of arrival at a nursing home, due to it being a weekend and staffing pressures.
Overdue
Annie Rose Gibson
Concerns: The report raises concerns for Saga Homecare regarding the circumstances surrounding the death of an 84-year-old lady who had fallen while receiving daily home care.
Overdue
Joan Mary Jones
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
Leslie Pates
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
Peter Norman Nott
Concerns: The coroner noted that the care home's procedures for post-fall examination were insufficient, as staff did not perform neurological observations. Concerns were also raised regarding inaccurate information provided to paramedics about the resident's consciousness.
Response (Elizabeth Finn Homes): • The organisation stated it would cascade updated procedures for neurological observations and head injury care to all clinical staff by April 1, 2014. • The organisation stated it would … (AI summary)
Responded
Margaret Easterfield
Concerns: The coroner raised concerns regarding the incidence of anastomotic leaks following surgery, noting its relative rarity and the potential implication of technical error by the surgeon.
Overdue
Lorna Cullen
Concerns: The coroner noted concerns regarding long waiting times for mental health assessments in hospital emergency departments, attributed to insufficient liaison psychiatry nurse staffing levels. The key issue identified was the long-term sustainability of adequate staffing after temporary funding for increased resources was set to expire.
Overdue
Wendy Brown
Concerns: The coroner noted concerns about the adequacy of public service signposting and funding routes for adult care, leading to a carer lacking respite support. There were also concerns about delays in processing applications for care packages, creating gaps in essential support for carers.
Response (Swindon Borough Council): • The Council confirmed that robust contractual arrangements and management, alongside internal audits, were in place for the separation of Adult Social Care functions. • An immediate action was taken … (AI summary)
Responded
Phyllis Barnes
Concerns: The coroner noted a visiting GP did not fully appreciate the patient's serious post-operative condition, and a nurse-led telephone consultation appeared superficial. Additionally, there was no formal opportunity for the patient's daughter to relay her mother's condition to healthcare providers.
Overdue
Danuta Corbett
Concerns: The coroner identified gaps in the documentation and application of the leave policy for informal patients, particularly regarding risk assessments and decisions for escorted leave. Critical patient information, including risks associated with her home, was not handed over to the escort.
Response (Sussex Partnership NHS Trust): • The consultant psychiatrist stated she now carefully reviews notes taken during ward reviews. • The Trust reinforced with staff the requirement to complete retrospective notes in specific circumstances. • … (AI summary)
Responded
Paul Ashton
Concerns: The Salford Royal Hospital lacked a protocol for perioperative management of heart transplant patients undergoing non-cardiac surgery. Additionally, Isoprenaline, an effective anti-bradycardic agent, was not available at the hospital during resuscitation attempts.
Response (Department of Health): • The Department of Health asked the NHS UK Medicines Information service to produce and distribute a "Shortage Memo" on isoprenaline, advising on alternatives. • NHS England will task its … (AI summary)
Overdue
Kathryn Sawyer
Concerns: The coroner raised concerns regarding the lack of a timely medication review for a patient with known addiction issues, and the absence of a detailed record of the medication discussion or a future plan for its reduction.
Response (Roundwell Medical Centre): • The medical centre stated that patients on addictive medication would be assigned to a single GP where possible to ensure continuity of care. • The medical centre committed to … (AI summary)
Responded
Sybil Roberts
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
Leonard Hudson
Concerns: The coroner identified a failure to follow the Trust's pressure ulcer policy, including inadequate incident reporting and risk identification. Further concerns related to insufficient record-keeping, confusion in patient care arrangements, and a lack of contingency for physiotherapy provision.
Overdue
John Bird
Concerns: The care home manager did not provide the falls risk assessment at the inquest. The coroner also noted that a carer was unfamiliar with a resident's high falls assessment and care plan, which the manager acknowledged was their responsibility to ensure staff knew.
Overdue
Michael Harman
Concerns: The coroner noted insufficient follow-up after Mr Harman was found soiled and that indicators of his deteriorating condition did not trigger a review beyond the annual schedule. Handover notes also lacked specific welfare check requests.
Response (Centra Support1): • Centra Support completed an internal review of locality working practices. • Centra Support completed a review of welfare checks and the warden call response process. • Centra Support drew … (AI summary)
Responded
Lana-Liza Chervonenko
Concerns: Insufficient medical cover and high activity on the labour ward led to delays in patient review, documentation errors, and communication gaps between clinical teams. The coroner also noted no system existed for theatre staff to proactively notify treating teams of theatre availability.
Overdue
Brian Marks
Concerns: The coroner noted the similar appearance of PEJ and PEG tubes could lead to confusion, suggesting a simple colour coding system to aid differentiation when the tubes are in situ.
Response (Department of Health): • The Medicines and Healthcare Products Regulatory Agency (MHRA) will bring the issue of tube misidentification to the attention of relevant Standards Committees. • The MHRA will include the risk … (AI summary)
Responded
John Matthews
Concerns: The report notes that the triage nurse did not see the ambulance patient report form and a locum doctor lacked access to complete computerised patient information. There were also concerns that necessary neurological observations were not instituted and an unnecessary CT scan was performed.
Response (Stockport NHS Trust): • The Trust amended its induction training pack in November 2014 to provide clear instructions on accessing electronic ambulance documents. • The ED Matron re-iterated to nursing staff the importance … (AI summary)
Responded
Paul Moroney
Concerns: The coroner noted a lack of oxygen saturation monitoring during the patient's first hospital visit and upon discharge, and that previous oxygen level records were unavailable on re-admission.
Response (Tameside Hospital NHS Trust): • The Trust stated that oxygen saturations were monitored and recorded during the patient's initial hospital visit. • The Trust provided specific oxygen saturation readings and times from the patient's … (AI summary)
Responded
Maria Silkin
Concerns: The care home's "Falls Risk Assessment" document incorrectly recorded no previous falls, despite evidence of multiple falls, which contributed to a delay in the person being taken to hospital.
Overdue
Michael Lyons
Concerns: The Care Agency did not determine the outcome of a swallowing assessment or implement steps to protect Mr Lyons from choking, and the care plan lacked a management strategy including supervision and specific food preparation instructions for carers.
Response (John Stanley Care Agency): • The agency audited log sheets from April 7, 2014, to September 22, 2014, and found no documented evidence that food had been cut up or that care workers had … (AI summary)
Responded
Maurice Camfield
Concerns: The coroner noted that Mr. Camfield's agreed care plan, which stipulated one-to-one nursing care at all times, was not strictly followed by those involved in his treatment.
Overdue
Eliza Bowen
Concerns: The coroner noted that regular blood glucose testing might have led to earlier identification and management of diabetes, especially given the patient's risk factors. They raised concerns about the availability of specific medical guidance for staff on diabetes screening and management in similar circumstances.
Overdue
Rita Paton
Concerns: The coroner raises concerns about the lack of a system to ensure requested blood tests are reported to GPs, and insufficient processes for patients lacking capacity to attend appointments. There is also a noted lack of readily available past medical and medication history for emergency crews.
Overdue
Rasharn Williams
Concerns: Rasharn's care plan lacked clarity regarding when to call an ambulance for breathlessness, potentially creating ambiguity for staff. A medical notice with his photograph and instructions was also not displayed at the time of his death.
Response (Berger Primary School): • The school reviewed existing care plans, specifically emergency provisions. • The policy for Education for Children with Medical Needs will be amended to clarify emergency actions in individual Healthcare … (AI summary)
Responded
Walter Willows
Concerns: Care plans for clients with swallowing difficulties, specifically their feeding regimes, were reviewed quarterly, which was insufficient to adjust diets to changing abilities. More frequent examination of these plans was required.
Overdue
Isabel Richardson
Concerns: The coroner identified a lack of clarity regarding the purpose, operation, and training of the school's pastoral team, noting the system was insufficiently robust to address the student's needs.
Overdue
Robert Mansfield
Concerns: Concerns were raised regarding the safety of the Millpond following three deaths, specifically the potential need for fencing, improved lighting, better warning notices, and accessible flotation equipment.
Overdue
Edna Cleaton
Concerns: The practice lacked systems to ensure patients on citalopram received appropriate medical reviews every 3-6 months, as one patient went over 3 years without review, potentially missing signs of deterioration.
Response (Edna Cleaton): • The practice stated that repeat prescriptions for antidepressants are issued for a maximum of six months, requiring a review thereafter. • The practice confirmed the existence of a repeat … (AI summary)
Responded
Joanna Bowring
Concerns: The patient and carer left an initial assessment without a clear understanding of the service or a care plan. Carers were not routinely included in risk assessments, their views were not actively sought, and they were not advised about behaviours indicating an increased risk of suicide.
Response (Joanna Bowring): • An Initial Action Plan Proforma is now required after every assessment to provide service users and their carers with written outcomes and next steps. • The Trust re-launched its … (AI summary)
Responded
Clifford Crofts
Concerns: The coroner identified issues with staff not following care plans or being aware of policies, difficulties escalating patient care and obtaining urgent CT scans, and insufficient weekend staffing levels.
Response (Clifford CROFTS): • The Trust has implemented changes to the scheduling of enterostomy procedures and developed an online training module for staff on nutritional care, including feeding enterostomies. • A pilot scheme … (AI summary)
Responded
Pamela Thurston
Concerns: The coroner identified insufficient direct supervision during mealtimes for a resident with dementia, who choked after being given toast following a 17-hour period without food. Her care plan was also not updated despite a prior related incident.
Response (Thurston): • The organisation issued a memorandum to all Home Managers, Regional Managers, and Head of Operations outlining requirements for timely meals, choking risk assessments, and supervision of at-risk service users … (AI summary)
Overdue
Dorothy Imisson
Concerns: The coroner identified that the District Nursing Service did not develop an appropriate care plan and did not adhere to NMC guidance on record-keeping or NICE clinical guidelines.
Overdue
Malcolm Bennett
Concerns: The coroner noted a three-hour delay in calling an ambulance for a person who had been hit, despite the care plan indicating immediate transfer to the emergency department for significant injury. This delay might have been contributory to the cause of death.
Response (Borough Care): • Risk management plans for residents prescribed anti-coagulants were updated to include instructions for immediate emergency service contact following a fall or injury. • Anti-coagulant warnings were placed on care … (AI summary)
Responded
Harold Goulding
Concerns: Communication broke down between the anti-coagulation clinic, the GP, and the care home regarding a resident's new GP details. Additionally, the General Practitioner did not consider the Medication Administration Record held by the home during new resident reviews, indicating a lack of a system for medication approval.
Response (Orchard Care Homes): • Meetings were held with nursing staff to discuss the incident and identify lessons. • Daily meetings were implemented, and a protocol document was created to improve communication with external … (AI summary)
Responded
Etheline De-Gale
Concerns: The care plan was too vague to guide carers, who also lacked training on how to undertake risk assessments. Insufficient staffing levels compromised resident safety, potentially leading to paramedic recommendations being ignored.
Response (Response Ambassador House Home): • Care plans will be updated to stipulate that residents must not be left unattended when bedrails are lowered for assistance. • Staff have been instructed to carry gloves at … (AI summary)
Responded
Michael Uriely
Concerns: The care management for chronic asthma lacked coordination, long-term planning, and adherence to clinical guidelines. Concerns also included insufficient communication between primary and secondary care, and a failure to refer to a tertiary respiratory service.
Response (Uriely): • NHS England detailed several ongoing initiatives, including the National Paediatric Asthma Collaborative, a national asthma audit, and the development of an e-learning pack and a severe paediatric asthma database. … (AI summary)
Response (Uriely Response2): • NICE has produced a quality standard on asthma that includes statements on coordinated care, personalised action plans, and specialist reviews. • NICE is developing new guidelines on asthma diagnosis, … (AI summary)
Overdue
Terence White
Concerns: The Care Centre lacked documentation of measures taken to treat a pressure sore and turning charts, which prevented senior staff from knowing if the condition was being treated properly.
Response (James white): • The care centre implemented a system where daily records, including turning/repositioning charts, are now kept in individual resident folders on each floor. • Nurses are required to sign off … (AI summary)
Overdue
Patrick Woods
Concerns: The coroner noted that the hospital's equipment portfolio was unknown, which prevented the identification of potentially dangerous equipment, subsequent risk assessment, and actions to prevent future harm to patients.
Response (Draeger Medical UK Limited): • Draeger updated its training documentation, including the Basic Skills Checklist, Workbook, Quick Guide, Practical Exercises, PowerPoint presentation, and Training Needs Analysis, to enhance clinician competence regarding machine functionality and … (AI summary)
Response (Luton Dunstable University Hospital): • The Trust stated it maintains an electronic database of all equipment, including location, service history, and risk categorization. • The Trust confirmed that incidents involving equipment are reviewed by … (AI summary)
Responded
Sheila Hynes
Concerns: During an operation, a mechanical aortic valve was remounted contrary to manufacturer instructions, without documented rationale or awareness of risks by the surgical team. An untrained scrub nurse was instructed to perform this procedure, and the primary surgeon had not instructed it.
Overdue
Patricia Norfolk
Concerns: The coroner noted that patients were not receiving daily senior clinician reviews and raised concerns about the interim period before new staff are recruited to address this.
Overdue
John Ramsden
Concerns: Concerns were raised that not all of John Ramsden's daughters were consulted about his end-of-life care and decisions regarding hospital admission for treatment.
Overdue
Cameron Chadwick
Concerns: The coroner identified a pothole in the carriageway, measured at 45mm deep, which exceeded Wigan Council's stated repair threshold of 40mm.
Response (Wigan Council): • Wigan Council stated that its officers measured the pothole at 36mm deep. • Wigan Council confirmed a temporary repair to the pothole was carried out on 6th July 2017. … (AI summary)
Responded
Rose Workman
Concerns: The report raises concerns about the sufficiency of measures employed by the district nursing service for effective monitoring of patients' ongoing conditions.
Response (Rose Workman): • The Trust re-engineered its electronic clinical record system to enhance patient monitoring, including new review templates, reporting frameworks, and assessment tools for conditions, pressure areas, and nutrition. • A … (AI summary)
Responded
John Davies
Concerns: There was no process for completing risk assessment plans when a resident's needs changed from care to nursing, leading to communication gaps between the care home and District Nursing Team. Patient records lacked detail and the correct procedure for pressure relieving strategies was not consistently followed.
Response (Stockport NHS Trust): • The Trust developed a multi-agency risk assessment, agreed on improved inter-team communication, addressed patient record deficiencies, and implemented measures for continuity of care and information sharing. • The District … (AI summary)
Responded
Robert Cardwell
Concerns: The coroner identified unreliable processes for relaying patient messages to the Multi-Disciplinary Team (MDT), leading to inappropriate discharge. Further concerns included the MDT not discussing referred patients and inadequate record-keeping during meetings.
Overdue
Constance Connolly
Concerns: The coroner identified gaps in follow-up for a critical scan, insufficient communication with the general practitioner regarding ongoing investigations, and procedural issues that led to the cancellation of an essential outpatient appointment.
Response (The Royal College of Emergency Medicine): • The Royal College of Emergency Medicine recently issued two guidance documents to its Fellows and Members on ensuring test results are followed up. • The College is preparing a … (AI summary)
Response (King's College Hospital NHS Foundation Trust): • The Trust has taken steps to ensure that formal discharge notifications are always sent to a patient's GP, detailing all relevant tests, assessments, and follow-up arrangements, even if the … (AI summary)
Responded
Janet Williams
Concerns: Inadequate recording of Ms Williams' care plan led to missed reviews and delayed medical appointments. Additionally, the care coordinator did not address family concerns and made undeclared retrospective entries in medical records.
Overdue
Maud Patrick
Concerns: The coroner identified gaps in assessing mental capacity, in the completion and handover of investigations from A&E to AMU, and in conducting neurological and general observations. The report also noted issues with staffing levels and competence on the ward.
Overdue
Select committee recommendations(43)
#116 —
Recommendation: However, Dr Guilfoyle cautioned that the integrated CSO, first piloted in 2016, âhas not been hugely effectiveâ. He told us that it may be because âwhen it first became operational the individuals themselves had to source the training or treatment …
Response attribution not verified
#109 —
Recommendation: Witnesses were particularly concerned about âputting people into situations where they have multiple appointments that they need to keep which they fail to do soâ: it can result in them being found in breach of their sentence and recalled before …
Response attribution not verified
#15 —
Recommendation: The Government should increase its support for local authorities to deliver EHCPs and closely monitor both the timeliness and robustness of their decision-making with reference to the 20-week timeline for producing a draft EHCP, as well as the proportion of …
Response attribution not verified
#14 —
Recommendation: Education, Health and Care Plans help young disabled people receive essential educational support and are fundamental to enabling many young disabled people to access employment programmes such as supported internships or more accessible apprenticeships. However, the current system does not …
Response attribution not verified
#8 —
Recommendation: Assessments of children’s needs must also effectively identify neurodivergence, and must lead to the provision of adequate support to meet the needs of neurodivergent children. (Recommendation, Paragraph 59)
Response status not verified
#18 —
Recommendation: NHSE has put in place multiple initiatives that aim to help with frailty. It has set requirements for ICBs and GPs to provide health services that aim to assess and support people living with moderate and severe frailty. They include …
Response attribution not verified
#15 —
Recommendation: We were concerned that GPs might not be prioritising care for those with or at risk of frailty. NHSE acknowledged that GPs were not formally assessing enough of their patients for frailty.32 NHSE recognised that it had pushed GP practices …
Response attribution not verified
#5 —
Recommendation: The frailty policy landscape is confusing and fragmented. NHSE and the Department are planning and developing several frailty specific initiatives, such as a national frailty dashboard, and a Modern Service Framework for frailty and dementia. There are also a number …
Response attribution not verified
#2 —
Recommendation: NHS England is not reducing the unacceptable variation in support for people with frailty across and within Integrated Care Boards (ICBs). There is significant and unexplained regional variation between areas – 32 out of 106 local NHS areas assessed less …
Response attribution not verified
#20 —
Recommendation: We disagree with the argument that older prisoners’ needs are too wide-ranging to generalise. Though it is important to treat each prisoner as an individual, there is a commonality among older prisoners which warrants a specific approach to their management. …
Response attribution not verified
#15 —
Recommendation: We recommend that the MoJ and Youth Custody Service set out how they have responded to the crisis in the context of the children’s estate and how the specific needs of children have been considered. It is also unclear why …
Gov response: Following publication of the National Framework for Prison Regimes and Services on 2 June, the YCS has developed Exceptional Delivery Models (EDMs), including developing ‘YCS-specific’ EDMs (specifically Education and P.E, Advocacy, the Custody Support Plan, …
Position Not Stated
#50 — Strengthen the role of mental health in health assessments for children in care.
Recommendation: The Department for Education and the Department of Health and Social Care should take forward this Committee’s recommendation to strengthen the role of mental health and emotional wellbeing in health assessments of children in care, ensuring that there is proper, …
Response attribution not verified
#21 —
Recommendation: An ageing prison population creates specific pressures on the prison system. Currently, the response to these and the treatment of older prisoners is highly inconsistent across the prison estate. Though the Model for Operational Delivery: Older Prisoners contains useful operational …
Response attribution not verified
#14 —
Recommendation: The ageing prison population has and will continue to increase the need for end-of- life and palliative care in prisons. We welcome the publication of the Dying Well in Custody Charter and the good practice at some establishments. But standards …
Response attribution not verified
#12 —
Recommendation: An ageing prison population will increase demand for social care services in prisons. While the Care Act 2014 has brought some improvements, standards of provision are highly variable across the estate. A more strategic and coordinated approach is needed to …
Response attribution not verified
#11 —
Recommendation: Continuing to incarcerate prisoners with severe dementia, who may no longer remember or understand why they are imprisoned, raises practical and ethical 46 Ageing prison population considerations, especially as their condition is very difficult to manage on the prison estate. …
Response attribution not verified
#16 —
Recommendation: We are concerned that there does not appear to be a sufficiently clear, separate plan on how the youth custodial estate will transition out of the current lockdown phase. We agree that plans need to be flexible enough to accommodate …
Response attribution not verified
#2 —
Recommendation: The Committee recognise the necessity of the measures introduced to minimise the spread of the virus and save lives and commend staff and prisoners for adapting to these changes. However, we do not believe that the current regime is sustainable …
Gov response: Our National Framework, which sets out in detail how we will take decisions about easing coronavirus-related restrictions in prisons, was published in June. This roadmap for easing restrictions in prisons has been guided by public …
Position Not Stated
#21 —
Recommendation: NHSE recognised that it needs more evidence to understand which interventions make a difference for patients with frailty and has commissioned a National Institute for Health and Care Research-led evaluation of frailty pathways and interventions.42 Changes to ICBs’ responsibilities
Response attribution not verified
#20 —
Recommendation: NHSE informed us that there are also a number of broader developments which may affect service provision for frailty including a forthcoming modern service framework, new funding models for ICBs, a frailty improvement collaborative involving seven sites around the country, …
Response attribution not verified
#12 —
Recommendation: NHSE has set requirements for ICBs and GPs to provide health services that aim to assess and support people living with moderate and severe frailty.25 NHSE considers that ICBs are responsible for managing and measuring performance of many of the …
Response attribution not verified
#10 —
Recommendation: The “reasonable endeavours” duty in relation to Education, Health and Care (EHC) Plans is a nebulous concept, which has been inconsistently interpreted and poorly understood by some local authorities, whose support for children and young people with special educational needs …
Response attribution not verified
#14 —
Recommendation: We recommend that staff involved in the treatment of autistic people and people with disabilities in inpatient settings receive training in care planning which has a clear and unhindered focus on: i) understanding that autistic people and people with learning …
Response attribution not verified
#1 —
Recommendation: We conclude, in line with our report on Social care: funding and workforce, the current social care system is “unfair and confusing”. Those living with dementia remain unprotected from unlimited costs and navigating the system is burdensome for those providing …
Response status not verified
#11 —
Recommendation: If the Secretary of State for Education’s power to invoke the “reasonable endeavours” duty in relation to EHC Plans is to remain in place, we recommend the Department for Education update its guidance to local authorities to include the factors …
Response attribution not verified
#7 —
Recommendation: On balance, and subject to our other recommendations to tighten guidance and increase transparency being implemented, we accept that the Care Act easement provisions may need to remain in place over the winter period. The Government should keep the need …
Response attribution not verified
#5 —
Recommendation: There is broad agreement that the Coronavirus Act’s Care Act easement provisions should be curtailed as soon as possible. They represent a substantial raising of the threshold at which disabled people’s care and support needs must be met. This regression …
Response attribution not verified
#2 —
Recommendation: Care Act easements are available as a last resort for local authorities, to help them prioritise care and support for people with higher levels of need, should resources become overstretched to a dangerous degree, potentially threatening life. We were concerned …
Response attribution not verified
#17 —
Recommendation: Collaboration between agencies is imperative if children’s resettlement needs are to be met during their time in custody and followed through to the community. We recognise that the quality and ease of collaboration between agencies may vary between establishments and …
Response attribution not verified
#15 —
Recommendation: Children with special educational needs and disabilities (SEND) who had an EHC plan were eligible to continue attending school throughout the pandemic, provided a risk assessment had determined that they would be at least as safe in school as at …
Response attribution not verified
#8 —
Recommendation: In pursuing that policy, we recommend that by the end of 2021 the Department and NHS England & Improvement: i) introduce weekly formal reviews of the suitability of admission for all autistic people and people with learning disabilities who have …
Response attribution not verified
#56 —
Recommendation: Although there was never national NHS guidance to apply “Do not attempt CPR” (DNACPR) notices to people with learning disabilities, there have been widespread concerns that there were cases in which they have been issued inappropriately during the pandemic.
Response attribution not verified
#56 —
Recommendation: Although there was never national NHS guidance to apply “Do not attempt CPR” (DNACPR) notices to people with learning disabilities, there have been widespread concerns that there were cases in which they have been issued inappropriately during the pandemic.
Response attribution not verified
#12 —
Recommendation: At the time of writing, the Special Educational Needs and Disability (Coronavirus) (Amendment) Regulations 2020, which temporarily modify the time limits in relation to EHC assessment and Plans, were due to expire on 25 September. This will add further pressure …
Response attribution not verified
#9 —
Recommendation: Assessing needs and securing provision for children and young people meeting the threshold for EHC Plans was an extreme challenge for local authorities during the peak of the pandemic earlier this year. Local authorities could not have been expected to …
Response attribution not verified
#6 —
Recommendation: Had the pandemic been more clearly under control, we would have recommended repeal of the Care Act easements at the first six-monthly review. However, the current precarious state of the pandemic, combined with the fragility of the social care system, …
Response attribution not verified
#3 —
Recommendation: We acknowledge that steps have been taken towards greater transparency in the Care Act easement process, notably the publication of an updated list of local authorities using the easements; however, we believe this falls short of a proportionate level of …
Response attribution not verified
#1 —
Recommendation: We were unable properly to scrutinise the effects of Care Act easements on disabled people because there are no published data, for example on the number and categories of people, or the types of social care services, affected. The Government …
Response attribution not verified
#14 —
Recommendation: On 1 May 2020, the Department temporarily changed aspects of the law on EHC needs assessments and plans, to give local authorities, health commissioning bodies, education providers and other bodies more flexibility in the context of the pandemic. These changes …
Response attribution not verified
#3 —
Recommendation: Protections for students, in the event of providers facing financial distress, are not strong enough. The OfS requires providers to have a student protection plan in place to address the risk of continuity of study for its students, but it …
Response attribution not verified
#8 —
Recommendation: The Ministry and HMPPS told us that there are mechanisms in the STC contracts to drive up performance. It is only as a last resort that they decant children to other settings, as they did in the case of Rainsbrook …
Response attribution not verified
#14 —
Recommendation: Compared to the existing adult social care framework in England of thresholds and the absence of any lifetime spending caps, the Government’s new policy proposals are more generous. All individuals will now have a lifetime cap on contributions where previously …
Response attribution not verified
#21 —
Recommendation: As a condition of registration, the OfS requires each higher education provider to have in place and publish a student protection plan setting out what it would do to safeguard students’ interests—such as by making arrangements for continuity of study— …
Response attribution not verified
HSSIB safety recommendations(31)
Potential under-recognised risk of harm from the use of propranolol
The Practice now schedules patient reviews at 12-month intervals in advance for patients with mental health needs.
Safety Action
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation support staff to develop ‘crisis plans’ for patients who self-manage insulin to protect their safety at a later point when their capacity to make decisions in relation to their care may change?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to gain an understanding of the care patients with diabetes need?
Learning Prompt
Nutrition management of acutely unwell patients in acute medical units
NHS trusts can improve patient safety in acute medical units by identifying and planning for the increased need for routine periodic and ongoing nutritional screening and monitoring to account for increased length of patient stays.
Learning Prompt
Patients at risk of self-harm: continuous observation
Is there a shared understanding of the different roles and responsibilities of mental and physical healthcare staff in caring for a patient, including checking their personal belongings for items that could be used to self-harm. Are the different roles and …
Learning Prompt
Workforce and patient safety
HSSIB recommends that NHS England/Department of Health and Social Care, working with other relevant organisations, reviews and evaluates the implementation of the care co-ordinator role. This is to ensure that all patients with long-term conditions have their care co-ordinated and …
Safety Recommendation
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
HSSIB recommends that NHS England/Department of Health and Social Care, working with other relevant organisations, reviews and evaluates the implementation of the care co-ordinator role. This is to ensure that all patients with long-term conditions have their care co-ordinated and …
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
The Practice developed new guidance for patients new to antidepressants. This prompts its GPs to arrange patient reviews at: two weeks, more frequently over the first three months, a three-month follow-up, and then a further follow-up in six to 12 …
Safety Action
Medication not given: discharge from an acute hospital to the community
How to adjust the insulin dose was discussed, as well as injection technique. The patient was given leaflets which detailed injection technique and what to do in the event of illness, and type 2 diabetes and healthy eating booklets were …
Learning Prompt
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
follow-up, and the management of any tests ordered.
Learning Prompt
Management of chronic asthma in children aged 16 years and under
It may be beneficial if children were coded as having suspected asthma if under five years of age and on inhalers without an asthma diagnosis, recognising that the lack of a formal diagnosis leads to suboptimal care.
Safety Observation
Management of chronic asthma in children aged 16 years and under
HSIB recommends that NHS England and NHS Improvement, as a commissioning body, supports local systems to implement evidence-based interventions, such as standardised information and wheeze management plans, for the parents/carers of pre-school children. This will be undertaken in conjunction with …
Safety Recommendation
Weight-based medication errors in children
It may be beneficial if a standard format for multidisciplinary care reviews (including handovers and huddles) was adopted by healthcare organisations, with a shared understanding of the management plans for individual patients.
Safety Observation
Access to critical patient information at the bedside
It may be beneficial if the language used to refer to cardiopulmonary resuscitation recommendations is standardised and clarified through the implementation of the Recommended Summary Plan for Emergency Care and Treatment.
Safety Observation
Access to critical patient information at the bedside
HSIB recommends that the Resuscitation Council UK clarifies and promotes expectations around the sharing, presentation, and language of cardiopulmonary resuscitation recommendations in hospital ward environments in line with the findings of this investigation.
Safety Recommendation
Investigation report: Mental health inpatient settings - out of area placements
Healthcare services can improve patient safety by conducting assessments for neurodevelopmental conditions such as autism and attention deficit hyperactivity disorder, where it is safe and clinically indicated, at the earliest opportunity when a person is in contact with community and …
Safety Observation
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
HSSIB recommends that the Department of Health and Social Care works with NHS England and other stakeholders, to develop a strategy that ensures that all diseases are given parity and that all people with a long-term condition in primary, secondary, …
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
The Practice carried out an audit of all patients on antidepressants and invited them for a review appointment. The Practice now sends text/call reminders to patients who do not attend appointments and also have depression.
Safety Action
Medication not given: anticoagulation before and after a procedure
How does your organisation support staff to identify and document decision making at critical decision points where anticoagulation should be reviewed?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure appropriate tools and resources are used to support the design and implementation of the care pathway?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you identify and resource dedicated support to implement new care pathways?
Learning Prompt
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
It may be beneficial if written safety netting advice is developed for pregnant and postpartum women about COVID-19 and other common conditions, incorporating the MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) recommendations. Related …
Safety Observation
Timely detection and treatment of cauda equina syndrome
HSIB recommends that NHS England and NHS Improvement develops a national cauda equina syndrome pathway. This should define the safety-critical elements of the pathway and highlight areas that can be adapted locally
Safety Recommendation
Missed detection of lung cancer on chest X-rays of patients being seen in primary care
HSIB recommends that the National Institute for Health and Care Excellence reviews its current safety netting advice to healthcare professionals with respect to the investigation of possible lung cancer. The wording of the advice should be amended as required to …
Safety Recommendation
Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to …
It may be beneficial for the clinical commissioning group to provide oversight of stroke pathways until a hyper-acute stroke unit is established, to ensure that there is a clearly understood pathway for FAST-positive patients between 23:00 hours and 08:00 hours. …
Safety Observation
Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to …
HSIB recommends that Trust B works collaboratively with Trust A to develop a harmonised, cross-trust stroke policy with a clearly defined joint emergency department overnight stroke protocol for FAST-positive patients.
Safety Recommendation
Advanced airway management in patients with a known complex disease
Healthcare organisations that commission elective (planned) surgical services for people with mucopolysaccharidoses (MPS) can improve safety by involving healthcare professionals from different disciplines who are experienced in airway evaluation and management, before, during and after a person’s surgery.
Safety Observation
Nutrition management of acutely unwell patients in acute medical units
NHS trusts can improve patient safety by reviewing policies, processes, and procedures in acute medical units to ensure they provide clear and easily accessible pathways to refer patients to dietetics or speech and language services.
Learning Prompt
Sepsis: a patient with diabetes and a foot infection
Review and update the requirements of vascular service provision between Hospital A and Hospital B.
Area of Improvement
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
There are challenges in how tools and processes enable the care of deteriorating patients to be escalated to, and overseen by, senior medical and nursing staff.
Area of Improvement
Healthcare provision in prisons: data sharing and IT
HSSIB recommends that NHS England/Department of Health and Social Care, working with healthcare service providers and their healthcare teams at prisons which hold remand prisoners, reviews and amends the process for GMS registration of patients on remand. This is to …
Safety Recommendation
NCEPOD recommendations(86)— showing 50 strongest matches
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
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
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
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
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
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
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
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
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
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
CQC inspection actions(335)— showing 50 strongest matches
Ashbourne House - Torquay
People's care plans did not meet their needs and were not reflective of their wishes and preferences. People's care plans were not always effectively reviewed to ensure they were reflective of the care being delivered.
Must Do
Worthing Hospital
The trust should ensure the consistent completion of DoLS paperwork that matches patient’s needs.
Must Do
The York Hospital
The trust should ensure that patients on the acute stroke ward 23 received their daily 45 minutes of rehabilitation.
Should Do
The Princess Royal Hospital
The trust should ensure that ReSPECT forms are completed appropriately and consistently.
Should Do
The Princess Royal Hospital
The trust should ensure that ReSPECT forms are completed appropriately and consistently.
Should Do
The Princess Alexandra Hospital
The trust must ensure full risk assessment and care plans are completed in line with policy for patients assessed to be at risk during triage.
Must Do
Sunderland Royal Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Should Do
Sunderland Royal Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Should Do
South Tyneside District Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Should Do
South Tyneside District Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Should Do
South Tyneside District Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, where care needs are assessed and planned to meet their individual needs.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately record mental capacity assessments and decisions made in service user’s best interests.
Must Do
South Tyneside District Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, where care needs are assessed and planned to meet their individual needs.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately record mental capacity assessments and decisions made in service users' best interests.
Must Do
South Tyneside District Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, care needs are assessed and planned to meet their individual needs.
Must Do
Southport & Formby District General Hospital
The trust should continue to improve the assessment of the nutrition and hydration needs of patients including the accurate completion of fluid and nutrition charts.
Should Do
Scarborough Hospital
The trust should ensure that patients on the acute stroke ward 23 received their daily 45 minutes of rehabilitation.
Should Do
Royal Victoria Infirmary
The service must ensure that patient records include plans for managing risks.
Must Do
Royal Shrewsbury Hospital
The trust should ensure that ReSPECT forms are completed appropriately and consistently.
Should Do
Royal Shrewsbury Hospital
The trust should ensure that ReSPECT forms are completed appropriately and consistently.
Should Do
Royal Preston Hospital
The service should ensure risk assessments, care plans and intentional rounding is completed regularly for all patients.
Should Do
Royal Lancaster Infirmary
The service must ensure that there is a clear protocol for identifying women for prioritisation of induction of labour and that it is recorded in the care records.
Must Do
Royal Lancaster Infirmary
The service must ensure that there is a clear protocol for identifying women for prioritisation of induction of labour and that it is recorded in the care records.
Must Do
Rotherham General Hospital
The trust must ensure staff implement appropriate risk management plans for all patients presenting with mental health conditions.
Must Do
Rawreth Court
Care plans were not in place for all people using the service and people did not always receive person-centred care that met their needs.
Must Do
North Middlesex University Hospital
The services should ensure staff undertakes a follow up assessment for patients who are at risk of malnutrition or obesity.
Should Do
North Manchester General Hospital
The trust should consider the development of a policy to manage post-operative nausea.
Should Do
North Devon District Hospital
Ensure the management of patients with different needs to the speciality of the ward are safe and ensure appropriate medical oversight.
Must Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatcapacityassessmentsandbestinterestdecisionsarefollowedandrecordedinlinewithlegislation.
Should Do
Lister Hospital
The service should ensure that all patients with dementia have their needs assessed and recorded as per policy to allow safe care in the absence of regular staff and the premises are suitable to meet these needs.
Should Do
Kidderminster Hospital and Treatment Centre
All do not attempt cardiopulmonary resuscitation (DNAR CPR) records should be reviewed on admission within the surgical service when transferred from the community services.
Should Do
Kidderminster Hospital and Treatment Centre
The trust should ensure that venous thromboembolism (VTE) assessments are repeated for all identified patients after 24 hours.
Should Do
Kidderminster Hospital and Treatment Centre
The trust must ensure patients have their clinical needs assessed and care delivered in accordance with national best practice standards, and within nationally defined timescales.
Must Do
Hemel Hempstead General Hospital
The trust should ensure patient resuscitation and treatment plan records are completed and information is easy to locate.
Should Do
Gloucestershire Royal Hospital
The trust should ensure care plans reflect national guidance for restraint, observation, and emergency sedation.
Should Do
Furness General Hospital
The service must ensure that there is a clear protocol for identifying women for prioritisation of induction of labour and that it is recorded in the care records.
Must Do
Furness General Hospital
The service must ensure that there is a clear protocol for identifying women for prioritisation of induction of labour and that it is recorded in the care records.
Must Do
Fleetwood Hospital
The trust should ensure the trust improves and monitors the use of patient passports in all surgical areas.
Should Do
Fleetwood Hospital
The trust should ensure that patients’ care plans are updated in a timely way.
Should Do
Fleetwood Hospital
The trust must ensure that patients’ care and treatment address the mental health problems identified during assessment.
Must Do
Doncaster Royal Infirmary
The trust should ensure that capacity assessments and best interest decisions are followed and recorded in line with legislation.
Should Do
Diana Princess of Wales Hospital
The service must ensure there is a consistent approach to the monitoring of pain relief and the reassessment of pain.
Must Do
Clatterbridge Hospital
The services should continue to develop sepsis pathways within in and ensure it is represented appropriately at trust wide steering groups.
Should Do
Clatterbridge Hospital
The services should ensure patients care plans reflect individual needs and preferences.
Should Do
Clatterbridge Hospital
The service must undertake the required patient risk assessments including pain, nutrition and pressure area assessments and implement a robust process for the monitoring of care and treatment received by patients.
Must Do
Clatterbridge Hospital
The service must ensure staff complete risk assessments and associated care plans for patients.
Must Do
Chorley and South Ribble Hospital
The service should ensure risk assessments, care plans and intentional rounding is completed regularly for all patients.
Should Do
Castle Hill Hospital
The service should consider reviewing and revising the electronic system to ensure all staff have access and the system allows personalisation of care plans
Should Do
Castle Hill Hospital
The service must ensure where responsibility for the care and treatment of service users is shared with, transferred to other persons, or working with such other persons, service users and other appropriate persons that timely care planning takes place to …
Must Do
Blackpool Victoria Hospital
The trust should ensure that women are fully informed about the reason for remaining in hospital ahead of an induction.
Should Do
PPO death in custody recommendations(22)
The Head of Healthcare at Parc
The Head of Healthcare at Parc should ensure that CVOP meetings are clinically multidisciplinary, that effective care plans are created and implemented, and that the meetings are accurately minuted.
The Head of Healthcare at HMP Buckley Hall
The Head of Healthcare at HMP Buckley Hall should ensure that all prisoners identified as having a severe and enduring mental illness have comprehensive care plans.
The Head of Healthcare
The Head of Healthcare should ensure that care plans are created for all patients with suspected coronary heart disease.
The Head of Healthcare
The Head of Healthcare ensures that all patients with a recognised long-term condition always have an up-to-date care plan for management of the condition.
The Head of Healthcare
The Head of Healthcare should ensure that personalised care plans with aims, planned interventions and monitoring, are in place for all patients with long-term health conditions.
The Head of Healthcare
The Head of Healthcare should ensure that all patients with a cancer diagnosis have a formal and regularly reviewed care plan, in accordance with NICE guidelines.
The Head of Healthcare and the manager of the integrated …
The Head of Healthcare and the manager of the integrated mental health team should ensure that prisoners with mental health issues have appropriate reviews and care plans which are recorded and implemented.
The Head of Healthcare
The Head of Healthcare should review the process for managing and monitoring long-term conditions to ensure the development of meaningful patient-centred care plans.
The Head of Healthcare
The Head of Healthcare should ensure care plans are implemented for prisoners who test positive for COVID-19 to ensure that appropriate individualised care is always delivered.
The Head of Healthcare
The Head of Healthcare should ensure that care plans are in place for patients with hypertension and other chronic conditions.
The Head of Healthcare
The Head of Healthcare should ensure that staff create care plans to support prisoners under their care, setting out a treatment plan including timescales for review.
The Head of Healthcare
The Head of Healthcare should ensure that: formal care plans are in place to manage patients with chronic health conditions; and healthcare staff record the details and outcome of assessments in patients’ medical records; and follow the protocols for escalating …
The Head of Healthcare
The Head of Healthcare should ensure that all patients with long term conditions have an appropriate nursing care plan within their healthcare record.
The Head of Healthcare
The Head of Healthcare should ensure that nursing care plans are implemented in a timely manner to deliver consistent, high-quality care.
The Head of Healthcare
The Head of Healthcare should ensure that all prisoners with long-term conditions are offered an annual review.
The Head of Healthcare
The Head of Healthcare should ensure that staff create timely care plans for the management of long-term conditions.
The Head of Healthcare
The Head of Healthcare should ensure that any new information received by the mental health team from the liaison and diversion services after a prisoner has arrived at Wandsworth must inform a review of the level of risk and plan …
The Head of Healthcare
The Head of Healthcare should rewrite the older person care plan to include: • Regular reviews by healthcare to monitor for signs of physical and mental deterioration, and. • Reviews of mobility and monitoring for signs of weight loss.
The Head of Healthcare
The Head of Healthcare should ensure that if a prisoner has a medical condition, a care plan is put in place as soon as healthcare staff are made aware of this condition and it is updated on a regular basis.
The Head of Healthcare
The Head of Healthcare should ensure that care plans are initiated when clinically indicated, including for hypertension.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners at risk of suicide or self-harm in line with policy, and in particular, staff should: ensure relevant staff involved in the prisoner’s care, including healthcare staff where appropriate, …
The Head of Healthcare (HMP Wandsworth)
The Head of Healthcare should ensure that the value of daily activity for those with long term mental health needs is included in relevant care plans and highlighted in clinical supervision.
IMB individual recommendations(57)— showing 50 strongest matches
Isis (2023)
Since at least 2014, the Board has drawn attention to the need for prisons receiving prisoners from the courts to complete an initial sentence plan (OASys) before onward transfer. The current system is clearly not working. How will the Prison Service address this and ensure that every prisoner on arrival at HMP/YOI Isis comes with a sentence plan that will …
HMPPS
Foston Hall (2023)
Carers for people with support needs can have long waits for escorts or even be turned away at the gate if a serious incident is in progress, leaving prisoners with unmet care needs. How can this be addressed?
Governor / Director
The Verne (2020)
The Board encourages the Governor, in collaboration with Dorset Council, to review the long-term provision of social care needs for the current population.
Governor / Director
Implemented
Cookham Wood (2021)
What steps will be taken to arrange transfers to the adult estate for young adults who are aged 18+ and have long sentences and/or complex needs?
HMPPS
In Progress
Cookham Wood (2021)
Sentence planning is required to ensure that young adults do not get stuck in YOIs pending transfer to the young adult estate.
HMPPS
In Progress
Swinfen Hall (2022)
What action will be taken to continue to reduce the backlog of OASys reports that clearly impacts negatively on outcomes for prisoners?
Governor / Director
Stoke Heath (2022)
Prisoners coming to Stoke Heath should be accompanied by a completed offender assessment (OASys) which includes sentence plan objectives assessing the risk of harm, risk of reoffending and educational needs.
HMPPS
Stocken (2022)
Does the Prison Service feel that it is acceptable that some establishments are allowing the transfer of prisoners without a completed OASys assessment and, if not, how does it propose to ask establishments to rectify this?
HMPPS
North Sea Camp (2022)
Community offender managers often take a long time to update their part of OASys and complete the paperwork to enable prisoners to sit ROTL boards. This can mean prisoners having to postpone Parole Board hearings as they have not done the required ROTLs and means prisoners may spend more time in prison than strictly necessary. Timescales for return of paperwork …
HMPPS
Coldingley (2023)
Since the start of 2023 there has been a near doubling of prisoners without sentence plans – it now amounts to around 10% of all Coldingley prisoners. How is this sudden deterioration to be addressed?
Governor / Director
Gatwick IRC (2024)
Review how key mechanisms intended to safeguard the detained men operate together to ensure that they provide effective outcomes: Detention Gatekeeper, healthcare arrival screening, Rule 34 assessments, Rule 35 processes, assessment, care and teamwork in detention plans (ACDT, used to monitor detained people who are considered at risk of self-harm), ACDT and vulnerable adult care plan (VACP) processes, and Adults …
Home Office
Partially Accepted
Downview (2024)
The management of PACT’s contracted family engagement by the prison appears to be poor (7.4).
Governor / Director
In Progress
Deerbolt (2024)
We now have a dozen IPP [imprisonment for public protection] prisoners at Deerbolt who do not understand what they need to do to gain release (particularly when they are past their original sentenced detention date) and whether Deerbolt can, in fact, offer the level of service necessary to let them attain their release. May we have clarity from the Minister …
Ministry of Justice
Ashfield (2024)
With the large number of elderly prisoners in the custodial estate (particularly in prisons such as Ashfield), cases of dementia and terminal illness requiring 24-hour care are increasing. The specific needs of these prisoners cannot be adequately met in normal prison conditions. What plans does the Prison Service have for addressing this issue through the creation of special custodial centres?
HMPPS
Charter Flight (2020)
If the reality of any such new agreements is that removal from the UK to the ‘safe’ country will be enforced removal, they must contain an express commitment to brief the receiving country on the needs of the returnee – a proper, structured handover of the sort not achieved in 2020, as evidenced in the report.
Other
Send (2021)
The Board is concerned that the Covid-19 restrictions have created barriers for some prisoners, making them unable to complete their sentence plans and progress towards release (7.3).
HMPPS
Implemented
Drake Hall (2021)
Due to operational pressure, increasing numbers of prisoners are transferred shortly before their release date. This has the potential to harm their successful transition from prison (see section 7.3).
HMPPS
In Progress
Hollesley Bay (2022)
That, as the prison population becomes older, greater attention is paid to the social care agenda and any matters appearing are cross-referenced with the prison’s health service providers.
Governor / Director
Hollesley Bay (2022)
That, as the prison population becomes older, greater attention is paid to the social care agenda and any matters appearing are cross-referenced with the prison’s health service providers.
Governor / Director
Dartmoor (2022)
Can the prison explain clearly to staff and prisoners what the purpose is of a challenge, support and intervention plan (CSIP), how to refer on to it, what the prisoner can expect to get from it and what completion looks like?
Governor / Director
Cookham Wood (2022)
Transition of 18+ boys: Is there end-to-end sentence planning and support for these boys? Do they carry their sentence plan with them when they transition to a young adult institution? Or do they have to start afresh? What steps will be taken to arrange transfers to the adult estate for young adults who are aged 18+ and have long sentences …
HMPPS
Werrington (2024)
The Board would like to know if the Minister believes that the implementation of Framework for Integrated Care has really improved the quality of the lives of young people in custody. And, if not, what steps will the Minister take to address this problem?
Ministry of Justice
In Progress
Rye Hill (2024)
The Board remains concerned that prisoner-requested transfers within the estate have remained all but impossible, meaning that many prisoners remain held a long distance from their family and friends. While acknowledging that the over-population issue is partly to blame, there does not seem to be any active consideration of family ties when decisions are made on where prisoners are located, …
HMPPS
Noted
Risley (2024)
The delays in resettlement for high-risk men and foreign nationals continues to disrupt their progression, does HMPPS believe the current processes are suitable for more complex cases?
HMPPS
In Progress
Ranby (2024)
The churn in the prison continues to increase. This has led to issues with resettlement and progression. What will the Prison Service do to address this problem?
HMPPS
In Progress
Preston (2024)
There appears to be a need for more family engagement by the OMU.
Governor / Director
North Sea Camp (2024)
Whilst this was addressed after last year’s annual report, there are still some apparent delays with community offender managers often taking a long time to update their part of the offender assessment system (OASys) risk assessment paperwork to enable prisoners to sit release on temporary transfer (ROTL) boards.
HMPPS
In Progress
Foston Hall (2024)
There are no social care buddies for prisoners with care and support needs. How will this be addressed?
Governor / Director
Downview (2024)
Can HMPPS provide clarity on how allocation criteria are set and managed for transfers [of women far away from their families]?
HMPPS
Noted
Five Wells (2025)
What improvements can be made to ensure all men arrive at Five Wells with a robust and up-to-date sentence plan?
HMPPS
Five Wells (2025)
What improvements can be made to ensure all men arrive at Five Wells with a robust and up-to-date sentence plan?
HMPPS
Brinsford (2023)
Challenge, support and intervention plans (CSIPs) are a good deterrent when they are working properly. Sadly, the Board recognises that they are often seen as less important as other processes & strategies such as assessment, care in custody and teamwork documents (ACCTs). Often the work involved is not completed within a timely manner. Some managers are totally on board with …
Governor / Director
Wetherby (2020)
The Board welcomes the implementation of the custody support plan (CuSP) but considers that it can only be of benefit if delivered with consistency. Is the establishment committed to ensuring that CuSP sessions are dealt with as a priority?
Governor / Director
Swinfen Hall (2020)
The huge increase in Board applications about sentence management is deeply worrying. Large numbers of prisoners do not have a completed OASys assessment, and therefore are not able to follow their sentence plans. While the origin of this is beyond the prison’s ability to resolve, can the Governor confirm that more prison effort will be directed to rectifying the position, …
Governor / Director
In Progress
Swinfen Hall (2020)
A significant number of prisoners arrive at the establishment without a completed offender assessment system (OASys) assessment. This places an excessive demand on prison staff and causes prisoners considerable stress because they cannot embark on proper and safe sentence planning or make progress with rehabilitation; it also has an adverse impact on confidence in the prison regime. The issue has …
HMPPS
In Progress
Norwich (2020)
Why are alerts stating that a prisoner should not be transferred to a specific establishment not adhered to? (See section 6.12)
HMPPS
Rejected
Exeter (2021)
Review the current arrangements for prisoners’ induction (particularly support for young adults) and implement quality assurance systems to make sure that prisoners new to custody are given all the information they need in their early days at Exeter. This should include information on the IMB (see 4.1).
Governor / Director
Styal (2022)
consideration needs to be given to a more holistic, multi-agency approach to release arrangements to ensure fair and consistent access to support.
HMPPS
Portland (2022)
What steps will the Governor undertake to ensure that all relevant information gathered during the induction process is shared appropriately across the prison to enhance each resident’s pathway to resettlement?
Governor / Director
Drake Hall (2022)
Due to operational pressure, increasing numbers of women continue to be transferred shortly before their release date. Undertaking work to prepare such women for release is then impossible (see section 7.3).
HMPPS
North East Midlands, Yorkshire & Humber STHF (2023)
We recommend that Border Force staff at STHFs ensure that all ongoing care and welfare checks are fully and properly recorded on the annex A form in the port.
Home Office
Hollesley Bay (2023)
If such schemes are to be introduced, the Board urges that account should always be taken of the time required to work with individuals in a meaningful way in preparation for their release.
Ministry of Justice
Implemented
Downview (2023)
We have seen evidence of unhelpful intervention by the Secretary of State for Justice in decision-making regarding women’s progression. We welcome the recent reversal in this area3, but query whether this would also extend to the situation referred to in section 7.3.
Other
Askham Grange (2023)
Can the Prison Service consider improving the provision of community offender managers to help speed up access to ROTLs and improve release planning?
HMPPS
In Progress
Springhill (2024)
The Board continues to report issues with securing the necessary information and engagement from outside probation and other agencies, which significantly delay men’s access to release on temporary licence (ROTL). An issue which is exacerbated by the introduction of new early release schemes. What more does the Prison Service intend to do to improve the capacity of outside probation and …
HMPPS
In Progress
Five Wells (2024)
What improvements can be made to ensure all men arrive at Five Wells with a robust and up to date sentence plan?
HMPPS
Partially Accepted
Deerbolt (2024)
Despite population pressures, how will the Minister ensure that HMPPS is held accountable for ensuring prisoners are located as close as reasonably possible to their families to better support and enable contact, as recommended in Lord Farmer’s report?
Ministry of Justice
Warren Hill (2025)
The IMB recognises that the age profile of the prisoner population is increasing. What is the Governor’s/HMPPS’s plan to accommodate elderly prisoners in a more purposeful way, including making physical adaptations to the prison to be age-friendly and ensuring appropriate care packages are in place for prisoners with social care needs?
HMPPS
In Progress
Erlestoke (2025)
What long term solutions are being proposed to manage the increasing numbers of elderly and frail prisoners who cannot be managed fairly or humanely in the main prison estate?
Ministry of Justice
In Progress
Foston Hall (2020)
There is a need for a specific sentence planning route, and intervention pathway for prisoners with autism (see paragraph 4.4.2).
HMPPS
In Progress
Health investigations(1134)
*Mental health homicide investigation legacy report into the care and … — Rec L5
The trust should continue to encourage risk panel meetings. In circumstances where there is significant uncertainty about an individual patient’s diagnosis and/or treatment plan, these cases should automatically be discussed in an appropriate forum, with other clinical colleagues, to assist in developing an appropriate care and risk management plan.
south_east
*Mental health homicide investigation legacy report into the care and … — Rec L2
The trust should assure itself that the current process for Care Programme Approach (including care planning, risk assessment, risk management planning) is robust. The clinical governance team should audit compliance at least every six months and report its findings to the board.
south_east
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xx)
The Trust and Council should audit the outcomes of the CPA procedures at intervals of not less than two years and should revise them as necessary.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xix)
The Council should ensure that in any case in which there is an assessed substantial need for assistance with a social problem careful consideration is given to the feasibility and best means of providing the requisite support.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xi)
The Trust and Council should introduce a course of instruction and training for mental health staff undertaking care co-ordination.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (x)
The Trust and Council should undertake an audit of the process of care co ordination with a view to establishing that suitable professionals are being assigned to service users on Enhanced CPA and that co-ordination is being effectively carried out in accordance with the current Practice Guidelines.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (viii)
The Trust and Council should ensure that the care plan for a service user on Enhanced CPA includes a contingency plan and a crisis plan and that they contain the information prescribed in the CPA Policy Document.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (vii)
The Trust and Council should ensure that following assessment of a service user entitled to aftercare a care plan is formulated which complies with the requirements of the CPA and Care Management.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (vi)
The Trust and Council should establish a procedure whereby a decision to regrade the service user (whether to a lower or higher category) is restricted to a Consultant following discussion with other professionals involved in the case and made not less than three months after discharge from hospital.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (v)
The Trust and Council should ensure that every service user is accurately categorised as a Standard or Enhanced CPA case.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (i)
The Central and North West London Mental Health NHS Trust and Brent Council should ensure that the health and social care needs of every service user entitled to aftercare pursuant to section 117 of the Mental Health Act are fully and properly assessed in accordance with the procedures set out …
london
Independent investigation: Sidney Waller, Manchester (2008) — Rec 2
The Trust should instigate quarterly review meetings to encompass the monitoring of care plans, which should: include a peer evaluation against agreed standards; ensure care planning, and the treatment and management of patients be informed and based on a comprehensive risk assessment.
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: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 9
The Trust should implement the recommendations and action plan of the CPA steering group and re audit compliance 12 months following its implementation/ or the publication of this report, whichever comes first. This review should: ensure that service users who are previously unknown to the service and make their first …
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 8
The Trust should consider making the distinction between Voluntary and Informal patients on admission documentation. This to include: policy revision and documentation revision as required; the requirement for the assessment and documentation of capacity of all service users on admission who are not admitted under detention.
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 5
The Trust should ensure that the MDT review encourages collaborative decision making whilst maintaining clear lines of accountability and responsibility for both the overall care and treatment plan and the individual elements of it.
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 4
The Trust should continue implementing New Ways of Working (NWW) in all acute wards to ensure an effective full daily multidisciplinary team (MDT) review of all patients‟ care and treatment. In order to achieve this the MDT will also need to: be subject to a full skill mix review which …
north_west
Independent investigation: Pauline Cole (partner), Manor Park, London (2003) — Rec 5
Barnet, Enfield and Haringey Mental Health NHS Trust and East London and The City Mental Health NHS Trusts should review all forensic patients with an element of care in another locality to ensure the application of CPA principles and follow-up.
london
Independent investigation: Pauline Cole (partner), Manor Park, London (2003) — Rec 4
Barnet, Enfield and Haringey and East London and The City Mental Health NHS Trusts should a) review the application of CPA principles, and b) ensure that the Barnet MDO team reviews its allocation of cases and application of CPA to all cases that are open but not active.
london
Independent investigation: Pauline Cole (partner), Manor Park, London (2003) — Rec 2
Barnet, Enfield and Haringey, and East London and The City NHS Mental Health Trusts, should review the implementation of CPA policy to ensure compliance with current guidance relating to the needs of carers.
london
Independent investigation: Pauline Cole (partner), Manor Park, London (2003) — Rec 1
East London and The City Mental Health NHS Trust (now incorporating Newham community mental health services) should 1) review the implementation of its CPA policy with a view to establishing the reasons why the referrals of PC to the East Newham CMHT in 2002 and 2003 did not occur and/or …
london
Independent investigation: Katie Kazmi, Reading (1999) — Rec 13
The trusts should consider the desirability of including in CPA documentation a note of the advice given to the patient on driving.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 10
Trusts and social services should ensure that there are both qualitative and quantitative audits of the implementation of local CPA guidance.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 7
The trusts should take urgent action to review clinical files and establish a universal system highlighting, and regularly reviewing: a basic chronology; a risk management plan including relapse profile; a care plan and clinical reviews.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 5
The trusts should ensure that CPA documentation contains a section referring to dual diagnosis. Where appropriate reasons should be given why a decision was made not to refer the patient for a specialist substance abuse assessment.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 3
The involvement of nurses in monitoring the mental state of an out-patient should only occur in the context of a full CPA process, with a clear and achievable purpose, full recording and recorded evidence of regular feed-back to the MDT.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 8
Social services and trusts should consider the desirability of including in CPA documentation a note of the advice given to the patient on driving.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
The trusts should consider the desirability of including in CPA documentation a note of the advice given to the patient on driving.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 1
Trusts and social services should ensure that there are both qualitative and quantitative audits of the implementation of local CPA guidance.
south_east
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 11
The Trust will ensure through the audit process that: all care plans are developed, where appropriate with carers; collateral information is sought from carers; information pertaining to risk is shared with carers and that, when appropriate, contingency and crisis plan information is shared in full with them; all carers, where …
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 10
The Trust will ensure through the audit process that: all care plans are developed, where possible with service users; all care and service delivery is provided in manner sensitive to the needs and wishes of the service users; all care plans are signed, where possible, by service users; all service …
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 6
The Trust can demonstrate improvement to processes around the delivery of effective care planning and risk assessment. This work is at an early implementation stage and work needs to continue to ensure its continued effectiveness. The following actions need to take place: all registered health and social care practitioners in …
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 5
The Trust can demonstrate improvement to processes around the delivery of effective care planning and risk assessment. This work is at an early implementation stage and work needs to continue to ensure its continued effectiveness. Audit processes should include: Assurance that all those referred to secondary mental health services have …
north_west
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (iv)
The Trust should ensure that following assessment of a patient a Care Plan which complies with the requirements of the CPA is always formulated and recorded and that it includes express reference to the Level on which the patient is to be managed and a review date.
london
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 2
Having revised its risk assessment, mangement and training policy the Trust should institute a regular quality audit to ensure: that the formulation of the individual’s problems and needs informs the understanding of his/her risk; that robust and meaningful care plans are put in place; that the service user and other …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 1
In line with current CPA guidance and the Trust’s own current CPA policy the Trust should undertake regular quality audits to ensure: all those referred to its secondary mental health services have a comprehensive assessment of their needs; there is a clear formulation of the individual’s difficulties and needs; care …
north_east_yorkshire
Independent investigation: Brian Cherry, Walthamstow (2004) — Rec R2
Areas for further assessment and intervention should include beliefs about the events of the offence, its impact on the victim’s family and his racial gender attitudes.
london
Independent investigation report into the care and treatment of Yusuf — Rec 3
A nutritional risk assessment (STAMP) was not completed. The impact of pre-admission reduced nutritional intake was not assessed. • The Trust should ensure the STAMP screening is completed accurately on admission as per Trust policy. • The Trust should review its STAMP guidance to ensure that pre-admission nutritional status is …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.1.6
The Health Board must ensure that a restricted patient has a Responsible Medical Officer at all times.
scotland
Independent investigation: Simon Breed, Wood Green (2004) — Rec R12
The 2008 CPA policy is reviewed and amended to take into account the problems that we have identified in the PT case and to ensure that policy is compatible with all other relevant trust policies and protocols.
london
Independent investigation: Sarah Jane Coghlan, Middlesbrough (2003) — Rec 5
Where CPA arrangements are in place, all documentation specified in the CPA policy should be completed, and full adherence to the CPA policy should be verified by audit. In the present case, this may have identified the fact that separate psychiatric outpatient appointments had ceased, and that no risk and …
north_east_yorkshire
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.9
The Independent Investigation Team believes that care planning could be improved by a slot being made available at the weekly MDT Meeting to allow for discussion of more complex care planning and ongoing planning issues. The documentation surrounding care planning should be reviewed to make it easier for care co-ordinators …
east_of_england
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.5
The Clinical Standards should be revised to include a process for referral of service users for psychological review and assessment.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec 4
The Case Worker Guide should be updated to require information not just from the RMO but from others who will bear responsibility for the after-care of the patient.
east_of_england
Independent investigation: Richard Marden, Towcester (1999) — Rec 5
That carers should have their own care-plan which includes names of key professionals and how to contact them.(Para 14.20)
midlands
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.2.c
The CPA The mental health services should review existing CPA guidance and procedures to ensure that: All CPA meetings routinely question MAPPA registration. CPA documentation, including risk assessment pro-formas, is amended to incorporate MAPPA status. CPA policy and procedures is amended to include guidance on those circumstances which might indicate …
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1.h
Change of care co-ordinator – enhanced CPA The policy should explicitly deal with the circumstances where there is to be a change of care co-ordinator for a person on enhanced CPA. There should preferably be a face-to-face transfer meeting involving a CPA review. The policy should take into account that …
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1.b
Dispute resolution The possibility of dispute between professionals about applying eligibility criteria for CPA and other CPA-related areas, for example the contents of care plans, should be explicitly recognised and the policy should contain procedures to resolve disputes.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1.a
Change of eligibility criteria The characteristics of people on CPA may change – for example a person on standard CPA may become eligible for enhanced CPA. The policy should explicitly deal with this and should contain guidance about reviewing each patient’s status.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1
Current CPA policy and procedures should be amended to take into account the following:
london
Scottish Fatal Accident Inquiries(11)
Hamish Adamson
The management of the Trust and the senior medical and midwifery management at Cresswell should carry out an urgent and thorough review of the practices and procedures at Cresswell in relation to a trial of labour by induction by prostaglandin gel by a woman who has previously undergone a caesarean section operation with particular reference to • The time of …
Dec 2000
Stuart Robert Hamilton
It is recommended that the instructions to ambulance crews to take all casualties to the Garrick Hospital be reconsidered and that consideration be given to establishing a protocol dealing with the circumstances in which a patient should be taken direct to a hospital other than the Garrick.
Jun 2002
Sharman Weir
I recommend: (a)That the Queen Mother's Hospital should identify a lead obstetric consultant to develop a system for the management of patients with pre-eclampsia and eclampsia. This should include protocol development and updating, and appropriate staff training. (b)That the training of all junior medical staff at the Queen Mother's Hospital should include their being taught (1) about the potential seriousness …
Jan 2003
James Maughland
Hospitals (other than psychiatric hospitals) should review how they deal with the admission of patients with learning disability or mental illness and devise a protocol for identifying such patients and to ensure that there is proper communication with them not only on admission but throughout their stay in such hospitals. Where there is a patient in a general hospital who …
Mar 2003
Chloe McIver
The Health Board, therefore, should review its procedures in this regard. This dichotomy of view between a Consultant Paediatrician and the Director of Nursing must be resolved and the appropriate protocol put in place. (c)It was clear from the evidence at the Inquiry that the midwives were not certain as to how they instigated the transfer of a sick baby …
Nov 2005
Angus MacDonald Malone
Oct 2009
Elijah Stirling
Those providing ante-natal care to women considering vaginal birth after Caesarean section (hereafter VBAC) should discuss and record the risks relating to the pregnancy and birth, the risks and benefits of VBAC versus Caesarean section (hereafter C-section) and the planned mode of delivery. Where the drug Syntocinon is to be employed in inducing a VBAC birth, there should be set …
Mar 2015
James Hutchison
(5) Recommendations I make the following recommendations (where I refer to a nursing home it should be understood that I am referring to a nursing home for elderly and mentally infirm persons, an EMI home) :- (a) When any elderly and mentally infirm person (probably therefore a person suffering from dementia) is to be admitted to a nursing home there …
Dec 2006
Anne Amos
1. That any pre-admission form designed to elicit information regarding a resident’s care needs, issued to the family or legal guardian of a resident, contains a series of questions, worded in laypersons’ language, sufficient to highlight the presence or potential risk of dysphagia or choking. 2. That a choking policy and pathway is put in place to identify and manage …
Dec 2025
Emma Agnes Frame
Accordingly I would recommend that there be a review of the practice in Yorkhill relating to first referrals of a child in order to establish whether a staightforward system to achieve this might be put in place.
May 2005
Erin Casey and Christina Fiorre Ilia
I recommend the following:- (1) The vast majority of patients with epilepsy, or their parents or carers where appropriate, should be advised of the risk of SUDEP on first diagnosis or if , in the particular circumstances of that patient, there are exceptional circumstances for delaying immediate provision of the information, then within a very short time thereafter. Advice about …
Aug 2011
Article 2 learning points(1)
Independent reviews(50)
Mental Health Taskforce 2016 — Rec 13
By 2020/21, NHS England should complete work with ALB partners to develop and publish a clear and comprehensive set of care pathways, with accompanying quality standards and guidance, based on the timetable set out in this report. These standards should incorporate the relevant physical health care interventions and the principles …
Health & Social Care
Harris Review: Deaths in Custody — Rec 76
Where a prisoner who is being transferred to another prison has been on an ACCT, and when the crisis plan of the SAVRAS has been implemented, which was closed within the last three months this must be highlighted and the Care Plan (ICP) reviewed within 24 hours of receiving the …
Justice & Legal
Harris Review: Deaths in Custody — Rec 75
During any transfer, where a prisoner has a SAVRAS (as all young adults will have) as part of their ICP, the receiving establishment must ensure that there must be no interruption of the ICP and/or SAVRAS as a result of the transfer.
Justice & Legal
Harris Review: Deaths in Custody — Rec 72
Case Reviews of the SAVRAS and ICP will be led by the CARO and must be multi-disciplinary and where necessary must include representatives from healthcare. Where appropriate, the CARO should consider including chaplaincy, education, relevant in-reach staff, VCS and the prisoners’ families/friends. CRC/NPS probation and TTG workers should also be …
Justice & Legal
Harris Review: Deaths in Custody — Rec 69
All young adults should have an up to date ICP and SAVRAS that is co-ordinated by their CARO, who will be accountable for assuring the quality of the documentation, its regular review, and ensuring that its various elements are implemented.
Justice & Legal
Harris Review: Deaths in Custody — Rec 62
The ICP should be developed by the CARO, in consultation with the young adult concerned in order to identify how, by whom and when their needs identified by the SAVRAS process, will be met.
Justice & Legal
Morecambe Bay Investigation — Rec 7
The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care operates without inflexible demarcations between professional groups. This should be …
Health & Social Care
Wessely Review — Rec 134
The new statutory Care and Treatment Plan should include a plan for readmission and consider what factors should be taken into account concerning use of informal admission, section 2 and recall.
Health & Social Care
Accepted
Wessely Review — Rec 122
Care and Treatment Reviews should be given statutory force in the MHA.
Health & Social Care
Accepted
Wessely Review — Rec 75
There should be a clear statement in the new Code of Practice of the purpose and content of the SCP and section 117 aftercare.
Health & Social Care
Accepted
Wessely Review — Rec 71
There should be a Statutory Care Plan (SCP) for people in contact with CMHTs, inpatient care and/or social care services.
Health & Social Care
Accepted
Wessely Review — Rec 43
Detention should require a comprehensive statutory Care and Treatment Plan (CTP) to be in place within 7 days and reviewed at 14 days. This should set out: a. the full range of treatment and support available to the patient from health and care organisations; b. any care which could be …
Health & Social Care
Accepted
Wessely Review — Rec 24
The statutory definition of IMHA advocacy should be amended to cover advocacy around care planning and advance choice.
Health & Social Care
Accepted
Wessely Review — Rec 17
Patients under Part III of the MHA who are not currently eligible to have a NR should have limited eligibility for a NP/INP in relation to care planning.
Health & Social Care
Accepted
Wessely Review — Rec 16
NPs should have the right to be consulted on care plans.
Health & Social Care
Accepted
Wessely Review — Rec 4
Shared decision-making between clinicians and patients should be used to develop care and treatment plans and all treatment decisions as far as is practicable.
Health & Social Care
Accepted
Ockenden Review — Rec 14
Neonatal care. Essential action: There must be clear pathways of care for provision of neonatal care. This review endorses the recommendations from the Neonatal Critical Care Review (December 2019) to expand neonatal critical care, increase neonatal cot numbers, develop the workforce and enhance the experience of families. This work must …
Health & Social Care
Accepted
Ockenden Review — Rec 13
Bereavement care. Essential action: Trusts must ensure that women who have suffered pregnancy loss have appropriate bereavement care services. • Trusts must provide bereavement care services for women and families who suffer pregnancy loss. This must be available daily, not just Monday to Friday. • All trusts must ensure adequate …
Health & Social Care
Accepted
Ockenden Review — Rec 9
Preterm birth. Essential action: The LMNS, commissioners and trusts must work collaboratively to ensure systems are in place for the management of women at high risk of preterm birth. Trusts must implement NHS Saving Babies Lives Version 2 (2019). • Senior clinicians must be involved in counselling women at high …
Health & Social Care
Accepted
Ockenden Review — Rec 8
Complex antenatal care. Essential action: Local Maternity Systems, Maternal Medicine Networks and trusts must ensure that women have access to pre-conception care. Trusts must provide services for women with multiple pregnancy in line with national guidance. Trusts must follow national guidance for managing women with diabetes and hypertension in pregnancy. …
Health & Social Care
Accepted
Cass Review — Rec 2
Clinicians should apply the assessment framework developed by the Review's Clinical Expert Group, to ensure children/young people referred to NHS gender services receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health …
Health & Social Care
Accepted
Narey-Owers Foster Care Review — Rec 28
Children must routinely be better prepared for a placement (as already required in Regulation 11) by being told much more about the carers, their family and the carers' home, day-to-day care and routines before the first meeting (including seeing video messages and scenes of their bedroom and learning about some …
Other
Shelley NHS Hospital Food Review — Rec 5
Technology: Every hospital to implement a digital meal ordering system by 2022, leading to: a) Safe ordering and mapping to patients' care plans. b) Menu offers tailored to patients' dietary needs and personal preferences. c) Minimum time between ordering and meal service. d) Reduction in waste.
Health & Social Care
Harris Review: Deaths in Custody — Rec 63
NOMS should consider whether the ICP, SAVRAS and CARO approach might also usefully apply to older adult prisoners.
Justice & Legal
Paterson Inquiry — Rec 8
We recommend that Spire should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in the same way that has been provided for patients in the …
Health & Social Care
Shaw Detention Review — Rec 24
Recommendation 24: I note that DSO 03/2013 on food and fluid refusal is currently the subject of internal review within the Home Office. I recommend that the review consider alternatives to treatment within a prison or IRC in light of my discussion of this issue.
Immigration
Harrington WCA Review (Year 1) — Rec 1
The review recommends that Jobcentre Plus manages and supports the claimant during the course of their benefit claim and identifies their chosen healthcare adviser.
Employment & Work
Wessely Review — Rec 139
There should be a common framework for assessment of risk across criminal courts, clinicians and the Justice Secretary. The assessment needs to be regularly reviewed (at least annually and before every Tribunal hearing). Every patient should have written in to the Care and Treatment Plan what their risk levels are.
Health & Social Care
Accepted
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 72
There should be a statutory duty for CCGs and Local Authorities to work together to deliver the SCPs.
Health & Social Care
Accepted
Wessely Review — Rec 65
The recall criteria should be updated and the process should be reformed to make it simpler.
Health & Social Care
Accepted
Wessely Review — Rec 63
As well as considering discharge, the Tribunal should, when refusing to discharge from the CTO, be able to order changes to the conditions of a CTO.
Health & Social Care
Accepted
Wessely Review — Rec 6
Statutory advance choice documents (ACDs) should be created that enable people to make a range of choices and statements about their inpatient care and treatment. These should be piloted to identify the detail needed to inform/impact practice.
Health & Social Care
Accepted
Gauke Review — Rec 6.7
Agree a strategy to manage older offenders’ complex health needs
Justice & Legal
Timpson Review — Rec 28
Relevant regulations and guidance should be changed so that social workers must be notified, alongside parents, when a Child in Need is moved out of their school, whether through a managed move, direction off-site into AP or to home education, as well as involved in any processes for challenging, reconsidering …
Education
Accepted
Ockenden Review — Rec 11
Obstetric anaesthesia. Essential action: In addition to routine inpatient obstetric anaesthesia follow-up, a pathway for outpatient postnatal anaesthetic follow-up must be available in every trust to address incidences of physical and psychological harm. Documentation of patient assessments and interactions by obstetric anaesthetists must improve. The determination of core datasets that …
Health & Social Care
Accepted
Laming Review (Baby P) — Rec 9
Every Children's Trust should ensure that the needs assessment that informs their Children and Young People's Plan regularly reviews the needs of all children and young people in their area, paying particular attention to the general need of children and those in need of protection. The National Safeguarding Delivery Unit …
Other
Selous Review — Rec 36
The Department for Education and the Ministry of Defence to explore how to avoid Service children’s Education, Health and Care Plans (ECHPs) lapsing as a result of accompanying their parents on deployments outside of England, to ensure a continuity of provision for Service children with EHCPs.
Other
Coates Prison Education Review — Rec 2
Every prisoner must have a Personal Learning Plan that specifies the educational activity that should be undertaken during their sentence. This should be in a consistent digital format that can follow the prisoner through the system if they move prisons. This plan should be informed by initial assessment, be subject …
Justice & Legal
Farmer Review (Women) — Rec 2
Liaison and diversion services, and police (whether upon arrest or when an out of court disposal is being considered) to take opportunities to collect information on women's key relationships to ensure better outcomes for them and their families. With her consent this will be held in a personal electronic file …
Justice & Legal
MacAlister Review — Rec 24
A Family Network Plan should be introduced and enabled in law to support and give oversight to family-led alternatives to care.
Education
MacAlister Review — Rec 17
Government should implement the recommendations of the Taylor Review to simplify the experiences of children in the youth justice system, and as a first step, should roll out the flexibility to all local authorities to integrate AssetPlus Assessments with children in need assessments.
Education
MacAlister Review — Rec 9
Government should ensure alignment in how the proposals in the SEND and Alternative Provision Green Paper and this review are implemented. The government should ask the Law Commission to review the current patchwork of legislation that exists to support disabled children and their families.
Education
Wessely Review — Rec 121
Amend the MHA Code of Practice to clarify best practice when the MHA is used for people with autism, learning disability or both.
Health & Social Care
Accepted
Wessely Review — Rec 113
Every inpatient child or young person should have a personalised care and treatment plan which records the views and wishes of the child or young person on each issue. Government should consider whether there should be a statutory duty for such a plan where the child or young person does …
Health & Social Care
Accepted
Wessely Review — Rec 56
Amendments to the MCA, the Codes of Practice, and relevant procedures before the Court of Protection and Tribunal should be made to clarify the position in relation to those in the community subject to both the MCA and the MHA. Dual authorisation under s.17 MHA and DoLS/LPS should not be …
Health & Social Care
Accepted
Modern Slavery Act Review — Rec 55
The wording of section 48 [of the Act] should be amended to ensure all children and young people who are believed to have been victims of human trafficking and all other forms of modern slavery are eligible for the ICTA service. The Act should be amended in the same way …
Justice & Legal
Accepted
Modern Slavery Act Review — Rec 39
The Government should remove the 18-month time limit for ICTA provision for those children that require a longer duration of support.
Justice & Legal
Accepted
Timpson Review — Rec 6
To ensure designated senior leads for mental health and Special Educational Needs Co-ordinators (SENCOs) are effective, DfE should: review the training and support available to SENCOs to equip them to be effective in their operational and strategic role as SEND leaders; ensure the training designated senior leads receive includes a …
Education
Accepted
Ockenden Review — Rec 12
Postnatal care. Essential action: Trusts must ensure that women readmitted to a postnatal ward and all unwell postnatal women have timely consultant review. Postnatal wards must be adequately staffed at all times. • All trusts must develop a system to ensure consultant review of all postnatal readmissions, and unwell postnatal …
Health & Social Care
Accepted
PHSO casework decisions(436)
P-001574 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs R complained Mr R was not allocated a care coordinator, discharged despite being at risk, and the Trust failed to diagnose Foetal Alcohol Syndrome.
NHS in England
Oct 2022
P-004784 — A practice in the Oadby and Wigston area
Ms A complained the practice decided her mother should be nil by mouth without a proper assessment, and about the time taken and lack of communication in complaint handling.
NHS in England
Upheld
Feb 2026
P-001295 — Tameside and Glossop Integrated Care NHS Foundation Trust
Daughter complained her father developed a pressure sore due to inadequate care and lack of family communication. She also alleged poor bladder/bowel care and medication errors.
NHS in England
Upheld
Feb 2022
P-001374 — Croydon Health Services NHS Trust
Mr N complained the Trust's district nurses failed to administer his mother's medication, which he believes led to her seizure and death.
NHS in England
Partly Upheld
Apr 2022
P-001828 — A GP practice in the Oldham area
Mr E complained the Practice improperly cancelled his son's referral to a paediatric surgeon without good reason or informing the family, causing extended pain.
NHS in England
Oct 2022
P-002557 — Lancashire and South Cumbria NHS Foundation Trust
The Trust failed to support her mother, discharged her too early without a care plan, and did not communicate with the family, leading to her premature death.
NHS in England
Apr 2024
P-002950 — County Durham and Darlington NHS Foundation Trust
Mrs U complained about poor communication, lack of an overarching care plan, unmet nutrition/hydration needs, and delayed palliative care for her father.
NHS in England
Partly Upheld
Sep 2024
P-002909 — Mid Cheshire Hospitals NHS Foundation Trust
Mrs O complained the Trust delayed referring her father to speech and language therapy, inappropriately changed his fluid provision, failed to keep him nil by mouth, and inserted an NG tube without consent.
NHS in England
Upheld
Sep 2024
P-004297 — University Hospitals Birmingham NHS Foundation Trust
Miss T complained the Trust failed to manage her mother's diabetes, did not provide condition updates, failed to notice her mother was unresponsive, and incorrectly recorded the cause of death.
NHS in England
Partly Upheld
Nov 2025
P-004370 — Bristol, North Somerset and South Gloucestershire Integrated Care …
Mr N complained the ICB failed to provide his son with an appropriate care plan, causing mental and physical decline, and significant distress to the family.
NHS in England
Nov 2025
P-004776 — Leicestershire Partnership NHS Trust
Mrs E complained the Trust failed to provide her child with trauma therapy, a lead professional, risk assessment, and care plan review, impacting her child's mental health.
NHS in England
Feb 2026
P-004623 — Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Mrs S alleged the Trust failed to implement a care plan, medically assess medication changes, complete mental capacity assessments, and manage her POA correctly for her mother, contributing to her distress.
NHS in England
Partly Upheld
Jan 2026
P-001316 — University Hospitals Birmingham NHS Foundation Trust
Daughter complained about inadequate monitoring and treatment of her mother's weight loss, nutrition, and mismanagement of a pressure ulcer by the Trust.
NHS in England
Partly Upheld
Feb 2022
P-001322 — Northampton General Hospital NHS Trust
Mrs E complained that Northampton General Hospital NHS Trust misdiagnosed her son's spinal injury, failed to perform an MRI scan, and discharged him without follow-up treatment.
NHS in England
Mar 2022
P-001365 — University Hospitals Birmingham NHS Foundation Trust
Mrs O complained radiotherapy caused her husband's paralysis, alleging lack of prior risk advice, insufficient emotional support, failure to investigate symptoms, and inappropriate discharge.
NHS in England
Upheld
Apr 2022
P-001353 — Royal Free London NHS Foundation Trust
Miss G complained her mother was discharged without sufficient diagnosis information, necessary equipment, and family visits were denied due to COVID-19 restrictions.
NHS in England
Apr 2022
P-001446 — A medical practice in the London Borough of …
Mr Y complained the Practice failed to advise a nursing home to hospitalise his father, inform him of his deteriorating health, and kept inadequate records, causing a delay in hospitalisation and his father's death.
NHS in England
May 2022
P-001415 — Mid and South Essex NHS Foundation Trust
Mrs R complained the Trust failed to provide timely chemotherapy, manage her husband's oesophageal stent, maintain records/communication, and that he contracted COVID-19, contributing to his death.
NHS in England
Upheld
Jun 2022
P-001417 — Lincolnshire Community Health Services NHS Trust
Mrs G complained the Trust's community nursing service mismanaged her husband's catheter, causing him significant discomfort and distress in his final days.
NHS in England
Partly Upheld
Jun 2022
P-001419 — Lancashire Teaching Hospitals NHS Foundation Trust
Mrs T complained about delays in oncology treatment, poor communication between hospitals and with family, delayed pain relief, insufficient palliative care support, and poor complaint handling regarding her late husband.
NHS in England
Upheld
Jun 2022
P-001476 — Oxford University Hospitals NHS Foundation Trust
Mr O complained the Trust failed to appropriately monitor and manage his wife's diabetes after knee surgery, resulting in dangerously high blood sugar levels that contributed to her death.
NHS in England
Jun 2022
P-001418 — East Suffolk and North Essex NHS Foundation Trust
Mr L complained the Trust reduced his COVID-19 father's oxygen and stopped antibiotics, commenced palliative care against his will, and failed to include the family in important discussions or provide vital information.
NHS in England
Upheld
Jun 2022
P-001562 — Birmingham Community Healthcare NHS Foundation Trust
Mr L complained the Trust failed to provide adequate care and treatment for Mrs L, administer medication, use appropriate discharge assessments, and properly communicate with him.
NHS in England
Oct 2022
P-004558 — Manchester University NHS Foundation Trust
Mr U complained about his wife's care at two Trusts, citing inadequate mobilisation, inappropriate pain medication, suspended anticoagulants, poor food/drink supervision, and no psychiatric treatment, allegedly contributing to her death.
NHS in England
Dec 2025
P-004560 — Lewisham and Greenwich NHS Trust
A daughter complained about her mother's care across three admissions, including pressure sores, sacral tear from bedpan use, diuretic withdrawal, oxygen mismanagement, hypoxia misdiagnosis, and inappropriate digoxin prescription.
NHS in England
Partly Upheld
Dec 2025
P-001729 — A practice in the Hertfordshire area
Mr H complained the Practice misdiagnosed his father with gallstones, which was actually stage four cancer, failed to refer him, and did not provide a care plan, leading to pain.
NHS in England
Jan 2023
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-001787 — Humber and North Yorkshire Integrated Care Board
A legal firm complained the ICB refused to complete a checklist/DST for Mrs A's Continuing Healthcare, denied an FNC appeal, and refused a previously unassessed period of care assessment.
NHS in England
Feb 2023
P-001908 — Northern Care Alliance NHS Foundation Trust
Mrs C complained the Trust failed to investigate her sister's symptoms and implement her care plan, delaying cancer diagnosis. She also cited insensitive staff comments.
NHS in England
Mar 2023
P-001892 — Guy's and St Thomas' NHS Foundation Trust
Mr C complained King's College Hospital failed to diagnose his wife's perforated oesophagus. Guy's and St Thomas' then failed to provide timely or appropriate treatment.
NHS in England
Not Upheld
Mar 2023
P-003882 — A practice in the Bournemouth area
Mrs A complained the Practice and Trust refused bariatric, hip, and knee surgery, and failed to provide a suitable treatment plan, worsening her condition and causing pain.
NHS in England
Jul 2023
P-003889 — United Lincolnshire Hospitals NHS Trust
Miss A complained her father died from aspiration pneumonia after being given a ham sandwich during a 'fit for discharge' assessment, despite needing a thick liquid diet.
NHS in England
Jul 2023
P-003819 — Northern Care Alliance NHS Group
The Trust failed to manage her husband's nutrition/hydration, delayed medication, and missed sepsis signs, leading to his avoidable death.
NHS in England
Sep 2023
P-002332 — Nottinghamshire Healthcare NHS Foundation Trust
The Trust failed to plan for his brother's care, ensure medication, and contact him before his death, leading to fatal clozapine poisoning.
NHS in England
Sep 2023
P-002385 — Chelsea and Westminster Hospital NHS Foundation Trust
Mr E complained the Trust failed to provide treatment for his wife's sarcopenia, lacked a care plan, and made no referrals or scans after a fall.
NHS in England
Nov 2023
P-002345 — University Hospitals Dorset NHS Foundation Trust
Mrs T complained her mother developed preventable pressure sores due to negligent care provided by the Trust.
NHS in England
Dec 2023
P-002379 — Luton and Dunstable University Hospital NHS Foundation Trust
Mrs A complained a Trust disregarded her father's "do not attempt CPR" order, performing chest compressions for nine minutes against his explicit wishes, causing severe distress.
NHS in England
Dec 2023
P-002380 — Coventry and Warwickshire Integrated Care Board
Dr U complained the ICB failed to provide his daughter with respite care as outlined in her care plan, causing frustration and carer strain for him and his partner.
NHS in England
Dec 2023
P-002682 — Humber and North Yorkshire Integrated Care Board
Ms D complained the CCG failed to properly assess and fund her mother's care needs, delayed setting up a personal health budget, and provided inaccurate information, causing financial loss and distress.
NHS in England
Upheld
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-002630 — A practice in the Sheffield area
Mrs L complained the Practice wrongly deemed her husband lacked capacity, failed to remove a DNACPR, mismanaged medication and records, and provided an inadequate home visit leading to his death.
NHS in England
May 2024
P-002645 — North Staffordshire Combined Healthcare NHS Trust
Ms H complained the Trust discharged her from mental health support without investigating root causes or arranging a care plan. She also alleged a data breach involving a lost sensitive statement.
NHS in England
May 2024
P-002674 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs G complained about multiple failings in Miss O's care, including delayed investigation/treatment, improper discharges, and poor communication, which she believed led to Miss O's death.
NHS in England
Jun 2024
P-002790 — Derbyshire Healthcare NHS Foundation Trust
Mrs A complained the Trust failed to recognise her son's autism and vulnerability, provide follow-up care after suicide attempts, and notify the family, contributing to his death.
NHS in England
Jul 2024
P-002832 — United Lincolnshire Hospitals NHS Trust
Ms O complained the Trust poorly communicated, failed to provide an appropriate diet, delayed rehabilitation, and poorly coordinated her brother's discharge, which she said contributed to his death. She also cited poor ED care.
NHS in England
Upheld
Jul 2024
P-002761 — A practice in the Hackney area
Miss P complained the Practice abruptly stopped her mother's medication without review, and then lied in its complaint response, which she believes led to her mother's death.
NHS in England
Jul 2024
P-002903 — Sheffield Teaching Hospitals NHS Foundation Trust
Mr K complained the Practice failed to recognise his sister's deterioration and delayed appropriate referrals after her fall, contributing to her death.
NHS in England
Partly Upheld
Aug 2024
P-002847 — Birmingham and Solihull Integrated Care Board
Miss N complained the ICB failed to implement promised service improvements regarding her father's continuing healthcare and delayed arranging a meeting to discuss her concerns.
NHS in England
Upheld
Aug 2024
P-002952 — Mid Yorkshire Teaching NHS Trust
Mrs A complained the Trust discharged her husband with uncontrolled diabetes, discussed a DNACPR without proper communication, and misinformed him about his condition.
NHS in England
Sep 2024
P-002922 — United Lincolnshire Hospitals NHS Trust
Mrs G complained the Trust poorly managed her husband's diabetes medication, delayed a diabetic nurse visit, wrongly placed him on end-of-life care, and failed to consider their wishes regarding a DNACPR.
NHS in England
Upheld
Sep 2024
LGO / SPSO decisions(3629)
22-007-258 — Surrey County Council
Summary: Mr X complains about the lack of support from the Council while he was caring for his great aunt, especially during the COVID-19 pandemic period. The Council has agreed to resolve the complaint early by providing a proportionate remedy for the injustice caused to Mr X by the faults …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-018-984 — Surrey County Council
Summary: Mr D complained the Council has failed to provide him with appropriate assistance in securing a care facility for his wife. He also says the Council delayed offering him respite care. We find the Council was at fault as it failed to respond to a request for information regarding …
LGO (Local Government & …
Adult Care Services
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
24-012-713 — Dorset Council
Summary: Mrs X complained the Council has not properly delivered the provision in her child’s Education Health and Care Plan since 2021. The Ombudsman finds the Council at fault which caused injustice. The Council has agreed to apologise and make a payment to Mrs X.
LGO (Local Government & …
Education
Upheld
Apr 2025
24-007-654 — London Borough of Bromley
Summary: Ms B complained the Council failed to put in place provision in her daughter’s education, health and care plan. I am satisfied some of the claimed missing provision was in place but the Council failed to put in place the speech and language therapy. The Council also failed to …
LGO (Local Government & …
Education
Upheld
Apr 2025
24-016-919 — Nottingham City Council
Summary: Mr Z complained the Council failed to ensure the care needs of his cousin, Mr X were met when Mr X’s parents left the country. Mr Z says he was forced to provide unpaid care which put him in a difficult position financially as he was unable to work …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-015-945 — Redcar & Cleveland Council
Summary: Mrs X complained that the Council’s delay in referring her mother for Continuing Healthcare (CHC) funding cost her some months of care home charges as well as a private assessment fee. The evidence shows the Council was not responsible for the costs incurred by Mrs X.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2025
24-015-684 — Devon County Council
Summary: Mr X complained the Council has repeatedly failed to follow its policies and procedures which has resulted in a failure to safeguard his daughter, Miss Y. We found
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-014-722 — Cambridgeshire County Council
Summary: Mr X complained the Council delayed completing his care assessment. Mr X says this meant he did not receive suitable support which has impacted his health. The Ombudsman finds the Council at fault which caused injustice. The Ombudsman is satisfied the action taken by the Council has remedied the …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-001-840 — London Borough of Lambeth
Summary: Mr X complains about the Council’s handling of his care and support needs. He says the Council failed to complete an appropriate care assessment and care plan. He says this means the Council is not meeting his care needs.
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
24-011-142 — Hampshire County Council
Summary: We will not investigate this complaint about delay completing an adult social care needs assessment. The Council has a queue of cases waiting, which it has triaged and prioritised. It has explained this to the complainant and apologised for the impact of the delay which is due to demand …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
24-010-339 — Nottinghamshire County Council
Summary: We will not investigate Mrs A and Mrs B’s complaint about the Council’s assessment of their cousin’s (Mrs D) needs before it decided she could return home. That is because we cannot achieve the outcomes they seek.
LGO (Local Government & …
Adult Care Services
Dec 2024
24-006-472 — Sefton Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s handling of arrangements for Ms V’s care and support because: the Court of Protection either supervises or should consider the arrangements; the Council has offered a suitable remedy for some shortfall in service and explained its decision on charges for …
LGO (Local Government & …
Adult Care Services
Dec 2024
23-020-972 — London Borough of Merton
Summary: There was delay by the Council in reviewing Ms Y’s care and support plan causing avoidable uncertainty. There was delay in complaint handling and a failure to provide a response, causing avoidable distress and time and trouble. The Council will make a payment, apologise, make a decision on funding …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
24-022-879 — Barchester Healthcare Homes Limited
Summary: The Care Provider failed to update Mrs Y’s care plan to reflect a change in her care needs around continence. There was also a failure to ensure Mrs Y saw a chiropodist regularly. This caused avoidable distress for which the Care Provider has apologised, completed staff training and introduced …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
25-010-177 — Medway Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Adult Care Services
Feb 2026
25-005-861 — Bournemouth, Christchurch and Poole Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2026
25-005-749 — London Borough of Hammersmith & Fulham
Ms X complained the Council has wrongly stopped funding overseas travel for her and her daughter, Miss Y, which they have used as respite care for many years. She complained the replacement respite care the Council has offered will not meet Miss Y’s needs. There was fault by the Council. …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2026
25-017-108 — Essex County Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Adult Care Services
Feb 2026
25-005-438 — Kent County Council
Mrs B complained about the Council’s failure to approve 2:1 support for her son Mr C at one of his placements for over a year. We found fault in the actions of the Council which caused Mrs B frustration and distress. The Council has agreed to apologise to Mrs B …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2026
25-002-493 — Wirral Metropolitan Borough Council
Summary: The Council was at fault in how it decided to meet Mrs X’s needs after she asked for help caring for her adult son. The Council also delayed assessing Mrs X’s needs and responding to her complaint. The fault caused Mrs X significant frustration and uncertainty, for which the …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
24-022-503 — Derby City Council
Ms X complained the Council failed to respond to complaints, failed to adhere to her agreed reasonable adjustments and failed to carry out a suitable care needs assessment. She also queried its actions about Direct Payments. We found no fault in the Council’s complaint responses. We found there was some …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
25-001-100 — Lincolnshire County Council
Summary: We will not investigate Mr X’s complaint about poor communication and not providing enough funding for care. There is not enough evidence of injustice to justify an investigation.
LGO (Local Government & …
Adult Care Services
Jan 2026
24-018-569 — London Borough of Hammersmith & Fulham
Summary: Mr X complained that the Council failed to properly investigate when he raised concerns that a care provider it commissioned was not providing appropriate care to his nephew. We found there were issues with the care his nephew received, and the Council had not addressed these robustly or promptly …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
21-003-354 — North Yorkshire County Council
Summary: Mr X and Ms Y complained the Council failed to make ‘reasonable endeavours’ to provide for their son, Z’s, special educational needs during the COVID-19 pandemic. The Council failed to properly consider and make ‘reasonable endeavours’ to arrange Z’s special education when there was an alternative provider available. It …
LGO (Local Government & …
Education
Upheld
Jan 2022
20-001-927 — London Borough of Redbridge
Summary: Miss X complains that the Council failed to provide special educational provision for her daughter in line with her Education, Health and Care plan. She also complains that the Council ignored her request for a personal budget and failed to respond to her complaint. Miss X says her daughter …
LGO (Local Government & …
Education
Upheld
Jan 2022
20-014-489 — Hertfordshire County Council
Summary: Ms C complains the Council failed to properly safeguard her mother or provide satisfactory information about funding for care homes. The Council is at fault for failing to carry out safeguarding, assessment, and complaint handling procedures correctly. It is also at fault for failing to properly advise Ms C …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-002-440 — Hertfordshire County Council
Summary: Mr E has complained about the mental health and social care of his sister, Mrs F, by the Council and Trust. We find fault with the mental health and social care of Mrs F but not with her mental health assessment or the Trust’s complaint handling. The Trust and …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-003-768 — London Borough of Redbridge
Summary: Mr B complained the Council delayed meeting his daughters’ assessed needs under the Care Act 2014. He says the Council delayed providing additional support after his daughters stopped attending college. We find the Council was at fault as it delayed responding to Mr B’s requests for additional support. The …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
20-009-729 — London Borough of Wandsworth
Summary: The Council acted with fault when it sent correspondence about Mr Y’s care and support in a format which was not suitable for his needs as a blind person. This caused Mr Y some time and trouble which the Council should apologise and pay £150 for. However, the fault …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-010-003 — Hertfordshire County Council
Summary: Mrs X complains the Council has failed to secure the provision in her son, Y’s, education, health and care (EHC) plan.
LGO (Local Government & …
Education
Upheld
Feb 2022
21-007-956 — London Borough of Lewisham
Summary: Mr X complained that the Council failed to provide his disabled son, Mr P, with an educational placement for up to two years. He says this has caused Mr X and his wife, Mrs X an injustice as the family have had to care and educate Mr P themselves. …
LGO (Local Government & …
Education
Upheld
Feb 2022
21-006-581 — London Borough of Richmond upon Thames
Summary: Mrs D complains about the Council’s handling of her son F’s Education, Health and Care plan. She says it did not adhere to the Special Educational Needs and Disabilities Code of Practice. Mrs D says she had to pay for privately arranged therapy and F missed education due to …
LGO (Local Government & …
Education
Upheld
Feb 2022
21-004-641 — Kent County Council
Summary: We upheld a complaint about a delay in issuing an Education, Health and Care Plan. The delay caused avoidable distress, a delay in appeal rights and a loss of education provision for Y who has autism. The Council will apologise, make payments and take action described in this statement.
LGO (Local Government & …
Education
Upheld
Feb 2022
20-010-965 — Devon County Council
Summary: Ms X complains the Council delayed in reviewing Ms Y’s care plan following an increase in the hourly rate of her care provider. The Council is at fault as it delayed in carrying out a review of Ms X’s care plan and making a decision on whether to increase …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
19-018-847 — North Lincolnshire Council
Summary: Mr X complained the Council has not provided him with adequate help and support to deal with his care needs. We find the Council was at fault as it failed to pursue an independent assessment to determine if Mr X needed more support. It also did not have an …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-007-811 — Surrey County Council
Summary: Ms C complained the Council has failed to arrange a care support package for her since July 2020. She says this resulted in significant distress, inconvenience and impacted her health, including her mental health. We have found fault with the Council not being able to find a care agency …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-005-184 — Surrey County Council
Summary: There was fault by the Council as its social care assessments contained inaccurate information about the source of a medical diagnosis. This caused Mr X avoidable distress. The Council will apologise, make Mr X a symbolic payment and rectify its records.
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-015-982 — Bournemouth, Christchurch and Poole Council
Summary: We will not investigate this complaint about how the Council completed Mr X’s care plan and provided his transport to his vocational placement. That is because there is not enough evidence of significant injustice to Mr X, or his Shared Lives carers, Mr and Mrs Y.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-015-944 — Wirral Metropolitan Borough Council
Summary: We will not investigate this late complaint about the Council’s decisions relating to Ms Y’s accommodation and how this would be funded. There is not a good reason Ms X did not complain sooner.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-009-579 — Leicestershire County Council
Summary: Ms X complained the Council failed to put in place education, health and care provision for Y, as set out in his plan. She also complained the Council failed to provide suitable education for Y was he was not attending school. This meant Y missed out on educational provision. …
LGO (Local Government & …
Education
Upheld
Mar 2022
20-007-526 — Bedford Borough Council
Summary: Ms X complains that she was billed for care that she did not receive and was not supported against financial abuse. There was fault by the Council because it did not include any contingency plan in Ms X’s care plan. The Council agreed a financial remedy to reflect the …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-017-269 — Brighton & Hove City Council
Summary: We will not investigate this complaint about how the Council assessed Ms X's care and support needs. That is because there is insufficient evidence of fault in the Council’s actions to warrant further investigation.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-016-064 — Worcestershire County Council
Summary: We will not investigate this complaint about the Council’s decision not to fund respite care for Mr X. That is because there is insufficient evidence of fault to warrant further investigation.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-003-770 — Devon County Council
Summary: Mrs D complained the Council failed to complete her daughter’s Education, Health and Care needs assessment as directed by the SEND Tribunal, and within the statutory timescales. As a result, Mrs D said she experienced distress and her daughter did not get the support she needed. We found the …
LGO (Local Government & …
Education
Upheld
Apr 2022
21-006-275 — Somerset County Council
Summary: Mrs X complained the Council failed to provide alternative education for her children and delayed assessing their special educational needs. There was fault in how the Council reviewed its decision following a mediation agreement and how it failed to consider its duty to arrange suitable alternative education. It agreed …
LGO (Local Government & …
Education
Upheld
Apr 2022
21-010-549 — London Borough of Hammersmith & Fulham
Summary: Miss X complained about the support the Council provided when she was moving home. Miss X also complained the Council refused to carry out a review of her care plan. Miss X says this has affected her mental and physical health. We find fault with the Council for a …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-007-208 — Hertfordshire County Council
Summary: The Council’s failure to consider the needs and practicalities of the wider family before agreeing that a proposal by the Borough Council would meet Miss X’s disabled child’s needs was fault. The Council has agreed to complete a new assessment.
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
Domestic Homicide Reviews(337)— showing 50 strongest matches
West Lancashire — recommendation 31
Southport and Ormskirk Hospital Trust to seek assurances that the Provider Enquiry Report is completed and returned to Sefton Local Authority due to concerns regarding errors in reinstating a package of care
Southport and Ormskirk Hospital NHS Trust
Southport and Ormskirk Hospital …
West Lancashire — recommendation 26
WLCSP to seek assurances from the NHS Integrated Care Board that the follow up of patients where there is a lack of engagement with services and where vulnerability is a feature is inherent within its policy
NHS Lancashire and South Cumbria Integrated …
NHS Lancashire and South …
West Lancashire — recommendation 18
WLCSP to seek assurance that Telecare referrals are not closed down if the service user did not answer a phone call particularly when poor telephone connection was the reason for the referral in the first place.
Lancashire County Council Safeguarding Adults
Kent — recommendation 2
Whenever there is a significant change of circumstance, such as a change of relationship, or any significant change of circumstance for those under supervision on conditional discharge, then a multi–agency meeting should be initiated and as a result to take and record any action that is required, the person(s) responsible …
NHS England
NHS England
Oxford — recommendation 1b
To ensure that any use of a reduced timetable is part of a holistic plan to re-engage a young person into full-time education.
Schools and Special Educational Needs
Herefordshire — recommendation PC2
The care pathway needs to be reviewed to assess whether it is fit for purpose for all age groups, amended as necessary and published on adult focused web
Herefordshire Clinical Commissioning Group
Herefordshire — recommendation PC1
Map of Medicine needs to include the car pathway for domestic abuse
Herefordshire Clinical Commissioning Group
Herefordshire — recommendation 10
Provide clear guidance on the process for ascertaining that a carers assessment has been requested, and undertaken or refused, should be reviewed, including its documentation and reference to actions in RIO.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Herefordshire — recommendation 8
Review the Herefordshire Memory Assessment and Older Person Services sharing of information with clinicians, patients and carers, including the practice of copying or addressing letters to patients. This will also consider the sharing of information regarding medication and care planning.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Herefordshire — recommendation 5
Conduct an audit of completion of care plans, risk assessments and crisis contingency plans for the Herefordshire Memory Assessment Service and Older Person Services.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
St Helens — recommendation 16
Assessments plans and monitoring arrangements need to take account of the potential for disguised non-compliance of service users and the impact of this on outcomes for the child
People’s Services
St Helens — recommendation 13
A single assessment should link to a plan of intervention that is subject to regular multi-agency review.
People’s Services
St Helens — recommendation 12
A management process to be developed to monitor service user engagement when they are referred to support services such as Addaction, the HELP Project or Freedom Project as part of an intervention plan. The purpose will be to determine if engagement (or otherwise) improves outcomes for children and/or provides evidence …
People’s Services
Barnet — recommendation 38
All non-attendance or poor engagement in elements of care plan (e.g. group, counselling, ETE or other recovery-based activity) to be reported to lead worker and canvassed in key work and care plan reviews and MDT. (IMR Recommendation)
Westminster Drug Project
Barnet — recommendation 20
The MARAC Steering Group to undertake a regular dip sample review of MARAC cases involving domestic abuse, substance misuse and mental ill-health, to ensure that information from all agencies has been shared, safety plans are appropriate, and all relevant services have offered actions to mitigate the heightened risk posed by …
Barnet MARAC Steering Group
Barnet — recommendation 19
When gathering pre-MARAC information to assess risk to a victim of domestic abuse all agencies and the MARAC chair must ensure that others in the household, including adults as well as children, are identified and if found to be vulnerable and at potential risk include them in the safety plan. …
Hestia | Barnet MARAC
Barnet — recommendation 12
BEH clinical supervision should ensure that it includes the active exploration of assessment of needs, formulation of care plans, risk assessment, and risk management using data from caseload records and information from all available sources. (IMR Recommendation).
Barnet, Enfield & Haringey Mental Health …
North London NHS Foundation …
Bristol — recommendation 17.2.2
Within this process, the importance of completing timely, thorough and holistic social work assessments which take fully into account the overall needs of each child, the overall circumstances of each carer or parent, and any relevant environmental issues or issues for the wider family should be reinforced. In particular, reminders …
Leicester Social Care and Safeguarding Service
Cardiff — recommendation 3
Day Centres to ensure proportionate follow up and further consideration where the “Getting to know you” forms are not completed and returned by the family.
Adult Social Services
Adult Social Services
Leeds — recommendation 5.1
Leeds Adult Social Care will ensure that actions to address domestic abuse are included within the recommendations section of a Mental Health Act Assessment where domestic abuse is a known issue.
Leeds Adult Social Care
Leeds — recommendation 3.4
Leeds Adult Social Care will ensure that domestic abuse is explicitly addressed within the recommendations section where it is a known issue within a Mental Health Act Assessment.
Leeds Adult Social Care
Herefordshire — recommendation CCG3
The CCG should work with GP practices to develop a universal care plan format which includes information regarding the social aspects of a person’s care
Herefordshire ICB
NHS Herefordshire and Worcestershire …
Herefordshire — recommendation 17
The care pathway needs to be reviewed to assess whether it is fit for purpose for all age groups, amended as necessary and published on adult focused web
Herefordshire Clinical Commissioning Group
Herefordshire — recommendation 8
Conduct an audit of completion of care plans, risk assessments and crisis contingency plans for the Herefordshire Memory Assessment Service and Older Person Services.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Bridgend — recommendation ABMU MH 6
Service users with personality disorder will be identified and their needs reflected in care and treatment plans. A bid for funding for the development of specialist personality disorder services will be submitted to Welsh Government.
Abertawe Bro Morgannwg University Health Board
Swansea Bay University Health …
Haringey — recommendation R19
The assessment identifies patients whose needs cannot be adequately met by the reconfigured service and a strategy developed to manage this deficit.
Camden & Islington NHS Foundation Trust
North London NHS Foundation …
Haringey — recommendation R9
Care planning for this group of patients is managed using the CPA process.
Camden & Islington NHS Foundation Trust
North London NHS Foundation …
Haringey — recommendation R5
The consultant psychiatrist in conjunction with the care coordinator undertakes a comprehensive review of the past record and current actual social circumstances of each such patient and provides a summary in the clinical record.
Camden & Islington NHS Foundation Trust
North London NHS Foundation …
Haringey — recommendation R4
The Trust identify all patients subject to Section 37/41 who are currently being managed by community services and who have not had a comprehensive review of their mental health history in the previous five years.
Camden & Islington NHS Foundation Trust
North London NHS Foundation …
Wiltshire — recommendation R70
BGSW CRC staff will ensure all requirements are started in a timely manner (or sequenced as appropriate). In addition, staff will continue to monitor key issues and undertake structured work to address the areas identified in the Risk Management and Sentence Plan.
BGSW CRC
Wiltshire — recommendation R29
All Offender Managers should complete an Initial Sentence Plan in a timely manner and in accordance with National Policy- within 10 working days of sentence and ensure the document is locked and marked as completed.
National Probation Service-Middle Managers-Gloucestershire and Wiltshire …
Wiltshire — recommendation R16
Implement NEET assessment and planning tool.
Early Help
Middlesbrough — recommendation 2
Patient’s care plans should accurately reflect the frequency of intended reviews and who is to conduct them.
Tees Esk and Wear Valleys NHS …
Tees, Esk and Wear …
East Sussex — recommendation 7
That all GP practices should assure themselves that they have a complex care mechanism for co-ordinating the care of high risk and vulnerable patients, with a way of identifying and tracking this cohort of patients.
NHS Sussex Integrated Care Board | …
NHS Sussex ICB
Norfolk — recommendation 23
Contingency planning within care plans should also be shared as required with involved services and related parties/carers.
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Norfolk — recommendation 21
The panel concluded that contingency planning should have been more robust with additional information related to this shared with the family. Contingency planning within care plans should also be shared as required with involved services and related parties/carers.
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Norfolk — recommendation 12
Mental Health Service contingency plans should take a ‘Think Family’ approach and be shared with related parties/carers having been written in plain English and avoiding professional jargon to ensure it is accessible to enable families and/or carers to fully understand the steps to take when required. This should include relevant …
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Norfolk — recommendation 23
Contingency planning within care plans should also be shared as required with involved services and related parties/carers.
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Norfolk — recommendation 22
That the Mental Health Trusts roll-out of DIALOG and DIALOG+ system be maintained and reviewed, and in due course audited to ensure social, cultural, familial, and other patient -based information can be built into care in Norfolk more effectively.
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Norfolk — recommendation 21
The panel concluded that contingency planning should have been more robust with additional information related to this shared with the family. Contingency planning within care plans should also be shared as required with involved services and related parties/carers.
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Norfolk — recommendation 3
All services undertaking assessments should take a ‘Think Family’ approach and: (a) Use their full assessment skills and professional curiosity to ensure information for assessments, care plans and risk assessments is fully inclusive of all family members /family structure, plus any carers, and where relevant note who is the home …
All Services
Cornwall — recommendation 4
Further identification of areas within current practice where processes need to be developed or tightened to ensure cohesive support for individuals and their immediate family.
NHS England
NHS England
Cornwall — recommendation 10
We recommend a programme of work to review recording processes and an associated regular audit of recording practice. In particular this should focus on the requirements to ensure written care plans are in place, that risk assessments are properly recorded and appropriately reviewed and updated. In addition, focus should be …
NHS Kernow | Cornwall Partnership NHS …
NHS Kernow
Croydon — recommendation AG
The Croydon Home Treatment team to revise the current system of updating care plans and risk assessment documentation to reflect risk levels and change in care needs so that these are completed at the time of identified risk changes
South London and Maudsley NHS Foundation …
South London and Maudsley …
Wolverhampton — recommendation Wolverhampton Childr
Practitioners and managers to ensure a holistic approach is implemented to assessment and action planning to ensure the needs of the children, victims and perpetrators are considered where they wish to remain together.
Wolverhampton Children’s Social Care
Wolverhampton — recommendation Wolverhampton Childr
Practitioners to receive training on outcome focused, time bound care planning.
Wolverhampton Children’s Social Care
Liverpool — recommendation 6
That Liverpool Children’s Social Care provides a report to Liverpool Community Safety Partnership on the co-ordination, supervision, and management of Early Help action plans. That report should address the identified learning within this review.
Liverpool Children’s Social Care
Rochford — recommendation 7
Essex Adult Social Care should ensure: - • That when reviews are being undertaken which may lead to the removal of a care package that previous concerns and risks are considered. • That the person’s finances are considered as a possible reason for the request for the care and support …
Essex Adult Social Care
Essex County Council
Rochford — recommendation 4
Essex Safeguarding Adult Board should be assured that the recommendation from the previous review in the case of Kimmi has clarified the pathways for persons suffering dementia and that there is clear support and review post diagnosis. This should include ensuring clarity in ongoing prescription of medication.
Essex Safeguarding Adult Board
Rochford — recommendation 3
Essex Adult Social Care should ensure that: - • Assessments include the views of other relevant persons, carers and family members, and this is recorded. • Where the local authority is to charge for care and support, there has been a financial assessment, of which the person has a copy, …
Essex Adult Social Care
Essex County Council
CQC enforcement actions(10)
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an inspection of their community-based mental health services for people of working age in October. Inspectors found safety concerns still needed addressing …
Mar 2023
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
CQC issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an unannounced focused inspection in November at Woodlands Hospital. Inspectors found staff had not completed mandatory training, risk assessments and care plans were not appropriately completed, …
Woodlands Hospital
Feb 2023
Warning Notice: East Sussex Hospitals NHS Trust
The Care Quality Commission (CQC) issued a warning notice to East Sussex Hospitals NHS Trust, requiring urgent improvements to patient care. Inspectors found insufficient staff to support proper patient care in some areas, and that care plans and risk assessments …
Jun 2011
Warning Notice: United Lincolnshire NHS Trust
Following a visit to Pilgrim Hospital, the Care Quality Commission found United Lincolnshire NHS Trust was not taking appropriate steps to ensure people receive effective, safe and appropriate care. Inspectors noted that care plans did not always reflect patient needs, …
Pilgrim Hospital
Mar 2011
Warning Notice: Lewisham and Greenwich NHS Trust
The Care Quality Commission (CQC) carried out an unannounced, focused inspection at Queen Elizabeth Hospital in December after receiving information that triggered concerns about the safety and quality of services relating to DNACPR orders. CQC told Lewisham and Greenwich NHS …
Queen Elizabeth Hospital
Jan 2021
Warning Notice: Mid and South Essex NHS Foundation Trust
CQC issued a warning notice requiring Mid and South Essex NHS Foundation Trust to make urgent improvements to ensure mothers and babies are safe in its maternity services at Basildon University Hospital. Inspectors found several concerns, including high-risk women giving …
Basildon University Hospital
Aug 2020
Warning Notice: Leeds and York Partnership NHS Foundation Trust
The Care Quality Commission (CQC) re-rated the long stay or rehabilitation mental health wards for working age adults, run by Leeds and York Partnership NHS Foundation Trust, as requires improvement. Following an inspection on 10 and 11 March, CQC found …
Asket Croft, Asket House and Newsam Centre Ward
Jul 2026
Warning Notice: Liverpool University Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) told Liverpool University Hospitals NHS Foundation Trust to take immediate action to improve the safety of some of its services following two inspections. Inspectors found a lack of effective systems to ensure all patients received …
Jan 2021
Warning Notice: Barts Health NHS Trust
The Care Quality Commission told Barts Health NHS Trust that it must improve patient care and support given to staff at the Royal London Hospital. This followed an unannounced inspection in June where the hospital was found to be not …
Royal London Hospital
Sep 2013
Conditions Imposed: Tavistock and Portman NHS Foundation Trust
The Care Quality Commission (CQC) imposed conditions on the registration of Tavistock and Portman NHS Foundation Trust following an announced, focused inspection in October and November. Inspectors found significant concerns within the Gender Identity Development Services (GIDS), including over 4,600 …
Jan 2021