Care risk assessment failures
Ineffective assessment, monitoring, and mitigation of health, safety, and welfare risks for individuals receiving personal care.
Source spread
Where this theme appears
This theme appears across 23 independent accountability sources, so the source mix matters as much as the headline total.
50 inquiry recs
152 PFD reports
26 committee recs
31 HSSIB recs
786 CQC actions
1 HMICFRS rec
6 PPO recs
7 IOPC recs
13 IMB recs
1 IMB report
15 Scottish FAIs
4 Article 2 learning points
1465 DHR recs
32 PHSO decisions
1491 LGO/SPSO decisions
4 CJINI reports
22 CQC enforcement actions
1 MNSI report
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(50)
101 — Medical examinations before placement
Recommendation: Medical examinations of children removed under Child Protection Orders should be carried out before they enter their placements (17.38).
Unknown
44 — Clear and cogent evidence for Orders
Recommendation: A Child Protection Order should only be sought where there is clear and cogent evidence to support the Order (16.16).
Unknown
11 — Objective assessment before referral or removal
Recommendation: In cases of child sexual abuse neither a referral nor a removal of a child should be undertaken unless both an objective assessment of the situation has been made and in addition meticulous planning, so as to balance the risk …
Unknown
77 — Measures for mentally disordered prisoners on wings
Recommendation: The measures which should be taken to minimise the risk which a mentally disordered prisoner on ordinary location poses to staff and other inmates includes: • not placing such a prisoner in a shared cell • if such a prisoner …
Unknown
74 — Mental health assessments to address risk
Recommendation: When prisoners are referred for a mental health assessment, the assessment should address the risk which they pose to staff and other inmates.
Unknown
73 — Reception health screen referral to mental health
Recommendation: The first reception health screen questionnaire should be revised so as to trigger a referral to a mental health professional on the healthcare team even if the prisoner has only self-harmed in prison. A referral should also be triggered where …
Unknown
62 — No separate risk classification
Recommendation: It is neither necessary nor desirable to introduce a risk classification, similar to the security classification, which identifies the degree of risk which a prisoner poses to staff and other inmates.
Unknown
61 — Risk management model for highest-risk prisoners
Recommendation: The risk management model for the management of prisoners to whom MAPPA applies and who have been identified as posing the greatest risk to the public should be adopted by all establishments. Prisoners who have been identified as being a …
Unknown
60 — OASys for short-sentence prisoners at induction
Recommendation: All adult prisoners serving sentences of less than 12 months’ imprisonment who had an OASys assessment before being sentenced should have that assessment reviewed during the induction process. The review need only address the risk of harm which the prisoner …
Unknown
59 — OASys assessor access to prior behaviour
Recommendation: OASys assessors should have access to information relating to prisoners’ behaviour while serving previous sentences and to information held in security files.
Unknown
58 — OASys use in all establishments
Recommendation: OASys should be used by all establishments to identify the risks posed by prisoners to staff and other inmates, and the risks which are identified should be fed back to the wings.
Unknown
57 — Register showing proportion of high-risk prisoners
Recommendation: The register of prisoners assessed as high or medium risk should identify what proportion of the establishment’s population those prisoners represent.
Unknown
56 — Monitoring implementation of risk minimisation plans
Recommendation: The officer responsible for monitoring the processes for implementing measures outlined in risk minimisation plans should also be responsible for monitoring their actual implementation.
Unknown
55 — Wing officers calling for reviews
Recommendation: Wing officers should be reminded of the need to call for a review of an assessment when the necessity for one is triggered by some occurrence which might affect the prisoner’s emotional well-being.
Unknown
53 — Timing of first review of assessment
Recommendation: The first review of the initial assessment should take place within one week of the initial assessment, and should take place in every case. It should be a multi-disciplinary review, with representatives from the prisoner’s wing, healthcare and the team …
Unknown
52 — Guidance for duty governors on risk assessment
Recommendation: The instructions for completing the form should give duty governors guidance on how to exercise the options available to them when dealing with prisoners who are both at risk of self-harm and a risk to their cellmate.
Unknown
51 — Instruction on completing form XF001
Recommendation: Staff who are tasked with completing form XF001 should be instructed on how to complete it by a senior officer. In particular, they should be reminded that they are only assessing the risk prisoners pose to other inmates. They should …
Unknown
39 — Missing cell-sharing risk assessment form on arrival
Recommendation: If prisoners arrive on a wing without a copy of the cell-sharing risk assessment form, they should be placed in a single cell until the form is found or a new one completed.
Unknown
9 — Guidelines on allocating shared cells
Recommendation: The Prison Service should publish guidelines to assist officers in allocating cells to those prisoners who have to share a cell.
Unknown
8 — System to apply change of prisoner status
Recommendation: All establishments should have a system for ensuring that immediate effect is given to a prisoner’s change of status, by making certain that they do not share a cell with a prisoner of a different status.
Unknown
R95 — Blue light protocol for at-risk registers
Recommendation: HSCTs must develop registers of those at risk of requiring unplanned inpatient treatment, similar to the NHS England ‘blue light protocol’, in order to target community resources efficiently and prevent the person having to leave their home in the community.
No response yet
R82 — Risk-based inspection prediction
Recommendation: RQIA should consider developing a risk-based way of predicting which services are in difficulty. It is well known that certain aspects of services tend to be associated with abuse: service users who are vulnerable, who have few communication skills; service …
No response yet
R68 — Cumulative risk assessment across protection plans
Recommendation: Protection plans should include an assessment of risks arising from the plan itself. Where multiple protection plans are in place for vulnerable adults within a single unit, cumulative risks arising from those individual protection plans across all residents must also …
No response yet
R35 — Inpatient facilities on risk register
Recommendation: Given the elevated risk of inappropriate use of restrictive practices with individuals with learning disabilities and/or autistic people, BHSCT and all HSCTs should automatically place any inpatient facility or facility for people with challenging behaviour on its risk register.
No response yet
R25 — Pressure damage risk assessment
Recommendation: Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool such as the Waterlow Score in accordance with best practice guidance. Where patients are identified as at risk …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
POH-14 — Post Office to engage in negotiations during HSSA appeal period
Recommendation: During the nine-month period afforded to claimants to submit an appeal to the Department in HSSA, the Post Office shall engage in negotiations and/or mediation with any claimants who notify the Post Office of a desire to seek a negotiated …
Gov response: Prior to the publication of the Inquiry’s report, DBT had been in discussion with claimants’ legal representatives about the deadlines for submission of HSS Appeals. In the light of the representatives’ concerns, DBT has agreed …
Accepted
POH-12 — Amend GLOS to allow claimants oral submissions at panel hearings
Recommendation: The scheme documents governing GLOS should be amended so that a right is conferred upon claimants (exercisable by the claimants themselves or their recognised legal representatives) to make oral submissions in support of their claim at the hearing convened by …
Gov response: All claimants in the GLOS already had the right to make oral submissions for up to one hour in support of their claim at the hearing convened by the independent panel. The same approach is …
Accepted
115 — Consistent background information for interviewers
Recommendation: Each interviewer should wherever possible have consistent and relevant background information about the child and in particular about his or her emotional, physical and mental development (17.54), and an assessment of the child’s wider family (17.55).
Unknown
2 — Objectives the Safety Case must demonstrate
Recommendation: The Safety Case should demonstrate that certain objectives have been met, including the following:- (i) that the safety management system of the company (SMS) and that of the installation are adequate to ensure that (a) the design and (b) the …
Unknown
10 — Guideline content: common background and interviews
Recommendation: The guidelines should proceed on the assumption that the lack of privacy which cell-sharing entails is more likely to be ameliorated if prisoners with a common ethnic and religious background share cells. But that should only be the starting point …
Unknown
57 — Distinguish CSE risk from actual exploitation
Recommendation: The Department for Education and the Welsh Government must ensure that their updated national guidance makes clear that signs that a child is being sexually exploited must never be treated as indications that a child is only 'at risk' of …
Gov response: 19. We recognise that local and national understanding of child sexual exploitation, including where perpetrated by organised networks, has progressed since the guide for practitioners was published in 2017. We therefore propose accepting these recommendations …
Accepted in part
R101 — Whole-system commissioning with cross-agency risk assessment
Recommendation: Planning and commissioning services for people with learning disabilities and autistic people should be done as a single process across the whole system (including primary care, housing, benefits and independent and third sector providers of services). There must be a …
No response yet
WATE-(33) — Base care plans on comprehensive assessment, prepared with child consultation
Recommendation: The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Unknown
WATE-(32) — Follow emergency child admissions with comprehensive assessment within prescribed period
Recommendation: All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Unknown
WATE-(31) — Require comprehensive child needs assessment before admission to care
Recommendation: Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Unknown
R28 — Nutritional screening
Recommendation: Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool. Where nutritional problems are identified further assessment should be undertaken to determine an individual care plan. Appropriate …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
6 — Draw up maternity risk assessment protocol
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
56 — Reporter's power to return the child
Recommendation: The Reporter’s existing power to have the child returned should continue but should be qualified in its exercise by the proviso that the return of the child would not expose the child to the risk of significant harm (16.29).
Unknown
53 — Written statement of grounds
Recommendation: At the time of making the application or within forty-eight hours thereafter a written statement of facts setting out the grounds for the perceived risk to the child should be prepared and presented to the Sheriff or JP (16.25) The …
Unknown
45 — Evidence sufficient to secure retention
Recommendation: Where there is a likelihood of harm continuing to the child if he or she is not retained in care the evidence for a Child Protection Order should be sufficient to give a reasonable expectation of securing such retention after …
Unknown
40 — Removal as last resort
Recommendation: Removal of a child should be recognised as a course to be considered where no alternative exists and the urgency of the risk requires it (16.9). Caution must be exercised (16.10). The gravity of the threat has to be considered …
Unknown
3 — Safety management system content
Recommendation: The SMS should be in respect of (a) the design (both conceptual and detailed) of the operator’s installations; and (b) the procedures (both operational and emergency) of those installations. In the case of existing installations the SMS in respect of …
Unknown
SP22 — LCC online harms risk assessment review
Recommendation: Lancashire County Council should undertake a comprehensive review of how its children’s services and Early Help teams (i.e. Children and Family Wellbeing Service) assess and manage risk and online harms to children. This review should ensure that all frontline staff …
Gov response: The Department for Education (DfE) is taking responsibility for this recommendation in place of the Department for Health and Social Care and expects to complete implementation of this recommendation by mid-2026. Progress and next steps: …
Accepted
SP2 — Shared multi-agency risk-assessment tool
Recommendation: Phase 2 should consider the development of a shared multi‑agency risk‑assessment tool that is clear, accessible and suitable for use across public sector services.
For a later phase of the inquiry
WATE-(46) — Prohibit emergency admissions to all private residential schools
Recommendation: Emergency admissions should not be made to private residential schools.
Unknown
7 — Audit maternity and paediatric services
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
JB-15.4 — Amend firearms authorisation forms for risk assessment and tipping points
Recommendation: There should be an amendment to FA (and equivalent) forms to: a. encourage a multidimensional risk assessment (to comply with Article 2) to minimise, to the greatest extent possible, recourse to lethal force; b. include a provision for reference to …
Gov response: As noted above, the FA forms utilised by the MPS are derived from elements of the national command log and developed to complement the MPS operational command model and process for seeking authority to deploy …
Response Unclear
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
R7 — Reorganisation due diligence
Recommendation: In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment should be undertaken by the Board or Boards responsible for all patient services before the reorganisation takes place. Subsequent to that reorganisation regular …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
JB-15.2 — Require multidimensional risk assessments throughout operations
Recommendation: Training should emphasise that multidimensional risk assessments must be carried out throughout police operations, including the planning and briefing of operations. Those risk assessments should assess the future threat and risk at all stages of the operation.
Gov response: The concept of multidimensional threat assessment has been included in APP-AP for some time. The concept is also dealt with in much greater detail within the current NPFTC than was the case in 2015. The …
Noted
Prevention of Future Deaths reports(152)— showing 50 strongest matches
Derek Edward Bartlett Twivey
Concerns: The coroner noted that a falls risk assessment for a patient with a known high falls risk was not conducted within the anticipated 24 hours of arrival at a nursing home, due to it being a weekend and staffing pressures.
Overdue
Annie Rose Gibson
Concerns: The report raises concerns for Saga Homecare regarding the circumstances surrounding the death of an 84-year-old lady who had fallen while receiving daily home care.
Overdue
May Gibson
Concerns: The coroner noted failures in obtaining and utilising community care assessments, developing an adequate care plan for Mrs Gibson, and conducting proper risk assessments and reduction plans. Concerns were also raised regarding a lack of cohesive management and insufficient staff training and supervision within the care home.
Overdue
Peter Pattinson
Concerns: Family requests for bed rails to be raised were not acted upon, documented, or risk assessed, and repairs were delayed. Additionally, daily statements were missing and unpaginated.
Response (European Care Group): • Bed rail risk assessments are now conducted within 24 hours of admission and reviewed monthly or when needs change. • A daily checking system for bed rail condition has … (AI summary)
Responded
George Renshaw Brown
Concerns: The coroner identified a lack of an efficient system for the speedy reassessment and transfer of patients whose condition is rapidly deteriorating, leading to delays in moving individuals to suitable alternative accommodation.
Overdue
John William Tugwell
Concerns: The coroner noted that a resident identified as a falls risk, with a history of previous falls, was allowed unsupervised access to stairs within the care home.
Overdue
Derrick Plater
Concerns: The coroner raised concerns that care home visits were not standard practice before placing individuals with complex needs, relying instead on the home's assurances. There was also uncertainty regarding guidelines or protocols for undertaking such visits during the assessment and placement process.
Response: • The organisation stated that a pre-placement visit by a social worker would not be introduced as part of the assessment and placement process. • It explained that social workers … (AI summary)
Responded
Ernest Harper
Concerns: Concerns were raised about a gap between a safety barrier and the back of a vehicle that allowed a fall. The report also notes that passenger health and mobility risk assessments relied solely on voluntary information rather than a formal process.
Response (Bedford Borough Council): • Devices were retro-fitted to the doors of all Ford Transit vehicles to block gaps between the vehicle and handrail. • A redesigned Client Transport Referral form was devised to … (AI summary)
Responded
Ross Boyd
Concerns: The coroner noted an inadequate needs assessment for Ross Boyd prior to his admission to The Willows, which resulted in an inappropriate placement for his care needs.
Response (Milton Keynes Council): • The council stated that Mr. Boyd's needs were assessed by multiple teams on 4 October 2013, and a care package was provided. • The council stated that the decision … (AI summary)
Pending
Harold de Mello
Concerns: The coroner identified inadequate good practice guidelines for assessments, resulting in incomplete and inconsistent evaluations of care needs. Concerns were raised about assessments failing to consider referrer reports or historical records, and insufficient investigation into available care.
Response (Tower Hamlets Local Authority): • An internal management review of the case was completed on 3 October 2014. • A new practice protocol was implemented to ensure copies of case closure letters are sent … (AI summary)
Responded
Elaine Jobe
Concerns: Insufficient record-keeping for risk assessments and observation levels, coupled with a lack of staff training records, was identified. Additionally, communication of patient status to incoming staff and named nurse responsibilities require review.
Response (Devon Partnership NHS Trust): • The Trust shared the coroner's findings with the service involved and across the wider trust. • The Trust stated that additional actions, detailed in an attached report, were expected … (AI summary)
Responded
Charles Lawrence
Concerns: Alexandra Rose Care Home does not have a protocol for calling a doctor to examine a resident who experiences more than one fall within a 24-hour period.
Response (Alexandra Rose Residential Care Home): • The care home devised a 'falls alert' notification protocol for residents experiencing multiple falls within a 24-hour period. • This protocol has been incorporated into each resident's care plan … (AI summary)
Responded
Edna Bulmer
Concerns: The coroner noted inconsistent recording of fall risk levels, delayed implementation of identified risk minimisation measures, and a lack of risk assessment review after subsequent fall incidents.
Overdue
Derek Hawkins
Concerns: The risk assessment tool relies on subjective practitioner assessment and lacks objective risk factor rating. This may hinder less experienced practitioners from identifying increased risk.
Overdue
Darren Hayes
Concerns: The coroner identified insufficient documentation and escalation of telephone contact attempts, significant delays in reaching Mr Hayes, and that his presenting risks were not fully considered. Relevant healthcare and support agencies were not contacted when direct communication failed.
Response (Norfolk County Council): • Staff have been made aware that all contact attempts, including those with no response, must be documented and escalated to a senior worker. • A Best Practice factsheet is … (AI summary)
Responded
George Hulme
Concerns: Agency staff lacked information and adequate induction to identify residents, resulting in an incorrect file retrieval and potentially inappropriate treatment. Resident rooms were also not clearly marked, which could lead to identification confusion during emergencies.
Overdue
Maria Silkin
Concerns: The care home's "Falls Risk Assessment" document incorrectly recorded no previous falls, despite evidence of multiple falls, which contributed to a delay in the person being taken to hospital.
Overdue
Thomas Taylor
Concerns: The coroner noted concerns that the falls risk assessment form does not presume increased risk for certain patient classes, which could lead to misclassification and potentially different outcomes.
Overdue
Emmeline Hampson
Concerns: The coroner identified a lack of procedures for reviewing falls risk assessments and documentation following a fall or significant change in a resident's condition. Concerns also included issues with alarm systems for falls and call bells, and insufficient training for agency staff on relevant procedures.
Overdue
Howell Fisher
Concerns: The report identifies insufficient staffing for a high-risk falls patient, meaning one-to-one nursing was not consistently delivered. There was also a lack of handover material on falls risk between hospitals and no formal risk assessments after successive falls.
Overdue
Ian Morley
Concerns: A fresh risk assessment was not evidently prompted following a noted deterioration in the deceased's condition. Additionally, the report describes inadequate fire risk management at Greenrod Place.
Overdue
John Lomas
Concerns: Concerns were raised regarding the lack of liaison and generic risk assessment prior to a white water rafting trip, alongside an inadequate dynamic risk assessment of river conditions and an absence of preparatory training, water confidence tests, and a safety kayak. There was also no obligation to liaise with the water company about discharge.
Response (Sport Camp Tirol): • The company stated that rafting companies are now informed by the hydro plant of planned discharges in advance, and the company has decided not to conduct trips downstream on … (AI summary)
Responded
Peter Furness
Concerns: The care home lacks a documented process for escalating incidents or concerns to trigger multi-disciplinary team meetings that review risk assessments and care plans for vulnerable residents.
Response (Nant Y Gaer Hall): • Nant Y Gaer Hall implemented a new alert system for escalating changes in residents' conditions and behaviours. • The new system includes a clear process, policy documents, flow charts, … (AI summary)
Responded
Peter Buckle
Concerns: The coroner identified that a risk assessment was not updated for a new, unsafe work method, and observed a lack of health and safety culture among ground-level employees despite prior training.
Response: • A 'stop and think' behavioural safety training program has been completed to improve safety culture and decision-making. • The company plans to confirm safety-critical communications in writing and to … (AI summary)
Responded
David White
Concerns: The coroner identified that the effect of Heparin in causing confusion was not recorded or acted upon, and despite documented fall risks, there was no supervision arrangement in place, with nursing notes on risks not being reviewed or acted upon.
Response: • Staff have been reminded to document allergies and adverse effects, and this issue was discussed in a Renal Mortality and Morbidity meeting. • Safety briefings during nursing handover now … (AI summary)
Responded
Alan Ludlow
Concerns: The coroner raises concerns about insufficient information exchange during assessments for residential and nursing placements, noting a new care home was not provided with critical past incident details about a resident.
Overdue
Joanna Bowring
Concerns: The patient and carer left an initial assessment without a clear understanding of the service or a care plan. Carers were not routinely included in risk assessments, their views were not actively sought, and they were not advised about behaviours indicating an increased risk of suicide.
Response (Joanna Bowring): • An Initial Action Plan Proforma is now required after every assessment to provide service users and their carers with written outcomes and next steps. • The Trust re-launched its … (AI summary)
Responded
Marjorie Wood
Concerns: The coroner noted the need for a full understanding of the legal status of individuals in care homes, as a lack of clarity could impact their care and treatment.
Response (Kingsley Healthcare Group): • The organisation confirmed its policy to follow the Deprivation of Liberty Safeguards Code of Practice for all service users. • It stated that revised forms for managing Deprivation of … (AI summary)
Overdue
Freda Cordy
Concerns: The coroner noted Mrs Cordy was placed in a care home with 2-hourly checks despite needing constant supervision. No specific falls risk assessment was undertaken despite a falls history, and only a floor mattress was provided for prevention.
Overdue
Micael McMonigle
Concerns: The coroner identified gaps in staff knowledge and adherence to policies for informal patient leave, leading to inadequate risk assessments and unclear communication of leave conditions. Significant delays and non-compliance with missing patient procedures were also noted.
Overdue
Maureen Flynn
Concerns: The coroner noted a falls risk assessment for Mrs. Flynn was incomplete, and care staff were unaware. The report identifies a need for a system to alert staff to incomplete assessments, an issue also not identified by the patient safety investigation.
Response (Stockport NHS Trust): • The Trust stated that falls risk assessments were completed in line with Trust policy. • The Trust shared the investigation findings via a ward newsletter in June 2016. • … (AI summary)
Responded
Demi Williams
Concerns: The coroner identified that specific risks described by Ms Williams regarding taking her own life were not considered during general risk assessments. The Trust's investigation also does not reflect this issue, potentially missing learning opportunities.
Overdue
Dorethea Parr
Concerns: The coroner noted a lack of notification to family and carers regarding new equipment delivery, preventing training and risk assessment for a high-risk patient. There were no formal protocols for informing District Nurses about new equipment or changes in patient fall risk.
Response (Cornwall Partnership NHS Trust): • The Trust confirmed it had embedded a policy for slips, trips, and falls into its community services as of 1 April 2016. • The policy requires staff to complete … (AI summary)
Responded
Raymond Shepherd
Concerns: The coroner noted poor record-keeping and a lack of updates to customer files in home care. Concerns included no action being taken after multiple reported falls or deterioration in condition, and the absence of a mental capacity assessment.
Response (Human Support Group): • A new care plan was developed to include sections on risks of falls, falls management, capacity, substance/alcohol abuse, and food and nutrition. • A new falls policy and procedure … (AI summary)
Overdue
David Cooper
Concerns: Concerns include inadequate handover between wards regarding falls risk, incomplete nursing notes, and deficiencies in the system for allocating one-to-one care for high-risk patients.
Response: • The Health Board established a Falls Management Group in September 2015, which reviewed policies and training requirements and introduced National Patient Safety Agency Risk Assessments. • The Falls Management … (AI summary)
Overdue
Roger Tombs
Concerns: The coroner raised concerns that placing fall sensor mats on top of crash mats at Sunrise of Knowle may reduce their effectiveness, potentially failing to alert staff when vulnerable residents mobilise and increasing the risk of falls and injury.
Response (Sunrise Senior Living): • Sunrise Senior Living stated it took steps immediately following the inquest to address concerns regarding the placement of sensor mats on crash mats. • Sunrise Senior Living invited the … (AI summary)
Response (Roger Tombs): • The Falls Team reviewed its practice regarding advice and training on sensor mats and found it to be consistent and accurate. • A guidance document outlining good practice in … (AI summary)
Overdue
Etheline De-Gale
Concerns: The care plan was too vague to guide carers, who also lacked training on how to undertake risk assessments. Insufficient staffing levels compromised resident safety, potentially leading to paramedic recommendations being ignored.
Response (Response Ambassador House Home): • Care plans will be updated to stipulate that residents must not be left unattended when bedrails are lowered for assistance. • Staff have been instructed to carry gloves at … (AI summary)
Responded
Patrick Woods
Concerns: The coroner noted that the hospital's equipment portfolio was unknown, which prevented the identification of potentially dangerous equipment, subsequent risk assessment, and actions to prevent future harm to patients.
Response (Draeger Medical UK Limited): • Draeger updated its training documentation, including the Basic Skills Checklist, Workbook, Quick Guide, Practical Exercises, PowerPoint presentation, and Training Needs Analysis, to enhance clinician competence regarding machine functionality and … (AI summary)
Response (Luton Dunstable University Hospital): • The Trust stated it maintains an electronic database of all equipment, including location, service history, and risk categorization. • The Trust confirmed that incidents involving equipment are reviewed by … (AI summary)
Responded
Sheila Hynes
Concerns: During an operation, a mechanical aortic valve was remounted contrary to manufacturer instructions, without documented rationale or awareness of risks by the surgical team. An untrained scrub nurse was instructed to perform this procedure, and the primary surgeon had not instructed it.
Overdue
Patricia Norfolk
Concerns: The coroner noted that patients were not receiving daily senior clinician reviews and raised concerns about the interim period before new staff are recruited to address this.
Overdue
John Ramsden
Concerns: Concerns were raised that not all of John Ramsden's daughters were consulted about his end-of-life care and decisions regarding hospital admission for treatment.
Overdue
Cameron Chadwick
Concerns: The coroner identified a pothole in the carriageway, measured at 45mm deep, which exceeded Wigan Council's stated repair threshold of 40mm.
Response (Wigan Council): • Wigan Council stated that its officers measured the pothole at 36mm deep. • Wigan Council confirmed a temporary repair to the pothole was carried out on 6th July 2017. … (AI summary)
Responded
Rose Workman
Concerns: The report raises concerns about the sufficiency of measures employed by the district nursing service for effective monitoring of patients' ongoing conditions.
Response (Rose Workman): • The Trust re-engineered its electronic clinical record system to enhance patient monitoring, including new review templates, reporting frameworks, and assessment tools for conditions, pressure areas, and nutrition. • A … (AI summary)
Responded
Robert Cardwell
Concerns: The coroner identified unreliable processes for relaying patient messages to the Multi-Disciplinary Team (MDT), leading to inappropriate discharge. Further concerns included the MDT not discussing referred patients and inadequate record-keeping during meetings.
Overdue
Constance Connolly
Concerns: The coroner identified gaps in follow-up for a critical scan, insufficient communication with the general practitioner regarding ongoing investigations, and procedural issues that led to the cancellation of an essential outpatient appointment.
Response (The Royal College of Emergency Medicine): • The Royal College of Emergency Medicine recently issued two guidance documents to its Fellows and Members on ensuring test results are followed up. • The College is preparing a … (AI summary)
Response (King's College Hospital NHS Foundation Trust): • The Trust has taken steps to ensure that formal discharge notifications are always sent to a patient's GP, detailing all relevant tests, assessments, and follow-up arrangements, even if the … (AI summary)
Responded
Lesley Hanson
Concerns: Care and risk assessments did not fully address risks from doors left open, the type of stair-gate, and the locking mechanism. There was also unclear responsibility for ensuring environmental safety measures at the property.
Response (Welsh Government): • The Welsh Government stated that Codes of practice to assess and meet the needs of individuals with care and support needs have been issued. • These codes set out … (AI summary)
Response: • The Council redesigned referral forms, developed new flowcharts, and implemented compatibility criteria checklists to capture risks and clarify professional roles in supported accommodation. • A comprehensive review of Internal … (AI summary)
Responded
Maya Kantengule
Concerns: The coroner identified a lack of formal health and safety training for staff and directors, an absence of specific risk assessments for swimming pool parties, and that safety procedures were not followed. Concerns also included a general lack of staff awareness in the pool area.
Response (Waveney River Centre): • The Centre stated it would no longer privately hire its swimming pool for parties. • Formal safety training courses, such as IOSH, have been arranged for staff. (AI summary)
Responded
John Lambton
Concerns: The coroner noted care home staff, lacking formal medical training, made assumptions about the resident's health following falls and disregarded a request for an ambulance. There was also insufficient communication with the GP about the resident's recent health events.
Overdue
David Sketchley
Concerns: The report identifies concerns regarding the quality of the BUPA investigation, which did not conclude on supervision levels or commode suitability. It also notes an absence of evidence that BUPA's practice reflects care service standards for commode assessments.
Response: • The Medicines and Healthcare products Regulatory Agency (MHRA) stated that commodes are not regulated as medical devices in the UK. • The MHRA will continue to pass reports of … (AI summary)
Overdue
Stanley Langdon
Concerns: The Haven Day Care Centre began providing services without an adequate care plan or needs assessment from Durham County Council. The council's systems to prevent this were not consistently applied, and the care plan eventually implemented was incomplete and not discussed with the family.
Response (Haven Day Centre): • The centre introduced a revised home assessment document for completion prior to new placements. • The centre changed its policy to only accept new placements when all relevant documentation … (AI summary)
Overdue
Select committee recommendations(26)
#122 —
Recommendation: Some witnesses, however, expressed reservations about the current use of out-of-court disposals (where the police deal with a low-level, often first-time offender without prosecution) in the UK. Tom Franklin referred to âan unregulated increase over the past few yearsâ, and …
Response attribution not verified
#32 —
Recommendation: The Probation Service, however, is not making the most out of these partnerships. Referrals do not always contain sufficient information, risk assessments are not always produced and shared in a timely manner, and commissioned partners find it difficult to feed …
Response attribution not verified
#10 —
Recommendation: However, conducting assessments of disabled children’s needs only through a child protection lens, rather than a support lens, can lead to the stigmatisation of carers and the failure to provide adequate support to children who might need it. The government …
Response status not verified
#9 —
Recommendation: In 2024–25, 32 of 106 local NHS areas (known as sub-ICBs) assessed less than 10% of their registered patients aged 65 or over. However, nine of 106 local areas assessed 90% or more of this group of people, suggesting that …
Response attribution not verified
#7 —
Recommendation: For all patients diagnosed with severe frailty, the GP contract requires GPs to do a clinical review. This includes a review of the patient’s medication, a falls risk assessment and a discussion with the patient of the benefits of having …
Response attribution not verified
#3 —
Recommendation: NHS England’s existing oversight arrangements are not improving GPs’ assessment and support of people with frailty. It is not clear exactly who is responsible for improving performance. NHSE considers that ICBs are responsible for commissioning services to meet the needs …
Response attribution not verified
#27 —
Recommendation: We welcome the fact that the Home Office is investigating these issues seriously. This investigation should engage with those raising these concerns, assessing whether the moves during lockdown were consistent with public health guidance and seeking detail on precisely how …
Response attribution not verified
#26 —
Recommendation: Asylum seekers should not have been moved to new accommodation during the pandemic without justified and urgent reasons for doing so or without a vulnerability assessment demonstrating that the move could be made safely. This must happen Home Office preparedness …
Response attribution not verified
#7 — Inadequate assessment of mental health for children and young people in care.
Recommendation: Young people in care are significantly more likely to have experienced trauma and adverse experiences than their peers, and therefore strong mental health support is crucial. Although local authorities are required to assess the emotional and mental health of children …
Response attribution not verified
#56 — Address inappropriate assessment processes for disabled children’s parents and implement Law Commission proposals.
Recommendation: It is deeply concerning to hear that parents of disabled children are being treated with suspicion and undergoing inappropriate assessment processes when reaching out for help. The Department for Education must address this as an urgent priority and ensure that …
Response attribution not verified
#194 —
Recommendation: The Probation Service, however, is not making the most out of these partnerships. Referrals do not always contain sufficient information, risk assessments are not always produced and shared in a timely manner, and commissioned partners find it difficult to feed …
Response attribution not verified
#175 —
Recommendation: Communication issues persist after initial referrals. Carrie Peters told us that ârisk and need are dynamicâ, meaning that the risk presented by an offender, as well as their rehabilitative needs, may evolve while they are on probation. She explained that …
Response attribution not verified
#7 —
Recommendation: We praise prison staff, HMPPS and MoJ officials for their work in responding to the Covid-19 pandemic. The virus has brought into sharp relief many of the issues affecting the prison system, including the particular health vulnerabilities of older cohorts. …
Response attribution not verified
#9 —
Recommendation: The risks posed to vulnerable individuals by Covid-19 make more urgent the necessity of a complete end to room sharing by unrelated adults. While the first peak of infection has passed in some parts of the UK, there continues to …
Response attribution not verified
#8 —
Recommendation: Our predecessor Committee recommended that shared accommodation should be phased out across the estate as a whole. While we welcome the progress towards ending this practice, we are extremely disappointed that the Home Office did not take the opportunity of …
Response attribution not verified
#6 —
Recommendation: Vulnerable people such as pregnant women, victims of abuse and people with PTSD should never be placed in accommodation in which they have to share a room with an unrelated adult, nor should they be required to use shared bathroom/toilet …
Response attribution not verified
#6 — Update Code of Guidance and end family placements sharing facilities with single adults.
Recommendation: We are alarmed to hear examples of families housed in temporary accommodation that included spaces shared with single adults with a history of domestic abuse. This is completely inappropriate and poses a potential safeguarding risk to children. Currently, there is …
Response attribution not verified
#3 — Mandate local authorities to conduct mandatory temporary accommodation inspections and publish annual reports.
Recommendation: Some local authorities are not taking sufficient account of the needs of children and families when making decisions on temporary accommodation placements. Many local authorities do not carry out any regular inspections of the conditions in the accommodation they use …
Response attribution not verified
#22 — CCRC leadership underestimates risks and impact of operating without full commissioner quota.
Recommendation: Karen Kneller told us that the “validity of the work of the CCRC or any decision taken is not impacted by commissioner numbers”. We question this assertion. Operating without a full quota of commissioners, in other words ‘short-staffed’, must place …
Response attribution not verified
#17 —
Recommendation: We agree with witnesses that children under 16 may be denied the opportunity to benefit from the rights provided by the Bill if their ability to make decisions for themselves is not properly assessed. Clarity in such assessments is therefore …
Response attribution not verified
#1 —
Recommendation: We conclude, in line with our report on Social care: funding and workforce, the current social care system is “unfair and confusing”. Those living with dementia remain unprotected from unlimited costs and navigating the system is burdensome for those providing …
Response status not verified
#18 — Home Office still developing specific safety measures for residents in large accommodation sites.
Recommendation: The Home Office is responsible for the safety and wellbeing of people in its care, whether they are claiming asylum or pending relocation. But the National Audit Office reported that, in January 2024, the Home Office was still developing specific …
Response attribution not verified
#1 — Persistent appalling conditions in temporary accommodation gravely endanger children's health and wellbeing.
Recommendation: The appalling conditions in some temporary accommodation in England are utterly shameful. We are concerned that issues of poor-quality temporary accommodation continue to persist, even though it is now over five years since the then Children’s Commissioner described these conditions …
Response attribution not verified
#11 — Site-specific viability assessments frequently reduce affordable housing requirements unjustifiably.
Recommendation: Too often, site-specific viability assessments are used by developers to negotiate down affordable housing requirements in circumstances where this is completely unjustifiable. Affordable housing contributions are frequently the first provision to be cut following a viability assessment, even where a …
Response attribution not verified
#14 —
Recommendation: Shortly after starting on the Restart scheme, participants undertake a ‘diagnostic assessment’ with providers, to understand the extent to which things like the physical and emotional demands of work, travel, literacy, numeracy, debt, housing, criminal convictions, and family life challenges …
Response attribution not verified
#7 —
Recommendation: As its understanding of the disease has grown, DHSC has developed a new risk assessment tool, QCovid, to identify people at risk based on wider factors which make them at more risk from COVID-19. DHSC described the tool as having …
Response attribution not verified
HSSIB safety recommendations(31)
Electronic patient record (EPR) systems – thematic review
How does your organisation proactively identify new and emerging risks associated with an EPR system, and ensure these are reviewed and mitigated as far as is practicable?
Learning Prompt
Electronic patient record (EPR) systems – thematic review
Does your organisation understand the expectations for clinical risk management of health IT systems in relation to deployment, ensuring these are met and regularly reviewed?
Learning Prompt
Patient care in temporary care environments
Does your organisation use a multidisciplinary team to assist risk-based decisions on where to situate temporary care environments and make decisions on which patients are appropriate to be placed in them?
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation identify and code patients – who may be more vulnerable to harm from insulin due to their circumstances – for increased monitoring? This may include patients who have their medications delivered to their home, who do …
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation ensure long-term condition reviews reliably take place for patients who may be at a higher risk of deterioration due to their circumstances, for example those with multiple long-term conditions?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure that risks to the care pathway are identified and mitigated to as low as reasonably practicable across different organisations?
Learning Prompt
The diagnosis of ectopic pregnancy
Care providers may benefit from conducting a proactive systematic risk analysis when designing or reviewing care pathways. Such an analysis should consider ‘work as done’ (the way work is actually carried out, which may differ from written policies and procedures) …
Safety Observation
The diagnosis of ectopic pregnancy
It is recommended that the Royal College of Obstetricians and Gynaecologists should provide guidance on the information that should be provided during referral to early pregnancy units to standardise and improve the flow of information required to identify those most …
Safety Recommendation
Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke
It would be beneficial for future venous thromboembolism (VTE) guidelines in relation to stroke to explicitly state when further VTE assessments are required during a patient’s stay in hospital.
Safety Observation
Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke
There is no validated venous thromboembolism (VTE) risk assessment tool in the UK that produces a stratified risk for predicting a patient’s likelihood of developing a deep vein thromboembolism or pulmonary embolism. If it is not possible to produce a …
Safety Observation
Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke
It is recommended that the Intercollegiate Stroke Working Party with support from the Joint Stroke Medicine Committee and NHS England and NHS Improvement develop a stroke specific venous thromboembolism (VTE) assessment tool and system for ordering the associated treatment for …
Safety Recommendation
The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period
It may be beneficial for organisations to consider guidance, such as the ‘principles for effectiveness and usability’ provided by the Chartered Institute of Ergonomics and Human Factors, when developing risk assessment tools. The aim being to ensure assessments are simple …
Safety Observation
Detection of jaundice in newborn babies
HSIB recommends that the National Institute for Health and Care Excellence reviews the available evidence and updates its guidance if appropriate, regarding: the reliability of visual signs to detect jaundice in newborn babies, particularly in babies with black and brown …
Safety Recommendation
Assessment of risk during the maternity pathway
a pregnant woman/person’s individual risks
Learning Prompt
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
Providers of inpatient children and young people’s mental health services can improve patient safety by ensuring there is not a blanket approach to safeguarding mitigation measures based on a person’s age, and that mitigation measures are individualised and based on …
Safety Observation
Potential under-recognised risk of harm from the use of propranolol
The Practice has developed a new depression scoring and screening tool to build on the existing good practice followed during Emma’s case, and ensures this approach is adopted consistently in future patient consultations.
Safety Action
Electronic patient record (EPR) systems – thematic review
How does your organisation identify whether an EPR system meets relevant standards, such as those that support clinical risk management and interoperability?
Learning Prompt
Patient care in temporary care environments
Does your organisation have a policy that governs the use of temporary care environments that includes potential risk mitigation strategies? Do these policies consider the severity of patients’ health conditions, the appropriateness of patients who can be assigned to a …
Learning Prompt
Healthcare provision in prisons: needs assessments and disability access
HSSIB recommends that HM Prison and Probation Service reviews and amends its information gathering processes for accommodation requirements for wheelchair users and people with mobility issues, to identify and mitigate risks for people whose accommodation does not meet their needs. …
Safety Recommendation
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you identify and mitigate potential harm caused when implementing a new care pathway?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you identify and mitigate unexpected challenges to patient safety arising from the care pathway’s implementation?
Learning Prompt
Management of chronic asthma in children aged 16 years and under
HSIB recommends that NHS Digital reviews the supporting information for triaging the breathless child up to 16 years of age, to determine whether there are features of life-threatening breathing difficulty.
Safety Recommendation
Wrong site surgery – wrong patient: invasive procedures in outpatient settings
HSIB recommends that NHS England and NHS Improvement leads a review of risks relating to patient identification in outpatient settings, working with partners to engage clinical and human factors expertise. This should assess the feasibility to enhance or implement layers …
Safety Recommendation
Timely detection and treatment of cauda equina syndrome
HSIB recommends that the British Association of Spine Surgeons, supported by the Royal College of Surgeons of England and the Royal College of Emergency Medicine, develops a decision-making tool to support the identification of patients who need an immediate MRI …
Safety Recommendation
Weight-based medication errors in children
It would be beneficial for trusts that have adult and paediatric prescribing supported through the same ePMA system to ensure they have adequately risk assessed the way in which the system supports the calculation of doses to ensure that adult …
Safety Observation
Sepsis: a patient with abdominal pain
New confusion in patients is not consistently accounted for in NEWS2 scores.
Area of Improvement
Sepsis: a patient with a urine infection
Lack of involvement of families to support the assessment of confusion in patients.
Area of Improvement
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation support staff to identify and code a person’s disabilities/impairments that may influence their competency to self-manage insulin, and ensure these are considered and adjusted for when deciding whether a person is competent?
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
HSSIB recommends that NHS England/Department of Health and Social Care develops a tool for use in community settings to support the assessment of competency of patients, their families and carers to manage and administer insulin and care for people with …
Safety Recommendation
Local integrated investigation pilot 2: Incorrect patient details on handover
It may be beneficial if the Acute Trust considers the results of current research to understand whether a way of visually identifying patients with dementia would be appropriate to help positive patient identification. HSIB notes the following specific national safety …
Safety Observation
Local integrated investigation pilot 2: Incorrect patient details on handover
HSIB recommends that the Acute Trust tests its positive patient identification procedure for patients with dementia in order to identify risks and support the development of effective mitigating controls.
Safety Recommendation
NCEPOD recommendations(29)
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Acute limb ischaemia
Wording not shown. See the report on NCEPOD's website.
Acute limb ischaemia
CQC inspection actions(786)— showing 50 strongest matches
Wythenshawe Hospital
The trust must ensure they assess and do all that is reasonably practicable to mitigate risks to women, birthing people and newborns. Regulation 12(1)(2)(a)(b)
Must Do
Worthing Hospital
The trust must ensure that all patients on medical wards receive regular risk assessments upon admission and throughout their stay and take all reasonable steps to mitigate any identified risks. This includes mouth care, skin and nutritional assessments as well …
Must Do
Worcestershire Royal Hospital
The trust should ensure patient venous thromboembolism risk assessments are completed as required.
Should Do
William Harvey Hospital
The trust should ensure a risk assessment is completed for the play area of the ward.
Should Do
William Harvey Hospital
The trust should ensure ligature risk is reassessed and added to the risk register for the paediatric emergency department.
Should Do
William Harvey Hospital
The trust should ensure all risk assessments on patients are completed on admission to medical wards.
Should Do
William Harvey Hospital
The trust must ensure all boarded patients have had a full risk assessment prior to boarding
Must Do
Westmorland General Hospital
The trust should ensure that patients waiting in corridors have formal assessments of skin integrity and pressure sores risk, if prompted by the Safe and seen document.
Should Do
Westmorland General Hospital
The service must ensure staff assess and mitigate the risks to women’s health and safety in an emergency situation either during home birth or at the unit. They must ensure appropriate escalation and transfer takes place.
Must Do
Westmorland General Hospital
The service must ensure staff assess the risks to women during and after birth in order to identify women at risk of deterioration.
Must Do
Westmorland General Hospital
The service must ensure risk assessments are completed and are actions taken to minimise any risks identified
Must Do
Westmorland General Hospital
The department must ensure that all known risks are singularly identified on the risk register and that risks are supported by robust action plans that can reduce or mitigate the risks. They must also ensure that these action plans are …
Must Do
Westmorland General Hospital
The trust must ensure that risk assessments and mental capacity assessments are carried out for mental health patients in line with trust policy.
Must Do
Westmorland General Hospital
The trust must ensure that risks in the organisation are correctly identified and appropriate mitigations put in place in a timely way
Must Do
West Cumberland Hospital
The trust must ensure that patient risk assessment are completed and updated so that staff can identify and act upon patients at risk of deterioration.Regulation12(1)(2)(a)(b).
Must Do
West Cumberland Hospital
The trust must ensure care and treatment is provided in a safe way for patients, including assessing the risks to the health and safety of service users of receiving the care or treatment and doing all that is reasonably practicable …
Must Do
Wavertree Bungalow
We recommend the provider reviews the system for determining the level of support people need to help them remain safe and review how this is recorded.
Should Do
University Hospital of Hartlepool
The service should ensure that they clearly document mitigating actions taken for each risk on the risk register and evidence they monitor and manage risks appropriately.
Should Do
The York Hospital
The service should ensure ED staff complete all sections of risk assessments for patients who show signs of mental ill health. They should consider revising this documentation’s length to improve staff compliance.
Should Do
The York Hospital
The trust should ensure that patients had venous thromboembolism (VTE) checks and risk assessments are completed and documented with in the current trust protocol within 14 hours.
Should Do
The York Hospital
The trust must ensure that where necessary patients have risk assessments completed and reviewed as per guidance employed.
Must Do
The York Hospital
The trust must ensure that where necessary patients have risk assessments completed and reviewed as per guidance employed.
Must Do
The York Hospital
The service must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with trust and national guidance.
Must Do
The York Hospital
The service must ensure they assess the risks during the triage process to ensure the health and safety of service users.
Must Do
The York Hospital
The service must ensure staff do not place patients at higher risks such as those with IV access or allergies in inappropriate environments for their needs and observe them accordingly.
Must Do
The York Hospital
The service must ensure ED staff accurately and consistently complete risk assessments for each patient on admission or arrival and review this regularly using appropriate screening tools (in which they are trained and familiar).
Must Do
The Tunbridge Wells Hospital at Pembury
The service must ensure there are effective governance systems and processes to identify and manage incidents, risks, issues and performance and to monitor progress through completion of audits, action plans and oversight of improvements and reduce the recurrence of incidents …
Must Do
The Royal Free Hospital
The trust must ensure that the risk register entry relating to the purchase of new ketone machines, covers the clinical risk and mitigations around the shortage of the machines.
Must Do
The Princess Royal Hospital
The trust must ensure bed rails assessments are carried out on patients who require them in line with national standards.
Must Do
The Princess Royal Hospital
The trust must ensure that all risk assessments, with particular attention to venous thromboembolism risk assessments are completed in line with trust policy, to reduce the risk of harm to patients.
Must Do
The Princess Royal Hospital
The service must ensure patients are risk assessed in a timely way and that risks associated with the delivery of healthcare is mitigated as far as is reasonably practicable.
Must Do
The Princess Alexandra Hospital
The trust must ensure full risk assessment and care plans are completed in line with policy for patients assessed to be at risk during triage.
Must Do
The County Hospital
The provider must ensure there are systems and processes to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activities. It must assess, monitor and mitigate the risks relating to …
Must Do
The County Hospital
The provider must ensure it is assessing the risks to the health and safety of patients of receiving care or treatment and doing all that is reasonably practicable to mitigate any such risk through effective and safe care to patients …
Must Do
The County Hospital
The provider must ensure it is assessing the risks to the health and safety of patients of receiving care or treatment and doing all that is reasonably practicable to mitigate any such risk through carrying out and documenting regular observations, …
Must Do
Sunderland Royal Hospital
The trust must ensure risk assessments including clinical service risk assessments are up to date, thoroughly assessed and documented and benchmarked against national statutory and best practice guidance. The trust must ensure records of risk assessments are effectively maintained.
Must Do
Sunderland Royal Hospital
The trust must ensure risk assessments including clinical service risk assessments are up to date, thoroughly assessed and documented and benchmarked against national statutory and best practice guidance. The trust must ensure records of risk assessments are effectively maintained.
Must Do
Sunderland Royal Hospital
The trust must ensure risks in services are appropriately recorded, assessed, escalated to the trust’s board where required, and regularly reviewed.
Must Do
Stroud Maternity Hospital
The service must ensure that staff complete accurate risk assessments to determine if women are suitable for assessments and to birth at Stroud Maternity Unit. Regulation 12(1)(a)(b)
Must Do
St Austell Hospital - Penrice Birthing Unit
The service must ensure that there is a full risk assessment for the level of emergency equipment at Penrice birthing unit. Regulation 12(2)(a)(b)
Must Do
St Albans City Hospital
The trust must ensure that risks are identified, reviewed and acted upon in a timely manner to mitigate risk.
Must Do
South Tyneside District Hospital
The trust must ensure risk assessments including clinical service risk assessments are up to date, thoroughly assessed and documented and benchmarked against national statutory and best practice guidance. The trust must ensure records of risk assessments are effectively maintained.
Must Do
South Tyneside District Hospital
The trust must ensure risk assessments including clinical service risk assessments are up to date, thoroughly assessed and documented and benchmarked against national statutory and best practice guidance. The trust must ensure records of risk assessments are effectively maintained.
Must Do
South Tyneside District Hospital
The trust must ensure risks in services are appropriately recorded, assessed, escalated to the trust’s board where required, and regularly reviewed.
Must Do
Southport & Formby District General Hospital
The trust should continue to improve the review of patient risk assessments.
Should Do
Scarborough Hospital
The service should ensure ED staff complete all sections of risk assessments for patients who show signs of mental ill health. They should consider revising this documentation’s length to improve staff compliance.
Should Do
Scarborough Hospital
The trust should ensure that patients had venous thromboembolism (VTE) checks and risk assessments are completed and documented within the current trust protocol within 14 hours.
Should Do
Scarborough Hospital
The trust must ensure that where necessary patients have risk assessments completed and reviewed as per guidance employed.
Must Do
Scarborough Hospital
The trust must ensure that where necessary patients have risk assessments completed and reviewed as per guidance employed.
Must Do
Scarborough Hospital
The service must ensure they assess the risks during the triage process to ensure the health and safety of service users.
Must Do
PPO death in custody recommendations(6)
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff complete the medical risk assessment in full, including signing and dating the form.
The Head of Healthcare
The Head of Healthcare should ensure that clinical checks on prisoners who are refusing food and/or fluids are carried out and recorded appropriately to ensure risks are managed.
The Governor
The Governor should ensure that before prisoners are located on B Wing, they are appropriately assessed to ensure they are vulnerable prisoners or are suitable to be housed with vulnerable prisoners.
The Governor
The Governor should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that authorising managers show that they have taken this information into account when assessing a …
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: • healthcare staff complete the medical …
The Governor
carry out fresh risk assessments for each escort when/if the prisoner’s condition changes to establish the appropriate level of restraints when travelling to and from hospital; and
IOPC learning recommendations(7)
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that Thames Valley Police reminds police officers who bring members of the public into custody, custody sergeants and healthcare professionals to be proactive when conducting a risk assessment for a detainee, by reviewing items that belong to …
Recommendation - West Midlands Police, April 2021
The IOPC recommends that West Midlands Police takes steps to ensure that an appropriate and consistent level of information is included in custody records/Electronic Detention Logs (EDLs) when completing a pre-release risk assessment. This should include considering: - minimum standards …
Recommendations - Nottinghamshire Police, February 2026
The IOPC recommends that Nottinghamshire Police introduce a process and standard document for its Internet Child Exploitation (ICE) team for conducting risk assessments on those subject to an enforcement visit, before the visit takes place and before the suspect is …
Recommendations - Devon and Cornwall Police - April 2022
The IOPC recommends that Devon & Cornwall Police review their processes when informing a suspect of a charging decision in cases where is an increased risk of suicide (either due to the suspect’s circumstances and/or the alleged offence), to ensure: …
Man found dead after being reported missing - Thames Valley Police, April …
Thames Valley Police’s (TVP) custody records contain a question asking detainees “If you are suffering from mental health problems, depression or considered mentally vulnerable we must put specific support in place. Do you need this support? If yes, give details”. …
Recommendations - West Midlands Police, April 2021
The IOPC recommends that West Midlands Police should take steps to formalise the escalation and vulnerability doctrines (as set out in the force document “HMIC Observations and action taken following September 2017 Inspection”) into a compulsory policy and take step …
Recommendations - Gloucestershire Constabulary, March 2025
The IOPC recommends that Gloucestershire Constabulary should ensure that their risk assessment processes are robust and detailed in circumstances where an alleged perpetrator of antisocial behaviour has been notified of pending legal actions against them. Depending on the circumstances of …
IMB individual recommendations(13)
Gatwick IRC/RSTHF (2022)
Ensure that relevant healthcare clinical staff, GPs and psychologists and psychiatrists are fully educated in the application of Rules 35(1) and 35(2) (section 4.4.2).
NHS / Healthcare Provider
Gatwick IRC/RSTHF (2022)
Building on the recommended review of AAR, ACDT and Rule 35, define and promulgate procedures and guidance to ensure cases of men “likely to be injuriously affected by continued detention” (Rule 35(1)) or who are suspected “of having suicidal intentions” (Rule 35(2)) are properly identified and assessed (section 4.4.2).
Home Office
Gatwick IRC/RSTHF (2022)
Undertake a complete review of Adults at Risk, ACDT and Rule 35 policy and procedure (repeated from 2019, 2020 and 2021) (section 4.4.1).
Home Office
Gatwick IRC (2024)
Review the mechanisms for informing and encouraging detained men to take up the offer of a Rule 34 appointment, as these are a vital safeguard, greatly increasing the likelihood of detection of vulnerabilities.
NHS / Healthcare Provider
In Progress
North East Midlands, Yorkshire & Humber STHF (2023)
We recommend that all arrival interviews should be conducted in the purpose-built interview room in the facility, with privacy and with participants seated in comfort and speaking at eye level. We regard this recommendation is vital for safety as the purpose of the interview is to discover and identify risk factors relating to sensitive and personal circumstances such as whether …
Other
Gatwick IRC (2024)
Provide suitable training and support to ensure that all healthcare staff, including General Practitioners, are clear about their obligations under Detention Centre Rule 35, and understand how these are to operate.
NHS / Healthcare Provider
In Progress
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
North East Midlands, Yorkshire & Humber STHF (2024)
We ask for confirmation that the proposed actions on yellow hatching and pre-departure risk assessments have been implemented and are working satisfactorily (see section 4.2.1).
Other
Lowdham Grange (2024)
Prisoners who have not been recently sentenced are being transferred to HMP Lowdham Grange without a completed or up-to-date offender assessment (OASys). This means the assessment has to be completed at this prison, adding to pressure on the offender management unit (OMU) and putting prisoners at risk until it is completed. Does HMPPS feel it is acceptable that some establishments …
HMPPS
Noted
Gatwick IRC (2024)
Operate with a presumption of release in cases of vulnerability, considering not just whether vulnerabilities can be accommodated in detention, but also at what cost to the detained man.
Home Office
Rejected
Gatwick IRC (2021)
As we have recommended for the past two years, there should be a full review of Adults at Risk (AAR), ACDT and Rule 35 policy and procedure (section 4.4).
Home Office
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
Swinfen Hall (2021)
What measures will be put in place to enable Swinfen Hall to continue to manage the increased number of prisoners arriving without a completed OASys assessment?
HMPPS
In Progress
Health investigations(1187)
Independent investigation: Alan Riddock, Bristol (2008) — Rec 3
The Avon and Wiltshire Mental Health Partnership NHS Trust should put in place appropriate mechanisms, including audit, to assure itself and its commissioner that risk management plans: • are informed by a current, up to date risk history; • are founded on a clear formulation and understanding of the risks …
south_west
*Mental health homicide investigation legacy report into the care and … — Rec Two
The Trust will conduct an audit of its risk assessment processes within six months of the publication of this report to determine: the compliance of all clinicians in the completion of risk assessments for every service user; the compliance of all clinicians in the development of risk management …
May 2008 This is the report of the independent investigation into the care and treatment of Mr Y . Mr Y had received care and treatment at Sussex Partnership NHS Foundation Trust
south_east
*Mental health homicide investigation legacy report into the care and … — Rec L7
Point 4 of the trust’s action plan states that the trust has delivered Historical, Clinical, Risk Management – 20 (HCR-20)training in response to the need to ensure that formalised risk assessment and management processes, including assessment of longitudinal risk over longer time periods, are in place and effectively used. However, …
south_east
*Mental health homicide investigation legacy report into the care and … — Rec L5
The trust should continue to encourage risk panel meetings. In circumstances where there is significant uncertainty about an individual patient’s diagnosis and/or treatment plan, these cases should automatically be discussed in an appropriate forum, with other clinical colleagues, to assist in developing an appropriate care and risk management plan.
south_east
*Mental health homicide investigation legacy report into the care and … — Rec L2
The trust should assure itself that the current process for Care Programme Approach (including care planning, risk assessment, risk management planning) is robust. The clinical governance team should audit compliance at least every six months and report its findings to the board.
south_east
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (iv)
The Trust and Council should provide a course of instruction and training for mental health staff in assessment and management of risk.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (iii)
The Trust and Council should ensure that risk assessment is appropriately carried out and properly recorded on the forms provided for that purpose.
london
Independent investigation: Sidney Waller, Manchester (2008) — Rec 2
In relation to risk management and risk assessment, the PCT will require assurances that all individuals have clear risk assessments and risk management plans in relation to Assertive Outreach and these are up-to-date and have appropriate reference to crisis management. The PCT will build this into performance management processes.
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 2
The Trust should instigate quarterly review meetings to encompass the monitoring of care plans, which should: include a peer evaluation against agreed standards; ensure care planning, and the treatment and management of patients be informed and based on a comprehensive risk assessment.
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 10
The Trust should extend the terms of reference of the CPA steering group to include processes relating to the new Trust Approved Risk Assessment (TARA) and the new Trust-wide Pennine Assessment Document (PAD). This to include: a restating of the clinical roles and responsibilities of all clinical staff, both individually, …
north_west
Independent investigation: Katie Kazmi, Reading (1999) — Rec 14
The trusts’ risk management policy should require consideration of whether: • the individual is a driver with access to a car; • driving for that individual would give rise to a significant risk; • the risk is such that advice is given not to drive • carers and significant others …
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 7
The trusts should take urgent action to review clinical files and establish a universal system highlighting, and regularly reviewing: a basic chronology; a risk management plan including relapse profile; a care plan and clinical reviews.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 9
Social services’ and the trusts’ risk management policy should require consideration of whether: • the individual is a driver with access to a car; • driving for that individual would give rise to a significant risk; • the risk is such that advice is given not to drive • carers …
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 8
Social services and trusts should consider the desirability of including in CPA documentation a note of the advice given to the patient on driving.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 3
The trusts’ risk management policy should require consideration of whether: • the individual is a driver with access to a car; • driving for that individual would give rise to a significant risk; • the risk is such that advice is given not to drive • carers and significant others …
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
The trusts’ risk management policy should require consideration of whether: • the individual is a driver with access to a car; • driving for that individual would give rise to a significant risk; • the risk is such that advice is given not to drive; • carers and significant others …
south_east
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 6
The Trust can demonstrate improvement to processes around the delivery of effective care planning and risk assessment. This work is at an early implementation stage and work needs to continue to ensure its continued effectiveness. The following actions need to take place: all registered health and social care practitioners in …
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 5
The Trust can demonstrate improvement to processes around the delivery of effective care planning and risk assessment. This work is at an early implementation stage and work needs to continue to ensure its continued effectiveness. Audit processes should include: Assurance that all those referred to secondary mental health services have …
north_west
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (iii)
The Trust should ensure that every assessment includes an evaluation of risk and that this is properly documented.
london
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 2
Having revised its risk assessment, mangement and training policy the Trust should institute a regular quality audit to ensure: that the formulation of the individual’s problems and needs informs the understanding of his/her risk; that robust and meaningful care plans are put in place; that the service user and other …
north_east_yorkshire
Independent investigation: Bridget MaclennanElizabeth Valad, Camden — Rec 19
Trusts should review their risk assessment forms to determine whether improvements can be made so that forms can contribute optimally to assessment and appraisal or risk. This should include consideration of a facility to record estimated levels of prediction and certainty – rather than omitting a risk because it is …
london
An independent investigation into the care and treatment of a … — Rec R4
The Early Intervention in Psychosis team to monitor the risk status and management plans of those individuals whose mental state appears to be deteriorating via a Red Board meeting three times per week. Clarity needed regarding the RAG [red/amber/green] ratings, criteria for each category and what to do and when …
south_east
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 5
The Metropolitan Police Service and mental health service providers and users should jointly review their arrangements for responding to potentially violent mentally ill persons in the community, with a view to developing a joint policy and operational protocol for managing such incidents. This should include clear guidelines on risk assessment, …
london
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 1
NHS Trusts and Health Authorities should ensure that there is a clear procedure for the transfer of the statutory after-care duty on mental health services when an individual moves away from an area, together with a standard format for passing on pertinent information on risk management. This should include a …
london
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.3.2
The Division should insist that a formal written risk assessment and risk management plan, including a crisis management plan, is in place, before submitting a recommendation for conditional discharge to the First Minister. It should ensure that the symptoms and signs of the individual’s mental disorder are addressed in such …
scotland
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.2.4
The Social Work Department should review the written clinical information that it requires to carry out its supervisory functions and ensure that this is contained within the individual’s case file. In the view of the Inquiry, this should include a formal risk assessment and risk management plan, including a crisis …
scotland
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.1.1
The Health Board must ensure that there is a systematic approach to risk assessment and management within the forensic psychiatry service. In the Inquiry’s view, the systematic use of formal risk assessment measures may be helpful in this, but they should not be regarded as sufficient. In the present case, …
scotland
Independent investigation: Stefan Welch, Brighton (2010) — Rec 3
The Trust will conduct an audit of its risk assessment processes within six months of the publication of this report to determine: the compliance of all clinicians in the completion of risk assessments for every service user; the compliance of clinicians in incorporating all relevant clinical information within …
south_east
Independent investigation: Simon Breed, Wood Green (2004) — Rec R20
The 2008 CPA policy is revised to include a requirement that a comprehensive risk assessment is undertaken by the care coordinator prior to the decision to close the case of any person subject to CPA.
london
Independent investigation: Simon Breed, Wood Green (2004) — Rec R13
To further evaluate the operation of the CPA the trust should consider the development of: a. A rolling programme of inpatient and community team inspections to assess the quality of risk assessments and risk management plans. Results should be fed back to the teams, be compared over time and should …
london
Independent investigation: Sarah Jane Coghlan, Middlesbrough (2003) — Rec 3
In relation to risk assessment and risk management, there should be mechanisms in place to ensure that risk factors are explicitly identified, with rigorous reviews of risk at appropriate stages in the care of a patient, particularly where steps such as conditional discharge or discharge of S.117 arrangements are being …
north_east_yorkshire
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1.f
Process of risk assessment This section of the policy should be amended to refer to MAPPA. It should contain a brief explanatory note about the function of MAPPA and about local routes to the MAPPPs.
london
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.6
Baseline drug screening should form part of the initial core ICPA assessment where the use of illicit drugs is reasonably suspected to contribute to a patient’s mental disorder, whether or not the patient admits to using illicit substances.
south_west
Independent investigation: Philip Ellison, Preston (2008) — Rec 9
The Trust must implement a system to ensure that adequate risk assessments are being completed and that regular care planning and multidisciplinary reviews are taking place for people resident in the supported tenancy schemes and similar accommodation where the trust and partner agencies provide services.
north_west
Independent investigation: Philip Ellison, Preston (2008) — Rec 1
The Trust should ensure that initial assessment of people with mental health problems takes full account of social care factors: this is particularly relevant when the service user has responsibilities as a carer and there are known child care difficulties. Initial assessments should include thorough analysis of social care factors …
north_west
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 2
A full social circumstances assessment must take place in any case in which issues in that area have been identified.
north_east_yorkshire
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 1
There should be a clear three stage approach to the question of clinical risk; first the identification of any risk, second a detailed assessment of any such risk and third a clear plan for the management of that risk.
north_east_yorkshire
Independent investigation: Patricia PhilpottsBen Philpotts, Trevarrian (2010) — Rec Recommendation 6
Where serious risks are identified as a result of non-engagement, staff should probe the reasons and not accept the rationalisations the service user presents. To help understand the issues more assertive and focused questioning is required and a pragmatic approach to optimise contact should be taken. The rationale for the …
south_west
Independent investigation: Patricia PhilpottsBen Philpotts, Trevarrian (2010) — Rec Recommendation 4
When a service user is known to have used violence in the past any additional risks should be identified and used to prepare an updated risk assessment and a management plan for that risk. Drinking alcohol and using illicit substances should always be recorded and included in the risk assessment. …
south_west
Independent investigation: Patricia PhilpottsBen Philpotts, Trevarrian (2010) — Rec Recommendation 2
Recognition of current risk profile: Mental health staff must obtain and record as much relevant information as possible about a new service user with complex issues or uncertainty with the formulation of diagnosis or appropriate treatment in order to understand their initial presentation and to put their situation within an …
south_west
Independent investigation: Michael Kahan, Manchester (2008) — Rec 5
The Trust should ensure that risk assessments are completed as part of the CPA process and that known risks are incorporated into the care plan. Processes should also be developed to ensure risk assessments are: dynamic and updated on a regular basis/as indicated by a change in presentation; formulated with …
north_west
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 24
Trusts should review all policies, formal or informal, that prescribe general rules for discharge from services, and ensure that they are not applied in a formulaic way. Discharge should be dictated not by non attendance per se, or by self evaluation, or by rigidly applying service criteria, but by clinical …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 8
Trusts should ensure that accurate and regularly updated risk assessments, using a reliable tool, are carried out, and that the results of these are incorporated into risk management plans. This should be supported by training and regular audit.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 7
Trusts should ensure that a thorough needs assessment is carried out for both carers and “significant others” to properly inform risk assessments and care plans.
north_east_yorkshire
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.g
The patient’s Responsible Medical Officer should discharge their responsibilities as set out in paragraph 27.6 of the Code, in particular the assessment of any risk to the patient or third parties and the consideration of the criteria for supervised discharge or guardianship.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.iv.h
All staff should receive training in clinical risk assessment and management. For example, a clinical base tool such as HCR20 is of use. This is not to suggest that all patients require such a risk tool, but the structure and questions asked in the HCR20 are to help in assessing …
north_west
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec p.
That where a detained patient has recently harmed themselves or others, or an injunction is in force, their current mental state must always be assessed and recorded by a qualified nurse before they are permitted any leave in accordance with their consultant‘s general authorisation.
midlands
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec i.
That each mental health team appoints a CPA convenor who, together with the team manager, is responsible for ensuring that all patients in contact with the team are (i) allocated to standard or enhanced CPA in accordance with national and local guidelines; (ii) allocated a care co-ordinator; (iii) receive a …
midlands
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 22
DPT will incorporate the key questions identified from the audit of clinical risk assessment into the Clinical Record Self Monitoring Process. This will improve the monitoring and performance management of this key area of practice by providing information which is then routinely considered at service and team level. This should …
south_west
Independent investigation: Lenny Leak, Gateshead (2001) — Rec 7
Despite the limitations of any risk assessment system, it is essential that organisations work within an agreed framework. All agencies should audit the implementation of risk assessment policies so as to ensure their consistent and effective use by practitioners. This would be assisted by a programme of joint multi agency …
north_east_yorkshire
Scottish Fatal Accident Inquiries(15)
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
Graham Rattray
It seems to me that where risks are identified those responsible for the daily care of the vulnerable adult must ensure that carers know and understand the identified risks, know and understand agreed strategies to minimise those risks and know and understand what to do in the event that the risks in fact manifest themselves.
Jan 2008
Thomas Kilpatrick
There ought also to be proper considered and written guidance for dealing with the morning intercom calls when no response is received. Whether he should have been allocated a place within this complex is another issue and it would be appropriate for very careful consideration, and assessment, to be carried out before such a person is allocated such a tenancy …
Apr 2009
Steven Taylor
3. In terms of Section 6(1)(e) of the said Act, that the vulnerability assessment form completed by police custody security officers in respect of persons held in police custody should accompany such persons in addition to the Personal Escort Record. 4. In terms of Section 6(1)(e) of the said Act, that investigation should be carried out by the Scottish Prison …
Feb 2015
James Birnie Milne
Consideration should be given by Police Scotland to including, as an appropriate risk assessment question for persons presented at the charge bar, whether he or she has any medical or dental implants or plates.
Sep 2015
Colin Donald Penrose
Having regard to the conflicting views amongst SPS employees as to what constitutes bullying, and to remove any question of judgement in the recording of incidents of violence against prisoners other than the assailant’s cell mate, I recommend that SPS revise their cell sharing risk assessment to include as a marker “violence against another prisoner” (that as a category separate …
Oct 2017
James Scott Miller
I recommended that when doctors are advising patients who drive for a living they should decide if they are fit to drive for a living, not on the type of vehicle they drive or type of licence held by the patient. In my view the DVLA should give further consideration to the distinctions currently used ie group entitlement and focus …
Jan 2018
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
Angela Smith
[51] Although I do not find established that system failures contributed to Angela Smith’s death, I consider the evidence which emerged in this long inquiry should be examined by the police service and NHS to ensure at-risk prisoners are flagged up with all relevant information known about the risk. Where a nursing assessment is indicated this should be carried out …
Dec 2009
Martin Jamieson
a) that all personnel, both police officers and civilian staff, involved in the initial processing of a person in custody must ensure that all relevant information about the person is communicated to the Custody Officer; b) that Custody Officers must ensure that during initial processing they undertake a risk assessment of the person based on all relevant information provided to …
Feb 2010
Gary Daniel Forbes
(i) That the Maritime and Coastguard Agency give consideration to amending The Merchant Shipping and Fishing Vessels (Health and Safety at Work) Regulations 1997 so that they apply to share fishermen, thereby requiring all persons on board fishing vessels to wear personal flotation devices or lifejackets when working on deck. (ii) That the Maritime and Coastguard Agency give consideration to …
Aug 2016
Keane Grace Wallis Bennett
All reasonable steps should be taken to reinforce that warning to ensure that measures are taken in both the public and private domain to assess the risk of the continued use of such walls with associated guidance on remedial measures which can be taken to promote safety and stability which failing safe and effective removal of such walls from use …
Aug 2017
Allan Menzies
However, the criteria to be used should, in my opinion, be known to both the staff and the prisoners and ought to include inter alia the index offence, the issues behind it, his home circumstances, his personal preferences within reason, any outstanding appeal and the length of time spent within the NIC, any health issues and with the prisoners being …
Dec 2005
Kyle Robert Brown
However given the important fact here that Miss Thomson in her call clearly indicated that the rash was of a bruising nature, that is to say involving comparatively large areas, rather than small spots, and given Dr Freeman’s evidence that concerned callers were likely to speak of bruises rather than rashes if that is what they looked like, I think …
Oct 2007
Mary MacMillan Smith Forrest
(1)There should be defined rules or guidelines for nurse co-ordinators and compulsory training for them. (2) All staff nurses or charge nurses who are not acting in the role of nurse co-ordinator should be fully aware of the role of co-ordinators. B514/08 Mary Macmillan Smith Forrest (3) Much more training on procedures including risk assessment, observation and documentation should be …
Dec 2005
Article 2 learning points(4)
— LP 3
I recommend that the Governor of HMP Ranby establishes: that the prison’s current practice complies with the requirement to check the OASys risk assessment of newly admitted prisoners and to inform their location of any identified risk of harm to self or others; and that residential staff at Ranby are …
The Governor (HMP Ranby)
— LP 2
The in-reach team should consider whether an algorithm based on risk presentation that is high, medium or low, would help to dictate time-frames for specific actions to be taken.
Central and North-West London NHS …
Accepted
— LP Healthcare 1
A range of information including that from assessment during custody and from court proceedings should be considered along with the presenting risk factors when undertaking an initial assessment of an individual’s risk of suicide/self-harm and the opening of a potential ACCT.
Healthcare Provider
— LP 4
I recommend that NOMS look into whether the requirement for early checking of OASys assessments for new prisoners is consistently observed in other prisons and consider whether further measures are necessary to ensure that the system is used and understood.
NOMS
Independent reviews(37)
Harris Review: Deaths in Custody — Rec 75
During any transfer, where a prisoner has a SAVRAS (as all young adults will have) as part of their ICP, the receiving establishment must ensure that there must be no interruption of the ICP and/or SAVRAS as a result of the transfer.
Justice & Legal
Harris Review: Deaths in Custody — Rec 73
At any stage during the young adult’s time in custody, all prison staff must be under a positive obligation to notify the CARO (or the person acting on their behalf in their absence) of any concerns about an individual’s risk/vulnerability. Appropriate out of hours cover arrangements for the role of …
Justice & Legal
Harris Review: Deaths in Custody — Rec 72
Case Reviews of the SAVRAS and ICP will be led by the CARO and must be multi-disciplinary and where necessary must include representatives from healthcare. Where appropriate, the CARO should consider including chaplaincy, education, relevant in-reach staff, VCS and the prisoners’ families/friends. CRC/NPS probation and TTG workers should also be …
Justice & Legal
Harris Review: Deaths in Custody — Rec 69
All young adults should have an up to date ICP and SAVRAS that is co-ordinated by their CARO, who will be accountable for assuring the quality of the documentation, its regular review, and ensuring that its various elements are implemented.
Justice & Legal
Harris Review: Deaths in Custody — Rec 61
With a view to developing an ICP, all young adults entering custody must undergo a full multi-disciplinary holistic needs assessment within 48 hours of their arrival in custody. This process, to be known as the Safety and Vulnerability, Risk Assessment and Support (SAVRAS) process, should be co-ordinated by a CARO, …
Justice & Legal
Harris Review: Deaths in Custody — Rec 46
When a court is considering passing any form of custodial sentence upon a young adult (18 to 24) then a full written pre-sentence report must be commissioned.
Justice & Legal
Harris Review: Deaths in Custody — Rec 35
NOMS should continue its useful work on developing a tool to measure maturity effectively, the aim of which should be to better identify and support those in custody who are vulnerable because of a relative lack of maturity. This tool should be appropriately tested and made operational as soon as …
Justice & Legal
Laming Review (Baby P) — Rec 21
The National Safeguarding Delivery Unit should urgently develop guidance on referral and assessment systems for children affected by domestic violence, adult mental health problems, and drugs and alcohol misuse using current best practice. This should be shared with local authorities, health and police with an expectation that the assessment of …
Other
Laming Review (Baby P) — Rec 13
Children's Trusts must ensure that all assessments of need for children and their families include evidence from all the professionals involved in their lives, take account of case histories and significant events (including previous assessments) and above all must include direct contact with the child.
Other
Laming Review (Baby P) — Rec 6
Directors of Children's Services, Chief Executives of Primary Care Trusts, Police Area Commanders and other senior service managers must regularly review all points of referral where concerns about a child's safety are received to ensure they are sound in terms of the quality of risk assessments, decision making, onward referrals …
Other
Tickell Review of the EYFS — Rec 35
I recommend that clear guidance is included in the EYFS about the amount of paperwork that should be kept in relation to risk assessments. I also recommend that practitioners should not have to undertake written risk assessments in relation to outings, but instead be able to demonstrate, if asked – …
Education
Shaw Detention Review — Rec 27
Recommendation 27: I recommend that the Home Office conduct an annual audit (or ask for an independent audit) of the RSRA process so that it remains an effective means of ensuring detainee safety.
Immigration
Shaw Detention Review — Rec 22
Recommendation 22: I further recommend that rule 35 (or its replacement) should apply to those detainees held in prisons as well as those in IRCs.
Immigration
Shaw Detention Review — Rec 21
Recommendation 21: I recommend that the Home Office immediately consider an alternative to the current rule 35 mechanism.
Immigration
Morecambe Bay Investigation — Rec 7
The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care operates without inflexible demarcations between professional groups. This should be …
Health & Social Care
Morecambe Bay Investigation — Rec 6
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 will carry out this assessment against which criteria; and how …
Health & Social Care
Wessely Review — Rec 86
Risk assessments of issues such as infection control should be designed specifically for mental health inpatient care, and not lifted from other health settings. The unintended psychosocial effects must also be considered.
Health & Social Care
Accepted
Wessely Review — Rec 42
Detention criteria concerning treatment and risk should be strengthened to require that: a. treatment is available which would benefit the patient, and not just serve public protection, which cannot be delivered without detention; and b. there is a substantial likelihood of significant harm to the health, safety or welfare of …
Health & Social Care
Accepted
Wessely Review — Rec 40
A patient's capacity to consent to their admission must always be assessed and recorded, including on the application form.
Health & Social Care
Accepted
Shawcross Review — Rec 20
The Home Office should investigate whether there is an imbalance, or disparity, in thresholds applied to Islamist and Extreme Right-Wing Channel cases, and if so why. Examine whether Islamist referrals tend to be individuals much further along the trajectory towards violence ('active risk', at a sub-Pursue level), compared to referrals …
Policing & Security
Accepted
Shawcross Review — Rec 2
Move away from 'vulnerability' language and towards 'susceptibility', wherever accurate. The Vulnerability Assessment Framework should become the Prevent Assessment Framework. 'Vulnerability' should be reserved for welfare concerns and circumstances beyond an individual's control.
Policing & Security
Accepted
Ockenden Review — Rec 10
Labour and birth. Essential action: Women who choose birth outside a hospital setting must receive accurate advice with regards to transfer times to an obstetric unit should this be necessary. Centralised CTG monitoring systems should be mandatory in obstetric units. • All women must undergo a full clinical assessment when …
Health & Social Care
Accepted
Cass Review — Rec 8
NHS England should review the policy on masculinising/feminising hormones. The option to provide masculinising/feminising hormones from age 16 is available, but the Review would recommend extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18.
Health & Social Care
Accepted
Cass Review — Rec 7
Long-standing gender incongruence should be an essential pre-requisite for medical treatment but is only one aspect of deciding whether a medical pathway is the right option for an individual.
Health & Social Care
Accepted
Cass Review — Rec 2
Clinicians should apply the assessment framework developed by the Review's Clinical Expert Group, to ensure children/young people referred to NHS gender services receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health …
Health & Social Care
Accepted
Harris Review: Deaths in Custody — Rec 70
Families must be provided with sufficient opportunities to feed into the SAVRAS process, including through providing potentially relevant information on the dedicated concern line, and any such information must be recorded within the SAVRAS documentation.
Justice & Legal
Harris Review: Deaths in Custody — Rec 63
NOMS should consider whether the ICP, SAVRAS and CARO approach might also usefully apply to older adult prisoners.
Justice & Legal
Shaw Detention Review — Rec 49
Recommendation 49: The Home Office and NHS England should promote the self-administration of drugs where risk assessments support that approach.
Immigration
Wessely Review — Rec 58
The onus should be on the RC to demonstrate that a CTO is a reasonable and necessary requirement to maintain engagement with services and protect the safety of the patient and others. The evidence threshold should be raised for demonstrating that contact with services has previously declined, and that this …
Health & Social Care
Accepted
Modern Slavery Act Review — Rec 37
The allocation of a one-to-one ICTA should be tailored to assess the risk, vulnerability and need for each individual child in consultation with other public authorities. There should not be a presumption that a child with effective parental responsibility does not require a one-to-one service. A child’s needs should be …
Justice & Legal
Accepted
Harris Review: Deaths in Custody — Rec 8
Any young adult where there are current concerns about their vulnerability recorded as part of their SAVRAS should not have their regime (IEP) status downgraded.
Justice & Legal
Shaw Detention Review — Rec 16
Recommendation 16: I recommend that a further clause should be added to the list in paragraph 55.10 of the EIG to reflect the dynamic nature of vulnerability and thus encompass 'persons otherwise identified as being sufficiently vulnerable that their continued detention would be injurious to their welfare'.
Immigration
Wessely Review — Rec 54
Only the MCA framework (DoLS, in future the LPS) should be used where a person lacks capacity to consent to their admission or treatment for mental disorder but it is clear that they are not objecting.
Health & Social Care
Accepted
Wessely Review — Rec 38
There needs to be a concerted, cross-organisation, drive to tackle the culture of risk aversion. This will need to include the Chief Coroner, CQC, NHSE, NHSI, ADASS, LGA, patients, carers and provider boards, to understand the cultural drivers behind their different conceptualisations of risk and how they can be harmonised.
Health & Social Care
Accepted
Angiolini Review — Rec 21
An NHS initiative at the national level should examine whether to prohibit the refusal of access to A&E or to health-based places of safety under section 136 Mental Health Act 1983 (section 136) on the basis of intoxication. It should also consider the redesign of A&E facilities to allow for …
Policing & Security
Accepted
Hackitt Review — Rec 3.3
The dutyholder for a HRRB should proactively demonstrate to the JCA through a safety case at regular intervals (as determined by level of risk) that they are discharging their responsibilities. The safety case must identify the hazards and risks, describe how risks are controlled, and describe the safety management system …
Building Safety
Accepted
Windrush Review — Rec 19
a) UK Visas and Immigration should ensure that where appropriate it builds in criteria for increasing direct contact with applicants, including frequency of contact, performance standards and monitoring arrangements; revises the criteria and process for assessing cases involving vulnerable applicants; and reviews its service standards and where appropriate provides new …
Immigration
Accepted
PHSO casework decisions(32)
P-001435 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mr T complained the Trust failed to follow his mother's falls risk assessment, leading to a fall, hip fracture, and health deterioration. He also alleged delayed family notification and an inappropriate post-falls review.
NHS in England
Upheld
Jun 2022
P-002496 — Gateshead Health NHS Foundation Trust
Ms A complained the Trust did not properly assess her father’s continence and falls risk, leading to him falling and his oxygen dislodging, which she believes led to his death.
NHS in England
Upheld
Mar 2024
P-002541 — Royal Devon University Healthcare NHS Foundation Trust
Ms V complained staff in A&E did not properly assess her or provide follow-up advice after an accident, leading to lasting cognitive, emotional, and behavioural issues. She sought apology and service improvements.
NHS in England
Upheld
Apr 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-003081 — A practice in the Rushcliffe area
Mr I and Mrs Y complained the Practice failed to assess their mother's stroke symptoms, delaying care. They also alleged poor end-of-life care, including inappropriate pain relief administration and a lack of compassion from the District Nursing Team.
NHS in England
Oct 2024
P-003303 — Manchester University NHS Foundation Trust
Mr G said the Trust failed to properly assess his father before discharge, leading to readmission within two hours and death the next day.
NHS in England
Jan 2025
P-003414 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs A complained the Trust failed to properly support and monitor her brother during a Trial Without Catheter (TWOC), and staff delayed acting on dangerous symptoms, leading to his death.
NHS in England
Mar 2025
P-003800 — West London NHS Trust
Mr L complained the Trust failed to appropriately assess and manage his daughter's risk, and communicate effectively, leading to her taking her own life.
NHS in England
Aug 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-001261 — Barking and Dagenham, Havering and Redbridge Clinical Commissioning …
Mrs U complained the CCG refused to reimburse advocate fees she paid while pursuing retrospective Continuing Healthcare (CHC) costs for her mother.
NHS in England
Jan 2022
P-001270 — NHS England - North (regional office)
Husband complained the Independent Review Panel incorrectly weighted assessment domains, denying his wife Continuing Healthcare funding despite her complex health needs.
NHS in England
Jan 2022
P-002055 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs A complained the Trust failed to identify her mother as a falls risk and left her bed rail down, causing a fall which Mrs A believes contributed to her mother's death.
NHS in England
Jun 2023
P-002404 — Sheffield Children's NHS Foundation Trust
Mrs B complained Sheffield Children's NHS Foundation Trust's ED made assumptions about her son's condition, failed to observe him, and discharged him before he died.
NHS in England
Jan 2024
P-002566 — Guy's and St Thomas' NHS Foundation Trust
Mrs C complained the Trust wrongly discharged her from orthopaedic care, alleging staff did not listen to her symptoms of cauda equina, leading to ongoing mobility issues. She sought a substantial financial payment.
NHS in England
Apr 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-003003 — East Sussex Healthcare NHS Trust
Miss A complained clinicians failed to act on her mother’s high risk of falls in December 2022, leading to serious injuries and her death. She also alleged documentation was falsified.
NHS in England
Sep 2024
P-003080 — Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr A complained his wife was prematurely discharged from hospital without a care package or explanation, causing stress that accelerated her deterioration and contributed to her subsequent death.
NHS in England
Oct 2024
P-003088 — Mid and South Essex NHS Foundation Trust
Mrs D complained her mother was inappropriately discharged without proper capacity assessment or consideration of safety concerns, leading to readmission and her mother's death in hospital.
NHS in England
Partly Upheld
Oct 2024
P-003391 — University Hospitals of North Midlands NHS Trust
Mrs A complained the Trust failed to investigate her daughter's symptoms adequately, potentially leading to her stroke and death. She also complained about a distressing, incorrect phone call regarding an overdose.
NHS in England
Mar 2025
P-003453 — Gateshead Health NHS Foundation Trust
Mrs H complained about Miss E's delayed toilet access after an enema and inadequate care, risk assessments, and one-to-one nursing, leading to injury and distress.
NHS in England
Partly Upheld
Mar 2025
P-003678 — Tees, Esk and Wear Valleys NHS Foundation Trust
Miss U complained about the Trust's inadequate risk management, unsafe transition, and poor communication regarding her daughter's care, which she believed caused her death.
NHS in England
Jul 2025
P-003758 — St George's University Hospitals NHS Foundation Trust
Mr G complained the Trust failed to conduct appropriate investigations or provide safety netting advice before discharging his son, N, potentially missing a Kawasaki disease diagnosis.
NHS in England
Aug 2025
P-004322 — University Hospitals Birmingham NHS Foundation Trust
Mr B complained the Trust failed in falls management, leading to his father's fall and potential stroke, left a sedative in his mouth, and imposed restrictions without proper assessments.
NHS in England
Nov 2025
P-004436 — Lancashire and South Cumbria NHS Foundation Trust
Mr A complains about the standard of care and treatment his mother received from the Trust from November - December 2020.
NHS in England
Upheld
Nov 2025
P-001570 — Mid and South Essex NHS Foundation Trust
Ms C complained the Trust failed to closely monitor Mr C, who was agitated, leading to his death. She also cited conflicting statements from staff about his end-of-life care.
NHS in England
Oct 2022
P-002281 — North West Ambulance Service NHS Trust
Mr U complained the Trust repeatedly failed to transport his mother to hospital due to poor risk assessments. He alleged this caused her pain, deterioration, mental distress, and contributed to her death.
NHS in England
Nov 2023
P-003114 — South West London Integrated Care Board
Mrs A complained the ICB inappropriately allowed her brother to sign a tenancy agreement without capacity, resulting in rental arrears for which she is now being pursued.
NHS in England
Nov 2024
P-003209 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mrs V complained about her mother's unsafe discharge with COVID-19 and an inappropriate care package, pressure ulcers, COVID ward placement, and lost hearing aid, leading to her death.
NHS in England
Not Upheld
Dec 2024
P-003312 — A practice in the Harlow area
Miss I complained a GP practice misdiagnosed her daughter and failed to refer her. She also alleged Princess Alexandra Hospital NHS Trust failed to fully assess her daughter's symptoms on multiple ED visits, delaying cancer diagnosis.
NHS in England
Partly Upheld
Jan 2025
P-003597 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs G complained the Trust didn't consider patient history for her foster child's injury, and a paediatrician's speculation in a report led to their arrest.
NHS in England
Jun 2025
P-002651 — Northumbria Healthcare NHS Foundation Trust
Mr R complained the Trust failed to monitor or escalate his wife's Addison’s disease, leading to her death and denying her recovery opportunity.
NHS in England
Not Upheld
May 2024
P-003141 — A practice in the East Riding of Yorkshire …
The Practice allegedly did not appropriately assess Mr I, negatively affecting his health and contributing to his death.
NHS in England
Nov 2024
LGO / SPSO decisions(1491)
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
NIPSO-18735 — Belfast Health and Social Care Trust
We have asked the Belfast Health and Social Care Trust, in consultation with the other Trusts and health and social care organisations, to agree a uniform approach for assessing all future applications for Continuing Healthcare in Northern Ireland.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
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
21-013-917 — Trafford Council
Summary: There was fault in the Council’s failure to communicate with Mrs B and Mrs D about a change in care provider. This caused distress to Mrs B and Mrs D. The Council has agreed to apologise to Mrs B and Mrs D and pay them £250.
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
23-013-427 — Suffolk County Council
Summary: Mr X complained the Council has not provided any education or provision set out in the Education Health and Care Plan for his son, Y. The Council has acknowledged fault and offered an appropriate financial remedy for Y’s missed education and provision and the distress caused to the family. …
LGO (Local Government & …
Education
Upheld
Jul 2024
24-000-025 — London Borough of Newham
Summary: We upheld Ms X’s complaint. There was a delay in assessing her son Mr Y’s social care needs and her need for support in her caring role. There was also a delay in agreeing funding for a day centre placement. The outcome and recommendations of assessments were confusing. The …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
23-008-538 — Oxfordshire County Council
Summary: Ms X complained about Oxfordshire County Council, Oxford Health NHS Foundation Trust, and NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board. She complained about faults relating to aftercare under section 117 of the Mental Health Act 1983. We have upheld Ms X’s complaints about discharge, assessment, care planning …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
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
25-000-452 — Berkley Care Blenheim Limited
Summary: There was fault in the quality of care provided to Mr X’s late grandfather Mr Y by the care home. It failed to carry out a thorough pre-assessment, delayed taking action when Mr Y’s food and fluid intake reduced and failed to properly assess and respond to Mr Y’s …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
25-010-177 — Medway Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Adult Care Services
Feb 2026
25-005-861 — Bournemouth, Christchurch and Poole Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2026
25-016-037 — Dudley Metropolitan Borough Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Adult Care Services
Feb 2026
24-007-618 — London Borough of Islington
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2026
25-005-749 — London Borough of Hammersmith & Fulham
Ms X complained the Council has wrongly stopped funding overseas travel for her and her daughter, Miss Y, which they have used as respite care for many years. She complained the replacement respite care the Council has offered will not meet Miss Y’s needs. There was fault by the Council. …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2026
25-017-108 — Essex County Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Adult Care Services
Feb 2026
25-005-438 — Kent County Council
Mrs B complained about the Council’s failure to approve 2:1 support for her son Mr C at one of his placements for over a year. We found fault in the actions of the Council which caused Mrs B frustration and distress. The Council has agreed to apologise to Mrs B …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2026
NIPSO-18433 — Northern Health and Social Care Trust
We recommended that the Northern Health & Social Care Trust, either individually or collectively with others, put in place the necessary arrangements for it to appropriately assess all future requests for Continuing Healthcare.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
25-002-493 — Wirral Metropolitan Borough Council
Summary: The Council was at fault in how it decided to meet Mrs X’s needs after she asked for help caring for her adult son. The Council also delayed assessing Mrs X’s needs and responding to her complaint. The fault caused Mrs X significant frustration and uncertainty, for which the …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
24-022-503 — Derby City Council
Ms X complained the Council failed to respond to complaints, failed to adhere to her agreed reasonable adjustments and failed to carry out a suitable care needs assessment. She also queried its actions about Direct Payments. We found no fault in the Council’s complaint responses. We found there was some …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
21-002-153 — Leicestershire County Council
Summary: Mrs Y complains about the failure of a care provider to ensure a sore on her mother’s leg was appropriately cleaned, dressed and treated. We find fault because there is no evidence to show the care provider properly assessed the sore or sought medical help. This fault creates distress …
LGO (Local Government & …
Adult Care Services
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
21-003-092 — Oxfordshire County Council
Summary: The Council was at fault for failing to provide appropriate education and special educational provision to Ms X’s son. It was also at fault for not reviewing Ms X’s son’s Education Health and Care plan within the required timeframe. The Council has agreed to apologise, make a payment for …
LGO (Local Government & …
Education
Upheld
Feb 2022
20-013-288 — Plymouth City Council
Summary: Mr B complained about the way his relative, Mr C, was discharged from psychiatric liaison services on two occasions over one weekend. We found no fault by the Council, Livewell Southwest or the Trust.
LGO (Local Government & …
Adult Care Services
Not 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
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
21-013-303 — Stockton-on-Tees Borough Council
Summary: Mr X complained about the Council’s decision not to appoint him as Relevant Person’s Representative for his mother’s Deprivation of Liberty Safeguards authorisation. We have ended the investigation as the appointed Relevant Person’s Representative has approached the Court of Protection and Mr X is party to the proceedings. The …
LGO (Local Government & …
Adult Care Services
Not 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
21-002-504 — London Borough of Southwark
Summary: Mrs B complained that the Council converted her bathroom into a shower room in 2018 but the work failed to meet her needs because of inadequate space and the Council has failed to resolve the matter. We found the Council was at fault in that the adaptations completed in …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
20-007-857 — Kent County Council
Summary: Ms C complains the Council has wrongly pursued her for arrears in home support charges and withdrawn her support. The Council is at fault for failing to communicate and assess charges properly and the way in which it reassessed Ms C’s care needs. The Council has agreed to apologise …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-014-878 — Gloucestershire County Council
Summary: Mr and Mrs X and Mrs Y complained about the Council’s decisions about Mrs B’s care and how it considered their views. They also said it wrongly investigated safeguarding concerns about them. We found no fault in how the Council reached its decisions about Mrs B’s capacity and care, …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2022
21-011-043 — City of York Council
Summary: Mr X complained about the Council’s handling of his parents’ home care package and his complaints. There was fault in how the Council failed to review Mr X’s parents’ care plans and did not follow the correct safeguarding process when investigating some concerns about Mr X’s parents. The Council …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
20-000-380b — NHS South West London Clinical Commissioning Group (20 …
Hospital A - Provides specialist treatment for people with severe and complex personality disorders. This hospital is
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
20-000-380a — South London and Maudsley NHS Foundation Trust (20 …
Hospital A Provides specialist treatment for people with severe and complex personality disorders. This hospital is
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
20-000-380 — London Borough of Croydon
Hospital A Provides specialist treatment for people with severe and complex personality disorders. This hospital is
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-008-355 — Staffordshire County Council
Summary: There was fault by two councils in the way they dealt with Mr Y’s care and support arrangements when he was released from prison. This caused avoidable distress. The councils will apologise, make a symbolic payment and review procedures.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-007-683 — Newcastle upon Tyne City Council
Summary: The Council reviewed the amount of Mrs X’s Direct Payment budget to enable her to purchase more overnight stays for her son M after she appealed its initial decision.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2022
Domestic Homicide Reviews(1465)— showing 50 strongest matches
Tewkesbury — recommendation 17.9.5
Supervisors to ensure that any incident identified as Domestic Abuse is fully updated detailing the fact that a DASH has been completed.
Gloucestershire Constabulary
Gloucestershire Constabulary
Tewkesbury — recommendation 17.9.3
Incidents of Domestic Abuse must not be closed without the attending officers confirming (within the incident itself) that a Risk Assessment has been completed and submitted to a supervising officer.
Gloucestershire Constabulary
Gloucestershire Constabulary
Rotherham — recommendation 17.17
The Trust should give active support to A&E staff undertaking DASH risk assessments and their domestic abuse policy should be revised to reflect negative disclosure.
Rotherham NHS Foundation Trust
Rotherham NHS Foundation Trust
Rotherham — recommendation 17.16
The Trust’s training programme for Band 6 and above A&E staff in undertaking DASH risk assessments should be completed.
Rotherham NHS Foundation Trust
Rotherham NHS Foundation Trust
Rotherham — recommendation 17.12
Inevitably, when organisations differ on the identification, assessment and level of service provided there is a greater chance that potential victims and perpetrators will be overlooked and opportunities to intervene will be missed. There should be a standardisation within the Safer Rotherham Partnership of risk assessment processes including risk assessment …
Safer Rotherham Partnership
Rotherham — recommendation 17.8
In the absence of national guidance, the Safer Rotherham Partnership should develop a local protocol to ensure life threatening injuries caused by other means are identified and highlighted appropriately
Safer Rotherham Partnership
Bury — recommendation 1
That Team Bury Community Safety Partnership considers whether its constituent agencies training on assessing risk in domestic abuse cases needs enhancing to ensure all risk factors are identified before setting the final risk level.
Team Bury Community Safety Partnership
Bromley — recommendation 4.5.6
That the MPS review their use of the ‘Recency-Frequency-Gravity-Risk’ model to ensure that it addresses the harm, opportunity and threat posed by high impact offenders of domestic abuse
Metropolitan Police Service
Metropolitan Police Service
Bromley — recommendation 4.3.2c
Investigating Officers are reminded that any DA Risk Assessment assessed as medium or high must lead to completion of a Part 2/Secondary risk assessment.
Metropolitan Police
Metropolitan Police Service
Kingston upon Hull — recommendation 10
Risk assessments need to be completed taking into account all available information to ensure the assessment is as comprehensive and current as is possible.
Humberside, Lincolnshire and North Yorkshire Community …
Kingston upon Hull — recommendation 4
Further training around risk assessing Domestic incidents. Officers who attend incidents are still looking at incidents in their single form and not holistically.
Humberside Police
Humberside Police
Lambeth — recommendation 4.9.4
The need for assessments to be reviewed in light of new information/changing circumstances and historical information to ensure any risks is re-assessed.
Lambeth Council Children & Young People’s …
London Borough of Lambeth
Lambeth — recommendation 4.9.3
The NRTPF‘s team to ensure all assessments are holistic, take account of all information known or recorded ,and do not have a narrow focus ,but ensure they review safeguarding concerns over and above the financial issues.
Lambeth Council Children & Young People’s …
London Borough of Lambeth
Lincoln — recommendation ii)
For Steps2Change Service Manager, in consultation with the Trust Safeguarding team, to review their Referral Screening Protocol and consider if changes are required to improve consistency amongst the screening staff in identifying and recording safeguarding and risk history when it is recorded on the separate clinical system RIO.
Lincolnshire Partnership NHS Foundation Trust
Lincolnshire Partnership NHS Foundation …
Lincoln — recommendation i)
The Trust to review how known risks and risk management plans identified within the Police custody environment translate from the CJL&D ‘Assessment of Needs and Outcomes’ into the ‘Clinical Risk Framework’ (where other LPFT services are involved or later become involved) to ensure the Clinical Risk Framework is a complete …
Lincolnshire Partnership NHS Foundation Trust
Lincolnshire Partnership NHS Foundation …
Cheltenham — recommendation GASC.9
For ASC practitioners to clearly document that they have considered the impact of domestic abuse on the person’s ability to make decisions with capacity free of coercion or controlling behaviours.
Gloucestershire Adult Social Care
Doncaster — recommendation 1
Clinicians should consider: • The Trust’s ‘Engagement and Discharge of Patients Referred to and in Contact with Aspire Drug and Alcohol Services Policy’ • Complete Risk Assessments To mitigate the risk to patients who are vulnerable but have a propensity to not engage in a consistent manner despite their ongoing …
Rotherham Doncaster and South Humber NHS …
Rotherham Doncaster and South …
Doncaster — recommendation 2
That all agencies provide assurances and evidence to Safer Stronger Doncaster Partnership that all known risk factors and vulnerabilities such as alcohol use, are taken into consideration, and that contact with victims of domestic abuse is undertaken in cognisance and with agreement of the victim.
Safer Stronger Doncaster Partnership
West Lancashire — recommendation 33
Completion of an audit by West Lancashire Home Treatment Team that focusses on the quality of risk assessments, with necessary further actions taken should there be evidence of further concerns in this regard
Lancashire and South Cumbria NHS Foundation …
Lancashire and South Cumbria …
West Lancashire — recommendation 21
WLCSP to seek assurances that formal COVID written risk assessments should be recorded prior to all LCC Safeguarding visits during present COVID risks.
Lancashire County Council Safeguarding Adults
West Lancashire — recommendation 8
WLCSP to share the learning from this DHR review with Lancashire Constabulary and the Office of the Police and Crime Commissioner (OPCC) so that they may jointly consider the most appropriate Domestic Abuse Risk Assessment tool for improved risk identification
Lancashire Constabulary | Office of the …
Lancashire Constabulary
Manchester — recommendation GMMH 2
Robust procedural guidance on the importance of using structure risk assessment tools such as the ‘Domestic Abuse Stalking and Honour Based’ risk assessment checklist (DASH).
GMMH
Greater Manchester Mental Health …
Manchester — recommendation GMP 2
When officers from GMP attended one particular incident, a DASH assessment was submitted but some of the questions were left blank. According to GMP’s policy and procedure, if a victim refuses to answer DASH questions, the officer responding should apply their professional judgement to make an assessment of risk. Officers …
Greater Manchester Police
Greater Manchester Police
Manchester — recommendation GMP 1
If the victim refuses to answer DASH questions, the officer should apply their professional judgement to make an assessment of risk.
Greater Manchester Police
Greater Manchester Police
Sheffield — recommendation SYP 3
Operational update / brief around the importance of completing a DASH and even submit where DA is suspected, this is regardless of whether the victim engages and assists by answering the questions.
SYP
South Yorkshire Police
Sheffield — recommendation 15
SYP should ensure a DASH risk assessment is completed in all domestic abuse incidents, even when the victim is refusing to engage.
SYP
South Yorkshire Police
Sheffield — recommendation 13
Health Visitors (working for Sheffield Children’s NHS Foundation Trust (SCFT) or Sheffield Health and Social Care Trust) should routinely submit a DASH (Domestic Abuse, Stalking, Harassment, and ‘Honour’ Based Abuse) risk assessment where domestic violence or abuse is identified or suspected, including inter-family violence.
Sheffield Children’s NHS Foundation Trust (SCFT) …
Sheffield Health and Social …
Sheffield — recommendation 8
As part of the ongoing review of ‘Did Not Attend’ strategy and policies, Sheffield CCG to consider whether they have the capacity to review the risk where patients demonstrate a consistent lack of engagement.
Sheffield ICB
Sheffield — recommendation 6
STHFT to raise awareness and understanding of professionals to ensure where domestic abuse is disclosed, within the Sheffield Teaching Hospital, a DASH should be submitted. Within the Emergency Department(s) a Domestic Abuse Communication Form should be used by health professionals.
STHFT
Doncaster — recommendation 1
Review the referral process for domestic abuse and scope the potential to use the Domestic Abuse, Stalking, Harassment and Honour-Based Violence (DASH) risk assessment tool to drive quality practice and provide a referral mechanism to the Multi-agency Risk Assessment Conference (MARAC) process.
Yorkshire Ambulance Service
Yorkshire Ambulance Service NHS …
Doncaster — recommendation 2
To ensure all people waiting for Care Act assessments are contacted on a regular basis to inform risk assessment.
Doncaster Adult Social Care
Gloucester — recommendation 5
Probation services to continue to roll-out DASH RIC and SARA training and to ensure, through case audits and discussion in supervision, that this is being applied. Probation services to monitor the identification of both male and female victims through these processes.
BGSW CRC
Gloucester — recommendation 2
Probation services to develop a pathway with P3 to effectively challenge each other’s risk assessments when looking at a service user’s suitability for accommodation. This may prevent delays in the system for vulnerable service users. The first step in this process will be to engage with the Gloucestershire Reducing Reoffending …
BGSW CRC
Gloucester — recommendation 4
Social workers working with challenging and non-engaging parents and who consider themselves at personal risk, should complete a risk assessment. They should be immediately and effectively supported by their Team Managers. The management of risk should be overseen by their respective Heads of Service.
Gloucestershire Children’s Social Care
Gloucester — recommendation 3
Ensure the VIST Risk Assessment is updated with information known by Officers when a victim does not wish to engage with the question set.
Gloucestershire Constabulary
Gloucestershire Constabulary
Gloucester — recommendation 14
DASV Strategic Coordinator to organise a multi-agency task group to review the risk factors in this case and how temporary situational factors affected risk assessment. Task group to dip sample standard and medium risk DASH RICs from partner agencies to be sure that the DASH RICs identify all the risks …
DASV Strategic Coordinator
Gloucester — recommendation 11
Gloucestershire MARAC agencies to review their policies and practices regarding risks to staff from clients and to consider how they share such information with other agencies. MARAC Steering Group to consider how the MARAC system can assist in the distribution of such risk information to partner agencies.
Gloucestershire MARAC agencies | MARAC Steering …
Kent — recommendation 11
The Probation Service to consider the findings from the three DHRs within Kent and Medway (Ann, Connie and Diana) which have raised significant concerns surrounding the identified lack of challenge by Responsible Officers and a practice of passive risk management and over reliance on the accounts provided by the perpetrator.
The Probation Service
Probation Service
Kent — recommendation 8
The MARAC process needs to consider that hearing current information surrounding the perpetrator, his background and mindset, can be beneficial as it can establish risk and dynamics. Nathan had a restraining order against him; it would have been beneficial to the meeting to understand Nathan’s comments surrounding this and whether …
Kent Police and the Probation service
Wokingham — recommendation R1
To make the whole risk assessment process for supporting people living with dementia more robust. As previously described in the IMR, the risk assessment process encompasses an assessment of the person, their environment and their physical and mental capacity. However, our risk assessment process also needs to evaluate potential risks …
Home Instead
Wokingham — recommendation R2
A new risk form has been developed by the Trust to identify risks to vulnerable adults due to carer stress. This new risk form has been supported with staff training and a recommendation from this IMR is that learning from this IMR will be included in risk management and adult …
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Wokingham — recommendation R2
Undertake an audit of cases open to adult social care which have a similar domestic profile to the case of Adult A and Adult B, and those of the couple in the first DHR. This audit will include a risk analysis of cases and provide recommendations for further operational review.
Wokingham Borough Council
Doncaster — recommendation 19.2.3
Provide practitioner refresher briefings for working with substance misusers - to reinforce the need to address and not lose sight of broader risk management issues due to the continuous focus on substance abuse for example other relationships, associates and accommodation.
South Yorkshire Community Rehabilitation Company
Doncaster — recommendation 9
That the Safer Stronger Doncaster Partnership determines whether its risk assessment tools, and agencies use of them, are effective when dealing with relationships where money and or drugs are exchanged for sex, and whether new interventions are needed.
Safer Stronger Doncaster Partnership
Doncaster — recommendation 6
That the Safer Stronger Doncaster Partnership produces a Joint Domestic Abuse protocol with the Doncaster Safeguarding Boards highlighting the importance of professional curiosity and risk assessment and how to deal with disclosures of sexual abuse.
Safer Stronger Doncaster Partnership | Doncaster …
Cheshire West and Chester — recommendation 7
Training regarding risk assessment and management to be reviewed to ensure the learning is embedded into practice.
Cheshire and Wirral Partnership NHS Foundation …
Cheshire and Wirral Partnership …
Kent — recommendation 12
When offenders subject to statutory supervision are related, professionals with offender management responsibility must work collaboratively in order to build a holistic view of the family to inform the assessment and management of risk.
NPS | YOS
National Probation Service
Kent — recommendation 11
When adult offenders have been previously subject to youth offending supervision, liaison must take place with the previous allocated YOT worker/s in order to gather information to inform risk assessment and risk management.
NPS | YOS
National Probation Service
Kent — recommendation 10
In considering the appropriateness of accommodation for persons leaving prison or detention centres, agencies involved should use their own risk assessment processes to determine the suitability of the premises in respect of the vulnerability of existing occupants. Information from risk assessments should be shared with other agencies.
Social Services | NPS | YOS …
National Probation Service
Kent — recommendation 9
Social Services have a responsibility to assist young adults leaving care, which will include helping them find suitable accommodation in which to live. In addition to establishing the accommodation is suitable for the care leaver, a risk assessment should also take place intended to identify safeguarding issues in relation to …
Kent Social Services | Medway Social …
CJINI inspection reports(4)
Northern Ireland Prison Service Mistaken Prisoner Releases
Prisons, Prisoner Rehabilitation and Release
Nov 2010
An Inspection Of Public Protection Arrangements Northern Ireland
Risk Management and public protection arrangements, Probati…
Jun 2011
An inspection of Public Protection Arrangements Northern Ireland
Risk Management and public protection arrangements, Probati…
Jun 2011
Probation Board for Northern Ireland Pre-Sentence Reports
Probation Board for Northern Ireland (PBNI), Probation and …
Jun 2011
CQC enforcement actions(22)
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an inspection of their community-based mental health services for people of working age in October. Inspectors found safety concerns still needed addressing …
Mar 2023
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
CQC issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an unannounced focused inspection in November at Woodlands Hospital. Inspectors found staff had not completed mandatory training, risk assessments and care plans were not appropriately completed, …
Woodlands Hospital
Feb 2023
Urgent Enforcement Action: Bedfordshire Hospitals NHS Foundation Trust
In September, CQC placed conditions on their registration requiring them to outline how they were going to make rapid improvements to risk management, how they were effectively governing the service, and ensuring staff completed the necessary mandatory training required to …
Bedford Hospital and Luton and Dunstable Hospital
Sep 2025
Warning Notice: East Sussex Hospitals NHS Trust
The Care Quality Commission (CQC) issued a warning notice to East Sussex Hospitals NHS Trust, requiring urgent improvements to patient care. Inspectors found insufficient staff to support proper patient care in some areas, and that care plans and risk assessments …
Jun 2011
Warning Notice: United Lincolnshire NHS Trust
Following a visit to Pilgrim Hospital, the Care Quality Commission found United Lincolnshire NHS Trust was not taking appropriate steps to ensure people receive effective, safe and appropriate care. Inspectors noted that care plans did not always reflect patient needs, …
Pilgrim Hospital
Mar 2011
Conditions Imposed: University Hospitals of Morecambe Bay NHS Foundation Trust
The Care Quality Commission (CQC) imposed conditions upon University Hospitals of Morecambe Bay NHS Foundation Trust following an inspection of stroke services. This action was taken to ensure the trust had an effective system for managing and responding to patient …
Royal Lancaster Infirmary and Furness General Hos…
Aug 2021
Warning Notice: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission (CQC) served Tees, Esk and Wear Valleys NHS Foundation Trust a section 29A warning notice following an unannounced focused inspection in January. Inspectors found concerns that urgently needed addressing, including risks not being assessed effectively or …
Mar 2021
Warning Notice: Brighton and Sussex University Hospitals NHS Trust
CQC issued a Warning Notice to Brighton and Sussex University Hospitals NHS Trust requiring significant improvements by 30 August in three areas. Inspectors found that the trust's systems to assess, monitor, and minimise risks to people receiving care and treatment …
Brighton and Haywards Heath
Aug 2016
Warning Notice: Wye Valley NHS Trust
The Care Quality Commission issued Wye Valley NHS Trust with a warning notice following an inspection in September and October 2015. The warning required the trust to make significant improvements to its systems for assessing, monitoring, and mitigating risks to …
Jan 2016
Warning Notice: Oxleas NHS Foundation Trust
The Care Quality Commission (CQC) served Oxleas NHS Foundation Trust with a warning notice, requiring immediate improvements to its mental health wards for older people. An inspection found out-of-date ligature risk assessments, a lack of clear mitigation for high-risk ligature …
Greenwich, Bromley, Bexley
Dec 2020
Warning Notice: Ashford and St Peter's Hospitals NHS Foundation Trust
Section 29A warning notice covering maternity services at St Peter's Hospital, Chertsey, following an unannounced focused inspection in January 2023 under the national maternity inspection programme. CQC rated the service inadequate for safe (requires improvement for well-led) and required the …
St Peter's Hospital, Chertsey
Jan 2023
Warning Notice: St George's University Hospitals NHS Foundation Trust
Section 29A warning notice covering maternity services at St George's Hospital, Tooting, following an inspection in March 2023 that rated the service inadequate. The notice focused the trust's attention on how it manages risks to women and people using the …
St George's Hospital, Tooting
Aug 2023
Criminal Prosecution: Gloucestershire Hospitals NHS Foundation Trust
The trust pled guilty to failing to provide safe care and treatment to Dr Chris Elliot, who was infected by a strain of pseudomonas bacteria at Cheltenham General Hospital, thereby causing him avoidable harm — one offence under Regulation 12(1) …
Jun 2026
£300000
Warning Notice: Croydon Health Services NHS Trust
CQC served the trust a warning notice due to concerns about triage, staff training and appraisal, risk assessments and record keeping, equipment and environment checks, and leadership and governance. Staff didn’t always complete risk assessments and records to the required …
Croydon University Hospital
Nov 2025
Warning Notice: Kettering General Hospital NHS Foundation Trust
The Care Quality Commission (CQC) published a report following an inspection of medical services at Kettering General Hospital NHS Foundation Trust in May due to concerns around patient falls. Following the inspection, the trust was issued with a warning notice …
Jul 2021
Warning Notice: Blackpool Teaching Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Blackpool Teaching Hospitals NHS Foundation Trust following an inspection in September and October. The CQC required the trust to make significant improvements regarding assessing and managing risks to patients waiting …
Jan 2022
Warning Notice: Leeds Teaching Hospitals NHS Trust
Section 29A warning notice covering maternity and neonatal services at Leeds General Infirmary and St James's University Hospital, following unannounced inspections in December 2024 and January 2025. CQC identified breaches relating to learning from incidents, risk management, the safety of …
Leeds General Infirmary and St James's University…
Jun 2025
Warning Notice: Leeds and York Partnership NHS Foundation Trust
The Care Quality Commission (CQC) re-rated the long stay or rehabilitation mental health wards for working age adults, run by Leeds and York Partnership NHS Foundation Trust, as requires improvement. Following an inspection on 10 and 11 March, CQC found …
Asket Croft, Asket House and Newsam Centre Ward
Jul 2026
Warning Notice: Southern Health NHS Foundation Trust
The Care Quality Commission issued a warning notice to Southern Health NHS Foundation Trust following an inspection in January 2016. The inspection found the Trust had not put in place robust governance arrangements to investigate incidents, including deaths, and had …
Evenlode, Oxfordshire and Kingsley ward at Melbur…
Apr 2016
Warning Notice: Central and North West London NHS Foundation Trust
The Care Quality Commission formally warned Central and North West London NHS Foundation Trust that it must improve the care it provides at the Campbell Centre, Milton Keynes, and 3 Beatrice Place, Kensington. At the Campbell Centre, warning notices were …
Campbell Centre, Milton Keynes and 3 Beatrice Pla…
Mar 2014
Warning Notice: Salisbury NHS Foundation Trust
The Care Quality Commission (CQC) told Salisbury NHS Foundation Trust that improvements needed to be made in its maternity and spinal services at Salisbury District Hospital following an inspection on 31 March 2021. CQC found that governance arrangements were not …
Salisbury District Hospital
Jul 2021
Warning Notice: Barts Health NHS Trust
Section 29A warning notice served on maternity services at Newham University Hospital. A CQC inspection in September 2018 rated the hospital's maternity service inadequate overall, with concerns that the systems to assess, monitor and mitigate risks to patients and the …
Newham University Hospital
Oct 2018