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 15 independent accountability sources, so the source mix matters as much as the headline total.
22 inquiry recs
152 PFD reports
21 committee recs
32 HSSIB recs
487 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
32 PHSO decisions
1491 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(22)
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.
Response Pending
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 …
Response Pending
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 …
Response Pending
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.
Response Pending
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: Section 4.1 of the Scottish Government's response addresses this by stating that the prevention and management of pressure ulcers is a fundamental aspect of nursing practice. Healthcare Improvement Scotland published a Best Practice Statement - …
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 agreed that instead of a nine-month period for postmasters to submit a full appeal there should be a three-month deadline to notify the Department of an …
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: Department for Business and Trade accepts this recommendation. GLOS claimants already had the right to make oral submissions for up to one hour at independent panel hearings prior to the panel making a binding determination. …
Accepted
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: On 30 June 2022, the UK government provided the Inquiry with its provisional response to this recommendation. The UK government stated its final response to this recommendation would be provided within six months of the …
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 …
Response Pending
WATE-(33) — Base care plans on comprehensive assessment, prepared with child consultation
Recommendation: The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Unknown
WATE-(32) — Follow emergency child admissions with comprehensive assessment within prescribed period
Recommendation: All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Unknown
WATE-(31) — Require comprehensive child needs assessment before admission to care
Recommendation: Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Unknown
R28 — Nutritional screening
Recommendation: Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool. Where nutritional problems are identified further assessment should be undertaken to determine an individual care plan. Appropriate …
Gov response: Section 4.1 of the Scottish Government's response acknowledges the report's criticisms of specific elements of nursing care, including the unsatisfactory assessment and recording of patients' nutritional status. The government unreservedly accepts in full the report's …
Accepted
6 — Draw up maternity risk assessment protocol
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
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.
Gov response: The government agrees with all 67 recommendations made by the Chair. The government recognises these five fundamental failings. These failings are unacceptable. The Chair has made 10 recommendations for issues to be considered further by …
Accepted
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 …
Accepted
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: MPS formally responded on 28 October 2022 (paras 12-14). Internal guidance issued to CTSFO Tac Advisors within MO19 on tailoring FA5 forms. Training time set aside for FA form usage and completion.
Accepted
WATE-(45) — Require social worker assessment and inter-departmental consultation before residential school placement
Recommendation: Any placement of a child by a local education department or by a social services department in a residential school should be preceded by: (a) consultation between the departments as to whether an assessment by an appropriate social worker of …
Unknown
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: Section 2.2 of the Scottish Government's response describes the 'Governance for Quality Healthcare in Scotland - an Agreement' and a 'clinical and care governance framework for integrated health and social care services' to ensure good …
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: MPS formally responded on 28 October 2022 (paras 7-8). Firearms trainers required to watch Inquiry hearing recordings. Particular focus now on multidimensionality at all stages of operational planning. MO19 supporting College of Policing on improved …
Accepted
Prevention of Future Deaths reports(152)— showing 50 strongest matches
Derek Edward Bartlett Twivey
Concerns: The coroner's concern relates to circumstances that could create a risk of future deaths, and action should be taken to prevent such occurrences.
Overdue
Annie Rose Gibson
Concerns: The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and communication of observations after a client fall.
Overdue
May Gibson
Concerns: The report identifies failures in obtaining and accounting for a community care assessment, performing pre-assessments, developing adequate care plans, conducting risk assessments, and implementing risk reduction plans at the care home.
Overdue
Peter Pattinson
Concerns: Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient records.
Response (European Care Group): The care group has implemented new bed rail risk assessment and checking systems, along with staff training on safe bed rail usage. They also numbered daily statement documents to prevent …
Responded
George Renshaw Brown
Concerns: A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving a patient to more suitable accommodation.
Overdue
John William Tugwell
Concerns: The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.
Overdue
Derrick Plater
Concerns: There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.
Response: The council believes that a pre-placement visit by a social worker would not have provided any added assurance and is not and will not be part of the assessment and …
Responded
Ernest Harper
Concerns: Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.
Response (Bedford Borough Council): Bedford Borough Council has retro-fitted devices to block gaps on Ford Transit vehicles. A new assessment form designed with Occupational Therapists will be introduced by July 14, 2014, and a …
Responded
Ross Boyd
Concerns: An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.
Response (Milton Keynes Council): Milton Keynes Council reviewed the case and believes the placement was appropriate given the information available at the time. They will ensure managers discuss the use of respite beds with …
Pending
Harold de Mello
Concerns: A lack of good practice guidelines led to incomplete and inaccurate assessments by First Response Officers, who failed to reconcile conflicting information, investigate actual care needs, or consult relevant family.
Response (Tower Hamlets Local Authority): Tower Hamlets Social Services has convened a Case Review meeting and commissioned an internal management review. They are developing a risk analysis tool, introducing an eco-mapping tool, and scheduling targeted …
Responded
Elaine Jobe
Concerns: The report cites inadequate record keeping related to risk assessments and observation levels, a lack of training records for staff on risk assessment and observation implementation, and the need to review communication of patient status among staff.
Response (Devon Partnership NHS Trust): Devon Partnership NHS Trust has reviewed their policies and plans to complete additional actions, including reviewing risk assessments and delivering ward-based training on the updated policy, by January 2015. They …
Responded
Charles Lawrence
Concerns: The care home lacks a critical protocol to ensure a doctor examines residents who experience multiple falls within a 24-hour period, indicating a gap in immediate medical assessment for recurrent fallers.
Response (Alexandra Rose Residential Care Home): The care home implemented a 'falls alert' notification to be faxed to residents' doctors after more than one fall in 24 hours, and included this protocol in resident care plans.
Responded
Edna Bulmer
Concerns: The coroner noted inconsistencies in the documented level of falls risk and that measures to minimise risk were not implemented promptly. It was also unclear whether a system was in place for reviewing risk assessments after further incidents.
Overdue
Derek Hawkins
Concerns: The risk assessment tool relies on subjective practitioner judgment, lacks objective rating, and may lead to less experienced staff failing to identify increased risks.
Overdue
Darren Hayes
Concerns: Patient contact attempts were not documented or escalated, resulting in a five-week delay to follow up a high-risk individual. Key external health providers were also not contacted for assistance.
Response (Norfolk County Council): Norfolk County Council has taken action regarding the individual worker involved and the Adult Social Services Quality Assurance Team is developing a Best Practice factsheet to formalise local custom and …
Responded
George Hulme
Concerns: Care home agency staff lacked resident identification information and adequate induction. Rooms were not clearly marked, leading to confusion during emergencies and incorrect patient file retrieval for treatment.
Overdue
Maria Silkin
Concerns: The care home's falls risk assessment contained inaccurate information regarding the patient's fall history. This misrepresentation led to a dangerous delay in appropriate medical intervention.
Overdue
Thomas Taylor
Concerns: The falls risk assessment policy fails to presume increased risk for certain patient classes, like stroke patients, potentially leading to misclassification and adverse outcomes. Individual assessment without this presumption is questioned.
Overdue
Emmeline Hampson
Concerns: Inadequate review of falls risk assessments after repeated falls and patient condition changes was noted. Poor documentation, an insufficient alarm system, and a lack of agency staff training were also concerns.
Overdue
Howell Fisher
Concerns: Insufficient staff led to multiple falls for a high-risk patient. There was a critical lack of falls risk assessment and handover information between hospitals.
Overdue
Ian Morley
Concerns: A patient's deteriorating condition failed to trigger a necessary fresh risk assessment, compounded by inadequate fire risk management at the care facility.
Overdue
John Lomas
Concerns: Inadequate risk assessment of river conditions, lack of essential safety protocols for white water rafting (e.g., training, safety kayak, appropriate raft capacity), and poor communication between organisers and the Army contributed to the death.
Response (Sport Camp Tirol): Sport Camp Tirol disputes several factual points in the coroner's report, asserts its guides acted appropriately, and blames the army for allowing a non-swimmer on the trip. It will require …
Responded
Peter Furness
Concerns: The care home lacked a documented process for escalating incidents and concerns to trigger multi-disciplinary team meetings for reviewing vulnerable residents' risk assessments and care plans.
Response (Nant Y Gaer Hall): Nant Y Gaer Hall has implemented a new alert system for changes in residents' conditions, with training and supervision for staff. The new system includes forms, flow charts, and posters, …
Responded
Peter Buckle
Concerns: An unsafe work method was adopted without a risk assessment, and a strong health and safety culture was absent among employees despite training.
Response: Wayland Farms implemented new health and safety programs including a behavioral safety training program ('stop and think'), and will provide further training with external consultant input. They acknowledge the need …
Responded
David White
Concerns: Critical medication side effects causing confusion were unrecorded and unaddressed. Despite documented fall risks in nursing notes, adequate supervision was absent, and these notes were not reviewed or acted upon.
Response: Staff have been reminded of the importance of documenting allergies and adverse effects, including in Renal Mortality and Morbidity meetings; the safety briefing during nursing handover will now include care …
Responded
Alan Ludlow
Concerns: Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This leads to new homes being unaware of vital safety history for vulnerable individuals.
Overdue
Joanna Bowring
Concerns: Carers were excluded from risk assessment processes and not advised on suicide risk behaviours, while the patient left an initial assessment without a clear understanding of services or a care plan.
Response (Joanna Bowring): The Trust re-launched its carers protocol in February 2016, which includes identifying possible "red flags" and behaviours carers may look out for. An audit of care plans and risk assessments …
Responded
Marjorie Wood
Concerns: There is a lack of clear understanding about the legal status of individuals in care homes, which can negatively impact their care and treatment.
Response (Kingsley Healthcare Group): Kingsley Healthcare Group has reviewed its Deprivation of Liberty Safeguards Policy and Procedure and has provided further training and supervision to staff and checked for completed application and authorization records …
Overdue
Freda Cordy
Concerns: A patient requiring constant supervision was placed in a care home only offering 2-hourly checks, with no specific falls risk assessment despite a history of falls, and inadequate preventative equipment.
Overdue
Micael McMonigle
Concerns: Staff showed a lack of knowledge and failure to follow policy regarding leave for informal patients, risk assessments were not updated, and the response to the patient's absence was delayed and did not conform with procedures; staff knowledge of leave policy was inadequate.
Overdue
Maureen Flynn
Concerns: A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.
Response (Stockport NHS Trust): The Trust has completed actions detailed in an updated Patient Safety Investigation report, including an audit of falls risk assessments, enhanced falls sensors, and sharing investigation findings via ward newsletters, …
Responded
Demi Williams
Concerns: Despite general risk assessments, no specific consideration was given to the method of self-harm Ms Williams had previously described. This critical oversight and its omission from the Trust's investigation risk missing crucial learning opportunities.
Overdue
Dorethea Parr
Concerns: Lack of notification to family and carers about new equipment prevented training and risk assessments. There were no formal protocols for informing district nurses about falls, leading to missed intervention opportunities.
Response (Cornwall Partnership NHS Trust): Cornwall Partnership NHS Trust has embedded a policy to deal with slips, trips and falls in the community, requiring staff to complete risk assessments and incident reports, and intends to …
Responded
Raymond Shepherd
Concerns: Poor record-keeping and unupdated customer files led to missed care visits and unaddressed patient deterioration. Repeated falls and health concerns went without appropriate referrals or a mental capacity assessment.
Response (Human Support Group): The Human Support Group has implemented several changes including revising the care planning process, incorporating falls prevention information into training, developing a falls poster, reviewing care planning matrix, and adding …
Overdue
David Cooper
Concerns: Critical concerns included inadequate handover for fall risks between wards and poor record-keeping, especially regarding falls documentation. There was also a lack of 'joined-up' thinking and insufficient systems for booking one-to-one care for high-risk patients.
Response: The University Health Board established a Falls Management Group, reviewed policies and training requirements, introduced National Patient Safety Agency's Risk Assessments, devolved falls management to Directly Managed Units, and will …
Overdue
Roger Tombs
Concerns: Fall sensor mats were improperly placed on crash mats, potentially reducing their effectiveness and increasing the risk of undetected falls, injury, and death for vulnerable residents.
Response (Sunrise Senior Living): Sunrise Senior Living acknowledges the report but states it is leaving the Home's management and registration with CQC on 1 March 2017. It invites dialogue and can describe immediate actions …
Response (Roger Tombs): The Falls Team reviewed its practices after the PFD report and found them consistent and accurate. A guidance document outlining good practice in sensor mat use was developed and sent …
Overdue
Etheline De-Gale
Concerns: Vague care plans and inadequate staff training on risk assessment led to carers misinterpreting assistance needs. Insufficient staffing levels also compromised resident safety and impacted decisions regarding hospital admissions.
Response (Response Ambassador House Home): Ambassador House Home reports that the care plan will stipulate that residents must not be left unattended when bedrails are lowered, and staff will carry gloves in their pockets at …
Responded
Patrick Woods
Concerns: The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.
Response (Draeger Medical UK Limited): Draeger Medical UK has updated its training documentation, including the Basic Skills Checklist and powerpoint presentation, to address the use of the ACGO switch and relevant ventilation modes. They are …
Response (Luton Dunstable University Hospital): Luton and Dunstable University Hospital has reconfigured default alarm settings on anaesthetic machines, educated staff on unused functionality, and implemented a system to manage medical equipment logs. The Clinical Director …
Overdue
Sheila Hynes
Concerns: A mechanical aortic valve was remounted against manufacturer instructions by an untrained scrub nurse, without recorded discussion or awareness of associated risks by the surgical team.
Overdue
Patricia Norfolk
Concerns: Patients lacked daily senior clinician reviews, raising concerns about the standard of care provided during the interim period before new staff can be recruited.
Overdue
John Ramsden
Concerns: Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.
Overdue
Cameron Chadwick
Concerns: A pothole exceeding the minimum depth for repair was present in the carriageway, contributing to a fatal accident.
Response (Wigan Council): Following the report, the council measured the pothole depth and repaired it, both temporarily and permanently. They assert this was done despite the pothole not meeting the threshold for intervention …
Responded
Rose Workman
Concerns: The district nursing service's measures for effectively monitoring patients' ongoing conditions are questioned as potentially insufficient.
Response (Rose Workman): The district nursing service employs measures to ensure that patients are effectively monitored of their ongoing conditions, and the electronic clinical patient record "SystmOne" has undergone extensive re-engineering, launched in …
Responded
Robert Cardwell
Concerns: Significant communication failures prevented crucial patient information from reaching the multi-disciplinary team, leading to inappropriate discharge and a lack of follow-up care due to disorganised meetings and poor record-keeping.
Overdue
Constance Connolly
Concerns: The report describes failures in the handover of patients needing urgent follow-up, including a doctor not following up on a scan they ordered, and a breakdown in communication between different care teams resulting in a cancelled appointment and no further action.
Response (The Royal College of Emergency Medicine): The Royal College of Emergency Medicine has issued guidance to Fellows and Members regarding follow-up of test results in two documents, and is preparing a safety alert reminding them to …
Response (King's College Hospital NHS Foundation Trust): King's College Hospital NHS Foundation Trust is setting up a "virtual review" of self-discharged patients to ensure any investigations or follow-ups can be appropriately actioned.
Responded
Lesley Hanson
Concerns: Inadequate care and risk assessments failed to address environmental safety hazards like open doors and stair-gate suitability, with unclear responsibility for control measures.
Response (Welsh Government): Since the death, codes of practice to assess and meet the needs of individuals with care and support needs have been issued which underpin the Social Services and Well-being (Wales) …
Response: The council has reviewed processes resulting in improvements to policy regarding suitability of stairs and stair-gates in supported accommodation schemes. A new referral form, stair assessment tool and training has …
Responded
Maya Kantengule
Concerns: Significant safety risks arose from a lack of formal health and safety training, absence of specific risk assessments for swimming pool birthday parties, and failures to follow safety procedures, including non-functional CCTV.
Response (Waveney River Centre): Following the incident, the Waveney River Centre no longer hires its pool for swimming parties. Staff formal safety training courses such as IOSH have been arranged.
Responded
John Lambton
Concerns: Care home staff, without medical training, made assumptions about a resident's health after falls, disregarded an ambulance request, and communicated insufficiently with the GP.
Overdue
David Sketchley
Concerns: The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Response: The CQC is gathering evidence into this matter with a view to deciding whether there has been a failure by BUPA and/or the Registered Manager to comply with the Health …
Overdue
Stanley Langdon
Concerns: A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar accidents.
Response (Haven Day Centre): The Haven Day Centre implemented all suggested improvements from a County Durham Commissioning team report, including obtaining signatures on risk assessments, reviewing complaints policies, unifying transport policies, improving training records, …
Overdue
Select committee recommendations(21)
#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 Pending
#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 …
Gov response: The government agrees with the Committee’s recommendation. Framework Delivery Plan’s progress by the end of the current Spending Review period in 2025. Treasury Minutes Archive1 Treasury Minutes are the government’s response to reports from the …
Response Pending
#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 …
Gov response: The government agrees with the Committee’s recommendation. the public and support them to make green choices. This includes ensuring that green choices are affordable and easier to make. In summer 2022 government launched a comprehensive …
Response Pending
#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 …
Gov response: appropriate to do so, and suitable alternative accommodation has been secured. Providers are required to give advance notice to service users and under normal operations this is at least seven days. In accordance with Public …
Position Not Stated
#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 …
Gov response: appropriate to do so, and suitable alternative accommodation has been secured. Providers are required to give advance notice to service users and under normal operations this is at least seven days. In accordance with Public …
Position Not Stated
#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 …
Gov response: Government response to Conclusion six: We know that provision of effective support, including mental health support, is crucial for children in care and care leavers. Regulations and statutory guidance already clearly stipulate requirements for assessment …
Accepted
#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 …
Gov response: As set out in the protocol between the Lord Chancellor and the Law Commission, a Department for Education Minister will provide an interim response to the Commission as soon as possible and in any event …
Response Not Attributed
#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. …
Gov response: • NHS England and NHS Improvement continue working in partnership with HMPPS colleagues to ensure that all vulnerable patient populations are managed and supported through healthcare and supported through an appropriate enablement process to engage …
Position Not Stated
#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 …
Gov response: The Home Office and its accommodation providers take the welfare of service users seriously and agree that accommodation should be provided that is appropriate to individual needs. There are strict criteria set out in the …
Not Accepted
#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 …
Gov response: Home Office preparedness for COVID-19 (coronavirus): institutional accommodation: 3
Position Not Stated
#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 …
Gov response: Home Office preparedness for COVID-19 (coronavirus): institutional accommodation: 3
Position Not Stated
#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 …
Gov response: 15. Current legislation is very clear that B&B accommodation is not suitable for children and should only be used in emergencies and then only for a maximum of six weeks. B&B accommodation is privately managed, …
Not Accepted
#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 …
Gov response: 11. There are legal requirements, guidance and redress routes in place for temporary accommodation. 12. We are already taking action on the issues raised by this recommendation. Through the Renters’ Rights Bill the Government is …
Position Not Stated
#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 …
Gov response: The report concludes that the amount of time taken to recruit Commissioners, and agree fee levels, is concerning. As noted in paragraph 18, the public appointment process to recruit Commissioners requires consultation at several stages. …
Not Addressed
#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 …
Gov response: It is our assessment that any legislative change which sought to introduce a statutory test in under the MHA, could have unintended consequences for how competence is assessed in other settings, in particular mental health …
Partially Accepted
#1 —
Recommendation: We conclude, in line with our report on Social care: funding and workforce, the current social care system is “unfair and confusing”. Those living with dementia remain unprotected from unlimited costs and navigating the system is burdensome for those providing …
No Published Response
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 All individuals are able to raise concerns with the department whilst their case is under consideration and where safeguarding concerns are raised, these are …
Accepted
#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 …
Gov response: 11. There are legal requirements, guidance and redress routes in place for temporary accommodation. 12. We are already taking action on the issues raised by this recommendation. Through the Renters’ Rights Bill the Government is …
Response Not Attributed
#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 …
Gov response: The Government is committed to delivering the biggest increase in social and affordable housing in a generation. The revised NPPF published in December 2024 is already clear that LPAs should assess the size, type and …
Response Not Attributed
#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 …
Gov response: 3. PAC conclusion: The Department and providers are not working together and sharing information as effectively as they might to support participants into work. 3a. PAC recommendation: The Department should ensure work coaches and Restart …
Accepted
#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 …
Gov response: 1.2 Shielding is an intervention to protect the clinically extremely vulnerable to reduce risk of severe illness or death. It is, therefore necessarily linked to susceptibility to disease. Shielding support was put in place to …
Not Addressed
HSSIB safety recommendations(32)
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
Electronic patient record systems – electronic referrals for ongoing care
Use of advice and guidance may introduce risks to patient safety and how they may be mitigated.
Investigation Scope
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
CQC inspection actions(487)— showing 50 strongest matches
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
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 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 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
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
Royal Victoria Infirmary
The service must ensure it has an up to date and robust risk register in place with appropriate oversight, management, and implementation of identified actions.
Must Do
Royal Victoria Infirmary
The service must have robust procedures in place for the identification, review, and management of risk.
Must Do
Royal Victoria Infirmary
The service must ensure they are delivering fundamental standards of care that meets the needs of women, birthing people, and babies. This includes assessing the health and safety risks and doing all that is reasonably practicable to mitigate any such …
Must Do
Royal Victoria Infirmary
The service must ensure care and treatment is provided in a safe way. This includes assessing the health and safety risks for service users receiving the care or treatment and doing all that is reasonably practicable to mitigate any such …
Must Do
Royal Victoria Infirmary
The service must have robust procedures in place for the identification, review and management of clinical risk when providing care and treatment.
Must Do
Royal Victoria Infirmary
The service must ensure risk assessments have been carried out to minimise ligature risks and ensure that the premises and equipment used by the service users are done so in a safe way.
Must Do
Royal Victoria Infirmary
The service must ensure they have an up to date and robust risk register in place, and there is appropriate oversight and management of this.
Must Do
Royal Victoria Infirmary
Senior managers must ensure robust systems and processes are in place to identify, manage, mitigate and if appropriate escalate risks. This must ensure senior managers and the board members have clear oversight of service risks.
Must Do
Royal Victoria Infirmary
The service must ensure care and treatment is provided in a safe way. This includes assessing the health and safety risks for service users receiving the care or treatment and doing all that is reasonably practicable to mitigate any such …
Must Do
Royal Victoria Infirmary
The service must have robust procedures in place for the identification, review and management of clinical risk when providing care and treatment.
Must Do
Royal Victoria Infirmary
The service must ensure risk assessments have been carried out to minimise ligature risks and ensure that the premises and equipment used by the service users are done so in a safe way.
Must Do
Royal Victoria Infirmary
The service must ensure they are doing all that is reasonably practicable to mitigate risks including following best practice guidance.
Must Do
Royal Victoria Infirmary
The service must ensure that patient records include plans for managing risks.
Must Do
Royal Victoria Infirmary
The trust must ensure that high level risks are fully assessed and mitigated to the lowest level of risk.
Must Do
Royal Victoria Infirmary
The trust must ensure that risks recorded at corporate level and in the board assurance framework are current and have clear actions for mitigation which can be monitored and measured.
Must Do
Royal Shrewsbury Hospital
The trust must ensure bed rails assessments are carried out on patients who require them in line with national standards.
Must Do
Royal Shrewsbury 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
Royal Shrewsbury 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
Queen's Hospital
The service should ensure that patients who are self-administering their medications are clearly risk assessed and this is documented, and these patients are identifiable in the ED to staff.
Should Do
Queen's Hospital
The service must ensure patient records consistently document risk assessments.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure all boarded patients have had a full risk assessment prior to boarding
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure the risks associated with reported safety concerns are mitigated promptly.
Must Do
North Devon District Hospital
The service must ensure risks are mitigated, including but not limited to ensuring staff have access to an evidence-based standardised risk assessment and prioritisation tool for maternity triage.Regulation12(2)(a)(b)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurerisksinservicesareappropriatelyrecorded,assessed,andregularlyreviewed.Regulation17(1)(2)(a)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensuresubstanceshazardoustohealtharealwaysstoredsecurely,inaccordancewithControlofSubstancesHazardoustoHealthRegulations2002andtrustpolicy.Regulation15(1)(a)
Must Do
Montagu Hospital, Mexborough
Thetrustmustassess,monitor,andmitigatetherisksrelatingtothehealth,safetyandwelfareofserviceusersandotherswhomaybeatriskwhicharisefromthecarryingonoftheregulatedactivity.Regulation17(1)(2)(b)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurerisksinservicesareappropriatelyrecorded,assessed,andregularlyreviewed.Regulation17(1)(2)(a)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensuresubstanceshazardoustohealtharealwaysstoredsecurely,inaccordancewithControlofSubstancesHazardoustoHealthRegulations2002andtrustpolicy.Regulation15(1)(a)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethementalhealthassessmentroomhasenvironmentalriskassessmentscompletedandsignsinformingpatientsandthepublicclosed-circuittelevision(CCTV)isinuse.Regulation15(1)(b)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurerisksinservicesareappropriatelyrecorded,assessed,andregularlyreviewed.Regulation17(1)(2)(a)
Must Do
Montagu Hospital, Mexborough
Theservicemustensurethatappropriatemalnutritionuniversalscreeningtool(MUST)riskassessmentsarecompletedandrecordedforpatientswhorequiredsupport.Regulation12(1)(2)(a)(b)
Must Do
Leicester Royal Infirmary
Care and treatment must be provided for patients in a safe way. The trust must ensure staff are assessing the risks to the health and safety of patients of receiving the care or treatment. Staff must be doing all that …
Must Do
King George Hospital
The service should ensure that patients who are self-administering their medications are clearly risk assessed and this is documented, and these patients are identifiable in the ED to staff.
Should Do
Kettering General Hospital
The service should ensure there is a clear documented and risk assessed procedure in place for transferring a paediatric patient from the paediatric emergency department to the resuscitation area in the event of an emergency where required.
Should Do
Kettering General Hospital
The servicemust ensure the paediatric emergency department is safely managed. This includes but is not limited to ensuring waiting areas are safe and risks are assessed and mitigated; ensuring there is appropriate visual supervision of patients at all times.
Must Do
Kettering General Hospital
The servicemust ensure patient risks are fully assessed and mitigated in a timely manner. This includes but is not limited to; tissue viability, falls and deterioration.
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(2)
Independent investigation into the care and treatment of Mr L — Rec 4
The Trust must assure itself that risk assessments and risk management plans are reviewed when new information comes to light. The Trust must also implement an ongoing audit programme to provide assurance about organisational compliance with this requirement.
L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr L — Rec 1
The Trust must ensure that where a violent patient has been admitted to its services following concerns by other agencies; or complaints by neighbours about anti-social behaviour and noise and that they have been made aware of: • The risks are assessed appropriately • There are care plans developed to …
L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
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
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
LGO (Local Government & …
Adult Care Services
25-005-861 — Bournemouth, Christchurch and Poole Council
LGO (Local Government & …
Adult Care Services
Upheld
25-016-037 — Dudley Metropolitan Borough Council
LGO (Local Government & …
Adult Care Services
24-007-618 — London Borough of Islington
LGO (Local Government & …
Adult Care Services
Upheld
25-005-749 — London Borough of Hammersmith & Fulham
Ms X complained the Council has wrongly stopped funding overseas travel for her and her daughter, Miss Y, which they have used as respite care for many years. She complained the replacement respite care the Council has offered will not meet Miss Y’s needs. There was fault by the Council. …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2026
25-017-108 — Essex County Council
LGO (Local Government & …
Adult Care Services
25-005-438 — Kent County Council
Mrs B complained about the Council’s failure to approve 2:1 support for her son Mr C at one of his placements for over a year. We found fault in the actions of the Council which caused Mrs B frustration and distress. The Council has agreed to apologise to Mrs B …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2026
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
LGO (Local Government & …
Adult Care Services
Upheld
24-022-503 — Derby City Council
LGO (Local Government & …
Adult Care Services
Upheld
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