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 12 independent accountability sources, so the source mix matters as much as the headline total.
33 inquiry recs
148 PFD reports
38 committee recs
31 HSSIB recs
189 CQC actions
22 PPO recs
57 IMB recs
11 Scottish FAIs
1 Article 2 learning point
436 PHSO decisions
3629 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(33)
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 …
Response Pending
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 …
Response Pending
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.
Response Pending
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 …
Response Pending
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 …
Response Pending
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: No formal response published by this government.
Unknown
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: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, provides specific guidance requiring clear and accurate records to be maintained. Nurses must …
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: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, provides specific guidance requiring clear and accurate records to be maintained. Nurses must …
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: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code requires nurses to maintain clear and accurate records, completing them as soon as possible after an event …
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: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, which nurses must follow, requires clear and accurate records to be maintained, completed at the time of …
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: Section 4.2 of the Scottish Government's response addresses this through professional standards for record-keeping. The revised NMC code, effective from March 2015, requires nurses and midwives to complete clear and accurate records at the time …
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: Section 4.2 of the Scottish Government's response details professional standards for record-keeping, with the revised NMC code requiring nurses and midwives to maintain clear and accurate records. This includes identifying any risks or problems and …
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: Section 4.1 of the Scottish Government's response notes that recommendation 39 focuses on the clinically and ethically challenging aspects of Do Not Attempt Cardiopulmonary Resuscitation (DNAR) orders. The report sets out precise standards for decision-making, …
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 …
Accepted
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: Section 4.1 of the Scottish Government's response acknowledges the report's criticisms of specific elements of nursing care, including the unsatisfactory assessment and recording of patients' nutritional status. The government unreservedly accepts in full the report's …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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 …
Accepted
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: UK Government 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 …
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: UK Government 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 …
Accepted
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(148)— showing 50 strongest matches
Derek Edward Bartlett Twivey
Concerns: The coroner's concern relates to circumstances that could create a risk of future deaths, and action should be taken to prevent such occurrences.
Overdue
Annie Rose Gibson
Concerns: The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and communication of observations after a client fall.
Overdue
Joan Mary Jones
Concerns: Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.
Response (The Manor): Following an inquest, the care home sent a memo to unit leads emphasizing communication protocols with families and healthcare professionals after GP visits. They also contacted the family and engaged …
Responded
Leslie Pates
Concerns: A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe pressure sores and no pressure-relieving mattress.
Response (Tamside Hospital NHS): Tameside Hospital NHS describes several actions taken to improve communication regarding discharge plans, including developing a checklist, ensuring documented evidence of discussions with patients and carers, raising the profile of …
Overdue
Peter Norman Nott
Concerns: Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Response (Elizabeth Finn Homes): Rush Court care home has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. Neurological observations will commence using the Glasgow Coma Scale …
Responded
Margaret Easterfield
Concerns: A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
Overdue
Lorna Cullen
Concerns: The coroner raised concerns about long-term liaison psychiatry nurse staffing levels covering hospital emergency departments, after evidence indicated patients needing mental health assessments were regularly waiting in excess of 2 hours due to staffing shortages.
Overdue
Wendy Brown
Concerns: Significant delays in implementing care packages and providing respite support for vulnerable carers, compounded by inadequate signposting of adult care services, complicated funding routes, and lengthy application processing times, put carers under severe strain.
Response (Swindon Borough Council): Swindon Borough Council recognises complexity and potential delays in decision making are real issues. An immediate action taken is that; were services over and above the indicative budget are requested, …
Responded
Phyllis Barnes
Concerns: A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective communication channel for family concerns.
Overdue
Danuta Corbett
Concerns: The hospital's leave policy for informal patients was not followed, and inadequate risk assessment for escorted leave, using an untrained agency worker, resulted in critical safety failures.
Response (Sussex Partnership NHS Trust): The consultant psychiatrist now carefully reviews notes taken during ward review. The Trust has reinforced with staff that should extraordinary circumstances arise again, a retrospective note must be completed, and …
Responded
Paul Ashton
Concerns: There was a lack of consultation with the cardiac transplant team and no established protocol for managing heart transplant patients undergoing non-cardiac surgery, leading to insufficient awareness of specific risks.
Response (Department of Health): NHS England will task its Rare Disease Advisory Group to prepare recommendations within six months for practical steps to improve care for heart transplant patients. NHS England will also ensure, …
Overdue
Kathryn Sawyer
Concerns: A failure to adequately review and plan a reduction of high-dose addiction medications occurred, alongside a lack of detailed record-keeping regarding medication discussions and future plans.
Response (Roundwell Medical Centre): Roundwell Medical Centre has implemented several immediate actions regarding patients on addictive medications including assigning a single GP where possible, detailing clinical plans, adding read codes for easy identification, and …
Responded
Sybil Roberts
Concerns: A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, leading to repeated falls due to unupdated care plans.
Overdue
Leonard Hudson
Concerns: Multiple failures in pressure ulcer prevention and management, including policy non-adherence, inadequate documentation, late referrals, inconsistent care, and poor record keeping.
Overdue
John Bird
Concerns: The care home manager failed to ensure staff were familiar with residents' falls risk assessments and care plans, leading to an untrained carer inaccurately assessing a high-risk patient's mobility.
Overdue
Michael Harman
Concerns: Inadequate checks were made on Mr. Harman's personal hygiene, and clear indicators of his deteriorating condition, unsuitable for independent living, were not adequately addressed or reviewed.
Response (Centra Support1): Centra Support conducted a full internal review of working practices and welfare checks. They drew up and rolled out local guidance protocols for reporting incidents, following up with service users …
Responded
Lana-Liza Chervonenko
Concerns: High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.
Overdue
Brian Marks
Concerns: PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.
Response (Department of Health): The MHRA will bring the issue of tube misidentification to the attention of the Standards Committees and intends to include the risk of misidentification of similar devices in the next …
Responded
John Matthews
Concerns: Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.
Response (Stockport NHS Trust): The Trust has formally discussed neurological observation needs in sisters' meetings and safety huddles, shared within the ED Quality Newsletter to all ED staff. To avoid a reoccurrence the Trust …
Responded
Paul Moroney
Concerns: Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.
Response (Tameside Hospital NHS Trust): The Trust asserts that oxygen saturations were monitored and recorded, contrary to the coroner's concern, and apologises for the lack of clarity during the inquest. They provide copies of the …
Responded
Maria Silkin
Concerns: The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to a dangerous delay in appropriate medical intervention.
Overdue
Michael Lyons
Concerns: The care agency failed to act on swallowing assessment recommendations, resulting in an inadequate care plan that did not specify choking prevention measures, and staff lacked crucial awareness regarding food preparation.
Response (John Stanley Care Agency): The care agency disputes responsibility, stating that they were not informed of Mr. Lyons' swallowing difficulties or risk of choking by social services or family, and therefore could not supervise …
Responded
Maurice Camfield
Concerns: Crucial one-to-one nursing care, stipulated in the agreed care plan, was not consistently provided to the patient.
Overdue
Eliza Bowen
Concerns: A patient with complex needs and known risk factors developed diabetic ketoacidosis, but critical blood glucose monitoring ceased in 2014, missing indications of evolving diabetes despite a previous raised reading.
Overdue
Rita Paton
Concerns: There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are excluded. Attending medical crews also lack access to vital past medical and medication history.
Overdue
Rasharn Williams
Concerns: The patient's care plan was unclear regarding emergency actions for breathlessness, potentially causing ambiguity for staff. A vital medical instruction notice for the child was also not displayed due to transitional arrangements.
Response (Berger Primary School): Berger Primary School has reviewed care plans, will refer unclear emergency provisions to school nurse/consultant, and amended its policy to ensure clarity in emergency situations. They will place photos and …
Responded
Walter Willows
Concerns: Care plans, especially feeding regimes, were reviewed insufficiently frequently for clients with changing needs, specifically regarding swallowing ability, leading to inadequate dietary adjustments.
Overdue
Isabel Richardson
Concerns: The school's Pastoral Team lacked clear purpose, operational structure, and adequate staff training, rendering it an insufficiently robust system to address student problems.
Overdue
Robert Mansfield
Concerns: Three deaths at the Millpond indicate significant safety concerns, highlighting the need for fencing, improved lighting, clear warning notices, and readily available flotation equipment.
Overdue
Edna Cleaton
Concerns: The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.
Response (Edna Cleaton): Midlands Medical Partnership has an agreed repeat prescribing protocol requiring reviews every six months for antidepressant prescriptions. They have also implemented an automatic electronic protocol within their clinical system that …
Responded
Joanna Bowring
Concerns: Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.
Response (Joanna Bowring): The Trust re-launched its carers protocol in February 2016, which includes identifying possible "red flags" and behaviours carers may look out for. An audit of care plans and risk assessments …
Responded
Clifford Crofts
Concerns: A critical post-operative care plan went missing, and nursing staff faced unsuccessful attempts to escalate care for acute pain. Significant delays occurred in obtaining a CT scan.
Response (Clifford CROFTS): The Trust has made several changes including no longer undertaking feeding enterostomies on Fridays or weekends, implementing the RIG care plan in radiology, making care plans available on the intranet, …
Responded
Pamela Thurston
Concerns: The care home failed to update the care plan for a patient with a choking risk and left her unsupervised to eat after a 17-hour period without food, leading to choking and subsequent death.
Response (Thurston): A memorandum was sent to all Home Managers regarding timely meals, choking risk assessments, and SALT referrals. The Senior Manager Monthly Report was amended to monitor Homes' adherence to the …
Overdue
Dorothy Imisson
Concerns: The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.
Overdue
Malcolm Bennett
Concerns: Staff at the care home delayed calling an ambulance for three hours after a significant injury, despite the care plan requiring immediate emergency department transfer, potentially contributing to the death.
Response (Borough Care): Borough Care has updated risk management plans for residents on Warfarin, placed anti-coagulant warnings on care plans and MAR sheets, discusses medication at handovers, reviewed medication training to include anticoagulant …
Responded
Harold Goulding
Concerns: Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs and ensure GPs review medication records.
Response (Orchard Care Homes): The care home created a handover document for sharing new resident information with GPs, and implemented protocols to ensure nurses accompany GPs on rounds to discuss medication charts and care …
Responded
Etheline De-Gale
Concerns: Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.
Response (Response Ambassador House Home): Ambassador House Home reports that the care plan will stipulate that residents must not be left unattended when bedrails are lowered, and staff will carry gloves in their pockets at …
Responded
Michael Uriely
Concerns: Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow guidelines and recognise deteriorating patient condition.
Response (Uriely): NHS England will share learning and support tools developed by the Healthy London Partnership, communicate up-to-date asthma guidelines to CCGs and GPs, and explore commissioning mechanisms to incentivise improved commissioning …
Response (Uriely Response2): NICE has produced a quality standard on asthma and is developing further guidelines on diagnosis, monitoring and management of asthma, to be published in October 2017, which will inform updates …
Overdue
Terence White
Concerns: The care centre failed to adequately document pressure sore treatment measures, specifically lacking turning charts, which prevented proper monitoring of the condition.
Response (James white): The Grange Care Centre has made changes to ensure more thorough record keeping for resident's care plans, with daily records kept in individual folders and signed off by the nurse …
Overdue
Patrick Woods
Concerns: The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.
Response (Draeger Medical UK Limited): Draeger Medical UK has updated its training documentation, including the Basic Skills Checklist and powerpoint presentation, to address the use of the ACGO switch and relevant ventilation modes. They are …
Response (Luton Dunstable University Hospital): Luton and Dunstable University Hospital has reconfigured default alarm settings on anaesthetic machines, educated staff on unused functionality, and implemented a system to manage medical equipment logs. The Clinical Director …
Overdue
Sheila Hynes
Concerns: A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.
Overdue
Patricia Norfolk
Concerns: Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.
Overdue
John Ramsden
Concerns: Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.
Overdue
Cameron Chadwick
Concerns: A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.
Response (Wigan Council): Following the report, the council measured the pothole depth and repaired it, both temporarily and permanently. They assert this was done despite the pothole not meeting the threshold for intervention …
Responded
Rose Workman
Concerns: The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.
Response (Rose Workman): The district nursing service employs measures to ensure that patients are effectively monitored of their ongoing conditions, and the electronic clinical patient record "SystmOne" has undergone extensive re-engineering, launched in …
Responded
John Davies
Concerns: There was no risk assessment plan when the resident's needs changed from care to nursing, the District Nursing Team was unaware of the change, and patient records lacked detail with little communication between the care home and the District Nursing Team.
Response (Stockport NHS Trust): A multi-agency risk assessment has been developed to support residential home managers and will be launched in June 2017 for patients waiting to be transferred to a nursing home. A …
Responded
Robert Cardwell
Concerns: Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.
Overdue
Constance Connolly
Concerns: The report describes failures in the handover of patients needing urgent follow-up, including a doctor not following up on a scan they ordered, and a breakdown in communication between different care teams resulting in a cancelled appointment and no further action.
Response (The Royal College of Emergency Medicine): The Royal College of Emergency Medicine has issued guidance to Fellows and Members regarding follow-up of test results in two documents, and is preparing a safety alert reminding them to …
Response (King's College Hospital NHS Foundation Trust): King's College Hospital NHS Foundation Trust is setting up a "virtual review" of self-discharged patients to ensure any investigations or follow-ups can be appropriately actioned.
Responded
Janet Williams
Concerns: The patient's care plan was not on the computer system, leading to missed reviews and alerts. The care co-ordinator dismissed family concerns, cancelled vital appointments, and made un-noted retrospective entries after the patient's death.
Overdue
Maud Patrick
Concerns: Systemic hospital care failures included no mental capacity assessment, poor A&E handover, unprogressed investigations, inadequate patient observations, and insufficient staffing and senior nursing leadership.
Overdue
Select committee recommendations(38)
#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 Pending
#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 Pending
#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 …
Gov response: The government agrees with the Committee’s recommendation. consider challenge outcomes for the current government net zero R&I portfolio as set out in the Net Zero Research and Innovation Framework Delivery Plan and agree these by …
Response Pending
#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 …
Gov response: The government agrees with the Committee’s recommendation. will likely continue to be required as we determine the pathways towards net zero that are most effective, sustainable and represent the best value for money. The government …
Response Pending
#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. …
Gov response: We agree that now is the time to produce a national strategy for older offenders, to ensure the prison system is best-placed to meet the needs of these offenders, and that they are treated consistently …
Response Not Attributed
#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, …
Gov response: 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, effective …
Position Not Stated
#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 …
Gov response: • We agree that now is the time to produce a national strategy for older offenders, to ensure the prison system is best-placed to meet the needs of these offenders, and that they are treated …
Position Not Stated
#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 …
Gov response: End-of-life and palliative care • HMPPS work with NHS England to identity men and women in our care who are at or near the end of their life, to ensure that services are in place …
Position Not Stated
#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 …
Gov response: • In response to the HMIP and the CQC’s joint thematic report, HMPPS continues to build on the findings of the report by developing social care in custody. • This includes the introduction of the …
Position Not Stated
#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. …
Gov response: • We are considering models for accommodating older offenders as part of the older offenders strategy, and we will update further once this is published.
Position Not Stated
#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 …
Gov response: Our National Framework is intentionally flexible enough to accommodate the different circumstances and situations of different establishments. It sets out that delivery will vary on this basis, taking into account the needs of children and …
Position Not Stated
#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 Pending
#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 Pending
#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 Pending
#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 …
Gov response: Education, Health and Care Plans (Paragraphs 53 and 54): WESC 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, …
Position Not Stated
#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 …
Gov response: We agree that staff in inpatient settings must receive appropriate training which enables them to provide high-quality, person-centred care and that this should include the principles set out by the Committee in parts (i-iii) of …
Accepted
#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 …
No Published Response
#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 …
Gov response: 28. The temporary changes to the law were kept under close review during the period that they were in force, to ensure that they could be ceased as soon as they were no longer necessary. …
Not Accepted
#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 …
Gov response: 21. The changes to the Care Act 2014 duties on local authorities will be kept under regular review and the Secretary of State will take a decision to suspend them based on expert clinical and …
Not Addressed
#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 …
Gov response: 21. The changes to the Care Act 2014 duties on local authorities will be kept under regular review and the Secretary of State will take a decision to suspend them based on expert clinical and …
Not Addressed
#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 …
Gov response: 11. The Government has been very clear that Care Act easements should only be used when absolutely necessary. To date, only eight local authorities out of 151 with social service responsibility have used easements to …
Accepted
#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 …
Gov response: 52. We acknowledge there has been duplication in resettlement work following an internal casework review conducted by the YCS that leaned on the findings of YJB’s ‘ How to Make Resettlement Constructive ’ report. Following …
Position Not Stated
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: Autumn 2021 3.2 As part of the department’s 2020-21 recovery plan, it is working closely with the Department for Health and Social Care (DHSC), …
Under Consideration
#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 …
Gov response: As set out in response to recommendation 3, we agree that where admission is absolutely necessary, it should be for the shortest time possible, with high quality, therapeutic care. We agree that care plans should …
Partially Accepted
#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.
Gov response: The government accepts this recommendation and recognises the importance of ensuring guidance on DNACPR decisions is clear and properly understood by all health and social care professionals as well as the patients involved. The recommendation …
Accepted
#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.
Gov response: The government accepts this recommendation and recognises the importance of considering the specific needs of people with a learning disability, autistic people, and their families in health emergencies. Throughout the pandemic, a range of measures …
Accepted
#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 …
Gov response: : WESC recommendation: The Department must set out a clear national strategy for managing the backlog of EHC assessments and Plans, to ensure children and young people with special educational needs and disabilities get the …
Position Not Stated
#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 …
Gov response: Education, Health and Care Plans (Paragraph 50): WESC recommendation: We recommend the Department review the information-gathering and decision-making processes in place with a view to making a faster decision to return to full EHC Plan …
Position Not Stated
#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, …
Gov response: Care Act Easements (Paragraphs 34 and 35): WESC 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 …
Position Not Stated
#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 …
Gov response: : WESC recommendation: We recommend guidance to local authorities on use of Care Act easements be updated to state that local authorities should keep a record of the reasons for their decisions and the anticipated …
Position Not Stated
#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 …
Gov response: : WESC recommendation: The Government must demonstrate that it is keeping local authorities’ use of Care Act easements under thorough review and allow for proper scrutiny of data on the effects on disabled people. We …
Position Not Stated
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: Autumn 2021 3.2 As part of the department’s 2020-21 recovery plan, it is working closely with the Department for Health and Social Care (DHSC), …
Under Consideration
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: March 2023 3.2 The OfS’s focus has been ensuring that protections are as robust as possible in those providers which might face financial distress. …
Accepted
#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 …
Gov response: 1. PAC conclusion: Current youth custody provision is inadequate for many vulnerable children’s needs, with particular concern over STCs. 1. PAC recommendation: In its Treasury Minute response, the Ministry and HMPPS should set out how …
Accepted
#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 …
Gov response: I thank the Committee for welcoming our social care charging reforms. The new £86,000 cap will end people’s worries that they may face unpredictable care costs, with roughly two thirds receiving some state support for …
Under Consideration
#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— …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: March 2023 3.2 The OfS’s focus has been ensuring that protections are as robust as possible in those providers which might face financial distress. …
Not Addressed
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
CQC inspection actions(189)— 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 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
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
Montagu Hospital, Mexborough
Thetrustshouldensurethatcapacityassessmentsandbestinterestdecisionsarefollowedandrecordedinlinewithlegislation.
Should Do
Gloucestershire Royal Hospital
The trust should ensure care plans reflect national guidance for restraint, observation, and emergency sedation.
Should 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
Darenth Grange Residential Home
The provider and registered manager failed to ensure care was planned to meet peoples need and preferences.
Must Do
Verve Health
The service must ensure that staff complete a comprehensive assessment and care plan and maintain accurate risk assessments for each service user and that staff complete effective risk management plans to reduce identified risks.
Must Do
Park Grange Care Home
The care plans we looked had not always been updated on a regular basis, some sections were not completed appropriately or were inaccurate. This meant we could not be sure people were receiving appropriate care and support to meet their …
Must Do
Attwood's Manor Care Home
The provider must ensure people's records are kept up to date as and when a person's needs have changed and daily notes reflect the care people need according to the plan of care.
Must Do
West Farm House
Care planning was not always reflective of people's needs. Risks were not identified or safely mitigated.
Must Do
Tralee Rest Home
Reviews of care plans had missed the opportunity to check for completeness and develop best practice procedures, such as when specialist advice and support was received from a healthcare professional.
Should Do
The Moat House
Care and treatment plans must contain appropriate information to ensure people receive personalised care that is responsive to their needs.
Must Do
The Laurels Residential Home - Draycott
People's care plans did not always reflect the care people needed and the care provided. The informal systems used to ensure the quality of the service and ensure necessary improvements were carried out had not been effective.
Must Do
Spindrift Care Home Limited
People's care needs were not thoroughly assessed. Plans of care had not been designed with the person to meet people's needs and achieve their preferences.
Must Do
South Network
Lack of clear up to date care plans with agreed goals. Regulation 9 (3) (a) (b) (c).
Must Do
Shenstone Hall Nursing Home
The provider must ensure improvements are made to people’s care records to identify all their support needs.
Must Do
Kings Den
Current care records were not always in place to inform staff of people's needs and risks.
Must Do
Keyznow Health and Social Care Ltd
People's care records and assessments did not comprehensively identify, assess and detail their care needs and preferences.
Must Do
Holly Court Care Home
electronic care plans required review to ensure they accurately reflected people's support needs
Should Do
Heritage Healthcare-Middlesbrough
The provider must ensure care records are person-centred and contain the information needed to provide appropriate care and support to people.
Must Do
Grace 247 Care Wiltshire
Care planning did not always demonstrate people's needs and the support they required. Regulation 9(1)(a)(b)(c)(3)(b)
Must Do
Brookthorpe Hall Care Centre
A current and consistent record of people's care needs and of the action the registered manager had taken in relation to the management had not always been recorded.
Must Do
Aspirations (Northampton)
Some care plans did not contain all the required information to ensure staff knew people's individual needs. For example, one person's care plan and risk assessment did not include the information of their thickened fluids and pureed food.
Should Do
Verve Health
The service must ensure that care plans meet client’s individual needs and preferences and are personalised, holistic and recovery oriented.
Must Do
The Homestead (Crowthorne) Limited
The registered person failed to ensure records reflected a clear care and treatment plan of people's individual needs and preferences.
Must Do
Stepping Out
Support plans did not contain accurate and detailed guidance for staff to deliver effective care.
Must Do
Park Grange Care Home
The care plans we looked at did not contain sufficient information to help staff to provide person centred care and there were limited activities for people.
Must Do
Oakleigh House Nursing Home
Care plans did not always document how peoples assessed needs were met. Regulation 9 (3) (a) (b).
Must Do
Havilah Office
People's care plans had not been fully reviewed to include personalised information about people's care.
Must Do
Haversham House Limited
The provider must ensure systems are in place and robust enough to ensure people's documentation reflects their needs and prescribed medicines and enables them to receive consistently safe care.
Must Do
Gledhow Lodge
Care plans did not evidence people received regular personal care and care plans were not always accurate and contemporaneous records of people's needs.
Must Do
Fairglen Residential Home
The provider must carry out an assessment of the needs for people.
Must Do
Etherley Lodge
The provider must ensure that care plans and risk assessments are in place for people’s nutrition, including specific dietary requirements and choices, to protect people from risks of inadequate nutrition and related health problems.
Must Do
Etherley Lodge
The provider must ensure that care records accurately reflect the care provided and that staff have access to comprehensive information describing people’s needs to enable them to provide appropriate care.
Must Do
Etherley Lodge
The provider must ensure that comprehensive care information is in place which describes how people are to be cared for, including appropriate risk assessments for identified risks such as falls, and that these are analysed and addressed.
Must Do
Etherley Lodge
The provider must ensure that information provided by other health and care professionals is included in people’s care plans to enable staff to care for people appropriately and to protect people's health and welfare.
Must Do
Bourne House
Systems for ensuring people's care and treatment was appropriate, met their needs and reflected their preference was not being used effectively.
Must Do
Benedict House Nursing Home
The registered provider must carry out monthly audits of all care plans and risk assessments to ensure they fully reflect people's current needs and must send the Care Quality Commission a report of any actions taken as a result of …
Must Do
Benedict House Nursing Home
The registered provider must immediately commence a thorough and comprehensive review of all service users' care plans and risk assessments to ensure they fully reflect people's current needs and the registered provider must provide the Care Quality Commission with details …
Must Do
Bellevue Healthcare Limited
The provider must ensure care plans are person-centred, accurately reflect individual needs and risks, are regularly reviewed, and include specific plans for short-term conditions.
Must Do
B&H Care Ltd
The provider must ensure people receive care that meets their personal care preferences and care needs, including respecting their wishes about staff, delivering care at agreed times, completing effective care reviews, and maintaining accurate and up-to-date care records.
Must Do
Ashbourne House - Torquay
People's nutritional needs were not always met in line with their needs, wishes and preferences. People's care plans were not always reflective of how their nutritional needs should be met.
Must Do
Royal Victoria Infirmary
The service must ensure that staff complete mental capacity and best interest decisions, where appropriate, when obtaining consent and that they clearly document the assessment and decision-making process.
Must Do
Royal Victoria Infirmary
The service must ensure that staff complete mental capacity and best interest decisions, when obtaining consent and that they clearly document the assessment and decision making process.
Must Do
Royal Victoria Infirmary
The service must ensure that staff complete mental capacity and best interest decisions, where appropriate, when obtaining consent and that they clearly document the assessment and decision-making process.
Must 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(4)
Independent investigation into the care and treatment of Mr L — Rec 1
The Trust must ensure that where a violent patient has been admitted to its services following concerns by other agencies; or complaints by neighbours about anti-social behaviour and noise and that they have been made aware of: • The risks are assessed appropriately • There are care plans developed to …
L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr L — Rec 2
The Trust must ensure that staff take responsibility for issuing formal invitations to all those they believe should be present at a Care Programme Approach meeting, or document discussions where this intention is changed
L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 3b
A national service specification should be developed to ensure consistent alignment with evidence-based guidance on informed decision-making, care planning and timely access to care. This should include a standardised service model setting out admission pathways, place of care, dedicated staffing, and routine consideration of induction capacity and flow within daily …
wales
Accepted
Independent investigation into the care and treatment of Mr L — Rec 1
The Trust must provide assurance that carer’s assessments and support are offered and documented in line with the Trust strategy and that there is a system for care co-ordinators to initiate monthly contact with carers of clients who are on Care Programme Approach.
L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
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 …
Sep 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)
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
LGO (Local Government & …
Adult Care Services
25-005-861 — Bournemouth, Christchurch and Poole Council
LGO (Local Government & …
Adult Care Services
Upheld
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
LGO (Local Government & …
Adult Care Services
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
LGO (Local Government & …
Adult Care Services
Upheld
24-022-503 — Derby City Council
LGO (Local Government & …
Adult Care Services
Upheld
25-001-100 — Lincolnshire County Council
LGO (Local Government & …
Adult Care Services
24-018-569 — London Borough of Hammersmith & Fulham
LGO (Local Government & …
Adult Care Services
Upheld
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